RSU MUHAMMADIYAH SURYA MELATI

TARIF TINDAKAN OPERATIF SPESIALIS BEDAH UMUM

SEWA
NO JENIS TINDAKAN KLAS SEWA OK BAHAN OPERATOR
ALAT

1 OPERASI KHUSUS
1 a.1 Elektif / Biasa VIP 200,000 250,000 100,000 3,600,000
1 a.2 Cito / Darurat 200,000 250,000 100,000 3,960,000
1 b.1 Elektif / Biasa I 200,000 250,000 100,000 3,300,000
1 b.2 Cito / Darurat 200,000 250,000 100,000 3,600,000
1 c.1 Elektif / Biasa II / III 200,000 250,000 100,000 3,000,000
1 c.2 Cito / Darurat 200,000 250,000 100,000 3,300,000

2 OPERASI BESAR
2 a.1 Elektif / Biasa VIP 175,000 200,000 100,000 3,300,000
2 a.2 Cito / Darurat 175,000 200,000 100,000 3,600,000
2 b.1 Elektif / Biasa I 175,000 200,000 100,000 3,000,000
2 b.2 Cito / Darurat 175,000 200,000 100,000 3,300,000
2 c.1 Elektif / Biasa II / III 175,000 200,000 100,000 2,400,000
2 c.2 Cito / Darurat 175,000 200,000 100,000 2,760,000

3 OPERASI SEDANG
3 a.1 Elektif / Biasa VIP 175,000 200,000 100,000 2,645,000
3 a.2 Cito / Darurat 175,000 200,000 100,000 2,875,000
3 b.1 Elektif / Biasa I 175,000 200,000 100,000 2,300,000
3 b.2 Cito / Darurat 175,000 200,000 100,000 2,645,000
3 c.1 Elektif / Biasa II / III 175,000 200,000 100,000 1,725,000
3 c.2 Cito / Darurat 175,000 200,000 100,000 2,070,000

4 OPERASI KECIL
4 a.1 Elektif / Biasa VIP 100,000 100,000 25,000 1,100,000
4 a.2 Cito / Darurat 100,000 100,000 25,000 1,650,000
4 b.1 Elektif / Biasa I 100,000 100,000 25,000 825,000
4 b.2 Cito / Darurat 100,000 100,000 25,000 935,000
4 c.1 Elektif / Biasa II / III 100,000 100,000 25,000 550,000
4 c.2 Cito / Darurat 100,000 100,000 25,000 715,000

RSU MUHAMMADIYAH SURYA MELATI

TARIF TINDAKAN OPERATIF SPESIALIS BEDAH UMUM

SEWA
NO JENIS TINDAKAN KLAS SEWA OK BAHAN OPERATOR
NO JENIS TINDAKAN KLAS SEWA OK BAHAN OPERATOR
ALAT

1 OPERASI KHUSUS
1 a.1 Elektif / Biasa VIP 200,000 250,000 100,000 2,160,000
1 a.2 Cito / Darurat 200,000 250,000 100,000 2,376,000
1 b.1 Elektif / Biasa I 200,000 250,000 100,000 1,980,000
1 b.2 Cito / Darurat 200,000 250,000 100,000 2,160,000
1 c.1 Elektif / Biasa II / III 200,000 250,000 100,000 1,800,000
1 c.2 Cito / Darurat 200,000 250,000 100,000 1,980,000

2 OPERASI BESAR
2 a.1 Elektif / Biasa VIP 175,000 200,000 100,000 1,980,000
2 a.2 Cito / Darurat 175,000 200,000 100,000 2,160,000
2 b.1 Elektif / Biasa I 175,000 200,000 100,000 1,800,000
2 b.2 Cito / Darurat 175,000 200,000 100,000 1,980,000
2 c.1 Elektif / Biasa II / III 175,000 200,000 100,000 1,440,000
2 c.2 Cito / Darurat 175,000 200,000 100,000 1,656,000

3 OPERASI SEDANG
3 a.1 Elektif / Biasa VIP 175,000 200,000 100,000 1,587,000
3 a.2 Cito / Darurat 175,000 200,000 100,000 1,725,000
3 b.1 Elektif / Biasa I 175,000 200,000 100,000 1,380,000
3 b.2 Cito / Darurat 175,000 200,000 100,000 1,587,000
3 c.1 Elektif / Biasa II / III 175,000 200,000 100,000 1,035,000
3 c.2 Cito / Darurat 175,000 200,000 100,000 1,242,000

4 OPERASI KECIL
4 a.1 Elektif / Biasa VIP 100,000 100,000 25,000 660,000
4 a.2 Cito / Darurat 100,000 100,000 25,000 990,000
4 b.1 Elektif / Biasa I 100,000 100,000 25,000 495,000
4 b.2 Cito / Darurat 100,000 100,000 25,000 561,000
4 c.1 Elektif / Biasa II / III 100,000 100,000 25,000 330,000
4 c.2 Cito / Darurat 100,000 100,000 25,000 429,000
 Pasien Umum

ASISTEN ANASTESI ASISTEN ANASTESI

OPERATOR Datang By Phone Mas Huda Ast Luar

540,000 1,440,000 900,000 410,000 150,000

594,000 1,584,000 990,000 446,000 150,000
495,000 1,320,000 825,000 380,000 150,000
540,000 1,440,000 900,000 410,000 150,000
450,000 1,200,000 750,000 350,000 150,000
495,000 1,320,000 825,000 380,000 150,000

