Tarif Layanan (Tindakan & Akomodasi)

Akomodasi
Nama Kelas Biaya
Kelas III 150,000
Non Kelas 180,000
Kelas II 180,000
Isolasi 180,000
Kelas 3 Infection Centre 216,000
Kelas I 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 HCU 500,000
VIP Infection Centre 500,000
VIP 500,000
Intensif 540,000
VIP I 550,000
VIP Intensif 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 Laser V Beam 250,000
2 17-OH Progesteron (LC-MS/MS) (P) 900,000
3 Abdominopelvic amputation 9,282,099
4 Abdominoperineal Pull - Through / Malformasi 6,175,000
5 Abdominoperineal Pull-Throug/ Swenson 6,175,000
6 Abdominorectal Pull - Through/Swenson Procedure 6,175,000
7 Ablatio Retina 10,926,000
8 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
9 Absisi Corpus Alinun 150,000
10 ACA IgG 438,000
11 ACA IgG (P) 671,000
12 ACA IgM 438,000
13 ACA IgM (P) 690,000
14 Achillotenotomy 9,390,000
15 Activated Clotting Time 400,000
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 + MOF/ Off Pump/ Aneurysmectomy / Arterial Switch Opeartion/ AVR-MVR + MOF/ CABG + MVR / CABG + AVR/ Congenital Heart Complex Repair/ Damuskez/ Noorwood Operation/ Senning Operation / TVR/AV Replacement 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 DJ Stent (ESWL) (Sore) 3,750,000
31 Aff Double Lumen 217,000
32 Aff Drain 83,000
33 Aff Hecting 72,000
34 Aff NGT 82,000
35 Aff-ORIF Fraktur Rahang Kompleks/Wajah Multiple 4,597,500
36 Aff-ORIF Fraktur Rahang Sederhana 2,670,000
37 AFO (Biasa) 961,000
38 AFO (Khusus) 2,850,000
39 AFO (Standar) 1,556,000
40 AFP _ 245,000
41 Agregasi Trombosit _ 400,000
42 Air Plumbage ( Bedah Paru/ Thorax ) 21,102,000
43 Akupuntur ( 4 x Tindakan ) 250,000
44 Akupuntur (Elektro + Termal) 120,000
45 Akupuntur Estetika 125,000
46 Akupuntur Laser Pen 100,000
47 Akupuntur Mikro 100,000
48 Akupuntur Tanam Benang 150,000
49 Albumin _ 32,000
50 Albumin Urine 30,000
51 Alkali Fosfatase _ 37,000
52 Allergi Test/Patch Test 66,000
53 ALPACA Repair/AP Window+MOF/AVSD Repair/BCPS On Off Pump + MOF/Corctasio Aorta+MOF 49,550,000
54 Alveolar Bone Graft 9,550,000
55 Alveolectomi 9,168,000
56 Alveolektomi Per Regio dengan Anastesi Lokal 1,119,000
57 Ambil Bahan Kultur/Biopsi/Swab/Kerokan 66,000
58 Ambulation and Gait Training 70,000
59 Amilase Darah 80,000
60 Amilase Urine 32,000
61 Amniocentesis / CVS / Chordocentesis 250,000
62 Amnioinfusi Trans Abdominal Dengan Anastesi Lokal 426,000
63 Amnioreduksi Dengan Anastesi Lokal 432,000
64 Amnioskopy dan Amniosintesis tranpag 88,000
65 Amputasi Jari (Multiple) (Bedah Plastik) 5,019,743
66 Amputation above knee 6,354,000
67 Amputation and disarticulation of finger 9,282,099
68 Amputation and disarticulation of thumb 9,282,099
69 Amputation of ankle through malleoli of tibia and fibula 5,244,099
70 Amputation of toe 5,244,099
71 Amputation through foot 5,244,099
72 Amputation through forearm 5,244,099
73 Amputation through hand 5,244,099
74 Amputation through humerus 5,244,099
75 Amylase Pancreatic (P) 305,000
76 Amylase Pancreatic Urine (P) 305,000
77 ANA - IF 800,000
78 ANA (IF) (P) 620,000
79 ANA (IF) & ANA Profile (P) 1,356,000
80 ANA Profile (P) 985,000
81 Analisa Batu _ 250,000
82 Analisa Batu Empedu (P) 110,000
83 Analisa Batu Ginjal (P) 292,000
84 Analisa Cairan Asites 280,000
85 Analisa Cairan Lain 200,000
86 Analisa Cairan Otak 200,000
87 Analisa Cairan Pleura 200,000
88 Analisa Cairan Sendi 250,000
89 Analisa Cetakan/Model Gigi 250,000
90 Analisa Faeces _ 70,000
91 Analisa Gas Darah 280,000
92 Analisa Gas Darah Plus Elektrolit (POCT) 350,000
93 Analisa Kromosom (P) 1,980,000
94 Analisa Sefalometri 500,000
95 Analisa Sperma _ 200,000
96 Analisis Status Alergi 100,000
97 Anastomosis end to end ureter 4,850,000
98 ANCA 221,000
99 Anca (P) 595,000
100 Aneurisma Aorta 4,860,000
101 Angiofibroma Nasofaring 5,773,712
102 Angiografi Coroner/Cerebral + Anestesi 5,324,718
103 Angiografi Koroner 4,442,718
104 Angiografi Perifer/Vaskuler/Arteriografy 4,582,688
105 Angiography arteri abdominal 6,431,386
106 Angiography Arteri Abdominal + Anastesi 9,820,000
107 Angiography cerebral 6,428,236
108 Angiography Cerebral + Anastesi 9,820,000
109 Angiography pada extremitas 6,428,236
110 Angiography Pada Extremitas + Anastesi 9,820,000
111 Angioplasti : A. Carotis 14,450,000
112 Angioplasti : A. Carotis + Anastesi 18,950,000
113 Angioplasti : A. Renalis 14,450,000
114 Angioplasti : A. Renalis + Anastesi 18,950,000
115 Angioplasti : Dialisis Graft 14,450,000
116 Angioplasti : Dialisis Graft + Anastesi 18,950,000
117 Angioplasti : Extremitas Inf/Sup 14,450,000
118 Angioplasti : Extremitas Inf/Sup + Anastesi 18,950,000
119 Angioplasti : Intrakranial 14,450,000
120 Angioplasti : Intrakranial + Anastesi 18,950,000
121 Angioplasti : Vasospasme Intracranial 14,450,000
122 Angioplasti : Vasospasme Intracranial + Anastesi 18,950,000
123 Angioplasty/Percutaneous Transluminal (Ballon) Multipel Vessel + Penyulit 56,705,000
124 Angioplasty/Percutaneous Transluminal (Ballon) Singel Vessel 43,410,000
125 Angioplasty/Percutaneous Transluminal (Ballon) Singel Vessel + Penyulit 46,655,000
126 Angkat Arch Bar 6,476,000
127 Angkat K - Wire 70,000
128 Ankle fusion 17,935,044
129 Anoplasty/Limited PSARP/repair anoplasty 7,802,000
130 Anterio/Posterior Sklerotomi 4,913,000
131 Anti - HAV IgM (P) 400,000
132 Anti Amuba 188,000
133 Anti Chikungunya 235,000
134 Anti CMV IgG _ 280,000
135 Anti CMV IgM _ 280,000
136 Anti Faktor Xa 225,000
137 Anti HAV IgM _ 220,000
138 Anti HAV Total 188,000
139 Anti HBc IgM _ 107,000
140 Anti HBc Total 250,000
141 Anti HBe 425,000
142 Anti Hbe (P) 490,000
143 Anti HBs _ 175,000
144 Anti HCV (CMIA) 280,000
145 Anti HCV (ICT) 98,000
146 Anti Helicobacter Pylori IgG 81,000
147 Anti Helicobacter Pylori IgM 81,000
148 Anti HEV IgM 650,000
149 Anti HIV (CMIA) 400,000
150 Anti HIV (ICT) 133,000
151 Anti HSV IgG _ 125,000
152 Anti HSV IgM _ 125,000
153 Anti HSV II IgG 125,000
154 Anti HSV II IgM 125,000
155 Anti Influenza A-B 313,000
156 Anti Jamur Intra Bladder 66,000
157 Anti Japanese B Encephalitis 250,000
158 Anti Kappa 74,000
159 Anti Lamda 74,000
160 Anti Leptospira 188,000
161 Anti Rubella IgG _ 275,000
162 Anti Rubella IgM _ 275,000
163 Anti TB 188,000
164 Anti Toxoplasma IgG _ 255,000
165 Anti Toxoplasma IgM _ 255,000
166 Anti-CCP IgG (P) 665,000
167 Anti-ds-DNA-NcX (P) 509,000
168 Anti-EBV VCA IgG (P) 950,000
169 Anti-EBV VCA IgM (P) 950,000
170 Anti-HAV (P) 463,000
171 Anti-HBc 249,000
172 Anti-HBc IgM 443,000
173 Anti-HBc IgM (P) 486,000
174 Anti-HBe 490,000
175 Anti-HBs 140,000
176 Anti-HSV 1 IgG (P) 585,000
177 Anti-HSV 1 IgM (P) 335,000
178 Anti-HSV 1/2 IgM (P) 565,000
179 Anti-HSV2 IgG 560,000
180 Antibodi Malaria 188,000
181 Antigen Malaria 150,000
182 Antigen Tuberkulosa 200,000
183 Aortography (Arteriography Of Aorta and Aortic Arch/Arteriography Of Spinal) + Dengan Penyulit + Anastesi General 16,545,000
184 Aortography (Arteriography Of Aorta and Aortic Arch/Arteriography Of Spinal) + Dengan Penyulit + Anastesi Lokal 12,515,000
185 Aortography (Arteriography Of Aorta and Aortic Arch/Arteriography Of Spinal) + Dengan Penyulit + Anastesi Lokal 12,515,000
186 Aortography (Arteriography Of Aorta and Aortic Arch/Arteriography Of Spinal) + Tanpa Penyulit + Anastesi Lokal 10,000,000
187 AP Window/ASD Primum/Extirpasi Tumor Tanpa Komplikasi/Repair PAPVD 42,350,000
188 APD Petugas 160,000
189 Apek Reseksi (Gigi) 2,850,000
190 Apeks Reseksi / Apikoektomy per Gigi dengan Anastesi Lokal 860,000
191 Apendektomi Akut 4,137,279
192 Apendektomi Laparaskopi 10,850,000
193 Apendektomi Perforata 5,004,189
194 Apikoektomi 1,723,000
195 Appendectomy Simple 3,850,000
196 Appendicitis Test 78,000
197 Application of external fixation device, carpals and metacarpals 4,767,815
198 Application of external fixation device, femur 4,767,815
199 Application of external fixation device, humerus 4,767,815
200 Application of external fixation device, radius and ulna 4,767,815
201 Application of external fixation device, tarsals and metatarsals 4,767,815
202 Application of external fixation device, tibia and fibula 17,936,491
203 Application of external fixation device, unspecified site 2,350,000
204 Application of neck support 2,350,000
205 Application of other cast 2,900,182
206 Application of plaster jacket 4,017,182
207 Application of splint 2,350,000
208 APTT _ 110,000
209 Arch Support 22,800
210 Argon Laser/Kenon 6,233,000
211 Argon Plasma Coagualation 9,590,000
212 Argon Plasma Coagulation (Sore) 14,380,000
213 Arm Sling (Biasa) 399,000
214 Arm Sling (Khusus) 1,500,000
215 Arteri Carotis 4,860,000
216 Arteri Renalis Stenosis 4,816,000
217 Arterial Chemoterapi Embolisation (TACE) 9,037,000
218 Arteriography 4,582,688
219 Arteriography + Anastesi 10,210,400
220 Arteriography Of Cerebral Arteries + Dengan Penyulit + 3 Dimensi + Anastesi General 21,905,000
221 Arteriography Of Cerebral Arteries + Dengan Penyulit + 3 Dimensi + Anastesi Lokal 17,020,000
222 Arteriography Of Cerebral Arteries + Dengan Penyulit + Anastesi General 17,120,000
223 Arteriography Of Cerebral Arteries + Dengan Penyulit + Anastesi Lokal 13,060,000
224 Arteriography Of Cerebral Arteries + Dengan Penyulit + Balloon Oculusion Test + Anastesi Lokal 67,770,000
225 Arteriography Of Cerebral Arteries + Dengan Penyulit + Wada Test/Intracarotid Amobarbital Test + Anastesi Lokal 23,530,000
226 Arteriography Of Cerebral Arteries + Tanpa Penyulit + 3 Dimensi + Anastesi Lokal 14,560,000
227 Arteriography Of Cerebral Arteries + Tanpa Penyulit + Anastesi Lokal 10,240,000
228 Arteriography Of Cerebral Arteries + Tanpa Penyulit + Balloon Oculusion Test + Anastesi Lokal 52,980,000
229 Arteriography Of Cerebral Arteries + Tanpa Penyulit + Wada Test/Intracarotid Amobarbital Test + Anastesi Lokal 22,000,000
230 Arthrocentesis 5,752,000
231 Arthrodesis of elbow 5,619,121
232 Arthrodesis of hip 3,856,600
233 Arthrodesis of knee 17,930,044
234 Arthrodesis of shoulder 5,619,121
235 Arthroplasty of carpocarpal or carpometacarpal joint with implant 8,105,000
236 Arthroplasty of carpocarpal or carpometacarpal joint without implant 8,488,000
237 Arthroplasty of metacarpophalangeal and interphalangeal joint with implant 8,105,000
238 Arthroplasty of metacarpophalangeal and interphalangeal joint without implant 8,105,000
239 Arthroscopy of ankle 5,752,000
240 Arthroscopy of elbow 5,752,000
241 Arthroscopy of foot and toe 5,752,000
242 Arthroscopy of hand and finger 5,752,000
243 Arthroscopy of hip 5,752,000
244 Arthroscopy of knee 16,585,212
245 Arthroscopy of shoulder 16,585,212
246 Arthroscopy of wrist 5,752,000
247 Arthrosplasty (Op.Gigi) 2,960,000
248 Asam Empedu 33,000
249 Asam Laktat 115,000
250 Asam Urat _ 32,000
251 Asam Urat (Urine) 30,000
252 Ascites Test 78,000
253 ASD Closure+PFO Creation+TV Repair (TAP DE VEGA) 41,950,000
254 ASD+MOF/CABG/Total Koreksi+AV Repair/PV Repair/Total Koreksi TOF+PDA Ligasi/Ligasi Ventricle Duuct 48,350,000
255 ASD+Reseksi Infudibular 45,150,000
256 Asisted Exercise 70,000
257 Aspirasi Abses Hati Percutaneus 3,580,000
258 Aspirasi Abses Hati Percutaneus (Sore) 5,370,000
259 Aspirasi Biopsi 140,000
260 Aspirasi Cairan Pericard / Pleura 53,000
261 Aspirasi Hemarthrosis 66,000
262 Aspirasi Jarum 49,000
263 Aspirasi Kista 675,000
264 Aspirasi sendi 135,000
265 Aspirasi SST dan Evaluasi _ 250,000
266 Aspiration of bursa of hand 3,125,000
267 Aspiration of other soft tissue 3,856,600
268 Aspiration of other soft tissue of hand 3,856,600
269 Assesment ADHD 75,000
270 Assesment Analysis Behavior 78,000
271 Assesment Autisme CARS 220,000
272 Assesment CAPD 350,000
273 Assesment Corners 50,000
274 Assesment dan Check Out Oetotis & Prostesis 66,000
275 Assesment Dekondisi 66,000
276 Assesment Diet DM asupan Oral 78,000
277 Assesment DSM IV untuk Autisme 150,000
278 Assesment DSM IV untuk GPPH 150,000
279 Assesment Edukasi Pengaturan Diet Dengan Dosis Insulin 120,000
280 Assesment Evaluasi Autis-CHAT 220,000
281 Assesment Evaluasi Hiperaktivitas GPPH 220,000
282 Assesment Fleksibilitas dan Lingkup Gerak 66,000
283 Assesment Fungsi Berkemih 66,000
284 Assesment Fungsi Defekasi 66,000
285 Assesment Fungsi Eksekusi Gerak 66,000
286 Assesment Fungsi Kardiorespirasi 66,000
287 Assesment Fungsi Komunikasi 66,000
288 Assesment Fungsi lokomotor 66,000
289 Assesment Fungsi Memori 66,000
290 Assesment Fungsi Menelan 66,000
291 Assesment Integrasi Sensori Motor 66,000
292 Assesment Kebugaran 66,000
293 Assesment Kekuatan Otot 66,000
294 Assesment Kemampuan Fungsional dan Perawatan Diri 66,000
295 Assesment Keseimbangan Statik dan Dinamik 66,000
296 Assesment Kontrol Postural 78,000
297 Assesment meningeal Sign 78,000
298 Assesment Motorik Halus 66,000
299 Assesment Nervus Cranialis (Saraf Anak) 100,000
300 Assesment Nervus Cranialis (Tumbuh Kembang Anak) 78,000
301 Assesment Nyeri 103,000
302 Assesment Parental Education 100,000
303 Assesment Pendengaran Manual 78,000
304 Assesment Perawakan Pendek 120,000
305 Assesment Perkembangan (Perkembangan Psikologis) 100,000
306 Assesment Perkembangan kognitif CAT-CLAMPS 270,000
307 Assesment Perkembangan Umum 170,000
308 Assesment Pertumbuhan 78,000
309 Assesment Pola Jalan 66,000
310 Assesment Postur 78,000
311 Assesment Postur Kontrol 66,000
312 Assesment Reflex Fisiologis 80,000
313 Assesment Reflex Patologis 80,000
314 Assesment Sensibilitas 78,000
315 Assesment Sensibilitas (Rehabilitasi Medik) 66,000
316 Assesment Sistem Saraf Otonom 78,000
317 Assesment Skiring masalah mental emosional 220,000
318 Assesment Status Nutrisi 65,000
319 Assesment Waktu Pendarahan 78,000
320 ASTO _ 165,000
321 Astresia Esofagus 9,464,367
322 Asuhan Nutrisi Pediatric 150,000
323 Atlas-axis spinal fusion 14,020,000
324 Attachment of pedicle or flap graft to hand 10,925,000
325 Attachment of pedicle or flap graft to other sites 10,925,000
326 Audiometri 150,000
327 AV Replacement (AVR) 65,150,000
328 AV Shunt dengan graft vena/sintetis 15,450,000
329 Baca Foto Intra dan Ekstra Oral 150,000
330 BAS / Pemasangan Coil + Anastesi 49,334,000
331 BAS di Cath Lab / Pemasangan Coil 38,935,861
332 BCPS + PA Banding 31,950,000
333 BCPS Bilateral+Mitral Cleft repair 39,150,000
334 BCPS On Pump atau off Pump/Repair Fistula Coroner/Repair Vascular ring 38,350,000
335 BCPS+Ligasi BT Shunt 38,750,000
336 BCPS+PDA Ligasi 38,990,000
337 BCR - ABL 2,800,000
338 BCR-ABL Kualitatif (P) 1,050,000
339 Bedah Beku (Besar) 750,000
340 Bedah Beku (Kecil) 250,000
341 Bedah Beku (Sedang) 470,000
342 Bedah Laparoskopi Anak 6,175,000
343 Bedah Listrik 66,000
344 Bedah Skapel 250,000
345 Belloq Tampon 50,000
346 Belloque Tampon Dalam Narkose 2,850,000
347 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
348 Beta HCG Kwantitatif 244,000
349 Beta 2 Glycoprotein 1 (B2GP-1) 563,000
350 Biakan dan Resistensi TB (medium Padat OAT Lini 1-2) 438,000
351 Biakan Salmonela Shigela (Biakan SS) 88,000
352 Bilas Lambung 66,000
353 Bilirubin Direk _ 32,000
354 Bilirubin Indirect 25,000
355 Bilirubin Total _ 32,000
356 Biofeed Back 28,800
357 Biometri 450,000
358 Biopsi Aspirasi transtorakal dengan tuntutan CT - SCAN 540,000
359 Biopsi Aspirasi transtorakal dengan tuntutan USG 318,000
360 Biopsi ca. penis & kel. inguinal 2,500,000
361 Biopsi Ca. Penis & Kel. Inguinal (Sore) 3,750,000
362 Biopsi Cerviks - Pasang Tampon 250,000
363 Biopsi Core 675,000
364 Biopsi dalam Narkose Umum 3,431,074
365 Biopsi Ductus Biliaris 1,300,000
366 Biopsi Ductus Biliaris (Poli Sore) 1,950,000
367 Biopsi Eksisi Kelenjar Getah Bening dengan Anastesi Umum 2,159,000
368 Biopsi Eksisional dalam Narkose 2,850,000
369 Biopsi Ekstirpasi dengan Anastesi Lokal 860,000
370 Biopsi Endoskopi 250,000
371 Biopsi Ginjal 222,000
372 Biopsi Ginjal Hemodialisa 5,200,000
373 Biopsi Ginjal perkutan 3,850,000
374 Biopsi Ginjal Terbuka 4,850,000
375 Biopsi Hati Percutaneus 8,170,000
376 Biopsi Hati Percutaneus (Sore) 12,250,000
377 Biopsi Hippfaring Onko 250,000
378 Biopsi Incisional dalam Narkose 2,850,000
379 Biopsi Insisi Dengan Lokal Anastesi 675,000
380 Biopsi Insisi Tumor dengan Anastesi Umum 3,431,074
381 Biopsi Insisional Tumor Leher Onko 250,000
382 Biopsi Jaringan 146,000
383 Biopsi Jaringan (Gastro) 479,000
384 Biopsi Jaringan + Anastesi 1,217,000
385 Biopsi Jaringan + Anastesi (OK Obgyn) 1,423,000
386 Biopsi Jaringan Besar 800,000
387 Biopsi Jaringan Kecil 400,000
388 Biopsi Jaringan Saluran Cerna Perendoskopi 655,000
389 Biopsi Jaringan Saluran Cerna Perendoskopi (Sore) 980,000
390 Biopsi Jaringan Sedang 600,000
391 Biopsi Jarum 63,000
392 Biopsi Jarum Halus 675,000
393 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) 1-2 Jaringan 400,000
394 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) 3-4 Jaringan 600,000
395 Biopsi khusus (Hati, Ginjal, Gaster, Colon, Esofagus) Lebih dari 4 Jaringan 800,000
396 Biopsi Kulit (Besar) 560,000
397 Biopsi Kulit (Sedang) 480,000
398 Biopsi Lidah Palatum Onko 250,000
399 Biopsi Nasofaring Fiber Onko 250,000
400 Biopsi Nasofaring Rigid Onko 250,000
401 Biopsi Penis 675,000
402 Biopsi Permukaan 120,000
403 Biopsi Prostat 3,796,000
404 Biopsi Prostat (ESWL) 2,500,000
405 Biopsi Prostat (ESWL) (Sore) 3,750,000
406 Biopsi rectum full thicknesis 3,431,074
407 Biopsi Saraf Kutaneus/Otot (Bedah Syaraf) 5,334,000
408 Biopsi Sinus Maksila Onko 250,000
409 Biopsi Telinga 2,850,000
410 Biopsi Testis 3,806,011
411 Biopsi Tumor Hidung Onko 250,000
412 Biopsi Tumor Hidung. Lidah. Nasofaring THT 2,850,000
413 Biopsi Tumor Kelopak 675,000
414 Biopsi Tumor Oral Cavity LF 250,000
415 Biopsi Tumor Orbita 3,850,000
416 Biopsi Vertebra (1 Level) 3,532,812
417 Biopsi/Proof Laparatomy 4,850,000
418 Biopsy of bone 9,190,468
419 Biopsy of bone marrow 2,998,053
420 Biopsy of carpals and metacarpals 5,202,000
421 Biopsy of femur 5,202,000
422 Biopsy of humerus 5,202,000
423 Biopsy of joint structure of ankle 5,752,000
424 Biopsy of joint structure of elbow 5,752,000
425 Biopsy of joint structure of foot and toe 5,752,000
426 Biopsy of joint structure of hand and finger 5,752,000
427 Biopsy of joint structure of hip 5,752,000
428 Biopsy of joint structure of knee 2,888,053
429 Biopsy of joint structure of shoulder 5,752,000
430 Biopsy of joint structure of wrist 5,752,000
431 Biopsy of joint structure, unspecified site 2,998,053
432 Biopsy of other bone, except facial bone 5,202,000
433 Biopsy of patella 5,202,000
434 Biopsy of radius and ulna 5,202,000
435 Biopsy of scapula, clavicle, and thorax (ribs and sternum) 5,202,000
436 Biopsy of soft tissue 3,864,200
437 Biopsy of spinal cord or spinal meninges 21,867,928
438 Biopsy of tarsals and metatarsals 5,202,000
439 Biopsy of tibia and fibula 5,202,000
440 Biotrainer 43,200
441 Blaas Functie 87,000
442 Bladder Neck Incision 6,923,000
443 Bladder Training 78,000
444 Blanket 46,000
445 Blanket Rol 46,000
446 Bleaching eksternal 3,500,000
447 Bleaching Internal 550,000
448 Blok Resectie 2,960,000
449 Blok Saraf Tepi 5,954,000
450 Blowing Exercise Meter 39,600
451 BMP (Bone Morrow Fucture) 1,000,000
452 BNO - IVP 375,000
453 Body Jacket 5,500,000
454 Bone graft of carpals and metacarpals 13,304,994
455 Bone graft of femur 13,154,994
456 Bone graft of humerus 13,254,994
457 Bone graft of patella 23,004,994
458 Bone graft of radius and ulna 13,254,994
459 Bone graft of scapula, clavicle, and thorax (ribs and sternum) 6,504,994
460 Bone graft of tarsals and metatarsals 8,504,994
461 Bone graft of tibia and fibula 23,004,994
462 Bone graft scapula, clavicle and thorax (ribs and sternum) 6,504,994
463 Bone Survey 450,000
464 Boston Brace 5,000,000
465 Bouginasi/ Dilatasi Urethra (ESWL) (Sore) 1,110,000
466 Bouginasi/Dilatasi Urethra (ESWL) 740,000
467 Brachytherapi - Base Of Tounge (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 19,000,000
468 Brachytherapi - Base Of Tounge (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 23,560,000
469 Brachytherapi - Base Of Tounge (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 23,000,000
470 Brachytherapi - Base Of Tounge (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 28,520,000
471 Brachytherapi - Cervix Implantas (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 11,000,000
472 Brachytherapi - Cervix Implantas (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 13,640,000
473 Brachytherapi - Cervix Implantas (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 13,000,000
474 Brachytherapi - Cervix Implantas (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 16,120,000
475 Brachytherapi - Cervix Implantas (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 16,000,000
476 Brachytherapi - Cervix Implantas (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 19,840,000
477 Brachytherapi - Cervix Intrakaviter Lengkap ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) 16,000,000
478 Brachytherapi - Cervix Intrakaviter Lengkap ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) + Anastesi 19,840,000
479 Brachytherapi - Cervix Intrakaviter Lengkap ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) 21,000,000
480 Brachytherapi - Cervix Intrakaviter Lengkap ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) + Anastesi 26,040,000
481 Brachytherapi - Kulit (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 6,000,000
482 Brachytherapi - Kulit (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 7,440,000
483 Brachytherapi - Kulit (1 X Tindakan + 3X Penyinaran + 1X Anestesi) 9,000,000
484 Brachytherapi - Kulit (1 X Tindakan + 3X Penyinaran + 1X Anestesi) + Anastesi 11,160,000
485 Brachytherapi - Lidah Anterior (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 13,000,000
486 Brachytherapi - Lidah Anterior (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 16,840,000
487 Brachytherapi - Lidah Anterior (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 19,000,000
488 Brachytherapi - Lidah Anterior (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 23,560,000
489 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 4X Penyinaran + 1X Anestesi) 12,000,000
490 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 4X Penyinaran + 1X Anestesi) + Anastesi 14,880,000
491 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 6X Penyinaran + 1X Anestesi) 15,000,000
492 Brachytherapi - Nasofaring Intralumen (1 X Tindakan + 6X Penyinaran + 1X Anestesi) + Anastesi 18,600,000
493 Brachytherapi - Ovoid ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) 10,000,000
494 Brachytherapi - Ovoid ( 2X Tindakan + 2X Penyinaran + 2X Anestesi ) + Anastesi 12,400,000
495 Brachytherapi - Ovoid ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) 16,000,000
496 Brachytherapi - Ovoid ( 3X Tindakan + 3X Penyinaran + 3X Anestesi ) + Anastesi 19,840,000
497 Brachytherapi - Payudara (1 X Tindakan + 1X Penyinaran + 1X Anestesi) 6,000,000
498 Brachytherapi - Payudara (1 X Tindakan + 1X Penyinaran + 1X Anestesi) + Anastesi 7,440,000
499 Brachytherapi - Payudara (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 9,000,000
500 Brachytherapi - Payudara (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 11,160,000
501 Brachytherapi - Perineal Implantasi (1 X Tindakan + 1X Penyinaran + 1X Anestesi) 10,000,000
502 Brachytherapi - Perineal Implantasi (1 X Tindakan + 1X Penyinaran + 1X Anestesi) + Anastesi 12,400,000
503 Brachytherapi - Perineal Implantasi (1 X Tindakan + 2X Penyinaran + 1X Anestesi) 11,000,000
504 Brachytherapi - Perineal Implantasi (1 X Tindakan + 2X Penyinaran + 1X Anestesi) + Anastesi 13,640,000
505 Brachytherapi - Perineal Implantasi (1X Tindakan + 3X Penyinaran + 1X Anestesi) 12,000,000
506 Brachytherapi - Perineal Implantasi (1X Tindakan + 3X Penyinaran + 1X Anestesi) + Anastesi 14,880,000
507 Brachytherapi - Radiasi Interna ( Terapi Iodium SO/2000/150 mCi ) 919,000
508 Brachytherapi - Radiasi Interna ( Terapi Samarium 50 mCi ) 788,000
509 Brainstem Evoked Response Audiometry (BERA) 880,000
510 Break up Time 33,000
