Tarif Layanan (Tindakan & Akomodasi)

Akomodasi
Nama Kelas Biaya
Kelas 3 150,000
Kelas 2 180,000
Isolasi 180,000
Kelas 3 Infection Centre 216,000
Kelas 1 240,000
Isolasi IC 270,000
Kelas 2 Infection Centre 270,000
HCU / Intermediate 300,000
Kelas 1 Infection Centre 324,000
HCU Infection Centre 360,000
VIP 500,000
VIP Infection Centre 500,000
Intensif Care 540,000
VIP A 550,000
VIP Intensive Care 720,000
CVCU (VIP) 720,000
Super VIP B 720,000
Super VIP A 770,000
Super VIP 770,000
Super VIP Intensif Care 970,000
CVCU (SUPER VIP) 970,000
Tindakan
No Nama Tindakan Tarif
1 17-OH Progesteron (LC-MS/MS) (P) 900,000
2 Abdominopelvic amputation 9,282,099
3 Abdominoperineal Pull - Through / Malformasi 6,175,000
4 Abdominoperineal Pull-Throug/ Swenson 6,175,000
5 Abdominorectal Pull - Through/Swenson Procedure 6,175,000
6 Ablatio Retina 10,926,000
7 Absebt Pulmonary Valve Syndrome Repair/ dengan atau tanpa MOF/ CABG High Risk/Operasi Mitral Valve Repair (MVR)/ Atrial Valve Repair (AVR) / Aortic Repair + PS 59,550,000
8 Absisi Corpus Alinun 150,000
9 ACA IgG 438,000
10 ACA IgG (P) 671,000
11 ACA IgM 438,000
12 ACA IgM (P) 690,000
13 Achillotenotomy 9,390,000
14 Activated Clotting Time 400,000
15 Acute Pain Service + Anastesi 734,000
16 Adductor tenotomy of hip 9,390,000
17 Adenoidektomi 3,850,000
18 Adenolisis 6,350,000
19 Adesolisis 5,931,446
20 ADL (Activity of Daily Living) 22,800
21 Administrasi Home Care 100,000
22 Administrasi Penyerahan Jenazah 120,000
23 Adrenalektomi Abdominotorakal 10,320,000
24 Adult Complex Repair/ Operation/ Alcapa Repair 90,000,000
25 Advancement of pedicle graft 10,925,000
26 Advancement of tendon 11,196,000
27 Advancement of tendon of hand 11,196,000
28 Aff DJ Stent 2,850,000
29 Aff DJ Stent (ESWL) 2,500,000
30 Aff Double Lumen 217,000
31 Aff Drain 83,000
32 Aff Hecting 35,000
33 Aff-ORIF Fraktur Rahang Kompleks/Wajah Multiple 4,597,500
34 Aff-ORIF Fraktur Rahang Sederhana 2,670,000
35 AFO (Biasa) 961,000
36 AFO (Khusus) 2,850,000
37 AFO (Standar) 1,556,000
38 AFP _ 245,000
39 Agregasi Trombosit _ 400,000
40 Air Plumbage ( Bedah Paru/ Thorax ) 21,102,000
41 Akupuntur ( 4 x Tindakan ) 250,000
42 Albumin _ 32,000
43 Albumin Urine 30,000
44 Alkali Fosfatase _ 37,000
45 Allergi Test/Patch Test 66,000
46 ALPACA Repair/AP Window+MOF/AVSD Repair/BCPS On Off Pump + MOF/Corctasio Aorta+MOF 49,550,000
47 Alveolar Bone Graft 9,550,000
48 Alveolectomi 2,850,000
49 Alveolektomi 2 Regio dengan Anastesi Lokal 0
50 Alveolektomi per Regio dengan Anastesi Lokal 270,000
51 Ambil Bahan Kultur/Biopsi/Swab/Kerokan 66,000
52 Ambulation and Gait Training 70,000
53 Amilase Darah 80,000
54 Amilase Urine 32,000
55 Amniocentesis / CVS / Chordocentesis 250,000
56 Amnioinfusi Trans Abdominal Dengan Anastesi Lokal 426,000
57 Amnioreduksi Dengan Anastesi Lokal 432,000
58 Amnioskopy dan Amniosintesis tranpag 88,000
59 Amputasi Jari (Multiple) (Bedah Plastik) 5,019,743
60 Amputation above knee 6,354,000
61 Amputation and disarticulation of finger 9,282,099
62 Amputation and disarticulation of thumb 9,282,099
63 Amputation of ankle through malleoli of tibia and fibula 5,244,099
64 Amputation of toe 5,244,099
65 Amputation through foot 5,244,099
66 Amputation through forearm 5,244,099
67 Amputation through hand 5,244,099
68 Amputation through humerus 5,244,099
69 Amylase Pancreatic (P) 305,000
70 Amylase Pancreatic Urine (P) 305,000
71 ANA - IF 800,000
72 ANA (IF) (P) 620,000
73 ANA (IF) & ANA Profile (P) 1,356,000
74 ANA Profile (P) 985,000
75 Analisa Batu _ 250,000
76 Analisa Batu Empedu (P) 110,000
77 Analisa Batu Ginjal (P) 292,000
78 Analisa Cairan Asites 280,000
79 Analisa Cairan Lain 200,000
80 Analisa Cairan Otak 200,000
81 Analisa Cairan Pleura 200,000
82 Analisa Cairan Sendi 250,000
83 Analisa Faeces _ 70,000
84 Analisa Gas Darah 280,000
85 Analisa Gas Darah Plus Elektrolit (POCT) 350,000
86 Analisa Kromosom (P) 1,980,000
87 Analisa Sperma _ 200,000
88 Analisis Status Alergi 100,000
89 Anasthesi/Trepanasi/Eksterpasi Saluran Akar (Gigi Anterior/Akar Tunggal) 0
90 Anasthesi/Trepanasi/Eksterpasi Saluran Akar (Gigi Posterior/Akar Jamak) 0
91 Anastomosis end to end ureter 4,850,000
92 ANCA 221,000
93 Anca (P) 595,000
94 Aneurisma Aorta 4,860,000
95 Angiofibroma Nasofaring 5,773,712
96 Angiografi Coroner/Cerebral + Anestesi 5,324,718
97 Angiografi Koroner 4,442,718
98 Angiografi Perifer/Vaskuler/Arteriografy 4,582,688
99 Angiography arteri abdominal 6,431,386
100 Angiography Arteri Abdominal + Anastesi 9,820,000
101 Angiography cerebral 6,428,236
102 Angiography Cerebral + Anastesi 9,820,000
103 Angiography pada extremitas 6,428,236
104 Angiography Pada Extremitas + Anastesi 9,820,000
105 Angioplasti : A. Carotis 14,450,000
106 Angioplasti : A. Carotis + Anastesi 18,950,000
107 Angioplasti : A. Renalis 14,450,000
108 Angioplasti : A. Renalis + Anastesi 18,950,000
109 Angioplasti : Dialisis Graft 14,450,000
110 Angioplasti : Dialisis Graft + Anastesi 18,950,000
111 Angioplasti : Extremitas Inf/Sup 14,450,000
112 Angioplasti : Extremitas Inf/Sup + Anastesi 18,950,000
113 Angioplasti : Intrakranial 14,450,000
114 Angioplasti : Intrakranial + Anastesi 18,950,000
115 Angioplasti : Vasospasme Intracranial 14,450,000
116 Angioplasti : Vasospasme Intracranial + Anastesi 18,950,000
117 Angkat Arch Bar 2,850,000
118 Angkat K - Wire 70,000
119 Angkat Silikon ( Hidung/Dagu ) 0
120 Ankle fusion 17,935,044
121 Anoplasty/Limited PSARP/repair anoplasty 7,802,000
122 Anterio/Posterior Sklerotomi 4,913,000
123 Anti - HAV IgM (P) 400,000
124 Anti Amuba 188,000
125 Anti Chikungunya 235,000
126 Anti CMV IgG _ 280,000
127 Anti CMV IgM _ 280,000
128 Anti Faktor Xa 225,000
129 Anti HAV IgM _ 220,000
130 Anti HAV Total 188,000
131 Anti HBc IgM _ 107,000
132 Anti HBc Total 250,000
133 Anti HBe 425,000
134 Anti Hbe (P) 490,000
135 Anti HBs _ 175,000
136 Anti HCV (Elisa) _ 280,000
137 Anti HCV (ICT) 98,000
138 Anti Helicobacter Pylori IgG 81,000
139 Anti Helicobacter Pylori IgM 81,000
140 Anti HIV (Elisa) _ 400,000
141 Anti HIV (ICT) 133,000
142 Anti HSV IgG _ 125,000
143 Anti HSV IgM _ 125,000
144 Anti HSV II IgG 125,000
145 Anti HSV II IgM 125,000
146 Anti Influenza A-B 313,000
147 Anti Jamur Intra Bladder 66,000
148 Anti Japanese B Encephalitis 250,000
149 Anti Kappa 74,000
150 Anti Lamda 74,000
151 Anti Leptospira 188,000
152 Anti Rubella IgG _ 275,000
153 Anti Rubella IgM _ 275,000
154 Anti TB 188,000
155 Anti Toxoplasma IgG _ 255,000
156 Anti Toxoplasma IgM _ 255,000
157 Anti-CCP IgG (P) 665,000
158 Anti-ds-DNA-NcX (P) 509,000
159 Anti-EBV VCA IgG (P) 650,000
160 Anti-EBV VCA IgM (P) 650,000
161 Anti-HAV (P) 463,000
162 Anti-HBc 249,000
163 Anti-HBc IgM 443,000
164 Anti-HBc IgM (P) 486,000
165 Anti-HBe 490,000
166 Anti-HBs 140,000
167 Anti-HSV 1 IgG (P) 335,000
168 Anti-HSV 1 IgM (P) 335,000
169 Antibodi Malaria 188,000
170 Antigen Malaria 150,000
171 Antigen Tuberkulosa 200,000
172 AP Window/ASD Primum/Extirpasi Tumor Tanpa Komplikasi/Repair PAPVD 42,350,000
173 APD Petugas 160,000
174 Apek Reseksi (Gigi) 2,850,000
175 Apek Reseksi Anasthesi Bedah 0
176 Apeks Reseksi / Apikoektomy per Gigi dengan Anastesi Lokal 860,000
177 Apeksifikasi 0
178 Apendektomi Akut 4,137,279
179 Apendektomi Laparaskopi 10,850,000
180 Apendektomi Perforata 5,004,189
181 Appendectomy Simple 3,850,000
182 Appendicitis Test 78,000
183 Application of external fixation device, carpals and metacarpals 4,767,815
184 Application of external fixation device, femur 4,767,815
185 Application of external fixation device, humerus 4,767,815
186 Application of external fixation device, radius and ulna 4,767,815
187 Application of external fixation device, tarsals and metatarsals 4,767,815
188 Application of external fixation device, tibia and fibula 17,936,491
189 Application of external fixation device, unspecified site 2,350,000
190 Application of neck support 2,350,000
191 Application of other cast 2,900,182
192 Application of plaster jacket 4,017,182
193 Application of splint 2,350,000
194 APTT _ 110,000
195 Arch Support 22,800
196 Argon Laser/Kenon 6,233,000
197 Arm Sling (Biasa) 399,000
198 Arm Sling (Khusus) 1,500,000
199 Arteri Carotis 4,860,000
200 Arteri Renalis Stenosis 4,816,000
201 Arterial Chemoterapi Embolisation (TACE) 9,037,000
202 Arteriography 4,582,688
203 Arteriography + Anastesi 10,210,400
204 Arthrocentesis 5,752,000
205 Arthrodesis of elbow 5,619,121
206 Arthrodesis of hip 3,856,600
207 Arthrodesis of knee 17,930,044
208 Arthrodesis of shoulder 5,619,121
209 Arthroplasty of carpocarpal or carpometacarpal joint with implant 8,105,000
210 Arthroplasty of carpocarpal or carpometacarpal joint without implant 8,488,000
211 Arthroplasty of metacarpophalangeal and interphalangeal joint with implant 8,105,000
212 Arthroplasty of metacarpophalangeal and interphalangeal joint without implant 8,105,000
213 Arthroscopy of ankle 5,752,000
214 Arthroscopy of elbow 5,752,000
215 Arthroscopy of foot and toe 5,752,000
216 Arthroscopy of hand and finger 5,752,000
217 Arthroscopy of hip 5,752,000
218 Arthroscopy of knee 16,585,212
219 Arthroscopy of shoulder 16,585,212
220 Arthroscopy of wrist 5,752,000
221 Arthrosplasty (Op.Gigi) 2,960,000
222 Asam Empedu 33,000
223 Asam Laktat 115,000
224 Asam Urat _ 32,000
225 Asam Urat (Urine) 30,000
226 Ascites Test 78,000
227 ASD Closure+PFO Creation+TV Repair (TAP DE VEGA) 41,950,000
228 ASD+MOF/CABG/Total Koreksi+AV Repair/PV Repair/Total Koreksi TOF+PDA Ligasi/Ligasi Ventricle Duuct 48,350,000
229 ASD+Reseksi Infudibular 45,150,000
230 Asisted Exercise 70,000
231 Aspirasi Biopsi 140,000
232 Aspirasi Cairan Pericard / Pleura 53,000
233 Aspirasi Hemarthrosis 66,000
234 Aspirasi Jarum 49,000
235 Aspirasi Kista 675,000
236 Aspirasi Kista / Eksisi dengan Lokal Anastesi 0
237 Aspirasi sendi 135,000
238 Aspirasi SST dan Evaluasi _ 250,000
239 Aspiration of bursa of hand 3,125,000
240 Aspiration of other soft tissue 3,856,600
241 Aspiration of other soft tissue of hand 3,856,600
242 Assesment ADHD 75,000
243 Assesment Analysis Behavior 78,000
244 Assesment Autisme CARS 220,000
245 Assesment CAPD 350,000
246 Assesment Corners 50,000
247 Assesment dan Check Out Oetotis & Prostesis 66,000
248 Assesment Dekondisi 66,000
249 Assesment Diet DM asupan Oral 78,000
250 Assesment DSM IV untuk Autisme 150,000
251 Assesment DSM IV untuk GPPH 150,000
252 Assesment Edukasi Pengaturan Diet Dengan Dosis Insulin 120,000
253 Assesment Evaluasi Autis-CHAT 220,000
254 Assesment Evaluasi Hiperaktivitas GPPH 220,000
255 Assesment Fleksibilitas dan Lingkup Gerak 66,000
256 Assesment Fungsi Berkemih 66,000
257 Assesment Fungsi Defekasi 66,000
258 Assesment Fungsi Eksekusi Gerak 66,000
259 Assesment Fungsi Kardiorespirasi 66,000
260 Assesment Fungsi Komunikasi 66,000
261 Assesment Fungsi lokomotor 66,000
262 Assesment Fungsi Memori 66,000
263 Assesment Fungsi Menelan 66,000
264 Assesment Integrasi Sensori Motor 66,000
265 Assesment Kebugaran 66,000
266 Assesment Kekuatan Otot 66,000
267 Assesment Kemampuan Fungsional dan Perawatan Diri 66,000
268 Assesment Keseimbangan Statik dan Dinamik 66,000
269 Assesment Kontrol Postural 78,000
270 Assesment meningeal Sign 78,000
271 Assesment Motorik Halus 66,000
272 Assesment Nervus Cranialis (Saraf Anak) 100,000
273 Assesment Nervus Cranialis (Tumbuh Kembang Anak) 78,000
274 Assesment Nyeri 103,000
275 Assesment Parental Education 100,000
276 Assesment Pendengaran Manual 78,000
277 Assesment Perawakan Pendek 120,000
278 Assesment Perkembangan kognitif CAT-CLAMPS 270,000
279 Assesment Perkembangan Umum 170,000
280 Assesment Pertumbuhan 78,000
281 Assesment Pola Jalan 66,000
282 Assesment Postur 78,000
283 Assesment Postur Kontrol 66,000
284 Assesment Reflex Fisiologis 80,000
285 Assesment Reflex Patologis 80,000
286 Assesment Sensibilitas 78,000
287 Assesment Sensibilitas (Rehabilitasi Medik) 66,000
288 Assesment Sistem Saraf Otonom 78,000
289 Assesment Skiring masalah mental emosional 220,000
290 Assesment Waktu Pendarahan 78,000
291 ASTO _ 165,000
292 Astresia Esofagus 9,464,367
293 Asuhan Nutrisi Pediatric 150,000
294 Atlas-axis spinal fusion 14,020,000
295 Attachment of pedicle or flap graft to hand 10,925,000
296 Attachment of pedicle or flap graft to other sites 10,925,000
297 Audiometri 150,000
298 AV Replacement (AVR) 65,150,000
299 AV Shunt dengan graft vena/sintetis 15,450,000
300 BAS / Pemasangan Coil + Anastesi 49,334,000
301 BAS di Cath Lab / Pemasangan Coil 38,935,861
302 BCPS + PA Banding 31,950,000
303 BCPS Bilateral+Mitral Cleft repair 39,150,000
304 BCPS On Pump atau off Pump/Repair Fistula Coroner/Repair Vascular ring 38,350,000
305 BCPS+Ligasi BT Shunt 38,750,000
306 BCPS+PDA Ligasi 38,990,000
307 BCR - ABL 2,800,000
308 BCR-ABL Kualitatif (P) 1,050,000
309 Bedah Beku (Besar) 750,000
310 Bedah Beku (Kecil) 250,000
311 Bedah Beku (Sedang) 470,000
312 Bedah Laparoskopi Anak 6,175,000
313 Bedah Listrik 66,000
314 Bedah Skapel 250,000
315 Belah Dagu 0
316 Belloq Tampon 50,000
317 Belloque Tampon Dalam Narkose 2,850,000
318 Bentall/Ross Procedure/Eksisi Sub Aortic Stenosis + VSD Closure + PDA Ligasi + Epicardial PPM/ Rastelli With Contegra / Operasi Jantung Terbuka dengan dua Katup dan Pacu Jantung Temporer 79,550,000
319 Beta HCG Kwantitatif 244,000
320 Beta 2 Glycoprotein 1 (B2GP-1) 563,000
321 Biakan dan Resistensi (Medium Cair) 500,000
322 Biakan dan Resistensi (Medium Padat) 400,000
323 Biakan dan Resistensi TB (medium Padat OAT Lini 1-2) 438,000
324 Biakan Salmonela Shigela (Biakan SS) 88,000
325 Bilas Lambung 66,000
326 Bilirubin Direk _ 32,000
327 Bilirubin Indirect 25,000
328 Bilirubin Total _ 32,000
329 Biofeed Back 28,800
330 Biometri 450,000
331 Biopsi Aspirasi transtorakal dengan tuntutan CT - SCAN 540,000
332 Biopsi Aspirasi transtorakal dengan tuntutan USG 318,000
333 Biopsi ca. penis & kel. inguinal 2,500,000
334 Biopsi Cerviks - Pasang Tampon 250,000
335 Biopsi Core 675,000
336 Biopsi dalam Narkose Umum 3,431,074
337 Biopsi Eksisi Kelenjar Getah Bening dengan Anastesi Umum 2,159,000
338 Biopsi Eksisional dalam Narkose 2,850,000
339 Biopsi Ekstirpasi dengan Anastesi Lokal 860,000
340 Biopsi Endoskopi 250,000
341 Biopsi Ginjal 222,000
342 Biopsi Ginjal Hemodialisa 5,200,000
343 Biopsi Ginjal perkutan 3,850,000
344 Biopsi Ginjal Terbuka 4,850,000
345 Biopsi Hippfaring Onko 250,000
346 Biopsi Incisional dalam Narkose 2,850,000
347 Biopsi Insisi Dengan Lokal Anastesi 675,000
348 Biopsi Insisi Tumor dengan Anastesi Umum 3,431,074
349 Biopsi Insisional Tumor Leher Onko 250,000
350 Biopsi Jaringan 146,000
351 Biopsi Jaringan (Gastro) 479,000
352 Biopsi Jaringan + Anastesi 1,217,000
353 Biopsi Jaringan + Anastesi (OK Obgyn) 1,423,000
354 Biopsi Jaringan Besar 800,000
355 Biopsi Jaringan Kecil 400,000
356 Biopsi Jaringan Sedang 600,000
357 Biopsi Jarum 63,000
358 Biopsi Jarum Halus 675,000
359 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) 1-2 Jaringan 400,000
360 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) 3-4 Jaringan 600,000
361 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) Lebih dari 4 Jaringan 800,000
362 Biopsi Kista 0
363 Biopsi Kulit (Besar) 560,000
364 Biopsi Kulit (Sedang) 480,000
365 Biopsi Lidah Palatum Onko 250,000
366 Biopsi Nasofaring Fiber Onko 250,000
367 Biopsi Nasofaring Rigid Onko 250,000
368 Biopsi Penis 675,000
369 Biopsi Permukaan 120,000
370 Biopsi Prostat 3,796,000
371 Biopsi Prostat (ESWL) 2,500,000
372 Biopsi rectum full thicknesis 3,431,074
373 Biopsi Saraf Kutaneus/Otot (Bedah Syaraf) 5,334,000
374 Biopsi Sinus Maksila Onko 250,000
375 Biopsi Telinga 2,850,000
376 Biopsi Testis 3,806,011
377 Biopsi Tumor Hidung Onko 250,000
378 Biopsi Tumor Hidung. Lidah. Nasofaring THT 2,850,000
379 Biopsi Tumor Kelopak 675,000
380 Biopsi Tumor Oral Cavity LF 250,000
381 Biopsi Tumor Orbita 3,850,000
382 Biopsi Vertebra (1 Level) 3,532,812
383 Biopsi/Proof Laparatomy 4,850,000
384 Biopsy of bone 9,190,468
385 Biopsy of bone marrow 2,998,053
386 Biopsy of carpals and metacarpals 5,202,000
387 Biopsy of femur 5,202,000
388 Biopsy of humerus 5,202,000
389 Biopsy of joint structure of ankle 5,752,000
390 Biopsy of joint structure of elbow 5,752,000
391 Biopsy of joint structure of foot and toe 5,752,000
392 Biopsy of joint structure of hand and finger 5,752,000
393 Biopsy of joint structure of hip 5,752,000
394 Biopsy of joint structure of knee 2,888,053
395 Biopsy of joint structure of shoulder 5,752,000
396 Biopsy of joint structure of wrist 5,752,000
397 Biopsy of joint structure, unspecified site 2,998,053
398 Biopsy of other bone, except facial bone 5,202,000
399 Biopsy of patella 5,202,000
400 Biopsy of radius and ulna 5,202,000
401 Biopsy of scapula, clavicle, and thorax (ribs and sternum) 5,202,000
402 Biopsy of soft tissue 3,864,200
403 Biopsy of spinal cord or spinal meninges 21,867,928
404 Biopsy of tarsals and metatarsals 5,202,000
405 Biopsy of tibia and fibula 5,202,000
406 Biotrainer 43,200
407 Blaas Functie 87,000
408 Bladder Neck Incision 6,923,000
409 Blandder Training 78,000
410 Blanket 46,000
411 Blanket Rol 46,000
412 Blanoplasty 0
413 Bleaching eksternal 0
414 Bleaching Internal 0
415 Blenharroplastik Atas 0
416 Blenharroplastik Bawah ( Kantong Mata ) 0
417 Blok Resectie 2,960,000
418 Blok Saraf Tepi 5,954,000
419 Blowing Exercise Meter 39,600
420 BMP (Bone Morrow Fucture) 1,000,000
421 BNO - IVP 375,000
422 Body Jacket 5,500,000
423 Bone graft of carpals and metacarpals 13,304,994
424 Bone graft of femur 13,154,994
425 Bone graft of humerus 13,254,994
426 Bone graft of patella 23,004,994
427 Bone graft of radius and ulna 13,254,994
428 Bone graft of scapula, clavicle, and thorax (ribs and sternum) 6,504,994
429 Bone graft of tarsals and metatarsals 8,504,994
430 Bone graft of tibia and fibula 23,004,994
431 Bone graft scapula, clavicle and thorax (ribs and sternum) 6,504,994
432 Bone Survey 450,000
433 Boston Brace 5,000,000
434 Bouginasi/Dilatasi Urethra (ESWL) 740,000
435 Brachytherapi - Base Of Tounge (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 19,000,000
436 Brachytherapi - Base Of Tounge (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 23,560,000
437 Brachytherapi - Base Of Tounge (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 23,000,000
438 Brachytherapi - Base Of Tounge (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 28,520,000
439 Brachytherapi - Cervix Implantas (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 11,000,000
440 Brachytherapi - Cervix Implantas (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 13,640,000
441 Brachytherapi - Cervix Implantas (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 13,000,000
442 Brachytherapi - Cervix Implantas (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 16,120,000
443 Brachytherapi - Cervix Implantas (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 16,000,000
444 Brachytherapi - Cervix Implantas (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 19,840,000
445 Brachytherapi - Cervix Intrakaviter Lengkap ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) 16,000,000
446 Brachytherapi - Cervix Intrakaviter Lengkap ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) + Anastesi 19,840,000
447 Brachytherapi - Cervix Intrakaviter Lengkap ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) 21,000,000
448 Brachytherapi - Cervix Intrakaviter Lengkap ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) + Anastesi 26,040,000
449 Brachytherapi - Kulit (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 6,000,000
450 Brachytherapi - Kulit (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 7,440,000
451 Brachytherapi - Kulit (1 X Tindakan + 3X Penyinaran + 1X Anestesi) 9,000,000
452 Brachytherapi - Kulit (1 X Tindakan + 3X Penyinaran + 1X Anestesi) + Anastesi 11,160,000
453 Brachytherapi - Lidah Anterior (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 13,000,000
454 Brachytherapi - Lidah Anterior (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 16,840,000
455 Brachytherapi - Lidah Anterior (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 19,000,000
456 Brachytherapi - Lidah Anterior (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 23,560,000
457 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 12,000,000
458 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 14,880,000
459 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 15,000,000
460 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 18,600,000
461 Brachytherapi - Ovoid ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) 10,000,000
462 Brachytherapi - Ovoid ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) + Anastesi 12,400,000
463 Brachytherapi - Ovoid ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) 16,000,000
464 Brachytherapi - Ovoid ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) + Anastesi 19,840,000
465 Brachytherapi - Payudara (1 X Tindakan + 1X Penyinaran + 1X Anestesi) 6,000,000
466 Brachytherapi - Payudara (1 X Tindakan + 1X Penyinaran + 1X Anestesi) + Anastesi 7,440,000
467 Brachytherapi - Payudara (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 9,000,000
468 Brachytherapi - Payudara (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 11,160,000
469 Brachytherapi - Perineal Implantasi (1 X Tindakan + 1X Penyinaran + 1X Anestesi) 10,000,000
470 Brachytherapi - Perineal Implantasi (1 X Tindakan + 1X Penyinaran + 1X Anestesi) + Anastesi 12,400,000
471 Brachytherapi - Perineal Implantasi (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 11,000,000