495,000 1,320,000 825,000 380,000 150,000

540,000 1,440,000 900,000 410,000 150,000
450,000 1,200,000 750,000 350,000 150,000
495,000 1,320,000 825,000 380,000 150,000
360,000 960,000 600,000 290,000 150,000
414,000 1,104,000 690,000 326,000 150,000

396,750 1,058,000 661,250 314,500 150,000

431,250 1,150,000 718,750 337,500 150,000
345,000 920,000 575,000 280,000 150,000
396,750 1,058,000 661,250 314,500 150,000
258,750 690,000 431,250 222,500 150,000
310,500 828,000 517,500 257,000 150,000

165,000 440,000 275,000 160,000 100,000

247,500 660,000 412,500 215,000 100,000
123,750 330,000 206,250 132,500 100,000
140,250 374,000 233,750 143,500 100,000
82,500 220,000 137,500 105,000 100,000
107,250 286,000 178,750 121,500 100,000

Pasien BPJS

ASISTEN ANASTESI ASISTEN ANASTESI

OPERATOR
 ASISTEN
OPERATOR Datang By Phone Mas Huda Ast Luar

324,000 864,000 540,000 266,000 150,000

356,400 950,400 594,000 287,600 150,000
297,000 792,000 495,000 248,000 150,000
324,000 864,000 540,000 266,000 150,000
270,000 720,000 450,000 230,000 150,000
297,000 792,000 495,000 248,000 150,000

297,000 792,000 495,000 248,000 150,000

324,000 864,000 540,000 266,000 150,000
270,000 720,000 450,000 230,000 150,000
297,000 792,000 495,000 248,000 150,000
216,000 576,000 360,000 194,000 150,000
248,400 662,400 414,000 215,600 150,000

238,050 634,800 396,750 208,700 150,000

258,750 690,000 431,250 222,500 150,000
207,000 552,000 345,000 188,000 150,000
238,050 634,800 396,750 208,700 150,000
155,250 414,000 258,750 153,500 150,000
186,300 496,800 310,500 174,200 150,000

99,000 264,000 165,000 116,000 100,000

148,500 396,000 247,500 149,000 100,000
74,250 198,000 123,750 99,500 100,000
84,150 224,400 140,250 106,100 100,000
49,500 132,000 82,500 83,000 100,000
64,350 171,600 107,250 92,900 100,000
TARIF TINDAKAN OBSGYN
RSU MUHAMMADIYAH SURYA MELATI

NO NAMA TINDAKAN KLAS SEWA SEWA BAHAN

OK / VK ALAT

1 Pasang IUD Ranap

Rajal
2 Ekstraksi IUD Ranap 75,000 75,000 25,000
Rajal
3 Papsmear Ranap
Rajal
4 Biopsi I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
5 Debridement Luka Operasi I 175,000 100,000 50,000
II 175,000 100,000 50,000
III 175,000 100,000 50,000
Rajal
6 Pasang Pesarium I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
7 Ekstripasi Polip I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
8 Pasang/Angkat Tampon I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
9 Suntik KB/Obat/Vaksin Ranap
Rajal
10 Induksi / Akselerasi Persalinan I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
11 Partus Pervaginam Tanpa Penyulit I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
12 Partus Pervaginam Dengan Penyulit I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
13 Manual Plasenta Post Partum I 75,000 75,000 25,000
II 75,000 75,000 25,000
 III 75,000 75,000 25,000
14 Manual Plasenta Rujukan I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
15 Jahitan Ruptur Perineum Grade 3-4 Post Partum, Robekan Ser I 75,000 75,000 50,000
II 75,000 75,000 50,000
III 75,000 75,000 50,000
16 Kuretase Pasca Persalinan I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
17 Kuretase Abortus I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
18 Sectio Caesaria tanpa penyulit I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
19 Sectio Caesaria dengan penyulit (perlekatan berat, histerograf I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
20 Sectio Caesaria + Histerectomi Obstetri I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
21 Operasi Obstetri Khusus (Plasenta Akreta) I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
Kecil
22 Kista Bartholin/Kista Gartner I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
23 Konisasi I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
24 Ekstraksi IUD dengan Anastesi I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
25 Polip Serviks I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
26 Kauterisasi Kondiloma Akuminata I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
27 Penjahitan Laserasi Ringan I 75,000 75,000 75,000
II 75,000 75,000 75,000
 III 75,000 75,000 75,000
Rajal 25,000
28 Drainase Abses I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
29 Shirodkar I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
Sedang
30 Mioma Geburt I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
31 Robekan Serviks/forniks I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
32 Hematoma/ruptur I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
33 Histeroraf I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
TINDAKAN GINEKOLOGI
Kecil
34 Tubektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
Rajal 50,000
Sedang
35 Kehamilan Ektopik I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
36 Miomektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
37 Kistektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
38 Salpingo - ooforektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
39 Laparatomi Diagnostik I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
40 Ligasi Arteri Hipogastrica / Uterina I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
41 Ekstirpasi Giant Condiloma I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
42 Penyulit + 50% I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
Besar
43 Histerektomi I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
44 Miomektomi I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
45 Reseksi Adenomiosis I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
46 Infeksi Panggul/PUS dengan Perlekatan I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
47 Adhesiolisis Perlekatan Berat Pelvik I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
48 Repair Tuba (Tubaplasti) I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
49 Transposisi Ovarium I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
50 Penyulit + 50% I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000