511 Breakfast (Cek-Up) 70,000
512 Breakfast Paket C 55,000
513 Breast Conserving Surgery 4,850,000
514 Breathing Exercise 70,000
515 Brock + BT Shunt / ASD Closure + PDA Ligasi 40,350,000
516 Brock/BT Shunt/Coarctasio Aorta/PA Banding/Sling/Unifokalisasi 29,950,000
517 Bronchoskopi Toileting dan Lavage 587,000
518 Bronchospirometri I 250,000
519 Bronchospirometri II 250,000
520 broncoskopi 900,000
521 Bronkoskopi Bilasan 805,000
522 Bronkoskopi Bilasan + Anastesi 1,585,000
523 Bronkoskopi Diagnostik 805,000
524 Bronkoskopi Diagnostik + Anastesi 1,585,000
525 Bronkoskopi Sikatan 805,000
526 Bronkoskopi Sikatan + Anastesi 1,585,000
527 Bronkoskopi+Balon Dilatasi Saluran Nafas Dengan Anestesi 13,247,000
528 Bronschoscopy (COT) 5,656,405
529 Brushing melalui Bronchoschopy 188,000
530 BSEF/FESS 1 : Mini 4,850,000
531 BSEF/FESS 2 : Mini+Maksila/etmoid 4,850,000
532 BSEF/FESS 3: Mini+Frontal/Sfenoid 5,850,000
533 BSEF/FESS 4 : Mini+maksila/etmoid+frontal/sfenoid 5,850,000
534 BSEF/FESS lanjut : Ekstirpasi Tumor.Penutupan defek intrakranial 5,850,000
535 BT Shunt+Ligasi MAPCA 36,190,000
536 BTA 1X Biakan Resistensi Medium Cair OAT Lini 1 438,000
537 BTA 1X Biakan Resistensi Medium Cair OAT Lini 2 500,000
538 BTA 3X Biakan Medium Cair 375,000
539 BTA 3X Biakan Medium Padat 188,000
540 Buka / Pasang Pesarium 116,000
541 Buka Gips 69,000
542 Buka IDW (Bedah Mulut) 935,000
543 Buka Jahitan (Poli Jantung) 150,000
544 Buka Obtorator 55,000
545 Buka Tampon / Kassa Kamicetin 140,000
546 Buka Wiring Dengan Anastesi Lokal (Bedah Mulut) 393,000
547 Buku ICV 25,000
548 Bunionectomy with soft tissue correction and arthrodesis 6,600,000
549 Bunionectomy with soft tissue correction and osteotomy of the first metatarsal 6,600,000
550 Bursectomy of hand 9,390,000
551 Bursotomy 9,390,000
552 Bursotomy of hand 11,196,000
553 Businasi 308,000
554 Businasi Hurtz (akhalasia) 966,000
555 Businasi Hurtz Esofagus + anastesi 8,040,000
556 Businasi Hurtz Esofagus + Anastesi (Sore) 12,060,000
557 Businasi Urethra 308,000
558 Butterfly Bath 98,400
559 C3 Komplemen (P) 828,000
560 C4 Komplemen (P) 828,000
561 CA 12-5 _ 265,000
562 CA 15-3 _ 350,000
563 CA 19-9 _ 300,000
564 CABG Lima + TV Repair/TAP DE VEGA + TPM + PPM/Endovasculer Stent Aorta 104,350,000
565 CABG Lima+Repair Aneurysme Artery Coroner 65,950,000
566 CABG+DVR 80,350,000
567 Cabut DJ Stent 3,125,000
568 Cabut Gigi Tetap dengan Komplikasi 1,028,000
569 Cabut Gigi Tetap dengan Penyulit 839,000
570 Cabut IUD dengan Penyulit 173,000
571 Cabut Susut dengan Penyulit 253,000
572 Caldwell Luc Anthrostomi 3,850,000
573 Calsium _ 35,000
574 Cantharidin < 5 Lesi / > 5 Lesi 66,000
575 Capsulotomi Posterior 2,500,000
576 Cardio Toco Graphy (CTG)/Kebidanan 299,000
577 Carotid Doppler 725,000
578 Carotid Duplex Doppler 400,000
579 Carporadial fusion 5,596,121
580 Catherisasi pada Retensi Urin 56,000
581 CEA _ 280,000
582 Cek GDS 15,000
583 Cek Permanent Pace Maker 75,000
584 Cervical Facet Joint Injection C-Arm <= 2 7,910,000
585 Cervical Facet Joint Injection C-Arm > 2 7,910,000
586 Cervical Interlaminar Injection C-Arm 8,200,000
587 Cervical Medial Branch Block Injection C-Arm <= 2 7,910,000
588 Cervical Medial Branch Block Injection C-Arm > 2 8,200,000
589 Cetak Film Ukuran Besar 70,000
590 Cetak Film Ukuran Kecil 50,000
591 Chairback (Biasa) 1,320,000
592 Chairback (Khusus) 2,850,000
593 Chemo surgery Podophyllin 66,000
594 Chemo surgery TCAA 66,000
595 ChemoEmbolisasi pada Hepatoma/tumor lain 24,883,390
596 ChemoEmbolisasi pada Hepatoma/tumor lain + Anastesi 45,450,000
597 Chest Port 14,450,000
598 Chest Port + Anastesi 18,950,000
599 Chest Re Open Rekonstruksi 14,750,000
600 Cimino (Bedah Vaskuler) 4,784,000
601 Circumsisi bayi dan anak dengan anastesi umum 2,159,000
602 CK _ 65,000
603 CK-MB _ 65,000
604 Clinical Kaustik 66,000
605 Clip Over The Scope 11,420,000
606 Clip Over The Scope (Poli Sore) 17,130,000
607 Closed Reduction dengan Anastesi Lokal 860,000
608 Closed reduction of dislocation of ankle 4,375,000
609 Closed reduction of dislocation of elbow 2,799,523
610 Closed reduction of dislocation of foot and toe 4,375,000
611 Closed reduction of dislocation of hand and finger 2,799,523
612 Closed reduction of dislocation of hip 3,899,523
613 Closed reduction of dislocation of knee 4,375,000
614 Closed reduction of dislocation of shoulder 2,849,523
615 Closed reduction of dislocation of wrist 4,375,000
616 Closed reduction of fracture with internal fixation, carpals and metacarpals 5,828,000
617 Closed reduction of fracture with internal fixation, femur 5,828,000
618 Closed reduction of fracture with internal fixation, humerus 5,828,000
619 Closed reduction of fracture with internal fixation, phalanges of foot 5,828,000
620 Closed reduction of fracture with internal fixation, radius and ulna 5,828,000
621 Closed reduction of fracture with internal fixation, tarsals and metatarsals 5,828,000
622 Closed reduction of fracture with internal fixation, tibia and fibula 5,828,000
623 Closed reduction of fracture with internal fixation,phalanges of hand 5,828,000
624 Closed reduction of fracture without internal fixation, carpals and metacarpals 2,963,182
625 Closed reduction of fracture without internal fixation, femur 2,963,182
626 Closed reduction of fracture without internal fixation, humerus 4,375,000
627 Closed reduction of fracture without internal fixation, phalanges of foot 4,375,000
628 Closed reduction of fracture without internal fixation, phalanges of hand 4,375,000
629 Closed reduction of fracture without internal fixation, radius and ulna 2,963,182
630 Closed reduction of fracture without internal fixation, tarsals and metatarsals 4,375,000
631 Closed reduction of fracture without internal fixation, tibia and fibula 2,963,182
632 Closed reduction of separated epiphysis of femur 4,375,000
633 Closed reduction of separated epiphysis of humerus 4,375,000
634 Closed reduction of separated epiphysis of radius and ulna 4,375,000
635 Closed reduction of separated epiphysis of tibia and fibula 4,375,000
636 Coartasio Aorta Repair+PDA Ligasi+PA Banding 31,630,000
637 Cock Up Splint (Biasa) 1,800,000
638 Cock Up Splint (Standar/Khusus) 2,500,000
639 Cognitive Behaviour Therapy 190,000
640 Colon - Inloop 500,000
641 Combination Therapi 43,200
642 Complicated Functional Neuro (P.Paraverteb/Visceral Blok) 9,094,887
643 Complicated Functional Neuro (Percuteneus Kordotomi) 11,110,887
644 Complicated Functional Neuro (Stereotaxy Kompleks) 14,736,887
645 Complicated Functional Neuro (Stereotaxy sederhana) 13,306,887
646 Comprehensive Geriatric Assesment (CGA) 66,000
647 Computer Spech Therapi 39,600
648 Condylotomy Mandibula 4,850,000
649 Cone Biopsi/ Konisasi/ LETZ 2,850,000
650 Congenital Formix Plastik/ Rekst Soket Berat 4,675,000
651 Cool Box (1X Pengiriman Darah) 10,000
652 Coombs' Test _ 160,000
653 Cor Analysa 400,000
654 Corangiography + TPM 7,033,000
655 Corangiography+Arteriografy/Corangiography+Katerisasi 9,200,000
656 Corpus Alinium Cornea 250,000
657 Correction of syndactyly 6,600,000
658 Cortisol (P) 448,000
659 Coustik Hidung 36,000
660 CPM 42,000
661 Cranial or peripheral nerve graft 11,682,099
662 Crisis Intervention 100,000
663 Croos Insisi 44,000
664 Cross Leg Flap 8,950,000
665 Cross Matching 170,000
666 Crown & Bridge (Acrylic per unit) 295,000
667 Crown & Bridge (Porcelain per unit) 765,000
668 CRP Kuantitatif 130,000
669 CRRT (Continous Renal Replacement Therapy) 33,720,000
670 CRT / ICD 81,550,000
671 Cryo Jet 75,000
672 Cryo Therapi 43,200
673 Cryoglobulin 25,000
674 CT Scan Simulator dengan kontras 1,671,000
675 CT Scan Simulator tanpa kontras 1,671,000
676 CT. Kepala (Dengan Contras) 900,000
677 Cuci Canule 38,000
678 Cuci Lambung 121,000
679 Curretage pada rentensi plasenta / Mola Pertama 352,000
680 Cutting and preparation of pedicle grafts or flaps 10,925,000
681 Cyclodia Termi 4,011,743
682 Cyclodialysa 3,997,000
683 Cyfra 21-1 _ 588,000
684 Cyro Surgery Besar 155,000
685 Cyro Surgery Ringan 90,000
686 Cysjejunostomi 6,175,000
687 Cystoscopy biopsi (ESWL) 2,500,000
688 Cystoscopy Biopsi (ESWL) (Sore) 3,750,000
689 D Dimer _ 450,000
690 Dacryo Cysto Rhinostomi 11,581,770
691 Daptone (Doppler) 57,000
692 Darah Lengkap 62,000
693 Darah Per Bag ( BDRS ) 400,000
694 Darah Per Bag (PMI) 325,000
695 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- Afaresis 3,500,000
696 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- FFP 325,000
697 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- PRC 325,000
698 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- WB 325,000
699 Darah Per Bag (PMI) A,B,O,AB,Rhesus -- WE 475,000
700 Darah Per Bag (UTD Provinsi Sul-Sel) 250,000
701 Darah Per Bag (UTD Provinsi Sul-Sel) (Tindakan Cross Matching dan Golongan Darah) 310,000
702 Darah Perifer Lengkap Serial 68,000
703 Daye Test 100,000
704 DCR + Silikon Tube 8,350,000
705 Debonding 600,000
706 Debridemen Intra Oral / Ekstra Oral dengan General Anestesi 9,220,000
707 Debridemen Luka Dengan Anastesi Lokal (Bedah Mulut) 794,000
708 Debridement and anterior fusion in TB spine 4,850,000
709 Debridement dengan falp 4,850,000
710 Debridement dengan Skingarfting Kecil 3,850,000
711 Debridement dengan Skingarfting Luas 4,850,000
712 Debridement of nail, nail bed, or nail fold 3,125,000
713 Debridement of open fracture of carpals and metacarpals 11,516,003
714 Debridement of open fracture of femur 11,116,003
715 Debridement of open fracture of humerus 3,125,000
716 Debridement of open fracture of phalanges of foot 6,486,003
717 Debridement of open fracture of phalanges of hand 11,516,003
718 Debridement of open fracture of radius and ulna 11,516,003
719 Debridement of open fracture of tarsals and metatarsals 6,486,003
720 Debridement of open fracture of tibia and fibula 23,016,003
721 Debridement Pada Luka Bakar < 40% 5,579,641
722 Debridement Pada Luka Bakar > 40% 6,348,641
723 Debridement Ulang Vaskuler/ Debridement dng amputasi mayor 2,850,000
724 Debridement/EmbolisasiSederhana/Op.JantungTertutup/PTA/TAI 13,150,000
725 Debulking 6,917,222
726 Defibrilator 1,067,000
727 Deflasi dengan Anastesi Lokal 860,000
728 Dekanulasi 250,000
729 Dekompresi orbita 6,357,000
730 Dekompresi Syaraf Tepi 5,382,587
731 Dekompresia Fasialis 5,482,645
732 Delayed suture of flexor tendon of hand 11,196,000
733 Delayed suture of other tendon of hand 9,682,099
734 Delayed suture of tendon 11,196,000
735 Dengue NS1 _ 250,000
736 Denis Brown 3,800,000
737 Dermabrasi (Luas) 598,000
738 Dermabrasi (Sedikit) 282,000
739 Deroofing/unroofing kista 4,850,000
740 Deseksi Kelenjar Inguinal 5,299,955
741 Desinfektan Jenazah 100,000
742 Desinfektan Mobil Jenazah 100,000
743 Detorsi testis + Orchidopexy 6,238,462
744 Devitalisasi Saluran Akar Dengan Anastesi 210,000
745 Devitalisasi Saluran Akar Dengan Arsen 210,000
746 DHF IGg/IgM (ICT) 220,000
747 Dialisis Peritoneal 66,000
748 Diathermy 75,000
749 Dietary Survielance and Councelling pada Penyakit Khusus 100,000
750 Dietary Survielance and Councelling pada Weight Management 100,000
751 Dikortikasi ( Bedah Paru/Thorax) 21,102,000
752 Dilatasi (dengan balon) Esofagus/Gaster/Duodenum/Colon/Rektosigmoid/Bilier 17,610,000
753 Dilatasi (Dengan Balon) Esofagus/Gaster/Duodenum/Colon/Rektosigmoid/Bilier (Sore) 17,610,000
754 Dilatasi Phimosis 66,000
755 Disarticulation of ankle 5,247,099
756 Disarticulation of elbow 5,247,099
757 Disarticulation of hip 5,247,099
758 Disarticulation of knee 5,247,099
759 Disarticulation of shoulder 5,247,099
760 Disarticulation of wrist 5,247,099
761 Diseksi KGB Pelvis 7,885,000
762 Diseksi Leher Radikal Modifikasi/Fungsional 4,599,000
763 Divertikulektomi 6,923,213
764 Divertikulektomi Vesika 8,215,530
765 Divertikulum uretra 4,850,000
766 Division of joint capsule, ligament, or cartilage of ankle 8,105,000
767 Division of joint capsule, ligament, or cartilage of elbow 8,105,000
768 Division of joint capsule, ligament, or cartilage of foot and toe 8,105,000
769 Division of joint capsule, ligament, or cartilage of hand and finger 8,105,000
770 Division of joint capsule, ligament, or cartilage of hip 8,105,000
771 Division of joint capsule, ligament, or cartilage of knee 8,105,000
772 Division of joint capsule, ligament, or cartilage of shoulder 8,105,000
773 Division of joint capsule, ligament, or cartilage of wrist 8,105,000
774 Donor Ginjal LLDN 166,000,000
775 Dorsal and dorsolumbar fusion, anterior technique 9,957,600
776 Dorsal and dorsolumbar fusion, posterior technique 9,957,600
777 Double Lumen Catheter 4,784,000
778 Drainage Asites Percutaneus (Sore) 28,000,000
779 Drainage Internal Pankreaas 9,590,000
780 Drainage Internal Pankreaas (Sore) 14,380,000
781 Drainage Kista Pankreas 3,850,000
782 Drainage Periureter 5,132,887
783 Drainase Pus Pada Tuboovarial Abses Dengan Punksi Doglasi 2,850,000
784 Dry Needling 250,000
785 Ductulography 375,000
786 Duedenoduodenostomi /Duodenojejunostomi 9,464,367
787 Ebstein(TV)Anomali Repair/TAPVD 53,150,000
788 Echo Anak 400,000
789 Echo Dewasa 300,000
790 Edema Test 78,000
791 Edukasi Gizi 120,000
792 Edukasi Keluarga 75,000
793 Edukasi Kemotherapi 100,000
794 EEG - Anak 960,000
795 EGD dengan Hemospray 18,210,000
796 EGD Dengan Hemospray (Sore) 18,210,000
797 EGFR Mutasi 1,620,000
798 EKG/Elektrokardiografi 73,000
799 Eksenterasi 12,661,000
800 Eksisi / Ekstirpasi Salolith dengan Anastesi Lokal 860,000
801 Eksisi / Esterpasi 80,000
802 Eksisi Angiofibroma Nasofaring 6,350,000
803 Eksisi Baker Cyst 5,008,000
804 Eksisi Basalioma 1,350,000
805 Eksisi Biopsy dengan Anastesi Lokal 860,000
806 Eksisi Ca Laring dengan Laser 3,850,000
807 Eksisi Chalazion/Hordeolum 675,000
808 Eksisi Chodee 5,149,000
809 Eksisi Chordae Hyspospadia 4,850,000
810 Eksisi Clavus 250,000
811 Eksisi Condiloma Accuminata 66,000
812 Eksisi Dengan Lokal Anastesi 675,000
813 Eksisi Denture Hyperplasia dengan Anastesi Lokal 860,000
814 Eksisi FAM < 5cm 2,623,437
815 Eksisi FAM > 5cm 2,850,000
816 Eksisi Fibroma 2,850,000
817 Eksisi Fistel Preauricular 2,850,000
818 Eksisi Giant Nevus (tampa skin graft) 2,850,000
819 Eksisi Giant Nevus + skin graft 4,850,000
820 Eksisi Granuloma 250,000
821 Eksisi Granuloma (Poli Mata) 675,000
822 Eksisi Granuloma Pyogenikum 250,000
823 Eksisi Granuloma/Granuloma Hibilical/Hemanioma Kecil 2,159,000
824 Eksisi Gynecomastie 4,995,000
825 Eksisi Heangiona Luas 6,792,089
826 Eksisi Hemangioma Besar skingraft STSG/FTSG 5,634,913
827 Eksisi Hemangioma Besar/Multiple 5,634,913
828 Eksisi Hemangioma Kecil 2,850,000
829 Eksisi Hemangioma Sedang 3,850,000
830 Eksisi Higroma 4,850,000
831 Eksisi Higroma Pada Anak 6,238,462
832 Eksisi Hygroma Colli/Axilla Neonatus 6,175,000
833 Eksisi Hygroma/Lympohagioma Simple 3,850,000
834 Eksisi Kelenjar Liur Submandibula 3,887,600
835 Eksisi Keloid < 5 cm 66,000
836 Eksisi Kista Brachialis 3,850,000
837 Eksisi Kista Branchiogenik 3,936,000
838 Eksisi Kista Bronchial 6,238,462
839 Eksisi Kista Duktus Kholedukhus 17,350,000
840 Eksisi Kista Duktus Triglosus 5,059,548
841 Eksisi Kista Saluran Empedu 6,175,000
842 Eksisi Kista Tiroglosus 3,892,000
843 Eksisi Kista Urachus 6,238,462
844 Eksisi Limfedema + skin graft (charles prosedur) 4,850,000
845 Eksisi Luas Lokal 4,850,000
846 Eksisi Luas Radikal + Rekontruksi 5,336,807
847 Eksisi Mammae Aberran (Klp. III) 4,518,992
848 Eksisi Multiple FAM 4,527,541
849 Eksisi Neuroblastoma 6,175,000
850 Eksisi Neurofibroma Multiple 4,990,913
851 Eksisi Pterigium Bare Sklera 675,000
852 Eksisi Skin Grafting 250,000
853 Eksisi Syringoma 66,000
854 Eksisi Tatto (Besar) 2,350,000
855 Eksisi Tatto (Lokal) 600,000
856 Eksisi Tatto (Sedang) 2,000,000
857 Eksisi Teratoma Ovarium 12,022,946
858 Eksisi Teratoma Retroperitoneal 6,151,418
859 Eksisi Teratoma Sacrococcygeal 11,130,825
860 Eksisi Torus Palatinus / Mansibularis dengan Anastesi Lokal 860,000
861 Eksisi Tragus Acsesories 2,850,000
862 Eksisi Tumor Adneksa Kecil 2,850,000
863 Eksisi Tumor Adneksa Sedang 3,850,000
864 Eksisi Veruka Vulgaris 66,000
865 Eksisi Webbed Penis 4,850,000
866 Eksisi Xantelasma 2,850,000
867 Eksisi Xantelasma (Besar) 2,350,000
868 Eksisi Xantelasma (Sedang) 2,000,000
869 Eksisi Xantoma 250,000
870 Eksisi/Ekstirpasi Tumor Jinak Kulit (Besar) 1,450,000
871 Eksisi/Ekstirpasi Tumor Jinak Kulit (Kecil) 700,000
872 Eksisi/Ekstirpasi Tumor Jinak Kulit (Sedang) 1,200,000
873 Eksisi/Esterpasi 80,000
874 Eksisi/Konisasi 6,074,400
875 Eksisi/Limfangioma Simple 4,986,687
876 Eksisi/Reduksi Neurofibroma Kompleks 4,850,000
877 Eksoftalmometri 30,000
878 Eksplorasi Abses Intra Oral/ Ekstra Oral 9,309,000
879 Eksplorasi Abses Mandibula 3,850,000
880 Eksplorasi Abses Multiple ( Bedah Vaskuler ) 3,850,000
881 Eksplorasi Abses Multiple THT 4,850,000
882 Eksplorasi Abses Parafaringeal 3,850,000
883 Eksplorasi Kista Branchial 5,767,645
884 Eksplorasi Kista Ductus Tiroglosus 5,767,645
885 Eksplorasi Kista Tiroid 5,788,179
886 Eksplorasi Kolekdokus 4,406,075
887 Eksplorasi Luka 60,000
888 Eksplorasi Multiple Abses 10,678,000
889 Eksplorasi Nasofaring 3,850,000
890 Eksterpasi / Biopsi Polip Serviks Kacil < 1/2 135,000
891 Eksterpasi dan Kuretase 840,000
892 Eksterpasi Fistel Preaurikuler 4,530,362
893 Eksterpasi Kista Ateroma/Lipoma Ganglion < 2cm 250,000
894 Eksterpasi Kista Bartholin 2,850,000
895 Eksterpasi Limpoma, ganglion kista epidermoid, neurolibroma sactase 2,159,000
896 Eksterpasi Miom Geburt 2,850,000
897 Ekstipasi Adenomiosis 4,850,000
898 Ekstipasi Tumor Scalp/Cranium 5,586,887
899 Ekstirpasi / Marsupialisasi Ranula 9,461,000
900 Ekstirpasi Corpus Alienum 150,000
901 Ekstirpasi Fibroma 2,850,000
902 Ekstirpasi Kista Ateroma / Lipoma / Ganglion > 2cm 2,850,000
903 Ekstirpasi Kista Epidermoid 250,000
904 Ekstirpasi Mucocele dengan Anastesi Lokal 1,798,000
905 Ekstirpasi Odontoma 9,070,000
906 Ekstirpasi Papiloma 3,850,000
907 Ekstirpasi Plunging Ranula 2,485,000
908 Ekstirpasi Preaurikuler Fistel THT 4,850,000
909 Ekstirpasi Ranula Dengan Anastesi Lokal 2,485,000
910 Ekstirpasi Tumor Ganas Adnesa + Rekonstruksi 12,350,000
911 Ekstirpasi Tumor Jinak 250,000
912 Ekstirpasi Tumor Jinak Kel.Liur THT 4,850,000
913 Ekstirpasi Tumor Jinak Kulit 0 < 3cm (Lipoma,Atheroma,dll) 2,850,000
914 Ekstirpasi Tumor Jinak Lain > 5 cm 3,850,000
915 Ekstirpasi Tumor Jinak Sinonasal Oral Cavity 3,850,000
916 Ekstirpasi Tumor Jinak THT 675,000
917 Ekstrackel benda asing dengan anastesi umum 2,159,000
918 Ekstraksi / Operasi (Alveolectomy pr Kwadran) 180,000
919 Ekstraksi / Operasi (Epulis) 165,000
920 Ekstraksi / Operasi (Fraktur Rahang) 450,000
921 Ekstraksi / Operasi (Gigi Permanent Komplikasi) 200,000
922 Ekstraksi / Operasi (Gigi Permanent Normal) 105,000
923 Ekstraksi / Operasi (Gigi Sulung / Chloraethyl) 70,000
924 Ekstraksi / Operasi (Gigi Sulung / Citoject) 75,000
925 Ekstraksi / Operasi (Incisi Abses) 250,000
926 Ekstraksi / Operasi (Kista) 330,000
927 Ekstraksi / Operasi (Mucocele) 350,000
928 Ekstraksi / Operasi (Odontektomi Dengan komplikasi) 455,000
929 Ekstraksi / Operasi (Odontektomi Tanpa komplikasi) 325,000
930 Ekstraksi Batu 4,850,000
931 Ekstraksi Batu dengan Basket/Balon 11,530,000
932 Ekstraksi Batu Dengan Basket/Balon (Sore) 17,290,000
933 Ekstraksi Benda Asing 552,000
934 Ekstraksi Benda Asing + Anastesi 1,247,000
935 Ekstraksi Benda Asing dengan Penyulit 250,000
936 Ekstraksi benda asing disaluran cerna bagian atas/bawah 2,850,000
937 Ekstraksi Benda Asing Saluran Cerna + Anastesi 4,270,000
938 Ekstraksi Benda Asing Saluran Cerna + Anastesi (Sore) 6,400,000
939 Ekstraksi Comedo 130,000
940 Ekstraksi Corpus Alienum 59,000
941 Ekstraksi Corpus Aliineum Cornea 250,000
942 Ekstraksi Gigi / Fragmen Gigi Penyulit dengan Anastesi 270,000
943 Ekstraksi jaringan granulasi pada telinga 66,000
944 Ekstraksi Kolesteatom Eksterna 250,000
945 Ekstraksi Kuku 250,000
946 Ekstraksi Kuku Berat (Besar) 317,000
947 Ekstraksi Kuku Sederhana (Sedang) 190,000
948 Ekstraksi Linear 4,866,237
949 Ekstraksi Per Gigi dengan Anastesi Lokal 140,000
950 Ekstraksi polip hidung ( polipektomi simpleks) 100,000
951 Ekstraksi Serumen Dengan Penyulit 66,000
952 Ekstraksi Serumen Telinga 26,000
953 Ekstraksi Stent Migrasi 3,610,000
954 Ekstraksi Stent Migrasi (Sore) 5,410,000
955 Ekstraksi Stent Non-Migrasi 3,700,000
956 Ekstraksi Stent Non-Migrasi (Sore) 5,550,000
957 Elbow Brace (Biasa) 1,500,000
958 Elbow Brace (Khusus) 2,750,000
959 Electroencephalography (EEG) 780,000
960 Electromyography (EMG) 930,000
961 Elektrikal Stimulasi 75,000
962 Elektro Couter Besar 385,000
963 Elektro Couter Kecil 222,000
964 Elektro Couter Sedang 302,000
965 Elektro Physiologi Study (EP Study) 15,350,000
966 Elektro Physiologi Study (EP Study) + Ablasi 36,350,000
967 Elektrofulgurasi 66,000
968 Elektrokauter Keratosis Seboroik 710,000
969 Elektrolit _ 120,000
970 Elektrolit Urine 24 Jam 100,000
971 Embolektomi/Pleurodesis/RedoOperationForStopBleeding/Thoracotomi 13,550,000
972 Embolisasi dengan Spongiostan (Preop) 16,309,000
973 Embolisasi dengan Spongiostan (Preop) + Anastesi 33,450,000
974 Embolisasi pada Perdarahan Intraabdominal / Extermitas yang Menggunakan Gel Foam + Anastesi 26,610,000
975 Embolisasi pada Perdarahan Intraabdominal / Extremitas yang Menggunakan Coil + Anastesi 26,900,000
976 Embolisasi pada perdarahan intraabdominal/extremitas yang menggunakan coil 20,044,886
977 Embolisasi pada perdarahan intraabdominal/extremitas yang menggunakan gel foam 19,975,590
978 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan gel foam 19,975,590
979 Embolisasi pada Tumor Intraabdominal / Extremitas yang Menggunakan Gel Foam + Anastesi 26,610,000
980 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan PVA 21,161,761
981 Embolisasi pada tumor intraabdominal / extremitas yang menggunakan PVA + Anastesi 31,750,000
982 Embriotomi (Eviserasi /punksi) 1,800,000
983 Embriotomi (Kranioklasi) 1,800,000
984 Embriotomi (Perforasi + Dekapitasi) 1,800,000
985 EMG - Anak 1,100,000
986 EMG Single Fiber 980,000
987 Endorectal pull-through/ soave Boley 6,175,000
988 Endoscopic Mucosal Resection (EMR) 5,900,000
989 Endoscopic Mucosal Resection (EMR) (Sore) 8,850,000
990 Endoscopic Papillary Balloon Dilatation (EPBD) / Endoscopic Papillary Large Balloon Dilatation (EPLBD) 9,340,000
991 Endoscopic Papillary Balloon Dilatation (EPBD) / Endoscopic Papillary Large Balloon Dilatation (EPLBD) (Sore) 14,010,000
992 Endoscopic Submucosal Disection (ESD) 26,640,000
993 Endoscopic Submucosal Disection (ESD) (Sore) 39,960,000
994 Endoscopic Ultrasound (EUS) Diagnostik 2,780,000
995 Endoscopic Ultrasound (EUS) Diagnostik (Sore) 4,170,000
996 Endoscopy Retrograde Cholangio Pankreatografi (ERCP) Diagnostik 15,890,000
997 Endoscopy Retrograde Cholangio Pankreatografi (ERCP) Diagnostik (Sore) 23,830,000
998 Endoscopy teurapeutic (BA) 6,175,000
999 Endovascular Aortic Repair (EVAR) 158,000,000
1000 Endovascular Coiling Of Aneurysm Using <= 3 Bare Coiling + GA 106,680,000
1001 Endovascular Coiling Of Aneurysm Using > 3 Bare Coiling + GA 155,225,000
1002 Endovascular Coiling Of Aneurysm Using Balloon Assited <= 3 Coiling + GA 153,015,000
1003 Endovascular Coiling Of Aneurysm Using Balloon Assited > 3 Coiling + GA 197,745,000
1004 Endovascular Coiling Of Aneurysm Using Flow Diverter/Stent Graft/Endovascular Graft + GA 293,805,000
1005 Endovascular Coiling Of Aneurysm Using Stent Assited <= 3 Coiling + GA 202,025,000
1006 Endovascular Coiling Of Aneurysm Using Stent Assited > 3 Coiling + GA 242,685,000
1007 Endovascular Occlusion Of Carotic Cavernous Fistula Using <= 3 Coil + GA 104,640,000
1008 Endovascular Occlusion Of Carotic Cavernous Fistula Using > 3 Coil + GA 155,525,000
1009 Endovascular Occlusion Of Carotic Cavernous Fistula With Parent Artery Sacrifice Using <= 3 Coil + GA 105,075,000
1010 Endovascular Occlusion Of Carotic Cavernous Fistula With Parent Artery Sacrifice Using > 3 Coil + GA 155,525,000