472 Brachytherapi - Perineal Implantasi (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 13,640,000
473 Brachytherapi - Perineal Implantasi (1X Tindakan + 3X Penyinaran + 1X Anestesi) 12,000,000
474 Brachytherapi - Perineal Implantasi (1X Tindakan + 3X Penyinaran + 1X Anestesi) + Anastesi 14,880,000
475 Brachytherapi - Radiasi Interna ( Terapi Iodium SO/2000/150 mCi ) 919,000
476 Brachytherapi - Radiasi Interna ( Terapi Samarium 50 mCi ) 788,000
477 Break up Time 33,000
478 Breakfast Paket C 55,000
479 Breast Conserving Surgery 4,850,000
480 Breathing Exercise 70,000
481 Brock + BT Shunt / ASD Closure + PDA Ligasi 40,350,000
482 Brock/BT Shunt/Coarctasio Aorta/PA Banding/Sling/Unifokalisasi 29,950,000
483 Bronchoskopi Toileting dan Lavage 587,000
484 Bronchospirometri 187,000
485 broncoskopi 900,000
486 Bronkoskopi Bilasan 805,000
487 Bronkoskopi Bilasan + Anastesi 1,585,000
488 Bronkoskopi Diagnostik 805,000
489 Bronkoskopi Diagnostik + Anastesi 1,585,000
490 Bronkoskopi Sikatan 805,000
491 Bronkoskopi Sikatan + Anastesi 1,585,000
492 Bronschoscopy (COT) 5,656,405
493 Brushing melalui Bronchoschopy 188,000
494 BSEF/FESS 1 : Mini 4,850,000
495 BSEF/FESS 2 : Mini+Maksila/etmoid 4,850,000
496 BSEF/FESS 3: Mini+Frontal/Sfenoid 5,850,000
497 BSEF/FESS 4 : Mini+maksila/etmoid+frontal/sfenoid 5,850,000
498 BSEF/FESS lanjut : Ekstirpasi Tumor.Penutupan defek intrakranial 5,850,000
499 BT Shunt+Ligasi MAPCA 36,190,000
500 BTA 1X Biakan Resistensi Medium Cair OAT Lini 1 438,000
501 BTA 1X Biakan Resistensi Medium Cair OAT Lini 2 500,000
502 BTA 3X Biakan Medium Cair 375,000
503 BTA 3X Biakan Medium Padat 188,000
504 Buka / Pasang Pesarium 116,000
505 Buka Gips 69,000
506 Buka Jahitan (Poli Jantung) 150,000
507 Buka Obtorator 55,000
508 Buka Tampon / Kassa Kamicetin 140,000
509 Buka Wiring dengan Anastesi Lokal 270,000
510 Buku ICV 25,000
511 Bunionectomy with soft tissue correction and arthrodesis 6,600,000
512 Bunionectomy with soft tissue correction and osteotomy of the first metatarsal 6,600,000
513 Bursectomy of hand 9,390,000
514 Bursotomy 9,390,000
515 Bursotomy of hand 11,196,000
516 Businasi 308,000
517 Businasi Hurtz (akhalasia) 966,000
518 Businasi Urethra 308,000
519 Butterfly Bath 98,400
520 C3 Komplemen (P) 500,000
521 C4 Komplemen (P) 500,000
522 CA 12-5 _ 265,000
523 CA 15-3 _ 350,000
524 CA 19-9 _ 300,000
525 CABG Lima + TV Repair/TAP DE VEGA + TPM + PPM/Endovasculer Stent Aorta 104,350,000
526 CABG Lima+Repair Aneurysme Artery Coroner 65,950,000
527 CABG+DVR 80,350,000
528 Cabut DJ Stent 3,125,000
529 Cabut IUD dengan Penyulit 173,000
530 Cabut Susut dengan Penyulit 253,000
531 Caldwell Luc Anthrostomi 3,850,000
532 Calsium _ 35,000
533 Cantharidin < 5 Lesi / > 5 Lesi 66,000
534 Capsulotomi Posterior 2,500,000
535 Cardio Toco Graphy (CTG)/Kebidanan 299,000
536 Carotid Doppler 725,000
537 Carotid Duplex Doppler 400,000
538 Carporadial fusion 5,596,121
539 Catherisasi pada Retensi Urin 56,000
540 CEA _ 280,000
541 Cek GDS 15,000
542 Cek Permanent Pace Maker 75,000
543 Cetak Film Ukuran Besar 70,000
544 Cetak Film Ukuran Kecil 50,000
545 Chairback (Biasa) 1,320,000
546 Chairback (Khusus) 2,850,000
547 Chemo surgery Podophyllin 66,000
548 Chemo surgery TCAA 66,000
549 ChemoEmbolisasi pada Hepatoma/tumor lain 24,883,390
550 ChemoEmbolisasi pada Hepatoma/tumor lain + Anastesi 45,450,000
551 Chest Port 14,450,000
552 Chest Port + Anastesi 18,950,000
553 Chest Re Open Rekonstruksi 14,750,000
554 Cimino (Bedah Vaskuler) 4,784,000
555 Circumsisi bayi dan anak dengan anastesi umum 2,159,000
556 CK _ 65,000
557 CK-MB _ 65,000
558 Clinical Kaustik 66,000
559 Closed Reduction dengan Anastesi Lokal 860,000
560 Closed reduction of dislocation of ankle 4,375,000
561 Closed reduction of dislocation of elbow 2,799,523
562 Closed reduction of dislocation of foot and toe 4,375,000
563 Closed reduction of dislocation of hand and finger 2,799,523
564 Closed reduction of dislocation of hip 3,899,523
565 Closed reduction of dislocation of knee 4,375,000
566 Closed reduction of dislocation of shoulder 2,849,523
567 Closed reduction of dislocation of wrist 4,375,000
568 Closed reduction of fracture with internal fixation, carpals and metacarpals 5,828,000
569 Closed reduction of fracture with internal fixation, femur 5,828,000
570 Closed reduction of fracture with internal fixation, humerus 5,828,000
571 Closed reduction of fracture with internal fixation, phalanges of foot 5,828,000
572 Closed reduction of fracture with internal fixation, radius and ulna 5,828,000
573 Closed reduction of fracture with internal fixation, tarsals and metatarsals 5,828,000
574 Closed reduction of fracture with internal fixation, tibia and fibula 5,828,000
575 Closed reduction of fracture with internal fixation,phalanges of hand 5,828,000
576 Closed reduction of fracture without internal fixation, carpals and metacarpals 2,963,182
577 Closed reduction of fracture without internal fixation, femur 2,963,182
578 Closed reduction of fracture without internal fixation, humerus 4,375,000
579 Closed reduction of fracture without internal fixation, phalanges of foot 4,375,000
580 Closed reduction of fracture without internal fixation, phalanges of hand 4,375,000
581 Closed reduction of fracture without internal fixation, radius and ulna 2,963,182
582 Closed reduction of fracture without internal fixation, tarsals and metatarsals 4,375,000
583 Closed reduction of fracture without internal fixation, tibia and fibula 2,963,182
584 Closed reduction of separated epiphysis of femur 4,375,000
585 Closed reduction of separated epiphysis of humerus 4,375,000
586 Closed reduction of separated epiphysis of radius and ulna 4,375,000
587 Closed reduction of separated epiphysis of tibia and fibula 4,375,000
588 Coartasio Aorta Repair+PDA Ligasi+PA Banding 31,630,000
589 Cock Up Splint (Biasa) 1,800,000
590 Cock Up Splint (Standar/Khusus) 2,500,000
591 Colon - Inloop 500,000
592 Combination Therapi 43,200
593 Complicated Functional Neuro (P.Paraverteb/Visceral Blok) 9,094,887
594 Complicated Functional Neuro (Percuteneus Kordotomi) 11,110,887
595 Complicated Functional Neuro (Stereotaxy Kompleks) 14,736,887
596 Complicated Functional Neuro (Stereotaxy sederhana) 13,306,887
597 Comprehensive Geriatric Assesment (CGA) 66,000
598 Computer Spech Therapi 39,600
599 Condylotomy Mandibula 4,850,000
600 Cone Biopsi/ Konisasi/ LETZ 2,850,000
601 Congenital Formix Plastik/ Rekst Soket Berat 4,675,000
602 Cool Box (1X Pengiriman Darah) 10,000
603 Coombs Test _ 160,000
604 Cor Analysa 400,000
605 Corangiography + TPM 7,033,000
606 Corangiography+Arteriografy/Corangiography+Katerisasi 9,200,000
607 Core Build-up Composite 0
608 Core Build-up Glass lonomer 0
609 Core Build-up Glass lonomer Pengambilan 2/3 Guttap 0
610 Corpus Alinium Cornea 250,000
611 Correction of syndactyly 6,600,000
612 Cortisol (P) 448,000
613 Coustik Hidung 36,000
614 CPM 42,000
615 Cranial or peripheral nerve graft 11,682,099
616 Croos Insisi 44,000
617 Cross Leg Flap 8,950,000
618 Cross Matching 170,000
619 Crown & Bridge (Acrylic per unit) 295,000
620 Crown & Bridge (Porcelain per unit) 765,000
621 CRP Kuantitatif 130,000
622 CRRT (Continous Renal Replacement Therapy) 33,720,000
623 CRT / ICD 81,550,000
624 Cryo Jet 75,000
625 Cryo Therapi 43,200
626 Cryoglobulin 25,000
627 CT Abdomen Atas/Bawah ( Dengan Kontras ) 1,500,000
628 CT Abdomen Atas/Bawah ( Dengan Kontras ) + Anestesi 1,780,000
629 CT Abdomen Atas/Bawah ( Dengan Kontras ) Rujukan Luar 0
630 CT Abdomen Atas/Bawah ( Tanpa Kontras ) 875,000
631 CT Abdomen Atas/Bawah ( Tanpa Kontras ) + Anestesi 1,075,000
632 CT Abdomen Atas/Bawah ( Tanpa Kontras ) Rujukan Luar 0
633 CT Cervical ( Dengan Kontras ) 1,500,000
634 CT Cervical ( Dengan Kontras ) + Anestesi 1,780,000
635 CT Cervical ( Tanpa Kontras ) 875,000
636 CT Cervical ( Tanpa Kontras ) + Anestesi 1,075,000
637 CT Ekstremitas Atas/Bawah ( Dengan Kontras ) 1,500,000
638 CT Ekstremitas Atas/Bawah ( Dengan Kontras ) + Anestesi 1,780,000
639 CT Ekstremitas Atas/Bawah ( Tanpa Kontras ) 875,000
640 CT Ekstremitas Atas/Bawah ( Tanpa Kontras ) + Anestesi 1,075,000
641 CT Kepala ( Dengan Kontras ) 900,000
642 CT Kepala ( Dengan Kontras ) + Anestesi 1,080,000
643 CT Kepala ( Tanpa Kontras ) 750,000
644 CT Kepala ( Tanpa Kontras ) + Anestesi 910,000
645 CT Lumbal ( Dengan Kontras ) 1,500,000
646 CT Lumbal ( Dengan Kontras ) + Anestesi 1,780,000
647 CT Lumbal ( Tanpa Kontras ) 875,000
648 CT Lumbal ( Tanpa Kontras ) + Anestesi 1,075,000
649 CT Mastoid ( Dengan Kontras ) 900,000
650 CT Mastoid ( Dengan Kontras ) + Anestesi 1,080,000
651 CT Mastoid ( Tanpa Kontras ) 750,000
652 CT Mastoid ( Tanpa Kontras ) + Anestesi 910,000
653 CT Nasofaring ( Dengan Kontras ) 900,000
654 CT Nasofaring ( Dengan Kontras ) + Anestesi 1,080,000
655 CT Nasofaring ( Tanpa Kontras ) 750,000
656 CT Nasofaring ( Tanpa Kontras ) + Anestesi 910,000
657 CT Pelvis ( Dengan Kontras ) 1,500,000
658 CT Pelvis ( Dengan Kontras ) + Anestesi 1,780,000
659 CT Pelvis ( Tanpa Kontras ) 875,000
660 CT Pelvis ( Tanpa Kontras ) + Anestesi 1,075,000
661 CT Scan Simulator dengan kontras 1,671,000
662 CT Scan Simulator tanpa kontras 1,671,000
663 CT Sinus Paranasal ( Dengan Kontras ) 900,000
664 CT Sinus Paranasal ( Dengan Kontras ) + Anestesi 1,080,000
665 CT Sinus Paranasal ( Tanpa Kontras ) 750,000
666 CT Sinus Paranasal ( Tanpa Kontras ) + Anestesi 910,000
667 CT Thoracal ( Dengan Kontras ) 1,500,000
668 CT Thoracal ( Dengan Kontras ) + Anestesi 1,780,000
669 CT Thoracal ( Tanpa Kontras ) 875,000
670 CT Thoracal ( Tanpa Kontras ) + Anestesi 1,075,000
671 CT Thoraks ( Dengan Kontras ) 1,500,000
672 CT Thoraks ( Dengan Kontras ) + Anestesi 1,780,000
673 CT Thoraks ( Tanpa Kontras ) 875,000
674 CT Thoraks ( Tanpa Kontras ) + Anestesi 1,075,000
675 CT Tyroid/Leher ( Dengan Kontras ) 900,000
676 CT Tyroid/Leher ( Dengan Kontras ) (Rujukan Luar) 900,000
677 CT Tyroid/Leher ( Dengan Kontras ) + Anestesi 1,080,000
678 CT Tyroid/Leher ( Tanpa Kontras ) 750,000
679 CT Tyroid/Leher ( Tanpa Kontras ) (Rujukan Luar) 750,000
680 CT Tyroid/Leher ( Tanpa Kontras ) + Anestesi 910,000
681 CT Whole Abdomen ( Dengan Kontras ) 2,375,000
682 CT Whole Abdomen ( Dengan Kontras ) + Anestesi 2,805,000
683 CT Whole Abdomen ( Tanpa Kontras ) 1,250,000
684 CT Whole Abdomen ( Tanpa Kontras ) + Anestesi 1,490,000
685 CT Whole Body ( Tanpa kontras ) 1,250,000
686 CT Whole Body ( Tanpa kontras ) + Anestesi 1,490,000
687 CT Whole Body (Dengan Kontras) 2,375,000
688 CT Whole Body (Dengan Kontras) + Anestesi 2,805,000
689 CT. Abdomen Full (Rujukan Luar) 0
690 CT. Kepala (Dengan Contras) 900,000
691 Cuci Canule 38,000
692 Cuci Lambung 121,000
693 Curretage pada rentensi plasenta / Mola Pertama 352,000
694 Custom Post/Saluran Akar 0
695 Cutting and preparation of pedicle grafts or flaps 10,925,000
696 Cyclodia Termi 4,011,743
697 Cyclodialysa 3,997,000
698 Cyfra 21-1 _ 588,000
699 Cyro Surgery Besar 155,000
700 Cyro Surgery Ringan 90,000
701 Cysjejunostomi 6,175,000
702 Cystoscopy biopsi (ESWL) 2,500,000
703 D Dimer _ 450,000
704 Dacryo Cysto Rhinostomi 11,581,770
705 Daptone (Doppler) 57,000
706 Darah Lengkap 62,000
707 Darah Per Bag ( BDRS ) 400,000
708 Darah Per Bag (PMI) 325,000
709 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- Afaresis 3,500,000
710 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- FFP 325,000
711 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- PRC 325,000
712 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- WB 325,000
713 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- WE 475,000
714 Darah Per Bag (UTD Provinsi Sul-Sel) 250,000
715 Darah Per Bag (UTD Provinsi Sul-Sel) (Tindakan Cross Matching dan Golongan Darah) 310,000
716 Darah Perifer Lengkap Serial 68,000
717 Darah Rutin 0
718 Daye Test 100,000
719 DCR + Silikon Tube 8,350,000
720 Debridemen Luka dengan Anastesi Lokal 270,000
721 Debridement and anterior fusion in TB spine 4,850,000
722 Debridement dengan falp 4,850,000
723 Debridement dengan Skingarfting Kecil 3,850,000
724 Debridement dengan Skingarfting Luas 4,850,000
725 Debridement of nail, nail bed, or nail fold 3,125,000
726 Debridement of open fracture of carpals and metacarpals 11,516,003
727 Debridement of open fracture of femur 11,116,003
728 Debridement of open fracture of humerus 3,125,000
729 Debridement of open fracture of phalanges of foot 6,486,003
730 Debridement of open fracture of phalanges of hand 11,516,003
731 Debridement of open fracture of radius and ulna 11,516,003
732 Debridement of open fracture of tarsals and metatarsals 6,486,003
733 Debridement of open fracture of tibia and fibula 23,016,003
734 Debridement Pada Luka Bakar < 40% 5,579,641
735 Debridement Pada Luka Bakar > 40% 6,348,641
736 Debridement Ulang Vaskuler/ Debridement dng amputasi mayor 2,850,000
737 Debridement/EmbolisasiSederhana/Op.JantungTertutup/PTA/TAI 13,150,000
738 Debulking 6,917,222
739 Defibrilator 1,067,000
740 Deflasi dengan Anastesi Lokal 860,000
741 Dekanulasi 250,000
742 Dekompresi orbita 6,357,000
743 Dekompresi Syaraf Tepi 5,382,587
744 Dekompresia Fasialis 5,482,645
745 Delayed suture of flexor tendon of hand 11,196,000
746 Delayed suture of other tendon of hand 9,682,099
747 Delayed suture of tendon 11,196,000
748 Dengue NS1 _ 250,000
749 Denis Brown 3,800,000
750 Dental Rontgen Foto (Non Rujukan) 0
751 Dermabrasi (Luas) 598,000
752 Dermabrasi (Sedikit) 282,000
753 Dermaroller 0
754 Deroofing/unroofing kista 4,850,000
755 Deseksi Kelenjar Inguinal 5,299,955
756 Desinfektan Jenazah 100,000
757 Desinfektan Mobil Jenazah 100,000
758 Detorsi testis + Orchidopexy 6,238,462
759 DHF IGg/IgM (ICT) 220,000
760 Dialisis Peritoneal 66,000
761 Diathermy 75,000
762 Dietary Survielance and Councelling pada Penyakit Khusus 100,000
763 Dietary Survielance and Councelling pada Weight Management 100,000
764 Dikortikasi ( Bedah Paru/Thorax) 21,102,000
765 Dilatasi Phimosis 66,000
766 Direct Veneer/(Composite) 0
767 Disarticulation of ankle 5,247,099
768 Disarticulation of elbow 5,247,099
769 Disarticulation of hip 5,247,099
770 Disarticulation of knee 5,247,099
771 Disarticulation of shoulder 5,247,099
772 Disarticulation of wrist 5,247,099
773 Diseksi KGB Pelvis 7,885,000
774 Diseksi Leher Radikal Modifikasi/Fungsional 4,599,000
775 Divertikulektomi 6,923,213
776 Divertikulektomi Vesika 8,215,530
777 Divertikulum uretra 4,850,000
778 Division of joint capsule, ligament, or cartilage of ankle 8,105,000
779 Division of joint capsule, ligament, or cartilage of elbow 8,105,000
780 Division of joint capsule, ligament, or cartilage of foot and toe 8,105,000
781 Division of joint capsule, ligament, or cartilage of hand and finger 8,105,000
782 Division of joint capsule, ligament, or cartilage of hip 8,105,000
783 Division of joint capsule, ligament, or cartilage of knee 8,105,000
784 Division of joint capsule, ligament, or cartilage of shoulder 8,105,000
785 Division of joint capsule, ligament, or cartilage of wrist 8,105,000
786 Dorsal and dorsolumbar fusion, anterior technique 9,957,600
787 Dorsal and dorsolumbar fusion, posterior technique 9,957,600
788 Double Lumen Catheter 4,784,000
789 Drainage Kista Pankreas 3,850,000
790 Drainage Periureter 5,132,887
791 Drainase Pus Pada Tuboovarial Abses Dengan Punksi Doglasi 2,850,000
792 Dry Needling 250,000
793 Ductulography 375,000
794 Duedenoduodenostomi /Duodenojejunostomi 9,464,367
795 Ebstein(TV)Anomali Repair/TAPVD 53,150,000
796 Echo Anak 400,000
797 Echo Dewasa 300,000
798 Echocardiography 0
799 Edema Test 78,000
800 Edukasi Keluarga 75,000
801 Edukasi Kemotherapi 100,000
802 EEG 695,000
803 EKG/Elektrokardiografi 73,000
804 Eksenterasi 12,661,000
805 Eksisi / Ekstirpasi Salolith dengan Anastesi Lokal 860,000
806 Eksisi / Esterpasi 80,000
807 Eksisi Angiofibroma Nasofaring 6,350,000
808 Eksisi Baker Cyst 5,008,000
809 Eksisi Basalioma 1,350,000
810 Eksisi Biopsy dengan Anastesi Lokal 860,000
811 Eksisi Ca Laring dengan Laser 3,850,000
812 Eksisi Chalazion/Hordeolum 675,000
813 Eksisi Chodee 5,149,000
814 Eksisi Chordae Hyspospadia 4,850,000
815 Eksisi Clavus 250,000
816 Eksisi Condiloma Accuminata 66,000
817 Eksisi Dengan Lokal Anastesi 675,000
818 Eksisi Denture Hyperplasia dengan Anastesi Lokal 860,000
819 Eksisi FAM < 5cm 2,623,437
820 Eksisi FAM > 5cm 2,850,000
821 Eksisi Fibroma 2,850,000
822 Eksisi Fistel Preauricular 2,850,000
823 Eksisi Giant Nevus (tampa skin graft) 2,850,000
824 Eksisi Giant Nevus + skin graft 4,850,000
825 Eksisi Granuloma 250,000
826 Eksisi Granuloma (Poli Mata) 675,000
827 Eksisi Granuloma Pyogenikum 250,000
828 Eksisi Granuloma/Granuloma Hibilical/Hemanioma Kecil 2,159,000
829 Eksisi Gynecomastie 4,995,000
830 Eksisi Heangiona Luas 6,792,089
831 Eksisi Hemangioma Besar skingraft STSG/FTSG 5,634,913
832 Eksisi Hemangioma Besar/Multiple 5,634,913
833 Eksisi Hemangioma Kecil 2,850,000
834 Eksisi Hemangioma Sedang 3,850,000
835 Eksisi Higroma 4,850,000
836 Eksisi Higroma Pada Anak 6,238,462
837 Eksisi Hygroma Colli/Axilla Neonatus 6,175,000
838 Eksisi Hygroma/Lympohagioma Simple 3,850,000
839 Eksisi Kelenjar Liur Submandibula 3,887,600
840 Eksisi Keloid < 5 cm 66,000
841 Eksisi Kista Brachialis 3,850,000
842 Eksisi Kista Branchiogenik 3,936,000
843 Eksisi Kista Bronchial 6,238,462
844 Eksisi Kista Duktus Kholedukhus 17,350,000
845 Eksisi Kista Duktus Triglosus 5,059,548
846 Eksisi Kista Saluran Empedu 6,175,000
847 Eksisi Kista Tiroglosus 3,892,000
848 Eksisi Kista Urachus 6,238,462
849 Eksisi Limfedema + skin graft (charles prosedur) 4,850,000
850 Eksisi Luas Lokal 4,850,000
851 Eksisi Luas Radikal + Rekontruksi 5,336,807
852 Eksisi Mammae Aberran (Klp. III) 4,518,992
853 Eksisi Multiple FAM 4,527,541
854 Eksisi Neuroblastoma 6,175,000
855 Eksisi Neurofibroma Multiple 4,990,913
856 Eksisi Pterigium Bare Sklera 675,000
857 Eksisi Skin Grafting 250,000
858 Eksisi Syringoma 66,000
859 Eksisi Tatto (Besar) 2,350,000
860 Eksisi Tatto (Lokal) 600,000
861 Eksisi Tatto (Sedang) 2,000,000
862 Eksisi Teratoma Ovarium 12,022,946
863 Eksisi Teratoma Retroperitoneal 6,151,418
864 Eksisi Teratoma Sacrococcygeal 11,130,825
865 Eksisi Torus Palatinus / Mansibularis dengan Anastesi Lokal 860,000
866 Eksisi Tragus Acsesories 2,850,000
867 Eksisi Tumor Adneksa Kecil 2,850,000
868 Eksisi Tumor Adneksa Sedang 3,850,000
869 Eksisi Veruka Vulgaris 66,000
870 Eksisi Webbed Penis 4,850,000
871 Eksisi Xantelasma 2,850,000
872 Eksisi Xantelasma (Besar) 2,350,000
873 Eksisi Xantelasma (Sedang) 2,000,000
874 Eksisi Xantoma 250,000
875 Eksisi/Ekstirpasi Tumor Jinak Kulit (Besar) 1,450,000
876 Eksisi/Ekstirpasi Tumor Jinak Kulit (Kecil) 700,000
877 Eksisi/Ekstirpasi Tumor Jinak Kulit (Sedang) 1,200,000
878 Eksisi/Esterpasi 80,000
879 Eksisi/Konisasi 6,074,400
880 Eksisi/Limfangioma Simple 4,986,687
881 Eksisi/Reduksi Neurofibroma Kompleks 4,850,000
882 Eksoftalmometri 30,000
883 Eksplorasi Abses Mandibula 3,850,000
884 Eksplorasi Abses Multiple ( Bedah Vaskuler ) 3,850,000
885 Eksplorasi Abses Multiple THT 4,850,000
886 Eksplorasi Abses Parafaringeal 3,850,000
887 Eksplorasi Kista Branchial 5,767,645
888 Eksplorasi Kista Ductus Tiroglosus 5,767,645
889 Eksplorasi Kista Tiroid 5,788,179
890 Eksplorasi Kolekdokus 4,406,075
891 Eksplorasi Luka 60,000
892 Eksplorasi Nasofaring 3,850,000
893 Eksterpasi / Biopsi Polip Serviks Kacil < 1/2 135,000
894 Eksterpasi dan Kuretase 840,000
895 Eksterpasi Fistel Preaurikuler 4,530,362
896 Eksterpasi Kista Ateroma/Lipoma Ganglion < 2cm 250,000
897 Eksterpasi Kista Bartholin 2,850,000
898 Eksterpasi Limpoma, ganglion kista epidermoid, neurolibroma sactase 2,159,000
899 Eksterpasi Miom Geburt 2,850,000
900 Ekstipasi Adenomiosis 4,850,000
901 Ekstipasi Tumor Scalp/Cranium 5,586,887
902 Ekstirpasi Corpus Alienum 150,000
903 Ekstirpasi Fibroma 2,850,000
904 Ekstirpasi Kista Ateroma / Lipoma / Ganglion > 2cm 2,850,000
905 Ekstirpasi Kista Epidermoid 250,000
906 Ekstirpasi Kuku 0
907 Ekstirpasi Papiloma 3,850,000
908 Ekstirpasi Preaurikuler Fistel THT 4,850,000
909 Ekstirpasi Tumor Ganas Adnesa + Rekonstruksi 12,350,000
910 Ekstirpasi Tumor Jinak 250,000
911 Ekstirpasi Tumor Jinak Kel.Liur THT 4,850,000
912 Ekstirpasi Tumor Jinak Kulit 0 < 3cm (Lipoma,Atheroma,dll) 2,850,000
913 Ekstirpasi Tumor Jinak Lain > 5 cm 3,850,000
914 Ekstirpasi Tumor Jinak Sinonasal Oral Cavity 3,850,000
915 Ekstirpasi Tumor Jinak THT 675,000
916 Ekstrackel benda asing dengan anastesi umum 2,159,000
917 Ekstraksi / Operasi (Alveolectomy pr Kwadran) 180,000
918 Ekstraksi / Operasi (Epulis) 165,000
919 Ekstraksi / Operasi (Fraktur Rahang) 450,000
920 Ekstraksi / Operasi (Gigi Permanent Komplikasi) 200,000
921 Ekstraksi / Operasi (Gigi Permanent Normal) 105,000
922 Ekstraksi / Operasi (Gigi Sulung / Chloraethyl) 70,000
923 Ekstraksi / Operasi (Gigi Sulung / Citoject) 75,000
924 Ekstraksi / Operasi (Incisi Abses) 250,000
925 Ekstraksi / Operasi (Kista) 330,000
926 Ekstraksi / Operasi (Mucocele) 350,000
927 Ekstraksi / Operasi (Odontektomi Dengan komplikasi) 455,000
928 Ekstraksi / Operasi (Odontektomi Tanpa komplikasi) 325,000
929 Ekstraksi Batu 4,850,000
930 Ekstraksi Benda Asing 552,000
931 Ekstraksi Benda Asing + Anastesi 1,247,000
932 Ekstraksi Benda Asing dengan Penyulit 250,000
933 Ekstraksi benda asing disaluran cerna bagian atas/bawah 2,850,000
934 Ekstraksi Comedo 130,000
935 Ekstraksi Corpus Alienum 59,000
936 Ekstraksi Corpus Aliineum Cornea 250,000
