tarif bsm 2012 ( siti )

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KDPMRLM Kode NAMAPMR PHRSTarif RSADM001 BIAYA ADMINISTRASI PASIEN BARU 15,000.00ADM002 BIAYA ADMINISTRASI 10,000.00ADM003 BIAYA ADMINISTRASI KARYAWAN 0.00ADM004 VISUME 15,000.00ADM005 PEMBUATAN KARTU PASIEN 5,000.00ADM006 ECG TANPA EXPERTISE 50,000.00

18.001.00 AKP001 STIMULATOR AKUPUNKTUR (10 JARUM PER TINDAKAN) 7,500.0018.002.01 AKP002 AKUPUNKTUR PELANGSINGAN 12,000.0018.006.00 AKP003 PAKET AKUPUNKTUR PELANGSINGAN (5 KALI DLM 1 BLN) 54,000.0018.002.02 AKP004 AKUPUNKTUR PERAWATAN KANTONG MATA 12,000.0018.002.03 AKP005 AKUPUNKTUR PERAWATAN FLEK-FLEK HITAM WAJAH 12,000.0018.002.04 AKP006 PERAWATAN JERAWAT 12,000.0018.002.05 AKP007 PERAWATAN KETOMBE 12,000.0018.002.06 AKP008 PERAWATAN KEBOTAKAN 12,000.0018.003.01 AKP009 AKUPUNKTUR DM 12,000.0018.003.02 AKP010 AKUPUNKTUR POST STROKE 12,000.0018.003.03 AKP011 AKUPUNKTUR VERTIGO 12,000.0018.004.00 AKP012 AQUAPUNKTUR PROLENE+ I CARNITINE/REDOXON 32,000.0018.005.00 AKP013 AKUPUNKTUR BADAN & WAJAH 24,000.0018.005.01 AKP014 AKUPUNKTUR WAJAH (1 KALI) 12,000.0018.005.02 AKP015 PAKET AKUPUNKTUR WAJAH (5 KALI DLM 1 BULAN) 54,000.0018.006.00 AKP016 PAKET AKUPUNKTUR KESEHATAN (5 KALI DLM 1 BULAN) 54,000.0018.007.01 AKP017 MENGECILKAN LENGAN (1 KALI) 12,000.0018.007.02 AKP018 PAKET MENGECILKAN LENGAN (5 KALI DLM 1 BULAN) 54,000.0018.008.01 AKP019 MENGECILKAN PERUT (1 KALI) 12,000.0018.008.02 AKP020 PAKET MENGECILKAN PERUT (5 KALI DLM 1 BULAN) 54,000.0018.009.01 AKP021 MENGECILKAN PAHA (1 KALI) 12,000.0018.009.02 AKP022 PAKET MENGECILKAN PAHA (5 KALI DLM 1 BULAN) 54,000.0018.010.01 AKP023 AQUAPUNKTUR : INJEKSI (CARLINE + LIDOCAIN 2%) 62,000.0018.010.02 AKP024 VITAMIN C / LAROS CORBINE 54,000.0018.010.03 AKP025 PLACENTA COMPOSITUM 62,000.0018.010.04 AKP026 COLLAGEN RODOTEX 54,000.0018.010.05 AKP027 THATIONIL 62,000.0018.010.06 AKP028 VITAMIN E 62,000.0018.010.07 AKP029 H3 / GEOVITAL 54,000.0018.010.08 AKP030 VITACICOL 82,000.0018.010.09 AKP031 REDOXON 28,000.00

