September 2016

TANDA BUKTI PENDAPATAN KEUANGAN UPTD PUSKESMAS CILAWU
(BERDASARKAN PERBUB NO. 1172 TAHUN 2016)

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
1
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
Pemeriksaan umum dan konsultasi pada rawat jalan
b
c
Pemeriksaan visum et repertum pro justica untuk pemeriksaan

luar
Pengujian Kesehatan (Keuring)
1 Melanjutkan Pendidikan
2 Melamar Pekerjaan
3 Pemeriksaan status kesehatan haji
4 Mengikuti asuransi
5 Pemeriksaan Calon Pegawai Negeri Sipil
6 Pemeriksaan / test kebugaran
7 Test Buta Warna
181,500
8,000
13
50,000
3
5,000
10,000
100,000
20,000
50,000
20,000
5,000
Klinik Gigi dan mulut

1
Penambalan Sementara untuk 1 gigi
25,000
Penambalan Permanen untuk 1 gigi
40,000
Perawatan saraf gigi (endodontic) setiap 1 (satu) gigi
20,000
Pencabutan untuk setiap 1 (satu) gigi anak dengan anestesi topikal
20,000
Pencabutan untuk setiap 1 (satu) gigi anak dengan anestesi injeksi
25,000
Pencabutan untuk setiap 1 (satu) gigi dewasa tanpa penyulit
30,000
Pencabutan untuk setiap 1 (satu) gigi dewasa dengan penyulit
75,000
Pencabutan untuk setiap gigi M3 (ondotectomy)
Tumpatan Tetap dengan Resin Komposit Light Curing (LC) Satu

Permukaan
Perawatan Eksisi Mukokel
Operculectomy/gingivectomy
Alveolectomy
Fluoridasi/topical application
10
11
12
13
14 Pembersihan karang gigi untuk setiap bagian rahang (8 gigi) (Ultra
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,491,50
Tindakan medis di rawat jalan, UGD dan rawat inap (Observasi > 6 jam
dikenakan tarif rawat inap satu hari)
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
220,000
NO.
UNIT LAYANAN
Pemeriksaan umum dan konsultasi pada UGD
Suntikan
Pemasangan infus
Visite
Pemasangan kateter kandung kemih
Pelepasan kateter kandung kemih
5,000
20,000
25,000
30,000
20,000
Perawatan luka ringan
10,000
7
8
Perawatan luka berat

Jahitan luka sampai dengan 3 (tiga)
30,000
20,000
Jahitan luka lebih dari 3 (tiga) per jahit di tambah
20,000
50,000
12 Ekstraksi Corpus Alienum Mata tanpa Komplikasi
25,000
13 Ekstraksi Cerumen Prop Telinga (1 telinga)
25,000
14 Ekstraksi Corpus Alienum Telinga (1 telinga)
25,000
15 Pengangkatan massa (ekstripasi) dengan ukuran < 2cm
50,000
16 Pengangkatan massa (ekstripasi) dengan ukuran 2cm s.d 5 cm
100,000
17 Pengangkatan massa (ekstripasi) dengan ukuran > 5 cm
200,000
20 Khitan (sirkumsisi) metode gunting atau cauter

21 Sonden hidung (NGT)
22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Resusitasi jantung dan paru (RJP)
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
750,000
120,000
150,000
175,000
250,000
Pelayanan perawatan rumah(Home Care) tidak termasuk obat, BMPH,

pemeriksaan penunjang diagnostik, perawatan full care setiasp satu kali
kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
sampai dg radius 3 Km
> 3 Km, penambahan setiap 1 km
JKN
Perawatan 1 (satua) hari / One day care bagi puskesmas non DTP
6
2
6
10,000
29 Pembidaian (pasangan spalk)
5,000
10 Sayatan (incisi/excisi)
11 Extraksi kuku kaki/tangan
19 Buka jahitan lebih dari 3 (tiga) perjahitan di tambah
10,000
1
2
3
4
5
18 Buka jahitan sampai dengan 3 (tiga)
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
Tindakan Kebidanan/ Persalinan
a
Persalinan normal (fisiologis)
oleh bidan di Puskesmas / PONED
Persalinan normal (fisiologis) oleh dokter di Puskesmas / PONED
3 Persalinan tidak normal (patologis) oleh dokter di Puskesmas /

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pengambilan Spesimen Pap Smear
Pemeriksaan IVA (Inspekulo Visual Asam)
Pijat Bayi
Plasenta manual
Eksplorasi Sisa Plasenta
Kompresi Bimanual Internal / Eksternal

Paket Penanganan Asfiksia
Pemeriksaan dalam (toucher)
Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
1
8
Pertolongan persalinan dg tindakan obat dah bahan habis pakai ( tidak

termasuk rawat inap, pemeriksaan penunjang diagnostik dan oksigen)
1
TARIF
6
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
2
4
1,255,500
PELAYANAN PENUNJANG MEDIS

1.
Pemeriksaan Laboratorium
a.
Pemeriksaan darah/urine
1)
Hematologi
a) Hematokrit
2)
5,000
b)
Leukosit (hitung jumlah)
5,000
c)
d)
e)
f)
g)
h)
Trombosit (hitung jumlah)

Hitung jenis leukosit
Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
Waktu pendarahan (BT)
7,000
j)
Waktu pembekuan (CT)
7,000
k)
Paket Hematologi rutin
45,000
l)
Paket Hematologi Lengkap
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
(1). Warna / kejernihan
3,500
(2). Berat Jenis (BJ)

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
(6). Paket pemeriksaan
1
n
1
1
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
a) Warna, lendir, darah
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Paket screening narkoba
Mikrobiologi
1)
BTA (mycobacterium tuberculose)
2)
BTA (mycobacterium leprae)
3)
Mycotek TB
4)
Diplococus gram negative (neisseria gonorhoe)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
Parasit saluran pencernaan
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
Golongan darah tanpa rhesus
1)
Golongan darah dengan rhesus
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
Widal (thypi H, thypi O, dan parathypi AH, AO)
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
Infulenza A dan B ag
9)
Malaria Pf/P.v rapid tes Ab
10) Malaria Pf/P.v rapid tes Ag
Pemeriksaan Foto Rontgen
a.
Film besar (setiap 1 (satu) posisi)
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
11) Sinus Paranasalis 2 posisi
12) Cervical 2 posisi
13) Ankle Joint
14) Pedis
c.
Film gigi
Pemeriksaan Ultrasonographi (USG)
Cetak hasil USG
Pemeriksaan Elektrokardiographi (EKG)
Pemeriksaan spirometry
ElektroMedis
a.
Pengukuran Densitas tulang
b.
Pemeriksaan Fetal Doppler
Pelayanan Farmasi
a.
Penyediaan obat dan alat kesehatan
TARIF
1
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000
Penggunaan ambulance puskesmas (belum termasuk pembelian bahan

bakar minyak/BBM) dan pendamping
a.
Pengangkutan pasien / Jenazah umum dengan jarak tempuh s/d 10

km
b.
Jarak tempuh lebih dari 10 km di tambah per km
c.
d.
Pendamping tenaga dokter

Pendamping tenaga perawat/bidan
e.
Bahan Bakar Minyak
10 Pemakaian Oksigen / tabung

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
11 Pelayanan P3K pada Event per Hari
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
1
n
100,000
250,000
150,000
50,000
100,000
50,000
Jumlah Pendapatan Pelayanan
3,747,000
NON PELAYANAN KESEHATAN

a
Pelayanan data dan informasi

1
Pendidikan, pendampingan dan bimbingan praktek kerja lapangan (per

org/hr)
a.
Bimbingan praktek kerja lapangan ( per org/hr )

1)
2)
3)
4)
b.
2
Pendampingan dan bimbingan magang kerja (orang/bulan)
250,000
1)
S3
2)
Pendidikan Profesi / S2
3)
D4 / S1
4)
D3
studi banding
1)
Pembekalan (per org /hari)
250,000
150,000
75,000
50,000
2)
100,000
Sarana Prasarana (per orang/hari)
100,000
Pemeriksaan sarana pelayanan kesehatan swasta

a.
b.
c.
Apotek
Toko obat
Klinik pratama rawat jalan (balai pengobatan)
150,000
100,000
100,000
d.
Klinik pratama rawat jalan dan rawat inap
250,000
Klinik utama/klinik spesialis rawat jalan
150,000
f.
g
h
i
j
k
l
m
n
o
p
q
Klinik utama rawat jalan dan rawat inap (RB)

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek dokter spesialis
Pengobatan komplementer alternatif
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
Pengobatan tradisonal
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
Jumlah Pendapatan non Pelayanan

I
II
10,000
8,000
6,000
5,000
Penelitian dan study banding

a.
Pengambilan data untuk penelitian (per judul/peneliti)
b.
D4 / S1
D3
SMA
JUMLAH PENDAPATAN JASA LAYANAN UMUM

JUMLAH PENDAPATAN JASA LAYANAN JKN
JUMLAH PENDAPATAN JASA LAYANAN
NO.
UNIT LAYANAN
TARIF
1
n
NDATANDA
BUKTI BUKTI
PENDAPATAN
PENDAPATAN
KEUANGAN
KEUANGAN
UPTD PUSKESMAS
UPTD PUSKESMAS
CILAWU
CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
1
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
181,500
8,000
104,000
50,000
5,000
10,000
30,000
0
30,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
47,500
25,000
40,000
20,000
20,000
40,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,491,500
7,500
8,000
8,000
7,500
0
0
220,000
220,000
NO.
UNIT LAYANAN
0
30,000
40,000
150,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
750,000
750,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
750,000
0
750,000
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
1,200,000
750,000
1,000,000
0
140,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
5,000
945,500
585,500
335,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
20,000
0
i)
7,000
j)
7,000
k)
45,000
315,000
50,000
0
245,000
0
0
0
0
0
0
75,000
0
0
60,000
a.
1)
Hematologi
a) Hematokrit
2)
0
0
40,000
100,000
0
1,255,500