937 Ekstraksi Gigi / Fragmen Gigi Penyulit dengan Anastesi 270,000
938 Ekstraksi jaringan granulasi pada telinga 66,000
939 Ekstraksi Kolesteatom Eksterna 250,000
940 Ekstraksi korpus alineum cavum nasi 0
941 Ekstraksi Kuku 250,000
942 Ekstraksi Kuku Berat (Besar) 317,000
943 Ekstraksi Kuku Sederhana (Sedang) 190,000
944 Ekstraksi Linear 4,866,237
945 Ekstraksi Per Gigi dengan Anastesi Lokal 140,000
946 Ekstraksi polip hidung ( polipektomi simpleks) 100,000
947 Ekstraksi Serumen Dengan Penyulit 66,000
948 Ekstraksi Serumen Telinga 26,000
949 Elbow Brace (Biasa) 1,500,000
950 Elbow Brace (Khusus) 2,750,000
951 Elektrikal Stimulasi 75,000
952 Elektro Couter Besar 385,000
953 Elektro Couter Kecil 222,000
954 Elektro Couter Sedang 302,000
955 Elektro Physiologi Study (EP Study) 15,350,000
956 Elektro Physiologi Study (EP Study) + Ablasi 36,350,000
957 Elektrofulgurasi 66,000
958 Elektrokauter Keratosis Seboroik 710,000
959 Elektrolit _ 120,000
960 Elektrolit Urine 24 Jam 100,000
961 Embolektomi/Pleurodesis/RedoOperationForStopBleeding/Thoracotomi 13,550,000
962 Embolisasi dengan Spongiostan (Preop) 16,309,000
963 Embolisasi dengan Spongiostan (Preop) + Anastesi 33,450,000
964 Embolisasi pada Perdarahan Intraabdominal / Extermitas yang Menggunakan Gel Foam + Anastesi 26,610,000
965 Embolisasi pada Perdarahan Intraabdominal / Extremitas yang Menggunakan Coil + Anastesi 26,900,000
966 Embolisasi pada perdarahan intraabdominal/extremitas yang menggunakan coil 20,044,886
967 Embolisasi pada perdarahan intraabdominal/extremitas yang menggunakan gel foam 19,975,590
968 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan gel foam 19,975,590
969 Embolisasi pada Tumor Intraabdominal / Extremitas yang Menggunakan Gel Foam + Anastesi 26,610,000
970 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan PVA 21,161,761
971 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan PVA + Anastesi 31,750,000
972 Embriotomi (Eviserasi /punksi) 1,800,000
973 Embriotomi (Kranioklasi) 1,800,000
974 Embriotomi (Perforasi + Dekapitasi) 1,800,000
975 EMG 568,000
976 Endodontic One Visit Gigi Anterior (Akar Tunggal) 0
977 Endodontic One Visit Gigi Posterior (Akar Jamak) 0
978 Endorectal pull-through/ soave Boley 6,175,000
979 Endoscopy teurapeutic (BA) 6,175,000
980 enucleatie kista 2,510,000
981 Enucleatie Kista D 42 4,850,000
982 Enukleasi + DFG 6,822,174
983 Enukleasi Besar dengan Anastesi Lokal 860,000
984 Enukleasi Kecil dengan Anastesi Lokal 860,000
985 Enukleasi Kista Ginjal 6,926,000
986 Enukleasi Milia 66,000
987 Enukleasi Mol 66,000
988 Enukleasi Moluskum Banyak (Besar) 152,000
989 Enukleasi Moluskum Sedikit (Sedang) 111,000
990 Epicardial Permanen Pace Maker(Microny)/PDA=MOF/Pengangkatan Embolusi(Device Embolusi) dengan CPB)/PS Repair 33,550,000
991 Epidimovasostomi/Epididimovasostomi 10,320,000
992 Epidural Steroid Cateter 765,000
993 Epidural Steroid Injection 633,000
994 Epilasi Bulu Mata 84,000
995 Episiotomi + Jahitan Perineum 120,000
996 ERCP (Endoscopy Retrograde Cholangio Pankreatografi) 5,020,000
997 ERCP + Extraksi Batu Inci Lithotriptor 3,125,000
998 ERCP Biopsy 6,860,000
999 ERCP Litotripsi Mechanical 14,126,000
1000 ERCP NBD (Nasobiliary Drainage) 7,378,000
1001 ERCP Sphincterotome 9,114,000
1002 ERCP Stent (Drainase Bilier) 8,960,000
1003 ERCP(Endoscopy Retrograde Cholangio Pankreatografi) (Rujukan Luar) 38,680,000
1004 Eritrosit Cuci (WE) Perkantong 475,000
1005 Esofagogastroduodenoskopi Diagnostik (GEH) 2,120,000
1006 Esofagogastroduodenoskopi Diagnostik (GEH) + Anastesi 3,155,000
1007 Esofagomyotomi 6,175,000
1008 Esofagoskopi Diagnostik 875,000
1009 Esofagoskopi Diagnostik + Anastesi 1,752,000
1010 Esofagostomi + Gastrotomi (Atresia Esophagus) 6,175,000
1011 Esoghageal Replacement Procedure (Transposisi Kolon, Transposisi gaster, gastric Pull-up) 6,175,000
1012 Esophagoscopy 5,647,645
1013 ESST 1 (Paket 12X Tindakan) 0
1014 ESST 1/2 (Paket 6X Tindakan) 0
1015 Estradiol 263,000
1016 Estradiol (P) 422,000
1017 ESWL FASE I 7,841,000
1018 ESWL FASE II 7,000,000
1019 ESWL Prostatron 5,376,000
1020 Ethmoidektomi (Intranasal) 5,827,645
1021 Evakuasi Bekuan Darah (Clot) 4,442,187
1022 Evaluasi SST _ 600,000
1023 Eviserasi + DFG 6,904,436
1024 Excisi Biopsi 77,000
1025 Excision of bone for graft, carpus and metacarpus 6,600,000
1026 Excision of bone for graft, femur 6,600,000
1027 Excision of bone for graft, humerus 6,600,000
1028 Excision of bone for graft, patella 6,600,000
1029 Excision of bone for graft, radius and ulna 6,600,000
1030 Excision of bone for graft, scapula, clavicle, and thorax (ribs and sternum) 6,600,000
1031 Excision of bone for graft, tarsals and metatarsals 6,600,000
1032 Excision of bone for graft, tibia and fibula 6,600,000
1033 Excision of intervertebral disc 14,020,000
1034 Excision of lesion of muscle 9,390,000
1035 Excision of lesion of muscle of hand 9,390,000
1036 Excision of lesion of other soft tissue 9,390,000
1037 Excision of lesion of tendon sheath 9,390,000
1038 Excision of lesion of tendon sheath of hand 9,390,000
1039 Excision of muscle or fascia for graft 11,196,000
1040 Excision of muscle or fascia of hand for graft 9,390,000
1041 Excision of other lesion of soft tissue of hand 9,390,000
1042 Excision of semilunar cartilage of knee 16,485,212
1043 Excision of skin for graft 7,522,000
1044 Excision of tendon of hand for graft 9,390,000
1045 Excision or correction of bunionette 6,600,000
1046 Excisional debridement of wound, infection, or burn 2,350,000
1047 Excohliasi 2,510,000
1048 Exercise / Latihan Wicara 22,800
1049 Exercise Not Elshewhere Classified 70,000
1050 Exercise Therapi ( Latihan ) 56,400
1051 Exflorasi Vagina 5,979,000
1052 Explorasi Testis Mikro Surgery 7,777,000
1053 Exploration of tendon sheath 9,390,000
1054 Exploration of tendon sheath of hand 11,196,000
1055 Exposure Mahkota Gigi Terpendam dengan Anastesi Lokal 860,000
1056 Extended Pyelolithektomi (Gilverne) 7,214,004
1057 Exterpasi / Eksisi Kecil 283,000
1058 Exterpasi Besar / Eksisi 386,000
1059 Extirpasi Polip 2,850,000
1060 Extirpasi Polip Cavum Nasi 4,532,000
1061 Extirpasi Tumor 2,510,000
1062 Extirpatie Plunging Ranula 2,960,000
1063 Extraksi Kalium Oxalat 66,000
1064 Extubasi 700,000
1065 Eye Reflex Test 78,000
1066 FAAL Paru 150,000
1067 Facet Blok (1 Level/Multilevel) 3,850,000
1068 Facial 65,000
1069 Facialis Parase 73,000
1070 Faktor IX (P) 416,000
1071 Faktor VIII (P) 416,000
1072 Family Therapi 33,000
1073 Faradic / Galvanic 45,600
1074 Fare Head Flap 5,482,645
1075 Faringotomi 5,482,645
1076 Fasciotomy 6,424,400
1077 Fasciotomy of hand 9,282,099
1078 Fe (Besi) _ 45,000
1079 Feeding Tube 36,000
1080 Feeling AHA / TCA 200,000
1081 Ferritine _ 230,000
1082 Fetocide Dengan Anastesi Lokal 396,000
1083 Fiber Post/buah 0
1084 Fibrinogen _ 200,000
1085 Fibro Adenom Mamae 3,444,000
1086 Fibro Adenoma ( Fibroma ) 0
1087 Fibro Adenoma ( Fibroma Multi ) 0
1088 Fibro Adenoma > Tumor (Besar) 480,000
1089 Fibroadenoma (Mammae) / Biji (Sedang) 157,000
1090 Fibroscan 832,000
1091 Filaria 27,500
1092 Fine Needle Aspirasi (FNA) 145,000
1093 Finger Insole 163,000
1094 Finger reattachment 10,675,000
1095 Finger Splint 316,000
1096 Fisioterapi Dengan Alat (4x Tindakan) 250,000
1097 Fistula Eterovesika 6,925,000
1098 Fistulectomi 2,850,000
1099 Fistulectomy Perianal 4,962,559
1100 Fistulektomi / Repair Fistel Uretra 4,442,187
1101 Fistulektomi/Fistula Ani 4,183,286
1102 Fistulografi 500,000
1103 Five-in-one repair of knee 8,105,000
1104 Flebektomi 2,850,000
1105 Flexible Endoscopy Evaluation Of Swallowing (FEES) 1,077,000
1106 Flourocences Insitu Hybridization 3,125,000
1107 Flusing CAPD 855,000
1108 Fontan/Kawashima/Penutupan VSD tanpa Pembedahan Dgn Menggunakan Device (AMVO)/Repair Aneuryema Of Sinus Valsava 68,031,954
1109 Fontan/Kawashima/Penutupan VSD tanpa Pembedahan Dgn Menggunakan Device (AMVO)/Repair Aneuryema Of Sinus Valsava + Anastesi 77,790,699
1110 Foot Glove Prosthesis 18,630,000
1111 Foot reattachment 10,675,000
1112 Foot Splint (Biasa) 1,500,000
1113 Foot Splint Orfit 3,500,000
1114 Fore Head flap (Bedah Plastik) 4,850,000
1115 Forearm Crutches (Biasa) 170,000
1116 Forearm Crutches (Standar) 385,000
1117 Forearm, wrist, or hand reattachment 10,675,000
1118 Forehead Flap THT 4,850,000
1119 Fosfor Anorganik (P) 98,000
1120 Fosfor Anorganik Urine (P) 98,000
1121 Foto Abdomen (1 Posisi/2 Posisi/BNO/Foto polos Abdomen) 125,000
1122 Foto Abdomen 3 Posisi 250,000
1123 Foto Abdomen Invertogram 160,000
1124 Foto Adenoid 125,000
1125 Foto Ankle Joint AP + Lateral D/S 160,000
1126 Foto Ankle Joint AP + Lateral D+S 180,000
1127 Foto Ankle Joint Mortise View 125,000
1128 Foto Ankle/Ankle Bilateral (AP/Lat/Keduanya) 125,000
1129 Foto Ante Brachii/Ante Brachii Bilateral 125,000
1130 Foto Antebrachi AP + Lateral D/S 160,000
1131 Foto Antebrachi AP + Lateral D+S 180,000
1132 Foto Basis Kranii 125,000
1133 Foto Bone Age 125,000
1134 Foto Cephalo 125,000
1135 Foto Cervical AP + Lateral + Obliq 3 Posisi 200,000
1136 Foto Cervical Open Mouth 125,000
1137 Foto Clavicula D/S 125,000
1138 Foto Clavicula D+S 180,000
1139 Foto Costae 125,000
1140 Foto Coxae 125,000
1141 Foto Cruris AP + Lateral D/S 160,000
1142 Foto Cruris AP + Lateral D+S 180,000
1143 Foto Cubiti/Cubiti Bilateral 125,000
1144 Foto Femur Ap + Lateral D/S 160,000
1145 Foto Femur Ap + Lateral D+S 180,000
1146 Foto Fundus 250,000
1147 Foto Genu AP + Lateral & Sky Line View D/S 180,000
1148 Foto Genu AP + Lateral & Sky Line View D+S 200,000
1149 Foto Genu/Knee Joint AP + Lateral D/S 160,000
1150 Foto Genu/Knee Joint AP + Lateral D+S 180,000
1151 Foto Humerus D/S 160,000
1152 Foto Humerus D+S 180,000
1153 Foto Jaringan Lunak 125,000
1154 Foto Kepala AP + Lateral 160,000
1155 Foto Kepala Water Position 125,000
1156 Foto Koagulasi (acc) 3,760,000
1157 Foto Koagulasi Laser 2,850,000
1158 Foto Koagulasi Laser (rujukan luar) 3,125,000
1159 Foto Kolumna Vertebralis 125,000
1160 Foto Leher AP + Lateral 160,000
1161 Foto Lumbal AP + Lateral 160,000
1162 Foto Lumbal Dynamic 160,000
1163 Foto Lumbosakral AP + Lateral 160,000
1164 Foto Lumbosakral AP + Lateral + Obliq 180,000
1165 Foto Mandibula / Rahang AP + Lateral 160,000
1166 Foto Mandibula / Rahang AP + Lateral (Rujukan Luar) 160,000
1167 Foto Manus AP + Obliq D/S 160,000
1168 Foto Manus AP + Obliq D+S 180,000
1169 Foto Mastoid 160,000
1170 Foto Metacarpai/Tangan 125,000
1171 Foto Orbita 160,000
1172 Foto Os Nasal 125,000
1173 Foto Pedis AP + Obliq D/S 160,000
1174 Foto Pedis AP + Obliq D+S 180,000
1175 Foto Pelvis/Panggul AP 125,000
1176 Foto Pelvis/Panggul Inlet + outlet AP 180,000
1177 Foto Polos Abdomen 125,000
1178 Foto Radius/Ulna (AP/Lat/Keduanya) 125,000
1179 Foto Rheese 125,000
1180 Foto Sakrum AP + Lateral 160,000
1181 Foto Scapula AP + Lateral D/S 160,000
1182 Foto Scapula AP + Lateral D+S 180,000
1183 Foto Schedel (AP/Lat/Keduanya) (evaluasi adenoid) 125,000
1184 Foto Sendi Bahu / Shoulder Joint D/S 160,000
1185 Foto Sendi Bahu / Shoulder Joint D+S 180,000
1186 Foto Sendi Siku / Elbow Joint D/S 160,000
1187 Foto Sendi Siku / Elbow Joint D+S 180,000
1188 Foto Sinus Adenoid 125,000
1189 Foto Sinus Paranasal 160,000
1190 Foto Stenvers 125,000
1191 Foto Temporomandibular Joint (TMJ) 180,000
1192 Foto Thoracal (AP/Lat/Keduanya) 125,000
1193 Foto Thoracal AP/Lat/Obi 125,000
1194 Foto Thoraco Lumbal AP/Lat/Obi 125,000
1195 Foto Thorakal AP + Lateral 160,000
1196 Foto Thoraks Lateral 125,000
1197 Foto Thoraks PA/AP 125,000
1198 Foto Thoraks PA/AP + Lateral 160,000
1199 Foto Thoraks RLD 125,000
1200 Foto Top Lordotik 125,000
1201 Foto Wrist Joint AP + Lateral D/S 160,000
1202 Foto Wrist Joint AP + Lateral D+S 180,000
1203 Foto X-RAY C ARM/Flouroscopy 350,000
1204 Foto X-RAY C ARM/Flouroscopy (Rujukan Luar) 1,320,000
1205 Fotokoagulasi Laser 2,500,000
1206 Four Poster Cervical Orthosis 2,850,000
1207 Fraktur Maksila/Zygoma 6,168,740
1208 Fraktur Muka Multiple (Tanpa Miniplate Screw) 9,451,305
1209 Fraktur Rahang 2,960,000
1210 Fraktur Rahang Sederhana 6,281,000
1211 Fraktur Sederhana os Nassal + Lokal 5,108,000
1212 Fraktur Sederhana os Nassal + Naskosa Umum 5,107,800
1213 Fraktur Tripodo/Multiple 6,913,000
1214 Free Field Test 73,000
1215 Free Flap Surgery (Bedah Plastik) 39,655,772
1216 Free skin graft 9,182,099
1217 Free skin graft, not otherwise specified 6,528,000
1218 Free T3 181,000
1219 Frenectomi 2,850,000
1220 Frenektomi dengan Anastesi Lokal 0
1221 Fronto-Orbital Advancement Pada Craniosynostosis 22,016,772
1222 Frosen Section (Potongan Beku) VC 900,000
1223 Fruktosamin 84,000
1224 FSH 200,000
1225 FSH (P) 352,000
1226 FT4 _ 210,000
1227 Full-thickness skin graft to hand 6,528,000
1228 Full-thickness skin graft to other sites 6,528,000
1229 Functie Pericard 351,000
1230 Functie Pertitoneum 87,000
1231 Function Evaluation 70,000
1232 Fundoplikasi Gaster 6,175,000
1233 Funduscopy 80,000
1234 Funduscopy Direct 54,000
1235 Funduscopy Indirect 58,000
1236 Fungsional Endoscopy Sinus Surgery (FESS) 4,243,393
1237 Fusi Korpus Vertebra Approach Anterior (Bedah Syaraf) 6,760,638
1238 Fusi Korpus Vertebra Approach Posterior (Bedah Syaraf) 10,705,638
1239 Fusion or refusion of 2-3 vertebrae 14,020,000
1240 Fusion or refusion of 4-8 vertebrae 14,020,000
1241 Fusion or refusion of 9 or more vertebrae 14,020,000
1242 Gali Kubur Dalam Kota 6,000,000
1243 Gali Kubur Luar Kota 11,000,000
1244 Gambaran Darah tepi * _ 190,000
1245 Gamma GT _ 40,000
1246 Ganti Colostomy Bag 308,000
1247 Ganti Drain 55,000
1248 Ganti Kanule 250,000
1249 Ganti Kawat IMF 55,000
1250 Ganti Nefrostomi 675,000
1251 Ganti Provox 250,000
1252 Ganti Rubber Elastik IMF 55,000
1253 Ganti Verban (Intensif) 83,000
1254 Ganti Verban Besar (Poli Gigi) 122,000
1255 Ganti Verban Kecil (Poli Gigi) 99,000
1256 Ganti Verband 83,000
1257 Ganti Verband (Radiotherapi) 83,000
1258 Ganti Verband Pasien (Besar) 64,000
1259 Ganti Verband Pasien (Kecil) 52,000
1260 Gasterctomi (Blroth 1 dan 2) 5,982,388
1261 Gastrectomi ( Bilroth 1 dan 2 ) 5,982,389
1262 Gastroduodenoskopi 4,995,000
1263 Gastroduodenoskopi Besar 4,995,000
1264 Gastrostomi Pada Neonatus 8,164,502
1265 Genitoplasty (Clitoroplasty, vaginoplasty) 6,175,000
1266 Gigi Tiruan Immediate Koreksi Posisi Protesa Delapan Gigi/Lebih 3,090,000
1267 Gigi Tiruan Immediate Koreksi Posisi Protesa Dua Gigi 970,000
1268 Gigi Tiruan Immediate Koreksi Posisi Protesa Empat Gigi 1,560,000
1269 Gigi Tiruan Immediate Koreksi Posisi Protesa Enam Gigi 2,150,000
1270 Gigi Tiruan Immediate Koreksi Posisi Protesa Lima Gigi 1,860,000
1271 Gigi Tiruan Immediate Koreksi Posisi Protesa Penuh 7,000,000
1272 Gigi Tiruan Immediate Koreksi Posisi Protesa Satu Gigi 600,000
1273 Gigi Tiruan Immediate Koreksi Posisi Protesa Satu Rahang 3,740,000
1274 Gigi Tiruan Immediate Koreksi Posisi Protesa Tiga Gigi 1,200,000
1275 Gigi Tiruan Immediate Koreksi Posisi Protesa Tujuh Gigi 2,295,000
1276 Gigi Tiruan Lepasan Akrilik Protesa Delapan/Lebih/Satu Rahang 1,240,000
1277 Gigi Tiruan Lepasan Akrilik Protesa Dua Gigi 370,000
1278 Gigi Tiruan Lepasan Akrilik Protesa Empat Gigi 560,000
1279 Gigi Tiruan Lepasan Akrilik Protesa Enam Gigi 725,000
1280 Gigi Tiruan Lepasan Akrilik Protesa Lima Gigi 650,000
1281 Gigi Tiruan Lepasan Akrilik Protesa Penuh Flabby Ridge 4,000,000
1282 Gigi Tiruan Lepasan Akrilik Protesa Penuh Flat Rata 3,500,000
1283 Gigi Tiruan Lepasan Akrilik Protesa Penuh Rahang Atas dan Bawah Biasa 2,500,000
1284 Gigi Tiruan Lepasan Akrilik Protesa Satu Gigi 300,000
1285 Gigi Tiruan Lepasan Akrilik Protesa Satu Rahang Dengan Flabby Ridge 2,000,000
1286 Gigi Tiruan Lepasan Akrilik Protesa Satu Rahang Dengan Flat Rata 1,700,000
1287 Gigi Tiruan Lepasan Akrilik Protesa Tiga Gigi 465,000
1288 Gigi Tiruan Lepasan Akrilik Protesa Tujuh Gigi 820,000
1289 Gigi Tiruan Lepasan Immediate Penuh Immediate 4,000,000
1290 Gigi Tiruan Lepasan Immediate Satu Rahang Immediate 2,240,000
1291 Gigi Tiruan Lepasan Immediate/Segera Protesa Delapan/Lebih/Satu Rahang 1,740,000
1292 Gigi Tiruan Lepasan Immediate/Segera Protesa Dua Gigi 670,000
1293 Gigi Tiruan Lepasan Immediate/Segera Protesa Empat Gigi 1,060,000
1294 Gigi Tiruan Lepasan Immediate/Segera Protesa Enam Gigi 1,425,000
1295 Gigi Tiruan Lepasan Immediate/Segera Protesa Lima Gigi 1,250,000
1296 Gigi Tiruan Lepasan Immediate/Segera Protesa Satu Gigi 550,000
1297 Gigi Tiruan Lepasan Immediate/Segera Protesa Tiga Gigi 865,000
1298 Gigi Tiruan Lepasan Immediate/Segera Protesa Tujuh Gigi 1,620,000
1299 Gigi Tiruan Overdenture Protesa Delapan/Lebih/Satu Rahang 1,280,000
1300 Gigi Tiruan Overdenture Protesa Dua Gigi 575,000
1301 Gigi Tiruan Overdenture Protesa Empat Gigi 800,000
1302 Gigi Tiruan Overdenture Protesa Enam Gigi 1,040,000
1303 Gigi Tiruan Overdenture Protesa Lima Gigi 920,000
1304 Gigi Tiruan Overdenture Protesa Penuh Rahang Atas dan Bawah Biasa 2,500,000
1305 Gigi Tiruan Overdenture Protesa Satu Gigi 475,000
1306 Gigi Tiruan Overdenture Protesa Tiga Gigi 680,000
1307 Gigi Tiruan Overdenture Protesa Tujuh Gigi 1,160,000
1308 Gingivectomy 2,850,000
1309 Gingivektomi / Gingivoplasty per Region dengan Anastesi Lokal 860,000
1310 Globulin _ 32,000
1311 Glosektomi Total 4,903,089
1312 Glosektomi Totalis 4,659,000
1313 Glukose 2 Jam PP _ 28,000
1314 Glukose Puasa _ 28,000
1315 Glukose Sewaktu _ 28,000
1316 Glukose Sewaktu (Rapid) 30,000
1317 Glukose Strip 30,000
1318 Glukose Toleransi _ 40,000
1319 Golongan Darah ABO, Rhesus 95,000
1320 Gonioplasty 2,850,000
1321 Goniotomi 4,235,000
1322 Goniotomi + anastesi 4,889,000
1323 GOT _ 33,000
1324 GPT _ 33,000
1325 Graf Vena Membuat A Vistula 4,860,000
1326 Graft Gingival dengan Anastesi Lokal 860,000
1327 Graft of muscle or fascia 11,196,000
1328 Grafting Pada Arterial Insufisiensi (Bedah Vaskuler) 4,860,000
1329 Grinding Gigi 55,000
1330 Group Therapi 39,600
1331 Group Therapi (Terapi Kelompok) Fisioterapi 22,800
1332 Group Therapi (Terapi Kelompok)Okupasi Terapi 22,800
1333 Group Therapi (Terapi Kelompok)Terapi Wicara 42,570
1334 Growth Hormone 347,000
1335 Gula Darah 2 Jam Puasa Strip 30,000
1336 Gula Puasa Strip 30,000
1337 GV Laparotomi Anak 24,000
1338 Gymnic Ball (Fisioterapi) 33,000
1339 Gymnic Ball (Okupasi Terapi) 33,000
1340 Ham s Test 31,000
1341 Hang Sling Set 33,000
1342 HBA 1c _ 175,000
1343 Hbe Ag 425,000
1344 HBe Ag (P) 389,000
1345 HBs Ag (Elisa) _ 128,000
1346 HBs Ag (ICT) 72,000
1347 HBsAg Konfirmasi (Elisa) 350,000
1348 HBsAg Kuantitatif (P) 314,000
1349 HBV DNA 2,000,000
1350 HBv DNA (P) 1,800,000
1351 HBV-DNA (Real Time PCR) (P) 1,800,000
1352 HCV RNA 2,300,000
1353 HCV-RNA (Real Time PCR) (P) 2,300,000
1354 HCV-RNA (Real Time PCR) & HCV Genotipe (P) 4,600,000
1355 Head Box 190,000
1356 Hecting 5 cm 113,000
1357 Hemangioma 787,000
1358 Hemangioma (OK Minor) 0
1359 Hematologi Rutin Automatik _ 100,000
1360 Hemiglosektomi + RND 5,077,000
1361 Hemiglosektomi THT 4,850,000
1362 Hemiglosektomi/Eksisi Tumor Lidah 3,968,000
1363 Hemimandibulektomi 4,850,000
1364 Hemipelvektomi 6,414,000
1365 Hemiseksi Gigi dengan Anastesi Lokal 860,000
1366 Hemiseksi/Bikuspidasi 0
1367 Hemmimandibulektomi 4,442,187
1368 Hemodialisa 1,300,000
1369 Hemoroidektomi 4,347,979
1370 Hemosiderin 24,000
1371 Hemostasis Saluran Cerna Bagian Atas/Bawah 2,850,000
1372 Hernia Incarcerata 4,255,565
1373 Herniatomi 4,515,165
1374 Herniatomi Bilateral 4,491,877
1375 Hernioraphi 4,515,165
1376 Herniotomi Bilateral 6,238,462
1377 Herniotomi hernia inkarserata/strangulate 5,782,479
1378 Herniotomi Unilateral 5,070,446
1379 Herniotomy + Laparatomy + Reseksi 6,851,507
1380 Hidrasi Alkalinisasi (hari) 66,000
1381 Hidrokel per Inguinal/Ligasi Tinggi 4,850,000
1382 Hidrokel per scrotal 3,850,000
1383 Hidroterapi 250,000
1384 High Flow Nasal Canule (Per Hari) 1,500,000
1385 Higroma Colli/Limfangioma Besar 6,238,462
1386 Hip Bone Densitometry 250,000
1387 Hiperexention Brace Khusus 2,800,000
1388 Histerectomi Trans Vaginal / Trans Abdominal et SOB 2,850,000
1389 Histerectomy Radikal 6,929,993
1390 HIV VIRAL LOAD 2,000,000
1391 Holter 516,000
1392 Holter Monitor 516,000
1393 Horsesche Kidney Koreksi 7,885,000
1394 Hot Pack 22,800
1395 HPV 1,700,000
1396 HRCT ( Dengan Kontras ) + Anastesi 6,240,000
1397 HRCT ( Tanpa Kontras ) + Anastesi 3,090,000
1398 HRCT (Dengan Kontras) 5,100,000
1399 HRCT (Tanpa Kontras) 2,200,000
1400 Hs Troponin I 400,000
1401 HSV II IgM 125,000
1402 Hydro Therapi 91,200
1403 hydrotubasi / Eksterpasi Polip Cerviks tanpa Anastesi 250,000
1404 Hysterectomy Supravaginal 7,850,000
1405 Hysterosalpingografi ( HSG ) 600,000
1406 Hystrectomy Partial 6,292,709
1407 Hystrectomy Total 6,273,291
1408 I V P 750,000
1409 ICCE/ECCE (tidak termasuk IOL) (acc) 4,276,711
1410 IgA / IgG / IgM 96,000
1411 IgE _ 119,000
1412 IgE Total (P) 320,000
1413 IgM Salmonella (TF Semikuantitatif) 250,000
1414 IHC (Immunohistochemistry) - AE1/AE3 (Cytokeratin) 500,000
1415 IHC (Immunohistochemistry) - CD 117 500,000
1416 IHC (Immunohistochemistry) - CD20 500,000
1417 IHC (Immunohistochemistry) - Ki67 500,000
1418 IHC (Immunohistochemistry) - LCA (CD45) 500,000
1419 IHC (Immunohistochemistry) - S100 500,000
1420 IHC (Immunohistochemistry) - Vimentin 500,000
1421 IHC (Immunohistochemistry) CD3 600,000
1422 IHC (Immunohistochemistry) ER, PR, HER-2 1,200,000
1423 IHC Paket Payudara (ER-PR,Crb/HER 2, Topo, P53) 1,200,000
1424 Ileal Condoit (Bricker)/Operasi 10,230,000
1425 Immunoterapi 120,000
1426 Immunotyping (P) 800,000
1427 Implantasi Koklea 13,850,000
1428 Imunisasi / Vaksinasi 45,000
1429 Imunisasi Mandiri 45,000
1430 Imuno Elektroforesis Anti IgG / IgA / IgM 96,000