TARIF TINDAKAN OBSGYN

RSU MUHAMMADIYAH SURYA MELATI

NO NAMA TINDAKAN KLAS SEWA SEWA BAHAN

OK / VK ALAT

1 Pasang IUD Ranap

Rajal
2 Ekstraksi IUD Ranap 75,000 75,000 25,000
Rajal
3 Papsmear Ranap
Rajal
4 Biopsi I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
5 Debridement Luka Operasi I 175,000 100,000 50,000
II 175,000 100,000 50,000
III 175,000 100,000 50,000
Rajal
6 Pasang Pesarium I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
7 Ekstripasi Polip I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
8 Pasang/Angkat Tampon I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
Rajal
9 Suntik KB/Obat/Vaksin Ranap
Rajal
10 Induksi / Akselerasi Persalinan I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
11 Partus Pervaginam Tanpa Penyulit I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
12 Partus Pervaginam Dengan Penyulit I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
13 Manual Plasenta Post Partum I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
14 Manual Plasenta Rujukan I 75,000 75,000 25,000
II 75,000 75,000 25,000
III 75,000 75,000 25,000
15 Jahitan Ruptur Perineum Grade 3-4 Post Partum, Robekan Ser I 75,000 75,000 50,000
II 75,000 75,000 50,000
III 75,000 75,000 50,000
16 Kuretase Pasca Persalinan I 75,000 75,000 75,000
 II 75,000 75,000 75,000
III 75,000 75,000 75,000
17 Kuretase Abortus I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
18 Sectio Caesaria tanpa penyulit I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
19 Sectio Caesaria dengan penyulit (perlekatan berat, histerograf I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
20 Sectio Caesaria + Histerectomi Obstetri I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
21 Operasi Obstetri Khusus (Plasenta Akreta) I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
Kecil
22 Kista Bartholin/Kista Gartner I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
23 Konisasi I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
24 Ekstraksi IUD dengan Anastesi I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
25 Polip Serviks I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
26 Kauterisasi Kondiloma Akuminata I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
27 Penjahitan Laserasi Ringan I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
28 Drainase Abses I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
Rajal 25,000
29 Shirodkar I 75,000 75,000 75,000
II 75,000 75,000 75,000
 III 75,000 75,000 75,000
Rajal 25,000
Sedang
30 Mioma Geburt I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
31 Robekan Serviks/forniks I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
32 Hematoma/ruptur I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
33 Histeroraf I 75,000 75,000 75,000
II 75,000 75,000 75,000
III 75,000 75,000 75,000
TINDAKAN GINEKOLOGI
Kecil
34 Tubektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
Rajal 50,000
Sedang
35 Kehamilan Ektopik I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
36 Miomektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
37 Kistektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
38 Salpingo - ooforektomi I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
39 Laparatomi Diagnostik I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
40 Ligasi Arteri Hipogastrica / Uterina I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
41 Ekstirpasi Giant Condiloma I 175,000 200,000 100,000
II 175,000 200,000 100,000
III 175,000 200,000 100,000
42 Penyulit + 50% I 175,000 200,000 100,000
II 175,000 200,000 100,000
 III 175,000 200,000 100,000
Besar
43 Histerektomi I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
44 Miomektomi I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
45 Reseksi Adenomiosis I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
46 Infeksi Panggul/PUS dengan Perlekatan I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
47 Adhesiolisis Perlekatan Berat Pelvik I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
48 Repair Tuba (Tubaplasti) I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
49 Transposisi Ovarium I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
50 Penyulit + 50% I 175,000 250,000 125,000
II 175,000 250,000 125,000
III 175,000 250,000 125,000
 40% 25% 10% 15% 10% 10%
OPERATOR ANASTESI ASISTEN OPERATOR ASISTEN ANASTESI
Datang By Phone dng B Tun Tnpa B Tun Mas Huda Ast Luar