1.
Rp
1,200,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
1
1,340,000

1
TARIF
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
30,000
80,000
0
5,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
5,500
0
0
0
5,500
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
360,000
0
0
40,000
360,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
1
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
235,000
100,000
100,000
5,000
35,000
125,000
100,000
0
100,000
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
75,000
0
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
1
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
3,747,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
3,747,000
3,747,000
NO.
UNIT LAYANAN
TARIF
1
Rp
I PENDAPATAN
TANDA KEUANGAN
BUKTI PENDAPATAN
UPTD PUSKESMAS
KEUANGAN
CILAWU
UPTD PUSKESMAS CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
2
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
64,000
8,000
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
994,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
280,000
NO.
UNIT LAYANAN
10,000
7
8

30,000
20,000
5,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
650,000
120,000
150,000
175,000
250,000

kunjungan
1
2
JKN
14
2
5
10,000
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
1
2
3
4
5
1.
TARIF
2
2
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
2
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
310,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
2
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
2
n
100,000
250,000
150,000
50,000
100,000
50,000
1,304,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
2
n
ATANTANDA
KEUANGAN
BUKTIUPTD
PENDAPATAN
PUSKESMAS
KEUANGAN
CILAWUUPTD PUSKESMAS CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
2
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
64,000
8,000
64,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
994,000
7,500
8,000
8,000
0
0
280,000
280,000
NO.
UNIT LAYANAN
10,000
70,000
40,000
125,000
0
0
10,000
7
8

30,000
20,000
0
20,000
5,000
15,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
650,000
650,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
650,000
0
300,000
350,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
2
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
310,000

1.
5,000
310,000
170,000
5,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
165,000
0
0
0
0
0
0
105,000
0
0
60,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
140,000
0
20,000
40,000
120,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
2
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
2
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,304,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,304,000
1,304,000
NO.
UNIT LAYANAN
TARIF
2
Rp
NGAN UPTD
TANDA
PUSKESMAS
BUKTI PENDAPATAN
CILAWU KEUANGAN UPTD PUSKESMAS CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
3
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
86,000
8,000
50,000
3
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,091,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
405,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
JKN
15,000
20,000
15,000
10,000
12,000
100,000
15,000
1
600,000
120,000
150,000
175,000
250,000

kunjungan
1
2
Aster
Anyelir
Azalea
Amarylis
40,000
50,000
LAYANAN RAWAT INAP
17
2
6
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
3
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
590,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
3
n
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
3
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
3
n
100,000
250,000
150,000
50,000
100,000
50,000
1,681,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
3
n
D PUSKESMAS
TANDA BUKTI
CILAWU
PENDAPATAN KEUANGAN UPTD PUSKESMAS CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
3
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
86,000
8,000
56,000
50,000
5,000
10,000
30,000
0
30,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,091,000
7,500
8,000
8,000
0
0
405,000
405,000
NO.
UNIT LAYANAN
10,000
85,000
40,000
150,000
0
0
10,000
7
8

30,000
20,000
0
20,000
5,000
20,000
50,000
0
0
25,000
25,000
50,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
600,000
600,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
600,000
0
600,000
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
3
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
590,000

1.
5,000
590,000
390,000
185,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
180,000
50,000
0
205,000
0
0
0
0
0
0
45,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
160,000
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
200,000
0
0
40,000
200,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
3
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
3
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,681,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,681,000
1,681,000
NO.
UNIT LAYANAN
TARIF
3
Rp
MAS CILAWU
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
4
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
4
0

1
TARIF
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
4
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
4
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
4
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
4
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
4
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
4
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
4
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
4
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
4
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
5
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
220,500
8,000
21
50,000
2
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,410,50
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
440,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
JKN
750,000
120,000
150,000
175,000
250,000

kunjungan
1
2
Aster
Anyelir
Azalea
Amarylis
40,000
50,000
LAYANAN RAWAT INAP
7
2
3
1
1
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
5
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
1,220,50

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5
n
2
2
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
5
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
5
n
100,000
250,000
150,000
50,000
100,000
50,000
2,631,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
5
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
5
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
220,500
8,000
168,000
50,000
5,000
10,000
20,000
0
20,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
32,500
25,000
40,000
20,000
20,000
25,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,410,500
7,500
8,000
8,000
7,500
0
0
440,000
440,000
NO.
UNIT LAYANAN
10,000
35,000
40,000
75,000
30,000
20,000
10,000
7
8

30,000
20,000
30,000
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
750,000
750,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
750,000
0
750,000
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
5
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
1,220,500

1.
5,000
985,500
645,500
330,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
15,000
0
i)
7,000
j)
7,000
k)
45,000
315,000
50,000
0
295,000
0
0
0
0
0
0
15,000
0
0
90,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
160,000
30,000
20,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
20,500
0
0
0
5,500
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
15,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
340,000
0
20,000
40,000
320,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
5
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
235,000
100,000
100,000
5,000
35,000
125,000
100,000
0
100,000
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
5
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,631,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,631,000
2,631,000
NO.
UNIT LAYANAN
TARIF
5
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
6
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
948,00
LAYANAN RAWAT JALAN

a
193,00
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
16
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
185,00
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
JKN
525,00
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
11
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
6
2

1
TARIF
2
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
1,070,00

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
6
n
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
6
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
6
n
100,000
250,000
150,000
50,000
100,000
50,000
2,018,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
6
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
6
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
948,000
LAYANAN RAWAT JALAN

a
193,000
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
128,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
65,000
25,000
40,000
20,000
20,000
25,000
50,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
15,000
0
0
185,000
185,000
NO.
UNIT LAYANAN
10,000
55,000
20,000
50,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
525,000
525,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
525,000
0
0
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
6
Rp

a
45,000

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
45,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
20,000
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
1,070,000

1.
5,000
1,070,000
750,000
315,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
315,000
50,000
0
420,000
0
0
0
0
0
0
120,000
0
0
270,000
a.
1)
Hematologi
a) Hematokrit
2)
0
0
0
25,000
0
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
30,000
15,000
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
15,000
0
0
0
0
0
urine rutin
15,000
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
320,000
0
0
40,000
320,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
6
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
6
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,018,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,018,000
2,018,000
NO.
UNIT LAYANAN
TARIF
6
Rp
rajal
igd
ranap
tin salin
penunjang

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
7
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
117,500
8,000
10
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,192,50
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
500,000
NO.
UNIT LAYANAN
10,000
7
8

30,000
20,000
5,000
12
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,575,00
120,000
150,000
175,000
250,000

kunjungan
1
2
JKN
24
3
8
10,000
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
1
2
3
4
5
1.
TARIF
7
3
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
7
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
449,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
1
1
4
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
7
n
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000

4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
7
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
7
n
100,000
250,000
150,000
50,000
100,000
50,000
2,641,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
7
n
600,000

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
7
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
117,500
8,000
80,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
37,500
25,000
40,000
20,000
20,000
25,000
30,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,192,500
7,500
8,000
8,000
7,500
0
0
500,000
500,000
NO.
UNIT LAYANAN
20,000
120,000
60,000
200,000
0
0
10,000
7
8

30,000
20,000
0
40,000
5,000
60,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,575,000
1,575,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
1,575,000
0
1,050,000
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
7
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
449,000

1.
5,000
449,000
329,000
135,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
135,000
50,000
0
150,000
0
0
0
0
15,000
15,000
60,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
30,000
44,000
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
44,000
0
0
14,000
0
0
urine rutin
15,000
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
15,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
120,000
0
0
40,000
120,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
7
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
7
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,641,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,641,500
2,641,500
NO.
UNIT LAYANAN
TARIF
7
Rp
14,022,500
862,500
2,030,000
4,850,000
1,385,000
4,895,000
14,022,500

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
8
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
88,000
8,000
11
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,088,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
255,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
JKN
745,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
19
3
2
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
1
3
1
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
8
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
325,500

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
8
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
8
n
100,000
250,000
150,000
50,000
100,000
50,000
1,413,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
8
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
8
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
88,000
8,000
88,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,088,000
7,500
8,000
8,000
0
0
0
255,000
255,000
NO.
UNIT LAYANAN
0
95,000
60,000
50,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
745,000
745,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
745,000
120,000
450,000
175,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
8
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
325,500

1.
5,000
325,500
145,500
95,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
90,000
50,000
0
45,000
0
0
0
0
0
0
15,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
5,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
5,500
0
0
0
5,500
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
180,000
0
20,000
40,000
160,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
8
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
8
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,413,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,413,500
1,413,500
NO.
UNIT LAYANAN
TARIF
8
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
9
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
124,000
8,000
13
50,000
2
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,879,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
480,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
1,275,00
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
JKN
22
3
10
1
1
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
5
3
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
9
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
325,500

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9
n
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
1
1
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
9
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
9
n
100,000
250,000
150,000
50,000
100,000
50,000
2,204,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
9
n

100,000
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
9
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
124,000
8,000
104,000
50,000
5,000
10,000
20,000
0
20,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,879,000
7,500
8,000
8,000
0
0
0
0
0
480,000
480,000
NO.
UNIT LAYANAN
10,000
110,000
60,000
250,000
30,000
20,000
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,275,000
1,275,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
1
2
3
4
5
1.
TARIF
JKN
1,275,000
0
750,000
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
9
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
325,500