1431 Imuno Elektroforesis Whole Anti Serum 96,000
1432 Imunohistokimia (IHC) )Per antibodi 500,000
1433 Incisi (Tutup Lubang Telinga) 47,000
1434 Incisi Ganed 120,000
1435 Incision and drainage of palmar or thenar space 11,196,000
1436 Incubator 88,000
1437 Indirect Veneer/Porcelain 0
1438 Induksi Partus 300,000
1439 Infant Warmer 66,000
1440 Infra Red Rays 22,800
1441 Infusion Pump 60,000
1442 Inhalasi 60,000
1443 Inisiasi Dini Menyusui (IDM) 10,000
1444 Injection of anaesthetic into spinal canal for analgesia 5,115,554
1445 Injection of other agent, except neurolytic 3,215,554
1446 Injection of therapeutic agent into joint or ligament 2,350,000
1447 Injection of therapeutic substance into bursa of hand 3,125,000
1448 Injection of therapeutic substance into joint or ligament 5,752,000
1449 Injection of therapeutic substance into tendon of hand 3,125,000
1450 Injeksi (Suntik) 30,000
1451 Injeksi (Suntik) II Dst 25,000
1452 Injeksi Antibiotik 0
1453 Injeksi Botulinum Toxin Phenol 250,000
1454 Injeksi Deferoxamine 60,000
1455 Injeksi Eritropoietin 60,000
1456 Injeksi Gonadotropin Releasing Hormone Analog (GnRH Analog/Leuprorelin Asetat) 90,000
1457 Injeksi Granulocyt Colony Stimulating Faktor 60,000
1458 Injeksi Haemoroid (Termasuk Obat) 675,000
1459 Injeksi HCG Test 90,000
1460 Injeksi Hormon Testosteron (Sustanon) 90,000
1461 Injeksi Intraartikuler 200,000
1462 Injeksi Kenacort Intralesi 97,000
1463 Injeksi Kenacort THT 66,000
1464 Injeksi Lokal Syaraf (Sederhana) 162,000
1465 Injeksi MTPS ( Injeksi Triger Ponit ) 250,000
1466 Injeksi Sensitivity Spinal Segmental 250,000
1467 Injeksi Varises (Termasuk Obat) 675,000
1468 Injeksi Zoledronic Acid (ZOMETA) 90,000
1469 INR 110,000
1470 Inseminasi Intra Urine 250,000
1471 Insersi DJ Stent 4,850,000
1472 Insersi Kateter Double Lumen : Semi Permanen 3,438,000
1473 Insersi Kateter Double Lumen : Temporer 1,688,000
1474 Insersie Inlay/Onlay 0
1475 Insersie Jacket Crown PFM/All porcelain 0
1476 Insersie Veneer Porcelain 0
1477 Insertion of interbody spinal fusion device 9,016,000
1478 Insertion of other spinal device 2,350,000
1479 Insisi + eskplorasi abses septi 47,000
1480 Insisi Abses 250,000
1481 Insisi Abses (Hepatoma Septum Nasi/Peritonsil) 250,000
1482 Insisi Abses Peri Tonsiler 250,000
1483 Insisi Abses Perineum 675,000
1484 Insisi Abses Single dengan Anastesi Lokal 270,000
1485 Insisi Abses Skrotum 675,000
1486 Insisi Abses Sub Madibula 250,000
1487 Insisi Biopsy dengan Anastesi Lokal 270,000
1488 Insisi Drainase Multiple dengan Anastesi Lokal 860,000
1489 Insisi Furunkel 66,000
1490 Insisi hematoma Vulva 107,000
1491 Insisi Kalazion / Hordeolun 153,000
1492 Insisi Mucocele 2,850,000
1493 Insisi Tongue Tie 4,995,000
1494 Insisi/drainase abses dengan anastesi umum 2,159,000
1495 Insisional Biopsi Kelenjar Leher 2,850,000
1496 Inspekulo 83,000
1497 Inspekulo (Apusan servix) 30,000
1498 Inspekulo (Kultur cairan servix) 30,000
1499 Inspekulo (Test KOH) 30,000
1500 Inspirasi 250,000
1501 Interferensi 75,000
1502 Interleukin 6 (IL-6) (P) 335,000
1503 Intermiten Positive Pressure Breathing (IPPB) 66,000
1504 Internal fixation of bone without fracture reduction on femur 5,828,000
1505 Internal fixation of bone without fracture reduction on humerus 5,828,000
1506 Internal fixation of bone without fracture reduction on patella 5,828,000
1507 Internal fixation of bone without fracture reduction on radius and ulna 5,828,000
1508 Internal fixation of bone without fracture reduction on scapula, clavicle, and thorax (ribs and sternum) 5,828,000
1509 Internal fixation of bone without fracture reduction on tarsals and metatarsals 4,804,456
1510 Internal fixation of bone without fracture reduction on tibia and fibula 5,828,000
1511 Internal fixation of bone without fracture reductionon carpals and metacarpals 5,828,000
1512 Internal fixation of patella without fracture reduction 18,596,121
1513 Internal Urethrotomi ( Sachse ) 7,458,259
1514 interphalangeal fusion 5,561,121
1515 Interthoracoscapular amputation 5,997,200
1516 Intervertebral chemonucleolysis 14,020,000
1517 Intra Dermal Test THT 250,000
1518 Intra-Aortic Balloon Pump (IABP) + Anestesi 17,198,000
1519 Intubasi 847,000
1520 Intubasi Double Lumen Tube 1,130,000
1521 Irigasi Hidung/sinus paranasalis 36,000
1522 Irigasi Kandung Kemih 25,000
1523 Irigasi Luka Operasi / Spooling 55,000
1524 Irigasi Sinus/DAWO 2,850,000
1525 Irigasi Telinga 55,000
1526 Iscole 87,000
1527 ISH per PROBE Inditu Hibridization 1,000,000
1528 Isonom Station ( Cybex ) 87,600
1529 Isthmolobektomi 4,488,256
1530 Isthobektomi 4,850,000
1531 IV Cavagram 2,000,000
1532 IV Cavagram + Anastesi 3,610,000
1533 IVC Filter 14,450,000
1534 IVC Filter + Anastesi 18,950,000
1535 Jacket Crown/gigi porcelain preparasi jacket 0
1536 Jahit Dehisensi Luka 163,000
1537 Jahit Dehisensi Luka (Poli) 163,000
1538 Jahit Luka 76,000
1539 Jahitan Perineum tingkat 1 & 2 60,000
1540 Jahitan Perineum tingkat 3 & 4 600,000
1541 Jamur 30,000
1542 Jarak sampai 7 Km (dalam kota) 80,000
1543 Jewett Brace (Biasa) 1,320,000
1544 Jewett Brace (Khusus) 1,600,000
1545 Johanson 4,850,000
1546 Johanson 1 4,850,000
1547 KAFO (Biasa) 3,500,000
1548 KAFO (Khusus) 5,000,000
1549 Kalibrasi Uretra 675,000
1550 Kalporeksis 5,840,933
1551 Kalsium Darah 45,000
1552 Kalsium Urine 45,000
1553 Kanaloplasti/ Pengangkatan massa tulang 6,050,000
1554 Kantong Jenazah 100,000
1555 Kapsulektomi Posterior 4,850,000
1556 karcis 10,000
1557 Karcis (ODC) 9,000
1558 Kardiotokografi (KTG) 299,000
1559 Kardioversi 1,076,000
1560 Katerisasi Urethra 39,000
1561 Kateterisasi Anak 4,120,000
1562 Kaustik 66,000
1563 Kaustik Faring 66,000
1564 Kaustik hidung ( AgNO3, tricolor acetat) 36,000
1565 Kaustik telinga (AgNo3,albotyl) 18,000
1566 Kauter Albotil/Cauter Podofiline 66,000
1567 Kauterisasi 675,000
1568 Kehamilan Ektopik Terganggu (KET) 6,119,720
1569 kelainan jari / ektremitas sederhana 5,175,000
1570 Kelasi Besi Suntik 66,000
1571 Kemotherapi + Anestesi 700,000
1572 Kemotherapy Ca Paru 410,000
1573 Keratometry 73,000
1574 Keratoplasti 11,350,000
1575 Keratoplastie Lamelar 4,093,930
1576 Khemoterapy 410,000
1577 Khordectomi 5,646,937
1578 Khordektomy pada Hyspopadia 4,850,000
1579 KHS ( Konduksi Hantaran Safar ) 62,400
1580 Kistektomi 6,165,762
1581 Klisma 66,000
1582 Knee Brace (Biasa) 1,650,000
1583 Knee Brace (Khusus) 2,500,000
1584 Knight Taylor 3,000,000
1585 KOH 33,000
1586 Koledoko Jejunostomi 5,240,302
1587 Kolesistektomi 4,342,099
1588 Kolesterol HDL _ 60,000
1589 Kolesterol LDL (Direk) _ 100,000
1590 Kolesterol Total _ 45,000
1591 Kolonoskopi 2,065,000
1592 Kolonoskopi + Anastesi 3,102,000
1593 Kolonoskopy 5,026,784
1594 Kolostomi 4,160,391
1595 Kolostomi Neonatus/Ikostomi/Jejunostomi 7,801,000
1596 Kolostomi/ikostomi/kemonostomi pada anak 7,801,000
1597 Kolpoperineorafi 675,000
1598 Kolposkopi dan Biopsi 396,000
1599 Komplemen C3 70,000
1600 Komplemen C4 70,000
1601 Komponen Trombosit Apheresis Per Bag (PMI) 3,500,000
1602 Kompresi Bimanual interna& eksterna 180,000
1603 Konkoplasti 4,850,000
1604 Konseling CAPD 420,000
1605 Konseling oleh Psikolog 130,000
1606 Konsul Dokter 52,000
1607 Konsul dr Ahli Alergi Imunologi Anak (IRNA) 96,000
1608 Konsul dr Ahli Anak (IRNA) 96,000
1609 Konsul dr Ahli Anastesi (IRNA) 96,000
1610 Konsul dr Ahli Bedah Anak (IRNA) 96,000
1611 Konsul dr Ahli Bedah Digestive (IRNA) 96,000
1612 Konsul dr Ahli Bedah Gastroentrohepatologi (IRNA) 96,000
1613 Konsul dr Ahli Bedah Orthopedi (IRNA) 96,000
1614 Konsul dr Ahli Bedah Plastik (IRNA) 96,000
1615 Konsul dr Ahli Bedah Saraf (IRNA) 96,000
1616 Konsul dr Ahli Bedah Thorax & Vask. (IRNA) 96,000
1617 Konsul dr Ahli Bedah Tumor (IRNA) 96,000
1618 Konsul dr Ahli Bedah Umum (IRNA) 96,000
1619 Konsul dr Ahli Bedah Urologi (IRNA) 96,000
1620 Konsul dr Ahli Cardiologi (IRNA) 96,000
1621 Konsul dr Ahli Endokrin (IRNA) 96,000
1622 Konsul dr Ahli Forensik (IRNA) 96,000
1623 Konsul dr Ahli Gastroentrohepatologi (IRNA) 96,000
1624 Konsul dr Ahli Geriatri (IRNA) 96,000
1625 Konsul dr Ahli Gigi dan Mulut (IRNA) 96,000
1626 Konsul dr Ahli Ginjal Hipertensi (IRNA) 96,000
1627 Konsul dr Ahli Gizi (IRNA) 96,000
1628 Konsul dr Ahli Hematologi (IRNA) 96,000
1629 Konsul dr Ahli Hiperbarik (IRNA) 96,000
1630 Konsul dr Ahli Infection Center (IRNA) 129,600
1631 Konsul dr Ahli Infeksi Tropis (IRNA) 96,000
1632 Konsul dr Ahli Jiwa (IRNA) 96,000
1633 Konsul dr Ahli Kulkel (IRNA) 96,000
1634 Konsul dr Ahli Mata (IRNA) 96,000
1635 Konsul dr Ahli Nefrologi (IRNA) 96,000
1636 Konsul dr Ahli Neurologi (IRNA) 96,000
1637 Konsul dr Ahli NICU (IRNA) 96,000
1638 Konsul dr Ahli Obgyn (IRNA) 96,000
1639 Konsul dr Ahli Ongko Obgyn ( IRNA ) 84,000
1640 Konsul dr Ahli Onkology (IRNA) 96,000
1641 Konsul dr Ahli Patologi Klinik (IRNA) 96,000
1642 Konsul dr Ahli Penyakit Dalam (IRNA) 96,000
1643 Konsul dr Ahli Penyakit Tropis (IRNA) 96,000
1644 Konsul dr Ahli PICU (IRNA) 96,000
1645 Konsul dr Ahli Psikiatri (IRNA) 96,000
1646 Konsul dr Ahli Pulmonologi (IRNA) 96,000
1647 Konsul dr Ahli Radiologi (IRNA) 96,000
1648 Konsul dr Ahli Radiotherapi (IRNA) 96,000
1649 Konsul dr Ahli Respiriology Anak ( IRNA) 84,000
1650 Konsul dr Ahli Rheumatologi (IRNA) 96,000
1651 Konsul dr Ahli Saraf (IRNA) 96,000
1652 Konsul dr Ahli THT (IRNA) 96,000
1653 Konsul dr Fisiotherapi (IRNA) 96,000
1654 Konsul dr Rehab Medik (IRNA) 96,000
1655 Konsultasi Dokter ( Rehab Medik ) 62,400
1656 Konsultasi Dokter Ahli (IRNA PCC) 96,000
1657 Konsultasi Dokter Ahli (IRNA PCC) Super VIP B 0
1658 Konsultasi Dokter Hiperbarik 120,000
1659 Konsultasi Psikologi 240,000
1660 Kontraktur + STSG 6,421,000
1661 Kontrol Protesa 42,000
1662 Koreksi + Rekonstruksi Ptosis 4,850,000
1663 Koreksi Atresia Ani 5,225,000
1664 Koreksi ektropion / entropion 4,515,574
1665 Koreksi ektropion / entropion ( Anak ) 4,380,574
1666 Koreksi Impresif Fraktur Sederhana 5,108,156
1667 Koreksi Priapismus 5,151,000
1668 Koreksi Simblefaron Berat 11,350,000
1669 Koreksi Symblepharon 3,850,000
1670 Korset (Biasa) 366,000
1671 Korset (Standar) 507,000
1672 Kranioplasti/Koreksi Fraktur 9,775,887
1673 Kraniotomi + Endoskopi 11,992,025
1674 Kraniotomi/Trepanasi Konvensional 10,554,887
1675 Kraniotomi+Bedah Mikro 11,775,887
1676 Kreatinin _ 35,000
1677 Kreatinin Klrens _ 92,000
1678 Kreatinin Urine 30,000
1679 Kruk Aluminium 271,000
1680 Kuldosintesis 120,000
1681 Kultur & Sensitivity OAT 400,000
1682 Kultur dan Sensitivitas Jamur 400,000
1683 Kultur dan Sensitivitas Manual 250,000
1684 Kultur dan Sensitivitas Otomatis 380,000
1685 Kulture jamur 54,000
1686 Kunjungan Rumah Analis Laboratorium ( Home Care ) 100,000
1687 Kunjungan Rumah Dokter ( Home Care ) 200,000
1688 Kunjungan Rumah Dokter Spesialis ( Home Care ) 300,000
1689 Kunjungan Rumah Fisioterapis ( Home Care ) 150,000
1690 Kunjungan Rumah Ners ( Perawat ) ( Home Care ) 100,000
1691 Kunjungan Rumah Nutrisionis ( Home Care ) 100,000
1692 Kuretase 140,000
1693 Kuretase Abortus Inkomplitus/ rest plasenta 600,000
1694 Kuretase dengan PUD / Polip 5,680,221
1695 Kuretase Diagnostik 400,000
1696 Kuretase molahidatidosa 720,000
1697 Kuretase Percobaan 400,000
1698 Kuretase Plasenta Retensio 720,000
1699 Kuretase plasenta/molahidatidosa anastesi 1,423,000
1700 Kuretase/Dilatasi Kuretase dengan Narkose 6,165,762
1701 Labiopalatoplasti Bilateral 6,866,000
1702 labioplasti 787,000
1703 Labioplasti Bilateral 6,761,255
1704 Labioplasti Unilateral 5,163,000
1705 Labioplasty (OK Minor) 0
1706 Ladds Procedure 9,464,367
1707 Laju Endap Darah Automotik _ 30,000
1708 Laktat Darah 50,000
1709 Laminektomi Kompleks (Bedah Syaraf) 9,331,885
1710 Laminektomi Sederhana (Bedah Syaraf) 7,459,885
1711 Laparascopy Kompleks 15,350,000
1712 Laparascopy Operatif 6,607,809
1713 Laparascopy Operatif (ODC) 4,260,000
1714 Laparascopy Operatif Hitroscopy 6,607,809
1715 Laparascopy Simple 13,350,000
1716 Laparaskopik Kolesistektomi 6,377,211
1717 Laparatomi + Apendoktomi apendix perforasi 9,464,367
1718 Laparatomi + Milking / Reseksi pada Invaginasi 9,464,367
1719 Laparatomi + Reksisi Usus Halus / Kolon 6,173,139
1720 Laparatomi + reseksi invaginasi 6,175,000
1721 Laparatomi Eksplorasi 4,377,586
1722 Laparatomi FC 6,286,074
1723 Laparatomi pada perforasi usus 6,175,000
1724 Laparatomi pada Peritonitis Neonatal 6,175,000
1725 Laparatomi pada Trauma Abdomen 6,181,401
1726 Laparatomy + Reseksi Usus pada Anak 11,350,000
1727 Laparatomy pada Perforasi Usus pada Anak 7,758,000
1728 Laparatomy Percobaan 6,058,221
1729 Laparoskopik Kolesistekstomi 6,377,211
1730 Laringektomi 3,781,100
1731 Laringgofisure 3,850,000
1732 Laringo Fisur/Eksplorasi Laring 5,482,645
1733 Laringoskopi dengan Ekstirpasi 3,850,000
1734 Laser CO2 1,000,000
1735 Laser Erbium & Tatto Besar 0
1736 Laser Erbium & Tatto Kecil 0
1737 Laser Erbium & Tatto Sedang 0
1738 Laser Iridotomi Perifer 2,850,000
1739 Laser Therapy 72,600
1740 Laser V Beam 250,000
1741 Latisimus Dorsi Flap 4,850,000
1742 Latissimus dorsi myocutaneous flap 2,382,099
1743 LDH _ 40,000
1744 Le-ford Advancement Surgery 9,556,772
1745 Legalisir Surat Keterangan Kematian (10 Lbr) 20,000
1746 Legallisir Surat Kematian /10 lmbr 20,000
1747 Lepto Dipstick 135,000
1748 Leptospira IgM 200,000
1749 Lesung Pipi 0
1750 Leukemia Phenotyping (P) 715,000
1751 LH 200,000
1752 LH (P) 338,000
1753 Ligasi A.Karotis Eksterna 4,850,000
1754 Ligasi Tinggi hidrokel pada anak 4,967,567
1755 Ligasi Varises SCBA 2,458,000
1756 Ligasi Varises SCBA + Anastesi 3,450,000
1757 Limb lengthening procedures, carpals and metacarpals 6,600,000
1758 Limb lengthening procedures, femur 6,600,000
1759 Limb lengthening procedures, humerus 6,600,000
1760 Limb lengthening procedures, radius and ulna 6,600,000
1761 Limb lengthening procedures, tarsals and metatarsals 6,600,000
1762 Limb lengthening procedures, tibia and fibula 6,600,000
1763 Limb shortening procedures, carpals and metacarpals 6,600,000
1764 Limb shortening procedures, femur 6,600,000
1765 Limb shortening procedures, humerus 6,600,000
1766 Limb shortening procedures, radius and ulna 6,600,000
1767 Limb shortening procedures, tarsals and metatarsals 6,600,000
1768 Limb shortening procedures, tibia and fibula 6,600,000
1769 Limfadenektomi Ileoinguinal 7,885,000
1770 Limfadenektomi Retroperitoneal 7,885,000
1771 Lipase (P) 225,000
1772 Lipase Darah 80,000
1773 Lipase Urine 63,000
1774 Lipoma Besar 0
1775 Lipoma Besar (Lipoma + Kista) 480,000
1776 Lipoma Kecil 0
1777 Lipoma Kecil ( Lipoma + Kista ) 157,000
1778 Lipoma Sedang 0
1779 Lipoma Sedang (Lipoma + Kista) 400,000
1780 Lithiasis 250,000
1781 Litrotipasi/litotripsi 7,160,799
1782 Lobektomi ( Bedah Paru/ Thorax ) 21,102,000
1783 Lobektomi Tiroid 4,850,000
1784 Lobulaplasti (1Telinga / 2Telinga) 2,850,000
1785 Local excision of lesion or tissue of carpals and metacarpals 3,125,000
1786 Local excision of lesion or tissue of femur 3,125,000
1787 Local excision of lesion or tissue of humerus 3,125,000
1788 Local excision of lesion or tissue of patella 3,125,000
1789 Local excision of lesion or tissue of radius and ulna 3,125,000
1790 Local excision of lesion or tissue of scapula, clavicle, and thorax (ribs and sternum) 3,125,000
1791 Local excision of lesion or tissue of tarsals and metatarsals 3,125,000
1792 Local excision of lesion or tissue of tibia and fibula 3,125,000
1793 Lokal Chemoterapi pada Hepatoma / tumor-tumor Metastasi Lain + Anastesi 45,450,000
1794 Lokal Chemoterapi pada tumor-tumor Extremitas + Anastesi 45,450,000
1795 Lokal chemotherapi pada Hepatoma/tumor-tumor metastasi lain 24,883,390
1796 Lokal chemotherapi pada tumor-tumor extremitas 24,883,390
1797 Longitudinal Nefrolithotomi (Kadet) 7,885,000
1798 Lontophoresis 72,600
1799 Lopografi 500,000
1800 Lower leg or ankle reattachment 10,675,000
1801 Luka Bakar Berat Umum 581,730
1802 Luka Bakar Ringan Umum 245,000
1803 Luka Bakar Sedang Umum 480,000
1804 Lumbal Bone Densitometry 250,000
1805 Lumbar and lumbosacral fusion, anterior technique 14,020,000
1806 Lumbar and lumbosacral fusion, lateral transverse process technique 14,020,000
1807 Lumbar and lumbosacral fusion, posterior technique 14,020,000
1808 Lysis of adhesions of hand 3,125,000
1809 Magnesium Darah 37,000
1810 Magneto Therapy 72,600
1811 Maksilektomi Partialis 4,850,000
1812 Maksilektomi Totalis 5,393,089
1813 Malaria Mikroskopik 120,000
1814 Mammography dan USG (Rujukan Luar) 250,000
1815 Mammography Digital 350,000
1816 Mammography Digital (Rujukan Luar) 350,000
1817 Managemen Laktasi 100,000
1818 Mandi Jenazah Infeksi 500,000
1819 Mandi Jenazah Non Infeksi 350,000
1820 Mandibulektomi 13,950,000
1821 Mandibulektomi Marginalis 4,018,158
1822 Mandibulektomi Parsial THT 4,850,000
1823 Mandibulektomi Partialis dengan Rekontruksi 5,111,414
1824 Mandibulektomi Totalis 5,443,284
1825 Manipulation Temporomandibular Joint 70,000
1826 Mantoux Test 80,000
1827 Manual and Mekanikal Traction 70,000
1828 Manual Plasenta 300,000
1829 Manual Test Kekuatan Otot 70,000
1830 Manual Test Tonus Otot 80,000
1831 Manual Testing Of Muscle Function 70,000
1832 Mapping Implan Koklea Komunitas 250,000
1833 Marsupialisasi Abses Bartholin 2,850,000
1834 Marsupialisasi (Partch Prosedur) dengan Anastesi Lokal 860,000
1835 Marsupialisasi Kista Bartholini 675,000
1836 Marsupialisasi Ranula 2,510,000
1837 Masa Lisis Euglobin 63,000
1838 Masase Prostate 675,000
1839 Masilektomi Partialis 4,027,668
1840 Massage 36,000
1841 Mastektomi Radikal 5,087,253
1842 Mastektomi Simple 4,009,175
1843 Mastektomi Simpleks 7,350,000
1844 Mastektomi Subkutaneus 4,396,100
1845 Mastoidektomi Radikal 5,278,621
1846 Mastoidektomi Radikal dengan Penyulit 5,850,000
1847 Mastoidektomi Sederhana 4,850,000
1848 MD (Maag Deudenum) 500,000
1849 Meatatomi (ESWL) 2,500,000
1850 Meatoplasti 3,850,000
1851 Meatotomi 3,796,000
1852 Medikasi Saluran Akar/Ganti Obat 0
1853 Mega Kolon Hierchprung 7,827,722
1854 Memandikan Larutan PK 135,000
1855 Mengumbah Lambung 124,000
1856 Menilai Pertumbuhan 78,000
1857 Mentoplastik ( Pakai Silikon ) 0
1858 Mentoplastik Tambah Dagu tanpa Silikon 0
1859 Message Perineum 11,000
1860 Metacarpocarpal fusion 5,596,121
1861 Metacarpophalangeal fusion 5,596,121
1862 Metatarsophalangeal fusion 5,476,800
1863 Micro Curatage tanpa Anastesi 250,000
1864 Micro Wave Diathemi 39,600
1865 Midtarsal fusion 5,476,800
1866 Mikro Dermabrasi Diamond 0
1867 Mikro Dermabrasi Kristal 0
1868 Mikro Kuret Untuk Deteksi Duulasi 198,000
1869 Mikrokuretase untuk deteksi ovulasi 360,000
1870 Mikrosurgen Ligasi Vena Spermatika 7,777,000
1871 Miles Operation 6,244,888
1872 Mini Laparotomy 675,000
1873 Miringoplasti 4,850,000
1874 MMK/ Sling uretra 4,850,000
1875 MMPI 104,000
1876 MMSE 0
1877 Mobilization Of Other Joint 70,000
1878 Mobilization Of Spine 70,000
1879 Montou Test 72,000
1880 MPPI 104,000
1881 MRI Ankle Joint ( Tanpa Kontras ) + Anastesi 4,940,000
1882 MRI Ankle Joint (Dengan Kontras) 5,100,000
1883 MRI Ankle Joint (Dengan Kontras) + Anastesi 6,240,000
1884 MRI Ankle Joint (Tanpa Kontras) 3,900,000
1885 MRI Ankle Joint Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1886 MRI Ankle Joint Bilateral (Dengan Kontras) 6,300,000
1887 MRI Ankle Joint Bilateral (Dengan Kontras) + Anastesi 7,550,000
1888 MRI Ankle Joint Bilateral (Tanpa Kontras) 5,200,000
1889 MRI Brain ( Dengan Kontras ) 5,100,000
1890 MRI Brain ( Dengan Kontras ) + Anastesi 6,240,000
1891 MRI Brain ( Tanpa Kontras ) 3,900,000
1892 MRI Brain ( Tanpa Kontras ) + Anastesi 4,940,000
1893 MRI Brain + Diffusion + Perfusion + Spektroscopy 6,300,000
1894 MRI Brain + Diffusion + Perfusion + Spektroscopy + Anastesi 7,550,000
1895 MRI Brain + Kontras + Tractografi 5,700,000
1896 MRI Brain + Kontras + Tractografi + Anastesi 6,890,000
1897 MRI Brain + MRA ( Dengan Kontras ) 1,900,000
1898 MRI Brain + MRA ( Dengan Kontras )(rujukan luar) 1,900,000
1899 MRI Brain + MRA ( Tanpa Kontras ) 1,500,000
1900 MRI Brain + MRA + Venograf + Diffusion (Tanpa Kontras) 4,900,000
1901 MRI Brain + MRA + Venografi ( Dengan Kontras ) 6,300,000
1902 MRI Brain + MRA + Venografi ( Dengan Kontras ) + Anastesi 7,550,000
1903 MRI Brain + MRA + Venografi ( Dengan Kontras )(rujukan luar) 1,900,000
1904 MRI Brain + MRA + Venografi ( Tanpa Kontras ) 1,500,000
1905 MRI Brain + MRA + Venografi ( Tanpa Kontras ) + Anastesi 6,760,000
1906 MRI Brain + MRA + Venografi ( Tanpa Kontras )(rujukan luar) 1,500,000
1907 MRI Brain + MRA + Venografi (Tanpa Kontras) 5,500,000
1908 MRI Brain + MRA + Venografi + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
1909 MRI Brain + MRA + Venografi + Diffusion ( Tanpa Kontras ) + Anastesi 6,050,000
1910 MRI Brain + MRA + Venografi + Diffusion (Dengan Kontras) 5,200,000
1911 MRI Brain + MRA Carotis (Tanpa Kontras) 4,900,000
1912 MRI Brain + MRA Carotis ( Dengan Kontras ) + Anastesi 7,440,000
1913 MRI Brain + MRA Carotis ( Tanpa Kontras ) + Anastesi 6,030,000
1914 MRI Brain + MRA Carotis (Dengan Kontras) 6,200,000
1915 MRI Cardiac ( Dengan Kontras ) + Anastesi 7,440,000
1916 MRI Cardiac ( Tanpa Kontras ) + Anastesi 5,590,000
1917 MRI Cardiac (Dengan Kontras) 6,200,000
1918 MRI Cardiac (Tanpa Kontras) 4,500,000
1919 MRI Cruris ( Tanpa Kontras ) + Anastesi 4,940,000
1920 MRI Cruris (Dengan Kontras) 5,100,000
1921 MRI Cruris (Dengan Kontras) + Anastesi 6,240,000
1922 MRI Cruris (Tanpa Kontras) 3,900,000
1923 MRI Cruris Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1924 MRI Cruris Bilateral (Dengan Kontras) 6,300,000
1925 MRI Cruris Bilateral (Dengan Kontras) + Anastesi 7,550,000
1926 MRI Cruris Bilateral (Tanpa Kontras) 5,200,000