93,750 9,375
93,750 9,375
93,750 9,375
93,750 9,375
250,000 25,000
250,000 25,000
250,000 25,000
218,750 21,875
218,750 21,875
250,000 25,000
250,000 100,000 62,500 25,000 40,000
250,000 100,000 62,500 25,000 40,000
218,750 87,500 54,688 21,875 36,875
218,750 87,500 54,688 21,875 36,875
187,500 18,750
187,500 18,750
156,250 15,625
156,250 15,625
250,000 25,000 40,000
250,000 25,000 40,000
218,750 21,875 36,875
218,750 21,875 36,875
93,750 9,375
93,750 9,375
87,500 8,750
87,500 8,750
37,500 3,750
37,500 3,750
187,500 18,750
187,500 18,750
156,250 15,625
1,062,500 106,250
956,250 95,625
860,625 86,063
1,562,500 156,250
1,406,250 140,625
1,265,625 126,563
187,500 18,750
187,500 18,750
 156,250 15,625
437,500 43,750
437,500 43,750
406,250 40,625
625,000 250,000 156,250 62,500 87,500
562,500 225,000 140,625 56,250 81,250
506,250 202,500 126,563 50,625 75,625
1,250,000 500,000 312,500 125,000 175,000
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
1,250,000 500,000 312,500 125,000 175,000
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
2,250,000 900,000 562,500 225,000 337,500 275,000 150,000
2,025,000 810,000 506,250 202,500 303,750 252,500 150,000
1,822,500 729,000 455,625 182,250 273,375 232,250 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,500,000 1,400,000 875,000 350,000 525,000 400,000 150,000
3,150,000 1,260,000 787,500 315,000 472,500 365,000 150,000
2,835,000 1,134,000 708,750 283,500 425,250 333,500 150,000
3,937,500 1,575,000 984,375 393,750 590,625 443,750 150,000
3,543,750 1,417,500 885,938 354,375 531,563 404,375 150,000
3,189,375 1,275,750 797,344 318,938 478,406 368,938 150,000
- - -
937,500 375,000 234,375 93,750 128,750
843,750 337,500 210,938 84,375 119,375
759,375 303,750 189,844 75,938 110,938
683,438 273,375 170,859 68,344 103,344
937,500 375,000 234,375 93,750
843,750 337,500 210,938 84,375
759,375 303,750 189,844 75,938
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
911,250 364,500 227,813 91,125 141,125
820,125 328,050 205,031 82,013 132,013
1,125,000 450,000 281,250 112,500
1,012,500 405,000 253,125 101,250
911,250 364,500 227,813 91,125
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
911,250 364,500 227,813 91,125 141,125
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
 911,250 364,500 227,813 91,125 141,125
820,125 328,050 205,031 82,013 132,013
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
911,250 364,500 227,813 91,125 141,125
820,125 328,050 205,031 82,013 132,013
1,125,000 450,000 281,250 112,500 162,500
1,012,500 405,000 253,125 101,250 151,250
911,250 364,500 227,813 91,125 141,125
820,125 328,050 205,031 82,013 132,013
- -
1,250,000 125,000 175,000 150,000
1,125,000 112,500 162,500 150,000
1,012,500 101,250 151,250 150,000
1,250,000 500,000 312,500 125,000 175,000 150,000
1,125,000 450,000 281,250 112,500 162,500 150,000
1,012,500 405,000 253,125 101,250 151,250 150,000
1,250,000 500,000 312,500 125,000 175,000 150,000
1,125,000 450,000 281,250 112,500 162,500 150,000
1,012,500 405,000 253,125 101,250 151,250 150,000
1,250,000 500,000 312,500 125,000 175,000 150,000
1,125,000 450,000 281,250 112,500 162,500 150,000
1,012,500 405,000 253,125 101,250 151,250 150,000

1,125,000 450,000 281,250 112,500 168,750 162,500 150,000

1,012,500 405,000 253,125 101,250 151,875 151,250 150,000
911,250 364,500 227,813 91,125 136,688 141,125 150,000
820,125 328,050 205,031 82,013 132,013 150,000
-
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
 2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
2,375,000 950,000 593,750 237,500 356,250 287,500 150,000
2,137,500 855,000 534,375 213,750 320,625 263,750 150,000
1,923,750 769,500 480,938 192,375 288,563 242,375 150,000
- - - -
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000
3,125,000 1,250,000 781,250 312,500 468,750 362,500 150,000
2,812,500 1,125,000 703,125 281,250 421,875 331,250 150,000
2,531,250 1,012,500 632,813 253,125 379,688 303,125 150,000

40% 25% 10% 15% 10% 10%

OPERATOR ANASTESI ASISTEN OPERATOR ASISTEN ANASTESI
Datang By Phone dng B Tun Tnpa B Tun Mas Huda Ast Luar