1.
5,000
250,500
110,500
60,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
15,000
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
30,000
0
0
0
0
0
0
15,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
15,000
20,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
20,500
0
0
0
5,500
0
urine rutin
15,000
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
140,000
0
20,000
40,000
120,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
9
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
75,000
0
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
9
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,204,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,204,500
2,204,500
NO.
UNIT LAYANAN
TARIF
9
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
10
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
117,500
LAYANAN RAWAT JALAN

a
117,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
10
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
10
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
10
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
100,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
10
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
10
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
10
n
100,000
250,000
150,000
50,000
100,000
50,000
217,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
10
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
10
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
117,500
LAYANAN RAWAT JALAN

a
117,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
80,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
37,500
25,000
40,000
20,000
20,000
25,000
30,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
7,500
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
10
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
10
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
100,000

1.
5,000
100,000
60,000
45,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
15,000
0
0
0
0
0
0
15,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
40,000
0
0
40,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
10
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
10
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
10
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
217,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
217,500
217,500
NO.
UNIT LAYANAN
TARIF
10
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
11
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
11
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
11
0

1
TARIF
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
11
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
11
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
11
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
11
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
11
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
11
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
11
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
11
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
11
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
11
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
11
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
12
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
12
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
12
0

1
TARIF
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
12
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
12
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
12
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
12
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
12
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
12
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
12
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
12
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
12
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
12
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
12
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
13
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
673,500
LAYANAN RAWAT JALAN

a
613,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
30
50,000
1
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
1
37
45,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
JKN
1
1
10,000
5,000
13
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
13
1

1
TARIF
1
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
1,230,00

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
13
n
2
4
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
13
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
13
n
100,000
250,000
150,000
50,000
100,000
50,000
1,903,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
13
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
13
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
673,500
LAYANAN RAWAT JALAN

a
613,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
240,000
50,000
5,000
10,000
10,000
0
10,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
67,500
25,000
40,000
20,000
20,000
25,000
30,000
60,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
7,500
296,000
296,000
45,000
45,000
NO.
UNIT LAYANAN
0
0
20,000
25,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
13
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
13
Rp

a
15,000

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
15,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
15,000
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
1,230,000

1.
5,000
845,000
565,000
270,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
270,000
50,000
0
295,000
0
0
0
0
0
0
45,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
160,000
60,000
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
280,000
0
0
40,000
280,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
13
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
13
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
235,000
100,000
100,000
5,000
35,000
125,000
100,000
0
100,000
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
150,000
0
150,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
13
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,903,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,903,500
1,903,500
NO.
UNIT LAYANAN
TARIF
13
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
14
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
248,500
8,000
17
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
3,103,50
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
10
680,000
NO.
UNIT LAYANAN
10,000
7
8

30,000
20,000
5,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
JKN
1,775,00
120,000
150,000
175,000
250,000

kunjungan
1
2
29
4
11
10,000
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
14
1
2
3
4
5
1.
TARIF
6
5
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
14
4

1
TARIF
4
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
2
2
75,000
200,000
300,000
20,000
25,000
100,000
271,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
14
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
2
1
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
14
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
14
n
100,000
250,000
150,000
50,000
100,000
50,000
3,374,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
14
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
14
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
248,500
8,000
136,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
32,500
25,000
40,000
20,000
20,000
25,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
3,103,500
7,500
8,000
8,000
7,500
80,000
0
80,000
680,000
680,000
NO.
UNIT LAYANAN
30,000
145,000
80,000
275,000
0
0
10,000
7
8

30,000
20,000
0
20,000
5,000
30,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
100,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,775,000
1,775,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
14
1
2
3
4
5
1.
TARIF
JKN
1,775,000
0
900,000
875,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
14
Rp

a
400,000

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
400,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
200,000
200,000
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
271,000

1.
5,000
271,000
191,000
15,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
15,000
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
150,000
0
0
0
0
0
0
60,000
0
0
90,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
26,000
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
26,000
0
0
0
11,000
0
urine rutin
15,000
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
80,000
0
40,000
40,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
14
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
14
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
14
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
3,374,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
3,374,500
3,374,500
NO.
UNIT LAYANAN
TARIF
14
Rp
9,113,500
1,191,500
1,460,000
3,795,000
415,000
2,252,000
9,113,500

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
15
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
839,500
LAYANAN RAWAT JALAN

a
169,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
14
50,000
1
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
145,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
525,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
JKN
8
1
3
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
15
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
15
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
135,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
15
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
15
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
15
n
100,000
250,000
150,000
50,000
100,000
50,000
974,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
15
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
15
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
839,500
LAYANAN RAWAT JALAN

a
169,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
112,000
50,000
5,000
10,000
10,000
0
10,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
47,500
25,000
40,000
20,000
20,000
40,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
7,500
0
0
145,000
145,000
NO.
UNIT LAYANAN
10,000
40,000
20,000
75,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
525,000
525,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
15
1
2
3
4
5
1.
TARIF
JKN
525,000
0
0
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
15
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
135,000

1.
5,000
135,000
95,000
50,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
45,000
0
0
0
0
0
0
15,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
40,000
0
0
40,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
15
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
15
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
15
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
974,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
10,000
8,000
6,000
5,000
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II

a.
b.

0
974,500
974,500
NO.
UNIT LAYANAN
TARIF
15
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
16
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
171,000
8,000
12
50,000
2
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,681,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
385,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
1,125,00
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
JKN
3,000
40,000
LAYANAN RAWAT INAP
15
2
10
10,000
5,000
16
10,000
1
2
3
4
5
1.
TARIF
4
3
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
16
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
585,500

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
16
n
2
1
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
16
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
16
n
100,000
250,000
150,000
50,000
100,000
50,000
2,266,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
16
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
16
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
171,000
8,000
96,000
50,000
5,000
10,000
20,000
0
20,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
55,000
25,000
40,000
20,000
20,000
40,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,681,000
7,500
8,000
8,000
15,000
0
385,000
385,000
NO.
UNIT LAYANAN
0
75,000
40,000
250,000
0
20,000
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,125,000
1,125,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
16
1
2
3
4
5
1.
TARIF
JKN
1,125,000
0
600,000
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
16
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
585,500

1.
5,000
585,500
445,500
190,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
10,000
0
i)
7,000
j)
7,000
k)
45,000
180,000
50,000
0
250,000
0
0
0
0
0
0
15,000
0
0
60,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
160,000
15,000
5,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
5,500
0
0
0
5,500
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
140,000
0
20,000
40,000
120,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
16
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
16
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
16
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,266,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,266,500
2,266,500
NO.
UNIT LAYANAN
TARIF
16
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
17
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
56,000
8,000
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
681,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
175,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
450,000
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
11
1
4
5,000
1.
10,000
1
2
3
4
5
17
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

1
2

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
17
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
405,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
1
1
NO.
UNIT LAYANAN
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
17
TARIF
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
17
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
17
100,000
250,000
150,000
50,000
100,000
50,000
1,086,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
17

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
17
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
56,000
8,000
56,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
681,000
7,500
8,000
8,000
0
0
175,000
175,000
NO.
UNIT LAYANAN
55,000
20,000
100,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
450,000
450,000
120,000
150,000
175,000
250,000

kunjungan
1
2
5,000
20,000
25,000
30,000
20,000
10,000
Suntikan
Pemasangan infus
Visite
17
1
2
3
4
5
1.
TARIF
JKN
450,000
0
450,000
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
17

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
405,000

1.
5,000
405,000
245,000
135,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
135,000
50,000
0
110,000
0
0
0
0
15,000
15,000
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
20,000
20,000
30,000
80,000
15,000
0
0
0
80,000
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
160,000
0
0
40,000
160,000
VDRL
18,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
9,000
4)
b.
c.
d.
17
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
17
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
17
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,086,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,086,000
1,086,000
NO.
UNIT LAYANAN
TARIF
17

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
18
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
18
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
18
0

1
TARIF
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
18
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
18
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
18
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
18
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
18
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
18
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
18
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
18
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
18
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
18
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
18
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
19
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
434,000
LAYANAN RAWAT JALAN

a
434,000
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
21
50,000
1
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
32
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
19
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a
n
0

PONED
b.
19

1
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
860,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
1
1
6
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
19
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
19
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
19
n
100,000
250,000
150,000
50,000
100,000
50,000
1,294,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
19
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
19
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
434,000
LAYANAN RAWAT JALAN

a
434,000
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
168,000
50,000
5,000
10,000
10,000
0
10,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
256,000
256,000
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
19
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
19
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
860,000

1.
5,000
860,000
560,000
290,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
20,000
0
i)
7,000
j)
7,000
k)
45,000
270,000
50,000
0
270,000
0
0
0
0
15,000
15,000
90,000
0
0
150,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
300,000
0
20,000
40,000
280,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
19
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
19
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
19
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,294,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,294,000
1,294,000
NO.
UNIT LAYANAN
TARIF
19
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
20
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
728,000
LAYANAN RAWAT JALAN

a
118,000
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
11
50,000
3
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
140,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
350,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
JKN
7
1
3
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
20
5,000
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
20
2

1
TARIF
2
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
1
1
75,000
200,000
300,000
20,000
25,000
100,000
250,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
20
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
20
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
20
n
100,000
250,000
150,000
50,000
100,000
50,000
978,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
20
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
20
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
728,000
LAYANAN RAWAT JALAN

a
118,000
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
88,000
50,000
5,000
10,000
30,000
0
30,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
140,000
140,000
NO.
UNIT LAYANAN
10,000
35,000
20,000
75,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
350,000
350,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
20
1
2
3
4
5
1.
TARIF
JKN
350,000
0
0
350,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
20
Rp

a
120,000

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
120,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
100,000
0
20,000
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
250,000