1011 Endovascular Occlusion Of Carotid Cavernous Fistula Using Detachable Baloon (Goldbal) + GA 68,095,000
1012 Endovascular Occlusion Of Carotid Cavernous Fistula Using Liquid Embolization + GA 131,685,000
1013 Endovascular Occlusion Of Ccf Using Flow Diverter + GA 293,375,000
1014 Endovascular Occlusion Of Head And Neck Tumour Using Coil <= 3 + GA 97,775,000
1015 Endovascular Occlusion Of Head And Neck Tumour Using Coil <= 3 + Penyulit + GA 146,415,000
1016 Endovascular Occlusion Of Head And Neck Tumour Using Coil > 3 + GA 150,800,000
1017 Endovascular Occlusion Of Head And Neck Tumour Using Coil > 3 + Penyulit + GA 152,075,000
1018 Endovascular Occlusion Of Head And Neck Tumour Using Liquid Embolization <= 3 + GA 138,065,000
1019 Endovascular Occlusion Of Head And Neck Tumour Using Liquid Embolization <= 3 + Penyulit + GA 141,775,000
1020 Endovascular Occlusion Of Head And Neck Tumour Using Liquid Embolization > 3 + GA 203,710,000
1021 Endovascular Occlusion Of Head And Neck Tumour Using Liquid Embolization > 3 + Penyulit + GA 215,190,000
1022 Endovascular Occlusion Of Head And Neck Tumour Using Particle + Penyulit + GA 98,885,000
1023 Endovascular Occlusion Of Head And Neck Tumour Using Particle <= 3 + GA 96,140,000
1024 Endovascular Occlusion Of Head And Neck Tumour Using Particle > 3 + GA 129,645,000
1025 enucleatie kista 2,510,000
1026 Enucleatie Kista D 42 4,850,000
1027 Enukleasi + DFG 6,822,174
1028 Enukleasi Besar dengan Anastesi Lokal 860,000
1029 Enukleasi Kecil dengan Anastesi Lokal 860,000
1030 Enukleasi Kista Dental dengan Anastesi Lokal 2,488,000
1031 Enukleasi Kista Ginjal 6,926,000
1032 Enukleasi Kista Odontogenik / Nonodontogenik 9,461,000
1033 Enukleasi Milia 66,000
1034 Enukleasi Mol 66,000
1035 Enukleasi Moluskum Banyak (Besar) 152,000
1036 Enukleasi Moluskum Sedikit (Sedang) 111,000
1037 Enukleasi Ranula 9,461,000
1038 Epicardial Permanen Pace Maker(Microny)/PDA=MOF/Pengangkatan Embolusi(Device Embolusi) dengan CPB)/PS Repair 33,550,000
1039 Epidimovasostomi/Epididimovasostomi 10,320,000
1040 Epidural Steroid Cateter 765,000
1041 Epidural Steroid Injection 633,000
1042 Epilasi Bulu Mata 84,000
1043 Episiotomi + Jahitan Perineum 120,000
1044 ERCP + Extraksi Batu Inci Lithotriptor 3,125,000
1045 ERCP Biopsy 6,860,000
1046 ERCP Biopsy Intraductal / Cytology Brush (Sore) 1,180,000
1047 ERCP Biopsy Intraductal /Cytology Brush 790,000
1048 ERCP Litotripsi Mechanical 14,126,000
1049 ERCP Litotripsi Mechanical - Large Stone 8,230,000
1050 ERCP Litotripsi Mechanical - Large Stone (Sore) 12,340,000
1051 ERCP Litotripsi Mechanical - Prosedur Soehendra 5,110,000
1052 ERCP Litotripsi Mechanical - Prosedur Soehendra (Sore) 7,660,000
1053 ERCP Litotripsi Mechanical - Small Stone 7,140,000
1054 ERCP Litotripsi Mechanical - Small Stone (Sore) 10,700,000
1055 ERCP NBD (Nasobiliary Drainage) 7,378,000
1056 ERCP Plastic Stent (Drainase Internal Bilier) 7,100,000
1057 ERCP Plastic Stent (Drainase Internal Bilier) (Sore) 10,640,000
1058 ERCP Sphincterotome / Precut 6,160,000
1059 ERCP Sphincterotome / Precut (Sore) 9,240,000
1060 ERCP Stent (Drainase Bilier) 8,960,000
1061 ERCP(Endoscopy Retrograde Cholangio Pankreatografi) (Rujukan Luar) 38,680,000
1062 Eritrosit Cuci (WE) Perkantong 475,000
1063 Esofagogastroduodenoskopi Diagnostik (GEH) 2,120,000
1064 Esofagogastroduodenoskopi Diagnostik (GEH) (Sore) 3,180,000
1065 Esofagogastroduodenoskopi Diagnostik (GEH) + Anastesi 3,155,000
1066 Esofagogastroduodenoskopi Diagnostik (GEH) + Anastesi (Sore) 4,320,000
1067 Esofagomyotomi 6,175,000
1068 Esofagoskopi Diagnostik 875,000
1069 Esofagoskopi Diagnostik + Anastesi 1,752,000
1070 Esofagostomi + Gastrotomi (Atresia Esophagus) 6,175,000
1071 Esoghageal Replacement Procedure (Transposisi Kolon, Transposisi gaster, gastric Pull-up) 6,175,000
1072 Esophagoscopy 5,647,645
1073 Estradiol 263,000
1074 Estradiol (P) 422,000
1075 ESWL FASE I 7,841,000
1076 ESWL Fase I (Sore) 11,470,000
1077 ESWL FASE II 7,000,000
1078 ESWL Fase II (Sore) 10,160,000
1079 ESWL Prostatron 5,376,000
1080 ESWL Prostatron (Sore) 8,070,000
1081 Ethmoidektomi (Intranasal) 5,827,645
1082 EUS Abiasi Trunkus Coeliacus (Sore) 3,870,000
1083 Eus Ablasi Trunkus Coeliacus 2,580,000
1084 Eus Biopsi Fine Needle Aspiration 27,460,000
1085 EUS Biopsi Fine Needle Aspiration (Sore) 41,190,000
1086 Eus Gastro Jejenal Bypass (Hot axios stent) 101,070,000
1087 EUS Gastro Jejenal Bypass (Hot Axios Stent) (Sore) 151,600,000
1088 Eus Kanulasi Rendervous 9,310,000
1089 EUS Kanulasi Rendervous (Sore) 13,960,000
1090 Eus Stent Biliogastric (Plastic Stent) 44,070,000
1091 EUS Stent Biliogastric (Plastic Stent) (Sore) 66,100,000
1092 Evakuasi Bekuan Darah (Clot) 4,442,187
1093 Evaluasi SST _ 600,000
1094 Eviserasi + DFG 6,904,436
1095 Excisi Biopsi 77,000
1096 Excision of bone for graft, carpus and metacarpus 6,600,000
1097 Excision of bone for graft, femur 6,600,000
1098 Excision of bone for graft, humerus 6,600,000
1099 Excision of bone for graft, patella 6,600,000
1100 Excision of bone for graft, radius and ulna 6,600,000
1101 Excision of bone for graft, scapula, clavicle, and thorax (ribs and sternum) 6,600,000
1102 Excision of bone for graft, tarsals and metatarsals 6,600,000
1103 Excision of bone for graft, tibia and fibula 6,600,000
1104 Excision of intervertebral disc 14,020,000
1105 Excision of lesion of muscle 9,390,000
1106 Excision of lesion of muscle of hand 9,390,000
1107 Excision of lesion of other soft tissue 9,390,000
1108 Excision of lesion of tendon sheath 9,390,000
1109 Excision of lesion of tendon sheath of hand 9,390,000
1110 Excision of muscle or fascia for graft 11,196,000
1111 Excision of muscle or fascia of hand for graft 9,390,000
1112 Excision of other lesion of soft tissue of hand 9,390,000
1113 Excision of semilunar cartilage of knee 16,485,212
1114 Excision of skin for graft 7,522,000
1115 Excision of tendon of hand for graft 9,390,000
1116 Excision or correction of bunionette 6,600,000
1117 Excisional debridement of wound, infection, or burn 2,350,000
1118 Excohliasi 2,510,000
1119 Exercise / Latihan Wicara 22,800
1120 Exercise Not Elshewhere Classified 70,000
1121 Exercise Therapi ( Latihan ) 56,400
1122 Exflorasi Vagina 5,979,000
1123 Explorasi Testis Mikro Surgery 7,777,000
1124 Exploration of tendon sheath 9,390,000
1125 Exploration of tendon sheath of hand 11,196,000
1126 Exposure Mahkota Gigi Terpendam dengan Anastesi Lokal 860,000
1127 Extended Pyelolithektomi (Gilverne) 7,214,004
1128 Exterpasi / Eksisi Kecil 283,000
1129 Exterpasi Besar / Eksisi 386,000
1130 Extirpasi Polip 2,850,000
1131 Extirpasi Polip Cavum Nasi 4,532,000
1132 Extirpasi Tumor 2,510,000
1133 Extraksi Kalium Oxalat 66,000
1134 Extubasi 700,000
1135 Eye Reflex Test 78,000
1136 FAAL Paru 150,000
1137 Facet Blok (1 Level/Multilevel) 3,850,000
1138 Facial 65,000
1139 Facialis Parase 73,000
1140 Faktor IX (P) 416,000
1141 Faktor VIII (P) 416,000
1142 Family Therapi 33,000
1143 Faradic / Galvanic 45,600
1144 Fare Head Flap 5,482,645
1145 Faringotomi 5,482,645
1146 Farmakopuntur 105,000
1147 Fasciotomy 6,424,400
1148 Fasciotomy of hand 9,282,099
1149 Fe (Besi) _ 45,000
1150 Feeding Tube 36,000
1151 Feeling AHA / TCA 200,000
1152 Ferritine _ 230,000
1153 Fetocide Dengan Anastesi Lokal 396,000
1154 Fiber Optic Laryngoscopy (FOL) 250,000
1155 Fibrinogen _ 200,000
1156 Fibro Adenom Mamae 3,444,000
1157 Fibro Adenoma > Tumor (Besar) 480,000
1158 Fibroadenoma (Mammae) / Biji (Sedang) 157,000
1159 Fibroscan 1,040,000
1160 Fibroscan (Sore) 1,560,000
1161 Fiksasi 193,000
1162 Fiksasi Archbar Per Rahang 1,784,000
1163 Fiksasi Composte Wiring Per Rahang 1,567,000
1164 Fiksasi Wiring Per Regio (Segmen) 1,227,000
1165 Fiksasi/ Wire Satu Gigi 298,000
1166 Filaria 27,500
1167 Fine Needle Aspirasi (FNA) 145,000
1168 Finger Insole 163,000
1169 Finger reattachment 10,675,000
1170 Finger Splint 316,000
1171 Fisioterapi Dengan Alat (4x Tindakan) 250,000
1172 Fistula Eterovesika 6,925,000
1173 Fistulectomi 2,850,000
1174 Fistulectomy Perianal 4,962,559
1175 Fistulektomi / Repair Fistel Uretra 4,442,187
1176 Fistulektomi/Fistula Ani 4,183,286
1177 Fistulografi 500,000
1178 Fitting Ortosis (Spinal, AGB, AGA) 241,000
1179 Fitting Ortosis Leher 100,000
1180 Fitting Prostesis Bawah Lutut 241,000
1181 Fitting Prostesis Kaki Atas Lutut 241,000
1182 Fitting Prostesis Kaki, Nit Otherwise Specified 241,000
1183 Fitting Prostesis Lengan Atas dan Bahu 241,000
1184 Fitting Prostesis Lengan Bawah dan Tangan 241,000
1185 Fitting Prostesis Lengan, Tidak Pada Lengan Spesifik 241,000
1186 Five-in-one repair of knee 8,105,000
1187 Flebektomi 2,850,000
1188 Flexible Endoscopy Evaluation Of Swallowing (FEES) 1,077,000
1189 Flourocences Insitu Hybridization 3,125,000
1190 Flusing CAPD 855,000
1191 Fontan/Kawashima/Penutupan VSD tanpa Pembedahan Dgn Menggunakan Device (AMVO)/Repair Aneuryema Of Sinus Valsava 68,031,954
1192 Fontan/Kawashima/Penutupan VSD tanpa Pembedahan Dgn Menggunakan Device (AMVO)/Repair Aneuryema Of Sinus Valsava + Anastesi 77,790,699
1193 Foot Glove Prosthesis 18,630,000
1194 Foot reattachment 10,675,000
1195 Foot Splint (Biasa) 1,500,000
1196 Foot Splint Orfit 3,500,000
1197 Fore Head flap (Bedah Plastik) 4,850,000
1198 Forearm Crutches (Biasa) 170,000
1199 Forearm Crutches (Standar) 385,000
1200 Forearm, wrist, or hand reattachment 10,675,000
1201 Forehead Flap THT 4,850,000
1202 Fosfor 195,000
1203 Fosfor Anorganik (P) 98,000
1204 Fosfor Anorganik Urine (P) 98,000
1205 Foto Abdomen (1 Posisi/2 Posisi/BNO/Foto polos Abdomen) 125,000
1206 Foto Abdomen 3 Posisi 250,000
1207 Foto Abdomen Invertogram 160,000
1208 Foto Adenoid 125,000
1209 Foto Ankle Joint AP + Lateral D/S 160,000
1210 Foto Ankle Joint AP + Lateral D+S 180,000
1211 Foto Ankle Joint Mortise View 125,000
1212 Foto Ankle/Ankle Bilateral (AP/Lat/Keduanya) 125,000
1213 Foto Ante Brachii/Ante Brachii Bilateral 125,000
1214 Foto Antebrachi AP + Lateral D/S 160,000
1215 Foto Antebrachi AP + Lateral D+S 180,000
1216 Foto Basis Kranii 125,000
1217 Foto Bone Age 125,000
1218 Foto Cephalo 125,000
1219 Foto Cervical AP + Lateral + Obliq 3 Posisi 200,000
1220 Foto Cervical Open Mouth 125,000
1221 Foto Clavicula D/S 125,000
1222 Foto Clavicula D+S 180,000
1223 Foto Costae 125,000
1224 Foto Coxae 125,000
1225 Foto Cruris AP + Lateral D/S 160,000
1226 Foto Cruris AP + Lateral D+S 180,000
1227 Foto Cubiti/Cubiti Bilateral 125,000
1228 Foto Femur Ap + Lateral D/S 160,000
1229 Foto Femur Ap + Lateral D+S 180,000
1230 Foto Fundus 250,000
1231 Foto Genu AP + Lateral & Sky Line View D/S 180,000
1232 Foto Genu AP + Lateral & Sky Line View D+S 200,000
1233 Foto Genu/Knee Joint AP + Lateral D/S 160,000
1234 Foto Genu/Knee Joint AP + Lateral D+S 180,000
1235 Foto Humerus D/S 160,000
1236 Foto Humerus D+S 180,000
1237 Foto Jaringan Lunak 125,000
1238 Foto Kepala AP + Lateral 160,000
1239 Foto Kepala Water Position 125,000
1240 Foto Koagulasi (acc) 3,760,000
1241 Foto Koagulasi Laser 2,850,000
1242 Foto Koagulasi Laser (rujukan luar) 3,125,000
1243 Foto Kolumna Vertebralis 125,000
1244 Foto Leher AP + Lateral 160,000
1245 Foto Lumbal AP + Lateral 160,000
1246 Foto Lumbal Dynamic 160,000
1247 Foto Lumbosakral AP + Lateral 160,000
1248 Foto Lumbosakral AP + Lateral + Obliq 180,000
1249 Foto Mandibula / Rahang AP + Lateral 160,000
1250 Foto Mandibula / Rahang AP + Lateral (Rujukan Luar) 160,000
1251 Foto Manus AP + Obliq D/S 160,000
1252 Foto Manus AP + Obliq D+S 180,000
1253 Foto Mastoid 160,000
1254 Foto Metacarpai/Tangan 125,000
1255 Foto Orbita 160,000
1256 Foto Os Nasal 125,000
1257 Foto Pedis AP + Obliq D/S 160,000
1258 Foto Pedis AP + Obliq D+S 180,000
1259 Foto Pelvis/Panggul AP 125,000
1260 Foto Pelvis/Panggul Inlet + outlet AP 180,000
1261 Foto Polos Abdomen 125,000
1262 Foto Radius/Ulna (AP/Lat/Keduanya) 125,000
1263 Foto Rheese 125,000
1264 Foto Sakrum AP + Lateral 160,000
1265 Foto Scapula AP + Lateral D/S 160,000
1266 Foto Scapula AP + Lateral D+S 180,000
1267 Foto Schedel (AP/Lat/Keduanya) (evaluasi adenoid) 125,000
1268 Foto Sendi Bahu / Shoulder Joint D/S 160,000
1269 Foto Sendi Bahu / Shoulder Joint D+S 180,000
1270 Foto Sendi Siku / Elbow Joint D/S 160,000
1271 Foto Sendi Siku / Elbow Joint D+S 180,000
1272 Foto Sinus Adenoid 125,000
1273 Foto Sinus Paranasal 160,000
1274 Foto Stenvers 125,000
1275 Foto Temporomandibular Joint (TMJ) 180,000
1276 Foto Thoracal (AP/Lat/Keduanya) 125,000
1277 Foto Thoracal AP/Lat/Obi 125,000
1278 Foto Thoraco Lumbal AP/Lat/Obi 125,000
1279 Foto Thorakal AP + Lateral 160,000
1280 Foto Thoraks Lateral 125,000
1281 Foto Thoraks PA/AP 125,000
1282 Foto Thoraks PA/AP + Lateral 160,000
1283 Foto Thoraks RLD 125,000
1284 Foto Top Lordotik 125,000
1285 Foto Wrist Joint AP + Lateral D/S 160,000
1286 Foto Wrist Joint AP + Lateral D+S 180,000
1287 Foto X-RAY C ARM/Flouroscopy 350,000
1288 Foto X-RAY C ARM/Flouroscopy (Rujukan Luar) 1,320,000
1289 Fotokoagulasi Laser 2,500,000
1290 Four Poster Cervical Orthosis 2,850,000
1291 Fraktur Maksila/Zygoma 6,168,740
1292 Fraktur Muka Multiple (Tanpa Miniplate Screw) 9,451,305
1293 Fraktur Rahang 2,960,000
1294 Fraktur Rahang Sederhana 6,281,000
1295 Fraktur Sederhana os Nassal + Lokal 5,108,000
1296 Fraktur Sederhana os Nassal + Naskosa Umum 5,107,800
1297 Fraktur Tripodo/Multiple 6,913,000
1298 Free Field Test 73,000
1299 Free Flap Surgery 39,655,772
1300 Free skin graft 9,182,099
1301 Free skin graft, not otherwise specified 6,528,000
1302 Free T3 181,000
1303 Frenectomi 2,850,000
1304 Frenektomi (Bedah Mulut) 1,464,000
1305 Fronto-Orbital Advancement Pada Craniosynostosis 22,016,772
1306 Frosen Section (Potongan Beku) VC 900,000
1307 Fruktosamin 84,000
1308 FSH 200,000
1309 FSH (P) 352,000
1310 FT4 _ 210,000
1311 Full-thickness skin graft to hand 6,528,000
1312 Full-thickness skin graft to other sites 6,528,000
1313 Functie Pericard 351,000
1314 Functie Pertitoneum 87,000
1315 Function Evaluation 70,000
1316 Fundoplikasi Gaster 6,175,000
1317 Funduscopy 80,000
1318 Funduscopy Direct 54,000
1319 Funduscopy Indirect 58,000
1320 Fungsional Endoscopy Sinus Surgery (FESS) 4,243,393
1321 Fusi Korpus Vertebra Approach Anterior (Bedah Syaraf) 6,760,638
1322 Fusi Korpus Vertebra Approach Posterior (Bedah Syaraf) 10,705,638
1323 Fusion or refusion of 2-3 vertebrae 14,020,000
1324 Fusion or refusion of 4-8 vertebrae 14,020,000
1325 Fusion or refusion of 9 or more vertebrae 14,020,000
1326 Gali Kubur Dalam Kota 6,000,000
1327 Gali Kubur Luar Kota 11,000,000
1328 Gambaran Darah tepi * _ 190,000
1329 Gamma GT _ 40,000
1330 Ganti Colostomy Bag 308,000
1331 Ganti Drain 55,000
1332 Ganti Kanule 250,000
1333 Ganti Kawat IMF 55,000
1334 Ganti Nefrostomi 675,000
1335 Ganti Provox 250,000
1336 Ganti Rubber Elastik IMF 55,000
1337 Ganti Verban (Intensif) 83,000
1338 Ganti Verban Besar (Poli Gigi) 122,000
1339 Ganti Verban Kecil (Poli Gigi) 99,000
1340 Ganti Verband 83,000
1341 Ganti Verband (Radiotherapi) 83,000
1342 Ganti Verband Pasien (Besar) 64,000
1343 Ganti Verband Pasien (Kecil) 52,000
1344 Gasterctomi (Blroth 1 dan 2) 5,982,388
1345 Gastrectomi ( Bilroth 1 dan 2 ) 5,982,389
1346 Gastroduodenoskopi 4,995,000
1347 Gastroduodenoskopi Besar 4,995,000
1348 Gastrostomi Pada Neonatus 8,164,502
1349 Genitoplasty (Clitoroplasty, vaginoplasty) 6,175,000
1350 Gigi Tiruan Immediate Koreksi Posisi Protesa Delapan Gigi/Lebih 3,090,000
1351 Gigi Tiruan Immediate Koreksi Posisi Protesa Dua Gigi 970,000
1352 Gigi Tiruan Immediate Koreksi Posisi Protesa Empat Gigi 1,560,000
1353 Gigi Tiruan Immediate Koreksi Posisi Protesa Enam Gigi 2,150,000
1354 Gigi Tiruan Immediate Koreksi Posisi Protesa Lima Gigi 1,860,000
1355 Gigi Tiruan Immediate Koreksi Posisi Protesa Penuh 7,000,000
1356 Gigi Tiruan Immediate Koreksi Posisi Protesa Satu Gigi 600,000
1357 Gigi Tiruan Immediate Koreksi Posisi Protesa Satu Rahang 3,740,000
1358 Gigi Tiruan Immediate Koreksi Posisi Protesa Tiga Gigi 1,200,000
1359 Gigi Tiruan Immediate Koreksi Posisi Protesa Tujuh Gigi 2,295,000
1360 Gigi Tiruan Lepasan Akrilik Protesa Delapan/Lebih/Satu Rahang 1,240,000
1361 Gigi Tiruan Lepasan Akrilik Protesa Dua Gigi 370,000
1362 Gigi Tiruan Lepasan Akrilik Protesa Empat Gigi 560,000
1363 Gigi Tiruan Lepasan Akrilik Protesa Enam Gigi 725,000
1364 Gigi Tiruan Lepasan Akrilik Protesa Lima Gigi 650,000
1365 Gigi Tiruan Lepasan Akrilik Protesa Penuh Flabby Ridge 4,000,000
1366 Gigi Tiruan Lepasan Akrilik Protesa Penuh Flat Rata 3,500,000
1367 Gigi Tiruan Lepasan Akrilik Protesa Penuh Rahang Atas dan Bawah Biasa 2,500,000
1368 Gigi Tiruan Lepasan Akrilik Protesa Satu Gigi 300,000
1369 Gigi Tiruan Lepasan Akrilik Protesa Satu Rahang Dengan Flabby Ridge 2,000,000
1370 Gigi Tiruan Lepasan Akrilik Protesa Satu Rahang Dengan Flat Rata 1,700,000
1371 Gigi Tiruan Lepasan Akrilik Protesa Tiga Gigi 465,000
1372 Gigi Tiruan Lepasan Akrilik Protesa Tujuh Gigi 820,000
1373 Gigi Tiruan Lepasan Immediate Penuh Immediate 4,000,000
1374 Gigi Tiruan Lepasan Immediate Satu Rahang Immediate 2,240,000
1375 Gigi Tiruan Lepasan Immediate/Segera Protesa Delapan/Lebih/Satu Rahang 1,740,000
1376 Gigi Tiruan Lepasan Immediate/Segera Protesa Dua Gigi 670,000
1377 Gigi Tiruan Lepasan Immediate/Segera Protesa Empat Gigi 1,060,000
1378 Gigi Tiruan Lepasan Immediate/Segera Protesa Enam Gigi 1,425,000
1379 Gigi Tiruan Lepasan Immediate/Segera Protesa Lima Gigi 1,250,000
1380 Gigi Tiruan Lepasan Immediate/Segera Protesa Satu Gigi 550,000
1381 Gigi Tiruan Lepasan Immediate/Segera Protesa Tiga Gigi 865,000
1382 Gigi Tiruan Lepasan Immediate/Segera Protesa Tujuh Gigi 1,620,000
1383 Gigi Tiruan Overdenture Protesa Delapan/Lebih/Satu Rahang 1,280,000
1384 Gigi Tiruan Overdenture Protesa Dua Gigi 575,000
1385 Gigi Tiruan Overdenture Protesa Empat Gigi 800,000
1386 Gigi Tiruan Overdenture Protesa Enam Gigi 1,040,000
1387 Gigi Tiruan Overdenture Protesa Lima Gigi 920,000
1388 Gigi Tiruan Overdenture Protesa Penuh Rahang Atas dan Bawah Biasa 2,500,000
1389 Gigi Tiruan Overdenture Protesa Satu Gigi 475,000
1390 Gigi Tiruan Overdenture Protesa Tiga Gigi 680,000
1391 Gigi Tiruan Overdenture Protesa Tujuh Gigi 1,160,000
1392 Gingivectomy 2,850,000
1393 Gingivektomi / Gingivoplasty per Region dengan Anastesi Lokal 860,000
1394 Globulin _ 32,000
1395 Glosektomi Total 4,903,089
1396 Glosektomi Totalis 4,659,000
1397 Glukose 2 Jam PP _ 28,000
1398 Glukose Puasa _ 28,000
1399 Glukose Sewaktu _ 28,000
1400 Glukose Sewaktu (Rapid) 30,000
1401 Glukose Strip 30,000
1402 Glukose Toleransi _ 40,000
1403 Golongan Darah ABO, Rhesus 95,000
1404 Gonioplasty 2,850,000
1405 Goniotomi 4,235,000
1406 Goniotomi + anastesi 4,889,000
1407 GOT _ 33,000
1408 GPT _ 33,000
1409 Graf Vena Membuat A Vistula 4,860,000
1410 Graft Gingival dengan Anastesi Lokal 860,000
1411 Graft of muscle or fascia 11,196,000
1412 Grafting Pada Arterial Insufisiensi (Bedah Vaskuler) 4,860,000
1413 Grinding Gigi 55,000
1414 Group Therapi 39,600
1415 Group Therapi (Terapi Kelompok) Fisioterapi 22,800
1416 Group Therapi (Terapi Kelompok)Okupasi Terapi 22,800
1417 Group Therapi (Terapi Kelompok)Terapi Wicara 42,570
1418 Growth Hormone 347,000
1419 Gula Darah 2 Jam Puasa Strip 30,000
1420 Gula Puasa Strip 30,000
1421 GV Laparotomi Anak 24,000
1422 Gymnic Ball (Fisioterapi) 33,000
1423 Gymnic Ball (Okupasi Terapi) 33,000
1424 Ham's Test 31,000
1425 Hang Sling Set 33,000
1426 HBA 1c _ 175,000
1427 Hbe Ag 425,000
1428 HBe Ag (P) 389,000
1429 HBs Ag (Elisa) _ 128,000
1430 HBs Ag (ICT) 72,000
1431 HBsAg (CMIA) 128,000
1432 HBsAg Konfirmasi (CMIA) 350,000
1433 HBsAg Konfirmasi (Elisa) 350,000
1434 HBsAg Kuantitatif (P) 314,000
1435 HBV DNA 2,000,000
1436 HBv DNA (P) 1,800,000
1437 HBV-DNA (Real Time PCR) (P) 1,800,000
1438 HCV RNA 2,300,000
1439 HCV-RNA (Real Time PCR) (P) 2,300,000
1440 HCV-RNA (Real Time PCR) & HCV Genotipe (P) 4,600,000
1441 Head Box 190,000
1442 Hecting 5 cm 113,000
1443 Hematologi Rutin Automatik _ 100,000
1444 Hemiglosektomi + RND 5,077,000
1445 Hemiglosektomi THT 4,850,000
1446 Hemiglosektomi/Eksisi Tumor Lidah 3,968,000
1447 Hemimandibulektomi 4,850,000
1448 Hemipelvektomi 6,414,000
1449 Hemiseksi Gigi dengan Anastesi Lokal 860,000
1450 Hemmimandibulektomi 4,442,187
1451 Hemodialisa 1,300,000
1452 Hemoroidektomi 4,347,979
1453 Hemosiderin 24,000
1454 Hemostasis Saluran Cerna Bagian Atas/Bawah 2,850,000
1455 Hemostatis dengan hemoclip 2,590,000
1456 Hemostatis Dengan Hemoclip (Sore) 2,590,000
1457 Hernia Incarcerata 4,255,565
1458 Herniatomi 4,515,165
1459 Herniatomi Bilateral 4,491,877
1460 Hernioraphi 4,515,165
1461 Herniotomi Bilateral 6,238,462
1462 Herniotomi hernia inkarserata/strangulate 5,782,479
1463 Herniotomi Unilateral 5,070,446
1464 Herniotomy + Laparatomy + Reseksi 6,851,507
1465 Hidrasi Alkalinisasi (hari) 66,000
1466 Hidrokel per Inguinal/Ligasi Tinggi 4,850,000
1467 Hidrokel per scrotal 3,850,000
1468 Hidroterapi 250,000
1469 High Flow Nasal Canule (Per Hari) 1,500,000
1470 Higroma Colli/Limfangioma Besar 6,238,462
1471 Hip Bone Densitometry 250,000
1472 Hiperexention Brace Khusus 2,800,000
1473 Hipnotherapy 100,000
1474 Histerectomi Trans Vaginal / Trans Abdominal et SOB 2,850,000
1475 Histerectomy Radikal 6,929,993
1476 HIV VIRAL LOAD 2,000,000
1477 Holter 516,000
1478 Holter Monitor 516,000
1479 Horsesche Kidney Koreksi 7,885,000
1480 Hot Pack 22,800
1481 HPV 1,700,000
1482 HRCT ( Dengan Kontras ) + Anastesi 6,240,000
1483 HRCT ( Tanpa Kontras ) + Anastesi 3,090,000
1484 HRCT (Dengan Kontras) 5,100,000
1485 HRCT (Tanpa Kontras) 2,200,000
1486 Hs Troponin I 400,000
1487 HSV II IgM 125,000
1488 Hydro Therapi 91,200
1489 hydrotubasi / Eksterpasi Polip Cerviks tanpa Anastesi 250,000
1490 Hysterectomy Supravaginal 7,850,000
1491 Hysterosalpingografi ( HSG ) 600,000
1492 Hystrectomy Partial 6,292,709
1493 Hystrectomy Total 6,273,291
1494 I V P 750,000
1495 ICCE/ECCE (tidak termasuk IOL) (acc) 4,276,711
1496 IDW 9,111,000
1497 IFN-Gamma Release Assay ( IGRA ) (P) 1,414,000
1498 IgA / IgG / IgM 96,000
1499 IgE _ 119,000
1500 IgE Total (P) 320,000
1501 IgM Salmonella (TF Semikuantitatif) 250,000
1502 IHC (Immunohistochemistry) - AE1/AE3 (Cytokeratin) 650,000
1503 IHC (Immunohistochemistry) - Calretinin 650,000
1504 IHC (Immunohistochemistry) - CD 117 650,000
1505 IHC (Immunohistochemistry) - CD20 650,000
1506 IHC (Immunohistochemistry) - CD3 650,000
1507 IHC (Immunohistochemistry) - Chromogranin 650,000
1508 IHC (Immunohistochemistry) - ER 650,000
1509 IHC (Immunohistochemistry) - ER, PR, HER-2 1,350,000
1510 IHC (Immunohistochemistry) - ER, PR, HER-2, Ki67 1,700,000
1511 IHC (Immunohistochemistry) - HER-2 650,000
1512 IHC (Immunohistochemistry) - Ki67 650,000
1513 IHC (Immunohistochemistry) - LCA (CD45) 650,000
1514 IHC (Immunohistochemistry) - PR 650,000
1515 IHC (Immunohistochemistry) - S100 650,000
1516 IHC (Immunohistochemistry) - Synaptophisin 650,000
1517 IHC (Immunohistochemistry) - TTF1 650,000
1518 IHC (Immunohistochemistry) - Vimentin 650,000
1519 Ileal Condoit (Bricker)/Operasi 10,230,000
1520 Immunoterapi 120,000
1521 Immunotyping (P) 800,000
1522 Implantasi Koklea 13,850,000
1523 Imunisasi / Vaksinasi 45,000
1524 Imunisasi Mandiri 45,000
1525 Imuno Elektroforesis Anti IgG / IgA / IgM 96,000
1526 Imuno Elektroforesis Whole Anti Serum 96,000
1527 Imunohistokimia (IHC) )Per antibodi 650,000
1528 Incisi (Tutup Lubang Telinga) 47,000
1529 Incisi Abses Intraoral 1,026,000
1530 Incisi Ganed 120,000
1531 Incision and drainage of palmar or thenar space 11,196,000
1532 Incubator 88,000
1533 Induksi Partus 300,000
1534 Infant Warmer 66,000
1535 Infra Red Rays 22,800
1536 Infusion Intra Arterial/Intravenous Enzimes Trombolitik (Streptocinase) (Tissue Plasminogen Aktifator/TPA) + Anastesi General + Intrakranial 49,485,000
1537 Infusion Intra Arterial/Intravenous Enzimes Trombolitik (Streptocinase) (Tissue Plasminogen Aktifator/TPA) + Anastesi General + Penyulit + Intrakranial 52,295,000