56,250 5,625
56,250 5,625
 56,250 5,625
56,250 5,625
150,000 15,000
150,000 15,000
150,000 15,000
131,250 13,125
131,250 13,125
150,000 15,000
150,000 60,000 37,500 15,000 30,000
150,000 60,000 37,500 15,000 30,000
131,250 52,500 32,813 13,125 28,125
131,250 52,500 32,813 13,125 28,125
112,500 11,250
112,500 11,250
93,750 9,375
93,750 9,375
150,000 15,000 30,000
150,000 15,000 30,000
131,250 13,125 28,125
131,250 13,125 28,125
56,250 5,625
56,250 5,625
52,500 5,250
52,500 5,250
22,500 2,250
22,500 2,250
112,500 11,250
112,500 11,250
93,750 9,375
637,500 63,750
573,750 57,375
516,375 51,638
937,500 93,750
843,750 84,375
759,375 75,938
112,500 11,250
112,500 11,250
93,750 9,375
262,500 26,250
262,500 26,250
243,750 24,375
375,000 150,000 93,750 37,500 62,500
337,500 135,000 84,375 33,750 58,750
303,750 121,500 75,938 30,375 55,375
750,000 300,000 187,500 75,000 125,000
 675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
750,000 300,000 187,500 75,000 125,000
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
1,350,000 540,000 337,500 135,000 202,500 185,000 150,000
1,215,000 486,000 303,750 121,500 182,250 171,500 150,000
1,093,500 437,400 273,375 109,350 164,025 159,350 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
2,100,000 840,000 525,000 210,000 315,000 260,000 150,000
1,890,000 756,000 472,500 189,000 283,500 239,000 150,000
1,701,000 680,400 425,250 170,100 255,150 220,100 150,000
2,362,500 945,000 590,625 236,250 354,375 286,250 150,000
2,126,250 850,500 531,563 212,625 318,938 262,625 150,000
1,913,625 765,450 478,406 191,363 287,044 241,363 150,000
- - -
562,500 225,000 140,625 56,250 91,250
506,250 202,500 126,563 50,625 85,625
455,625 182,250 113,906 45,563 80,563
410,063 164,025 102,516 41,006 76,006
562,500 225,000 140,625 56,250
506,250 202,500 126,563 50,625
455,625 182,250 113,906 45,563
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
546,750 218,700 136,688 54,675 104,675
492,075 196,830 123,019 49,208 99,208
675,000 270,000 168,750 67,500
607,500 243,000 151,875 60,750
546,750 218,700 136,688 54,675
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
546,750 218,700 136,688 54,675 104,675
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
546,750 218,700 136,688 54,675 104,675
492,075 196,830 123,019 49,208 99,208
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
546,750 218,700 136,688 54,675 104,675
492,075 196,830 123,019 49,208 99,208
675,000 270,000 168,750 67,500 117,500
607,500 243,000 151,875 60,750 110,750
 546,750 218,700 136,688 54,675 104,675
492,075 196,830 123,019 49,208 99,208
- -
750,000 75,000 125,000 150,000
675,000 67,500 117,500 150,000
607,500 60,750 110,750 150,000
750,000 300,000 187,500 75,000 125,000 150,000
675,000 270,000 168,750 67,500 117,500 150,000
607,500 243,000 151,875 60,750 110,750 150,000
750,000 300,000 187,500 75,000 125,000 150,000
675,000 270,000 168,750 67,500 117,500 150,000
607,500 243,000 151,875 60,750 110,750 150,000
750,000 300,000 187,500 75,000 125,000 150,000
675,000 270,000 168,750 67,500 117,500 150,000
607,500 243,000 151,875 60,750 110,750 150,000

675,000 270,000 168,750 67,500 101,250 117,500 150,000

607,500 243,000 151,875 60,750 91,125 110,750 150,000
546,750 218,700 136,688 54,675 82,013 104,675 150,000
492,075 196,830 123,019 49,208 99,208 150,000
-
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
1,425,000 570,000 356,250 142,500 213,750 192,500 150,000
1,282,500 513,000 320,625 128,250 192,375 178,250 150,000
1,154,250 461,700 288,563 115,425 173,138 165,425 150,000
- - - -
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
1,875,000 750,000 468,750 187,500 281,250 237,500 150,000
1,687,500 675,000 421,875 168,750 253,125 218,750 150,000
1,518,750 607,500 379,688 151,875 227,813 201,875 150,000
Pasien Umum

KETERANGAN

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Pasien BPJS

KETERANGAN
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di OK tambah 125 rb

Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb
Bila di OK tambah 125 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb

Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
Bila di VK kurangi 200 rb
TARIF SPESIALIS MATA
RSU MUHAMMADIYAH SURYA MELATI

NO NAMA TINDAKAN KLAS SEWA OK/VK SEWA ALAT BAHAN

1 Visite I
2 Visite II
3 Visite III
4 Jasa Periksa Klinik
5 Asessment Kelainan Papil Klinik
6 Asessment Pergerakan Bola Mata Klinik
Diagnostik I
7 Biometri Clinic/All Class
8 Refraksi Clinic/All Class
9 Tonometri Clinic/All Class
Diagnostik II
10 Fundoscopy I
II
III
Klinik
Tindakan Non Bedah
11 Epilasi Bulu Mata I
II
III
Klinik
12 Ekstraksi Corpus Alienum Cornea/ I
conjungtiva 150.000 II
III
Klinik
13 Lithiasis I
II
III
Klinik
14 Spoelling / irigasi bola mata I
II
III
Klinik
Tindakan Bedah Minor
15 Eksisi Chalazion / Hordeolum I 50,000 25,000
II 50,000 25,000
III 50,000 25,000
16 Corpus Alienum dengan operating microsc I 50,000 25,000
II 50,000 25,000
III 50,000 25,000
 Kamar Bedah
17 Angkat Jahitan Kornea I 175,000 200,000 50,000
II 175,000 200,000 50,000
III 175,000 200,000 50,000
18 Aspirasi / Irigasi / Reformasi COA I 175,000 200,000 50,000
II 175,000 200,000 50,000
III 175,000 200,000 50,000
19 Flap Conjungtiva / Amnion Graf I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
20 ECCE/ICCE/SICS I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
21 ECCE/SICS + IOL I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
22 Eksisi Pterigium I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
23 Phakik IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
24 Repair Of Laceration, Cornea, Non Perforati I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
25 Repair Of Laceration, Cornea and/ I 175,000 250,000 75,000
or Sclera, Perforating II 175,000 250,000 75,000
III 175,000 250,000 75,000
26 Reposisi IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
27 Reposisi Iris I 175,000 200,000 75,000
II 175,000 200,000 75,000
III 175,000 200,000 75,000
28 Sekunder IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
29 Ekstraksi IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
30 Ekstraksi Corpus Alienum Cornea I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
31 Ekstraksi Corpus Alienum segmen anterior I 175,000 250,000 75,000
II 175,000 250,000 75,000
 III 175,000 250,000 75,000
32 Exchange IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
Glaukoma
33 Iridectomy Perifer I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
34 Paracentesis I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
35 Trabekulektomi I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
36 Reformasi COA I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
37 Injeksi Intravitreal I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
Rekonstruksi Bedah Mata
38 Eksisi tumor kecil kelopak I 175,000 200,000 50,000
II 175,000 200,000 50,000
III 175,000 200,000 50,000
39 Eviserasi / enukleasi I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
40 Fraktur multiple I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
41 Repair ruptur palpebra I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
42 Repair ruptur palpebra I 175,000 250,000 100,000
(dgn rupture canalis lacrimalis) II 175,000 250,000 100,000
III 175,000 250,000 100,000
43 Tarsoraf I 175,000 250,000 50,000
II 175,000 250,000 50,000
III 175,000 250,000 50,000