AKP032 PAKET 6 KALI TINDAKAN AKUPUNTUR 240,000.00AKP033 PAKET 12 KALI TINDAKAN AKUPUNTUR 480,000.00

01.100.01 AMB001 AMBULANCE JARAK < 5 KM 100,000.0001.100.02 AMB002 AMBULANCE JARAK 5 - 10 KM 150,000.0001.100.03 AMB003 AMBULANCE JARAK 10 - 20 KM 250,000.0001.100.04 AMB004 AMBULANCE JARAK > 20 KM (DKI & BOTABEK) 400,000.0001.100.05 AMB005 ADMINISTRASI AMBULANCE UNTUK RUJUKAN 100,000.0001.101.01 AMB006 AMBULANCE DENGAN DOKTER JARAK < 5 KM 200,000.0001.101.02 AMB007 AMBULANCE DENGAN DOKTER JARAK 5 - 10 KM 250,000.0001.101.03 AMB008 AMBULANCE DENGAN DOKTER JARAK 10 - 20 KM 350,000.0001.101.04 AMB009 AMBULANCE DENGAN DOKTER JARAK > 20 KM (DKI & BOTA 500,000.00

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20.001.00 ANK001 JASA SUNTIK (IMUNISASI) 10,000.0020.002.00 ANK002 TINDIK TELINGA BAYI 15,000.0020.003.00 ANK003 SUNAT BAYI PEREMPUAN 10,000.00

ANK004 TEST MANTOUX 50,000.0020.004.01 ANK005 VAKSIN BCG 20,000.0020.004.02 ANK006 VAKSIN DPT 15,000.0020.004.03 ANK007 VAKSIN DT 15,000.0020.004.04 ANK008 VAKSIN POLIO 10,000.0020.004.05 ANK009 VAKSIN CAMPAK 20,000.0020.004.06 ANK010 VAKSIN HEPATITIS (UNTUK 3 KALI SUNTIK) 60,000.0005.001.01 BDH001 AF HECHTING (1 - 5) 10,000.0005.001.02 BDH002 AF HECHTING (6 -10) 15,000.0005.001.03 BDH003 AF HECHTING (> 10) 20,000.0005.002.00 BDH004 ANUSCOPY 30,000.0005.003.00 BDH005 BIOPSI ( PUNCH BIOPSY ) 80,000.0005.004.01 BDH006 BUKA GIPS MAYOR ( TUNGKAI BAWAH ) 60,000.0005.004.02 BDH007 BUKA GIPS MINOR ( TUNGKAI ATAS ) 20,000.0005.005.01 BDH008 CIRCUMCISI ANAK-ANAK (< 12 Th) 300,000.0005.005.02 BDH009 CIRCUMCISI DEWASA 400,000.0005.006.00 BDH010 DILATASI PREPUTIUM 25,000.0005.007.01 BDH011 EKSTIRPASI ATHEROMA LIPOMA BESAR 100,000.0005.007.02 BDH012 EKSTIRPASI ATHEROMA LIPOMA SEDANG 80,000.0005.007.03 BDH013 EKSTIRPASI ATHEROMA LIPOMA KECIL 50,000.0005.007.04 BDH014 EKSTIRPASI GANGLION SEDANG 120,000.0005.007.05 BDH015 EKSTIRPASI GANGLION KECIL 80,000.0005.009.01 BDH016 GANTI VERBAN KECIL 10,000.0005.009.02 BDH017 GANTI VERBAN SEDANG 16,000.00

BDH018 PAKET ALKES GANTI VERBAN (INCL ALKES : MAX 10-15 PCS 25,000.00BDH019 PAKET ALKES GANTI VERBAN (INCL ALKES : 15 - 20 PCS KAS 30,000.00