1538 Infusion Intra Arterial/Intravenous Enzimes Trombolitik (Streptocinase) (Tissue Plasminogen Aktifator/TPA) + Anastesi Lokal + Dengan Penyulit + Intrakranial 42,570,000
1539 Infusion Intra Arterial/Intravenous Enzimes Trombolitik (Streptocinase) (Tissue Plasminogen Aktifator/TPA) + Anastesi Lokal + Intrakranial 40,060,000
1540 Infusion Pump 60,000
1541 Inhalasi 60,000
1542 Inisiasi Dini Menyusui (IDM) 10,000
1543 Injection of anaesthetic into spinal canal for analgesia 5,115,554
1544 Injection of other agent, except neurolytic 3,215,554
1545 Injection of therapeutic agent into joint or ligament 2,350,000
1546 Injection of therapeutic substance into bursa of hand 3,125,000
1547 Injection of therapeutic substance into joint or ligament 5,752,000
1548 Injection of therapeutic substance into tendon of hand 3,125,000
1549 Injeksi (Suntik) 30,000
1550 Injeksi (Suntik) II Dst 25,000
1551 Injeksi Botulinum Toxin Phenol 250,000
1552 Injeksi Deferoxamine 60,000
1553 Injeksi Eritropoietin 60,000
1554 Injeksi Gonadotropin Releasing Hormone Analog (GnRH Analog/Leuprorelin Asetat) 90,000
1555 Injeksi Granulocyt Colony Stimulating Faktor 60,000
1556 Injeksi Haemoroid (Termasuk Obat) 675,000
1557 Injeksi HCG Test 90,000
1558 Injeksi Hormon Testosteron (Sustanon) 90,000
1559 Injeksi Intraartikuler 200,000
1560 Injeksi Kenacort Intralesi 97,000
1561 Injeksi Kenacort THT 66,000
1562 Injeksi Khusus Saraf Guiding USG 670,000
1563 Injeksi Lokal Syaraf (Sederhana) 162,000
1564 Injeksi MTPS ( Injeksi Triger Ponit ) 250,000
1565 Injeksi Sensitivity Spinal Segmental 250,000
1566 Injeksi Varises (Termasuk Obat) 675,000
1567 Injeksi Zoledronic Acid (ZOMETA) 90,000
1568 INR 110,000
1569 Inseminasi Intra Urine 250,000
1570 Insersi DJ Stent 4,850,000
1571 Insersi Jacket Crown / Full Crown Dengan PFM 550,000
1572 Insersi Kateter Double Lumen : Semi Permanen 3,438,000
1573 Insersi Kateter Double Lumen : Temporer 1,688,000
1574 Insersi Pasak Custom 890,000
1575 Insersi Pasak Fiber Post 1,200,000
1576 Insersi Veneer Indirect 1,100,000
1577 Insertion of interbody spinal fusion device 9,016,000
1578 Insertion of other spinal device 2,350,000
1579 Insici Abses Ekstraoral 1,026,000
1580 Insisi + eskplorasi abses septi 47,000
1581 Insisi Abses 250,000
1582 Insisi Abses (Hepatoma Septum Nasi/Peritonsil) 250,000
1583 Insisi Abses Peri Tonsiler 250,000
1584 Insisi Abses Perineum 675,000
1585 Insisi Abses Single dengan Anastesi Lokal 270,000
1586 Insisi Abses Skrotum 675,000
1587 Insisi Abses Sub Madibula 250,000
1588 Insisi Biopsy dengan Anastesi Lokal 270,000
1589 Insisi Drainase Multiple dengan Anastesi Lokal 860,000
1590 Insisi Furunkel 66,000
1591 Insisi hematoma Vulva 107,000
1592 Insisi Kalazion / Hordeolun 153,000
1593 Insisi Mucocele 2,850,000
1594 Insisi Tongue Tie 8,245,000
1595 Insisi/drainase abses dengan anastesi umum 2,159,000
1596 Insisional Biopsi Kelenjar Leher 2,850,000
1597 Inspekulo 83,000
1598 Inspekulo (Apusan servix) 30,000
1599 Inspekulo (Kultur cairan servix) 30,000
1600 Inspekulo (Test KOH) 30,000
1601 Inspirasi 250,000
1602 Interferensi 75,000
1603 Interleukin 6 (IL-6) (P) 335,000
1604 Intermiten Positive Pressure Breathing (IPPB) 66,000
1605 Internal fixation of bone without fracture reduction on femur 5,828,000
1606 Internal fixation of bone without fracture reduction on humerus 5,828,000
1607 Internal fixation of bone without fracture reduction on patella 5,828,000
1608 Internal fixation of bone without fracture reduction on radius and ulna 5,828,000
1609 Internal fixation of bone without fracture reduction on scapula, clavicle, and thorax (ribs and sternum) 5,828,000
1610 Internal fixation of bone without fracture reduction on tarsals and metatarsals 4,804,456
1611 Internal fixation of bone without fracture reduction on tibia and fibula 5,828,000
1612 Internal fixation of bone without fracture reductionon carpals and metacarpals 5,828,000
1613 Internal fixation of patella without fracture reduction 18,596,121
1614 Internal Urethrotomi ( Sachse ) 7,458,259
1615 interphalangeal fusion 5,561,121
1616 Interthoracoscapular amputation 5,997,200
1617 Intervertebral chemonucleolysis 14,020,000
1618 Intra Arterial Mekanical Trombektomi Using Aspirasi Device 41,690,000
1619 Intra Arterial Mekanical Trombektomi Using Aspirasi Device + Penyulit 45,295,000
1620 Intra Arterial Mekanical Trombektomi Using Stent Retriever 96,925,000
1621 Intra Arterial Mekanical Trombektomi Using Stent Retriever + Penyulit 102,660,000
1622 Intra Dermal Test THT 250,000
1623 Intra-Aortic Balloon Pump (IABP) + Anestesi 17,198,000
1624 Intubasi 847,000
1625 Intubasi Double Lumen Tube 1,130,000
1626 Irigasi Hidung/sinus paranasalis 36,000
1627 Irigasi Kandung Kemih 25,000
1628 Irigasi Luka Operasi / Spooling 55,000
1629 Irigasi Sinus/DAWO 2,850,000
1630 Irigasi Telinga 55,000
1631 Iscole 87,000
1632 ISH per PROBE Inditu Hibridization 1,000,000
1633 Isonom Station ( Cybex ) 87,600
1634 Isthmolobektomi 4,488,256
1635 Isthobektomi 4,850,000
1636 IV Cavagram 2,000,000
1637 IV Cavagram + Anastesi 3,610,000
1638 IVC Filter 14,450,000
1639 IVC Filter + Anastesi 18,950,000
1640 Jahit Dehisensi Luka 163,000
1641 Jahit Dehisensi Luka (Poli) 163,000
1642 Jahit Luka 76,000
1643 Jahitan Perineum tingkat 1 & 2 60,000
1644 Jahitan Perineum tingkat 3 & 4 600,000
1645 Jamur 30,000
1646 Jarak sampai 7 Km (dalam kota) 80,000
1647 Jewett Brace (Biasa) 1,320,000
1648 Jewett Brace (Khusus) 1,600,000
1649 Johanson 4,850,000
1650 Johanson 1 4,850,000
1651 KAFO (Biasa) 3,500,000
1652 KAFO (Khusus) 5,000,000
1653 Kalibrasi Uretra 675,000
1654 Kalporeksis 5,840,933
1655 Kalsium Darah 45,000
1656 Kalsium Urine 45,000
1657 Kanaloplasti/ Pengangkatan massa tulang 6,050,000
1658 Kantong Jenazah 100,000
1659 Kapsulektomi Posterior 4,850,000
1660 karcis 10,000
1661 Karcis (ODC) 9,000
1662 Kardiotokografi (KTG) 299,000
1663 Kardioversi 1,076,000
1664 Katerisasi Urethra 39,000
1665 Kateterisasi Anak 4,120,000
1666 Kaustik 66,000
1667 Kaustik Faring 66,000
1668 Kaustik hidung ( AgNO3, tricolor acetat) 36,000
1669 Kaustik telinga (AgNo3,albotyl) 18,000
1670 Kauter Albotil/Cauter Podofiline 66,000
1671 Kauterisasi 675,000
1672 Kehamilan Ektopik Terganggu (KET) 6,119,720
1673 kelainan jari / ektremitas sederhana 5,175,000
1674 Kelasi Besi Suntik 66,000
1675 Kemoterapi Intratekal Anak 1,460,000
1676 Kemoterapi Intratekal Dewasa 1,135,000
1677 Kemoterapi Intravena Anak 660,000
1678 Kemoterapi Intravena Dewasa 540,000
1679 Kemotherapy Ca Paru 410,000
1680 Keratometry 73,000
1681 Keratoplasti 11,350,000
1682 Keratoplastie Lamelar 4,093,930
1683 Khordectomi 5,646,937
1684 Khordektomy pada Hyspopadia 4,850,000
1685 KHS ( Konduksi Hantaran Safar ) 62,400
1686 Kistektomi 6,165,762
1687 Klinik Memori 390,000
1688 Klisma 66,000
1689 Knee Brace (Biasa) 1,650,000
1690 Knee Brace (Khusus) 2,500,000
1691 Knight Taylor 3,000,000
1692 KOH 33,000
1693 Koledoko Jejunostomi 5,240,302
1694 Kolesistektomi 4,342,099
1695 Kolesterol HDL _ 60,000
1696 Kolesterol LDL (Direk) _ 100,000
1697 Kolesterol Total _ 45,000
1698 Kolonoskopi 2,360,000
1699 Kolonoskopi (Sore) 3,540,000
1700 Kolonoskopi + Anastesi 3,150,000
1701 Kolonoskopi + Anastesi (Sore) 4,720,000
1702 Kolonoskopy 5,026,784
1703 Kolostomi 4,160,391
1704 Kolostomi Neonatus/Ikostomi/Jejunostomi 7,801,000
1705 Kolostomi/ikostomi/kemonostomi pada anak 7,801,000
1706 Kolpoperineorafi 675,000
1707 Kolposkopi dan Biopsi 396,000
1708 Komplemen C3 70,000
1709 Komplemen C4 70,000
1710 Komponen Trombosit Apheresis Per Bag (PMI) 3,500,000
1711 Kompresi Bimanual interna& eksterna 180,000
1712 Konkoplasti 4,850,000
1713 Konseling CAPD 420,000
1714 Konseling Keluarga Berencana 95,000
1715 Konseling oleh Psikolog 130,000
1716 Konsul Dokter 52,000
1717 Konsul dr Ahli Alergi Imunologi Anak (IRNA) 60,000
1718 Konsul dr Ahli Anak (IRNA) 60,000
1719 Konsul dr Ahli Anastesi (IRNA) 60,000
1720 Konsul dr Ahli Bedah Anak (IRNA) 60,000
1721 Konsul dr Ahli Bedah Digestive (IRNA) 60,000
1722 Konsul dr Ahli Bedah Gastroentrohepatologi (IRNA) 60,000
1723 Konsul dr Ahli Bedah Orthopedi (IRNA) 60,000
1724 Konsul dr Ahli Bedah Plastik (IRNA) 60,000
1725 Konsul dr Ahli Bedah Saraf (IRNA) 60,000
1726 Konsul dr Ahli Bedah Thorax & Vask. (IRNA) 60,000
1727 Konsul dr Ahli Bedah Tumor (IRNA) 60,000
1728 Konsul dr Ahli Bedah Umum (IRNA) 60,000
1729 Konsul dr Ahli Bedah Urologi (IRNA) 60,000
1730 Konsul dr Ahli Cardiologi (IRNA) 60,000
1731 Konsul dr Ahli Endokrin (IRNA) 60,000
1732 Konsul dr Ahli Forensik (IRNA) 60,000
1733 Konsul dr Ahli Gastroentrohepatologi (IRNA) 60,000
1734 Konsul dr Ahli Geriatri (IRNA) 60,000
1735 Konsul dr Ahli Gigi dan Mulut (IRNA) 60,000
1736 Konsul dr Ahli Ginjal Hipertensi (IRNA) 60,000
1737 Konsul dr Ahli Gizi (IRNA) 60,000
1738 Konsul dr Ahli Hematologi (IRNA) 60,000
1739 Konsul dr Ahli Hiperbarik (IRNA) 60,000
1740 Konsul dr Ahli Infection Center (IRNA) 108,000
1741 Konsul dr Ahli Infeksi Tropis (IRNA) 60,000
1742 Konsul dr Ahli Jiwa (IRNA) 60,000
1743 Konsul dr Ahli Kulkel (IRNA) 60,000
1744 Konsul dr Ahli Mata (IRNA) 60,000
1745 Konsul dr Ahli Nefrologi (IRNA) 60,000
1746 Konsul dr Ahli Neurologi (IRNA) 60,000
1747 Konsul dr Ahli NICU (IRNA) 60,000
1748 Konsul dr Ahli Obgyn (IRNA) 60,000
1749 Konsul dr Ahli Ongko Obgyn ( IRNA ) 51,400
1750 Konsul dr Ahli Onkology (IRNA) 60,000
1751 Konsul dr Ahli Patologi Klinik (IRNA) 60,000
1752 Konsul dr Ahli Penyakit Dalam (IRNA) 60,000
1753 Konsul dr Ahli Penyakit Tropis (IRNA) 60,000
1754 Konsul dr Ahli PICU (IRNA) 60,000
1755 Konsul dr Ahli Psikiatri (IRNA) 60,000
1756 Konsul dr Ahli Pulmonologi (IRNA) 60,000
1757 Konsul dr Ahli Radiologi (IRNA) 60,000
1758 Konsul dr Ahli Radiologi Intervensi (IRNA) 60,000
1759 Konsul dr Ahli Radiotherapi (IRNA) 60,000
1760 Konsul dr Ahli Respiriology Anak ( IRNA) 51,400
1761 Konsul dr Ahli Rheumatologi (IRNA) 60,000
1762 Konsul dr Ahli Saraf (IRNA) 60,000
1763 Konsul dr Ahli THT (IRNA) 60,000
1764 Konsul dr Fisiotherapi (IRNA) 60,000
1765 Konsul dr Rehab Medik (IRNA) 60,000
1766 Konsultasi Ahli Psikiatri 150,000
1767 Konsultasi Dokter ( Rehab Medik ) 62,400
1768 Konsultasi Dokter Ahli (IRNA PCC) 60,000
1769 Konsultasi Dokter Hiperbarik 120,000
1770 Konsultasi Psikologi 240,000
1771 Kontraktur + STSG 6,421,000
1772 Kontrol Protesa 42,000
1773 Koreksi + Rekonstruksi Ptosis 4,850,000
1774 Koreksi Atresia Ani 5,225,000
1775 Koreksi ektropion / entropion 4,515,574
1776 Koreksi ektropion / entropion ( Anak ) 4,380,574
1777 Koreksi Elektrolit 130,000
1778 Koreksi Impresif Fraktur Sederhana 5,108,156
1779 Koreksi Magnesium 130,000
1780 Koreksi Priapismus 5,151,000
1781 Koreksi Simblefaron Berat 11,350,000
1782 Koreksi Symblepharon 3,850,000
1783 Koreksi Vitamin 130,000
1784 Korset (Biasa) 366,000
1785 Korset (Standar) 507,000
1786 Kranioplasti/Koreksi Fraktur 9,775,887
1787 Kraniotomi + Endoskopi 11,992,025
1788 Kraniotomi/Trepanasi Konvensional 10,554,887
1789 Kraniotomi+Bedah Mikro 11,775,887
1790 Kreatinin _ 35,000
1791 Kreatinin Klrens _ 92,000
1792 Kreatinin Urine 30,000
1793 Kruk Aluminium 271,000
1794 Kuldosintesis 120,000
1795 Kultur & Sensitivity OAT 400,000
1796 Kultur dan Sensitivitas Jamur 400,000
1797 Kultur dan Sensitivitas Manual 250,000
1798 Kultur dan Sensitivitas Obat Medium Cair 500,000
1799 Kultur dan Sensitivitas Obat Medium Padat 400,000
1800 Kultur dan Sensitivitas Otomatis 380,000
1801 Kulture jamur 54,000
1802 Kunjungan Rumah Analis Laboratorium ( Home Care ) 100,000
1803 Kunjungan Rumah Dokter ( Home Care ) 200,000
1804 Kunjungan Rumah Dokter Spesialis ( Home Care ) 300,000
1805 Kunjungan Rumah Fisioterapis ( Home Care ) 150,000
1806 Kunjungan Rumah Ners ( Perawat ) ( Home Care ) 100,000
1807 Kunjungan Rumah Nutrisionis ( Home Care ) 100,000
1808 Kuretase 140,000
1809 Kuretase Abortus Inkomplitus/ rest plasenta 600,000
1810 Kuretase dengan PUD / Polip 5,680,221
1811 Kuretase Diagnostik 400,000
1812 Kuretase molahidatidosa 720,000
1813 Kuretase Percobaan 400,000
1814 Kuretase Plasenta Retensio 720,000
1815 Kuretase plasenta/molahidatidosa anastesi 1,423,000
1816 Kuretase/Dilatasi Kuretase dengan Narkose 6,165,762
1817 Labiopalatoplasti Bilateral 6,866,000
1818 labioplasti 787,000
1819 Labioplasti Bilateral 6,761,255
1820 Labioplasti Unilateral 5,163,000
1821 Ladds Procedure 9,464,367
1822 Laju Endap Darah Automotik _ 30,000
1823 Laktat Darah 50,000
1824 Laminektomi Kompleks (Bedah Syaraf) 9,331,885
1825 Laminektomi Sederhana (Bedah Syaraf) 7,459,885
1826 Laparascopy Kompleks 15,350,000
1827 Laparascopy Operatif 6,607,809
1828 Laparascopy Operatif (ODC) 4,260,000
1829 Laparascopy Operatif Hitroscopy 6,607,809
1830 Laparascopy Simple 13,350,000
1831 Laparaskopik Kolesistektomi 6,377,211
1832 Laparatomi + Apendoktomi apendix perforasi 9,464,367
1833 Laparatomi + Milking / Reseksi pada Invaginasi 9,464,367
1834 Laparatomi + Reksisi Usus Halus / Kolon 6,173,139
1835 Laparatomi + reseksi invaginasi 6,175,000
1836 Laparatomi Eksplorasi 4,377,586
1837 Laparatomi FC 6,286,074
1838 Laparatomi pada perforasi usus 6,175,000
1839 Laparatomi pada Peritonitis Neonatal 6,175,000
1840 Laparatomi pada Trauma Abdomen 6,181,401
1841 Laparatomy + Reseksi Usus pada Anak 11,350,000
1842 Laparatomy pada Perforasi Usus pada Anak 7,758,000
1843 Laparatomy Percobaan 6,058,221
1844 Laparoskopik Kolesistekstomi 6,377,211
1845 Laringektomi 3,781,100
1846 Laringgofisure 3,850,000
1847 Laringo Fisur/Eksplorasi Laring 5,482,645
1848 Laringoskopi dengan Ekstirpasi 3,850,000
1849 Laser CO2 1,000,000
1850 Laser Iridotomi Perifer 2,850,000
1851 Laser Therapy 72,600
1852 Latisimus Dorsi Flap 4,850,000
1853 Latissimus dorsi myocutaneous flap 2,382,099
1854 LDH _ 40,000
1855 Le-ford Advancement Surgery 9,556,772
1856 Legalisir Surat Keterangan Kematian (10 Lbr) 20,000
1857 Legallisir Surat Kematian /10 lmbr 20,000
1858 Lepto Dipstick _ 135,000
1859 Leptospira IgM 200,000
1860 Leucodepleted 650,000
1861 Leukemia Phenotyping (P) 715,000
1862 LH 200,000
1863 LH (P) 338,000
1864 Ligasi A.Karotis Eksterna 4,850,000
1865 Ligasi Hemorhoid + Anastesi (Sore) 7,180,000
1866 Ligasi Hemorrhoid + Anastesi 7,180,000
1867 Ligasi Tinggi hidrokel pada anak 4,967,567
1868 Ligasi Varises SCBA 7,580,000
1869 Ligasi Varises SCBA (Sore) 7,580,000
1870 Ligasi Varises SCBA + Anastesi 10,100,000
1871 Ligasi Varises SCBA + Anastesi (Sore) 10,100,000
1872 Limb lengthening procedures, carpals and metacarpals 6,600,000
1873 Limb lengthening procedures, femur 6,600,000
1874 Limb lengthening procedures, humerus 6,600,000
1875 Limb lengthening procedures, radius and ulna 6,600,000
1876 Limb lengthening procedures, tarsals and metatarsals 6,600,000
1877 Limb lengthening procedures, tibia and fibula 6,600,000
1878 Limb shortening procedures, carpals and metacarpals 6,600,000
1879 Limb shortening procedures, femur 6,600,000
1880 Limb shortening procedures, humerus 6,600,000
1881 Limb shortening procedures, radius and ulna 6,600,000
1882 Limb shortening procedures, tarsals and metatarsals 6,600,000
1883 Limb shortening procedures, tibia and fibula 6,600,000
1884 Limfadenektomi Ileoinguinal 7,885,000
1885 Limfadenektomi Retroperitoneal 7,885,000
1886 Lipase (P) 225,000
1887 Lipase Darah 80,000
1888 Lipase Urine 63,000
1889 Lipoma Besar (Lipoma + Kista) 480,000
1890 Lipoma Kecil ( Lipoma + Kista ) 157,000
1891 Lipoma Sedang (Lipoma + Kista) 400,000
1892 Liquid Embolization For Occlusion For Atriovenous Fistula <= 3 Feeder 138,110,000
1893 Liquid Embolization For Occlusion For Atriovenous Fistula <= 3 Feeder + Penyulit 141,815,000
1894 Liquid Embolization For Occlusion For Atriovenous Fistula > 3 Feeder 203,710,000
1895 Liquid Embolization For Occlusion For Atriovenous Fistula > 3 Feeder + Penyulit 213,465,000
1896 Liquid Embolization For Occlusion For Atriovenous Malformation <= 3 Freder 138,110,000
1897 Liquid Embolization For Occlusion For Atriovenous Malformation <= 3 Freder + Penyulit 141,815,000
1898 Liquid Embolization For Occlusion For Atriovenous Malformation > 3 Freder + Penyulit 232,870,000
1899 Lithiasis 250,000
1900 Litotripsi dengan EHL 3,860,000
1901 Litotripsi dengan EHL (Sore) 5,790,000
1902 Litotripsi dengan Laser 5,810,000
1903 Litotripsi dengan Laser (Sore) 8,710,000
1904 Litrotipasi/litotripsi 7,160,799
1905 Lobektomi ( Bedah Paru/ Thorax ) 21,102,000
1906 Lobektomi Tiroid 4,850,000
1907 Lobulaplasti (1Telinga / 2Telinga) 2,850,000
1908 Local excision of lesion or tissue of carpals and metacarpals 3,125,000
1909 Local excision of lesion or tissue of femur 3,125,000
1910 Local excision of lesion or tissue of humerus 3,125,000
1911 Local excision of lesion or tissue of patella 3,125,000
1912 Local excision of lesion or tissue of radius and ulna 3,125,000
1913 Local excision of lesion or tissue of scapula, clavicle, and thorax (ribs and sternum) 3,125,000
1914 Local excision of lesion or tissue of tarsals and metatarsals 3,125,000
1915 Local excision of lesion or tissue of tibia and fibula 3,125,000
1916 Lokal Chemoterapi pada Hepatoma / tumor-tumor Metastasi Lain + Anastesi 45,450,000
1917 Lokal Chemoterapi pada tumor-tumor Extremitas + Anastesi 45,450,000
1918 Lokal chemotherapi pada Hepatoma/tumor-tumor metastasi lain 24,883,390
1919 Lokal chemotherapi pada tumor-tumor extremitas 24,883,390
1920 Longitudinal Nefrolithotomi (Kadet) 7,885,000
1921 Lontophoresis 72,600
1922 Lopografi 500,000
1923 Lower leg or ankle reattachment 10,675,000
1924 Luka Bakar Berat Umum 581,730
1925 Luka Bakar Ringan Umum 245,000
1926 Luka Bakar Sedang Umum 480,000
1927 Lumbal Bone Densitometry 250,000
1928 Lumbar and lumbosacral fusion, anterior technique 14,020,000
1929 Lumbar and lumbosacral fusion, lateral transverse process technique 14,020,000
1930 Lumbar and lumbosacral fusion, posterior technique 14,020,000
1931 Lumbar Facet Joint Injection C-Arm <= 2 5,550,000
1932 Lumbar Facet Joint Injection C-Arm > 2 7,910,000
1933 Lumbar Interlaminar Injection C-Arm 8,165,000
1934 Lumbar Medial Branch Block Injection C-Arm <= 2 8,715,000
1935 Lumbar Medial Branch Block Injection C-Arm > 2 8,200,000
1936 Lumbar Transforaminal Injection C-Arm <= 2 8,165,000
1937 Lumbar Transforaminal Injection C-Arm > 2 7,910,000
1938 Lysis of adhesions of hand 3,125,000
1939 Magnesium Darah 37,000
1940 Magneto Therapy 72,600
1941 Maksilektomi Partialis 4,850,000
1942 Maksilektomi Totalis 5,393,089
1943 Malaria Mikroskopik 120,000
1944 Mammography dan USG (Rujukan Luar) 250,000
1945 Mammography Digital 350,000
1946 Mammography Digital (Rujukan Luar) 350,000
1947 Managemen Laktasi 100,000
1948 Manajemen Ekstrapiramidal Sindrom (EPS) 250,000
1949 Manajemen Gaduh Gelisah 275,000
1950 Manajemen Resiko Bunuh Diri 196,000
1951 Mandi Jenazah Infeksi 500,000
1952 Mandi Jenazah Non Infeksi 350,000
1953 Mandibulektomi 13,950,000
1954 Mandibulektomi Marginalis 4,018,158
1955 Mandibulektomi Parsial THT 4,850,000
1956 Mandibulektomi Partialis dengan Rekontruksi 5,111,414
1957 Mandibulektomi Total + Rekonstruksi 19,278,000
1958 Mandibulektomi Totalis 5,443,284
1959 Manipulation Temporomandibular Joint 70,000
1960 Mantoux Test 80,000
1961 Manual and Mekanikal Traction 70,000
1962 Manual Plasenta 300,000
1963 Manual Test Kekuatan Otot 70,000
1964 Manual Test Tonus Otot 80,000
1965 Manual Testing Of Muscle Function 70,000
1966 Mapping Implan Koklea Komunitas 250,000
1967 Marsupialisasi Abses Bartholin 2,850,000
1968 Marsupialisasi (Partch Prosedur) dengan Anastesi Lokal 860,000
1969 Marsupialisasi Kista Bartholini 675,000
1970 Marsupialisasi Kista Dental dengan Anastesi Lokal 2,493,000
1971 Marsupialisasi Ranula 2,510,000
1972 Masa Lisis Euglobin 63,000
1973 Masase Prostate 675,000
1974 Masilektomi Partialis 4,027,668
1975 Massage 36,000
1976 Mastektomi Radikal 5,087,253
1977 Mastektomi Simple 4,009,175
1978 Mastektomi Simpleks 7,350,000
1979 Mastektomi Subkutaneus 4,396,100
1980 Mastoidektomi Radikal 5,278,621
1981 Mastoidektomi Radikal dengan Penyulit 5,850,000
1982 Mastoidektomi Sederhana 4,850,000
1983 MD (Maag Deudenum) 500,000
1984 Meatatomi (ESWL) 2,500,000
1985 Meatatomi (ESWL) (Sore) 3,750,000
1986 Meatoplasti 3,850,000
1987 Meatotomi 3,796,000
1988 Medikasi Saluran Akar Dengan Cresophene/CHKM (Akar Jamak) 450,000
1989 Medikasi Saluran Akar Dengan Cresophene/CHKM (Akar Tunggal) 280,000
1990 Medikasi Saluran Akar Dengan Ultracal (Akar Jamak) 620,000
1991 Medikasi Saluran Akar Dengan Ultracal (Akar Tunggal) 370,000
1992 Mega Kolon Hierchprung 7,827,722
1993 Memandikan Larutan PK 135,000
1994 Mengumbah Lambung 124,000
1995 Menilai Pertumbuhan 78,000
1996 Message Perineum 11,000
1997 Metacarpocarpal fusion 5,596,121
1998 Metacarpophalangeal fusion 5,596,121
1999 Metatarsophalangeal fusion 5,476,800
2000 Micro Curatage tanpa Anastesi 250,000
2001 Micro Wave Diathemi 39,600
2002 Midtarsal fusion 5,476,800
2003 Mikro Kuret Untuk Deteksi Duulasi 198,000
2004 Mikrokuretase untuk deteksi ovulasi 360,000
2005 Mikrosurgen Ligasi Vena Spermatika 7,777,000
2006 Miles Operation 6,244,888
2007 Mini Laparotomy 675,000
2008 Miringoplasti 4,850,000
2009 MMK/ Sling uretra 4,850,000
2010 MMPI Umum 212,000
2011 Mobilization Of Other Joint 70,000
2012 Mobilization Of Spine 70,000
2013 Montou Test 72,000
2014 MPPI 104,000
2015 MRI Ankle Joint ( Tanpa Kontras ) + Anastesi 4,940,000
2016 MRI Ankle Joint (Dengan Kontras) 5,100,000
2017 MRI Ankle Joint (Dengan Kontras) + Anastesi 6,240,000
2018 MRI Ankle Joint (Tanpa Kontras) 3,900,000
2019 MRI Ankle Joint Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2020 MRI Ankle Joint Bilateral (Dengan Kontras) 6,300,000
2021 MRI Ankle Joint Bilateral (Dengan Kontras) + Anastesi 7,550,000
2022 MRI Ankle Joint Bilateral (Tanpa Kontras) 5,200,000
2023 MRI Brain ( Dengan Kontras ) 5,100,000
2024 MRI Brain ( Dengan Kontras ) + Anastesi 6,240,000
2025 MRI Brain ( Tanpa Kontras ) 3,900,000
2026 MRI Brain ( Tanpa Kontras ) + Anastesi 4,940,000
2027 MRI Brain + Diffusion + Perfusion + Spektroscopy 6,300,000
2028 MRI Brain + Diffusion + Perfusion + Spektroscopy + Anastesi 7,550,000
2029 MRI Brain + Kontras + Tractografi 5,700,000
2030 MRI Brain + Kontras + Tractografi + Anastesi 6,890,000
2031 MRI Brain + MRA ( Dengan Kontras ) 1,900,000
2032 MRI Brain + MRA ( Dengan Kontras )(rujukan luar) 1,900,000
2033 MRI Brain + MRA ( Tanpa Kontras ) 1,500,000
2034 MRI Brain + MRA + Venograf + Diffusion (Tanpa Kontras) 4,900,000
2035 MRI Brain + MRA + Venografi ( Dengan Kontras ) 6,300,000
2036 MRI Brain + MRA + Venografi ( Dengan Kontras ) + Anastesi 7,550,000
2037 MRI Brain + MRA + Venografi ( Dengan Kontras )(rujukan luar) 1,900,000
2038 MRI Brain + MRA + Venografi ( Tanpa Kontras ) 1,500,000
2039 MRI Brain + MRA + Venografi ( Tanpa Kontras ) + Anastesi 6,760,000
2040 MRI Brain + MRA + Venografi ( Tanpa Kontras )(rujukan luar) 1,500,000
2041 MRI Brain + MRA + Venografi (Tanpa Kontras) 5,500,000
2042 MRI Brain + MRA + Venografi + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2043 MRI Brain + MRA + Venografi + Diffusion ( Tanpa Kontras ) + Anastesi 6,050,000
2044 MRI Brain + MRA + Venografi + Diffusion (Dengan Kontras) 5,200,000
2045 MRI Brain + MRA Carotis (Tanpa Kontras) 4,900,000
2046 MRI Brain + MRA Carotis ( Dengan Kontras ) + Anastesi 7,440,000
2047 MRI Brain + MRA Carotis ( Tanpa Kontras ) + Anastesi 6,030,000
2048 MRI Brain + MRA Carotis (Dengan Kontras) 6,200,000
2049 MRI Cardiac ( Dengan Kontras ) + Anastesi 7,440,000
2050 MRI Cardiac ( Tanpa Kontras ) + Anastesi 5,590,000
2051 MRI Cardiac (Dengan Kontras) 6,200,000
2052 MRI Cardiac (Tanpa Kontras) 4,500,000
2053 MRI Cruris ( Tanpa Kontras ) + Anastesi 4,940,000
2054 MRI Cruris (Dengan Kontras) 5,100,000
2055 MRI Cruris (Dengan Kontras) + Anastesi 6,240,000
2056 MRI Cruris (Tanpa Kontras) 3,900,000
2057 MRI Cruris Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2058 MRI Cruris Bilateral (Dengan Kontras) 6,300,000