1.
5,000
250,000
230,000
20,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
20,000
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
210,000
0
0
0
0
0
0
90,000
0
0
120,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
20,000
0
20,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
20
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
20
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
20
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
978,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
978,000
978,000
NO.
UNIT LAYANAN
TARIF
20
Rp
6,599,000
948,500
845,000
2,450,000
120,000
2,235,500
6,599,000

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
21
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
124,000
8,000
13
50,000
2
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,949,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
400,000
NO.
UNIT LAYANAN
17
3
9
10,000
7
8

30,000
20,000
5,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,425,00
120,000
150,000
175,000
250,000

kunjungan
1
2
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
21
1
2
3
4
5
1.
TARIF
JKN
6
3
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
21
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
545,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
21
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
21
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
21
n
100,000
250,000
150,000
50,000
100,000
50,000
2,494,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
21
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
21
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
124,000
8,000
104,000
50,000
5,000
10,000
20,000
0
20,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,949,000
7,500
8,000
8,000
0
0
400,000
400,000
NO.
UNIT LAYANAN
20,000
85,000
60,000
225,000
0
0
10,000
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,425,000
1,425,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
21
1
2
3
4
5
1.
TARIF
JKN
1,425,000
0
900,000
525,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
21
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
545,000

1.
5,000
545,000
345,000
315,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
315,000
50,000
0
30,000
0
0
0
0
0
0
30,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
200,000
0
0
40,000
200,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
21
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
21
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
21
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,494,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,494,000
2,494,000
NO.
UNIT LAYANAN
TARIF
21
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
22
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
98,000
8,000
11
50,000
1
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
181,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
83,000
NO.
UNIT LAYANAN
10,000
7
8

30,000
20,000
5,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
22
1
2
3
4
5
1.
TARIF
JKN
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
22
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
965,500

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
22
n
1
1
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.
22
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
22
n
100,000
250,000
150,000
50,000
100,000
50,000
1,146,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
22
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
22
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
98,000
8,000
88,000
50,000
5,000
10,000
10,000
0
10,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
181,000
7,500
8,000
8,000
0
0
0
83,000
83,000
NO.
UNIT LAYANAN
20,000
0
0
0
0
0
10,000
7
8

30,000
20,000
0
20,000
5,000
30,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
10,000
3,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
22
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
22
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
965,500

1.
5,000
905,500
605,500
320,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
315,000
50,000
0
280,000
0
0
0
0
0
0
60,000
0
0
60,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
80,000
80,000
5,500
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
5,500
0
0
0
5,500
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
300,000
0
20,000
40,000
280,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
22
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
22
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
60,000
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
22
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,146,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,146,500
1,146,500
NO.
UNIT LAYANAN
TARIF
22
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
23
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
141,500
LAYANAN RAWAT JALAN

a
141,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
13
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
23
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
23
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
220,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
23
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
23
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
23
n
100,000
250,000
150,000
50,000
100,000
50,000
361,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
23
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
23
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
141,500
LAYANAN RAWAT JALAN

a
141,500
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
104,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
37,500
25,000
40,000
20,000
20,000
25,000
30,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
7,500
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
23
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
23
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
220,000

1.
5,000
220,000
140,000
140,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
135,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
80,000
0
0
40,000
80,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
23
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
23
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
23
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
361,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
361,500
361,500
NO.
UNIT LAYANAN
TARIF
23
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
24
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
80,000
8,000
10
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,270,0
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
620,00
NO.
UNIT LAYANAN
10,000
7
8

30,000
20,000
1
1
5,000
27
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,550,00
120,000
150,000
175,000
250,000

kunjungan
1
2
JKN
23
3
10
10,000
5,000
20,000
25,000
30,000
20,000
Suntikan
Pemasangan infus
Visite
10,000
24
1
2
3
4
5
1.
TARIF
8
2
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
24
1

1
TARIF
1
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
100,00

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
24
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
24
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
24
n
100,000
250,000
150,000
50,000
100,000
50,000
2,370,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
24
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
24
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
80,000
8,000
80,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,270,000
7,500
8,000
8,000
0
0
620,000
620,000
NO.
UNIT LAYANAN
10,000
115,000
60,000
250,000
0
0
10,000
7
8

30,000
20,000
30,000
20,000
5,000
135,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,550,000
1,550,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
24
1
2
3
4
5
1.
TARIF
JKN
1,550,000
0
1,200,000
350,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
24
Rp

a
20,000

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
20,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
20,000
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
100,000

1.
5,000
100,000
60,000
45,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
15,000
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
15,000
0
0
0
0
0
urine rutin
15,000
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
40,000
0
0
40,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
24
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
24
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
24
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,370,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,370,000
2,370,000
NO.
UNIT LAYANAN
TARIF
24
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
25
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
25
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
25
0

1
TARIF
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
25
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
25
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
25
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
25
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
25
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
25
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
25
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
25
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
25
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
25
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
25
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
26
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
400,000
8,000
22
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,325,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
28
275,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
650,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
JKN
13
3
6
10,000
5,000
26
10,000
1
2
3
4
5
1.
TARIF
2
2
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
26
n
0

1
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
165,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
1
1
3
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
26
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
26
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
26
n
100,000
250,000
150,000
50,000
100,000
50,000
1,490,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
26
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
26
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
400,000
8,000
176,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,325,000
7,500
8,000
8,000
0
224,000
224,000
275,000
275,000
NO.
UNIT LAYANAN
0
65,000
60,000
150,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
650,000
650,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
26
1
2
3
4
5
1.
TARIF
JKN
650,000
0
300,000
350,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
26
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
165,000

1.
5,000
165,000
125,000
50,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
5,000
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
75,000
0
0
0
0
15,000
15,000
45,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
40,000
0
0
40,000
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
26
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
26
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
26
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
1,490,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
1,490,000
1,490,000
NO.
UNIT LAYANAN
TARIF
26
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
27
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
200,000
8,000
15
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,295,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
10
345,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
JKN
750,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
6
2
5
10,000
5,000
27
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
27
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
1,191,00

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
1
1
4
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
27
n
1
1
2
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
27
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
27
n
100,000
250,000
150,000
50,000
100,000
50,000
2,486,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
27
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
27
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
200,000
8,000
120,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,295,000
7,500
8,000
8,000
0
80,000
0
80,000
345,000
345,000
NO.
UNIT LAYANAN
0
30,000
40,000
125,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
150,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
750,000
750,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
27
1
2
3
4
5
1.
TARIF
JKN
750,000
0
750,000
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
27
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
1,191,000

1.
5,000
956,000
656,000
370,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
10,000
0
i)
7,000
j)
7,000
k)
45,000
360,000
50,000
0
230,000
0
0
0
0
15,000
15,000
60,000
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
30,000
80,000
30,000
56,000
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
56,000
0
0
0
11,000
0
urine rutin
15,000
30,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
15,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
300,000
0
20,000
40,000
280,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
27
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
27
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
235,000
100,000
100,000
5,000
35,000
125,000
100,000
0
100,000
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
27
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,486,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,486,000
2,486,000
NO.
UNIT LAYANAN
TARIF
27
Rp
10,348,000

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
28
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
112,000
8,000
14
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,552,00
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
515,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
1,925,00
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
JKN
31
3
12
10,000
5,000
28
10,000
1
2
3
4
5
1.
TARIF
7
5
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
28
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
755,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
28
n
1
2
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
28
n
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
28
n
100,000
250,000
150,000
50,000
100,000
50,000
3,307,00

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
28
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
28
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
112,000
8,000
112,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2,552,000
7,500
8,000
8,000
0
0
0
515,000
515,000
NO.
UNIT LAYANAN
0
155,000
60,000
300,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
1,925,000
1,925,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
28
1
2
3
4
5
1.
TARIF
JKN
1,925,000
0
1,050,000
875,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
28
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
755,000

1.
5,000
605,000
365,000
195,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
15,000
0
i)
7,000
j)
7,000
k)
45,000
180,000
50,000
0
170,000
0
0
0
0
0
0
30,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
80,000
30,000
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
240,000
0
0
40,000
240,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
28
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
28
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
150,000
0
150,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
28
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
3,307,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
3,307,000
3,307,000
NO.
UNIT LAYANAN
TARIF
28
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
29
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
355,500
8,000
16
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,590,50
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
25
310,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
15,000
20,000
15,000
10,000
12,000
100,000
15,000
Aster
Anyelir
Azalea
Amarylis
925,000
120,000
150,000
175,000
250,000

kunjungan
1
2
40,000
50,000
LAYANAN RAWAT INAP
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
JKN
15
3
7
10,000
5,000
29
10,000
1
2
3
4
5
1.
TARIF
5
1
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
29
0

1
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
415,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
29
n
2
3
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
29
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
29
n
100,000
250,000
150,000
50,000
100,000
50,000
2,005,50

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
29
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
29
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
355,500
8,000
128,000
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
27,500
25,000
40,000
20,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
1,590,500
7,500
8,000
8,000
7,500
200,000
0
200,000
310,000
310,000
NO.
UNIT LAYANAN
0
75,000
60,000
175,000
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
925,000
925,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
29
1
2
3
4
5
1.
TARIF
JKN
925,000
0
750,000
175,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
29
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
415,000

1.
5,000
415,000
295,000
45,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
45,000
50,000
0
250,000
0
0
0
0
0
0
15,000
0
0
30,000
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
160,000
45,000
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
120,000
0
0
40,000
120,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
29
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
29
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
29
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
2,005,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
2,005,500
2,005,500
NO.
UNIT LAYANAN
TARIF
29
Rp
5,312,500