TARIF SPESIALIS MATA

RSU MUHAMMADIYAH SURYA MELATI
NO NAMA TINDAKAN KLAS SEWA OK/VK SEWA ALAT BAHAN

1 Visite I
2 Visite II
3 Visite III
4 Jasa Periksa Klinik
5 Asessment Kelainan Papil Klinik
6 Asessment Pergerakan Bola Mata Klinik
Diagnostik I
7 Biometri Clinic/All Class
8 Refraksi Clinic/All Class
9 Tonometri Clinic/All Class
Diagnostik II
10 Fundoscopy I
II
III
Klinik
Tindakan Non Bedah
11 Epilasi Bulu Mata I
II
III
Klinik
12 Ekstraksi Corpus Alienum Cornea/ I
conjungtiva 150.000 II
III
Klinik
13 Lithiasis I
II
III
Klinik
14 Spoelling / irigasi bola mata I
II
III
Klinik
Tindakan Bedah Minor
15 Eksisi Chalazion / Hordeolum I 50,000 25,000
II 50,000 25,000
III 50,000 25,000
16 Corpus Alienum dengan operating microsc I 50,000 25,000
II 50,000 25,000
III 50,000 25,000
Kamar Bedah
17 Angkat Jahitan Kornea I 175,000 200,000 50,000
II 175,000 200,000 50,000
 III 175,000 200,000 50,000
18 Aspirasi / Irigasi / Reformasi COA I 175,000 200,000 50,000
II 175,000 200,000 50,000
III 175,000 200,000 50,000
19 Flap Conjungtiva / Amnion Graf I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
20 ECCE/ICCE/SICS I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
21 ECCE/SICS + IOL I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
22 Eksisi Pterigium I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
23 Phakik IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
24 Repair Of Laceration, Cornea, Non Perforati I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
25 Repair Of Laceration, Cornea and/ I 175,000 250,000 75,000
or Sclera, Perforating II 175,000 250,000 75,000
III 175,000 250,000 75,000
26 Reposisi IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
27 Reposisi Iris I 175,000 200,000 75,000
II 175,000 200,000 75,000
III 175,000 200,000 75,000
28 Sekunder IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
29 Ekstraksi IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
30 Ekstraksi Corpus Alienum Cornea I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
31 Ekstraksi Corpus Alienum segmen anterior I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
32 Exchange IOL I 175,000 250,000 75,000
II 175,000 250,000 75,000
 III 175,000 250,000 75,000
Glaukoma
33 Iridectomy Perifer I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
34 Paracentesis I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
35 Trabekulektomi I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
36 Reformasi COA I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
37 Injeksi Intravitreal I 175,000 200,000 25,000
II 175,000 200,000 25,000
III 175,000 200,000 25,000
Rekonstruksi Bedah Mata
38 Eksisi tumor kecil kelopak I 175,000 200,000 50,000
II 175,000 200,000 50,000
III 175,000 200,000 50,000
39 Eviserasi / enukleasi I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
40 Fraktur multiple I 175,000 250,000 100,000
II 175,000 250,000 100,000
III 175,000 250,000 100,000
41 Repair ruptur palpebra I 175,000 250,000 75,000
II 175,000 250,000 75,000
III 175,000 250,000 75,000
42 Repair ruptur palpebra I 175,000 250,000 100,000
(dgn rupture canalis lacrimalis) II 175,000 250,000 100,000
III 175,000 250,000 100,000
43 Tarsoraf I 175,000 250,000 50,000
II 175,000 250,000 50,000
III 175,000 250,000 50,000
 10% Pasien Umum
40% 25% 15% 10% 10%
ANASTESI ASISTEN ASISTEN ANASTESI
OPERATOR
DATANG BY PHONE OPERATOR Mas Huda Ast Luar

75,000
65,000
55,000
75,000
70,000
70,000

25,000
25,000
25,000

125,000 12,500
112,500 11,250
100,000 10,000
125,000 12,500

125,000 12,500
112,500 11,250
100,000 10,000
125,000 12,500
225,000 22,500
202,500 20,250
180,000 18,000
225,000 22,500
225,000 22,500
202,500 20,250
180,000 18,000
225,000 22,500
225,000 22,500
202,500 20,250
180,000 18,000
225,000 22,500