2059 MRI Cruris Bilateral (Dengan Kontras) + Anastesi 7,550,000
2060 MRI Cruris Bilateral (Tanpa Kontras) 5,200,000
2061 MRI Elbow ( Dengan Kontras ) + Anastesi 6,240,000
2062 MRI Elbow ( Tanpa Kontras ) + Anastesi 4,940,000
2063 MRI Elbow (Dengan Kontras) 5,100,000
2064 MRI Elbow (Dengan Kontras)(rujukan luar) 1,900,000
2065 MRI Elbow (Tanpa Kontras) 3,900,000
2066 MRI Elbow (Tanpa Kontras)(rujukan luar) 1,350,000
2067 MRI Elbow Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
2068 MRI Elbow Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2069 MRI Elbow Bilateral (Dengan Kontras) 6,300,000
2070 MRI Elbow Bilateral (Tanpa Kontras) 5,200,000
2071 MRI Femur ( Dengan Kontras) + Anastesi 6,240,000
2072 MRI Femur ( Tanpa Kontras ) + Anastesi 4,940,000
2073 MRI Femur (Dengan Kontras) 5,100,000
2074 MRI Femur (Tanpa Kontras) 3,900,000
2075 MRI Femur Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2076 MRI Femur Bilateral (Dengan Kontras) 6,300,000
2077 MRI Femur Bilateral (Dengan Kontras) + Anastesi 7,550,000
2078 MRI Femur Bilateral (Tanpa Kontras) 5,200,000
2079 MRI Genu ( Dengan Kontras ) + Anastesi 6,240,000
2080 MRI Genu ( Tanpa Kontras ) + Anastesi 4,940,000
2081 MRI Genu ( Tanpa Kontras) 3,900,000
2082 MRI Genu (Dengan Kontras) 5,100,000
2083 MRI Genu Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2084 MRI Genu Bilateral (Dengan Kontras) 6,300,000
2085 MRI Genu Bilateral (Dengan Kontras) + Anastesi 7,550,000
2086 MRI Genu Bilateral (Tanpa Kontras) 5,200,000
2087 MRI Ginekologis ( Dengan Kontras ) + Anastesi 6,780,000
2088 MRI Ginekologis ( Tanpa Kontras ) + Anastesi 5,590,000
2089 MRI Ginekologis (Dengan Kontras) 5,600,000
2090 MRI Ginekologis (Tanpa Kontras) 4,500,000
2091 MRI Ginekologis + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2092 MRI Ginekologis + Diffusion ( Tanpa Kontras ) + Anastesi 4,940,000
2093 MRI Ginekologis + Diffusion (Dengan Kontras) 5,200,000
2094 MRI Ginekologis + Diffusion (Tanpa Kontras) 3,900,000
2095 MRI Ginjal + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2096 MRI Ginjal + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
2097 MRI Ginjal + Diffusion (Dengan Kontras) 5,200,000
2098 MRI Ginjal + Diffusion (Tanpa Kontras) 4,800,000
2099 MRI Hip Joint ( Tanpa Kontras ) + Anastesi 4,940,000
2100 MRI Hip Joint (Dengan Kontras) 5,100,000
2101 MRI Hip Joint (Dengan Kontras) + Anastesi 6,240,000
2102 MRI Hip Joint (Tanpa Kontras) 3,900,000
2103 MRI Humerus ( Tanpa Kontras ) 3,900,000
2104 MRI Humerus ( Tanpa Kontras ) + Anastesi 4,940,000
2105 MRI Humerus (Dengan Kontras) 5,100,000
2106 MRI Humerus (Dengan Kontras) + Anastesi 6,240,000
2107 MRI Humerus Bilateral ( Tanpa Kontras ) 5,200,000
2108 MRI Humerus Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2109 MRI Humerus Bilateral (Dengan Kontras) 6,300,000
2110 MRI Humerus Bilateral (Dengan Kontras) + Anastesi 7,550,000
2111 MRI Leher ( Dengan Kontras ) + Anastesi 6,240,000
2112 MRI Leher ( Tanpa Kontras ) + Anastesi 4,940,000
2113 MRI Leher (Dengan Kontras) 5,100,000
2114 MRI Leher (Tanpa Kontras) 3,900,000
2115 MRI Liver + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2116 MRI Liver + Diffusion ( Tanpa Kontras ) + Anastesi 4,940,000
2117 MRI Liver + Diffusion (Dengan Kontras) 5,200,000
2118 MRI Liver + Diffusion (Tanpa Kontras) 3,900,000
2119 MRI Lumbosakral ( Dengan Kontras ) + Anastesi 6,240,000
2120 MRI Lumbosakral ( Tanpa Kontras ) + Anastesi 4,940,000
2121 MRI Lumbosakral (Dengan Kontras) 5,100,000
2122 MRI Lumbosakral (Tanpa Kontras) 3,900,000
2123 MRI Mamae ( Dengan Kontras ) + Anastesi 6,780,000
2124 MRI Mamae ( Tanpa Kontras ) + Anastesi 5,830,000
2125 MRI Mamae (Dengan Kontras) 5,600,000
2126 MRI Mamae (Tanpa Kontras) 4,700,000
2127 MRI Manus ( Dengan Kontras ) + Anastesi 6,240,000
2128 MRI Manus ( Tanpa Kontras ) + Anastesi 4,940,000
2129 MRI Manus (Dengan Kontras) 5,100,000
2130 MRI Manus (Tanpa Kontras) 3,900,000
2131 MRI Manus Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
2132 MRI Manus Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2133 MRI Manus Bilateral (Dengan Kontras) 6,300,000
2134 MRI Manus Bilateral (Tanpa Kontras) 5,200,000
2135 MRI MRCP ( Tanpa Kontras ) + Anastesi 6,030,000
2136 MRI MRCP (Dengan Kontras) 5,300,000
2137 MRI MRCP (Dengan Kontras) + Anastesi 6,460,000
2138 MRI MRCP (Tanpa Kontras) 4,900,000
2139 MRI Nasofaring ( Dengan Kontras ) + Anastesi 6,240,000
2140 MRI Nasofaring ( Tanpa Kontras ) + Anastesi 4,940,000
2141 MRI Nasofaring (Dengan Kontras) 5,100,000
2142 MRI Nasofaring (Tanpa Kontras) 3,900,000
2143 MRI Orbita ( Dengan Kontras ) + Anastesi 6,350,000
2144 MRI Orbita ( Tanpa Kontras ) + Anastesi 4,940,000
2145 MRI Orbita (Dengan Kontras) 5,200,000
2146 MRI Orbita (Tanpa Kontras) 3,900,000
2147 MRI Pedis ( Dengan Kontras ) + Anastesi 6,240,000
2148 MRI Pedis ( Tanpa Kontras ) + Anastesi 4,940,000
2149 MRI Pedis (Dengan Kontras) 5,100,000
2150 MRI Pedis (Tanpa Kontras) 3,900,000
2151 MRI Pedis Bilateral ( Dengan Kontras ) + Anastesi 7,550,000
2152 MRI Pedis Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2153 MRI Pedis Bilateral (Dengan Kontras) 6,300,000
2154 MRI Pedis Bilateral (Tanpa Kontras) 5,200,000
2155 MRI Pelvis ( Dengan Kontras )(rujukan luar) 1,900,000
2156 MRI Pelvis ( Tanpa Kontras ) 4,500,000
2157 MRI Pelvis ( Tanpa Kontras ) + Anastesi 5,590,000
2158 MRI Pelvis ( Tanpa Kontras )(rujukan luar) 1,350,000
2159 MRI Pelvis (Dengan Kontras) 5,100,000
2160 MRI Pelvis (Dengan Kontras) + Anastesi 6,240,000
2161 MRI Plexus Brachialis ( Dengan Kontras ) + Anastesi 6,780,000
2162 MRI Plexus Brachialis ( Tanpa Kontras ) + Anastesi 5,950,000
2163 MRI Plexus Brachialis (Dengan Kontras) 5,600,000
2164 MRI Plexus Brachialis (Tanpa Kontras) 4,800,000
2165 MRI Prostat + Diffusion ( Dengan Kontras ) + Anastesi 6,350,000
2166 MRI Prostat + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
2167 MRI Prostat + Diffusion (Dengan Kontras) 5,200,000
2168 MRI Prostat + Diffusion (Tanpa Kontras) 4,800,000
2169 MRI Prostat Dynamic Kontras + Perfusion + Diffusion 5,700,000
2170 MRI Prostat Dynamic Kontras + Perfusion + Diffusion + Anastesi 6,890,000
2171 MRI Sella Tursika Dynamic Kontras + Diffusion 5,700,000
2172 MRI Sella Tursika Dynamic Kontras + Diffusion + Anastesi 6,890,000
2173 MRI Servikal ( Dengan Kontras ) + Anastesi 6,240,000
2174 MRI Servikal ( Tanpa Kontras ) + Anastesi 4,940,000
2175 MRI Servikal (Dengan Kontras) 5,100,000
2176 MRI Servikal (Tanpa Kontras) 3,900,000
2177 MRI Shoulder ( Tanpa Kontras ) 3,900,000
2178 MRI Shoulder ( Tanpa Kontras ) + Anastesi 4,940,000
2179 MRI Shoulder (Dengan Kontras) 5,100,000
2180 MRI Shoulder (Dengan Kontras) + Anastesi 6,240,000
2181 MRI Shoulder Bilateral ( Tanpa Kontras ) 5,200,000
2182 MRI Shoulder Bilateral ( Tanpa Kontras ) + Anastesi 6,420,000
2183 MRI Shoulder Bilateral (Dengan Kontras) 6,300,000
2184 MRI Shoulder Bilateral (Dengan Kontras) + Anastesi 7,550,000
2185 MRI Sinus Paranasal ( Dengan Kontras ) + Anastesi 6,240,000
2186 MRI Sinus Paranasal ( Tanpa Kontras ) + Anastesi 6,220,000
2187 MRI Sinus Paranasal (Dengan Kontras) 5,100,000
2188 MRI Sinus Paranasal (Tanpa Kontras) 5,000,000
2189 MRI Thoracal ( Dengan Kontras ) + Anastesi 6,240,000
2190 MRI Thoracal ( Tanpa Kontras ) + Anastesi 4,940,000
2191 MRI Thoracal (Dengan Kontras) 5,100,000
2192 MRI Thoracal (Dengan Kontras)(rujukan luar) 1,900,000
2193 MRI Thoracal (Tanpa Kontras) 3,900,000
2194 MRI Thoracal (Tanpa Kontras)(rujukan luar) 1,350,000
2195 MRI Thoraks ( Dengan Kontras ) + Anastesi 6,350,000
2196 MRI Thoraks ( Tanpa Kontras ) + Anastesi 6,560,000
2197 MRI Thoraks (Dengan Kontras) 5,200,000
2198 MRI Thoraks (Tanpa Kontras) 5,300,000
2199 MRI Thoraks + Diffusion ( Dengan Kontras ) + Anastesi 6,780,000
2200 MRI Thoraks + Diffusion ( Tanpa Kontras ) + Anastesi 5,950,000
2201 MRI Thoraks + Diffusion (Dengan Kontras) 5,600,000
2202 MRI Thoraks + Diffusion (Tanpa Kontras) 4,800,000
2203 MRI Total Spine ( Dengan Kontras ) + Anastesi 7,550,000
2204 MRI Total Spine ( Tanpa Kontras ) + Anastesi 6,420,000
2205 MRI Total Spine (Dengan Kontras) 6,300,000
2206 MRI Total Spine (Tanpa Kontras) 5,200,000
2207 MRI Upper Abdomen ( Tanpa Kontras ) + Anastesi 5,830,000
2208 MRI Upper Abdomen (Dengan Kontras) 5,300,000
2209 MRI Upper Abdomen (Dengan Kontras) + Anastesi 6,460,000
2210 MRI Upper Abdomen (Tanpa Kontras) 4,700,000
2211 MRI Upper Abdomen Dynamic Kontras 5,700,000
2212 MRI Upper Abdomen Dynamic Kontras + Anastesi 6,890,000
2213 MRI Urografi ( Tanpa Kontras ) + Anastesi 6,030,000
2214 MRI Urografi (Dengan Kontras) 5,300,000
2215 MRI Urografi (Dengan Kontras) + Anastesi 6,460,000
2216 MRI Urografi (Tanpa Kontras) 4,900,000
2217 MRI Whole Body ( Dengan Kontras ) + Anastesi 7,440,000
2218 MRI Whole Body ( Tanpa Kontras ) + Anastesi 5,590,000
2219 MRI Whole Body (Dengan Kontras) 6,200,000
2220 MRI Whole Body (Tanpa Kontras) 4,500,000
2221 MSCT Ankle ( Dengan Kontras ) + Anastesi 6,460,000
2222 MSCT Ankle ( Tanpa Kontras ) + Anastesi 2,980,000
2223 MSCT Ankle (Dengan Kontras) 5,300,000
2224 MSCT Ankle (Tanpa Kontras) 2,100,000
2225 MSCT Antebrachi ( Dengan Kontras ) + Anastesi 4,720,000
2226 MSCT Antebrachi ( Tanpa Kontras ) + Anastesi 2,980,000
2227 MSCT Antebrachi (Dengan Kontras) 3,700,000
2228 MSCT Antebrachi (Tanpa Kontras) 2,100,000
2229 MSCT Biopsi + Film Non Kontras 1,000,000
2230 MSCT Biopsi Non Kontras 850,000
2231 MSCT Brain ( Dengan Kontras ) + Anastesi 4,500,000
2232 MSCT Brain ( Tanpa Kontras ) + Anastesi 2,550,000
2233 MSCT Brain (Dengan Kontras) 3,500,000
2234 MSCT Brain (Tanpa Kontras) 1,700,000
2235 MSCT Calsium Score ( Dengan Kontras ) + Anastesi 6,240,000
2236 MSCT Calsium Score ( Tanpa Kontras ) + Anastesi 2,870,000
2237 MSCT Calsium Score (Dengan Kontras) 5,100,000
2238 MSCT Calsium Score (Tanpa Kontras) 2,000,000
2239 MSCT Cerebral Carotis 6,300,000
2240 MSCT Cruris ( Dengan Kontras ) + Anastesi 6,240,000
2241 MSCT Cruris ( Tanpa Kontras ) + Anastesi 2,980,000
2242 MSCT Cruris (Dengan Kontras) 5,100,000
2243 MSCT Cruris (Tanpa Kontras) 2,100,000
2244 MSCT Ekstremitas (Dengan Kontras) 2,300,000
2245 MSCT Ekstremitas (Non Kontras) 1,500,000
2246 MSCT Ekstremitas Superior 2,900,000
2247 MSCT Elbow ( Dengan Kontras ) + Anastesi 4,720,000
2248 MSCT Elbow ( Tanpa Kontras ) + Anastesi 2,980,000
2249 MSCT Elbow (Dengan Kontras) 3,700,000
2250 MSCT Elbow (Tanpa Kontras) 2,100,000
2251 MSCT Elbow Bilateral ( Dengan Kontras ) + Anastesi 4,720,000
2252 MSCT Elbow Bilateral ( Tanpa Kontras ) + Anastesi 2,980,000
2253 MSCT Elbow Bilateral (Dengan Kontras) 3,700,000
2254 MSCT Elbow Bilateral (Tanpa Kontras) 2,100,000
2255 MSCT Femur ( Dengan Kontras ) + Anastesi 6,240,000
2256 MSCT Femur ( Tanpa Kontras ) + Anastesi 2,980,000
2257 MSCT Femur (Dengan Kontras) 5,100,000
2258 MSCT Femur (Tanpa Kontras) 2,100,000
2259 MSCT Genu ( Dengan Kontras ) + Anastesi 7,550,000
2260 MSCT Genu ( Tanpa Kontras ) + Anastesi 2,980,000
2261 MSCT Genu (Dengan Kontras) 6,300,000
2262 MSCT Genu (Tanpa Kontras) 2,100,000
2263 MSCT Humerus ( Dengan Kontras ) + Anastesi 4,720,000
2264 MSCT Humerus ( Tanpa Kontras ) + Anastesi 2,980,000
2265 MSCT Humerus (Dengan Kontras) 3,700,000
2266 MSCT Humerus (Tanpa Kontras) 2,100,000
2267 MSCT Kepala (Dengan Kontras) 1,700,000
2268 MSCT Kepala 3 Dimensi ( Dengan Kontras ) + Anastesi 4,720,000
2269 MSCT Kepala 3 Dimensi ( Tanpa Kontras ) + Anastesi 2,980,000
2270 MSCT Kepala 3 Dimensi (Dengan Kontras) 3,700,000
2271 MSCT Kepala 3 Dimensi (Tanpa Kontras) 2,100,000
2272 MSCT Laring ( Dengan Kontras ) + Anastesi 4,610,000
2273 MSCT Laring ( Tanpa Kontras ) + Anastesi 2,980,000
2274 MSCT Laring (Dengan Kontras) 3,600,000
2275 MSCT Laring (Tanpa Kontras) 2,100,000
2276 MSCT Leher ( Dengan Kontras ) + Anastesi 4,610,000
2277 MSCT Leher ( Tanpa Kontras ) + Anastesi 2,550,000
2278 MSCT Leher (Dengan Kontras) 3,600,000
2279 MSCT Leher (Tanpa Kontras) 1,700,000
2280 MSCT Lower Abdomen ( Dengan Kontras ) + Anastesi 5,040,000
2281 MSCT Lower Abdomen ( Tanpa Kontras ) + Anastesi 3,090,000
2282 MSCT Lower Abdomen (Dengan Kontras) 4,000,000
2283 MSCT Lower Abdomen (Tanpa Kontras) 2,200,000
2284 MSCT Lumbosakral ( Dengan Kontras ) + Anastesi 4,720,000
2285 MSCT Lumbosakral (Dengan Kontras) 3,700,000
2286 MSCT Lumbosakral (Tanpa Kontras ) + Anastesi 3,410,000
2287 MSCT Lumbosakral (Tanpa Kontras) 2,500,000
2288 MSCT Manus ( Dengan Kontras ) + Anastesi 4,720,000
2289 MSCT Manus ( Tanpa Kontras ) + Anastesi 2,980,000
2290 MSCT Manus (Dengan Kontras) 3,700,000
2291 MSCT Manus (Tanpa Kontras) 2,100,000
2292 MSCT Mastoid ( Dengan Kontras ) + Anastesi 4,500,000
2293 MSCT Mastoid ( Tanpa Kontras ) + Anastesi 2,550,000
2294 MSCT Mastoid (Dengan Kontras) 3,500,000
2295 MSCT Mastoid (Tanpa Kontras) 1,700,000
2296 MSCT Nasofaring ( Dengan Kontras ) + Anastesi 4,500,000
2297 MSCT Nasofaring ( Tanpa Kontras ) + Anastesi 2,550,000
2298 MSCT Nasofaring (Dengan Kontras) 3,500,000
2299 MSCT Nasofaring (Tanpa Kontras) 1,700,000
2300 MSCT Pedis ( Dengan Kontras ) + Anastesi 6,460,000
2301 MSCT Pedis ( Tanpa Kontras ) + Anastesi 2,980,000
2302 MSCT Pedis (Dengan Kontras) 5,300,000
2303 MSCT Pedis (Tanpa Kontras) 2,100,000
2304 MSCT Pelvis ( Dengan Kontras ) + Anastesi 4,720,000
2305 MSCT Pelvis ( Tanpa Kontras ) + Anastesi 3,090,000
2306 MSCT Pelvis (Dengan Kontras) 3,700,000
2307 MSCT Pelvis (Tanpa Kontras) 2,200,000
2308 MSCT Servikal ( Dengan Kontras ) + Anastesi 4,720,000
2309 MSCT Servikal ( Tanpa Kontras ) + Anastesi 2,980,000
2310 MSCT Servikal (Dengan Kontras) 3,700,000
2311 MSCT Servikal (Tanpa Kontras) 2,100,000
2312 MSCT Sinus (Dengan Kontras) 1,700,000
2313 MSCT Sinus Paranasal ( Dengan Kontras ) + Anastesi 4,500,000
2314 MSCT Sinus Paranasal (Dengan Kontras) 3,500,000
2315 MSCT Sinus Paranasal (Tanpa Kontras ) + Anastesi 2,550,000
2316 MSCT Sinus Paranasal (Tanpa Kontras) 1,700,000
2317 MSCT Thoraco-Abdominal ( Dengan Kontras ) + Anastesi 6,240,000
2318 MSCT Thoraco-Abdominal ( Tanpa Kontras ) + Anastesi 4,500,000
2319 MSCT Thoraco-Abdominal (Dengan Kontras) 5,100,000
2320 MSCT Thoraco-Abdominal (Tanpa Kontras) 3,500,000
2321 MSCT Thorakal ( Dengan Kontras ) + Anastesi 4,720,000
2322 MSCT Thorakal ( Tanpa Kontras ) + Anastesi 3,410,000
2323 MSCT Thorakal (Dengan Kontras) 3,700,000
2324 MSCT Thorakal (Tanpa Kontras) 2,500,000
2325 MSCT Thoraks ( Dengan Kontras ) + Anastesi 6,240,000
2326 MSCT Thoraks ( Tanpa Kontras ) + Anastesi 3,200,000
2327 MSCT Thoraks (Dengan Kontras) 5,100,000
2328 MSCT Thoraks (Tanpa Kontras) 2,300,000
2329 MSCT Total Spine ( Dengan Kontras ) + Anastesi 4,720,000
2330 MSCT Total Spine (Dengan Kontras) 3,700,000
2331 MSCT Total Spine (Tanpa Kontras ) + Anastesi 2,980,000
2332 MSCT Total Spine (Tanpa Kontras) 2,100,000
2333 MSCT Tyroid ( Dengan Kontras ) + Anastesi 4,610,000
2334 MSCT Tyroid ( Tanpa Kontras ) + Anastesi 2,870,000
2335 MSCT Tyroid (Dengan Kontras) 3,600,000
2336 MSCT Tyroid (Tanpa Kontras) 2,000,000
2337 MSCT Upper Abdomen ( Dengan Kontras ) + Anastesi 5,040,000
2338 MSCT Upper Abdomen ( Tanpa Kontras ) + Anastesi 3,090,000
2339 MSCT Upper Abdomen (Dengan Kontras) 4,000,000
2340 MSCT Upper Abdomen (Tanpa Kontras) 2,200,000
2341 MSCT Virtual Colonoscopy ( Dengan Kontras ) + Anastesi 6,460,000
2342 MSCT Virtual Colonoscopy ( Tanpa Kontras ) + Anastesi 3,410,000
2343 MSCT Virtual Colonoscopy (Dengan Kontras) 5,300,000
2344 MSCT Virtual Colonoscopy (Tanpa Kontras) 2,500,000
2345 MSCT Virtual Colonoscopy Non Kontras 1,650,000
2346 MSCT Whole Abdomen ( Dengan Kontras ) + Anastesi 6,890,000
2347 MSCT Whole Abdomen ( Tanpa Kontras ) + Anastesi 3,640,000
2348 MSCT Whole Abdomen (Dengan Kontras) 5,700,000
2349 MSCT Whole Abdomen (Tanpa Kontras) 2,700,000
2350 MSCTA Cerebral 2,219,800
2351 MSCTA Perfusion 1,419,800
2352 MSCTA Brain Perfusion 6,300,000
2353 MSCTA Brain Perfusion + Anastesi 7,550,000
2354 MSCTA Cardiac 6,300,000
2355 MSCTA Cardiac + Anastesi 7,550,000
2356 MSCTA Cardiac + Functional 5,100,000
2357 MSCTA Cardiac + Functional + Anastesi 6,240,000
2358 MSCTA Cerebral 5,100,000
2359 MSCTA Cerebral + Anastesi 6,240,000
2360 MSCTA Cerebral Carotis + Anastesi 7,550,000
2361 MSCTA Dental 6,300,000
2362 MSCTA Dental + Anastesi 7,550,000
2363 MSCTA Dynamic 2 Phase Liver 5,100,000
2364 MSCTA Dynamic 2 Phase Liver + Anastesi 6,240,000
2365 MSCTA Dynamic 3 Phase Liver 6,300,000
2366 MSCTA Dynamic 3 Phase Liver + Anastesi 7,550,000
2367 MSCTA Ekstremitas Atas 5,100,000
2368 MSCTA Ekstremitas Atas + Anastesi 6,240,000
2369 MSCTA Pulmunal 5,100,000
2370 MSCTA Pulmunal + Anastesi 6,240,000
2371 MSCTA Renal 5,100,000
2372 MSCTA Renal + Anastesi 6,240,000
2373 MSCTA Run Off / Ekstremitas Inferior 6,300,000
2374 MSCTA Run Off / Ekstremitas Inferior + Anastesi 7,550,000
2375 MSCTA Thoracal 6,300,000
2376 MSCTA Thoracal + Abdominal 5,100,000
2377 MSCTA Thoracal + Abdominal + Anastesi 6,240,000
2378 MSCTA Thoracal + Anastesi 7,550,000
2379 MSCTA Whole Body 5,100,000
2380 MSCTA Whole Body + Anastesi 6,240,000
2381 Multi - Slici Scanning 4,000,000
2382 Multiple Ekstraksi 9,334,000
2383 Multiple Ekstraksi dengan General Anastesi 6,000,000
2384 Muscle Plombage ( Bedah Paru/ Thorax ) 21,102,000
2385 Muscle Test 22,800
2386 Muscle transfer or transplantation 11,196,000
2387 Myelography 500,000
2388 Myocutaneus Flap/Pectoral Mayor 5,393,089
2389 Myoglobin _ 500,000
2390 Myomectomy 6,083,892
2391 Myotomy 9,390,000
2392 Myotomy of hand 11,196,000
2393 Naevus Pigmatosus 66,000
2394 Nasalance (Komunitas) 66,000
2395 Nasoendoscopy-set 800,000
2396 Nasoendoskopi Dengan Fiber 250,000
2397 Nasoendoskopi/Nasoendoskopi dengan Tindakan 250,000
2398 Nasoendoskopilaryng Rigid 250,000
2399 Nasofaring BSO Onko 250,000
2400 Nasofaringoskopi 250,000
2401 Nasopharyngolaryngeal (NPL) - Endoscopy 1,177,000
2402 Nasopharyngolaryngeal (NPL) - Endoscopy + Anastesi 1,935,000
2403 Near Total Tiroidektomi 4,850,000
2404 Nebulasi/Therapi Inhalasi 66,000
2405 Nebulizer I 175,000
2406 Nebulizer II 91,000
2407 Necototomi (ESWL) 2,500,000
2408 Necototomi (ESWL) (Sore) 3,750,000
2409 Necrotomi 125,000
2410 Nefrectomi Partial 6,122,557
2411 Nefrektomi Partikal / Partial 7,567,078
2412 Nefreuretektomi Parsial 10,325,221
2413 Nefro Ureterektomi 10,325,221
2414 Nefropeksi/Renopeksi 4,850,000
2415 Nefropexie 6,928,435
2416 Nefrostomi 6,928,435
2417 Nefrostomi Percutan 7,525,000
2418 Nefrostomi Percutan (ESWL) 2,500,000
2419 Nefrostomi Percutan (ESWL) (Sore) 3,750,000
2420 NefrostomiTerbuka/Permanen 4,850,000
2421 Nefrouretectomy Tumor Wilms 14,350,000
2422 Nefus Sedang, xantoma Crac Revisi 300,000
2423 Nefus yang diwajah 600,000
2424 Nekretomi 66,000
2425 Nekrotomi dengan Anastesi Lokal 270,000
2426 Neurodevelopment Test 100,000
2427 Neurofeedback - Anak 840,000
2428 Neuroktomi Saraf Vidian 5,482,645
2429 Neuroktomi/ Neurolise 7,308,000
2430 Neuroplasti/Anastomosis/Eksplorasi (N.Cranialis/Spinalis Perifer) 10,803,887
2431 Neuroplasti/Anastomosis/Eksplorasi (Plexus Brakhialis/Lumbalis Sacralis) 13,351,887
2432 Night Care 225,000
2433 Nitrogen Cair 66,000
2434 Non-Invasive Ventilation (Per Hari) 2,000,000
2435 Nonexcisional debridement of wound, infection, or burn 2,350,000
2436 Nonoperative removal of therapeutic device from head and neck 4,375,000
2437 Nt-proBNP 800,000
2438 OAE (Oto Acoustik Emission) 200,000
2439 Observasi (dr. Obs ) 23,000
2440 Observasi Kecerdasan (Komunitas) 66,000
2441 Obturasi Atau Pengisian Saluran Akar (Akar Jamak) 1,200,000
2442 Obturasi Atau Pengisian Saluran Akar (Akar Tunggal) 760,000
2443 Obturator 2,510,000
2444 Obturator + gigi 4,068,000
2445 Obturator Sementara 500,000
2446 ODC Paket A 3,182,000
2447 ODC Paket B 4,250,000
2448 ODC Paket C 8,150,000
2449 ODC Umum ( > 6 jam ) 156,000
2450 Odentectomy > 2 elemen dengan narkose 2,725,000
2451 Odontectomy Berat Per Gigi 2,436,000
2452 Odontectomy Lebih dari 2 elemen 2,880,000
2453 Odontectomy Ringan Per Gigi 1,491,000
2454 Odontectomy Sedang Per Gigi 1,993,000
2455 Odontektomi dengan Anastesi Lokal 1,000,000
2456 Odontektomi dengan General Anastesi 9,334,000
2457 Oesophagigrafi 400,000
2458 Omentumpexi ( Bedah Paru / Thorax ) 21,102,000
2459 Open reduction dan stabilisation of spinal Fracture 4,850,000
2460 Open reduction of dislocation of ankle 22,971,664
2461 Open reduction of dislocation of elbow 11,203,072
2462 Open reduction of dislocation of foot and toe 8,831,664
2463 Open reduction of dislocation of hip 9,133,709
2464 Open reduction of dislocation of knee 22,938,709
2465 Open reduction of dislocation of shoulder 9,238,709
2466 Open reduction of dislocation of wrist 8,521,664
2467 Open reduction of fracture of other specified bone, except facial bones, with internal fixation 4,835,044
2468 Open reduction of fracture with internal fixation, carpals and metacarpals 4,835,044
2469 Open reduction of fracture with internal fixation, femur 7,090,400
2470 Open reduction of fracture with internal fixation, humerus 3,405,196
2471 Open reduction of fracture with internal fixation, other specified bone 4,835,044
2472 Open reduction of fracture with internal fixation, phalanges of foot 9,351,000
2473 Open reduction of fracture with internal fixation, phalanges of hand 4,835,044
2474 Open reduction of fracture with internal fixation, radius and ulna 5,611,121
2475 Open reduction of fracture with internal fixation, tarsals and metatarsals 7,090,400
2476 Open reduction of fracture with internal fixation, tibia and fibula 18,115,044
2477 Open reduction of separated epiphysis of femur 4,515,044
2478 Open reduction of separated epiphysis of humerus 9,351,000
2479 Open reduction of separated epiphysis of radius and ulna 9,351,000
2480 Open reduction of separated epiphysis of tibia and fibula 9,351,000
2481 Open Renal Biopsi 5,352,084
2482 Operasi Commando 6,350,000
2483 Operasi Hernia dengan Komplikasi 6,595,462
2484 Operasi Hernia Dengan Komplikasi (Hernia Incarcerata) 7,350,000
2485 Operasi Hernia tanpa Komplikasi 6,599,674
2486 Operasi Hydrokel 6,588,140
2487 Operasi Hypospadia/Kordectomy 8,183,889
2488 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
2489 Operasi Jantung Terbuka dengan Pacu Jantung Temporer/TOF 53,295,000
2490 Operasi Jantung Terbuka Dengan satu Katup dan Pacu Jantung Temporer / TOF+MOF 57,950,000
2491 Operasi Jantung Terbuka dua Katup 91,711,314
2492 Operasi Jantung Terbuka satu Katup 73,450,000
2493 Operasi Jantung Terbuka Standar/ASD 53,295,000
2494 Operasi Jantung Terbuka Standar/VSD/ASD Closure+Reseksi Infudibulum + Transanular Patch/Repair Left Ventricle Out Flow Track + VSD Closure 29,240,000
2495 Operasi Jantung Tertutup/PDA 37,705,000
2496 Operasi Kasai 17,350,000
2497 Operasi Konvensional plexus Brakhialias /Lumbalis / Sacralis / Cranialis / Spinalis perifer 9,392,000
2498 Operasi Laringcopi biopsi 4,375,000
2499 Operasi Manchester Fortegil 6,115,000
2500 Operasi micro Plexus Brakhialis /Lumbalis Sacralis 11,941,616
2501 Operasi Mikrotia 6,821,000
2502 Operasi Pasang Kateter Tenckhoff untuk CAPD 3,850,000
2503 Operasi Perineum 6,073,000
2504 Operasi Peyronie 6,928,435
2505 Operasi priapismus (prosedur winter) 3,850,000
2506 Operasi Repair Bull Trauma 4,850,000
2507 Operasi Tumor Ganas Ovarium 6,526,000
2508 Operasi Tumor Jinak Ovarium 6,073,000
2509 Operasi Tumor Pembuluh Darah 4,850,000
2510 Operasi Tumor Spinal Daerah Kraniospinal 13,194,095
2511 Operasi Usus (Duhamel) 6,509,511
2512 Operasi Vaskuler Tehnik Operasi Khusus 4,884,949
2513 Operculectomy 8,614,000
2514 Operculectomy Per Regio 997,000
2515 Operkulektomi dengan Anastesi Lokal 270,000
2516 Ophorektomi Bilateral (Onkology) 3,939,234
2517 Optical Coherence Tomography 600,000
2518 Orbiotomi Anterior 4,850,000
2519 Orbitotomi Anterior 8,135,000
2520 Orbitotomi Lateral 6,830,745
2521 Orchidectomy pada anak 4,966,754
2522 Orchidectomy/Orchidopexy Unilateral 7,165,911
2523 Orchidektomi Ligasi Tinggi 6,869,778
2524 Orchidektomi Subkapsuler 5,137,089
2525 Orchidektomi/orchidektomi subkapsuler 3,850,000