1927 MRI Elbow ( Dengan Kontras ) + Anastesi 6,240,000
1928 MRI Elbow ( Tanpa Kontras ) + Anastesi 4,940,000
1929 MRI Elbow (Dengan Kontras) 5,100,000
1930 MRI Elbow (Dengan Kontras)(rujukan luar) 1,900,000
1931 MRI Elbow (Tanpa Kontras) 3,900,000
1932 MRI Elbow (Tanpa Kontras)(rujukan luar) 1,350,000
1933 MRI Elbow Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
1934 MRI Elbow Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1935 MRI Elbow Bilateral (Dengan Kontras) 6,300,000
1936 MRI Elbow Bilateral (Tanpa Kontras) 5,200,000
1937 MRI Femur ( Dengan Kontras) + Anastesi 6,240,000
1938 MRI Femur ( Tanpa Kontras ) + Anastesi 4,940,000
1939 MRI Femur (Dengan Kontras) 5,100,000
1940 MRI Femur (Tanpa Kontras) 3,900,000
1941 MRI Femur Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1942 MRI Femur Bilateral (Dengan Kontras) 6,300,000
1943 MRI Femur Bilateral (Dengan Kontras) + Anastesi 7,550,000
1944 MRI Femur Bilateral (Tanpa Kontras) 5,200,000
1945 MRI Genu ( Dengan Kontras ) + Anastesi 6,240,000
1946 MRI Genu ( Tanpa Kontras ) + Anastesi 4,940,000
1947 MRI Genu ( Tanpa Kontras) 3,900,000
1948 MRI Genu (Dengan Kontras) 5,100,000
1949 MRI Genu Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1950 MRI Genu Bilateral (Dengan Kontras) 6,300,000
1951 MRI Genu Bilateral (Dengan Kontras) + Anastesi 7,550,000
1952 MRI Genu Bilateral (Tanpa Kontras) 5,200,000
1953 MRI Ginekologis ( Dengan Kontras ) + Anastesi 6,780,000
1954 MRI Ginekologis ( Tanpa Kontras ) + Anastesi 5,590,000
1955 MRI Ginekologis (Dengan Kontras) 5,600,000
1956 MRI Ginekologis (Tanpa Kontras) 4,500,000
1957 MRI Ginekologis + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
1958 MRI Ginekologis + Diffusion ( Tanpa Kontras ) + Anastesi 4,940,000
1959 MRI Ginekologis + Diffusion (Dengan Kontras) 5,200,000
1960 MRI Ginekologis + Diffusion (Tanpa Kontras) 3,900,000
1961 MRI Ginjal + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
1962 MRI Ginjal + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
1963 MRI Ginjal + Diffusion (Dengan Kontras) 5,200,000
1964 MRI Ginjal + Diffusion (Tanpa Kontras) 4,800,000
1965 MRI Hip Joint ( Tanpa Kontras ) + Anastesi 4,940,000
1966 MRI Hip Joint (Dengan Kontras) 5,100,000
1967 MRI Hip Joint (Dengan Kontras) + Anastesi 6,240,000
1968 MRI Hip Joint (Tanpa Kontras) 3,900,000
1969 MRI Humerus ( Tanpa Kontras ) 3,900,000
1970 MRI Humerus ( Tanpa Kontras ) + Anastesi 4,940,000
1971 MRI Humerus (Dengan Kontras) 5,100,000
1972 MRI Humerus (Dengan Kontras) + Anastesi 6,240,000
1973 MRI Humerus Bilateral ( Tanpa Kontras ) 5,200,000
1974 MRI Humerus Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1975 MRI Humerus Bilateral (Dengan Kontras) 6,300,000
1976 MRI Humerus Bilateral (Dengan Kontras) + Anastesi 7,550,000
1977 MRI Leher ( Dengan Kontras ) + Anastesi 6,240,000
1978 MRI Leher ( Tanpa Kontras ) + Anastesi 4,940,000
1979 MRI Leher (Dengan Kontras) 5,100,000
1980 MRI Leher (Tanpa Kontras) 3,900,000
1981 MRI Liver + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
1982 MRI Liver + Diffusion ( Tanpa Kontras ) + Anastesi 4,940,000
1983 MRI Liver + Diffusion (Dengan Kontras) 5,200,000
1984 MRI Liver + Diffusion (Tanpa Kontras) 3,900,000
1985 MRI Lumbosakral ( Dengan Kontras ) + Anastesi 6,240,000
1986 MRI Lumbosakral ( Tanpa Kontras ) + Anastesi 4,940,000
1987 MRI Lumbosakral (Dengan Kontras) 5,100,000
1988 MRI Lumbosakral (Tanpa Kontras) 3,900,000
1989 MRI Mamae ( Dengan Kontras ) + Anastesi 6,780,000
1990 MRI Mamae ( Tanpa Kontras ) + Anastesi 5,830,000
1991 MRI Mamae (Dengan Kontras) 5,600,000
1992 MRI Mamae (Tanpa Kontras) 4,700,000
1993 MRI Manus ( Dengan Kontras ) + Anastesi 6,240,000
1994 MRI Manus ( Tanpa Kontras ) + Anastesi 4,940,000
1995 MRI Manus (Dengan Kontras) 5,100,000
1996 MRI Manus (Tanpa Kontras) 3,900,000
1997 MRI Manus Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
1998 MRI Manus Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
1999 MRI Manus Bilateral (Dengan Kontras) 6,300,000
2000 MRI Manus Bilateral (Tanpa Kontras) 5,200,000
2001 MRI MRCP ( Tanpa Kontras ) + Anastesi 6,030,000
2002 MRI MRCP (Dengan Kontras) 5,300,000
2003 MRI MRCP (Dengan Kontras) + Anastesi 6,460,000
2004 MRI MRCP (Tanpa Kontras) 4,900,000
2005 MRI Nasofaring ( Dengan Kontras ) + Anastesi 6,240,000
2006 MRI Nasofaring ( Tanpa Kontras ) + Anastesi 4,940,000
2007 MRI Nasofaring (Dengan Kontras) 5,100,000
2008 MRI Nasofaring (Tanpa Kontras) 3,900,000
2009 MRI Orbita ( Dengan Kontras ) + Anastesi 6,350,000
2010 MRI Orbita ( Tanpa Kontras ) + Anastesi 4,940,000
2011 MRI Orbita (Dengan Kontras) 5,200,000
2012 MRI Orbita (Tanpa Kontras) 3,900,000
2013 MRI Pedis ( Dengan Kontras ) + Anastesi 6,240,000
2014 MRI Pedis ( Tanpa Kontras ) + Anastesi 4,940,000
2015 MRI Pedis (Dengan Kontras) 5,100,000
2016 MRI Pedis (Tanpa Kontras) 3,900,000
2017 MRI Pedis Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
2018 MRI Pedis Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2019 MRI Pedis Bilateral (Dengan Kontras) 6,300,000
2020 MRI Pedis Bilateral (Tanpa Kontras) 5,200,000
2021 MRI Pelvis ( Dengan Kontras )(rujukan luar) 1,900,000
2022 MRI Pelvis ( Tanpa Kontras ) 4,500,000
2023 MRI Pelvis ( Tanpa Kontras ) + Anastesi 5,590,000
2024 MRI Pelvis ( Tanpa Kontras )(rujukan luar) 1,350,000
2025 MRI Pelvis (Dengan Kontras) 5,100,000
2026 MRI Pelvis (Dengan Kontras) + Anastesi 6,240,000
2027 MRI Plexus Brachialis ( Dengan Kontras ) + Anastesi 6,780,000
2028 MRI Plexus Brachialis ( Tanpa Kontras ) + Anastesi 5,950,000
2029 MRI Plexus Brachialis (Dengan Kontras) 5,600,000
2030 MRI Plexus Brachialis (Tanpa Kontras) 4,800,000
2031 MRI Prostat + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2032 MRI Prostat + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
2033 MRI Prostat + Diffusion (Dengan Kontras) 5,200,000
2034 MRI Prostat + Diffusion (Tanpa Kontras) 4,800,000
2035 MRI Prostat Dynamic Kontras + Perfusion + Diffusion 5,700,000
2036 MRI Prostat Dynamic Kontras + Perfusion + Diffusion + Anastesi 6,890,000
2037 MRI Sella Tursika Dynamic Kontras + Diffusion 5,700,000
2038 MRI Sella Tursika Dynamic Kontras + Diffusion + Anastesi 6,890,000
2039 MRI Servikal ( Dengan Kontras ) + Anastesi 6,240,000
2040 MRI Servikal ( Tanpa Kontras ) + Anastesi 4,940,000
2041 MRI Servikal (Dengan Kontras) 5,100,000
2042 MRI Servikal (Tanpa Kontras) 3,900,000
2043 MRI Shoulder ( Tanpa Kontras ) 3,900,000
2044 MRI Shoulder ( Tanpa Kontras ) + Anastesi 4,940,000
2045 MRI Shoulder (Dengan Kontras) 5,100,000
2046 MRI Shoulder (Dengan Kontras) + Anastesi 6,240,000
2047 MRI Shoulder Bilateral ( Tanpa Kontras ) 5,200,000
2048 MRI Shoulder Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2049 MRI Shoulder Bilateral (Dengan Kontras) 6,300,000
2050 MRI Shoulder Bilateral (Dengan Kontras) + Anastesi 7,550,000
2051 MRI Sinus Paranasal ( Dengan Kontras ) + Anastesi 6,240,000
2052 MRI Sinus Paranasal ( Tanpa Kontras ) + Anastesi 6,220,000
2053 MRI Sinus Paranasal (Dengan Kontras) 5,100,000
2054 MRI Sinus Paranasal (Tanpa Kontras) 5,000,000
2055 MRI Thoracal ( Dengan Kontras ) + Anastesi 6,240,000
2056 MRI Thoracal ( Tanpa Kontras ) + Anastesi 4,940,000
2057 MRI Thoracal (Dengan Kontras) 5,100,000
2058 MRI Thoracal (Dengan Kontras)(rujukan luar) 1,900,000
2059 MRI Thoracal (Tanpa Kontras) 3,900,000
2060 MRI Thoracal (Tanpa Kontras)(rujukan luar) 1,350,000
2061 MRI Thoraks ( Dengan Kontras ) + Anastesi 6,350,000
2062 MRI Thoraks ( Tanpa Kontras ) + Anastesi 6,560,000
2063 MRI Thoraks (Dengan Kontras) 5,200,000
2064 MRI Thoraks (Tanpa Kontras) 5,300,000
2065 MRI Thoraks + Diffusion ( Dengan Kontras ) + Anastesi 6,780,000
2066 MRI Thoraks + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
2067 MRI Thoraks + Diffusion (Dengan Kontras) 5,600,000
2068 MRI Thoraks + Diffusion (Tanpa Kontras) 4,800,000
2069 MRI Total Spine ( Dengan Kontras ) + Anastesi 7,550,000
2070 MRI Total Spine ( Tanpa Kontras ) + Anastesi 6,420,000
2071 MRI Total Spine (Dengan Kontras) 6,300,000
2072 MRI Total Spine (Tanpa Kontras) 5,200,000
2073 MRI Upper Abdomen ( Tanpa Kontras ) + Anastesi 5,830,000
2074 MRI Upper Abdomen (Dengan Kontras) 5,300,000
2075 MRI Upper Abdomen (Dengan Kontras) + Anastesi 6,460,000
2076 MRI Upper Abdomen (Tanpa Kontras) 4,700,000
2077 MRI Upper Abdomen Dynamic Kontras 5,700,000
2078 MRI Upper Abdomen Dynamic Kontras + Anastesi 6,890,000
2079 MRI Urografi ( Tanpa Kontras ) + Anastesi 6,030,000
2080 MRI Urografi (Dengan Kontras) 5,300,000
2081 MRI Urografi (Dengan Kontras) + Anastesi 6,460,000
2082 MRI Urografi (Tanpa Kontras) 4,900,000
2083 MRI Whole Body ( Dengan Kontras ) + Anastesi 7,440,000
2084 MRI Whole Body ( Tanpa Kontras ) + Anastesi 5,590,000
2085 MRI Whole Body (Dengan Kontras) 6,200,000
2086 MRI Whole Body (Tanpa Kontras) 4,500,000
2087 MSCT Ankle ( Dengan Kontras ) + Anastesi 6,460,000
2088 MSCT Ankle ( Tanpa Kontras ) + Anastesi 2,980,000
2089 MSCT Ankle (Dengan Kontras) 5,300,000
2090 MSCT Ankle (Tanpa Kontras) 2,100,000
2091 MSCT Antebrachi ( Dengan Kontras ) + Anastesi 4,720,000
2092 MSCT Antebrachi ( Tanpa Kontras ) + Anastesi 2,980,000
2093 MSCT Antebrachi (Dengan Kontras) 3,700,000
2094 MSCT Antebrachi (Tanpa Kontras) 2,100,000
2095 MSCT Biopsi + Film Non Kontras 1,000,000
2096 MSCT Biopsi Non Kontras 850,000
2097 MSCT Brain ( Dengan Kontras ) + Anastesi 4,500,000
2098 MSCT Brain ( Tanpa Kontras ) + Anastesi 2,550,000
2099 MSCT Brain (Dengan Kontras) 3,500,000
2100 MSCT Brain (Tanpa Kontras) 1,700,000
2101 MSCT Calsium Score ( Dengan Kontras ) + Anastesi 6,240,000
2102 MSCT Calsium Score ( Tanpa Kontras ) + Anastesi 2,870,000
2103 MSCT Calsium Score (Dengan Kontras) 5,100,000
2104 MSCT Calsium Score (Tanpa Kontras) 2,000,000
2105 MSCT Cerebral Carotis 6,300,000
2106 MSCT Cruris ( Dengan Kontras ) + Anastesi 6,240,000
2107 MSCT Cruris ( Tanpa Kontras ) + Anastesi 2,980,000
2108 MSCT Cruris (Dengan Kontras) 5,100,000
2109 MSCT Cruris (Tanpa Kontras) 2,100,000
2110 MSCT Ekstremitas (Dengan Kontras) 2,300,000
2111 MSCT Ekstremitas (Non Kontras) 1,500,000
2112 MSCT Ekstremitas Superior 2,900,000
2113 MSCT Elbow ( Dengan Kontras ) + Anastesi 4,720,000
2114 MSCT Elbow ( Tanpa Kontras ) + Anastesi 2,980,000
2115 MSCT Elbow (Dengan Kontras) 3,700,000
2116 MSCT Elbow (Tanpa Kontras) 2,100,000
2117 MSCT Elbow Bilateral ( Dengan Kontras ) + Anastesi 4,720,000
2118 MSCT Elbow Bilateral ( Tanpa Kontras ) + Anastesi 2,980,000
2119 MSCT Elbow Bilateral (Dengan Kontras) 3,700,000
2120 MSCT Elbow Bilateral (Tanpa Kontras) 2,100,000
2121 MSCT Femur ( Dengan Kontras ) + Anastesi 6,240,000
2122 MSCT Femur ( Tanpa Kontras ) + Anastesi 2,980,000
2123 MSCT Femur (Dengan Kontras) 5,100,000
2124 MSCT Femur (Tanpa Kontras) 2,100,000
2125 MSCT Genu ( Dengan Kontras ) + Anastesi 7,550,000
2126 MSCT Genu ( Tanpa Kontras ) + Anastesi 2,980,000
2127 MSCT Genu (Dengan Kontras) 6,300,000
2128 MSCT Genu (Tanpa Kontras) 2,100,000
2129 MSCT Humerus ( Dengan Kontras ) + Anastesi 4,720,000
2130 MSCT Humerus ( Tanpa Kontras ) + Anastesi 2,980,000
2131 MSCT Humerus (Dengan Kontras) 3,700,000
2132 MSCT Humerus (Tanpa Kontras) 2,100,000
2133 MSCT Kepala (Dengan Kontras) 1,700,000
2134 MSCT Kepala 3 Dimensi ( Dengan Kontras ) + Anastesi 4,720,000
2135 MSCT Kepala 3 Dimensi ( Tanpa Kontras ) + Anastesi 2,980,000
2136 MSCT Kepala 3 Dimensi (Dengan Kontras) 3,700,000
2137 MSCT Kepala 3 Dimensi (Tanpa Kontras) 2,100,000
2138 MSCT Laring ( Dengan Kontras ) + Anastesi 4,610,000
2139 MSCT Laring ( Tanpa Kontras ) + Anastesi 2,980,000
2140 MSCT Laring (Dengan Kontras) 3,600,000
2141 MSCT Laring (Tanpa Kontras) 2,100,000
2142 MSCT Leher ( Dengan Kontras ) + Anastesi 4,610,000
2143 MSCT Leher ( Tanpa Kontras ) + Anastesi 2,550,000
2144 MSCT Leher (Dengan Kontras) 3,600,000
2145 MSCT Leher (Tanpa Kontras) 1,700,000
2146 MSCT Lower Abdomen ( Dengan Kontras ) + Anastesi 5,040,000
2147 MSCT Lower Abdomen ( Tanpa Kontras ) + Anastesi 3,090,000
2148 MSCT Lower Abdomen (Dengan Kontras) 4,000,000
2149 MSCT Lower Abdomen (Tanpa Kontras) 2,200,000
2150 MSCT Lumbosakral ( Dengan Kontras ) + Anastesi 4,720,000
2151 MSCT Lumbosakral (Dengan Kontras) 3,700,000
2152 MSCT Lumbosakral (Tanpa Kontras ) + Anastesi 3,410,000
2153 MSCT Lumbosakral (Tanpa Kontras) 2,500,000
2154 MSCT Manus ( Dengan Kontras ) + Anastesi 4,720,000
2155 MSCT Manus ( Tanpa Kontras ) + Anastesi 2,980,000
2156 MSCT Manus (Dengan Kontras) 3,700,000
2157 MSCT Manus (Tanpa Kontras) 2,100,000
2158 MSCT Mastoid ( Dengan Kontras ) + Anastesi 4,500,000
2159 MSCT Mastoid ( Tanpa Kontras ) + Anastesi 2,550,000
2160 MSCT Mastoid (Dengan Kontras) 3,500,000
2161 MSCT Mastoid (Tanpa Kontras) 1,700,000
2162 MSCT Nasofaring ( Dengan Kontras ) + Anastesi 4,500,000
2163 MSCT Nasofaring ( Tanpa Kontras ) + Anastesi 2,550,000
2164 MSCT Nasofaring (Dengan Kontras) 3,500,000
2165 MSCT Nasofaring (Tanpa Kontras) 1,700,000
2166 MSCT Pedis ( Dengan Kontras ) + Anastesi 6,460,000
2167 MSCT Pedis ( Tanpa Kontras ) + Anastesi 2,980,000
2168 MSCT Pedis (Dengan Kontras) 5,300,000
2169 MSCT Pedis (Tanpa Kontras) 2,100,000
2170 MSCT Pelvis ( Dengan Kontras ) + Anastesi 4,720,000
2171 MSCT Pelvis ( Tanpa Kontras ) + Anastesi 3,090,000
2172 MSCT Pelvis (Dengan Kontras) 3,700,000
2173 MSCT Pelvis (Tanpa Kontras) 2,200,000
2174 MSCT Servikal ( Dengan Kontras ) + Anastesi 4,720,000
2175 MSCT Servikal ( Tanpa Kontras ) + Anastesi 2,980,000
2176 MSCT Servikal (Dengan Kontras) 3,700,000
2177 MSCT Servikal (Tanpa Kontras) 2,100,000
2178 MSCT Sinus (Dengan Kontras) 1,700,000
2179 MSCT Sinus Paranasal ( Dengan Kontras ) + Anastesi 4,500,000
2180 MSCT Sinus Paranasal (Dengan Kontras) 3,500,000
2181 MSCT Sinus Paranasal (Tanpa Kontras ) + Anastesi 2,550,000
2182 MSCT Sinus Paranasal (Tanpa Kontras) 1,700,000
2183 MSCT Thoraco-Abdominal ( Dengan Kontras ) + Anastesi 6,240,000
2184 MSCT Thoraco-Abdominal ( Tanpa Kontras ) + Anastesi 4,500,000
2185 MSCT Thoraco-Abdominal (Dengan Kontras) 5,100,000
2186 MSCT Thoraco-Abdominal (Tanpa Kontras) 3,500,000
2187 MSCT Thorakal ( Dengan Kontras ) + Anastesi 4,720,000
2188 MSCT Thorakal ( Tanpa Kontras ) + Anastesi 3,410,000
2189 MSCT Thorakal (Dengan Kontras) 3,700,000
2190 MSCT Thorakal (Tanpa Kontras) 2,500,000
2191 MSCT Thoraks ( Dengan Kontras ) + Anastesi 6,240,000
2192 MSCT Thoraks ( Tanpa Kontras ) + Anastesi 3,200,000
2193 MSCT Thoraks (Dengan Kontras) 5,100,000
2194 MSCT Thoraks (Tanpa Kontras) 2,300,000
2195 MSCT Total Spine ( Dengan Kontras ) + Anastesi 4,720,000
2196 MSCT Total Spine (Dengan Kontras) 3,700,000
2197 MSCT Total Spine (Tanpa Kontras ) + Anastesi 2,980,000
2198 MSCT Total Spine (Tanpa Kontras) 2,100,000
2199 MSCT Tyroid ( Dengan Kontras ) + Anastesi 4,610,000
2200 MSCT Tyroid ( Tanpa Kontras ) + Anastesi 2,870,000
2201 MSCT Tyroid (Dengan Kontras) 3,600,000
2202 MSCT Tyroid (Tanpa Kontras) 2,000,000
2203 MSCT Upper Abdomen ( Dengan Kontras ) + Anastesi 5,040,000
2204 MSCT Upper Abdomen ( Tanpa Kontras ) + Anastesi 3,090,000
2205 MSCT Upper Abdomen (Dengan Kontras) 4,000,000
2206 MSCT Upper Abdomen (Tanpa Kontras) 2,200,000
2207 MSCT Virtual Colonoscopy ( Dengan Kontras ) + Anastesi 6,460,000
2208 MSCT Virtual Colonoscopy ( Tanpa Kontras ) + Anastesi 3,410,000
2209 MSCT Virtual Colonoscopy (Dengan Kontras) 5,300,000
2210 MSCT Virtual Colonoscopy (Tanpa Kontras) 2,500,000
2211 MSCT Virtual Colonoscopy Non Kontras 1,650,000
2212 MSCT Whole Abdomen ( Dengan Kontras ) + Anastesi 6,890,000
2213 MSCT Whole Abdomen ( Tanpa Kontras ) + Anastesi 3,640,000
2214 MSCT Whole Abdomen (Dengan Kontras) 5,700,000
2215 MSCT Whole Abdomen (Tanpa Kontras) 2,700,000
2216 MSCTA Cerebral 2,219,800
2217 MSCTA Perfusion 1,419,800
2218 MSCTA Brain Perfusion 6,300,000
2219 MSCTA Brain Perfusion + Anastesi 7,550,000
2220 MSCTA Cardiac 6,300,000
2221 MSCTA Cardiac + Anastesi 7,550,000
2222 MSCTA Cardiac + Functional 5,100,000
2223 MSCTA Cardiac + Functional + Anastesi 6,240,000
2224 MSCTA Cerebral 5,100,000
2225 MSCTA Cerebral + Anastesi 6,240,000
2226 MSCTA Cerebral Carotis + Anastesi 7,550,000
2227 MSCTA Dental 6,300,000
2228 MSCTA Dental + Anastesi 7,550,000
2229 MSCTA Dynamic 2 Phase Liver 5,100,000
2230 MSCTA Dynamic 2 Phase Liver + Anastesi 6,240,000
2231 MSCTA Dynamic 3 Phase Liver 6,300,000
2232 MSCTA Dynamic 3 Phase Liver + Anastesi 7,550,000
2233 MSCTA Ekstremitas Atas 5,100,000
2234 MSCTA Ekstremitas Atas + Anastesi 6,240,000
2235 MSCTA Pulmunal 5,100,000
2236 MSCTA Pulmunal + Anastesi 6,240,000
2237 MSCTA Renal 5,100,000
2238 MSCTA Renal + Anastesi 6,240,000
2239 MSCTA Run Off / Ekstremitas Inferior 6,300,000
2240 MSCTA Run Off / Ekstremitas Inferior + Anastesi 7,550,000
2241 MSCTA Thoracal 6,300,000
2242 MSCTA Thoracal + Abdominal 5,100,000
2243 MSCTA Thoracal + Abdominal + Anastesi 6,240,000
2244 MSCTA Thoracal + Anastesi 7,550,000
2245 MSCTA Whole Body 5,100,000
2246 MSCTA Whole Body + Anastesi 6,240,000
2247 Multi - Slici Scanning 4,000,000
2248 Muscle Plombage ( Bedah Paru/ Thorax ) 21,102,000
2249 Muscle Test 22,800
2250 Muscle transfer or transplantation 11,196,000
2251 Myelography 500,000
2252 Myocutaneus Flap/Pectoral Mayor 5,393,089
2253 Myoglobin _ 500,000
2254 Myomectomy 6,083,892
2255 Myotomy 9,390,000
2256 Myotomy of hand 11,196,000
2257 Naeum di Tepi Kelopak Mata 0
2258 Naevus Pigmatosus 66,000
2259 Nasalance (Komunitas) 66,000
2260 Nasoendoscopy-set 800,000
2261 Nasoendoskopi Dengan Fiber 250,000
2262 Nasoendoskopi/Nasoendoskopi dengan Tindakan 250,000
2263 Nasoendoskopilaryng Rigid 250,000
2264 Nasofaring BSO Onko 250,000
2265 Nasofaringoskopi 250,000
2266 Nasopharyngolaryngeal (NPL) - Endoscopy 1,177,000
2267 Nasopharyngolaryngeal (NPL) - Endoscopy + Anastesi 1,935,000
2268 Near Total Tiroidektomi 4,850,000
2269 Nebulasi/Therapi Inhalasi 66,000
2270 Nebulizer I 175,000
2271 Nebulizer II 91,000
2272 Necototomi (ESWL) 2,500,000
2273 Necrotomi 125,000
2274 Nefrectomi Partial 6,122,557
2275 Nefrektomi Partikal / Partial 7,567,078
2276 Nefreuretektomi Parsial 10,325,221
2277 Nefro Ureterektomi 10,325,221
2278 Nefropeksi/Renopeksi 4,850,000
2279 Nefropexie 6,928,435
2280 Nefrostomi 6,928,435
2281 Nefrostomi Percutan 7,525,000
2282 Nefrostomi Percutan (ESWL) 2,500,000
2283 NefrostomiTerbuka/Permanen 4,850,000
2284 Nefrouretectomy Tumor Wilms 14,350,000
2285 Nefus Sedang, xantoma Crac Revisi 300,000
2286 Nefus yang diwajah 600,000
2287 Nefus Yang Diwajah (Besar) 0
2288 Nefus Yang Diwajah (Sedang) 0
2289 Nekretomi 66,000
2290 Nekrotomi dengan Anastesi Lokal 270,000
2291 Neurodevelopment Test 100,000
2292 Neuroktomi Saraf Vidian 5,482,645
2293 Neuroktomi/ Neurolise 7,308,000
2294 Neuroplasti/Anastomosis/Eksplorasi (N.Cranialis/Spinalis Perifer) 10,803,887
2295 Neuroplasti/Anastomosis/Eksplorasi (Plexus Brakhialis/Lumbalis Sacralis) 13,351,887
2296 Night Care 225,000
2297 Nitrogen Cair 66,000
2298 Non-Invasive Ventilation (Per Hari) 2,000,000
2299 Nonexcisional debridement of wound, infection, or burn 2,350,000
2300 Nonoperative removal of therapeutic device from head and neck 4,375,000
2301 Nt-proBNP 800,000
2302 OAE (Oto Acoustik Emission) 200,000
2303 Observasi (dr. Obs ) 23,000
2304 Observasi Kecerdasan (Komunitas) 66,000
2305 Obturasi (Pengisian Saluran Akar) Gigi Anterior (Akar Tunggal) 0
2306 Obturasi (Pengisian Saluran Akar) Gigi Posterior (Akar Jamak) 0
2307 Obturator 2,510,000
2308 Obturator + gigi 4,068,000
2309 ODC Paket A 3,182,000
2310 ODC Paket B 4,250,000
2311 ODC Paket C 8,150,000
2312 ODC Umum ( > 6 jam ) 156,000
2313 Odentectomy > 2 elemen dengan narkose 2,725,000
2314 Odontectomy Lebih dari 2 elemen 2,880,000
2315 Odontektomi dengan Anastesi Lokal 1,000,000
2316 Oesophagigrafi 400,000
2317 Omentumpexi ( Bedah Paru / Thorax ) 21,102,000
2318 Open reduction dan stabilisation of spinal Fracture 4,850,000
2319 Open Reduction Dislokasi Panggul dan Femoral Osteomy 4,666,000
2320 Open reduction of dislocation of ankle 22,971,664
2321 Open reduction of dislocation of elbow 11,203,072
2322 Open reduction of dislocation of foot and toe 8,831,664
2323 Open reduction of dislocation of hip 9,133,709
2324 Open reduction of dislocation of knee 22,938,709
2325 Open reduction of dislocation of shoulder 9,238,709
2326 Open reduction of dislocation of wrist 8,521,664
2327 Open reduction of fracture of other specified bone, except facial bones, with internal fixation 4,835,044
2328 Open reduction of fracture with internal fixation, carpals and metacarpals 4,835,044
2329 Open reduction of fracture with internal fixation, femur 7,090,400
2330 Open reduction of fracture with internal fixation, humerus 3,405,196
2331 Open reduction of fracture with internal fixation, other specified bone 4,835,044
2332 Open reduction of fracture with internal fixation, phalanges of foot 9,351,000
2333 Open reduction of fracture with internal fixation, phalanges of hand 4,835,044
2334 Open reduction of fracture with internal fixation, radius and ulna 5,611,121
2335 Open reduction of fracture with internal fixation, tarsals and metatarsals 7,090,400
2336 Open reduction of fracture with internal fixation, tibia and fibula 18,115,044
2337 Open reduction of separated epiphysis of femur 4,515,044
2338 Open reduction of separated epiphysis of humerus 9,351,000
2339 Open reduction of separated epiphysis of radius and ulna 9,351,000
2340 Open reduction of separated epiphysis of tibia and fibula 9,351,000
2341 Open Renal Biopsi 5,352,084
2342 Operasi Commando 6,350,000
2343 Operasi Hernia dengan Komplikasi 6,595,462
2344 Operasi Hernia Dengan Komplikasi (Hernia Incarcerata) 7,350,000