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
30
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
30
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
600,000
750,000
1,000,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
30
0

1
TARIF
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
30
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
30
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
30
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
30
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
30
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
30
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
30
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
30
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
30
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
30
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
30
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
31
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
0
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
50,000
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
200,000
30 Nebulisasi
3,000
40,000
LAYANAN RAWAT INAP
10,000
JKN
5,000
31
10,000
1
2
3
4
5
1.
TARIF
0
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000
0

1.
n
0

PONED
b.
31

1
TARIF
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
31
n
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
31
n
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
31
n
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
31
n

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
31
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
0
0
0
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
0
0
0
0
0
0
NO.
UNIT LAYANAN
0
0
0
0
0
0
10,000
7
8

30,000
20,000
0
0
5,000
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
0
0
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
31
1
2
3
4
5
1.
TARIF
JKN
0
0
0
0
0
0
50,000
10,000
100,000
0
0
100,000
NO.
5
UNIT LAYANAN
31
Rp

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
0
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
0
0
0
0
0
0
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
0
0
0
0

1.
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
0
0
i)
7,000
j)
7,000
k)
45,000
50,000
0
0
0
0
0
0
0
0
0
0
0
0
a.
1)
Hematologi
a) Hematokrit
2)
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
TARIF
0
0
0
0
0
0
0
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
0
0
0
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
0
40,000
VDRL
18,000
b)
c)
9,000
4)
b.
c.
d.
Rp
20,000
20,000
30,000
80,000
15,000
3)
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
31
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
31
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100,000
5,000
125,000
100,000
0
0
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
0
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
31
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
0
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

0
0
0
NO.
UNIT LAYANAN
TARIF
31
Rp
Mengetahu
Kepala UPTD Puskes
dr. Hj.Nia Sonia

NIP. 197204172003

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
JUM
TARIF
kasus
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
335
0
5,000
10,000
21
0
21
100,000
20,000
50,000
20,000
5,000
0
0
0
0
25,000
40,000
20,000
20,000
25,000
30,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
7,500
8,000
8,000
13
0
97
25
20
NO.
UNIT LAYANAN
295
45
123
2
3
10,000
7
8

30,000
20,000
2
7
5,000
54
20,000
50,000
0
0
25,000
25,000
25,000
50,000
100,000
200,000
10,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
12
120,000
150,000
175,000
250,000
0
1
77
38
0

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis

kunjungan
1
2
17
5,000
20,000
25,000
30,000
20,000
kasus
Suntikan
Pemasangan infus
Visite
10,000
JUM
1
2
3
4
5
1.
TARIF
JKN
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
kasus
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
JUM
18

1
TARIF
16
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
3
2
3
0
0
1
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000
0
0
2
5
0

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
0
0
0
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
35
0
i)
7,000
j)
7,000
k)
45,000
84
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
0
0
0
0
5
5
68
0
0
38
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
NO.
UNIT LAYANAN
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
0
0
0
2
10
0
urine rutin
15,000
(7). Tes kehamilan

4)
Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
0
0
11
40,000
99
VDRL
18,000
c)
d.
kasus
0
0
2
15
24
0
0
b)
c.
JUM
20,000
20,000
30,000
80,000
15,000
3)
b.
TARIF
9,000
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
JUM
kasus
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
100,000
5,000
28
125,000
100,000
0
4
0
0

a.
Tabung besar
b.
Tabung kecil
200
75,000
0
0
6
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
100,000
250,000
150,000
50,000
100,000
50,000
JUM
kasus
0
0
0
0
0
0
0

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
10,000
8,000
6,000
5,000
0
0
0
0
250,000

a.
b.
0
0
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000
a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II

0
0
0
NO.
UNIT LAYANAN
TARIF
JUM
kasus
Mengetahui
Kepala UPTD Puskesmas Cilawu
dr. Hj.Nia Soniawaty

NIP. 197204172003122005
38,541,667
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
JUMLAH
TARIF
Rp
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
8,000
2,680,000
50,000
5,000
10,000
210,000
0
210,000
100,000
20,000
50,000
20,000
5,000
0
0
0
0
487,500
25,000
40,000
20,000
20,000
140,000
25,000
100,000
30,000
150,000
75,000
100,000

Permukaan
Alveolectomy
75,000
100,000
100,000
100,000
15,000
0
0
0
0
30,000
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
31,656,500
4,513,500
7,500
8,000
8,000
97,500
1,136,000
776,000
200,000
160,000
6,883,000
NO.
UNIT LAYANAN
170,000
1,475,000
900,000
3,075,000
60,000
60,000
10,000
10,000
7
8

30,000
20,000
60,000
140,000
5,000
270,000
20,000
50,000
0
0
25,000
25,000
50,000
25,000
50,000
100,000
200,000
10,000
10,000
3,000
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
0
0
0
0
0
0
0
40,000
30 Nebulisasi
50,000
600,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
18,320,000
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
20,000
25,000
30,000
20,000
Rp
Suntikan
Pemasangan infus
Visite
JUMLAH
1
2
3
4
5
1.
TARIF
JKN
18,320,000
120,000
11,550,000
6,650,000
0
0
50,000
10,000
100,000
0
0
0
100,000
NO.
5
UNIT LAYANAN
a

PONED
b.
Rp
1,200,000
600,000
1,200,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
740,000
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
300,000
200,000
60,000
0
0
15,000
0
0
0
75,000
200,000
300,000
20,000
25,000
100,000

1.
JUMLAH
1,940,000

1
TARIF
a.
1)
Hematologi
a) Hematokrit
2)
0
0
40,000
125,000
0
13,739,000
5,000
12,289,000
8,109,000
3,955,000
0
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
0
0
0
0
175,000
0
i)
7,000
j)
7,000
k)
45,000
3,780,000
50,000
0
3,935,000
0
0
0
0
75,000
75,000
1,020,000
0
0
1,140,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
5,500
5,500
7,000
5,500
5,500
0
0
0
0
219,000
0
0
14,000
55,000
0
urine rutin
15,000
105,000
(7). Tes kehamilan

4)
Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
12,000
12,000
95,000
45,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
0
0
0
0
0
0
0
0
4,180,000
0
220,000
40,000
3,960,000
VDRL
18,000
c)
d.
Rp
0
0
60,000
1,200,000
365,000
219,000
0
b)
c.
JUMLAH
20,000
20,000
30,000
80,000
15,000
3)
b.
TARIF
9,000
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak
JUMLAH
Rp
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
60,000
0
0
0
0
0
0
940,000
100,000
400,000
5,000
140,000
125,000
100,000
0
400,000
0
a.
Tabung besar
b.
Tabung kecil
200
75,000
450,000
0
450,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
JUMLAH
Rp
0
0
0
0
0
0
0
100,000
250,000
150,000
50,000
100,000
50,000
45,395,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
D4 / S1
D3
SMA
0
0
0
0
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
100,000
0
0
0
0
0
0
2)
100,000
a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
0
0
0
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000
0
0
0
0
0
0
0
0
0
0
0
0

I
II
10,000
8,000
6,000
5,000

a.
b.

45,395,500
0
45,395,500
NO.
UNIT LAYANAN
TARIF
JUMLAH
Kepala UPTD Puskesmas Cilawu
Rp

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
TARIF
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
JKN
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
100,000
250,000
150,000
50,000
100,000
50,000

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
Cilawu,
Bendahara Pener
NIP. 19

BULAN
SEPTEMBER
NO.
UNIT LAYANAN
2016
TARIF
KETERANGA
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
50,000
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
8,000
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
4,513,500
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
10,000
1
2
3
4
5
1.
TARIF
JKN
50,000
10,000
100,000
100,000
KETERANGA
6,883,000
NO.
5
UNIT LAYANAN
KETERANGA

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
KETERANGA
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
KETERANGA
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
KETERANGA
100,000
250,000
150,000
50,000
100,000
50,000
45,395,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
Cilawu,KETERANGA
30 Septem
Bendahara Penerimaan Pem
Dedi, SKM
NIP. 19681022199
BERDASARKAN PERBUB NO. 1172 TAHUN 2016)
BULAN
SEPTEMBER
NO.
UNIT LAYANAN
PELAYANAN KESEHATAN
A
Pelayanan medis
LAYANAN RAWAT JALAN

a
b
c

luar
2 Melamar Pekerjaan
7 Test Buta Warna
TARIF
KETERANGAN
4,513,500
8,000
50,000
5,000
10,000
100,000
20,000
50,000
20,000
5,000

1
25,000
40,000
20,000
20,000
25,000
30,000
75,000

Permukaan
Alveolectomy
10
11
12
13
Sonic Scaler)
15 Pramedikasi
Pendapatan Pustu
a.
Pustu Genteng
b.
Pustu Mangkurayat
c.
Pustu Sukahati
2
2016
100,000
75,000
100,000
100,000
100,000
15,000
30,000
7,500
8,000
8,000
NO.
UNIT LAYANAN
Suntikan
Pemasangan infus
Visite
5,000
20,000
25,000
30,000
20,000
10,000
7
8

30,000
20,000
20,000
50,000
25,000
25,000
25,000
50,000
100,000
200,000

22
23
24
25
26
27
28
Bilas lambung
Lavement
Memandikan bayi
Memandikan anak
Memandikan dewasa
Tampon hidung
3,000
200,000
40,000
15,000
20,000
15,000
10,000
12,000
100,000
15,000
40,000
30 Nebulisasi
50,000
LAYANAN RAWAT INAP
LAYANAN RAWAT INAP