05.009.03 BDH020 GANTI VERBAN BESAR 30,000.0005.010.00 BDH021 INCISI ABSES 30,000.0005.011.01 BDH022 INJEKSI VARICES ( SCLERO THERAPY ) 50,000.0005.011.02 BDH023 INJEKSI INTRARTIBULAR 30,000.0005.011.03 BDH024 INJEKSI KELOID 30,000.0005.012.00 BDH025 HECHTING SEKUNDER 40,000.0005.013.00 BDH026 LIGASI HEMOROID (OK) 100,000.0005.014.00 BDH027 PASANG FOLLEY CHATETER 35,000.0005.015.01 BDH028 PASANG GIPS MAYOR (EKSTREMITAS) 140,000.0005.015.02 BDH029 PASANG GIPS MINOR (JARI) 70,000.0005.016.00 BDH030 40,000.0005.017.00 BDH031 SKLEROTHERAPY HEMOROID 60,000.0005.018.00 BDH032 VENA SEKSI 60,000.0005.019.01 BDH033 NEKROTOMI KECIL 20,000.0005.019.02 BDH034 NEKROTOMI SEDANG 30,000.0005.019.03 BDH035 NEKROTOMI BESAR 40,000.0005.020.00 BDH036 DEBRIDEMENT 40,000.0005.021.00 BDH037 PASANG SPALK 20,000.0005.022.00 BDH038 PASANG CLOSTHE BANDAGE 20,000.0005.008.00 BDH040 EKSPLORASI / ANGKAT BENDA ASING 70,000.00

BDH041 SEWA SET GV 5,000.00

ROZERPLASTY ( EKSTRAKSI KUKU ) / NAEGEL EKSTRASI

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BDH042 50,000.00BDH043 GANTI VERBAN KECIL ( INCL ALKES : MAX 10 - 15 PCS KAIN 35,000.00BDH044 GANTI VERBAN KECIL ( INCL ALKES : MAX 15 - 20 PCS KAIN 40,000.00BDH045 GANTI VERBAN SEDANG ( INCL ALKES : MAX 10 - 15 PCS KAI 41,000.00BDH046 GANTI VERBAN SEDANG ( INCL ALKES : MAX 15 - 20 PCS KAI 46,000.00BDH047 GANTI VERBAN BESAR ( INCL ALKES : MAX 10 - 15 PCS KAIN 55,000.00BDH048 GANTI VERBAN BESAR ( INCL ALKES : MAX 15 - 20 PCS KAIN 60,000.00

31.500.02 BDM001 BONE DENSITOMETRI 1 OBY 300,000.0031.500.03 BDM002 BONE DENSITOMETRI 2 OBY 375,000.0031.500.04 BDM003 BONE DENSITOMETRI 3 OBY 395,000.0031.500.01 BDM004 ERCP 375,000.00