2345 Operasi Hernia tanpa Komplikasi 6,599,674
2346 Operasi Hydrokel 6,588,140
2347 Operasi Hypospadia/Kordectomy 8,183,889
2348 Operasi Jantung Terbuka Dengan Pacu Jantung Temporer/Penutupan PDA Tanpa Pembedahan dengan menggunakan Device ADO/Plug Ocluder/PDA+PA Banding/Corangiography + IABP (Intra Aortic Ballon Pump) 25,950,000
2349 Operasi Jantung Terbuka dengan Pacu Jantung Temporer/TOF 53,295,000
2350 Operasi Jantung Terbuka Dengan satu Katup dan Pacu Jantung Temporer / TOF+MOF 57,950,000
2351 Operasi Jantung Terbuka dua Katup 91,711,314
2352 Operasi Jantung Terbuka satu Katup 73,450,000
2353 Operasi Jantung Terbuka Standar/ASD 53,295,000
2354 Operasi Jantung Terbuka Standar/VSD/ASD Closure+Reseksi Infudibulum + Transanular Patch/Repair Left Ventricle Out Flow Track + VSD Closure 29,240,000
2355 Operasi Jantung Tertutup/PDA 37,705,000
2356 Operasi Kasai 17,350,000
2357 Operasi Konvensional plexus Brakhialias /Lumbalis / Sacralis / Cranialis / Spinalis perifer 9,392,000
2358 Operasi Laringcopi biopsi 4,375,000
2359 Operasi Manchester Fortegil 6,115,000
2360 Operasi micro Plexus Brakhialis /Lumbalis Sacralis 11,941,616
2361 Operasi Mikrotia 6,821,000
2362 Operasi Pasang Kateter Tenckhoff untuk CAPD 3,850,000
2363 Operasi Perineum 6,073,000
2364 Operasi Peyronie 6,928,435
2365 Operasi priapismus (prosedur winter) 3,850,000
2366 Operasi Repair Bull Trauma 4,850,000
2367 Operasi Tumor Ganas Ovarium 6,526,000
2368 Operasi Tumor Jinak Ovarium 6,073,000
2369 Operasi Tumor Pembuluh Darah 4,850,000
2370 Operasi Tumor Spinal Daerah Kraniospinal 13,194,095
2371 Operasi Usus (Duhamel) 6,509,511
2372 Operasi Vaskuler Tehnik Operasi Khusus 4,884,949
2373 Operculectomy 2,850,000
2374 Operkulektomi dengan Anastesi Lokal 270,000
2375 Ophorektomi Bilateral (Onkology) 3,939,234
2376 Optical Coherence Tomography 600,000
2377 Oral Diagnosa 0
2378 Orbiotomi Anterior 4,850,000
2379 Orbitotomi Anterior 8,135,000
2380 Orbitotomi Lateral 6,830,745
2381 Orchidectomy pada anak 4,966,754
2382 Orchidectomy/Orchidopexy Unilateral 7,165,911
2383 Orchidektomi Ligasi Tinggi 6,869,778
2384 Orchidektomi Subkapsuler 5,137,089
2385 Orchidektomi/orchidektomi subkapsuler 3,850,000
2386 Orchidopexi 7,165,911
2387 Orkhidektomi extended 4,850,000
2388 Orkhidopeksi Per Laparaskopi 6,478,211
2389 Orthodentic Fixed (Ceramic Bracket) Control Orthodentic 0
2390 Orthodentic Fixed (Ceramic Bracket) Rahang Atas / Rahang Bawah 0
2391 Orthodentic Fixed (Ceramic Bracket) Rahang Atas + Rahang Bawah 0
2392 Orthodentic Fixed (Control Orthodontik) 56,000
2393 Orthodentic Fixed (Metal Bracket) Control Orthodentic 0
2394 Orthodentic Fixed (Metal Bracket) Rahang Atas / Rahang Bawah 0
2395 Orthodentic Fixed (Metal Bracket) Rahang Atas + Rahang Bawah 0
2396 Orthodontik Fixed (Rahang atas / bawah) 3,478,000
2397 Orthodontik Fixed (Rahang atas + bawah) 5,040,000
2398 Orthognatic Surgery 8,888,772
2399 Orthopedic Shoes 3,000,000
2400 Other Active Musculoskeletal Exercise 70,000
2401 Other amputation below knee 5,242,099
2402 Other and unspecified repair of the anulus fibrosus 14,020,000
2403 Other anstomosis of cranial or peripheral nerve 11,582,099
2404 Other bunionectomy with soft tissue correction 6,600,000
2405 Other cervical fusion, anterior technique 14,020,000
2406 Other cervical fusion, posterior technique 14,020,000
2407 Other change in muscle or tendon length 11,196,000
2408 Other change in muscle or tendon length of hand 11,196,000
2409 Other destruction of intervertebral disc 14,020,000
2410 Other diagnostic procedures on joint structures 5,752,000
2411 Other diagnostic procedures on muscle, tendon, fascia, and bursa, including that of hand 5,202,000
2412 Other division of carpals and metacarpals 10,675,000
2413 Other division of soft tissue 9,390,000
2414 Other division of soft tissue of hand 9,390,000
2415 Other excision of ankle joint 8,105,000
2416 Other excision of elbow joint 8,105,000
2417 Other excision of hip joint 8,105,000
2418 Other excision of joint of foot and toe 8,105,000
2419 Other excision of joint of hand and finger 8,105,000
2420 Other excision of knee joint 8,105,000
2421 Other excision of shoulder joint 8,105,000
2422 Other excision of soft tissue 11,196,000
2423 Other excision of soft tissue of hand 9,390,000
2424 Other excision of wrist joint 8,105,000
2425 Other excision, fusion, and repair of toes 6,600,000
2426 Other exploration and decompresion of spinal canal 31,267,928
2427 Other fasciectomy 11,196,000
2428 Other fasciectomy of hand 9,390,000
2429 Other fusion of foot 5,476,800
2430 Other hand muscle transfer or transplantation 11,196,000
2431 Other hand muscle transposition 11,196,000
2432 Other hand tendon transfer or transplantation 11,196,000
2433 Other hand tendon transposition 11,196,000
2434 Other Immobilization,pressure,and attention to wound 2,350,000
2435 Other incision of soft tissue 9,390,000
2436 Other incision of soft tissue of hand 11,196,000
2437 Other injection of locally-acting therapeutic substance into soft tissue 3,125,000
2438 Other local excision or destruction of lesion of ankle joint 8,105,000
2439 Other local excision or destruction of lesion of elbow joint 8,105,000
2440 Other local excision or destruction of lesion of hip joint 8,105,000
2441 Other local excision or destruction of lesion of joint of foot and toe 8,105,000
2442 Other local excision or destruction of lesion of joint of hand and finger 8,105,000
2443 Other local excision or destruction of lesion of knee joint 8,105,000
2444 Other local excision or destruction of lesion of shoulder joint 8,105,000
2445 Other local excision or destruction of lesion of wrist joint 8,105,000
2446 Other local excision or destruction of lesion or tissue of skin and 3,125,000
2447 Other muscle transposition 11,196,000
2448 Other myectomy 11,196,000
2449 Other myectomy of hand 9,390,000
2450 Other nonoperative replacements 4,375,000
2451 Other operations on joint structures 5,752,000
2452 Other operations on muscle, tendon, and fascia of hand 3,125,000
2453 Other partial ostectomy carpals and metacarpals 4,632,099
2454 Other partial ostectomy humerus 4,632,099
2455 Other partial ostectomy of carpals and metacarpals 6,600,000
2456 Other partial ostectomy of femur 4,342,099
2457 Other partial ostectomy of humerus 6,600,000
2458 Other partial ostectomy of patella 18,432,099
2459 Other partial ostectomy of radius and ulna 6,600,000
2460 Other partial ostectomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
2461 Other partial ostectomy of tarsals and metatarsals 4,739,600
2462 Other partial ostectomy of tibia and fibula 18,432,099
2463 Other partial ostectomy radius and ulna 4,662,099
2464 Other partial ostectomy scapula, clavicle, and thorax (rib and sternum) 6,600,000
2465 Other Passive Musculoskeletal Exercise 70,000
2466 Other peripheral nerve or ganglion decompression or lysis of adhesions 11,604,994
2467 Other plastic operations on fascia 11,196,000
2468 Other plastic operations on hand 10,675,000
2469 Other plastic operations on muscle 11,196,000
2470 Other plastic operations on tendon 11,196,000
2471 Other reconstruction of thumb 10,675,000
2472 Other repair and reconstruction of skin and subcutaneous tissue 4,739,600
2473 Other repair of elbow 8,105,000
2474 Other repair of hand, fingers, and wrist 8,105,000
2475 Other repair of joint 5,752,000
2476 Other repair of knee 16,585,212
2477 Other repair of shoulder 8,105,000
2478 Other repair of the collateral ligaments 17,985,212
2479 Other repair of the cruciate ligaments 17,985,212
2480 Other skin graft to hand 6,528,000
2481 Other suture of flexor tendon of hand 11,196,000
2482 Other suture of muscle or fascia 11,196,000
2483 Other suture of other tendon of hand 11,196,000
2484 Other suture of tendon 11,196,000
2485 Other tendon transposition 11,196,000
2486 Other tenodesis of hand 10,675,000
2487 Other tenonectomy 11,196,000
2488 Other tenonectomy of hand 6,883,430
2489 Other tenoplasty of hand 10,675,000
2490 Other tenotomy 9,390,000
2491 Otomikroskopi 73,000
2492 Otoplasty THT 4,850,000
2493 Oval Fat Body 25,000
2494 PA Potong Beku (VC) Besar 875,000
2495 PA Potong Beku (VC) Kecil 438,000
2496 Pain Management 100,000
2497 Paket Hormonal 500,000
2498 Paket Limfoma Kasus Sukar 1,500,000
2499 Paket Perawatan Luka (Konsultasi + Tindakan) 440,000
2500 Paket Sputum 3x Serial 359,000
2501 Palatoplasti 6,794,335
2502 Panendoskopi (Eksplorasi NF.Laringoskopi.Esofagoskopi.Bronkoskopi dengan Biopsi) 4,850,000
2503 Pankreaktektomi 6,482,351
2504 Panoramic 125,000
2505 PAP / Vaginal Smer 81,000
2506 Pap Smear 81,000
2507 Paper Patch Therapy 0
2508 Parafin Bath 33,000
2509 Parasentase Telinga 66,000
2510 Parasentesa 4,850,000
2511 Parasintesis 60,000
2512 Paravin 75,000
2513 Parotidektomi 3,933,656
2514 Parotidektomi (THT) 5,482,645
2515 Parotidektomi Radikal + mandibulektomi 5,077,000
2516 Partial hip replacement 5,661,098
2517 Partial shoulder replacement 8,105,000
2518 Partus Fisiologi (Anak) 127,500
2519 Partus Fisiologi (Obgyn) 672,500
2520 Partus Letak Bokong (Anak) 203,750
2521 Partus Letak Bokong (Obgyn) 996,250
2522 Partus normal + infeksi menular (hiv-aids, hepatitis) 1,542,000
2523 Pasang / Cabut IUD 103,000
2524 Pasang / Cabut Pesarium 116,000
2525 Pasang / Cabut Susut KB 127,000
2526 Pasang Akses port celsite 9,150,000
2527 Pasang Albumin 37,000
2528 Pasang Arterial Line Intra Arterial Pressure (IAP) 2,906,000
2529 Pasang Back Slab 75,000
2530 Pasang Balon Kateter 337,000
2531 Pasang Catheter Epidural 900,000
2532 Pasang Catheter Dokter 200,000
2533 Pasang Catheter Perawat 200,000
2534 Pasang Central Venous Catheter (CVC) 2,915,000
2535 Pasang Central Venous Catheter Dengan USG Guided 2,923,000
2536 Pasang Central Venous Catheter Untuk HD 2,061,000
2537 Pasang Central Venous Catheter Untuk HD Dengan USG Guided 2,070,000
2538 Pasang CVP 290,000
2539 Pasang Gips Tanpa Narcose (Aff Hecting) 35,000
2540 Pasang Gips Tanpa Narcose (Aspirasi sendi) 135,000
2541 Pasang Gips Tanpa Narcose (Body Jaket Gips) 56,000
2542 Pasang Gips Tanpa Narcose (Buka Gips) 69,000
2543 Pasang Gips Tanpa Narcose (Cabut K. Wire) 69,000
2544 Pasang Gips Tanpa Narcose (Cabut Screw) 74,000
2545 Pasang Gips Tanpa Narcose (Cabut Wire) 69,000
2546 Pasang Gips Tanpa Narcose (Fore Arm Slab) 52,000
2547 Pasang Gips Tanpa Narcose (Long Arm Plester) 56,000
2548 Pasang Gips Tanpa Narcose (Long Leg Plester) 56,000
2549 Pasang Gips Tanpa Narcose (Pasang Body Cast) 106,000
2550 Pasang Gips Tanpa Narcose (Sarmento Plester) 56,000
2551 Pasang Gips Tanpa Narcose (Short Leg Plester) 56,000
2552 Pasang Gips Tanpa Narcose (Spica Gips) 56,000
2553 Pasang Gips Tanpa Narcose (U - Slab) 52,000
2554 Pasang Gips Tanpa Narcose (Uip Gips) 56,000
2555 Pasang Gudel 90,000
2556 Pasang Infus 127,000
2557 Pasang Infus Neonatus (Intensif) 75,000
2558 Pasang Infus Sulit + Anastesi 326,000
2559 Pasang Kateter dengan Mandrain 675,000
2560 Pasang Kateter Urin ( Home Care ) 50,000
2561 Pasang Laminaria/Folley Catheter 250,000
2562 Pasang Lmainaria Stift 250,000
2563 Pasang Maag Slang Dokter 154,000
2564 Pasang Maag Slang Perawat 154,000
2565 Pasang Mitellah 75,000
2566 Pasang Monitor 142,000
2567 Pasang Monitoring Invasif Kontinyu (PICCO2) 4,412,000
2568 Pasang Necloler 75,000
2569 Pasang Neopuff 110,000
2570 Pasang NGT Sulit + Anastesi 297,000
2571 Pasang O2 81,000
2572 Pasang OGT 34,000
2573 Pasang PD Catheter 1,500,000
2574 Pasang Periheral Insertion Central Catheter (PICC) 1,298,000
2575 Pasang Pulmonari Arteri Catheter (Swan-Gans) 5,655,000
2576 Pasang Saturasi 63,000
2577 Pasang Skeletal Traction 78,000
2578 Pasang Skin Traksi 47,000
2579 Pasang Stent Metal Esofagus 44,530,000
2580 Pasang Traksi Vertebra (Tulang Belakang) 675,000
2581 Pasang Transfusi 95,000
2582 Pasang Transfusi Albumin 86,000
2583 Pasang Trombolitik (Intensif) 103,000
2584 Pasang Umbilical Catheter 136,000
2585 Pasang WSD 1,300,000
2586 Pasang WSD (CathLab) 1,300,000
2587 Pasang/Angkat Jahit 66,000
2588 Pasang/Buka Gips Sirkular 250,000
2589 Pasang/Buka Tampon Vagina 66,000
2590 Pasang/Cabut Catheter 66,000
2591 Pasang/cabut susuk KB/Inplan 127,000
2592 Patch Test Diagnostik (Gendang Telinga) 66,000
2593 Patellar stabilization 8,105,000
2594 PDA Ligasi 15,550,000
2595 Peak Flow Meter 46,200
2596 Peak Flow Rate (PFR) 73,000
2597 Pedicle grafts or flaps 13,154,994
2598 Pedicle or flap graft, not otherwise specified 13,154,994
2599 Peeling Kimia (Deep) 320,000
2600 Peeling Kimia (Superficial) 200,000
2601 Peeling Kimiawi Dalam 165,000
2602 Peeling Kimiawi Superfisial 90,000
2603 Pelacakan Sindrom 90,000
2604 Pelatihan Autis 60,000
2605 Pelepasan Peripheral Insertion Central Catheter (PICC) 200,000
2606 Pelepasan Synechia Vaginalis 120,000
2607 Pem Psikotest MMPI 2 276,000
2608 Pemasangan / Penggantian Pack / Kassa Kemicitine 270,000
2609 Pemasangan Abutmen 860,000
2610 Pemasangan Arteri Line 930,000
2611 Pemasangan Balon Mitral 24,475,000
2612 Pemasangan Belog Tampon 66,000
2613 Pemasangan Bite Riser 270,000
2614 Pemasangan Cimino 5,000,000
2615 Pemasangan CPAP 229,000
2616 Pemasangan Dental Implant 1 Gigi dengan Anastesi Lokal 0
2617 Pemasangan Dental Implant 2 Gigi dengan Anastesi Lokal 0
2618 Pemasangan Dental Implant 3 Gigi dengan Anastesi Lokal 0
2619 Pemasangan Fiksasi Interna 6,882,000
2620 Pemasangan Flocare 2,850,000
2621 Pemasangan Grommet dgn Narkose (Diluar Alkes Gromet) 2,850,000
2622 Pemasangan Kateter (ESWL) 740,000
2623 Pemasangan kateter ureter (ESWL) 2,500,000
2624 Pemasangan Long Line 210,000
2625 Pemasangan Mahkota Implant 860,000
2626 Pemasangan NGT 52,000
2627 Pemasangan PCA CADD 307,000
2628 Pemasangan Pilar Implant/Somnoplasty 2,850,000
2629 Pemasangan Pintasan VA/VP Shunt 7,337,579
2630 Pemasangan Pipa Shepard 3,850,000
2631 Pemasangan Stent Non Vascular 3,000,000
2632 Pemasangan Stent Non Vascular + Anastesi 4,790,000
2633 Pemasangan T Tube 3,850,000
2634 Pemasangan TIPS 14,450,000
2635 Pemasangan TIPS + Anastesi 18,950,000
2636 Pemasangan Traksi Cervical/ dan Pemasangan Halovest 5,926,089
2637 Pemasangan Traksi Servikal 6,116,000
2638 Pemasangan Vena Dalam 451,000
2639 Pembedahan Forequarter (Bedah Onkology) 6,472,000
2640 Pemberian Nutrisi Via NGT 48,000
2641 Pemberian Obat Via Rectal 77,000
2642 Pemberian Sitotastika 250,000
2643 Pemberian Sonde 25,000
2644 Pemberian Surfaktan 653,000
2645 Pemberian Tetes Mata 40,000
2646 Pembersihan Karang Gigi (Banyak 1/2 Rahang) 70,000
2647 Pembersihan Karang Gigi (Rahang Bawah + Rahang Atas) 140,000
2648 Pembersihan Karang Gigi RA/RB (Kronis) 0
2649 Pembersihan Karang Gigi RA/RB (Simple) 0
2650 Pembukaan lubang hidung THT 3,850,000
2651 Pembuluh Darah Abdominal Kompleks (Berat)/Evar 9,544,246
2652 Pembuluh Darah Torasik Kompleks (Berat)/Tevar 13,672,246
2653 Pemeriksaan Adekusi Kt/v CAPD 1,450,000
2654 Pemeriksaan Antropometri Dokter 126,000
2655 Pemeriksaan Antropometri Paramedis 126,000
2656 Pemeriksaan Body/Fat Composition 150,000
2657 Pemeriksaan Cairan Aspirasi (FNAB) Deep (Guidance) 750,000
2658 Pemeriksaan Cairan Aspirasi (FNAB) superfisial 500,000
2659 Pemeriksaan Cairan Prostat (Massage Prostat) 135,000
2660 Pemeriksaan Candidiasis Vaginalis (Flour Albus) 115,000
2661 Pemeriksaan Dokter ( Pemeriksaan fisik )(Home Care) 52,000
2662 Pemeriksaan Easy Nogal Secret Hidung 100,000
2663 Pemeriksaan Fisik (check up) 20,000
2664 Pemeriksaan Fisik / Konsultasi Dokter Ahli 95,000
2665 Pemeriksaan Fisik / Konsultasi Dokter Umum 0
2666 Pemeriksaan Fisik Vaginal dengan Speculum 47,000
2667 Pemeriksaan Fisik/Konsultasi Dr. Ahli (Pemeriksaan Gigi) 137,000
2668 Pemeriksaan Fisik/Konsultasi Dr. Ahli (Pemeriksaan Neurologi) 137,000
2669 Pemeriksaan Fisik/Konsultasi dr. Ahli (Poli Sore) 250,000
2670 Pemeriksaan garpu tala 20,000
2671 Pemeriksaan Gram 95,000
2672 Pemeriksaan impedans 73,000
2673 Pemeriksaan Kesehatan ( Khusus ) 35,000
2674 Pemeriksaan Kesehatan (CPNS) 45,000
2675 Pemeriksaan Kondiloma (As. Asetat) 95,000
2676 Pemeriksaan Korban Kekerasan Sexual (Korban Hidup) + VER 250,000
2677 Pemeriksaan Korban Keracunan (Korban Hidup) + VER 250,000
2678 Pemeriksaan Korban Perlukaan (Korban Hidup) + VER 250,000
2679 Pemeriksaan Lampu Wood 105,000
2680 Pemeriksaan Limfadenopati 96,000
2681 Pemeriksaan Luar Jenazah WNA 1,100,000
2682 Pemeriksaan PET 1,670,000
2683 Pemeriksaan Psikologis 0
2684 Pemeriksaan Sarcoptei Scabies 115,000
2685 Pemeriksaan Scoliosis Program 350,000
2686 Pemeriksaan Tekanan Intraokuler 78,000
2687 Pemeriksaan Tiroid 80,000
2688 Pemeriksaan Trichomoniasis 115,000
2689 Pemeriksaan Umum Psikiatri 60,000
2690 Pemulasaran Jenazah 550,000
2691 Penambahan Pontik Per Pontik 860,000
2692 Penambalan Gigi Sementara 0
2693 Pencabutan WSD 180,000
2694 Pencabutan gigi dan dengan komplikasi 2,850,000
2695 Pencampuran Nutrisi Parental 48,000
2696 Pencampuran Obat Sitostatika 195,000
2697 Pencetakan Alginat Per Rahang 140,000
2698 Pencetakan Double Impression 270,000
2699 Penektomi 5,173,218
2700 Penektomi Parsial 4,850,000
2701 Pengambilan 2/3 Guttap 0
2702 Pengambilan Kultur 66,000
2703 Pengambilan Kultur Cairan CAPD 116,000
2704 Pengambilan Sampel Darah 31,000
2705 Pengambilan Sampel Swab Nasofaring dan Orofaring 100,000
2706 Pengangkatan Bite Riser 140,000
2707 Pengangkatan Fibro Adenom Mamae 2,850,000
2708 Pengangkatan Neuro Fibroma 250,000
2709 Pengangkatan Nevus Margo Palpebra 675,000
2710 Pengangkatan Pack 140,000
2711 Pengangkatan Skin Tag 250,000
2712 Pengangkatan Tandur Kulit 250,000
2713 Pengantaran Jenasah Melalui Laut 1,750,000
2714 Pengantaran Jenasah Melalui Penerbangan 2,750,000
2715 Pengaturan Diet 100,000
2716 Pengawetan Jenazah Pasca Otopsi 1,500,000
2717 Pengawetan jenazah WNA Infeksi ( HIV, AIDS) 3,800,000
2718 Pengawetan jenazah WNA Non Infeksi 2,000,000
2719 Pengecatan Gram 30,000
2720 Penggantian Kateter Dialisis 3,000,000
2721 Penggantian Kateter Dialisis + Anastesi 4,790,000
2722 Penggunaan Kamar Pendingin 300,000
2723 Penggunaan Nitrit Oxide 14,000,000
2724 Penggunaan Ruang Inap Keluarga Duka 150,000
2725 Penggunaan Ruangan VIP 150,000
2726 Penggunaan Rumah Duka 100,000
2727 Pengobatan Epistaksis 66,000
2728 Pengukuran 70,000
2729 Pengukuran Kelenjar Tiroid 65,000
2730 Pengukuran Panjang Penis 65,000
2731 Pengukuran Pas 70,000
2732 Pengurangan Bite Riser 140,000
2733 Penilaian Status Pubertas 78,000
2734 Penile Length Test 78,000
2735 Penjahitan < 10 Jahitan 140,000
2736 Penjahitan > 10 Jahitan 270,000
2737 Penutupan ASD tanpa Pembedahan dengan menggunakan Device (ASO)/ Penutupan PFO tanpa Pembedahan dengan Device (PFO Ocluder)/PTA Carotis dengan Stent 80,200,082
2738 Penutupan ASD tanpa Pembedahan dengan menggunakan Device (ASO)/ Penutupan PFO tanpa Pembedahan dengan Device (PFO Ocluder)/PTA Carotis dengan Stent + Anastesi 92,563,349
2739 Penutupan Defek Hernia Diafragmatika 9,464,367
2740 Penutupan Fistula Extra Oral dengan Anastesia Lokal 860,000
2741 Penutupan Fistula Oro Antral dengan Anastesia Lokal 860,000
2742 Penutupan Oroantral Fistula 2,850,000
2743 Penyadapan Jantung 39,915,008
2744 Penyadapan Jantung + Anastesi 43,630,247
2745 Penyakit Pembuluh Darah Perifer 4,842,820
2746 Penyelesaian Problem RS 33,000
2747 Perawatan Bayi Lahir dengan Sectio Caesaria 489,000
2748 Perawatan Cranule 72,000
2749 Perawatan Cranule Trachea 72,000
2750 Perawatan Cranule WSD 72,000
2751 Perawatan Exit Site 164,000
2752 Perawatan Luka Perineum 10,000
2753 Perawatan Payudara 10,000
2754 Perawatan Pengawetan jenazah + Jenazah Infeksi ( HIV, AIDS) 2,268,000
2755 Perawatan Pengawetan jenazah + Jenazah Non Infeksi 900,000
2756 Perawatan Pulpa Capping 70,000
2757 Perawatan Rumah 24 Jam/3 Shift (Home Care) 750,000
2758 Perawatan Rumah Shift Pagi (Home Care) 250,000
2759 Perawatan Rumah Shift Sore (Home Care) 250,000
2760 Perawatan Saluran Akar 60,000
2761 Perawatan Tali Pusat 23,000
2762 Percutaneous Dilatation Trakeostomi (PDT) 3,588,000
2763 Percutaneous Endoscopic Gastrostomy (PEG) 8,730,000
2764 Percutaneous Mitral Commissurotomy Transvenous (PTMC)/Baloon Mitral Valvotomy (BMV) 13,110,000
2765 Percutaneous Nephrolithostripst (PNCL) 11,245,000
2766 Percutaneous vertebroplasty 14,020,000
2767 Percutaneus Trans Biliary Duct. (PTBD) 18,866,131
2768 Percutaneus Trans Biliary Duct. (PTBD) + Anastesi 24,950,000
2769 Pergantian Cairan CAPD 415,000
2770 Pergantian Transfer Set 528,000
2771 Perhitungan Total Parenteral Nutrition 400,000
2772 Pericardial Sintesis (Tapping) 36,691,997
2773 Pericardial Sintesis (Tapping) + Anastesi 39,735,130
2774 Pericardiosintesis 19,450,000
2775 Pericardiosintesis / Pilkasi Diafragma 12,530,000
2776 Periksa Dalam Jenazah + VER 3,000,000
2777 Periksa Dalam Jenazah WNA 4,230,000
2778 Periksa Luar Jenazah + VER 500,000
2779 Perimetri 36,000
2780 Perkutaneus Gastrostomi / Pemasangan PEG 14,450,000
2781 Perkutaneus Gastrostomi / Pemasangan PEG + Anastesi 18,950,000
2782 Peti Jenazah 1,750,000
2783 Phacoemulsifikasi 6,850,000
2784 Pharingoplasty 4,850,000
2785 Pharyngeal Flap 5,482,645
2786 Philadelphia Collar 950,000
2787 Phonophoresis 72,600
2788 Phosphat Darah 31,000
2789 Phosphat Urine 31,000
2790 Phototherapy 60,000
2791 Pick Up 1a 350,000
2792 Pick Up 1b 450,000
2793 Pick Up 2a 450,000
2794 Pick Up 2b 550,000
2795 Pick Up 3a 450,000
2796 Pick Up 4a 550,000
2797 Pick Up 4b 650,000
2798 Pielolitotomi 4,850,000
2799 Pilkasi Diafragma 6,175,000
2800 Plano Test (HCG) 25,000
2801 Plaster aplication of extremity & spine 3,850,000
2802 Plastic operation on hand with graft of muscle or fascia 10,675,000