750,000 300,000 187,500 112,500 100,000

675,000 270,000 168,750 101,250 92,500
600,000 240,000 150,000 90,000 85,000
750,000 300,000 187,500 112,500 100,000
675,000 270,000 168,750 101,250 92,500
600,000 240,000 150,000 90,000 85,000
 700,000 280,000 175,000 105,000 120,000
630,000 252,000 157,500 94,500 113,000
560,000 224,000 140,000 84,000 106,000
700,000 280,000 175,000 105,000 120,000
630,000 252,000 157,500 94,500 113,000
560,000 224,000 140,000 84,000 106,000
1,750,000 700,000 437,500 262,500 225,000 150,000
1,575,000 630,000 393,750 236,250 207,500 150,000
1,400,000 560,000 350,000 210,000 190,000 150,000
3,000,000 1,200,000 750,000 450,000 350,000 150,000
2,700,000 1,080,000 675,000 405,000 320,000 150,000
2,400,000 960,000 600,000 360,000 290,000 150,000
3,000,000 1,200,000 750,000 450,000 350,000 150,000
2,700,000 1,080,000 675,000 405,000 320,000 150,000
2,400,000 960,000 600,000 360,000 290,000 150,000
1,250,000 500,000 312,500 187,500 175,000 150,000
1,125,000 450,000 281,250 168,750 162,500 150,000
1,000,000 400,000 250,000 150,000 150,000 150,000
2,250,000 900,000 562,500 337,500 275,000 150,000
2,025,000 810,000 506,250 303,750 252,500 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,300,000 520,000 325,000 195,000 180,000 150,000
1,170,000 468,000 292,500 175,500 167,000 150,000
1,040,000 416,000 260,000 156,000 154,000 150,000
2,800,000 1,120,000 700,000 420,000 330,000 150,000
2,520,000 1,008,000 630,000 378,000 302,000 150,000
2,240,000 896,000 560,000 336,000 274,000 150,000
1,750,000 700,000 437,500 262,500 225,000 150,000
1,575,000 630,000 393,750 236,250 207,500 150,000
1,400,000 560,000 350,000 210,000 190,000 150,000
1,100,000 440,000 275,000 165,000 160,000 100,000
990,000 396,000 247,500 148,500 149,000 100,000
880,000 352,000 220,000 132,000 138,000 100,000
2,250,000 900,000 562,500 337,500 275,000 150,000
2,025,000 810,000 506,250 303,750 252,500 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,300,000 520,000 325,000 195,000 180,000 150,000
1,170,000 468,000 292,500 175,500 167,000 150,000
1,040,000 416,000 260,000 156,000 154,000 150,000
700,000 280,000 175,000 105,000 120,000 100,000
630,000 252,000 157,500 94,500 113,000 100,000
560,000 224,000 140,000 84,000 106,000 100,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,620,000 648,000 405,000 243,000 212,000 150,000
1,440,000 576,000 360,000 216,000 194,000 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,620,000 648,000 405,000 243,000 212,000 150,000
1,440,000 576,000 360,000 216,000 194,000 150,000

750,000 300,000 187,500 112,500 125,000 150,000

675,000 270,000 168,750 101,250 117,500 150,000
600,000 240,000 150,000 90,000 110,000 150,000
1,100,000 440,000 275,000 165,000 160,000 150,000
990,000 396,000 247,500 148,500 149,000 150,000
880,000 352,000 220,000 132,000 138,000 150,000
1,100,000 440,000 275,000 165,000 160,000 150,000
990,000 396,000 247,500 148,500 149,000 150,000
880,000 352,000 220,000 132,000 138,000 150,000
750,000 300,000 187,500 112,500 125,000 150,000
675,000 270,000 168,750 101,250 117,500 150,000
600,000 240,000 150,000 90,000 110,000 150,000
750,000 300,000 187,500 112,500 125,000 150,000
675,000 270,000 168,750 101,250 117,500 150,000
600,000 240,000 150,000 90,000 110,000 150,000

1,200,000 480,000 300,000 180,000 170,000 150,000

1,080,000 432,000 270,000 162,000 158,000 150,000
960,000 384,000 240,000 144,000 146,000 150,000
2,150,000 860,000 537,500 322,500 265,000 150,000
1,935,000 774,000 483,750 290,250 243,500 150,000
1,720,000 688,000 430,000 258,000 222,000 150,000
7,100,000 2,840,000 1,775,000 1,065,000 760,000 200,000
6,390,000 2,556,000 1,597,500 958,500 689,000 200,000
5,680,000 2,272,000 1,420,000 852,000 618,000 200,000
2,000,000 800,000 500,000 300,000 250,000 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,600,000 640,000 400,000 240,000 210,000 150,000
3,500,000 1,400,000 875,000 525,000 400,000 175,000
3,150,000 1,260,000 787,500 472,500 365,000 175,000
2,800,000 1,120,000 700,000 420,000 330,000 175,000
1,150,000 460,000 287,500 172,500 165,000 150,000
1,035,000 414,000 258,750 155,250 153,500 150,000
920,000 368,000 230,000 138,000 142,000 150,000

10% Pasien BPJS

40% 25% 15% 10% 10%
 ANASTESI ASISTEN ASISTEN ANASTESI
OPERATOR
DATANG BY PHONE OPERATOR Mas Huda Ast Luar

60,000
50,000
40,000
60,000
60,000
60,000

25,000
25,000
25,000

75,000 7,500
67,500 6,750
60,000 6,000
75,000 7,500

75,000 7,500
67,500 6,750
60,000 6,000
75,000 7,500
135,000 13,500
121,500 12,150
108,000 10,800
135,000 13,500
135,000 13,500
121,500 12,150
108,000 10,800
135,000 13,500
135,000 13,500
121,500 12,150
108,000 10,800
135,000 13,500