Umum
a.
Ruang
b.
Ruang
c.
Ruang
b.
Ruang
Aster
Anyelir
Azalea
Amarylis
120,000
150,000
175,000
250,000

kunjungan
1
2
10,000
5,000
KETERANGAN
6,883,000
10,000
1
2
3
4
5
1.
TARIF
JKN
50,000
10,000
100,000
100,000
NO.
5
UNIT LAYANAN
KETERANGAN

a

1
2

PONED
b.
600,000
750,000
1,000,000
Tindakan Kebidanan
a
b.
c.
d
e
f
g
h
i
Pemasangan IUD
Pencabutan IUD
Kontrol IUD
Pemasangan implant
Pencabutan implant
Pijat Bayi
Plasenta manual

Tindik telinga
Inkubator/hari
l
m
n
o
B
TARIF
100,000
100,000
20,000
100,000
100,000
15,000
15,000
15,000
175,000
75,000
200,000
300,000
20,000
25,000
100,000

1.
a.
1)
Hematologi
a) Hematokrit
2)
5,000
b)
5,000
c)
d)
e)
f)
g)
h)

Jumlah eritrosit
Laju endap darah
Hemoglobin
Retraksi bekuan
5,000
5,000
5,000
5,000
5,000
8,000
i)
7,000
j)
7,000
k)
45,000
l)
Kimia Klinik
a) Albumin
b) Gamma GT
c)
Phosphatase alkali
d) Protein total
e)
SGOT
f)
SGPT
g) Asam urat
h) Kreatinin
i)
Ureum
j)
Kolestrol total
50,000
16,500
32,000
22,000
12,000
15,000
15,000
15,000
15,000
15,000
30,000
NO.
UNIT LAYANAN
3)
TARIF
KETERANGAN
20,000
k) Kolestrol HDL
l)
Kolestrol LDL
m) Trigliserid
n) Paket lemak
o) Glukosa
Urinalis
a) Makroskopis
b)
c)
20,000
30,000
80,000
15,000
3,500

(3). PH
Mikroskopis
Sedimen
Urine Kimiawi
(1). Keton
(2). Bilirubin
(3). Glukosa
(4). Protein
(5). Urobilinogen
3,500
3,500
9,000
5,500
5,500
7,000
5,500
5,500
urine rutin
15,000
(7). Tes kehamilan

Tinja
b) Darah samar
c)
Sisa pencernaan
d) Telur cacing
e)
Amuba
f)
Tinja rutin
Toksikologi
1)
Amphetamine
2)
THC
3)
Morfin
4)
Benzodiazepin
5)
Metampetamin
6)
Barbiture
7)
Coccain
8)
Mikrobiologi
1)
2)
3)
Mycotek TB
4)
15,000
4)
b.
c.
d.
5)
Mikrofilaria
6)
7)
Jamur permukaan
8)
Coliform
9)
E. Coli
10) Salmonella spp
11) Syphylis
12) Chikungunya
Imunologi
1)
2)
2)
3)
11,000
25,000
11,000
14,500
14,500
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
115,000
12,000
12,000
95,000
11,000
15,500
11,000
9,000
30,000
30,000
60,500
33,000
176,000
10,000
20,000
40,000
VDRL
18,000
NO.
UNIT LAYANAN
2.
3
4
5
6
7
8
9
4)
HBsAg
5)
Anti HCV
6)
Anti HIV
7)
NS1 Dengue
8)
9)
a.
1)
Thorax
2)
Pelvis
3)
Lumbosacral
4)
Abdomen
5)
BNO
6)
Femur
7)
Cruris
b.
Film kecil
1)
Manus
2)
Wrist Joint
3)
Antebrachi
4)
Elbow Joint
5)
Humeri
6)
Shoulder Joint
7)
Clavicula
8)
Scapula
9)
Cranium 2 posisi
10) Thorax Anak
13) Ankle Joint
14) Pedis
c.
Film gigi
Cetak hasil USG
ElektroMedis
a.
b.
Pelayanan Farmasi
a.
TARIF
KETERANGAN
30,000
35,000
55,000
250,000
126,500
52,000
63,000
70,000
70,000
70,000
70,000
70,000
70,000
70,000
75,000
75,000
75,000
75,000
75,000
75,000
70,000
70,000
140,000
70,000
70,000
140,000
75,000
75,000
25,000
50,000
25,000
60,000
150,000
60,000
10,000

a.

km
b.
c.
d.

e.
Bahan Bakar Minyak

a.
Tabung besar
b.
Tabung kecil
100,000
5,000
125,000
100,000
200
75,000
NO.
UNIT LAYANAN
a.
Operasional Ambulan
b.
Jasa Medis / Dokter
c.
Jasa Perawat
d.
Jasa Pengemudi
e.
Obat-obatan
f.
Bahan Bakar Minyak
TARIF
KETERANGAN
100,000
250,000
150,000
50,000
100,000
50,000
45,395,500

a

1

org/hr)
a.

1)
2)
3)
4)
b.
2
250,000
1)
S3
2)
3)
D4 / S1
4)
D3
studi banding
1)
250,000
150,000
75,000
50,000
2)
100,000
100,000

a.
b.
c.
Apotek
Toko obat
150,000
100,000
100,000
d.
250,000
150,000
f.
g
h
i
j
k
l
m
n
o
p
q

Laboratorium klinik
Praktek dokter umum
Praktek dokter gigi
Praktek bidan
Praktek perawat
Praktek fisioterapi
Toko optical
Toko kacamata
400,000
150,000
100,000
100,000
150,000
100,000
100,000
100,000
100,000
150,000
100,000
75,000

I
II
10,000
8,000
6,000
5,000

a.
b.
D4 / S1
D3
SMA

NO.
UNIT LAYANAN
TARIF
Cilawu,KETERANGAN
30 September 2016
Bendahara Penerimaan Pembantu
Dedi, SKM
NIP. 196810221991011001
PEMERINTAH
BUKU PENERIMA
BENDAHARA
UPTD
PUSKESMAS CILAWU
Periode
SEPTEMBER
2016
Tanggal 01 s.d. 30 September 2016

PENERIMAAN
No
Tanggal
No. Bukti
Cara Pembayaran
Kode rekening
9/1/2016
001
Tunai
51100
9/2/2016
002
Tunai
51100
9/3/2016
003
Tunai
51100
9/4/2016
004
Tunai
51100
9/5/2016
005
Tunai
51100
9/6/2016
006
Tunai
51100
8/7/2016
006
Tunai
51100
9/8/2016
007
Tunai
51100
9/9/2016
008
Tunai
51100
10
9/10/2016
009
Tunai
51100
11
9/11/2016
010
Tunai
51100
12
9/12/2016
011
Tunai
51100
13
9/13/2016
012
Tunai
51100
12
8/14/2016
012
Tunai
51100
14
9/15/2016
013
Tunai
51100
15
9/15/2016
11220
16
9/15/2016
11220
17
9/16/2016
014
Tunai
51100
17
8/17/2016
015
Tunai
51100
18
9/18/2016
015
Tunai
51100
19
9/19/2016
016
Tunai
51100
20
9/20/2016
017
Tunai
51100
20
8/21/2016
018
Tunai
51100
21
9/22/2016
018
Tunai
51100
22
23/098/2016
019
Tunai
51100
23
9/24/2016
020
Tunai
51100
24
9/25/2016
021
Tunai
51100
25
9/26/2016
022
Tunai
51100
27
9/27/2016
023
Tunai
51100
26
8/28/2016
024
Tunai
51100
28
9/29/2016
024
Tunai
51100
29
9/30/2016
025
Tunai
51100
30
31/09/2016
026
Tunai
51100
31
31/09/2016
54200
32
31/09/2016
11210
1
1
Jumlah Penerimaan bulan ini

- Jumlah Saldo bawa bulan Agustus 2016
- Jumlah Penerimaan BLUD bulan ini
- Jumlah Penerimaan JKN bulan ini
46,095,500
700,000
#REF!
0
- Jumlah Penerimaan klim persalinan bulan januari 2016
#REF!
- Jumlah Penerimaan jasa giro JKN bulan ini
- Jumlah Penerimaan jasa giro BLUD bulan ini
Jumlah yang disetorkan
30,435,000
Saldo Kas di Bendahara Penerimaan

Terdiri atas :
a. Tunai sebesar
#REF!
b. Bank sebesar
c. Lainnya
Mengetahui/menyetujui:
Kuasa Pengguna Anggaran
dr. Hj. Nia Soniawaty

NIP. 197204172003122005
PEMERINTAH KABUPATEN GARUT

BUKU PENERIMAAN DAN PENYETORAN
BENDAHARA PENERIMAAN BLUD
PENERIMAAN
PENYETORAN
Uraian
Jumlah Rp
Tanggal
Saldo bawa bulan Agustus 2016
700,000
Terima uang pendapatan layanan umum
3,747,000
1,304,000
1,681,000
2,631,000
2,018,000
2,641,500
1,413,500
2,204,500
217,500
1,903,500
3,374,500
974,500
Terima uang kapitasi susulan bulan Agustus 2016

Terima uang Kapitasi JKN Bulan September 2016
2,266,500
1,086,000
1,294,000
978,000
2,494,000
1,146,500
361,500
2,370,000
1,490,000
2,486,000
3,307,000
2,005,500
Jasa giro BLUD

Jas giro JKN
46,095,500
Cilawu, 30 September 2016

Dedi, SKM
NIP.19681022 199101 1 001
PENYETORAN
No. STS
Jumlah Rp
10
52
700,000
53
14,022,500
54
9,113,500
55
6,599,000
56
57
238000
163952500
7195000
2258455
173643955
11,996,500
24,110,500
36,107,000
30,435,000
#REF!
0
#REF!
#REF!
#REF!