2526 Orchidopexi 7,165,911
2527 Orkhidektomi extended 4,850,000
2528 Orkhidopeksi Per Laparaskopi 6,478,211
2529 Orthodentic Fixed (Control Orthodontik) 56,000
2530 Orthodontik Fixed (Rahang atas / bawah) 3,478,000
2531 Orthodontik Fixed (Rahang atas + bawah) 5,040,000
2532 Orthognatic Surgery 8,888,772
2533 Orthopedic Shoes 3,000,000
2534 Other Active Musculoskeletal Exercise 70,000
2535 Other amputation below knee 5,242,099
2536 Other and unspecified repair of the anulus fibrosus 14,020,000
2537 Other anstomosis of cranial or peripheral nerve 11,582,099
2538 Other bunionectomy with soft tissue correction 6,600,000
2539 Other cervical fusion, anterior technique 14,020,000
2540 Other cervical fusion, posterior technique 14,020,000
2541 Other change in muscle or tendon length 11,196,000
2542 Other change in muscle or tendon length of hand 11,196,000
2543 Other destruction of intervertebral disc 14,020,000
2544 Other diagnostic procedures on joint structures 5,752,000
2545 Other diagnostic procedures on muscle, tendon, fascia, and bursa, including that of hand 5,202,000
2546 Other division of carpals and metacarpals 10,675,000
2547 Other division of soft tissue 9,390,000
2548 Other division of soft tissue of hand 9,390,000
2549 Other excision of ankle joint 8,105,000
2550 Other excision of elbow joint 8,105,000
2551 Other excision of hip joint 8,105,000
2552 Other excision of joint of foot and toe 8,105,000
2553 Other excision of joint of hand and finger 8,105,000
2554 Other excision of knee joint 8,105,000
2555 Other excision of shoulder joint 8,105,000
2556 Other excision of soft tissue 11,196,000
2557 Other excision of soft tissue of hand 9,390,000
2558 Other excision of wrist joint 8,105,000
2559 Other excision, fusion, and repair of toes 6,600,000
2560 Other exploration and decompresion of spinal canal 31,267,928
2561 Other fasciectomy 11,196,000
2562 Other fasciectomy of hand 9,390,000
2563 Other fusion of foot 5,476,800
2564 Other hand muscle transfer or transplantation 11,196,000
2565 Other hand muscle transposition 11,196,000
2566 Other hand tendon transfer or transplantation 11,196,000
2567 Other hand tendon transposition 11,196,000
2568 Other Immobilization,pressure,and attention to wound 2,350,000
2569 Other incision of soft tissue 9,390,000
2570 Other incision of soft tissue of hand 11,196,000
2571 Other injection of locally-acting therapeutic substance into soft tissue 3,125,000
2572 Other local excision or destruction of lesion of ankle joint 8,105,000
2573 Other local excision or destruction of lesion of elbow joint 8,105,000
2574 Other local excision or destruction of lesion of hip joint 8,105,000
2575 Other local excision or destruction of lesion of joint of foot and toe 8,105,000
2576 Other local excision or destruction of lesion of joint of hand and finger 8,105,000
2577 Other local excision or destruction of lesion of knee joint 8,105,000
2578 Other local excision or destruction of lesion of shoulder joint 8,105,000
2579 Other local excision or destruction of lesion of wrist joint 8,105,000
2580 Other local excision or destruction of lesion or tissue of skin and 3,125,000
2581 Other muscle transposition 11,196,000
2582 Other myectomy 11,196,000
2583 Other myectomy of hand 9,390,000
2584 Other nonoperative replacements 4,375,000
2585 Other operations on joint structures 5,752,000
2586 Other operations on muscle, tendon, and fascia of hand 3,125,000
2587 Other partial ostectomy carpals and metacarpals 4,632,099
2588 Other partial ostectomy humerus 4,632,099
2589 Other partial ostectomy of carpals and metacarpals 6,600,000
2590 Other partial ostectomy of femur 4,342,099
2591 Other partial ostectomy of humerus 6,600,000
2592 Other partial ostectomy of patella 18,432,099
2593 Other partial ostectomy of radius and ulna 6,600,000
2594 Other partial ostectomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
2595 Other partial ostectomy of tarsals and metatarsals 4,739,600
2596 Other partial ostectomy of tibia and fibula 18,432,099
2597 Other partial ostectomy radius and ulna 4,662,099
2598 Other partial ostectomy scapula, clavicle, and thorax (rib and sternum) 6,600,000
2599 Other Passive Musculoskeletal Exercise 70,000
2600 Other peripheral nerve or ganglion decompression or lysis of adhesions 11,604,994
2601 Other plastic operations on fascia 11,196,000
2602 Other plastic operations on hand 10,675,000
2603 Other plastic operations on muscle 11,196,000
2604 Other plastic operations on tendon 11,196,000
2605 Other reconstruction of thumb 10,675,000
2606 Other repair and reconstruction of skin and subcutaneous tissue 4,739,600
2607 Other repair of elbow 8,105,000
2608 Other repair of hand, fingers, and wrist 8,105,000
2609 Other repair of joint 5,752,000
2610 Other repair of knee 16,585,212
2611 Other repair of shoulder 8,105,000
2612 Other repair of the collateral ligaments 17,985,212
2613 Other repair of the cruciate ligaments 17,985,212
2614 Other skin graft to hand 6,528,000
2615 Other suture of flexor tendon of hand 11,196,000
2616 Other suture of muscle or fascia 11,196,000
2617 Other suture of other tendon of hand 11,196,000
2618 Other suture of tendon 11,196,000
2619 Other tendon transposition 11,196,000
2620 Other tenodesis of hand 10,675,000
2621 Other tenonectomy 11,196,000
2622 Other tenonectomy of hand 6,883,430
2623 Other tenoplasty of hand 10,675,000
2624 Other tenotomy 9,390,000
2625 Otomikroskopi 73,000
2626 Otoplasty THT 4,850,000
2627 Oval Fat Body 25,000
2628 PA Potong Beku (VC) Besar 875,000
2629 PA Potong Beku (VC) Kecil 438,000
2630 Pain Management 100,000
2631 Paket Hormonal 500,000
2632 Paket Limfoma Kasus Sukar 1,500,000
2633 Paket Perawatan Luka (Konsultasi + Tindakan) 440,000
2634 Paket Sputum 3x Serial 359,000
2635 Palatoplasti 6,794,335
2636 Panendoskopi (Eksplorasi NF.Laringoskopi.Esofagoskopi.Bronkoskopi dengan Biopsi) 4,850,000
2637 Pankreaktektomi 6,482,351
2638 Panoramic 125,000
2639 PAP / Vaginal Smer 81,000
2640 Pap Smear 81,000
2641 Parafin Bath 33,000
2642 Parasentase Telinga 66,000
2643 Parasentesa 4,850,000
2644 Parasintesis 60,000
2645 Paravin 75,000
2646 Parotidektomi 3,933,656
2647 Parotidektomi (THT) 5,482,645
2648 Parotidektomi Radikal + mandibulektomi 5,077,000
2649 Partial hip replacement 5,661,098
2650 Partial shoulder replacement 8,105,000
2651 Partus Fisiologi (Anak) 127,500
2652 Partus Fisiologi (Obgyn) 672,500
2653 Partus Letak Bokong (Anak) 203,750
2654 Partus Letak Bokong (Obgyn) 996,250
2655 Partus normal + infeksi menular (hiv-aids, hepatitis) 1,542,000
2656 Pasang / Cabut IUD 103,000
2657 Pasang / Cabut Pesarium 116,000
2658 Pasang / Cabut Susut KB 127,000
2659 Pasang Akses port celsite 9,150,000
2660 Pasang Albumin 37,000
2661 Pasang Arterial Line Intra Arterial Pressure (IAP) 2,906,000
2662 Pasang Back Slab 75,000
2663 Pasang Balon Kateter 337,000
2664 Pasang Catheter Epidural 900,000
2665 Pasang Catheter Dokter 200,000
2666 Pasang Catheter Perawat 200,000
2667 Pasang Central Venous Catheter (CVC) 2,915,000
2668 Pasang Central Venous Catheter Dengan USG Guided 2,923,000
2669 Pasang Central Venous Catheter Untuk HD 2,061,000
2670 Pasang Central Venous Catheter Untuk HD Dengan USG Guided 2,070,000
2671 Pasang CVP 290,000
2672 Pasang Gips Tanpa Narcose (Aff Hecting) 35,000
2673 Pasang Gips Tanpa Narcose (Aspirasi sendi) 135,000
2674 Pasang Gips Tanpa Narcose (Body Jaket Gips) 56,000
2675 Pasang Gips Tanpa Narcose (Buka Gips) 69,000
2676 Pasang Gips Tanpa Narcose (Cabut K. Wire) 69,000
2677 Pasang Gips Tanpa Narcose (Cabut Screw) 74,000
2678 Pasang Gips Tanpa Narcose (Cabut Wire) 69,000
2679 Pasang Gips Tanpa Narcose (Fore Arm Slab) 52,000
2680 Pasang Gips Tanpa Narcose (Long Arm Plester) 56,000
2681 Pasang Gips Tanpa Narcose (Long Leg Plester) 56,000
2682 Pasang Gips Tanpa Narcose (Pasang Body Cast) 106,000
2683 Pasang Gips Tanpa Narcose (Sarmento Plester) 56,000
2684 Pasang Gips Tanpa Narcose (Short Leg Plester) 56,000
2685 Pasang Gips Tanpa Narcose (Spica Gips) 56,000
2686 Pasang Gips Tanpa Narcose (U - Slab) 52,000
2687 Pasang Gips Tanpa Narcose (Uip Gips) 56,000
2688 Pasang Gudel 90,000
2689 Pasang Infus 127,000
2690 Pasang Infus Neonatus (Intensif) 75,000
2691 Pasang Infus Sulit + Anastesi 326,000
2692 Pasang Kateter dengan Mandrain 675,000
2693 Pasang Kateter Urin ( Home Care ) 50,000
2694 Pasang Laminaria/Folley Catheter 250,000
2695 Pasang Lmainaria Stift 250,000
2696 Pasang Maag Slang Dokter 154,000
2697 Pasang Maag Slang Perawat 154,000
2698 Pasang Mitellah 75,000
2699 Pasang Monitor 142,000
2700 Pasang Monitoring Invasif Kontinyu (PICCO2) 4,412,000
2701 Pasang Necloler 75,000
2702 Pasang Neopuff 110,000
2703 Pasang NGT Sulit + Anastesi 297,000
2704 Pasang O2 81,000
2705 Pasang OGT 34,000
2706 Pasang PD Catheter 1,220,000
2707 Pasang Periheral Insertion Central Catheter (PICC) 1,298,000
2708 Pasang Pulmonari Arteri Catheter (Swan-Gans) 5,655,000
2709 Pasang Saturasi 63,000
2710 Pasang Skeletal Traction 78,000
2711 Pasang Skin Traksi 47,000
2712 Pasang Stent Metal Esofagus 44,530,000
2713 Pasang Traksi Vertebra (Tulang Belakang) 675,000
2714 Pasang Transfusi 95,000
2715 Pasang Transfusi Albumin 86,000
2716 Pasang Trombolitik (Intensif) 103,000
2717 Pasang Umbilical Catheter 136,000
2718 Pasang WSD 1,300,000
2719 Pasang WSD (CathLab) 1,300,000
2720 Pasang/Angkat Jahit 66,000
2721 Pasang/Buka Gips Sirkular 250,000
2722 Pasang/Buka Tampon Vagina 66,000
2723 Pasang/cabut susuk KB/Inplan 127,000
2724 Patch Test Diagnostik (Gendang Telinga) 66,000
2725 Patellar stabilization 8,105,000
2726 PCR EBV ( Eipstein-Bar Virus ) (P) 934,000
2727 PDA Ligasi 15,550,000
2728 Peak Flow Meter 46,200
2729 Peak Flow Rate (PFR) 73,000
2730 Pedicle grafts or flaps 13,154,994
2731 Pedicle or flap graft, not otherwise specified 13,154,994
2732 Peeling Kimia (Deep) 320,000
2733 Peeling Kimia (Superficial) 200,000
2734 Peeling Kimiawi Dalam 165,000
2735 Peeling Kimiawi Superfisial 90,000
2736 Pelacakan Sindrom 90,000
2737 Pelatihan Autis 60,000
2738 Pelepasan Mini Screw 200,000
2739 Pelepasan Peripheral Insertion Central Catheter (PICC) 200,000
2740 Pelepasan Synechia Vaginalis 120,000
2741 Pelipektomi 4,310,000
2742 Pelipektomi + Anastesi 5,750,000
2743 Pem Psikotest MMPI 2 276,000
2744 Pemasangan / Penggantian Pack / Kassa Kemicitine 270,000
2745 Pemasangan Abutmen 860,000
2746 Pemasangan Arteri Line 930,000
2747 Pemasangan Balon Mitral 24,475,000
2748 Pemasangan Belog Tampon 66,000
2749 Pemasangan Bite Riser 270,000
2750 Pemasangan Button 300,000
2751 Pemasangan Cimino 5,000,000
2752 Pemasangan CPAP 229,000
2753 Pemasangan Ekspansi Rahang 1,500,000
2754 Pemasangan Elastik 50,000
2755 Pemasangan Fiksasi Interna 6,882,000
2756 Pemasangan Flocare 2,850,000
2757 Pemasangan Grommet dgn Narkose (Diluar Alkes Gromet) 2,850,000
2758 Pemasangan Kateter (ESWL) 740,000
2759 Pemasangan Kateter (ESWL) (Sore) 1,110,000
2760 Pemasangan kateter ureter (ESWL) 2,500,000
2761 Pemasangan Kateter Ureter (ESWL) (Sore) 3,750,000
2762 Pemasangan Kembali Molar Band 70,000
2763 Pemasangan Kruk 99,000
2764 Pemasangan Lingual Bar 1,100,000
2765 Pemasangan Long Line 210,000
2766 Pemasangan Mahkota Implant 860,000
2767 Pemasangan Mini Screw 1,500,000
2768 Pemasangan NGT 52,000
2769 Pemasangan PCA CADD 307,000
2770 Pemasangan Pilar Implant/Somnoplasty 2,850,000
2771 Pemasangan Pintasan VA/VP Shunt 7,337,579
2772 Pemasangan Pipa Shepard 3,850,000
2773 Pemasangan Retainer Bening Satu Rahang 400,000
2774 Pemasangan Retainer Cekat Satu Rahang 1,000,000
2775 Pemasangan Retainer Plat Satu Rahang 400,000
2776 Pemasangan Separator Per Set 100,000
2777 Pemasangan Stent Metal Bilier 42,590,000
2778 Pemasangan Stent Metal Bilier (Sore) 42,590,000
2779 Pemasangan Stent Metal Esofagus/ Gaster/ Duodenum/ Colon/ Rektosigmoid (Sore) 55,760,000
2780 Pemasangan Stent Metal Esofagus/Gaster/Duodenum/Colon/Rektosigmoid 37,180,000
2781 Pemasangan Stent Non Vascular 3,000,000
2782 Pemasangan Stent Non Vascular + Anastesi 4,790,000
2783 Pemasangan T Tube 3,850,000
2784 Pemasangan TIPS 14,450,000
2785 Pemasangan TIPS + Anastesi 18,950,000
2786 Pemasangan TPA 100,000
2787 Pemasangan Traksi Cervical/ dan Pemasangan Halovest 5,926,089
2788 Pemasangan Traksi Servikal 6,116,000
2789 Pemasangan Vena Dalam 451,000
2790 Pembedahan Forequarter (Bedah Onkology) 6,472,000
2791 Pemberian Enteral Nutrisi 85,000
2792 Pemberian Immunonutrisi 225,000
2793 Pemberian Nutrisi Via NGT 48,000
2794 Pemberian Obat Via Rectal 77,000
2795 Pemberian Parental Nutrisi/Total Parental Nutrisi 225,000
2796 Pemberian Parenteral Nutrisi / Total Parenteral Nutrisi 225,000
2797 Pemberian Sitotastika 250,000
2798 Pemberian Sonde 25,000
2799 Pemberian Surfaktan 653,000
2800 Pemberian Tetes Mata 40,000
2801 Pembersihan Karang Gigi (Banyak 1/2 Rahang) 70,000
2802 Pembersihan Karang Gigi (Rahang Bawah + Rahang Atas) 140,000
2803 Pembersihan Karang Gigi RA/RB (Kronis) 670,000
2804 Pembersihan Karang Gigi RA/RB (Simple) 540,000
2805 Pembuatan Cervical Collar Semi Rigid 179,000
2806 Pembuatan Cervical Collar Soft 264,000
2807 Pembuatan CTO Cervical Thoracal Ortosis 776,000
2808 Pembuatan Jadwal Makan 50,000
2809 Pembuatan LS Korset (LSO Semi Rigid) 136,000
2810 Pembuatan LSO (F-E-L) Kontrol, Knight Brace 1,053,000
2811 Pembuatan LSO (F-E) Kontrol , Chairback 1,477,000
2812 Pembuatan LSO Jacket, Boston Overlap 1,141,000
2813 Pembuatan Prostesis Bawah Lutut Komponen Khusus 12,003,000
2814 Pembuatan Prostesis Chopart Biasa 2,474,000
2815 Pembuatan TLS Korset (TLSO Semi Rigid) 186,000
2816 Pembuatan TLSO (F-E-L) Control Ortosis, Knight Taylor Brace 1,056,000
2817 Pembuatan TLSO (F-E) Control Ortosis, Taylor Brace 1,027,000
2818 Pembuatan TLSO Hyperextension Brace (Jewwet) 1,027,000
2819 Pembukaan lubang hidung THT 3,850,000
2820 Pemeriksaan Adekusi Kt/v CAPD 1,450,000
2821 Pemeriksaan Antropometri Dokter 126,000
2822 Pemeriksaan Antropometri Paramedis 126,000
2823 Pemeriksaan Body/Fat Composition 150,000
2824 Pemeriksaan Cairan Aspirasi (FNAB) Deep (Guidance) 750,000
2825 Pemeriksaan Cairan Aspirasi (FNAB) superfisial 500,000
2826 Pemeriksaan Cairan Prostat (Massage Prostat) 135,000
2827 Pemeriksaan Candidiasis Vaginalis (Flour Albus) 115,000
2828 Pemeriksaan Dokter ( Pemeriksaan fisik )(Home Care) 52,000
2829 Pemeriksaan Easy Nogal Secret Hidung 100,000
2830 Pemeriksaan Fisik / Konsultasi Dokter Ahli 95,000
2831 Pemeriksaan Fisik Vaginal dengan Speculum 47,000
2832 Pemeriksaan Fisik/Konsultasi Dr. Ahli (Pemeriksaan Gigi) 137,000
2833 Pemeriksaan Fisik/Konsultasi Dr. Ahli (Pemeriksaan Neurologi) 137,000
2834 Pemeriksaan garpu tala 20,000
2835 Pemeriksaan Gram 95,000
2836 Pemeriksaan impedans 73,000
2837 Pemeriksaan Kalorimetri Indirect 855,000
2838 Pemeriksaan Kesehatan ( Khusus ) 35,000
2839 Pemeriksaan Kesehatan (CPNS) 45,000
2840 Pemeriksaan Kondiloma (As. Asetat) 95,000
2841 Pemeriksaan Korban Kekerasan Sexual (Korban Hidup) + VER 250,000
2842 Pemeriksaan Korban Keracunan (Korban Hidup) + VER 250,000
2843 Pemeriksaan Korban Perlukaan (Korban Hidup) + VER 250,000
2844 Pemeriksaan Lampu Wood 105,000
2845 Pemeriksaan Lapangan Pandang Humphrey 250,000
2846 Pemeriksaan Limfadenopati 96,000
2847 Pemeriksaan Luar Jenazah WNA 1,100,000
2848 Pemeriksaan PET 1,670,000
2849 Pemeriksaan Sarcoptei Scabies 115,000
2850 Pemeriksaan Scoliosis Program 350,000
2851 Pemeriksaan Status Mental 150,000
2852 Pemeriksaan TCM 25,000
2853 Pemeriksaan Tekanan Intraokuler 78,000
2854 Pemeriksaan Tiroid 80,000
2855 Pemeriksaan Trichomoniasis 115,000
2856 Pemeriksaan Umum Psikiatri / Wawancara Psikiatri Terstruktur 150,000
2857 Pemulasaran Jenazah 550,000
2858 Penambahan Pontik Per Pontik 860,000
2859 Pencabutan WSD 180,000
2860 Pencabutan gigi dan dengan komplikasi 2,850,000
2861 Pencabutan Gigi Tanpa Komplikasi 393,000
2862 Pencampuran Nutrisi Parental 48,000
2863 Pencampuran Obat Sitostatika 195,000
2864 Pencetakan Alginat Per Rahang 140,000
2865 Pencetakan Double Impression 270,000
2866 Pencetakan Gigi RA dan RB 250,000
2867 Penektomi 5,173,218
2868 Penektomi Parsial 4,850,000
2869 Penentuan Kebutuhan Energi Basal 65,000
2870 Pengambilan Kultur 66,000
2871 Pengambilan Kultur Cairan CAPD 116,000
2872 Pengambilan Sampel Darah 31,000
2873 Pengambilan Sampel Swab Nasofaring dan Orofaring 100,000
2874 Pengangkatan Bite Riser 140,000
2875 Pengangkatan Fibro Adenom Mamae 2,850,000
2876 Pengangkatan Neuro Fibroma 250,000
2877 Pengangkatan Nevus Margo Palpebra 675,000
2878 Pengangkatan Pack 140,000
2879 Pengangkatan Skin Tag 250,000
2880 Pengangkatan Tandur Kulit 250,000
2881 Pengantaran Jenasah Melalui Laut 1,750,000
2882 Pengantaran Jenasah Melalui Penerbangan 2,750,000
2883 Pengaturan Diet 100,000
2884 Pengawetan Jenazah Pasca Otopsi 1,500,000
2885 Pengawetan jenazah WNA Infeksi ( HIV, AIDS) 3,800,000
2886 Pengawetan jenazah WNA Non Infeksi 2,000,000
2887 Pengecatan Gram 30,000
2888 Penggantian Archwire NiTi (1 Rahang) 170,000
2889 Penggantian Archwire NiTi (2 Rahang) 200,000
2890 Penggantian Archwire SS (1 Rahang) 150,000
2891 Penggantian Archwire SS (2 Rahang) 170,000
2892 Penggantian Bracket 150,000
2893 Penggantian Buccal Tube 200,000
2894 Penggantian Kateter Dialisis 3,000,000
2895 Penggantian Kateter Dialisis + Anastesi 4,790,000
2896 Penggantian Molar Band 250,000
2897 Penggantian Open/Close Coil Spring (1 Gigi) 50,000
2898 Penggantian Open/Close Coil Spring (2 s/d 4 Gigi) 150,000
2899 Penggunaan Kamar Pendingin 300,000
2900 Penggunaan Nitrit Oxide 14,000,000
2901 Penggunaan Ruang Inap Keluarga Duka 150,000
2902 Penggunaan Ruangan VIP 150,000
2903 Penggunaan Rumah Duka 100,000
2904 Pengkajian Status Gizi 65,000
2905 Pengobatan Epistaksis 66,000
2906 Pengukuran 70,000
2907 Pengukuran & Interpretasi BIA Bedridden/Fat Composition 300,000
2908 Pengukuran Berat Badan (Bb) 40,000
2909 Pengukuran Kelenjar Tiroid 65,000
2910 Pengukuran Lingkar Lengan Atas (LLA) 54,000
2911 Pengukuran Ortosis / Prostesis 184,000
2912 Pengukuran Panjang Lengan (Demispan) 40,000
2913 Pengukuran Panjang Penis 65,000
2914 Pengukuran Tebal Lipatan Kulit (TLK) 40,000
2915 Pengukuran Tinggi Badan (Tb) / Pengukuran Panjang Badan (Pb) 40,000
2916 Pengukuran Tinggi Lutut (Knee High) 75,000
2917 Pengukuran Vas 70,000
2918 Pengurangan Bite Riser 140,000
2919 Penilaian Status Pubertas 78,000
2920 Penile Length Test 78,000
2921 Penjahitan < 10 Jahitan 140,000
2922 Penjahitan > 10 Jahitan 270,000
2923 Penutupan ASD tanpa Pembedahan dengan menggunakan Device (ASO)/ Penutupan PFO tanpa Pembedahan dengan Device (PFO Ocluder)/PTA Carotis dengan Stent 80,200,082
2924 Penutupan ASD tanpa Pembedahan dengan menggunakan Device (ASO)/ Penutupan PFO tanpa Pembedahan dengan Device (PFO Ocluder)/PTA Carotis dengan Stent + Anastesi 92,563,349
2925 Penutupan Defek Hernia Diafragmatika 9,464,367
2926 Penutupan Fistula Extra Oral dengan Anastesia Lokal 860,000
2927 Penutupan Fistula Oro Antral dengan Anastesia Lokal 860,000
2928 Penutupan Oroantral Fistula 2,850,000
2929 Penyadapan Jantung 39,915,008
2930 Penyadapan Jantung + Anastesi 43,630,247
2931 Penyakit Pembuluh Darah Perifer 4,842,820
2932 Penyelesaian Problem RS 33,000
2933 Per Oral Endoscopic Mucosectomy (POEM) 34,420,000
2934 Per Oral Endoscopic Mucosectomy (POEM) (Sore) 51,630,000
2935 Perawatan Bayi Lahir dengan Sectio Caesaria 489,000
2936 Perawatan Cranule 72,000
2937 Perawatan Cranule Trachea 72,000
2938 Perawatan Cranule WSD 72,000
2939 Perawatan Exit Site 164,000
2940 Perawatan Fixed Orthodonti Metal Bracket Dua Rahang 7,340,000
2941 Perawatan Fixed Orthodonti Metal Bracket Satu Rahang 3,950,000
2942 Perawatan Fixed Orthodonti Metal Bracket Seperempat Rahang 2,490,000
2943 Perawatan Fixed Orthodonti Porcelain Bracket Dua Rahang 12,390,000
2944 Perawatan Fixed Orthodonti Porcelain Bracket Satu Rahang 6,380,000
2945 Perawatan Fixed Orthodonti Self Ligating Bracket 14,960,000
2946 Perawatan Luka Perineum 10,000
2947 Perawatan Payudara 10,000
2948 Perawatan Pengawetan jenazah + Jenazah Infeksi ( HIV, AIDS) 2,268,000
2949 Perawatan Pengawetan jenazah + Jenazah Non Infeksi 900,000
2950 Perawatan Pulpa Capping 70,000
2951 Perawatan Rumah 24 Jam/3 Shift (Home Care) 750,000
2952 Perawatan Rumah Shift Pagi (Home Care) 250,000
2953 Perawatan Rumah Shift Sore (Home Care) 250,000
2954 Perawatan Saluran Akar 60,000
2955 Perawatan Saluran Akar Dengan One Visit (Akar Jamak) 2,800,000
2956 Perawatan Saluran Akar Dengan One Visit (Akar Tunggal) 1,870,000
2957 Perawatan Tali Pusat 23,000
2958 Percutaneous Dilatation Trakeostomi (PDT) 3,588,000
2959 Percutaneous Endoscopic Gastrostomy (PEG) 8,730,000
2960 Percutaneous Endoscopic Gastrostomy (PEG) / Colostomy (PEC) 9,620,000
2961 Percutaneous Endoscopic Gastrostomy (PEG)/ Colostomy (PEC) (Sore) 14,430,000
2962 Percutaneous Mitral Commissurotomy Transvenous (PTMC)/Baloon Mitral Valvotomy (BMV) 13,110,000
2963 Percutaneous Nephrolithostripst (PNCL) 11,245,000
2964 Percutaneous Transhepatic Biliary Drainage 18,320,000
2965 Percutaneous vertebroplasty 14,020,000
2966 Percutaneus Insertion Of Extracranial Carotid Arteri Stent 76,740,000
2967 Percutaneus Insertion Of Extracranial Carotid Arteri Stent + Penyulit 82,575,000
2968 Percutaneus Insertion Of Intracranial Carotid Arteri Stent 76,740,000
2969 Percutaneus Insertion Of Intracranial Carotid Arteri Stent + Penyulit 82,575,000
2970 Percutaneus Trans Biliary Duct. (PTBD) 18,866,131
2971 Percutaneus Trans Biliary Duct. (PTBD) + Anastesi 24,950,000
2972 Percutaneus Transhepatic Biliary Drainage (Sore) 21,250,000
2973 Pergantian Cairan CAPD 415,000
2974 Pergantian Transfer Set 528,000
2975 Perhitungan Total Parenteral Nutrition 400,000
2976 Pericardial Sintesis (Tapping) 36,691,997
2977 Pericardial Sintesis (Tapping) + Anastesi 39,735,130
2978 Pericardiosintesis 19,450,000
2979 Pericardiosintesis / Pilkasi Diafragma 12,530,000
2980 Periksa Dalam Jenazah + VER 3,000,000
2981 Periksa Dalam Jenazah WNA 4,230,000
2982 Periksa Luar Jenazah + VER 500,000
2983 Perimetri 36,000
2984 Perkutaneus Gastrostomi / Pemasangan PEG 14,450,000
2985 Perkutaneus Gastrostomi / Pemasangan PEG + Anastesi 18,950,000
2986 Peti Jenazah 1,750,000
2987 Pewarnaan Khusus Histokimia - PAS 600,000
2988 Pewarnaan Khusus Histokimia - Trichrome Masson 600,000
2989 Phacoemulsifikasi 6,850,000
2990 Pharingoplasty 4,850,000
2991 Pharyngeal Flap 5,482,645
2992 Philadelphia Collar 950,000
2993 Phonophoresis 72,600
2994 Phosphat Darah 31,000
2995 Phosphat Urine 31,000
2996 Phototherapy 60,000
2997 Pick Up 1a 350,000
2998 Pick Up 1b 450,000
2999 Pick Up 2a 450,000
3000 Pick Up 2b 550,000
3001 Pick Up 3a 450,000
3002 Pick Up 4a 550,000
3003 Pick Up 4b 650,000
3004 Pielolitotomi 4,850,000
3005 Pilkasi Diafragma 6,175,000
3006 Piriformis Syndrom C-Arm Billateral 7,910,000
3007 Piriformis Syndrom C-Arm Unilateral 8,715,000
3008 Plano Test (HCG) 25,000
3009 Plaster aplication of extremity & spine 3,850,000
3010 Plastic operation on hand with graft of muscle or fascia 10,675,000
3011 Plastic operation on hand with other graft or implant 10,675,000
3012 Plastik Erat 260,000
3013 Play Terapi 40,000
3014 Plebography Bilateral 718,000
3015 Plebography Bilateral + Anastesi 2,730,000
3016 Plebography Unilateral 555,000
3017 Plebography Unilateral + Anastesi 2,100,000
3018 Plebotomi Tarapeutik 600,000
3019 Pleurodesis 675,000
3020 PMK Intermitten 54,000
3021 PMK Kontinue 54,000
3022 Pnemonektomi ( Bedah Paru/ Thorax ) 21,102,000
3023 Podopilin 25% 1-5 Lesi 66,000
3024 Podopilin 35% 1-5 Lesi 66,000
3025 Poliklinik CAPD 350,000
3026 Polipektomi 5,420,000
3027 Polipektomi (Sore) 5,420,000
3028 Polipektomi + Anastesi 7,230,000
3029 Polipektomi + Anastesi (Sore) 7,230,000
3030 Polipektomi Saluran Cerna Bagian Atas/Bawah 2,850,000
3031 Polis Tambalan 36,000
3032 Polisomnografi (PSG) 3,550,000
3033 Pollicization operation carrying over nerves and blood supply 10,675,000
3034 Polypectomy Rectum 3,850,000