DOK001 JASA DOKTER JAGA ICU 0.00DOK002 JASA KONSUL DOKTER UGD - 08.01 - 21.00 30,000.00DOK003 JASA KONSUL DOKTER UGD - 21.01 - 08.00 35,000.00DOK004 JASA KONSULTASI AHLI AKUPUNKTUR (PRAKTEK KTK) 35,000.00DOK005 JASA KONSULTASI DOKTER GIZI 20,000.00DOK006 JASA KONSULTASI DOKTER SPESIALIS 20,000.00DOK007 JASA KONSULTASI DOKTER SPESIALIS ANAK 20,000.00DOK008 JASA KONSULTASI DOKTER SPESIALIS ANAK (PRAKTEK KTK) 20,000.00DOK009 JASA KONSULTASI DOKTER SPESIALIS BEDAH MULUT 20,000.00DOK010 JASA KONSULTASI DOKTER SPESIALIS BEDAH SYARAF 20,000.00DOK011 JASA KONSULTASI DOKTER SPESIALIS BEDAH TULANG 20,000.00DOK012 JASA KONSULTASI DOKTER SPESIALIS BEDAH UMUM 20,000.00DOK013 JASA KONSULTASI DOKTER SPESIALIS BEDAH UROLOGI 20,000.00DOK014 JASA KONSULTASI DOKTER SPESIALIS JANTUNG & PEMBULU 20,000.00DOK015 JASA KONSULTASI DOKTER SPESIALIS KEBIDANAN DAN KA 20,000.00DOK016 JASA KONSULTASI DOKTER SPESIALIS KESEHATAN JIWA 20,000.00DOK017 JASA KONSULTASI DOKTER SPESIALIS KULIT & KELAMIN 20,000.00DOK018 JASA KONSULTASI DOKTER SPESIALIS MATA 20,000.00DOK019 JASA KONSULTASI DOKTER SPESIALIS PARU & ASMA 20,000.00DOK020 JASA KONSULTASI DOKTER SPESIALIS PATOLOGI KLINIK 20,000.00DOK021 JASA KONSULTASI DOKTER SPESIALIS PENYAKIT DALAM 20,000.00DOK022 JASA KONSULTASI DOKTER SPESIALIS PERIODONTIST 20,000.00DOK023 JASA KONSULTASI DOKTER SPESIALIS PROSTHODONTIST 20,000.00DOK024 JASA KONSULTASI DOKTER SPESIALIS PSIKOLOGI 20,000.00DOK025 JASA KONSULTASI DOKTER SPESIALIS RM (PRAKTEK KTK) 20,000.00DOK026 JASA KONSULTASI DOKTER SPESIALIS SYARAF 20,000.00DOK027 JASA KONSULTASI DOKTER SPESIALIS T H T 20,000.00DOK028 JASA KONSULTASI DOKTER UMUM 30,000.00DOK029 JASA KONSULTASI DOKTER UMUM KECANTIKAN (SPA) 24,000.00DOK030 JASA KONSULTASI FISIOTERAPI 0.00DOK031 JASA KONSULTASI FISIOTERAPI_KTK 0.00DOK032 JASA KONSULTASI FISIOTERAPI_SPA 0.00DOK033 ON CALL DOKTER SPESIALIS 30,000.00DOK034 ON DUTY DOKTER SPESIALIS 20,000.00DOK035 VISITE DOKTER KELAS 1 0.00DOK036 VISITE DOKTER KELAS 2A 0.00DOK037 VISITE DOKTER KELAS 2B 0.00DOK038 VISITE DOKTER KELAS 3 0.00DOK039 VISITE DOKTER SVIP 0.00

ASPIRING ASPIRASI

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DOK040 VISITE DOKTER VIP 0.00DOK041 VISITE DOKTER NICU 0.00FIS ORDER PEMERIKSAAN FISIOTERAPI 0.00

19.001.00 FIS001 MEDICAL MASSAGE (PER REGIO) 28,000.0019.002.01 FIS002 EXERCISE TERAPI - EXERCISE 28,000.0019.002.02 FIS003 EXERCISE TERAPI - GENERAL EXERCISE 48,000.0019.003.00 FIS004 LASER 80,000.0019.004.01 FIS005 AKTINOTERAPI - INFRA RED 24,000.0019.005.01 FIS006 ELEKTROTERAPI - SWD (SHORT WAVE DIATHERMY) 28,000.0019.005.02 FIS007 ELEKTROTERAPI - MWD (MICRO WAVE DIATHERMY) 28,000.0019.005.03 FIS008 ELEKTROTERAPI - US (ULTRA SOUND) 28,000.0019.005.04 FIS009 ELEKTROTERAPI - ES (ELEKTRICAL STIMULATION) 28,000.0019.005.05 FIS010 ELEKTROTERAPI - TENS (TRANCUTANEUS ELEKTRICAL NERV 28,000.0019.005.06 FIS011 ELEKTROTERAPI - MODALITAS 2 ALAT YANG BERBEDA UNT 52,000.0019.005.07 FIS012 ELEKTROTERAPI - MODALITAS 3 ALAT YANG BERBEDA UNT 76,000.0019.005.08 FIS013 ELEKTROTERAPI - MODALITAS 4 ALAT YANG BERBEDA UNT 100,000.0019.006.01 FIS014 NEBULIZER - INHALASI + CHEST TERAPI 48,000.0019.006.02 FIS015 NEBULIZER - INHALASI + MWD + CHEST TERAPI 64,000.0019.006.03 FIS016 NEBULIZER - INHALASI + IR + CHEST TERAPI 56,000.0019.007.00 FIS017 TRAKSI LUMBAL 28,000.0019.008.00 FIS018 TRAKSI CERVICAL 28,000.0019.009.01 FIS019 HIDROTERAPI - PARAFIN BATH 24,000.0019.009.02 FIS020 HIDROTERAPI - COLD PACK 24,000.0019.009.03 FIS021 HIDROTERAPI - HOT PACK 24,000.00