Dedi, SKM
NIP.19681022 199101 1 001
1-30 juni
jasa
jml
tgl 30
jml
PEMERINTAH PROVIN
RE
UPTD PU
BULAN
AGUSTUS 2016
Bendahara Penerimaan UPTD Puskesmas Cilawu
NO NO. STS
TANGGAL
KODE REKENING
52
12/30/1899
51100
53
12/30/1899
51100
54
12/30/1899
51100
55
12/30/1899
51100
56
12/30/1899
51100
57
12/30/1899
51100
JUMLAH
Mengetahui /menyetujui:

NIP. 197204172003122005
PEMERINTAH PROVINSI / KABUPATEN / KOTA GARUT

REGISTER STS
esmas Cilawu
URAIAN
JUMLAH
PENYETOR
Disetorkan uang pendapatan layanan umum
700,000
Dedi SKM
14,022,500
Dedi SKM
9,113,500
Dedi SKM
6,599,000
Dedi SKM
Dedi SKM
Dedi SKM
30,435,000
Bendahara Penerimaan Pemb
Dedi, SKM
NIP.19681022 199101 1 00
OTA GARUT
KETERANGAN
saldo bawa bulan Agustus 2016

Dedi, SKM
NIP.19681022 199101 1 001
PEMERINTAH KABU
DINAS KESE
UPTD PUSKESM
LAPORAN PENDAPATAN BLUD UPTD PUSKESMAS CILAWU
BULAN
NO
1
2
3
4
5
AGUSTUS
2016
ANGGARAN DALAM DPA
URAIAN
Pendapatan BLUD
JASA LAYANAN
a. Umum
b.Kapitasi JKN
c. Non Kapitasi JKN
HIBAH
HASIL KERJASAMA
PENDAPATAN LAIN YANG SAH
a. Jasa giro JKN
b. Jas giro BLUD
JUMLAH
Mengetahui/menyetujui:

NIP. 197204172003122005

DINAS KESEHATAN
SKESMAS CILAWU
REALISASI S/D BULAN LALU REALISASI BULAN INI
339,032,000
1,145,048,500
75,195,000 Err:509
0
0
0
10,757,143
626,597
1,570,659,240
45,395,500
0
REALISASI S/D BULAN INI
0
0
0
0
0
384,427,500
1,145,048,500
Err:509
0
0
0
10,757,143
626,597
Err:509
Err:509
Cilawu ,30 September 2016
Dedi, SKM
NIP.19681022 199101 1 001
LEBIH (KURANG)
296500
163,192,000
Err:509
Cilawu ,30 September 2016
DINAS KESEHATAN KABUPATEN GARUT

UPTD PUSKESMAS CILAWU KECAMATAN CILAWU
Jl. Raya Garut-Tasik Km 08 Kec. Cilawu Kab. Garut ' (0262) 238677
email ; puskesmascilawudtp@gmail.com
LAPORAN PERTANGGUNGJAWABAN ADMINISTRATIF

Unit Kerja
Periode
A.
Penerimaan
1.
Tunai melalui bendahara penerimaan
2.
Tunai melalui bendahara penerimaan pembantu
Saldo bawa bulan Juli 2016
3.
Melalui
Melalui
Melalui
Melalui
Melalui
Melalui
ke
ke
ke
ke
ke
ke
rekening
rekening
rekening
rekening
rekening
rekening
Rp.
Rp.
Rp.
0
#REF!
700,000
bendahara penerimaan
( Non Kapitasi JKN)
( Kapitasi JKN)
( jasa giro BLUD )
( jasa giro JKN )
kas umum daerah
Rp.
Rp.
Rp.
Rp.
0
0
0
0
Jumlah penerimaan yang harus disetorkan (A1+A2)

Jumlah penyetoran
Saldo kas di bendahara
1.
Bendahara penerimaan
2.
Bendahara penerimaan pembantu
Rp.
Rp.
#REF!
4.
B.
C.
D.
: Puskesmas Cilawu
: Bulan Agustus 2016
Menyetujui

NIP. 197204172003122005
Err:509

Bendahara Penerimaan
Dedi ,SKM
NIP. 196810221991011001
DINAS KESEHATAN KABUPATEN GARUT

UPTD PUSKESMAS CILAWU KECAMATAN CILAWU
Jl. Raya Garut-Tasik Km 08 Kec. Cilawu Kab. Garut ' (0262) 238677
email ; puskesmascilawudtp@gmail.com
LAPORAN PERTANGGUNGJAWABAN ADMINISTRATIF

Unit Kerja
Periode
: Puskesmas Cilawu
: Bulan Mei 2016
Tanggal 1 s.d 30 Mei 2016
A.
B.
C.
D.
Penerimaan
1.
Tunai melalui bendahara penerimaan
2.
Tunai melalui bendahara penerimaan pembantu
Saldo bawa bulan April 2016
3.
Melalui ke rekening bendahara penerimaan
4.
Melalui ke rekening kas umum daerah
Jumlah penerimaan yang harus disetorkan (A1+A2+A3)
Jumlah penyetoran
Saldo kas di bendahara
1.
Bendahara penerimaan
2.
Bendahara penerimaan pembantu
Menyetujui
Pengguna Anggaran

NIP. 197204172003122005
Rp.
Rp.
0
36,026,500
2,986,000
Rp.
Rp.
Rp.
Rp.
Cilawu, 30 Mei 2016

Bendahara Penerimaan
Dedi ,SKM
NIP. 196810221991011001
AWU
38677
RATIF
Rp.
45,395,500
Rp.
Rp.
Rp.
Rp.
#REF!
30,435,000
, 30 September 2016
hara Penerimaan
edi ,SKM
6810221991011001
AWU
38677
RATIF
Rp.
39,012,500
Rp.
Rp.
Rp.
39,012,500
39,012,500
, 30 Mei 2016
hara Penerimaan
edi ,SKM
6810221991011001

SURAT TANDA SETOTAN
(STS)
STS No : 52
Bulan
: Agustus
2016
Dari tanggal
: 01 s.d 07 Agustus 2016
Harap diterima uang sebesar :
(dengan huruf)
Nama Rek
Bank
No. Rekening
Rp
: Rekening Giro BLUD

: BJb CAB. GARUT
: 0069.340.504.001
8,368,500
delapan juta tiga ratus enam puluh delapan ribu lima ratus rupia
Dengan rincian penerimaan sebagai berikut :

NO
1.
KODE REKENING
5 1 1 0 0
URAIAN RINCIAN OBJEK
JUMLA
Pendapatan jasa layanan umum Puskesmas Cilawu :

1. Rawat jalan
2. Tindakan medik/ UGD
3. Rawat inap
4. Poned/ Tindakan persalinan
5. Pelayanan Penunjang diagnostik
6. Kesekretariatan (Pely. Data dan informasi)
JUMLAH
Uang tersebut diterima pada tanggal
Mengetahui

NIP. 197204172003122005
Rp
08Agustus 2016
Cilawu,7 Agustu
Bendahara Penerim
Puskesma
Pejabat Pengelola Anggaran
Pimpinan BLUD Puskesmas Cilawu
Rp
Rp
Rp
Rp
Rp
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 53
Bulan
: September
2016
Dari tanggal
: 01 s.d 11 September 2016
(dengan huruf)
Nama Rek
Bank
No. Rekening
Rp

: BJb CAB. GARUT
: 0069.340.504.001
8,307,000
delapan juta tiga ratus tujuh ribu rupiah

NO
1.
KODE REKENING
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui
JUMLA
Rp
Rp
Rp
Rp
Rp
Rp
12 Agustus 2016
Cilawu, 11 Agus
Bendahara Penerim
Puskesma

NIP. 197204172003122005
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 49
Bulan
: September
2016
Dari tanggal
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
5,690,500
lima juta enam ratus sembilan puluh ribu lima ratus rupiah

NO
1.
KODE REKENING
5 1 1 0 0
JUMLA

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui

NIP. 197204172003122005
Rp
Rp
Rp
Rp
Rp
Rp
18 Agustus 2016
Cilawu, 16 Agus
Bendahara Penerim
Puskesma
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 50
Bulan
: September
2016
Dari tanggal
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
8,982,000
delapan juta sembilan ratus delapan puluh dua ribu rupiah

NO
KODE REKENING
JUMLA
1.
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui
24 Agustus 2016
Cilawu, 22 Agus
Bendahara Penerim
Puskesma

NIP. 197204172003122005
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 51
Bulan
: September
2016
Dari tanggal
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
10,778,000
sepuluh juta tujuh ratus tujuh puluh delapan ribu rupiah

NO
1.
KODE REKENING
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
JUMLAH
Uang tersebut diterima pada tanggal 30 Agustus 2016
Mengetahui

NIP. 197204172003122005
JUMLA
Dedi Koesdiana
NIP. 19630429 198903 1 005
Rp
Rp
Rp
Rp
Rp
Rp
Cilawu, 30 Agus
Bendahara Penerim
Puskesma
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 46
Bulan
: Juli
2016
Dari tanggal
: 29 s.d 30 Juli 2016
(dengan huruf)
Nama Rek
Bank
No. Rekening
Rp

: BJb CAB. GARUT
: 0069.340.504.001
5,901,000
#NAME?