2803 Plastic operation on hand with other graft or implant 10,675,000
2804 Plastik Erat 260,000
2805 Play Terapi 40,000
2806 Plebography Bilateral 718,000
2807 Plebography Bilateral + Anastesi 2,730,000
2808 Plebography Unilateral 555,000
2809 Plebography Unilateral + Anastesi 2,100,000
2810 Plebotomi Tarapeutik 600,000
2811 Pleurodesis 675,000
2812 PMK Intermitten 54,000
2813 PMK Kontinue 54,000
2814 Pnemonektomi ( Bedah Paru/ Thorax ) 21,102,000
2815 Podopilin 25% 1-5 Lesi 66,000
2816 Podopilin 35% 1-5 Lesi 66,000
2817 Poliklinik CAPD 350,000
2818 Polipektomi 3,552,000
2819 Polipektomi + Anastesi 4,772,000
2820 Polipektomi Saluran Cerna Bagian Atas/Bawah 2,850,000
2821 Polis Tambalan 36,000
2822 Pollicization operation carrying over nerves and blood supply 10,675,000
2823 Polypectomy Rectum 3,850,000
2824 Poroentrostomi (Operasi Kasal) 6,175,000
2825 Postero Sagital Anorecto Vagino Urethra Plasty (PSARPUV) 17,350,000
2826 Postero Sagittal Anorectolasty / PSARP 9,464,367
2827 Postero Sagittal/Anorectovaginorethroplasty 6,138,408
2828 Potong Stump (Rectum) 4,978,718
2829 Potong Flap (Bedah Onkology) 3,573,535
2830 PPD Tes 66,000
2831 PPM (Permanent Pace Maker) 9,896,883
2832 PPM Double Chamber 34,454,000
2833 Prefabricated post logam/buah 0
2834 Preparasi Inlay Cetak Double Impression 0
2835 Preparasi Onlay Cetak Double Impression 0
2836 Preparasi Saluran Akar Gigi anterior/Akar Tunggal Dengan Rotary/Manual Protaper 0
2837 Preparasi Saluran Akar Gigi Posterior/Akar Jamak Dengan Rotary/Manual Protaper 0
2838 Prick Test (Ingestan) 136,000
2839 Prick Test (Rinala) 136,000
2840 Primary PCI 11,175,225
2841 Progesteron 269,000
2842 Progesteron (P) 445,000
2843 Prokalsitonin 660,000
2844 Prolactin (P) 325,000
2845 Prolactine 200,000
2846 Prolaktin 200,000
2847 Pronto Etmoidektomi (Ekstranasal) 5,482,645
2848 Proof laparatomy/biopsi per laparatomy 6,175,000
2849 Prosedur Tiersch (Prolapsus Recti) 6,238,462
2850 Prostatektomi Retropubik 7,252,252
2851 Prostatektomi terbuka 4,850,000
2852 Prostatektomi terbuka dan sectio Alta 4,850,000
2853 Protein Bence Jones (P) 70,000
2854 Protein C 313,000
2855 Protein Electrophoresis (P) 195,000
2856 Protein Esbach _ 30,000
2857 Protein Kuantitatif Urine 65,000
2858 Protein S 313,000
2859 Protein Total _ 32,000
2860 Protesa 1 Gigi 413,000
2861 Protesa 2 Gigi 328,000
2862 Protesa 3 Gigi 380,000
2863 Protesa 4 Gigi 465,000
2864 Protesa 5 Gigi 568,000
2865 Protesa 6 Gigi 661,000
2866 Protesa 7 Gigi 723,000
2867 Protesa Atas Lutut (Khusus) 27,000,000
2868 Protesa Atas Lutut (Standar) 19,500,000
2869 Protesa Atas Siku (Standar) 16,700,000
2870 Protesa Bawah Siku (Khusus) 19,000,000
2871 Protesa Bawah Siku (Standar) 11,050,000
2872 Protesa Full Denture 1,576,000
2873 Protesa Lebih dari 7 Gigi=1/2 Full 761,000
2874 Protesa Opturator 600,000
2875 PRP (Platelet Rich Plasma) 600,000
2876 PS1.5 Ventrikular Repair/RVOT Repair/AVR+VSD Closure+ASD Closure 45,950,000
2877 PSA 6,331,000
2878 PSA _ 265,000
2879 PSARP Laparatomi 6,118,524
2880 Pseudokista THT 250,000
2881 Psikometri Individu (HDRS/HARS Mini Metal) 32,000
2882 Psikometri Individu (Warteg HTP Rorschach) 32,000
2883 Psikoterapi (Family Terapi) 75,000
2884 Psikoterapi (Kognitif Terapi) 75,000
2885 Psikoterapi (Support Terapi) 75,000
2886 Psikoterapi I 40,000
2887 Psikoterapi II 65,000
2888 Psikoterapi Individual oleh Psikiater anak 150,000
2889 Psoas Histch/Boari Flap 6,943,000
2890 PTA + 1 Buah (Sub Clavia, Femoralis, Renalis) 19,490,000
2891 PTA + 2 Stent 45,300,000
2892 PTA Carotis Tanpa Stent 16,010,000
2893 PTB Prothesis (Khusus) 20,000,000
2894 PTB Prothesis (Standar) 9,800,000
2895 PTBD (Percutaneous Biliary Drainage) 12,086,000
2896 PTCA 11,011,434
2897 PTCA + TPM 12,820,000
2898 PTCA+1 Stent BMS 11,093,434
2899 PTCA+1 Stent DES 11,149,852
2900 PTCA+1 Stent DES+1 BMS 11,166,852
2901 PTCA+2 Stent BMS 11,110,434
2902 PTCA+2 Stent DES 11,223,270
2903 PTCA+2 Stent DES+1 BMS 11,305,270
2904 PTCA+3 Stent DES 11,361,688
2905 Pterigium + CLG 2,850,000
2906 PTH intact (P) 608,000
2907 Pthisis Bulbi (Graft Mukosa Bibir) 3,850,000
2908 Ptosis 5,586,093
2909 Ptosis + anastesi 6,823,000
2910 Puberty Test 78,000
2911 Pull Through (Soave.Duhamel.Sewnson) 9,464,367
2912 Pulmonal Valve Replacement 55,550,000
2913 Pulp Capping 0
2914 Pulse Oxymeter 63,000
2915 Puncti Pleura 675,000
2916 Punctie + Kenacort (0.5/1/2cc) Sendi Besar 325,000
2917 Punctie + Kenacort (0.5/1/2cc) Sendi Kecil 320,000
2918 Punctie Ascites 675,000
2919 Punctie Capung Duglasi 142,000
2920 Punctie Lumbal 242,000
2921 Punctie Pertitoneum 87,000
2922 Punctie Sendi Besar 300,000
2923 Punctie Sendi Kecil 295,000
2924 Punksi / Irigasi Pleura 675,000
2925 Punksi Acites/Punksi Pleura 0
2926 Punksi Batu 66,000
2927 Punksi Cairan Otak 4,892,887
2928 Punksi Hematoma Telinga 66,000
2929 Punksi Sumsum Tulang 250,000
2930 Puntie Pertitoneum 87,000
2931 PVR + TVR + Infidibulectomy 43,850,000
2932 Pyelolithotomi 6,911,502
2933 Pyeloplasty 6,499,717
2934 Pyloromiotomi (operasi fredet-ramstedt) 9,464,367
2935 Quadricepsplasty 11,196,000
2936 R.P.G ( Retrograde Pyelografi ) 450,000
2937 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif 21,250,000
2938 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster 2,500,000
2939 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster (rujukan luar) 500,000
2940 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster + Anastesi 3,100,000
2941 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif (rujukan luar) 607,150
2942 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif + Anastesi 26,350,000
2943 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster 4,375,000
2944 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster (rujukan luar) 875,000
2945 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster + Anastesi 5,425,000
2946 Radiasi Eksterna - IMRT / IGRT - Kuratif Defenitif + Anastesi 31,000,000
2947 Radiasi Eksterna - IMRT / IGRT - Kuratif Definitif 25,000,000
2948 Radiasi Eksterna - IMRT / IGRT - Kuratif Definitif (rujukan luar ) 714,300
2949 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif 8,800,000
2950 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant 10,800,000
2951 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant (rujukan luar) 432,000
2952 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant + Anastesi 12,960,000
2953 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif 11,500,000
2954 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif (rujukan luar) 328,600
2955 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif + Anastesi 14,020,000
2956 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif (rujukan luar) 1,760,000
2957 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif + Anastesi 10,120,000
2958 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant 12,500,000
2959 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant (rujukan luar) 500,000
2960 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant + Anastesi 15,020,000
2961 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif 13,300,000
2962 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif (rujukan luar) 380,000
2963 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif + Anastesi 16,180,000
2964 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif 11,000,000
2965 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif (rujukan luar) 2,200,000
2966 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif + Anastesi 13,520,000
2967 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan 8,600,000
2968 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan (rujukan luar) 1,720,000
2969 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan + Anastesi 9,800,000
2970 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS) + Alat Bantu) - Paliatif 8,750,000
2971 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS) + Alat Bantu) - Paliatif (rujukan luar) 1,750,000
2972 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant 12,500,000
2973 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant (rujukan luar) 500,000
2974 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant + Anastesi 15,380,000
2975 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif 15,000,000
2976 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif (rujukan luar) 428,600
2977 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif + Anastesi 17,040,000
2978 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Paliatif + Anastesi 10,790,000
2979 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery 9,375,000
2980 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery (rujukan luar) 9,375,000
2981 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery + Anastesi 11,625,000
2982 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery 31,250,000
2983 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery (rujukan luar) 31,250,000
2984 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery + Anastesi 38,750,000
2985 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix 9,375,000
2986 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix (rujukan luar) 1,875,000
2987 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix + Anastesi 11,625,000
2988 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix 31,250,000
2989 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix (rujukan luar) 6,250,000
2990 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix + Anastesi 38,750,000
2991 Radiasi Eksterna 3D 1 x radiasi 1,154,000
2992 Radiasi Eksterna IMRT 1 x radiasi 1,154,000
2993 Radical excision of skin lesion 3,125,000
2994 Radikal Cystektomi 11,981,598
2995 Radikal Neck Desection 4,063,694
2996 Radikal Nefroktomi 9,356,913
2997 Radikal Prostatektomi 11,130,825
2998 Radioderm 0
2999 Radiofrekuensi + PTBV 23,550,000
3000 Rasio IT 190,000
3001 Raven Test/IQ test 33,000
3002 Rawat Colostomy 93,000
3003 Rawat Luka Berat 110,000
3004 Rawat Luka Ringan 47,000
3005 Rawat Luka Sedang 76,000
3006 Rawat Traechestomy 190,000
3007 Re-Treatment 0
3008 Real Time - PCR Covid-19 (Untuk Perjalanan) 295,000
3009 Reapir Komplikasi AV Shunt 2,850,000
3010 Reattachment of extremity 2,350,000
3011 Reattachment of muscle 11,196,000
3012 Reattachment of muscle of hand 11,196,000
3013 Reattachment of tendon 11,196,000
3014 Reattachment of tendon of hand 11,196,000
3015 Recession of tendon 11,196,000
3016 Recession of tendon of hand 11,196,000
3017 Reconstruction Anterior 4,375,000
3018 Reconstruction of muscle and tendon 3,271,994
3019 Reconstruction of thumb 5,561,121
3020 Rectal / Vaginal Toucher 77,000
3021 Rectal Toucher 77,000
3022 Rectorectal pull-through/duhamel procedure 6,175,000
3023 Redo BT Shunt / Redo PS Repair / VSD + PS Repair 48,750,000
3024 Refraktometri 25,000
3025 Refusion of atlas-axis spine 10,791,458
3026 Refusion of dorsal and dorolumbarspine, anterior technique 14,020,000
3027 Refusion of dorsal and dorolumbarspine, posterior technique 14,020,000
3028 Refusion of lumbar and lumbosacral spine, anterior technique 14,020,000
3029 Refusion of lumbar and lumbosacral spine, lateral transverse technique 14,020,000
3030 Refusion of lumbar and lumbosacral spine, posterior technique 14,020,000
3031 Refusion of other cervical spine, anterior technique 14,020,000
3032 Refusion of other cervical spine, posterior technique 14,020,000
3033 Refusion of spine, NEC 14,020,000
3034 Regional Flap 5,011,958
3035 Regional Flap Tidak Luas THT 4,850,000
3036 Rehabilitasi Medik Fase II dan Fase III 200,000
3037 Rehabilitasi Sosial 33,000
3038 Rehidrasi Pada Dehidrasi Berat 200,000
3039 Rehidrasi Pada Dehidrasi Ringan/Sedang 168,000
3040 Reimplantasi Gigi Asli dengan Anastesi Lokal 860,000
3041 Reimplantasi Ureter 6,175,000
3042 Rekanalisasi Central Line 3,000,000
3043 Rekanalisasi Central Line + Anastesi 4,790,000
3044 Rekanalisasi Ruptura / Transkanal 4,392,000
3045 Rekons defek / kelainan tubuh yang simple 3,850,000
3046 Rekonstruksi avulsi kulit 4,850,000
3047 Rekonstruksi Club hand 4,850,000
3048 Rekonstruksi Craniosinostosis 4,850,000
3049 Rekonstruksi defek dengan flap jauh 4,850,000
3050 Rekonstruksi defek dengan flap lokal 4,850,000
3051 Rekonstruksi Defek/Kelainan Tubuh Yang Kompleks 5,394,025
3052 Rekonstruksi Degloving Injury 8,888,772
3053 Rekonstruksi Duktus Lacrimalis / Stenosis Sederhana 4,850,000
3054 Rekonstruksi Fraktur Muka Dengan Palte Screw THT 8,850,000
3055 Rekonstruksi Fraktur Rahang THT 4,850,000
3056 Rekonstruksi Gigantomastia 4,850,000
3057 Rekonstruksi Hidung Dengan Defek THT 7,850,000
3058 Rekonstruksi Jenazah Tk.Berat 1,000,000
3059 Rekonstruksi Jenazah Tk.Ringan 500,000
3060 Rekonstruksi Jenazah Tk.Sedang 750,000
3061 Rekonstruksi Kelainan Craniofacial Congenila 4,850,000
3062 Rekonstruksi kelainan jari (polidaktil simple) 2,850,000
3063 Rekonstruksi Kelainan Mata/kontraktur palpebra 4,850,000
3064 Rekonstruksi Kontraktur Difus 4,850,000
3065 Rekonstruksi Kontraktur Kompleks (Bedah THT) 4,850,000
3066 Rekonstruksi koreksi Camplodactyl/Clinidactyl 4,850,000
3067 Rekonstruksi koreksi Makrodactyl 4,850,000
3068 Rekonstruksi Mammae dengan miocutaneus 4,850,000
3069 Rekonstruksi Mandibula THT 7,850,000
3070 Rekonstruksi Mayor 7,750,000
3071 Rekonstruksi Meningo Encephalocele Anterior (MEA) 4,850,000
3072 Rekonstruksi Meningokel Kranial (Anterior/ Posterior) 7,667,000
3073 Rekonstruksi Meningokel Spina Bifida 7,662,000
3074 Rekonstruksi orbita kongenital 6,823,000
3075 Rekonstruksi Pulley Tendon 4,375,000
3076 Rekonstruksi Repair Tendon Complikate 4,850,000
3077 Rekonstruksi Ring Avulsion 4,850,000
3078 Rekonstruksi Sedang (STSG.FTSG.Flap Lokal) 4,850,000
3079 Rekonstruksi Telinga 9,950,000
3080 Rekonstruksi Telinga ( Tahap 1/ tahap 2 ) 9,950,000
3081 Rekonstruksi Ulkus Decubitus dengan Flap 4,850,000
3082 Rekonstruksi Urogenitalia 12,327,000
3083 Rekonstruksi Vagina 4,377,586
3084 Rekonstruksi Vaskuler Sederhana 2,850,000
3085 Rekonstruksi/Flap 250,000
3086 Rekontruksi Blassemeck / Bladder Neck 6,925,000
3087 Rekontruksi Kelopak Berat 6,849,023
3088 Rekontruksi Orbita Congenital 6,823,000
3089 Rekontruksi Renovaskuler 8,011,000
3090 Rekontruksi Saket Berat 6,944,450
3091 Rekontruksi Vesika 6,925,000
3092 Relaxation of scar or web contracture of skin 6,600,000
3093 Release Kontraktur 3,850,000
3094 Release Kontraktur + Flap 6,388,884
3095 Release Kontraktur Kompleks + STSG 6,789,135
3096 Release of carpal tunnel 6,455,000
3097 Release of clubfoot, not elsewhere classified 11,947,140
3098 Release of tarsal tunnel 6,455,000
3099 Release Sinekhia Vulva 4,991,000
3100 Release Syndacil Kompleks 4,850,000
3101 Release Tongue Tie 2,850,000
3102 Remedial Teaching 60,000
3103 Removal of external immobilization device 2,350,000
3104 Removal of foreign body from foot without incision 3,125,000
3105 Removal of foreign body from hand without incision 3,125,000
3106 Removal of foreign body from spinal canal 14,020,000
3107 Removal of foreign body without incision from lower limb, except foot 3,125,000
3108 Removal of foreign body without incision from upper limb, except hand 3,125,000
3109 Removal of foreign body, not otherwise specified 2,350,000
3110 Removal of implanted device from carpals and metacarpals 4,952,586
3111 Removal of implanted device from femur 3,814,600
3112 Removal of implanted device from humerus 5,078,000
3113 Removal of implanted device from patella 3,814,600
3114 Removal of implanted device from radius and ulna 3,814,600
3115 Removal of implanted device from scapula, clavicle, and thorax (ribs and sternum) 6,154,994
3116 Removal of implanted device from tarsal and metatarsals 3,814,600
3117 Removal of implanted device from tibia and fibula 3,814,600
3118 Removal of implanted device, unspesified site 2,350,000
3119 Removal of nail, nailbed, or nail fold 2,350,000
3120 Removal of other device from trunk 4,375,000
3121 Removal of other foreign body without incision from head and neck 3,125,000
3122 Reopening of laminectomy site 14,020,000
3123 Repair bladder extrophy (BA) 6,175,000
3124 Repair cloacal 6,175,000
3125 Repair Defek Dinding Perut 9,464,367
3126 Repair Defek Hernia Umbilikalis 5,008,000
3127 Repair Fistel 6,054,980
3128 Repair Fistel Recto-vaginal 6,175,000
3129 Repair Fistel Urethra Pascauretroplasti 5,193,000
3130 Repair Fistel Vesikokutan 4,850,000
3131 Repair Fistula rcto Vaginal 6,238,462
3132 Repair Luka Pada Wajah Kompleks 6,767,221
3133 Repair Luka Pada Wajah melibatkan saraf ducyus lakrimal/kelenjar liur 4,850,000
3134 Repair Luka Robek Sederhana Pada Wajah 5,193,000
3135 Repair Muscle/Tendon 5,121,824
3136 Repair of claw toe 6,600,000
3137 Repair of cleft hand 10,675,000
3138 Repair of hammer toe 6,600,000
3139 Repair of macrodactyly 10,675,000
3140 Repair of mallet finger 10,675,000
3141 Repair of recurrent dislocation of shoulder 8,105,000
3142 Repair of the anulus fibrosus with graft or prosthesis 14,020,000
3143 Repair Perinium Grade III - IV Pasca Persalinan 2,850,000
3144 Repair Ruptur Korneosklera 4,850,000
3145 Repair Ruptur Palpebra Simpel 2,850,000
3146 Repair Ruptur Palpebra Transkanal 3,850,000
3147 Repair Tendon Jari (Bedah Plastik) 6,883,430
3148 Repair Trauma Amputasi Jari 91,000
3149 Repair Vesico Vagina Fistel Complex 9,464,367
3150 Repair VP Shunt 5,010,202
3151 Repair WSD 180,000
3152 Reparasi Fistula Vesiko Vaginal 6,968,000
3153 Replacement of cast on lower limb 4,375,000
3154 Replacement of cast on upper limb 4,375,000
3155 Replacement of other cast 4,375,000
3156 Replacement of other device for musculoskeletal immobilization 4,375,000
3157 Replantasi (Bedah Plastik) 39,652,089
3158 Reposisi / Fiksasi Fr.Maksila & Mandibula 9,350,000
3159 Reposisi / Fiksasi Fr.Naso Orbita Edmoe (NOE) 9,350,000
3160 Reposisi & Fiksasi Fr. Naso Orbita Edmoe (NOE) 11,250,000
3161 Reposisi & Fiksasi Fraktur Tunggal Tulang Wajah 4,850,000
3162 Reposisi dengan Anestesi Lokal 675,000
3163 Reposisi dislokasi Temporo mandibula (TMJ) 3,850,000
3164 Reposisi Fraktur Mandibula Multiple/ Kompleks 6,767,221
3165 Reposisi Fraktur Mandibula Sederhana 4,850,000
3166 Reposisi Fraktur Rahang Simple 4,850,000
3167 Reposisi fraktur sederhana os nassal 2,850,000
3168 Reposisi Hidung THT 250,000
3169 Reposisi IOL 2,850,000
3170 Reposisi Iris 2,850,000
3171 Reposisi Luksasi Rahang 270,000
3172 Reposisi Luksasi Rahang Berat 860,000
3173 Reposisi Terbuka dan Fiksasi 4,375,000
3174 Reposisi TPM 1,945,000
3175 Reposisi Trauma Hidung sederhana 250,000
3176 Reposisi/ Fiksasi Fr. Orbita 9,950,000
3177 Resectie Rahang 4,442,187
3178 Reseksi + Anastomosis Esophagos 6,180,370
3179 Reseksi Adenomiosis 6,323,408
3180 Reseksi Anastomosis 4,455,809
3181 Reseksi Anastomosis Atresia usus,duplikasi 6,136,962
3182 Reseksi anterior reh bein 6,175,000
3183 Reseksi Esofagus + Interposisi Kolon 7,131,625
3184 Reseksi Gaster 6,175,000
3185 Reseksi Hepar 6,171,198
3186 Reseksi Partial Vesika 6,942,000
3187 Reseksi Reduksi 6,894,000
3188 Reseksi Trachea ( Bedah Paru / Thorax ) 21,102,000
3189 Reshaping Untuk Torus (Op.Gigi) 2,510,000
3190 Reshaping untuk Torus/Tumor Tulang 4,757,000
3191 Resisted exe 70,000
3192 Resusitasi Jantung Paru ( RJP) 931,000
3193 Resusitasi Syok 750,000
3194 Retcam + Narkose 2,850,000
3195 Retikulosit Otomatik + Hematologi Rutin _ 150,000
3196 Revisi Jaringan Parut THT 250,000
3197 Revisi Parut Per Biji 66,000
3198 Revisi Parut THT 2,850,000
3199 Revision of joint replacement of upper extremity 5,752,000
3200 Rewiring Sternum 3,850,000
3201 RF _ 100,000
3202 RF Dasar Lidah THT 4,850,000
3203 Rhinoplastik ( Diluar Silikon ) 0
3204 Rhinoplastik ( Pakai Silikon ) 0
3205 Rigde Augmentasi dengan Anastesi Lokal 860,000
3206 Rigid Endoskopi ( Naso endoskopi ) 258,000
3207 Rinoplasty dgn Augmentasi Tulang Rawan THT 8,350,000
3208 Rinoplasty THT 4,850,000
3209 Rinotomi Lateralis 7,850,000
3210 Robekan Porsio + Jahitan 600,000
3211 Roda Dua (>10 - 15 km) 6,000
3212 Roda Dua (>15 - 20 km) 8,000
3213 Roda Dua (>20 - 25 km) 10,000
3214 Roda Dua (>25 km) 15,000
3215 Roda Dua (>5 - 10 km) 4,000
3216 Roda Dua (0 - 5 km) 2,000
3217 Rong Of Motion Testing 70,000
3218 Rontgen (Poli Jantung) 75,000
3219 Rotator cuff repair 11,196,000
3220 RPG 740,000
3221 RPLND 12,022,946
3222 Ruptur Palpebra Moderate 4,850,000
3223 Sach Foot 5,500,000
3224 Salphingo Oophorektomi Bilateral 4,850,000
3225 Salphingo Oophorektomi Unilateral 3,850,000
3226 Salpingo Ophorectomy Bilateral 6,095,575
3227 Salpingo Ovarektomi/Unilateral 6,094,334
3228 Salvaging Operasi Mikro 42,591,000
3229 Saturasi Oksigen 27,000
3230 Savariy Bougie 2,850,000
3231 SC dengan B Lynch 6,458,138
3232 SC dengan HT subtotal 6,881,118
3233 SC dengan Ligasi Arteri Uterine 6,764,059
3234 SC dengan SO ( Torsi Kista) - COT 6,844,000
3235 Scar Revisi 0
3236 Sceral Buckling 4,850,000
3237 Scheral Buckel + Cryo + C3F8 7,850,000
3238 Schrimer Test 20,000
3239 Scintigraphy TL 120 4,000,000
3240 Screening & Tatalaksana Gizi Anak 100,000
3241 Scrotoplasty + Chordectomy 6,175,000
3242 Sediaan Langsung Pewarnaan BTA 30,000
3243 Sediment Urine _ 22,000
3244 Segmentektomi 3,573,535
3245 Segmentektomi ( Bedah Paru/Thorax ) 21,102,000
3246 Seksio En Caul 6,458,138
3247 Seksio Sesaria 5,605,334
3248 Sel LE _ 120,000
3249 Senam ( Stroke / Hamil / Asma ) 22,800
3250 Septectomy (Potong Septum) 5,031,000
3251 Septoplasti 4,850,000
3252 Septoplasty ec trauma hidung 4,850,000
3253 Septorinoplasty THT 7,850,000
3254 Septum Reseksi 3,850,000
3255 Sequesterectomy 21,953,072
3256 Serum Autotest 66,000