FIS022 MODALITAS UNTUK AREA YANG LAIN 25,000.0006.100.01 GGI001 KONSULTASI DOKTER GIGI UMUM 20,400.0006.100.02 GGI002 KONSULTASI DOKTER GIGI SPESIALIS 36,000.0006.100.03 GGI003 PREMEDIKASI DOKTER GIGI UMUM 21,600.0006.100.04 GGI004 PREMEDIKASI DOKTER GIGI SPESIALIS 43,200.0006.101.00 GGI005 SCREENING 72,000.0006.102.00 GGI006 BUKA JAHITAN 36,000.0006.103.00 GGI007 KONTROL PASKA OPERASI 21,600.0006.104.01 GGI008 CETAK MODEL GIGI 1 RAHANG 21,600.0006.104.02 GGI009 CETAK MODEL GIGI 2 RAHANG 36,000.0006.105.00 GGI010 MOUTH GUARD 1 RAHANG 162,000.0006.201.00 GGI011 FOTO DENTAL (PER FOTO) 21,600.0006.301.00 GGI012 DHE & ORAL PROFILAKSIS 54,000.0006.302.00 GGI013 FLUORIDASI TOPIKAL 72,000.0006.303.00 GGI014 PIT & FISSURE SEALANT 54,000.0006.401.01 GGI015 TUMPATAN GIC KECIL 54,000.0006.401.02 GGI016 TUMPATAN GIC SEDANG 72,000.0006.401.03 GGI017 TUMPATAN GIC BESAR 90,000.0006.402.01 GGI018 RAINBOW FILLING KECIL 54,000.0006.402.02 GGI019 RAINBOW FILLING SEDANG 72,000.0006.402.03 GGI020 RAINBOW FILLING BESAR 90,000.0006.403.01 GGI021 PUPOTOMI DOKTER GIGI UMUM 36,000.0006.403.02 GGI022 PUPOTOMI DOKTER GIGI SPESIALIS 54,000.0006.404.01 GGI023 ENDODONTIK GIGI SUSU DOKTER GIGI UMUM 36,000.0006.404.02 GGI024 ENDODONTIK GIGI SUSU DOKTER GIGI SPESIALIS 54,000.0006.405.01 GGI025 EKSTRAKSI GIGI SUSU TANPA INJEKSI 36,000.00