NO
1.
KODE REKENING
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui

NIP. 197204172003122005
JUMLA
Rp
Rp
Rp
Rp
Rp
Rp
Rp
28 juni 2016
Dedi Koesdiana
NIP. 19630429 198903 1 005

SURAT TANDA SETOTAN
Cilawu, 24 Juni
Bendahara Penerim
Puskesma
Dedi,
NIP. 19681022
(STS)
STS No : 38
Bulan
: Juni
2016
Dari tanggal
: 25 s.d 29 Juni 2016
(dengan huruf)
Nama Rek
Bank
No. Rekening
Rp

: BJb CAB. GARUT
: 0069.340.504.001
6,621,000
#NAME?

NO
1.
KODE REKENING
5 1 1 0 0
JUMLA

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui

NIP. 197204172003122005
Rp
30 juni 2016
Cilawu, 29 Juni
Bendahara Penerim
Puskesma
Rp
Rp
Rp
Rp
Rp
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 32
Bulan
: Juni
2016
Dari tanggal
: 01 s.d 05 Juni 2016
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
9,867,000
Sembilan juta delapan ratus enam puluh tujuh ribu rupiah

NO
1.
KODE REKENING
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
JUMLAH
Mengetahui
JUMLA
Rp
Rp
Rp
Rp
Rp
Rp
03 Mei 2016
Cilawu, 5 Juni 2
Bendahara Penerim
Puskesma

NIP. 197204172003122005
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 32
Bulan
: Juni
2016
Dari tanggal
: 01 s.d 05 Juni 2016
(dengan huruf)
Nama Rek
Bank
No. Rekening
Rp

: BJb CAB. GARUT
: 0069.340.504.001
9,875,000

NO
1.
KODE REKENING
5 1 1 0 0
JUMLA

1. Rawat jalan
Rp
Rp
Rp
Rp
Rp
3. Rawat inap
6. Kesekretariatan
JUMLAH
Mengetahui
Rp
03 Mei 2016
Cilawu, 5 Juni 2
Bendahara Penerim
Puskesma

NIP. 197204172003122005
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 32
Bulan
: Juni
2016
Dari tanggal
: 01 s.d 05 Juni 2016
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
5,542,500

NO
1.
KODE REKENING
5 1 1 0 0
JUMLA

1. Rawat jalan
3. Rawat inap
6. Kesekretariatan
Rp
Rp
Rp
Rp
Rp
JUMLAH
Mengetahui
Rp
03 Mei 2016
Cilawu, 5 Juni 2
Bendahara Penerim
Puskesma

NIP. 197204172003122005
Dedi Koesdiana
NIP. 19630429 198903 1 005
Dedi,
NIP. 19681022

SURAT TANDA SETOTAN
(STS)
STS No : 32
Bulan
: Juni
2016
Dari tanggal
: 01 s.d 05 Juni 2016
(dengan huruf)
Rp
Nama Rek
Bank
No. Rekening

: BJb CAB. GARUT
: 0069.340.504.001
4,957,500

NO
1.
KODE REKENING
5 1 1 0 0

1. Rawat jalan
3. Rawat inap
6. Kesekretariatan
JUMLAH
Mengetahui

NIP. 197204172003122005
JUMLA
Rp
Rp
Rp
Rp
Rp
03 Mei 2016
Dedi Koesdiana
NIP. 19630429 198903 1 005
Cilawu, 5 Juni 2
Bendahara Penerim
Puskesma
Dedi,
NIP. 19681022
o BLUD Puskesmas Cilawu

RUT
4.001
s rupiah
JUMLAH
795,500
1,375,000
3,590,000
2,608,000
286
205
875
106
125
195
800
485
1851
515
621
320.5
1440.5
88
300
525
20
485
1418
605
700
2200
20
1805.5
5330.5
8,368,500
Agustus 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
958,500
1,430,000
3,110,000
2,808,500
8,307,000
1 Agustus 2016
enerimaan Pembantu
300
65
300
460
135
245
450
20
465
147
355
1050
600
610
582
665
1800
620
1535
5202
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
911,000
1,103,000
1,625,000
2,051,500
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
136
465
1325
108
345
185
300
471
175
640.5
809
815
2125
20
1806.5
1470.5
5575.5
5575.5
5,690,500
6 Agustus 2016
enerimaan Pembantu
kesmas Cilawu
220
165
500
20
520
1425
2397
283
1,006,500
1,430,000
4,275,000
2,270,500
8,982,000
2 Agustus 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
1,522,000
1,420,000
4,125,000
775,000
2,936,000
10,778,000
0 Agustus 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001
178
209
525
134
210
525
186
310
450
410
210.5
655
75
498
729
1500
0
1275.5
75
4077.5

RUT
4.001
JUMLAH
366,000
765,000
2,625,000
1,820,000
325,000
5,901,000
4 Juni 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001
101
70
93
64
300
1050
460
370
345
631
463
1759
108
395
1575
0
645
325
3048
366
765
2625
0
1820
325
5901
5901

RUT
4.001
JUMLAH
860,000
1,205,000
3,275,000
25,000
1,256,000
6,621,000
9 Juni 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
7,672,000
325,000
1,175,000
695,000
9,867,000
Juni 2016
enerimaan Pembantu
kesmas Cilawu
48
375
875
440
130
300
191
305
1050
155
1453
500.5
1370.5
410.5
1956.5
181
395
1050
25
190
1841
860
1205
3275
25
1256
6621
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
2,160,000
570,000
1,250,000
25,000
5,870,000
9,875,000
Juni 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
860,000
810,000
1,800,000
20,000
2,052,500
5,542,500
Juni 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001

RUT
4.001
JUMLAH
1,316,000
520,000
1,675,000
1,446,500
4,957,500
Juni 2016
enerimaan Pembantu
kesmas Cilawu
Dedi, SKM
81022 199101 1 001
1806.5
aceng
rina
nanang
iing
5/17/2016
5/20/2016
5/21/2016
7/19/2016
7/20/2016
7/21/2016
8/16/2016
168,000
180,000
88,000
128,000
564,000
?
182,000
80,000
64,000

September 2016

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TANDA BUKTI PENDAPATAN KEUANGAN UPTD PUSKESMAS CILAWU

(BERDASARKAN PERBUB NO. 1172 TAHUN 2016)

LAYANAN RAWAT JALAN

Pemeriksaan visum et repertum pro justica untuk pemeriksaan

Klinik Gigi dan mulut

Penambalan Sementara untuk 1 gigi

Penambalan Permanen untuk 1 gigi

Perawatan saraf gigi (endodontic) setiap 1 (satu) gigi

Pencabutan untuk setiap 1 (satu) gigi anak dengan anestesi topikal

Pencabutan untuk setiap 1 (satu) gigi anak dengan anestesi injeksi

Pencabutan untuk setiap 1 (satu) gigi dewasa tanpa penyulit

Pencabutan untuk setiap 1 (satu) gigi dewasa dengan penyulit

Pencabutan untuk setiap gigi M3 (ondotectomy)

Tumpatan Tetap dengan Resin Komposit Light Curing (LC) Satu

Perawatan luka ringan

Perawatan luka berat

Jahitan luka lebih dari 3 (tiga) per jahit di tambah

12 Ekstraksi Corpus Alienum Mata tanpa Komplikasi

13 Ekstraksi Cerumen Prop Telinga (1 telinga)

14 Ekstraksi Corpus Alienum Telinga (1 telinga)

15 Pengangkatan massa (ekstripasi) dengan ukuran < 2cm

16 Pengangkatan massa (ekstripasi) dengan ukuran 2cm s.d 5 cm

17 Pengangkatan massa (ekstripasi) dengan ukuran > 5 cm

20 Khitan (sirkumsisi) metode gunting atau cauter

Pelayanan perawatan rumah(Home Care) tidak termasuk obat, BMPH,

LAYANAN RAWAT INAP

LAYANAN RAWAT INAP

29 Pembidaian (pasangan spalk)

19 Buka jahitan lebih dari 3 (tiga) perjahitan di tambah

18 Buka jahitan sampai dengan 3 (tiga)

Persalinan normal (fisiologis)

oleh bidan di Puskesmas / PONED

Persalinan normal (fisiologis) oleh dokter di Puskesmas / PONED

3 Persalinan tidak normal (patologis) oleh dokter di Puskesmas /

Eksplorasi Sisa Plasenta

Kompresi Bimanual Internal / Eksternal

Pertolongan persalinan dg tindakan obat dah bahan habis pakai ( tidak

PELAYANAN PENUNJANG MEDIS

Leukosit (hitung jumlah)

Trombosit (hitung jumlah)

Waktu pendarahan (BT)

Waktu pembekuan (CT)

Paket Hematologi rutin

(1). Warna / kejernihan

(2). Berat Jenis (BJ)

(6). Paket pemeriksaan

(7). Tes kehamilan

Widal (thypi H, thypi O, dan parathypi AH, AO)

Penggunaan ambulance puskesmas (belum termasuk pembelian bahan

Pengangkutan pasien / Jenazah umum dengan jarak tempuh s/d 10

Jarak tempuh lebih dari 10 km di tambah per km

Pendamping tenaga dokter

Bahan Bakar Minyak

10 Pemakaian Oksigen / tabung

Jumlah Pendapatan Pelayanan

NON PELAYANAN KESEHATAN

Pelayanan data dan informasi

Pendidikan, pendampingan dan bimbingan praktek kerja lapangan (per

Bimbingan praktek kerja lapangan ( per org/hr )

Pendampingan dan bimbingan magang kerja (orang/bulan)

Sarana Prasarana (per orang/hari)

Pemeriksaan sarana pelayanan kesehatan swasta

Klinik pratama rawat jalan dan rawat inap