3257 Service Cost Darah Aferesis (Tromboferesis) 3,500,000
3258 Shigella Antigen 235,000
3259 Short Wave Diathermi 39,600
3260 Shunting Femoralis ( Bedah Vaskuler) 4,860,000
3261 Shunting Poplitea/Tibialis ( Bedah Vaskuler) 4,860,000
3262 Shunting Splenorea 4,816,000
3263 Shunting Splenorea (Vaskuler) 4,816,000
3264 Sialografi 375,000
3265 Simpatektomi 4,816,000
3266 Simple Functional N Surgery (Percutaneus Facet Denevation dll) 5,852,000
3267 Simple Functional N Surgery (Percutaneus Rhizotomy/PRGR) 5,813,000
3268 Simulasi menurut usia 150,000
3269 Sinus Lifting dengan Anastesi Lokal 860,000
3270 Sinuskopi/Sinoskopi Dengan Tindakan 2,850,000
3271 Sirklase 5,950,000
3272 Sirkumsisi ( Sunat ) 200,000
3273 Sirkumsisi ( Umur diatas 6 tahun ) (ESWL) 2,500,000
3274 Sirkumsisi dengan Phymosis 3,812,293
3275 Sirkumsisi pada Phymosis dengan Narkose 3,812,293
3276 Sistoplasti Reduksi 6,941,000
3277 Sistoskopi 3,930,682
3278 Sistoskopi (ESWL) 2,500,000
3279 Sistoskopi ODS 3,850,000
3280 Sistostomi 3,864,658
3281 Sistostomi perkutan 3,850,000
3282 Sistostomi Perkutan (ESWL) 2,500,000
3283 Sitologi (Sputum, Sikatan, Bilasan) 140,000
3284 Sitologi 3x Serial 96,000
3285 Sitologi Bone Marrow Punction (BMP) Biopsi 191,000
3286 Sitologi Cairan Efusi, ascites, sputum, urin 400,000
3287 Sitologi Pap Smear 150,000
3288 Sitostomi terbuka 3,850,000
3289 Six Minute Walking Test 165,000
3290 Size reduction plastic operation 6,600,000
3291 SKBN 38,000
3292 Skeletal traction and Other traction 2,350,000
3293 Skin Flap 559,000
3294 Skin Graft 560,000
3295 Skin Laser Treatment 4,850,000
3296 Skin Prick Test THT 250,000
3297 Skin Test 32,000
3298 Skin Traction 47,000
3299 Skingrafting yang Luas (Bedah Plastik) 7,587,525
3300 Skingrafting Yang Tidak Luas (Bedah Plastik) 6,777,729
3301 Skingrafting Yang Tidak Luas THT 3,850,000
3302 Skleroterapi Varises Esofagus 2,850,000
3303 Skleroterapi Varises SCBA 6,296,000
3304 Skleroterapi Varises SCBA + Anastesi 7,810,000
3305 Skrining Antibodi 600,000
3306 Skrotoplasti 6,238,462
3307 Sleepnasoendoskopi 675,000
3308 Slevece Lobektomi ( Bedah Paru / Thorax ) 21,102,000
3309 Slit Lamp Examination 73,000
3310 Soft Collar 145,000
3311 Solarium/Photo Therapi 66,000
3312 Solonektomi 4,816,000
3313 Solux 140,000
3314 Somnoplasty 2,850,000
3315 Sondage Canalculi Lacrimalis 250,000
3316 Speak Audio Meter 48,300
3317 Specular Microscope 400,000
3318 Speech Assement (Komunitas) 66,000
3319 Speech Audiometri 73,000
3320 Spermatocele 5,134,089
3321 Spermatokel (ESWL) 2,500,000
3322 Spermatokelektomi 3,850,000
3323 Sphincterotomy / Lynn Procedure 5,008,000
3324 Sphyngterotomy 7,350,000
3325 Spirometer 142,000
3326 Spirometri 138,000
3327 Spleenektomi 7,367,878
3328 Splenectomy pda trauma 6,622,000
3329 Splenektomi (Bedah Vaskuler) 4,850,000
3330 Splenektomi (Thalasemia, hipersplenisme) 11,981,598
3331 Splenektomi ec.Hipertensi Portal/ Kelainan Hematologi lain 14,690,000
3332 Splenektomi Partial 6,331,000
3333 Splinting dengan Anastesi Lokal 270,000
3334 Spool Slang WSD 26,000
3335 Spooling Blast 308,000
3336 Spooling Bola Mata 42,000
3337 Spooling CAPD 253,000
3338 Spooling Catheter 308,000
3339 Spooling Colostomy 308,000
3340 Spooling Double Lumen 338,000
3341 Spooling Intoksikasi 40,000
3342 Spooling Serumen Telinga 66,000
3343 Spooling Sinus 43,000
3344 Spooling Telinga 45,000
3345 Spray & Stretch 250,000
3346 Sputum 1x Sikatan 223,000
3347 Sputum BTA 1 X (Pewarnaan) 35,000
3348 Sputum BTA 3 X (Pewarnaan) 65,000
3349 Squesterektomi per Rahang dengan Anastesi Lokal 1,500,000
3350 Sretching Of Fascia 70,000
3351 Stapedektomi 4,046,000
3352 STE Hemorroid 660,000
3353 STE Hemorroid + Anastesi 1,422,000
3354 Stellate Ganglion Block 177,000
3355 Stick / Cane 142,000
3356 Strabismus 5,122,073
3357 Strabismus 3-4 Otot 8,350,000
3358 Streching Of Muscle Or Tendom 70,000
3359 Stress Management 33,000
3360 Stress Treadmill Dobutamin 300,000
3361 Strest Echo Dobupamin 656,000
3362 Stripping Varises 2 tungkai dengan multipel flebektomi 4,842,820
3363 Subtalar fusion 3,856,600
3364 Subtalar joint arthroereisis 5,476,800
3365 Subtipe Limfosit : CD4 _ 317,000
3366 Suction 73,000
3367 Suction Blister Grafting 250,000
3368 Sudase Ureter 2,500,000
3369 Suquestractomy 2,510,000
3370 Surat Keterangan Bebas Narkoba 50,000
3371 Surgical Staging (Bedah Obgyn) 6,559,543
3372 Suture of artery 28,004,994
3373 Suture of capsule or ligament of ankle and foot 5,752,000
3374 Suture of capsule or ligament of other lower extremity 5,752,000
3375 Suture of capsule or ligament of upper extremity 5,752,000
3376 Suture of muscle or fascia of hand 11,196,000
3377 Suture of muscle, tendon, and fascia 4,891,625
3378 Suture of tendon sheath 11,196,000
3379 Suture of tendon sheath of hand 11,196,000
3380 Swab Discar Lesi 66,000
3381 Symblepharon 3,851,142
3382 Symblepharon + anastesi 3,724,142
3383 Symne Protesis (Biasa) 3,200,000
3384 Symne Protesis (Khusus) 13,000,000
3385 Symne Protesis (Standar) 6,000,000
3386 Syndroma Blefarophimosis 11,350,000
3387 Synovectomy 13,254,994
3388 Synovectomy of ankle 5,474,000
3389 Synovectomy of elbow 5,474,000
3390 Synovectomy of foot and toe 5,474,000
3391 Synovectomy of hand and finger 5,474,000
3392 Synovectomy of hip 5,474,000
3393 Synovectomy of knee 26,604,994
3394 Synovectomy of shoulder 13,054,994
3395 Synovectomy of wrist 5,474,000
3396 Syringe Pump 68,000
3397 T - Tube Cholangiografi 400,000
3398 T Cel dan B Cel 69,000
3399 T3 140,000
3400 T3 (Total) (P) 256,000
3401 T3 Up Take 75,000
3402 T4 140,000
3403 T4 (Total) (P) 256,000
3404 Tabel 5 US Navy 1,000,000
3405 Tabel 6 A US Navy 2,000,000
3406 Tabel 6 US Navy 2,000,000
3407 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter 450,000
3408 Tabel Autis 300,000
3409 Tambalan/Restorasi Amalgam 0
3410 Tambalan/Restorasi Dengan Composite (Besar) 0
3411 Tambalan/Restorasi Dengan Composite (Kecil) 0
3412 Tambalan/Restorasi Dengan Glass Lonomer 0
3413 Tampon Bellogue 120,000
3414 Tampon Boor Zulf Covu Nasi 42,000
3415 Tampon Burowi/ telinga 14,000
3416 Tampon cavum nasi ( boorzalf) 42,000
3417 Tampon Cavum Nasi (Lidokain + Efedrin) 31,000
3418 Tampon Hidung 14,000
3419 Tampon Mata 14,000
3420 Tampon utero-vagina 70,000
3421 Tampon Vagina 66,000
3422 Tapping & Strapping 250,000
3423 Tarif Penunggu Pasien 210,000
3424 Tarif Penunggu Pasien Super VIP A 770,000
3425 Tarif Penunggu Pasien VIP A 550,000
3426 Tarif Penunggu Pasien VIP B 500,000
3427 Tarsometatarsal fusion 5,476,800
3428 Taylor Brace (Biasa) 1,320,000
3429 Taylor Brace (Khusus) 2,850,000
3430 TCD 654,000
3431 TCM Mycobacterium Tuberculosa (Genexpert Tb) 2,000,000
3432 Temporal Bone Resection 5,393,089
3433 Tendon graft 11,196,000
3434 Tendon pulley reconstruction 13,754,994
3435 Tendon Transfer Ekstremitas Bawah Pada Kasus Neuromuskular Anak 3,532,812
3436 Tendon transfer or transplantation 7,533,800
3437 Tenotomy of hand 9,390,000
3438 Tens 39,600
3439 Terapi Bicara Komunitas ( Paket 4x Datang ) 250,000
3440 Terapi CPA Pulse 66,000
3441 Terapi Diet Alergi 100,000
3442 Terapi Diet DM 78,000
3443 Terapi Diet Sindroma Nefrotik & Gnaps 78,000
3444 Terapi Kelompok 75,000
3445 Terapi Oksigen 150,000
3446 Terapi Perilaku 100,000
3447 Terapi Plasmaferesis/Leukoferesis/Tromboferesis 3,300,000
3448 Terapi Sklerosing 5,193,000
3449 Tes Alergi Asthma 323,000
3450 Tes Anel 234,000
3451 Tes Antibodi Covid - 19 Metode Rapid Test 130,000
3452 Tes Antibodi Covid-19 (IgG dan IgM) 350,000
3453 Tes Antigen Covid-19 Metode Rapid Tes 109,000
3454 Tes Bakat ( GABT Paket ) 60,000
3455 Tes Cepat Molekuler RT-PCR Covid-19 750,000
3456 Tes Elektroforesis Hb 370,000
3457 Tes Elektroforesis Protein 270,000
3458 Tes Feming 33,000
3459 Tes Fluoresin 29,000
3460 Tes Fungsi Kortikal Luhur (Pasien Baru) 261,000
3461 Tes Fungsi Kortikal Luhur (Pasien Lama) 153,000
3462 Tes Intelegensi 75,000
3463 Tes Kepribadian 50,000
3464 Tes Mutasi KRAS 2,338,000
3465 Tes Narkoba ( 3 Jenis Obat ) 253,000
3466 Tes Narkoba ( 5 Jenis Obat ) 200,000
3467 Tes Narkoba ( 6 Jenis Obat ) 368,000
3468 Tes Perspirasi 150,000
3469 Tes Provokasi Bronkus 323,000
3470 Tes Psikolog (Komunitas) 66,000
3471 Tes Rose Bengal 33,000
3472 Tes RT-PCR Covid-19 dengan Viral Respiratory Infection (10 Virus VRI) 4,000,000
3473 Tes Schirmen 33,000
3474 Test Intelegensi WAIS 60,000
3475 Test Intelegensi WISC/SPPSI 60,000
3476 Test Kepribadian EPPS 33,000
3477 Test Kepribadian Grafis 33,000
3478 Test Meningeal Sign 78,000
3479 Test Nervus Cranialis (Saraf - Anak) 100,000
3480 Test Nervus Cranialis (Tumbuh Kembang - Anak) 78,000
3481 Test Pendengaran Manual 78,000
3482 Test Perkembangan 33,000
3483 Test Perkembangan Kognitif CAT-CLAMPS 270,000
3484 Test Personal Sosial 100,000
3485 Test Reflex Fisiologis 80,000
3486 Test Reflex Patologis 80,000
3487 Test Sensibilitas 78,000
3488 Test Sisi / Decay 73,000
3489 Test Sistem Saraf Otonom 78,000
3490 Test Skiring Masalah Mental Emosional 220,000
3491 Test Tanda-tanda Vital 100,000
3492 Test Tempel Slektif 73,000
3493 Test Waktu Pendarahan 78,000
3494 Testosteron (P) 400,000
3495 Testoteron 288,000
3496 Therapi Afasia Anak 39,600
3497 Therapi Afasia Dewasa 39,600
3498 Therapi Bermain 25,200
3499 Therapi Delayed Speech (Okupasi Terapi) 39,600
3500 Therapi Delayed Speech (Terapi Wicara) 39,600
3501 Therapi Dimensia 39,600
3502 Therapi Disatria 39,600
3503 Therapi Disaudia 39,600
3504 Therapi Disfagia 39,600
3505 Therapi Disglosia 39,600
3506 Therapi Inderek / Konsultasi 39,600
3507 Therapi Irama Kelancaran 39,600
3508 Therapi Kreativitas 39,600
3509 Thigh reattachment 7,676,900
3510 Thrombine Time (TT) 200,000
3511 Thromboplastin Generation Time (TGT) 115,000
3512 Thrombotest 113,000
3513 Thumb reattachment 10,675,000
3514 TIBC _ 90,000
3515 Tilting Table (Fisioterapi) 39,600
3516 Tilting Table (Okupasi Terapi) 60,000
3517 Timpano Plastik 4,593,472
3518 Timpanometri 150,000
3519 Tind. Akupuntur, Tind TDP, Tind Cupping 55,000
3520 Tindakan Anoscopy 66,000
3521 Tindakan Ballon Detachable 12,950,000
3522 Tindakan Ballon Detachable + Anastesi 43,270,000
3523 Tindakan Balloning Dilatator 18,350,000
3524 Tindakan Balloning Dilatator + Anastesi 63,850,000
3525 Tindakan Bedah Flap 250,000
3526 Tindakan Biopsi 143,000
3527 Tindakan CABG 67,000,000
3528 Tindakan CABG High Risk/MVR/AVR 75,600,000
3529 Tindakan Coiling 17,350,000
3530 Tindakan Coiling + Anastesi 58,650,000
3531 Tindakan Congenital Fornix Plastik 4,375,000
3532 Tindakan Dekompresi Fasialis 9,350,000
3533 Tindakan Dermabrasi 250,000
3534 Tindakan Embolisasio dengan Bead Block 11,283,000
3535 Tindakan Embolisasio dengan Bead Block + Anastesi 32,440,000
3536 Tindakan Embolisasio dengan Gel Foam 6,683,000
3537 Tindakan Embolisasio dengan Gel Foam + Anastesi 22,520,000
3538 Tindakan Manual Plasenta 2,850,000
3539 Tindakan MVR/AVR 75,600,000
3540 Tindakan Pada Keratosis Seboroika 675,000
3541 Tindakan Pharyngeal Flap 4,850,000
3542 Tindakan Resusitasi 66,000
3543 Tindakan Roser Plasty 675,000
3544 Tindakan Stenting 25,350,000
3545 Tindakan Stenting + Anastesi 85,250,000
3546 Tindakan Trans Arterial Chemoterapi Infunsion (TACI/E) 6,435,000
3547 Tindakan Transfusi Darah (Poliklinik - Rawat Inap) 66,000
3548 Tindakan Trombolis 18,050,000
3549 Tindakan Trombolis + Anastesi 63,790,000
3550 Tindih Telinga (Pemasangan Anting) 170,000
3551 Tirodektomi 4,850,000
3552 Tirodektomi Total 4,527,541
3553 Tiroidektomi THT 4,850,000
3554 Toe reattachment 10,675,000
3555 TOF Low Risk/ASD Closure+MV Repair/Cleft Repair/VSD+PDA Division+Coarctasio Repair/VSD Closure+AV Repair/MV Repair 44,350,000
3556 Tonografi 73,000
3557 Tonometri 14,000
3558 Tonsilektomi 4,549,405
3559 Tonsilo Edenoidectomi 3,850,000
3560 Toracotomi + Anastomosis Esophagus 6,124,671
3561 Torakoplasty ( Bedah Paru/ Thorax ) 21,102,000
3562 Torakotomi (Paket A Bedah Paru) 19,450,000
3563 Torsio Testis 5,134,089
3564 Total elbow replacement 8,105,000
3565 Total hip replacement 5,741,098
3566 Total knee replacement 5,741,098
3567 Total ostectomy of carpals and metacarpals 6,600,000
3568 Total ostectomy of femur 6,600,000
3569 Total ostectomy of humerus 6,600,000
3570 Total ostectomy of patella 6,600,000
3571 Total ostectomy of radius and ulna 6,600,000
3572 Total ostectomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
3573 Total ostectomy of tarsals and metatarsals 6,600,000
3574 Total ostectomy of tibia and fibula 6,600,000
3575 Total shoulder replacement 8,105,000
3576 Total wrist replacement 8,105,000
3577 Touch Massage 150,000
3578 Touch Therapy 150,000
3579 TPM (Temporary Pace Maker) 3,682,250
3580 TRAb (P) 1,164,000
3581 Trabekulektomi 6,260,937
3582 Trabekulektomi +ECCE/ Phacoemulsifikasi 7,850,000
3583 Tracheostomi 3,900,504
3584 Tracheostomi (CathLab) 1,945,000
3585 Training CAPD : Perawatan Exit Site 150,000
3586 Training CAPD : Training Ganti Cairan 1,050,000
3587 Trakbekulektomi 4,488,393
3588 Trakeoplasi ( Bedah Paru / Thorax ) 21,102,000
3589 Trakestomi dengan penyulit 3,850,000
3590 Traksi 33,000
3591 Tram Flap 4,850,000
3592 Trancheostomi 5,676,074
3593 Trans Esophageal Echocardiogram (TEE) 1,800,000
3594 Trans Esophageal Echocardiogram (TEE) + Anastesi 2,500,000
3595 Transeksi Esofagus 4,399,600
3596 Transfer of finger, except thumb 10,675,000
3597 Transferrin 124,000
3598 Transfusi Faktor Pembekuan 102,000
3599 Transfusi Tukar 307,000
3600 Transjuguler Liver Biopsi 14,450,000
3601 Transjuguler Liver Biopsi + Anastesi 18,950,000
3602 Transplantasi Organ (Pendonor) 11,300,000
3603 Transplantasi Organ (Penerima) 95,800,000
3604 Transplantation of muscle and tendon of hand 13,754,994
3605 Transport Mobil Jenazah 500,000
3606 Trauma jaringan lunak wajah sederhana 2,850,000
3607 Trauma Kompleks Jaringan Lunak Wajah 5,075,000
3608 Treadment ESMR 20,000,000
3609 Treadmill Exercice 105,600
3610 Treadmill Test 400,000
3611 Tree Imirror Guinoscopy 20,000
3612 Trepanasi Gigi 140,000
3613 Trepoma Palidum H Antigen (TPHA) 145,000
3614 Triad knee repair 8,105,000
3615 Triage (dr. Triage ) 18,000
3616 Triage (ODC) 22,500
3617 Trial Aspiraction / Fungsi Percobaan 75,000
3618 Tridenelisis 4,047,000
3619 Trigger Point Injection 68,000
3620 Trigliserida _ 40,000
3621 Trikeopitelioma 250,000
3622 Triple arthrodesis 18,465,044
3623 Triple Prosedur Keratoplasti dengan Glaukoma 6,927,026
3624 Trombektomi/Lysis dengan Catheter For Vein 2,850,000
3625 Trombolisis : Dialisis Graf 14,450,000
3626 Trombolisis : Dialisis Graf + Anastesi 18,950,000
3627 Trombolisis : Extremitas Inferior 14,450,000
3628 Trombolisis : Extremitas Inferior + Anastesi 18,950,000
3629 Trombolisis : Stroke 14,450,000
3630 Trombolisis : Stroke + Anastesi 18,950,000
3631 Trombolisis : Trombosis Intrakranial 14,450,000
3632 Trombolisis : Trombosis Intrakranial + Anastesi 18,950,000
3633 Troponin I 350,000
3634 Troponin T 220,000
3635 Trust Taus 1,000,000
3636 TSHs 180,000
3637 Tuba Plasty 2,850,000
3638 Tubektomi 5,716,458
3639 Tuberculin Test 75,000
3640 Tumor Besar 0
3641 Tumor Ganas/ Adnesa Luas Rekontruksi 3,902,175
3642 Tumor Kecil 0
3643 Tumor Pembuluh Darah 5,396,887
3644 Tumor Spinal Daerah Cervikal (Bedah Syaraf) 9,482,094
3645 Tumor Spinal Daerah Torakolumbal (Bedah Syaraf) 7,917,094
3646 Tumpatan Amalgan 110,000
3647 Tumpatan Glassionomer 90,000
3648 Tumpatan komposit / L Curing Besar 200,000
3649 Tumpatan Komposit / L. Curing kecil 140,000
3650 Tumpatan Komposit Silikat 70,000
3651 TUR Prostat 8,838,281
3652 TUR Tumor Buli-Buli 9,133,281
3653 Turbinektomi 4,514,000
3654 Turbinoplasty 2,850,000
3655 TVP/TMP 4,850,000
3656 Uji Neurokognitif 250,000
3657 Uji Penisilin 66,000
3658 Uji Provokasi Obat 66,000
3659 Uji Psikometri/Tes IQ 100,000
3660 Uji Psikometrik 120,000
3661 Uji Tusuk Obat 66,000
3662 Uji Tusuk Standar 66,000
3663 Ultra Sound Diathermi 75,000
3664 Upper arm reattachment 10,675,000
3665 Urea Klirens 33,000
3666 Urea N Urine (P) 52,000
3667 Uretero Sigmoidostomi 8,164,502
3668 Uretero Ureterostomi 7,802,000
3669 Ureterocutanneostomi 7,801,000
3670 Ureterolithotomi 8,740,947
3671 Ureterolithotomi proksimal 4,850,000
3672 Ureterolysis 5,133,934
3673 Ureterostomi 5,905,186
3674 Uretetoneo Cystosthomi 8,185,000
3675 Urethocystography 525,000
3676 Urethrektomi 7,758,000
3677 Urethroplasty 7,144,677
3678 Uretrografi 450,000
3679 Uretroplasti (Bedah Plastik) 7,603,306
3680 Uretroplasty 7,921,000
3681 Urettroskopi/uretrosistoskopi 3,850,000
3682 Ureum _ 40,000
3683 Ureum Urine (UUN) 60,000
3684 Urin Kehamilan (HCG) _ 50,000
3685 Urina Infiltrate Superficial 2,500,000
3686 Urine 4 Porsi/Kurve Harian 31,000
3687 Urine Lengkap 25,000
3688 Urine Rutin _ 50,000
3689 Urine Serial 3x 107,000
3690 UROFLOWMETRI 500,000
3691 URS 7,921,000
3692 USG (Ultrasonograpi) Abdominal 227,000
3693 USG (Ultrasonograpi) Doppler 250,000
3694 USG (Ultrasonograpi) Transvaginal 251,000
3695 USG 4D 580,000
3696 USG Abdomen (Kertas) 77,000
3697 USG Abdomen (Polaroid Berwarna) 117,000
3698 USG Abdomen (Polaroid Tidak Berwarna) 114,000
3699 USG Abdomen Atas ( Upper ) 225,000
3700 USG Abdomen Atas + Bawah (Whole Abdomen) 250,000
3701 USG Abdomen Bawah ( Lower ) 225,000
3702 USG Abdomen/Prostat 0
3703 USG Ankle 163,000
3704 USG Ankle Bilateral 200,000
3705 USG Appendiks 200,000
3706 USG Bahu 163,000
3707 USG Bahu Bilateral 200,000
3708 USG Bayi 250,000
3709 USG Cardia 375,000
3710 USG Cimino 375,000
3711 USG Colour Doppler 3 Dimensi 125,000
3712 USG Dopler Vaskuler 254,000
3713 USG Doppler 350,000
3714 USG Doppler Carotis/TCD (Trans Cranial Doppler) 375,000
3715 USG Doppler Extremitas 350,000
3716 USG Doppler Testis 375,000
3717 USG Elbow 163,000
3718 USG Genu 163,000
3719 USG Genu Bilateral 200,000
3720 USG Ginekologi 227,000
3721 USG Ginjal, Buli-Buli dan Prostat 200,000
3722 USG Guiding 350,000
3723 USG Intravagina 225,000
3724 USG Kandungan 200,000
3725 USG Kandungan (Polaroid Berwarna) 111,000
3726 USG Kepala 250,000
3727 USG Leher 110,000
3728 USG Lengan 163,000
3729 USG Lengan Bilateral 200,000
3730 USG Mamma ( Payudara ) 250,000
3731 USG Mata 200,000
3732 USG Mata ( Poli/Irna ) 103,000
3733 USG Musculosckletal Lain 163,000
3734 USG Musculosckletal Lain Bilateral 200,000
3735 USG Musculus Sceletal Ankle 250,000
3736 USG Musculus Sceletal Antebrachii 250,000
3737 USG Musculus Sceletal Elbow 250,000
3738 USG Musculus Sceletal Genu 250,000
3739 USG Musculus Sceletal Shoulder 250,000
3740 USG Musculus Sceletal Wrist 250,000
3741 USG Obstetri 227,000
3742 USG Pedis 163,000
3743 USG Pedis Bilateral 200,000
3744 USG Pelvis 200,000
3745 USG Soft Tissue 200,000
3746 USG Testis 225,000
3747 USG Thorax 200,000
3748 USG Thyroid 200,000
3749 USG Urologi 200,000
3750 USG Whole Abdomen 250,000
3751 USG Wrist 163,000
3752 USG Wrist Bilateral 200,000
3753 Vacum Unit 39,600
3754 Vaksin Rabies 92,000
3755 Vaksinasi Meningitis 280,000
3756 Vaksinasi Rabies 92,000
3757 Vakum Ekstraksi 1,800,000
3758 Varikokelektomi (Palomo) 3,850,000
3759 Vasektomi 2,850,000
3760 Vasektomi (ESWL) 2,500,000
3761 Vasektomi dengan Narkose 2,850,000
3762 Vaskuler Dopler 1 Tungkai 364,000
3763 Vaskuler Dopler 2 Tungkai 660,000
3764 Vasografi 5,149,000
3765 VDRL _ 40,000
3766 Vena Seksi 344,000
3767 Venaseksi Anastesi Anak 66,000
3768 Ventilator 572,000
3769 Ventrikulostomi/VE Drainage 4,084,000
3770 Vericocele/Palomo 5,149,000
3771 Vertrikel Tap 250,000
3772 Vesicolithotomi (Sectio Alta) 5,346,294
3773 Vestibuloplasty Per Regio dengan Anastesi Lokal 860,000
3774 Visite Dokter dan Perawat 160,000
3775 Visite Dokter dan Perawat (HCU) 200,000
3776 Visite Dokter dan Perawat (PJT) 160,000
3777 Visite Dokter & perawat (Super Vip A) 140,000
3778 Visite Dokter & perawat (Super Vip B) 140,000
3779 Visite Dokter & Perawat Bayi 96,000
3780 Visite Dokter dan Perawat (CVCU PJT) 360,000
3781 Visite Dokter dan Perawat (HCU Infection Center) 240,000
3782 Visite Dokter dan Perawat (Infection Center) 216,000
3783 Visite dokter perawat HCU bayi 100,000
3784 Visite Dokter Perawat Intensif (ICCU/CVCU) 360,000
3785 Visite Dokter Perawat Intensif (NICU, PICU, ICU, Brain) 360,000
3786 Visite Rawat Bersama 96,000
3787 Visite Rawat Bersama (CVCU PJT) 216,000
3788 Visite Rawat Bersama (HCU Infection Center) 144,000
3789 Visite Rawat Bersama (HCU) 120,000
3790 Visite Rawat Bersama (Infection Center) 129,600
3791 Visite Rawat Bersama (Intensif) 216,000
3792 Visus / Refraksi 73,000
3793 Vitamin D 650,000
3794 Vitrektomi 12,103,000
3795 Vitrektomi + Endo Laser + SB + Silikon Oil/Gas 19,350,000
3796 VMA Urine (P) 99,000
3797 VSD Closure+Reroute PAPVD+TV Repair 51,550,000
3798 VSD+MOF(<10 Hari Perawatan) 51,150,000
3799 Vulvektomi 6,490,781
3800 Waktu Bekuan _ 15,000
3801 Waktu Pendarahan _ 15,000
3802 Waktu Prothtrombine (PT) _ 180,000
3803 Washing melalui Bronchoschopy 188,000
3804 Water Drinking Test 66,000
3805 Wawancara Sosial 22,800
3806 Wawancara Test 0
3807 Wedge osteotomy of carpals and metacarpals 6,600,000
3808 Wedge osteotomy of femur 6,600,000
3809 Wedge osteotomy of humerus 6,600,000
3810 Wedge osteotomy of patella 6,600,000
3811 Wedge osteotomy of radius and ulna 6,600,000
3812 Wedge osteotomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
3813 Wedge osteotomy of tarsals and metatarsals 6,600,000
3814 Wedge osteotomy of tibia and fibula 6,600,000
3815 Whirpoll 39,600
3816 Whole Body Bone Densitometry 300,000
3817 Widal _ 60,000
3818 Wide eksisi tumor tonsil.orofaring 4,850,000
3819 Wiring dengan Anastesi Lokal 860,000
3820 Wiring Per Rahang Dengan Anastesi Lokal 0
3821 Wrist Splint (Biasa) 1,500,000
3822 Wrist Splint (Khusus) 2,500,000
3823 Xanthoma 0
3824 Yag Laser 2,850,000