3035 Poroentrostomi (Operasi Kasal) 6,175,000
3036 Postero Sagital Anorecto Vagino Urethra Plasty (PSARPUV) 17,350,000
3037 Postero Sagittal Anorectolasty / PSARP 9,464,367
3038 Postero Sagittal/Anorectovaginorethroplasty 6,138,408
3039 Potong Stump (Rectum) 4,978,718
3040 Potong Flap (Bedah Onkology) 3,573,535
3041 PPD Tes 66,000
3042 PPM (Permanent Pace Maker) 9,896,883
3043 PPM Double Chamber 34,454,000
3044 Preparasi dan Pencetakan Onlay / Jacket Crown / Full Crown 750,000
3045 Preparasi dan Pencetakan Veneer Indirect 1,070,000
3046 Preparasi Saluran Akar Dengan Hand Use Protaper (Akar Jamak) 1,590,000
3047 Preparasi Saluran Akar Dengan Hand Use Protaper (Akar Tunggal) 770,000
3048 Preparasi Saluran Akar Dengan Protaper Rotary Instrumen (Akar Jamak) 1,330,000
3049 Preparasi Saluran Akar Dengan Protaper Rotary Instrumen (Akar Tunggal) 1,080,000
3050 Prick Test (Ingestan) 136,000
3051 Prick Test (Rinala) 136,000
3052 Primary PCI 11,175,225
3053 Produk Apharesis 4,000,000
3054 Progesteron _ 269,000
3055 Progesteron (P) 445,000
3056 Prokalsitonin 660,000
3057 Prolactin (P) 325,000
3058 Prolactine 200,000
3059 Prolaktin _ 200,000
3060 Pronto Etmoidektomi (Ekstranasal) 5,482,645
3061 Proof laparatomy/biopsi per laparatomy 6,175,000
3062 Prosedur Pemasangan atau Fitting Prostesis Kaki 239,000
3063 Prosedur Tiersch (Prolapsus Recti) 6,238,462
3064 Prostatektomi Retropubik 7,252,252
3065 Prostatektomi terbuka 4,850,000
3066 Prostatektomi terbuka dan sectio Alta 4,850,000
3067 Protein Bence Jones (P) 70,000
3068 Protein C 313,000
3069 Protein Electrophoresis (P) 195,000
3070 Protein Esbach _ 30,000
3071 Protein Kuantitatif Urine 65,000
3072 Protein S 313,000
3073 Protein Total _ 32,000
3074 Protesa 1 Gigi 413,000
3075 Protesa 2 Gigi 328,000
3076 Protesa 3 Gigi 380,000
3077 Protesa 4 Gigi 465,000
3078 Protesa 5 Gigi 568,000
3079 Protesa 6 Gigi 661,000
3080 Protesa 7 Gigi 723,000
3081 Protesa Atas Lutut (Khusus) 27,000,000
3082 Protesa Atas Lutut (Standar) 19,500,000
3083 Protesa Atas Siku (Standar) 16,700,000
3084 Protesa Bawah Siku (Khusus) 19,000,000
3085 Protesa Bawah Siku (Standar) 11,050,000
3086 Protesa Full Denture 1,576,000
3087 Protesa Lebih dari 7 Gigi=1/2 Full 761,000
3088 Protesa Opturator 600,000
3089 Provocative Test Brugada Sindrome 1,799,000
3090 PRP (Platelet Rich Plasma) 600,000
3091 PS1.5 Ventrikular Repair/RVOT Repair/AVR+VSD Closure+ASD Closure 45,950,000
3092 PSA 6,331,000
3093 PSA _ 265,000
3094 PSARP Laparatomi 6,118,524
3095 Pseudokista THT 250,000
3096 Psikoedukasi Keluarga 150,000
3097 Psikometri Individu (Abberant Behaviour Checklist Irritability) 100,000
3098 Psikometri Individu (Abbreviated Conners Rating Scale) 100,000
3099 Psikometri Individu (Activity Daily Living / Barthel Index / IADL / FAQ) 100,000
3100 Psikometri Individu (Addiction Severity Index) 100,000
3101 Psikometri Individu (Brief Psyciatric Rating Scale) 100,000
3102 Psikometri Individu (Child Depresi Inventory / Berrige House Depression Screening Questionare) 100,000
3103 Psikometri Individu (Clinical Dementia Rating Scale) 100,000
3104 Psikometri Individu (Clinical Global Impression Scale) 100,000
3105 Psikometri Individu (Confussion Assesment Methode) 100,000
3106 Psikometri Individu (CSRS / Skala Bunuh Diri) 100,000
3107 Psikometri Individu (Ekstrapiramidal Sympton Rating Scale / SAS) 100,000
3108 Psikometri Individu (Geriatric Depression Scale / GDS 15 / 30) 100,000
3109 Psikometri Individu (HARS / GAD-7) 100,000
3110 Psikometri Individu (HDRS / BDI / MADRS / PHQ-9) 100,000
3111 Psikometri Individu (HDRS/HARS Mini Metal) 32,000
3112 Psikometri Individu (Insomnia Rating Scale) 100,000
3113 Psikometri Individu (Kuesioner Kekuatan dan Kesulitan Pada Anak) 100,000
3114 Psikometri Individu (Mini-Mental State Examination / MMSE) 100,000
3115 Psikometri Individu (Montreal Cognitive Assesment / MoCA-INA) 100,000
3116 Psikometri Individu (PANSS EC) 100,000
3117 Psikometri Individu (PANSS) 100,000
3118 Psikometri Individu (Pemeriksaan Mini Cognitif dan Clock Drawing Test / CDT ) 100,000
3119 Psikometri Individu (Penilaian Resiko Jatuh Pada Lansia) 100,000
3120 Psikometri Individu (Score Iskemik Haschinski) 100,000
3121 Psikometri Individu (Status Psikiatri Anak & Remaja) 100,000
3122 Psikometri Individu (Warteg HTP Rorschach) 100,000
3123 Psikometri Individu (Yale Brown Obsessive Compulsive Scale) 100,000
3124 Psikometri Individu (Young Mania Rating Scale) 100,000
3125 Psikometri MMPI (Pasien) 212,000
3126 Psikoterapi I 40,000
3127 Psikoterapi II 65,000
3128 Psikoterapi Individual oleh Psikiater anak 150,000
3129 Psikoterapi Keluarga / Family Therapy 190,000
3130 Psikoterapi Psikodinamik 190,000
3131 Psikoterapi Suportif 100,000
3132 Psoas Histch/Boari Flap 6,943,000
3133 PTA + 1 Buah (Sub Clavia, Femoralis, Renalis) 19,490,000
3134 PTA + 2 Stent 45,300,000
3135 PTA Carotis Tanpa Stent 16,010,000
3136 PTB Prothesis (Khusus) 20,000,000
3137 PTB Prothesis (Standar) 9,800,000
3138 PTBD (Percutaneous Biliary Drainage) 12,086,000
3139 PTCA 11,011,434
3140 PTCA + TPM 12,820,000
3141 PTCA+1 Stent BMS 11,093,434
3142 PTCA+1 Stent DES 11,149,852
3143 PTCA+1 Stent DES+1 BMS 11,166,852
3144 PTCA+2 Stent BMS 11,110,434
3145 PTCA+2 Stent DES 11,223,270
3146 PTCA+2 Stent DES+1 BMS 11,305,270
3147 PTCA+3 Stent DES 11,361,688
3148 Pterigium + CLG 2,850,000
3149 PTH intact (P) 608,000
3150 Pthisis Bulbi (Graft Mukosa Bibir) 3,850,000
3151 Ptosis 5,586,093
3152 Ptosis + anastesi 6,823,000
3153 Puberty Test 78,000
3154 Pull Through (Soave.Duhamel.Sewnson) 9,464,367
3155 Pulmonal Valve Replacement 55,550,000
3156 Pulp Capping 500,000
3157 Pulse Oxymeter 63,000
3158 Punctie + Kenacort (0.5/1/2cc) Sendi Besar 325,000
3159 Punctie + Kenacort (0.5/1/2cc) Sendi Kecil 320,000
3160 Punctie Ascites 675,000
3161 Punctie Ascites (Endoscopy) 1,200,000
3162 Punctie Ascites (Endoscopy) (Sore) 1,800,000
3163 Punctie Capung Duglasi 142,000
3164 Punctie Lumbal 242,000
3165 Punctie Pertitoneum 87,000
3166 Punctie Pleura 675,000
3167 Punctie Sendi Besar 300,000
3168 Punctie Sendi Kecil 295,000
3169 Punksi / Irigasi Pleura 675,000
3170 Punksi Batu 66,000
3171 Punksi Cairan Otak 4,892,887
3172 Punksi Hematoma Telinga 66,000
3173 Punksi Sumsum Tulang 250,000
3174 Puntie Pertitoneum 87,000
3175 PVR + TVR + Infidibulectomy 43,850,000
3176 Pyelolithotomi 6,911,502
3177 Pyeloplasty 6,499,717
3178 Pyloromiotomi (operasi fredet-ramstedt) 9,464,367
3179 Quadricepsplasty 11,196,000
3180 R.P.G ( Retrograde Pyelografi ) 450,000
3181 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif 21,250,000
3182 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster 2,500,000
3183 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster (rujukan luar) 500,000
3184 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Booster + Anastesi 3,100,000
3185 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif (rujukan luar) 607,150
3186 Radiasi Eksterna - CT Simulator / 3 D - Kuratif Definitif + Anastesi 26,350,000
3187 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster 4,375,000
3188 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster (rujukan luar) 875,000
3189 Radiasi Eksterna - IMRT / IGRT - Kuratif Booster + Anastesi 5,425,000
3190 Radiasi Eksterna - IMRT / IGRT - Kuratif Defenitif + Anastesi 31,000,000
3191 Radiasi Eksterna - IMRT / IGRT - Kuratif Definitif 25,000,000
3192 Radiasi Eksterna - IMRT / IGRT - Kuratif Definitif (rujukan luar ) 714,300
3193 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif 8,800,000
3194 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant 10,800,000
3195 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant (rujukan luar) 432,000
3196 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Adjuvant + Anastesi 12,960,000
3197 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif 11,500,000
3198 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif (rujukan luar) 328,600
3199 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Kuratif Defenitif + Anastesi 14,020,000
3200 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif (rujukan luar) 1,760,000
3201 Radiasi Eksterna - Paket I (Pesawat + Simulator) - Paliatif + Anastesi 10,120,000
3202 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant 12,500,000
3203 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant (rujukan luar) 500,000
3204 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Adjuvant + Anastesi 15,020,000
3205 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif 13,300,000
3206 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif (rujukan luar) 380,000
3207 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Kuratif Defenitif + Anastesi 16,180,000
3208 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif 11,000,000
3209 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif (rujukan luar) 2,200,000
3210 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Paliatif + Anastesi 13,520,000
3211 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan 8,600,000
3212 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan (rujukan luar) 1,720,000
3213 Radiasi Eksterna - Paket II (Theartment Planning System) TPS + Simulator - Radiokastrasi/Non Keganasan + Anastesi 9,800,000
3214 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS) + Alat Bantu) - Paliatif 8,750,000
3215 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS) + Alat Bantu) - Paliatif (rujukan luar) 1,750,000
3216 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant 12,500,000
3217 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant (rujukan luar) 500,000
3218 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Adjuvant + Anastesi 15,380,000
3219 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif 15,000,000
3220 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif (rujukan luar) 428,600
3221 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Kuratif Defenitif + Anastesi 17,040,000
3222 Radiasi Eksterna - Paket III ( Pesawat + Simulator + Treatmen Planning System (TPS)+Alat Bantu) - Paliatif + Anastesi 10,790,000
3223 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery 9,375,000
3224 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery (rujukan luar) 9,375,000
3225 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Booster + SRS Headfix / Alat Surgery + Anastesi 11,625,000
3226 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery 31,250,000
3227 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery (rujukan luar) 31,250,000
3228 Radiasi Eksterna - Stereotactic Radiosurgery (SRS) - Kuratif Definitif + SRS Headfix / Alat Surgery + Anastesi 38,750,000
3229 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix 9,375,000
3230 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix (rujukan luar) 1,875,000
3231 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Booster + SRT Headfix / Bodfix + Anastesi 11,625,000
3232 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix 31,250,000
3233 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix (rujukan luar) 6,250,000
3234 Radiasi Eksterna - Stereotactic Radiotherapy (SRT) - Kuratif Definitif + SRT Headfix / Bodfix + Anastesi 38,750,000
3235 Radiasi Eksterna 3D 1 x radiasi 1,154,000
3236 Radiasi Eksterna IMRT 1 x radiasi 1,154,000
3237 Radical excision of skin lesion 3,125,000
3238 Radikal Cystektomi 11,981,598
3239 Radikal Neck Desection 4,063,694
3240 Radikal Nefroktomi 9,356,913
3241 Radikal Prostatektomi 11,130,825
3242 Radiofrekuensi + PTBV 23,550,000
3243 Radiofrequency Ablation 29,940,000
3244 Radiofrequency Ablation (Sore) 36,250,000
3245 Rasio IT 190,000
3246 Rawat Colostomy 93,000
3247 Rawat Luka (THT) 105,000
3248 Rawat Luka Berat 110,000
3249 Rawat Luka Ringan 47,000
3250 Rawat Luka Sedang 76,000
3251 Rawat Stoma Trakeostomi 185,000
3252 Rawat Traechestomy 190,000
3253 Re-treatment Saluran Akar Jamak 1,400,000
3254 Re-treatment Saluran Akar Tunggal 1,100,000
3255 Real Time - PCR Covid-19 (Untuk Perjalanan) 295,000
3256 Reapir Komplikasi AV Shunt 2,850,000
3257 Reattachment of extremity 2,350,000
3258 Reattachment of muscle 11,196,000
3259 Reattachment of muscle of hand 11,196,000
3260 Reattachment of tendon 11,196,000
3261 Reattachment of tendon of hand 11,196,000
3262 Rebonding Per Bracket 150,000
3263 Recession of tendon 11,196,000
3264 Recession of tendon of hand 11,196,000
3265 Reconstruction Anterior 4,375,000
3266 Reconstruction of muscle and tendon 3,271,994
3267 Reconstruction of thumb 5,561,121
3268 Rectal / Vaginal Toucher 77,000
3269 Rectal Toucher 77,000
3270 Rectorectal pull-through/duhamel procedure 6,175,000
3271 Redo BT Shunt / Redo PS Repair / VSD + PS Repair 48,750,000
3272 Refraktometri 25,000
3273 Refusion of atlas-axis spine 10,791,458
3274 Refusion of dorsal and dorolumbarspine, anterior technique 14,020,000
3275 Refusion of dorsal and dorolumbarspine, posterior technique 14,020,000
3276 Refusion of lumbar and lumbosacral spine, anterior technique 14,020,000
3277 Refusion of lumbar and lumbosacral spine, lateral transverse technique 14,020,000
3278 Refusion of lumbar and lumbosacral spine, posterior technique 14,020,000
3279 Refusion of other cervical spine, anterior technique 14,020,000
3280 Refusion of other cervical spine, posterior technique 14,020,000
3281 Refusion of spine, NEC 14,020,000
3282 Regional Flap 5,011,958
3283 Regional Flap Tidak Luas THT 4,850,000
3284 Rehabilitasi Medik Fase II dan Fase III 200,000
3285 Rehabilitasi Sosial 33,000
3286 Rehidrasi Pada Dehidrasi Berat 200,000
3287 Rehidrasi Pada Dehidrasi Ringan/Sedang 168,000
3288 Reimplantasi Gigi Asli dengan Anastesi Lokal 860,000
3289 Reimplantasi Ureter 6,175,000
3290 Rekanalisasi Central Line 3,000,000
3291 Rekanalisasi Central Line + Anastesi 4,790,000
3292 Rekanalisasi Ruptura / Transkanal 4,392,000
3293 Rekanalisasi Saluran Kelenjar Saliva 3,762,000
3294 Rekons defek / kelainan tubuh yang simple 3,850,000
3295 Rekonstruksi avulsi kulit 4,850,000
3296 Rekonstruksi Club hand 4,850,000
3297 Rekonstruksi Craniosinostosis 4,850,000
3298 Rekonstruksi defek dengan flap jauh 4,850,000
3299 Rekonstruksi defek dengan flap lokal 4,850,000
3300 Rekonstruksi Defek/Kelainan Tubuh Yang Kompleks 5,394,025
3301 Rekonstruksi Degloving Injury 8,888,772
3302 Rekonstruksi Duktus Lacrimalis / Stenosis Sederhana 4,850,000
3303 Rekonstruksi Fraktur Muka Dengan Palte Screw THT 8,850,000
3304 Rekonstruksi Fraktur Rahang THT 4,850,000
3305 Rekonstruksi Gigantomastia 4,850,000
3306 Rekonstruksi Hidung Dengan Defek THT 7,850,000
3307 Rekonstruksi Jenazah Tk.Berat 1,000,000
3308 Rekonstruksi Jenazah Tk.Ringan 500,000
3309 Rekonstruksi Jenazah Tk.Sedang 750,000
3310 Rekonstruksi Kelainan Craniofacial Congenila 4,850,000
3311 Rekonstruksi kelainan jari (polidaktil simple) 2,850,000
3312 Rekonstruksi Kelainan Mata/kontraktur palpebra 4,850,000
3313 Rekonstruksi Kontraktur Difus 4,850,000
3314 Rekonstruksi Kontraktur Kompleks (Bedah THT) 4,850,000
3315 Rekonstruksi koreksi Camplodactyl/Clinidactyl 4,850,000
3316 Rekonstruksi koreksi Makrodactyl 4,850,000
3317 Rekonstruksi Lidah 8,654,000
3318 Rekonstruksi Mammae dengan miocutaneus 4,850,000
3319 Rekonstruksi Mandibula THT 7,850,000
3320 Rekonstruksi Mayor 7,750,000
3321 Rekonstruksi Meningo Encephalocele Anterior (MEA) 4,850,000
3322 Rekonstruksi Meningokel Kranial (Anterior/ Posterior) 7,667,000
3323 Rekonstruksi Meningokel Spina Bifida 7,662,000
3324 Rekonstruksi orbita kongenital 6,823,000
3325 Rekonstruksi Pulley Tendon 4,375,000
3326 Rekonstruksi Repair Tendon Complikate 4,850,000
3327 Rekonstruksi Ring Avulsion 4,850,000
3328 Rekonstruksi Sedang (STSG.FTSG.Flap Lokal) 4,850,000
3329 Rekonstruksi Telinga 9,950,000
3330 Rekonstruksi Telinga ( Tahap 1/ tahap 2 ) 9,950,000
3331 Rekonstruksi Ulkus Decubitus dengan Flap 4,850,000
3332 Rekonstruksi Urogenitalia 12,327,000
3333 Rekonstruksi Vagina 4,377,586
3334 Rekonstruksi Vaskuler Sederhana 2,850,000
3335 Rekonstruksi/Flap 250,000
3336 Rekontruksi Blassemeck / Bladder Neck 6,925,000
3337 Rekontruksi Kelopak Berat 6,849,023
3338 Rekontruksi Orbita Congenital 6,823,000
3339 Rekontruksi Renovaskuler 8,011,000
3340 Rekontruksi Saket Berat 6,944,450
3341 Rekontruksi Vesika 6,925,000
3342 Relaxation of scar or web contracture of skin 6,600,000
3343 Release Kontraktur 3,850,000
3344 Release Kontraktur + Flap 6,388,884
3345 Release Kontraktur Kompleks + STSG 6,789,135
3346 Release of carpal tunnel 6,455,000
3347 Release of clubfoot, not elsewhere classified 11,947,140
3348 Release of tarsal tunnel 6,455,000
3349 Release Sinekhia Vulva 4,991,000
3350 Release Syndacil Kompleks 4,850,000
3351 Release Tongue Tie 2,850,000
3352 Remedial Teaching 60,000
3353 Removal of external immobilization device 2,350,000
3354 Removal of foreign body from foot without incision 3,125,000
3355 Removal of foreign body from hand without incision 3,125,000
3356 Removal of foreign body from spinal canal 14,020,000
3357 Removal of foreign body without incision from lower limb, except foot 3,125,000
3358 Removal of foreign body without incision from upper limb, except hand 3,125,000
3359 Removal of foreign body, not otherwise specified 2,350,000
3360 Removal of implanted device from carpals and metacarpals 4,952,586
3361 Removal of implanted device from femur 3,814,600
3362 Removal of implanted device from humerus 5,078,000
3363 Removal of implanted device from patella 3,814,600
3364 Removal of implanted device from radius and ulna 3,814,600
3365 Removal of implanted device from scapula, clavicle, and thorax (ribs and sternum) 6,154,994
3366 Removal of implanted device from tarsal and metatarsals 3,814,600
3367 Removal of implanted device from tibia and fibula 3,814,600
3368 Removal of implanted device, unspesified site 2,350,000
3369 Removal of nail, nailbed, or nail fold 2,350,000
3370 Removal of other device from trunk 4,375,000
3371 Removal of other foreign body without incision from head and neck 3,125,000
3372 Reopening of laminectomy site 14,020,000
3373 Repair bladder extrophy (BA) 6,175,000
3374 Repair cloacal 6,175,000
3375 Repair Defek Dinding Perut 9,464,367
3376 Repair Defek Hernia Umbilikalis 5,008,000
3377 Repair Fistel 6,054,980
3378 Repair Fistel Intra Oral / Ekstra Oral 9,312,000
3379 Repair Fistel Recto-vaginal 6,175,000
3380 Repair Fistel Urethra Pascauretroplasti 5,193,000
3381 Repair Fistel Vesikokutan 4,850,000
3382 Repair Fistula rcto Vaginal 6,238,462
3383 Repair Luka Pada Wajah Kompleks 6,767,221
3384 Repair Luka Pada Wajah melibatkan saraf ducyus lakrimal/kelenjar liur 4,850,000
3385 Repair Luka Robek Sederhana Pada Wajah 5,193,000
3386 Repair Muscle/Tendon 5,121,824
3387 Repair of claw toe 6,600,000
3388 Repair of cleft hand 10,675,000
3389 Repair of hammer toe 6,600,000
3390 Repair of macrodactyly 10,675,000
3391 Repair of mallet finger 10,675,000
3392 Repair of recurrent dislocation of shoulder 8,105,000
3393 Repair of the anulus fibrosus with graft or prosthesis 14,020,000
3394 Repair Perinium Grade III - IV Pasca Persalinan 2,850,000
3395 Repair Ruptur Korneosklera 4,850,000
3396 Repair Ruptur Palpebra Simpel 2,850,000
3397 Repair Ruptur Palpebra Transkanal 3,850,000
3398 Repair Tendon Jari (Bedah Plastik) 6,883,430
3399 Repair Trauma Amputasi Jari 91,000
3400 Repair Vesico Vagina Fistel Complex 9,464,367
3401 Repair VP Shunt 5,010,202
3402 Repair WSD 180,000
3403 Reparasi Fistula Vesiko Vaginal 6,968,000
3404 Replacement of cast on lower limb 4,375,000
3405 Replacement of cast on upper limb 4,375,000
3406 Replacement of other cast 4,375,000
3407 Replacement of other device for musculoskeletal immobilization 4,375,000
3408 Replantasi 39,652,089
3409 Reposisi / Fiksasi Fr.Maksila & Mandibula 9,350,000
3410 Reposisi / Fiksasi Fr.Naso Orbita Edmoe (NOE) 9,350,000
3411 Reposisi & Fiksasi Fr. Naso Orbita Edmoe (NOE) 11,250,000
3412 Reposisi & Fiksasi Fraktur Tunggal Tulang Wajah 4,850,000
3413 Reposisi dengan Anestesi Lokal 675,000
3414 Reposisi dislokasi Temporo mandibula (TMJ) 9,982,000
3415 Reposisi Fraktur Mandibula Multiple/ Kompleks 6,767,221
3416 Reposisi Fraktur Mandibula Sederhana 4,850,000
3417 Reposisi Fraktur Rahang Simple 4,850,000
3418 Reposisi fraktur sederhana os nassal 2,850,000
3419 Reposisi Hidung THT 250,000
3420 Reposisi IOL 2,850,000
3421 Reposisi Iris 2,850,000
3422 Reposisi Luksasi Rahang 270,000
3423 Reposisi Luksasi Rahang Berat 860,000
3424 Reposisi Terbuka dan Fiksasi 4,375,000
3425 Reposisi TMJ (Bedah Mulut) 1,470,000
3426 Reposisi TPM 1,945,000
3427 Reposisi Trauma Hidung sederhana 250,000
3428 Reposisi/ Fiksasi Fr. Orbita 9,950,000
3429 Reprogram Pacemaker 221,000
3430 Resectie Rahang 4,442,187
3431 Reseksi + Anastomosis Esophagos 6,180,370
3432 Reseksi Adenomiosis 6,323,408
3433 Reseksi Anastomosis 4,455,809
3434 Reseksi Anastomosis Atresia usus,duplikasi 6,136,962
3435 Reseksi anterior reh bein 6,175,000
3436 Reseksi Esofagus + Interposisi Kolon 7,131,625
3437 Reseksi Gaster 6,175,000
3438 Reseksi Hepar 6,171,198
3439 Reseksi Marginal 14,255,000
3440 Reseksi Partial Vesika 6,942,000
3441 Reseksi Reduksi 6,894,000
3442 Reseksi Trachea ( Bedah Paru / Thorax ) 21,102,000
3443 Reshape Mahkota Gigi 450,000
3444 Reshaping Untuk Torus (Op.Gigi) 2,510,000
3445 Reshaping untuk Torus/Tumor Tulang 4,757,000
3446 Resisted exe 70,000
3447 Restorasi dengan Composite Besar 600,000
3448 Restorasi dengan Composite Kecil 480,000
3449 Restorasi Gigi Dengan Glass Lonomer (Fuji IX) 520,000
3450 Resusitasi Jantung Paru ( RJP) 931,000
3451 Resusitasi Syok 750,000
3452 Retcam + Narkose 2,850,000
3453 Retikulosit Otomatik + Hematologi Rutin _ 150,000
3454 Revisi Jaringan Parut THT 250,000
3455 Revisi Parut Per Biji 66,000
3456 Revisi Parut THT 2,850,000
3457 Revision of joint replacement of upper extremity 5,752,000
3458 Rewiring Sternum 3,850,000
3459 RF _ 100,000
3460 RF Dasar Lidah THT 4,850,000
3461 Rigde Augmentasi dengan Anastesi Lokal 860,000
3462 Rigid Endoskopi ( Naso endoskopi ) 258,000
3463 Rinoplasty dgn Augmentasi Tulang Rawan THT 8,350,000
3464 Rinoplasty THT 4,850,000
3465 Rinotomi Lateralis 7,850,000
3466 Robekan Porsio + Jahitan 600,000
3467 Roda Dua (>10 - 15 km) 6,000
3468 Roda Dua (>15 - 20 km) 8,000
3469 Roda Dua (>20 - 25 km) 10,000
3470 Roda Dua (>25 km) 15,000
3471 Roda Dua (>5 - 10 km) 4,000
3472 Roda Dua (0 - 5 km) 2,000
3473 Rong Of Motion Testing 70,000
3474 Rontgen (Poli Jantung) 75,000
3475 Rotator cuff repair 11,196,000
3476 RPG 740,000
3477 RPG (Sore) 1,110,000
3478 RPLND 12,022,946
3479 Ruptur Palpebra Moderate 4,850,000
3480 S Gene Target Failure (SGTF) SARS CoV-2 1,100,000
3481 Sach Foot 5,500,000
3482 Sacral Epidural Injection C-Arm 8,715,000
3483 Sacroiliac Joint Disorde C-Arm Billateral 7,910,000
3484 Sacroiliac Joint Disorde C-Arm Unilateral 8,715,000
3485 Salphingo Oophorektomi Bilateral 4,850,000
3486 Salphingo Oophorektomi Unilateral 3,850,000
3487 Salpingo Ophorectomy Bilateral 6,095,575
3488 Salpingo Ovarektomi/Unilateral 6,094,334
3489 Salvaging Operasi Mikro 42,591,000
3490 Saturasi Oksigen 27,000
3491 Savariy Bougie 2,850,000
3492 SC dengan B Lynch 6,458,138
3493 SC dengan HT subtotal 6,881,118
3494 SC dengan Ligasi Arteri Uterine 6,764,059
3495 SC dengan SO ( Torsi Kista) - COT 6,844,000
3496 Sceral Buckling 4,850,000
3497 Scheral Buckel + Cryo + C3F8 7,850,000
3498 Schrimer Test 20,000
3499 Scintigraphy TL 120 4,000,000
3500 Screening & Tatalaksana Gizi Anak 100,000
3501 Screening Pendonor 45,450,000
3502 Screening Resipien 55,000,000
3503 Scrotoplasty + Chordectomy 6,175,000
3504 Sediaan Langsung Pewarnaan BTA 30,000
3505 Sediment Urine _ 22,000
3506 Segmentektomi 3,573,535
3507 Segmentektomi ( Bedah Paru/Thorax ) 21,102,000
3508 Seksio En Caul 6,458,138
3509 Seksio Sesaria 5,605,334
3510 Sel LE _ 120,000
3511 Senam ( Stroke / Hamil / Asma ) 22,800
3512 Septectomy (Potong Septum) 5,031,000
3513 Septoplasti 4,850,000