450,000 180,000 112,500 67,500 70,000

405,000 162,000 101,250 60,750 65,500
360,000 144,000 90,000 54,000 61,000
450,000 180,000 112,500 67,500 70,000
405,000 162,000 101,250 60,750 65,500
360,000 144,000 90,000 54,000 61,000

420,000 168,000 105,000 63,000 92,000

378,000 151,200 94,500 56,700 87,800
 336,000 134,400 84,000 50,400 83,600
420,000 168,000 105,000 63,000 92,000
378,000 151,200 94,500 56,700 87,800
336,000 134,400 84,000 50,400 83,600
1,050,000 420,000 262,500 157,500 155,000 150,000
945,000 378,000 236,250 141,750 144,500 150,000
840,000 336,000 210,000 126,000 134,000 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,620,000 648,000 405,000 243,000 212,000 150,000
1,440,000 576,000 360,000 216,000 194,000 150,000
1,800,000 720,000 450,000 270,000 230,000 150,000
1,620,000 648,000 405,000 243,000 212,000 150,000
1,440,000 576,000 360,000 216,000 194,000 150,000
750,000 300,000 187,500 112,500 125,000 150,000
675,000 270,000 168,750 101,250 117,500 150,000
600,000 240,000 150,000 90,000 110,000 150,000
1,350,000 540,000 337,500 202,500 185,000 150,000
1,215,000 486,000 303,750 182,250 171,500 150,000
1,080,000 432,000 270,000 162,000 158,000 150,000
780,000 312,000 195,000 117,000 128,000 150,000
702,000 280,800 175,500 105,300 120,200 150,000
624,000 249,600 156,000 93,600 112,400 150,000
1,680,000 672,000 420,000 252,000 218,000 150,000
1,512,000 604,800 378,000 226,800 201,200 150,000
1,344,000 537,600 336,000 201,600 184,400 150,000
1,050,000 420,000 262,500 157,500 155,000 150,000
945,000 378,000 236,250 141,750 144,500 150,000
840,000 336,000 210,000 126,000 134,000 150,000
660,000 264,000 165,000 99,000 116,000 100,000
594,000 237,600 148,500 89,100 109,400 100,000
528,000 211,200 132,000 79,200 102,800 100,000
1,350,000 540,000 337,500 202,500 185,000 150,000
1,215,000 486,000 303,750 182,250 171,500 150,000
1,080,000 432,000 270,000 162,000 158,000 150,000
780,000 312,000 195,000 117,000 128,000 150,000
702,000 280,800 175,500 105,300 120,200 150,000
624,000 249,600 156,000 93,600 112,400 150,000
420,000 168,000 105,000 63,000 92,000 100,000
378,000 151,200 94,500 56,700 87,800 100,000
336,000 134,400 84,000 50,400 83,600 100,000
1,080,000 432,000 270,000 162,000 158,000 150,000
972,000 388,800 243,000 145,800 147,200 150,000
864,000 345,600 216,000 129,600 136,400 150,000
1,080,000 432,000 270,000 162,000 158,000 150,000
972,000 388,800 243,000 145,800 147,200 150,000
 864,000 345,600 216,000 129,600 136,400 150,000

450,000 180,000 112,500 67,500 95,000 150,000

405,000 162,000 101,250 60,750 90,500 150,000
360,000 144,000 90,000 54,000 86,000 150,000
660,000 264,000 165,000 99,000 116,000 150,000
594,000 237,600 148,500 89,100 109,400 150,000
528,000 211,200 132,000 79,200 102,800 150,000
660,000 264,000 165,000 99,000 116,000 150,000
594,000 237,600 148,500 89,100 109,400 150,000
528,000 211,200 132,000 79,200 102,800 150,000
450,000 180,000 112,500 67,500 95,000 150,000
405,000 162,000 101,250 60,750 90,500 150,000
360,000 144,000 90,000 54,000 86,000 150,000
450,000 180,000 112,500 67,500 95,000 150,000
405,000 162,000 101,250 60,750 90,500 150,000
360,000 144,000 90,000 54,000 86,000 150,000

720,000 288,000 180,000 108,000 122,000 150,000

648,000 259,200 162,000 97,200 114,800 150,000
576,000 230,400 144,000 86,400 107,600 150,000
1,290,000 516,000 322,500 193,500 179,000 150,000
1,161,000 464,400 290,250 174,150 166,100 150,000
1,032,000 412,800 258,000 154,800 153,200 150,000
4,260,000 1,704,000 1,065,000 639,000 476,000 200,000
3,834,000 1,533,600 958,500 575,100 433,400 200,000
3,408,000 1,363,200 852,000 511,200 390,800 200,000
1,200,000 480,000 300,000 180,000 170,000 150,000
1,080,000 432,000 270,000 162,000 158,000 150,000
960,000 384,000 240,000 144,000 146,000 150,000
2,100,000 840,000 525,000 315,000 260,000 175,000
1,890,000 756,000 472,500 283,500 239,000 175,000
1,680,000 672,000 420,000 252,000 218,000 175,000
690,000 276,000 172,500 103,500 119,000 150,000
621,000 248,400 155,250 93,150 112,100 150,000
552,000 220,800 138,000 82,800 105,200 150,000