3514 Septoplasty ec trauma hidung 4,850,000
3515 Septorinoplasty THT 7,850,000
3516 Septum Reseksi 3,850,000
3517 Sequesterectomy 11,023,000
3518 Sequesterektomi Per Regio Berat 2,500,000
3519 Sequesterektomi Per Regio Ringan 1,980,000
3520 Serial Ekstraksi 9,334,000
3521 Serum Autotest 66,000
3522 Service Cost Darah Aferesis (Tromboferesis) 3,500,000
3523 Shigella Antigen 235,000
3524 Short Wave Diathermi 39,600
3525 Shunting Femoralis ( Bedah Vaskuler) 4,860,000
3526 Shunting Poplitea/Tibialis ( Bedah Vaskuler) 4,860,000
3527 Shunting Splenorea 4,816,000
3528 Shunting Splenorea (Vaskuler) 4,816,000
3529 Sialografi 375,000
3530 Sikatan Ductus Biliaris 2,780,000
3531 Sikatan Ductus Biliaris (Sore) 4,170,000
3532 Simpatektomi 4,816,000
3533 Simple Functional N Surgery (Percutaneus Facet Denevation dll) 5,852,000
3534 Simple Functional N Surgery (Percutaneus Rhizotomy/PRGR) 5,813,000
3535 Simulasi menurut usia 150,000
3536 Sinus Lifting dengan Anastesi Lokal 860,000
3537 Sinuskopi/Sinoskopi Dengan Tindakan 2,850,000
3538 Sirklase 5,950,000
3539 Sirkumsisi ( Sunat ) 200,000
3540 Sirkumsisi ( Umur diatas 6 tahun ) (ESWL) 2,500,000
3541 Sirkumsisi (Umur diatas 6 Tahun) (ESWL) (Sore) 3,750,000
3542 Sirkumsisi dengan Phymosis 3,812,293
3543 Sirkumsisi pada Phymosis dengan Narkose 3,812,293
3544 Sistoplasti Reduksi 6,941,000
3545 Sistoskopi 3,930,682
3546 Sistoskopi (ESWL) 2,500,000
3547 Sistoskopi (ESWL) (Sore) 3,750,000
3548 Sistoskopi ODS 3,850,000
3549 Sistostomi 3,864,658
3550 Sistostomi perkutan 3,850,000
3551 Sistostomi Perkutan (ESWL) 2,500,000
3552 Sistostomi Perkutan (ESWL) (Sore) 3,750,000
3553 Sitologi (Sputum, Sikatan, Bilasan) 140,000
3554 Sitologi 3x Serial 96,000
3555 Sitologi Bone Marrow Punction (BMP) Biopsi 191,000
3556 Sitologi Cairan Efusi, ascites, sputum, urin 400,000
3557 Sitologi Pap Smear 150,000
3558 Sitostomi terbuka 3,850,000
3559 Six Minute Walking Test 165,000
3560 Size reduction plastic operation 6,600,000
3561 SKBN 38,000
3562 Skeletal traction and Other traction 2,350,000
3563 Skin Flap 559,000
3564 Skin Graft 560,000
3565 Skin Laser Treatment 4,850,000
3566 Skin Prick Test THT 250,000
3567 Skin Test 32,000
3568 Skin Traction 47,000
3569 Skingrafting yang Luas (Bedah Plastik) 7,587,525
3570 Skingrafting Yang Tidak Luas (Bedah Plastik) 6,777,729
3571 Skingrafting Yang Tidak Luas THT 3,850,000
3572 Skleroterapi Hemorhoid 1,430,000
3573 Skleroterapi Hemorhoid (Sore) 11,900,000
3574 Skleroterapi Varises Esofagus 2,850,000
3575 Skleroterapi Varises SCBA 6,296,000
3576 Skleroterapi Varises SCBA + Anastesi 14,570,000
3577 Skleroterapi Varises SCBA + Anastesi (sore) 21,850,000
3578 Skrining Antibodi 600,000
3579 Skrining Hipotiroid Kongenital ( SHK ) 65,000
3580 Skrotoplasti 6,238,462
3581 Sleepnasoendoskopi 675,000
3582 Slevece Lobektomi ( Bedah Paru / Thorax ) 21,102,000
3583 Slit Lamp Examination 73,000
3584 Soft Collar 145,000
3585 Solarium/Photo Therapi 66,000
3586 Solonektomi 4,816,000
3587 Solux 140,000
3588 Somnoplasty 2,850,000
3589 Sondage Canalculi Lacrimalis 250,000
3590 Speak Audio Meter 48,300
3591 Specular Microscope 400,000
3592 Speech Assement (Komunitas) 66,000
3593 Speech Audiometri 73,000
3594 Spermatocele 5,134,089
3595 Spermatokel (ESWL) 2,500,000
3596 Spermatokel (ESWL) (Sore) 3,750,000
3597 Spermatokelektomi 3,850,000
3598 Sphincterotomy / Lynn Procedure 5,008,000
3599 Spirometer 142,000
3600 Spirometri 138,000
3601 Spleenektomi 7,367,878
3602 Splenectomy pda trauma 6,622,000
3603 Splenektomi (Bedah Vaskuler) 4,850,000
3604 Splenektomi (Thalasemia, hipersplenisme) 11,981,598
3605 Splenektomi ec.Hipertensi Portal/ Kelainan Hematologi lain 14,690,000
3606 Splenektomi Partial 6,331,000
3607 Splinting dengan Anastesi Lokal 270,000
3608 Spool Slang WSD 26,000
3609 Spooling Blast 308,000
3610 Spooling Bola Mata 42,000
3611 Spooling Catheter 308,000
3612 Spooling Colostomy 308,000
3613 Spooling Double Lumen 338,000
3614 Spooling Intoksikasi 40,000
3615 Spooling Rectal 253,000
3616 Spooling Serumen Telinga 66,000
3617 Spooling Sinus 43,000
3618 Spooling Telinga 45,000
3619 Spray & Stretch 250,000
3620 Sputum 1x Sikatan 223,000
3621 Sputum BTA 1 X (Pewarnaan) 35,000
3622 Sputum BTA 3 X (Pewarnaan) 65,000
3623 Spy Glass Diagnostik 6,980,000
3624 Spy Glass Diagnostik (Sore) 10,470,000
3625 Squesterektomi per Rahang dengan Anastesi Lokal 1,500,000
3626 Sretching Of Fascia 70,000
3627 Stapedektomi 4,046,000
3628 STE Hemorroid 660,000
3629 STE Hemorroid + Anastesi 1,422,000
3630 Stellate Ganglion Block 177,000
3631 Stick / Cane 142,000
3632 Stimulasi Memori 370,000
3633 Strabismus 5,122,073
3634 Strabismus 3-4 Otot 8,350,000
3635 Streching Of Muscle Or Tendon 70,000
3636 Stress Management 33,000
3637 Stress Treadmill Dobutamin 300,000
3638 Strest Echo Dobutamin 656,000
3639 Stripping Per Gigi 300,000
3640 Stripping Varises 2 tungkai dengan multipel flebektomi 4,842,820
3641 Subtalar fusion 3,856,600
3642 Subtalar joint arthroereisis 5,476,800
3643 Subtipe Limfosit : CD4 _ 317,000
3644 Suction 73,000
3645 Suction Blister Grafting 250,000
3646 Sudase Ureter 2,500,000
3647 Sudase Ureter (Sore) 3,750,000
3648 Suquestractomy 2,510,000
3649 Surat Keterangan Bebas Narkoba 50,000
3650 Surgical Staging (Bedah Obgyn) 6,559,543
3651 Suture of artery 28,004,994
3652 Suture of capsule or ligament of ankle and foot 5,752,000
3653 Suture of capsule or ligament of other lower extremity 5,752,000
3654 Suture of capsule or ligament of upper extremity 5,752,000
3655 Suture of muscle or fascia of hand 11,196,000
3656 Suture of muscle, tendon, and fascia 4,891,625
3657 Suture of tendon sheath 11,196,000
3658 Suture of tendon sheath of hand 11,196,000
3659 Swab Discar Lesi 66,000
3660 Symblepharon 3,851,142
3661 Symblepharon + anastesi 3,724,142
3662 Symne Protesis (Biasa) 3,200,000
3663 Symne Protesis (Khusus) 13,000,000
3664 Symne Protesis (Standar) 6,000,000
3665 Syndroma Blefarophimosis 11,350,000
3666 Synovectomy 13,254,994
3667 Synovectomy of ankle 5,474,000
3668 Synovectomy of elbow 5,474,000
3669 Synovectomy of foot and toe 5,474,000
3670 Synovectomy of hand and finger 5,474,000
3671 Synovectomy of hip 5,474,000
3672 Synovectomy of knee 26,604,994
3673 Synovectomy of shoulder 13,054,994
3674 Synovectomy of wrist 5,474,000
3675 Syringe Pump 68,000
3676 T - Tube Cholangiografi 400,000
3677 T Cel dan B Cel 69,000
3678 T3 140,000
3679 T3 (Total) (P) 256,000
3680 T3 Up Take 75,000
3681 T4 140,000
3682 T4 (Total) (P) 256,000
3683 Tabel 5 US Navy 650,000
3684 Tabel 6 A US Navy 2,965,000
3685 Tabel 6 US Navy 2,965,000
3686 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter 345,000
3687 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter (Paket Kelompok I; 8 Orang) 300,000
3688 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter (Paket Kelompok II; 5 Orang) 320,000
3689 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter (Paket Sehat 3 kali datang dalam 1 bulan) - Terapi Ke 1 960,000
3690 Tabel 9 / Pengobatan Penyakit Klinis Guritno 14 Meter (Paket Sehat 5 kali datang dalam 1 bulan) - Terapi Ke 1 1,500,000
3691 Tabel Autis 300,000
3692 Tacrolimus 1,975,000
3693 Tampon Bellogue 120,000
3694 Tampon Boor Zulf Covu Nasi 42,000
3695 Tampon Burowi/ telinga 14,000
3696 Tampon cavum nasi ( boorzalf) 42,000
3697 Tampon Cavum Nasi (Lidokain + Efedrin) 31,000
3698 Tampon Hidung 14,000
3699 Tampon Mata 14,000
3700 Tampon utero-vagina 70,000
3701 Tampon Vagina 66,000
3702 Tapping & Strapping 250,000
3703 Tarsometatarsal fusion 5,476,800
3704 Taylor Brace (Biasa) 1,320,000
3705 Taylor Brace (Khusus) 2,850,000
3706 TCM Mycobacterium Tuberculosa (Genexpert Tb) 2,000,000
3707 Telemedicine 150,000
3708 Temporal Bone Resection 5,393,089
3709 Tendon graft 11,196,000
3710 Tendon pulley reconstruction 13,754,994
3711 Tendon Transfer Ekstremitas Bawah Pada Kasus Neuromuskular Anak 3,532,812
3712 Tendon transfer or transplantation 7,533,800
3713 Tenotomy of hand 9,390,000
3714 Tens 39,600
3715 Terapi Aferesis 5,000,000
3716 Terapi Aktivitas Kelompok 300,000
3717 Terapi Bicara Komunitas ( Paket 4x Datang ) 250,000
3718 Terapi CPA Pulse 66,000
3719 Terapi Diet Alergi 100,000
3720 Terapi Diet DM 78,000
3721 Terapi Diet Sindroma Nefrotik & Gnaps 78,000
3722 Terapi Injeksi Long Acting 100,000
3723 Terapi Kelompok 75,000
3724 Terapi Oksigen 150,000
3725 Terapi Perilaku 100,000
3726 Terapi Plasma Exchange 5,000,000
3727 Terapi Plasmaferesis/Leukoferesis/Tromboferesis 3,300,000
3728 Terapi Sklerosing 5,193,000
3729 Tes Alergi Asthma 323,000
3730 Tes Anel 234,000
3731 Tes Antibodi Covid - 19 Metode Rapid Test 130,000
3732 Tes Antibodi Covid-19 (IgG dan IgM) 350,000
3733 Tes Antigen Covid-19 Metode Rapid Tes 109,000
3734 Tes Bakat ( GABT Paket ) 60,000
3735 Tes Cepat Molekuler RT-PCR Covid-19 750,000
3736 Tes Elektroforesis Hb 370,000
3737 Tes Elektroforesis Protein 270,000
3738 Tes Feming 33,000
3739 Tes Fluoresin 29,000
3740 Tes Fungsi Kortikal Luhur (Pasien Baru) 261,000
3741 Tes Fungsi Kortikal Luhur (Pasien Lama) 153,000
3742 Tes Fungsi Tuba 110,000
3743 Tes Intelegensi 75,000
3744 Tes IQ / Raven Test 100,000
3745 Tes Kepribadian 50,000
3746 Tes Mutasi KRAS 2,338,000
3747 Tes Narkoba ( 3 Jenis Obat ) 255,000
3748 Tes Narkoba ( 5 Jenis Obat ) 300,000
3749 Tes Narkoba ( 6 Jenis Obat ) 368,000
3750 Tes Perspirasi 150,000
3751 Tes Provokasi Bronkus 323,000
3752 Tes Psikolog (Komunitas) 66,000
3753 Tes Rose Bengal 33,000
3754 Tes RT-PCR Covid-19 dengan Viral Respiratory Infection (10 Virus VRI) 4,000,000
3755 Tes Schirmen 33,000
3756 Tes Vestibuler 90,000
3757 Test Intelegensi WAIS 60,000
3758 Test Intelegensi WISC/SPPSI 60,000
3759 Test Kepribadian EPPS 33,000
3760 Test Kepribadian Grafis 33,000
3761 Test Meningeal Sign 78,000
3762 Test Nervus Cranialis (Saraf - Anak) 100,000
3763 Test Nervus Cranialis (Tumbuh Kembang - Anak) 78,000
3764 Test Pendengaran Manual 78,000
3765 Test Perkembangan 33,000
3766 Test Perkembangan Kognitif CAT-CLAMPS 270,000
3767 Test Personal Sosial 100,000
3768 Test Reflex Fisiologis 80,000
3769 Test Reflex Patologis 80,000
3770 Test Sensibilitas 78,000
3771 Test Sisi / Decay 73,000
3772 Test Sistem Saraf Otonom 78,000
3773 Test Skiring Masalah Mental Emosional 220,000
3774 Test Tanda-tanda Vital 100,000
3775 Test Tempel Slektif 73,000
3776 Test Waktu Pendarahan 78,000
3777 Testosteron (P) 400,000
3778 Testoteron _ 288,000
3779 Therapi Afasia Anak 39,600
3780 Therapi Afasia Dewasa 39,600
3781 Therapi Bermain 25,200
3782 Therapi Delayed Speech (Okupasi Terapi) 39,600
3783 Therapi Delayed Speech (Terapi Wicara) 39,600
3784 Therapi Dimensia 39,600
3785 Therapi Disatria 39,600
3786 Therapi Disaudia 39,600
3787 Therapi Disfagia 39,600
3788 Therapi Disglosia 39,600
3789 Therapi Inderek / Konsultasi 39,600
3790 Therapi Irama Kelancaran 39,600
3791 Therapi Kreativitas 39,600
3792 Thigh reattachment 7,676,900
3793 Thoracal Facet Joint Injection C-Arm <= 2 8,715,000
3794 Thoracal Facet Joint Injection C-Arm > 2 6,660,000
3795 Thoracal Interlaminar Injection C-Arm 8,715,000
3796 Thoracal Medial Branch Block Injection C-Arm <= 2 8,715,000
3797 Thoracal Medial Branch Block Injection C-Arm > 2 6,660,000
3798 Thoracal Transforaminal Injection C-Arm <= 2 10,610,000
3799 Thoracal Transforaminal Injection C-Arm > 2 7,910,000
3800 Thoracic Endovascular Aortic Repair (TEVAR) 158,000,000
3801 Thrombine Time (TT) 200,000
3802 Thromboplastin Generation Time (TGT) 115,000
3803 Thrombotest 113,000
3804 Thumb reattachment 10,675,000
3805 TIBC _ 90,000
3806 Tilt-Table Test (Kardiovaskular) 731,000
3807 Tilting Table (Fisioterapi) 39,600
3808 Tilting Table (Okupasi Terapi) 60,000
3809 Timpano Plastik 4,593,472
3810 Timpanometri 150,000
3811 Tind. Akupuntur, Tind TDP, Tind Cupping 55,000
3812 Tindakan Analisis Asupan ( Food Recall 24 Jam dan Riwayat Asupan) 100,000
3813 Tindakan Anoscopy 66,000
3814 Tindakan Ballon Detachable 12,950,000
3815 Tindakan Ballon Detachable + Anastesi 43,270,000
3816 Tindakan Balloning Dilatator 18,350,000
3817 Tindakan Balloning Dilatator + Anastesi 63,850,000
3818 Tindakan Bedah Flap 250,000
3819 Tindakan Biopsi 143,000
3820 Tindakan CABG 67,000,000
3821 Tindakan CABG High Risk/MVR/AVR 75,600,000
3822 Tindakan Coiling 17,350,000
3823 Tindakan Coiling + Anastesi 58,650,000
3824 Tindakan Congenital Fornix Plastik 4,375,000
3825 Tindakan Dekompresi Fasialis 9,350,000
3826 Tindakan Dermabrasi 250,000
3827 Tindakan Embolisasio dengan Bead Block 11,283,000
3828 Tindakan Embolisasio dengan Bead Block + Anastesi 32,440,000
3829 Tindakan Embolisasio dengan Gel Foam 6,683,000
3830 Tindakan Embolisasio dengan Gel Foam + Anastesi 22,520,000
3831 Tindakan Manual Plasenta 2,850,000
3832 Tindakan MVR/AVR 75,600,000
3833 Tindakan Pada Keratosis Seboroika 675,000
3834 Tindakan Pharyngeal Flap 4,850,000
3835 Tindakan Resusitasi 66,000
3836 Tindakan Roser Plasty 675,000
3837 Tindakan Stenting 25,350,000
3838 Tindakan Stenting + Anastesi 85,250,000
3839 Tindakan Trans Arterial Chemoterapi Infunsion (TACI/E) 6,435,000
3840 Tindakan Transfusi Darah (Poliklinik - Rawat Inap) 66,000
3841 Tindakan Trombolis 18,050,000
3842 Tindakan Trombolis + Anastesi 63,790,000
3843 Tindih Telinga (Pemasangan Anting) 170,000
3844 Tirodektomi 4,850,000
3845 Tirodektomi Total 4,527,541
3846 Tiroidektomi THT 4,850,000
3847 Toe reattachment 10,675,000
3848 TOF Low Risk/ASD Closure+MV Repair/Cleft Repair/VSD+PDA Division+Coarctasio Repair/VSD Closure+AV Repair/MV Repair 44,350,000
3849 Toilet Hidung 95,000
3850 Toilet Telinga 65,000
3851 Tonografi 73,000
3852 Tonometri 14,000
3853 Tonsilektomi 4,549,405
3854 Tonsilo Edenoidectomi 3,850,000
3855 Toracotomi + Anastomosis Esophagus 6,124,671
3856 Torakoplasty ( Bedah Paru/ Thorax ) 21,102,000
3857 Torakoskopi 14,611,000
3858 Torakotomi (Paket A Bedah Paru) 19,450,000
3859 Torsio Testis 5,134,089
3860 Total elbow replacement 8,105,000
3861 Total hip replacement 5,741,098
3862 Total knee replacement 5,741,098
3863 Total ostectomy of carpals and metacarpals 6,600,000
3864 Total ostectomy of femur 6,600,000
3865 Total ostectomy of humerus 6,600,000
3866 Total ostectomy of patella 6,600,000
3867 Total ostectomy of radius and ulna 6,600,000
3868 Total ostectomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
3869 Total ostectomy of tarsals and metatarsals 6,600,000
3870 Total ostectomy of tibia and fibula 6,600,000
3871 Total shoulder replacement 8,105,000
3872 Total wrist replacement 8,105,000
3873 Touch Massage 150,000
3874 Touch Therapy 150,000
3875 TPM (Temporary Pace Maker) 3,682,250
3876 TRAb (P) 1,164,000
3877 Trabekulektomi 6,260,937
3878 Trabekulektomi +ECCE/ Phacoemulsifikasi 7,850,000
3879 Tracheostomi 3,900,504
3880 Tracheostomi (CathLab) 1,945,000
3881 Training CAPD : Perawatan Exit Site 150,000
3882 Training CAPD : Training Ganti Cairan 1,050,000
3883 Trakbekulektomi 4,488,393
3884 Trakeoplasi ( Bedah Paru / Thorax ) 21,102,000
3885 Trakestomi dengan penyulit 3,850,000
3886 Traksi 33,000
3887 Tram Flap 4,850,000
3888 Trancheostomi 5,676,074
3889 Trans Esophageal Echocardiogram (TEE) 1,800,000
3890 Trans Esophageal Echocardiogram (TEE) + Anastesi 2,500,000
3891 Transcranial Doppler(TCD) 850,000
3892 Transcranial Magnetic Stimulation (TMS) 520,000
3893 Transeksi Esofagus 4,399,600
3894 Transfer of finger, except thumb 10,675,000
3895 Transferrin 124,000
3896 Transfusi Faktor Pembekuan 102,000
3897 Transfusi Tukar 307,000
3898 Transjuguler Liver Biopsi 14,450,000
3899 Transjuguler Liver Biopsi + Anastesi 18,950,000
3900 Transplantasi Ginjal Resipien 55,000,000
3901 Transplantasi Organ (Pendonor) 11,300,000
3902 Transplantasi Organ (Penerima) 95,800,000
3903 Transplantation of muscle and tendon of hand 13,754,994
3904 Transport Mobil Jenazah 500,000
3905 Trauma jaringan lunak wajah sederhana 2,850,000
3906 Trauma Kompleks Jaringan Lunak Wajah 5,075,000
3907 Treadment ESMR 20,000,000
3908 Treadmill Exercice 105,600
3909 Treadmill Test 400,000
3910 Tree Imirror Guinoscopy 20,000
3911 Trepanasi Gigi 140,000
3912 Treponema Pallidum Haemagglutination Assay (TPHA) 145,000
3913 Triad knee repair 8,105,000
3914 Triage (dr. Triage ) 18,000
3915 Triage (ODC) 22,500
3916 Trial Aspiraction / Fungsi Percobaan 75,000
3917 Tridenelisis 4,047,000
3918 Trigger Point Injection 68,000
3919 Trigliserida _ 40,000
3920 Trikeopitelioma 250,000
3921 Triple arthrodesis 18,465,044
3922 Triple Prosedur Keratoplasti dengan Glaukoma 6,927,026
3923 Trombektomi/Lysis dengan Catheter For Vein 2,850,000
3924 Trombolisis : Dialisis Graf 14,450,000
3925 Trombolisis : Dialisis Graf + Anastesi 18,950,000
3926 Trombolisis : Extremitas Inferior 14,450,000
3927 Trombolisis : Extremitas Inferior + Anastesi 18,950,000
3928 Trombolisis : Stroke 14,450,000
3929 Trombolisis : Stroke + Anastesi 18,950,000
3930 Trombolisis : Trombosis Intrakranial 14,450,000
3931 Trombolisis : Trombosis Intrakranial + Anastesi 18,950,000
3932 Troponin I 350,000
3933 Troponin T 220,000
3934 Trust Taus 1,000,000
3935 Trust Taus (Sore) 1,500,000
3936 TSHs 180,000
3937 Tuba Plasty 2,850,000
3938 Tubektomi 5,716,458
3939 Tuberculin Test 75,000
3940 Tumor Ganas/ Adnesa Luas Rekontruksi 3,902,175
3941 Tumor Pembuluh Darah 5,396,887
3942 Tumor Spinal Daerah Cervikal (Bedah Syaraf) 9,482,094
3943 Tumor Spinal Daerah Torakolumbal (Bedah Syaraf) 7,917,094
3944 Tumpatan Amalgan 110,000
3945 Tumpatan Glassionomer 90,000
3946 Tumpatan komposit / L Curing Besar 200,000
3947 Tumpatan Komposit / L. Curing kecil 140,000
3948 Tumpatan Komposit Silikat 70,000
3949 TUR Prostat 8,838,281
3950 TUR Tumor Buli-Buli 9,133,281
3951 Turbinektomi 4,514,000
3952 Turbinoplasty 2,850,000
3953 TVP/TMP 4,850,000
3954 Uji Kekuatan Genggam Tangan Dengan Handgrip Dynamometer 75,000
3955 Uji Neurokognitif 250,000
3956 Uji Penisilin 66,000
3957 Uji Provokasi Obat 66,000
3958 Uji Psikometrik 120,000
3959 Uji Tusuk Obat 66,000
3960 Uji Tusuk Standar 66,000
3961 Ultra Sound Diathermi 75,000
3962 Upper arm reattachment 10,675,000
3963 Urea Klirens 33,000
3964 Urea N Urine (P) 52,000
3965 Uretero Sigmoidostomi 8,164,502
3966 Uretero Ureterostomi 7,802,000
3967 Ureterocutanneostomi 7,801,000
3968 Ureterolithotomi 8,740,947
3969 Ureterolithotomi proksimal 4,850,000
3970 Ureterolysis 5,133,934
3971 Ureterostomi 5,905,186
3972 Uretetoneo Cystosthomi 8,185,000
3973 Urethocystography 525,000
3974 Urethrektomi 7,758,000
3975 Urethroplasty 7,144,677
3976 Uretrografi 450,000
3977 Uretroplasti (Bedah Plastik) 7,603,306
3978 Uretroplasty 7,921,000
3979 Urettroskopi/uretrosistoskopi 3,850,000
3980 Ureum _ 40,000
3981 Ureum Urine (UUN) 60,000
3982 Urin Kehamilan (HCG) _ 50,000
3983 Urina Infiltrate Superficial 2,500,000
3984 Urina Infiltrate Superficial (Sore) 3,750,000
3985 Urine 4 Porsi/Kurve Harian 31,000
3986 Urine Lengkap 25,000
3987 Urine Rutin _ 50,000
3988 Urine Serial 3x 107,000
3989 Urodinamik 7,100,000
3990 UROFLOWMETRI 500,000
3991 Uroflowmetri (Sore) 750,000
3992 URS 7,921,000
3993 USG (Ultrasonograpi) Abdominal 227,000
3994 USG (Ultrasonograpi) Doppler 250,000
3995 USG (Ultrasonograpi) Transvaginal 251,000
3996 USG 4D 580,000
3997 USG Abdomen (Kertas) 77,000
3998 USG Abdomen (Polaroid Berwarna) 117,000
3999 USG Abdomen (Polaroid Tidak Berwarna) 114,000
4000 USG Abdomen Atas ( Upper ) 225,000
4001 USG Abdomen Atas + Bawah (Whole Abdomen) 250,000
4002 USG Abdomen Bawah ( Lower ) 225,000
4003 USG Ankle 163,000
4004 USG Ankle Bilateral 200,000
4005 USG Appendiks 200,000
4006 USG Bahu 163,000
4007 USG Bahu Bilateral 200,000
4008 USG Bayi 250,000
4009 USG Cardia 375,000
4010 USG Cimino 375,000
4011 USG Colour Doppler 3 Dimensi 125,000
4012 USG Dopler Vaskuler 254,000
4013 USG Doppler 350,000
4014 USG Doppler Carotis/TCD (Trans Cranial Doppler) 375,000
4015 USG Doppler Extremitas 350,000
4016 USG Doppler Testis 375,000
4017 USG Elbow 163,000
4018 USG Genu 163,000
4019 USG Genu Bilateral 200,000
4020 USG Ginekologi 227,000
4021 USG Ginjal, Buli-Buli dan Prostat 200,000
4022 USG Guiding 350,000
4023 USG Hepatopankreatobilier 540,000
4024 USG Hepatopankreatobilier (Sore) 810,000
4025 USG Intravagina 225,000
4026 USG Kandungan 200,000
4027 USG Kandungan (Polaroid Berwarna) 111,000
4028 USG Kepala 250,000
4029 USG Leher 110,000
4030 USG Lengan 163,000
4031 USG Lengan Bilateral 200,000
4032 USG Mamma ( Payudara ) 250,000
4033 USG Mata 200,000
4034 USG Mata ( Poli/Irna ) 103,000
4035 USG Musculosckletal Lain 163,000
4036 USG Musculosckletal Lain Bilateral 200,000
4037 USG Musculoskeletal 600,000
4038 USG Musculus Sceletal Ankle 250,000
4039 USG Musculus Sceletal Antebrachii 250,000
4040 USG Musculus Sceletal Elbow 250,000
4041 USG Musculus Sceletal Genu 250,000
4042 USG Musculus Sceletal Shoulder 250,000
4043 USG Musculus Sceletal Wrist 250,000
4044 USG Obstetri 227,000
4045 USG Pedis 163,000
4046 USG Pedis Bilateral 200,000
4047 USG Pelvis 200,000
4048 USG Soft Tissue 200,000
4049 USG Testis 225,000
4050 USG Thorax 200,000
4051 USG Thyroid 200,000
4052 USG Urologi 200,000
4053 USG Whole Abdomen 250,000
4054 USG Wrist 163,000
4055 USG Wrist Bilateral 200,000
4056 Vacum Unit 39,600
4057 Vaksin Rabies 92,000
4058 Vaksinasi Meningitis 280,000
4059 Vaksinasi Rabies 92,000
4060 Vakum Ekstraksi 1,800,000
4061 Varikokelektomi (Palomo) 3,850,000
4062 Vasektomi 2,850,000
4063 Vasektomi (ESWL) 2,500,000
4064 Vasektomi (ESWL) (Sore) 3,750,000
4065 Vasektomi dengan Narkose 2,850,000
4066 Vaskuler Dopler 1 Tungkai 364,000
4067 Vaskuler Dopler 2 Tungkai 660,000
4068 Vasografi 5,149,000
4069 VDRL _ 40,000
4070 Vena Seksi 344,000
4071 Venaseksi Anastesi Anak 66,000
4072 Ventilator 572,000
4073 Ventrikulostomi/VE Drainage 4,084,000
4074 Vericocele/Palomo 5,149,000
4075 Vertrikel Tap 250,000
4076 Vesicolithotomi (Sectio Alta) 5,346,294
4077 Vestibuloplasty Per Regio dengan Anastesi Lokal 860,000
4078 Video Urodinamik 16,575,000
4079 Visite Dokter dan Perawat 120,000
4080 Visite Dokter dan Perawat (HCU) 200,000
4081 Visite Dokter dan Perawat (PJT) 120,000
4082 Visite Dokter & Perawat Bayi 60,000
4083 Visite Dokter dan Perawat (CVCU PJT) 360,000
4084 Visite Dokter dan Perawat (HCU Infection Center) 240,000
4085 Visite Dokter dan Perawat (Infection Center) 180,000
4086 Visite dokter perawat HCU bayi 100,000
4087 Visite Dokter Perawat Intensif (ICCU/CVCU) 360,000
4088 Visite Dokter Perawat Intensif (NICU, PICU, ICU, Brain) 360,000
4089 Visite Rawat Bersama 60,000
4090 Visite Rawat Bersama (CVCU PJT) 216,000
4091 Visite Rawat Bersama (HCU Infection Center) 144,000
4092 Visite Rawat Bersama (HCU) 120,000
4093 Visite Rawat Bersama (Infection Center) 108,000
4094 Visite Rawat Bersama (Intensif) 216,000
4095 Visum Et Repertum 28,000
4096 Visus / Refraksi 73,000
4097 Vitamin D 650,000
4098 Vitrektomi 12,103,000
4099 Vitrektomi + Endo Laser + SB + Silikon Oil/Gas 19,350,000
4100 VMA Urine (P) 99,000
4101 VSD Closure+Reroute PAPVD+TV Repair 51,550,000
4102 VSD+MOF(<10 Hari Perawatan) 51,150,000
4103 Vulvektomi 6,490,781
4104 Waktu Bekuan _ 15,000
4105 Waktu Pendarahan _ 15,000
4106 Waktu Prothtrombine (PT) _ 180,000
4107 Washing melalui Bronchoschopy 188,000
4108 Water Drinking Test 66,000
4109 Wawancara Sosial 22,800
4110 Wedge osteotomy of carpals and metacarpals 6,600,000
4111 Wedge osteotomy of femur 6,600,000
4112 Wedge osteotomy of humerus 6,600,000
4113 Wedge osteotomy of patella 6,600,000
4114 Wedge osteotomy of radius and ulna 6,600,000
4115 Wedge osteotomy of scapula, clavicle, and thorax (ribs and sternum) 6,600,000
4116 Wedge osteotomy of tarsals and metatarsals 6,600,000
4117 Wedge osteotomy of tibia and fibula 6,600,000
4118 Whirpoll 39,600
4119 Whole Body Bone Densitometry 300,000
4120 Widal _ 60,000
4121 Wide Eksisi 9,461,000
4122 Wide eksisi tumor tonsil.orofaring 4,850,000
4123 Wiring dengan Anastesi Lokal 860,000
4124 Wrist Splint (Biasa) 1,500,000
4125 Wrist Splint (Khusus) 2,500,000
4126 Yag Laser 2,850,000
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