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06.405.02 GGI026 EKSTRAKSI GIGI SUSU DENGAN INJEKSI 54,000.0006.406.00 GGI027 SPACE MAINTAINER 126,000.0006.501.00 GGI028 TUMPATAN SEMENTARA 54,000.0006.502.00 GGI029 PULP CAPPING 54,000.0006.503.01 GGI030 PERAWATAN ENDODONTIK PER KUNJUNGAN AKAR TUNGGAL 54,000.0006.503.02 GGI031 PERAWATAN ENDODONTIK PER KUNJUNGAN AKAR GANDA 72,000.0006.504.01 GGI032 TUMPATAN KOMPOSIT KECIL 72,000.0006.504.02 GGI033 TUMPATAN KOMPOSIT SEDANG 90,000.0006.504.03 GGI034 TUMPATAN KOMPOSIT BESAR 108,000.0006.505.01 GGI035 INLAY / ONLAY / UPLAY METAL 234,000.0006.505.02 GGI036 INLAY / ONLAY / UPLAY KERAMIK 324,000.0006.506.00 GGI037 HOME BLEACHING 900,000.0006.507.00 GGI038 OFFICE BLEACHING 1,440,000.0006.601.01 GGI039 EKSTRAKSI GIGI PERMANEN 72,000.0006.601.02 GGI040 EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS MUDAH 108,000.0006.601.03 GGI041 EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS SEDANG 126,000.0006.601.04 GGI042 EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS SULIT 144,000.0006.602.01 GGI043 ODONTECTOMY KELAS I 540,000.0006.602.02 GGI044 ODONTECTOMY KELAS II 720,000.0006.602.03 GGI045 ODONTECTOMY KELAS III 900,000.0006.603.00 GGI046 ALVEOLECTOMY PER REGIO 180,000.0006.604.00 GGI047 IMPLANT 6,480,000.0006.605.00 GGI048 INSISI ABSES INTRA ORAL 72,000.0006.606.00 GGI049 INSISI ABSES EXTRA ORAL 216,000.0006.607.00 GGI050 EKSISI 270,000.0006.608.00 GGI051 APEX RESEKSI PER GIGI 540,000.0006.609.00 GGI052 OPERCULETOMY 180,000.0006.610.00 GGI053 EKSTIRPASI MUCOCEL 270,000.0006.611.00 GGI054 BONE GRAFT 2,160,000.0006.612.00 GGI055 FIKSASI FRAKTUR 540,000.0006.613.00 GGI056 KURET DRY SOCKET 72,000.0006.701.01 GGI057 JACKET CROWN METAL ACRYLIC 216,000.0006.701.02 GGI058 JACKET CROWN METAL PORCELAIN 450,000.0006.701.03 GGI059 JACKET CROWN ALL ACRYLIC 144,000.0006.701.04 GGI060 JACKET CROWN ALL PORCELAIN 720,000.0006.701.05 GGI061 JACKET CROWN ALL METAL 198,000.0006.702.00 GGI062 PIN FIBER & CROWN 900,000.0006.703.00 GGI063 PIN METAL & CROWN 540,000.0006.704.00 GGI064 MAHKOTA SEMENTARA 72,000.0006.705.01 GGI065 SEMENTASI CROWN (1-2 GIGI) 72,000.0006.705.02 GGI066 SEMENTASI CROWN (> 2 GIGI) 54,000.0006.706.01 GGI067 PLAT AKRILIK & 1 GIGI AKRILIK 198,000.0006.706.02 GGI068 PLAT AKRILIK & 1 GIGI PORSELEN 288,000.0006.707.00 GGI069 PLAT FRAME 540,000.0006.708.01 GGI070 FLEXY DENTURE SADDLE & 1 GIGI 360,000.0006.708.02 GGI071 FLEXY DENTURE BILATERAL & 1 GIGI 360,000.0006.709.01 GGI072 SINGLE COMPLETE DENTURE AKRILIK 792,000.0006.709.02 GGI073 SINGLE COMPLETE DENTURE PORSELEN 990,000.0006.710.01 GGI074 FULL DENTURE AKRILIK RA & RB 1,584,000.0006.710.02 GGI075 FULL DENTURE PORSELEN RA & RB 1,800,000.00

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06.711.01 GGI076 ELEMEN GIGI TIRUAN AKRILIK 63,000.0006.711.02 GGI077 ELEMEN GIGI TIRUAN PORSELEN 90,000.0006.711.03 GGI078 ELEMEN GIGI TIRUAN FLEXY DENTURE 54,000.0006.712.00 GGI079 CENGKERAM (PER CENGKRAM) 36,000.0006.713.01 GGI080 REPARASI KASUS MUDAH 72,000.0006.713.02 GGI081 REPARASI KASUS SEDANG 90,000.0006.713.03 GGI082 REPARASI KASUS SULIT 288,000.0006.714.01 GGI083 RELINING KASUS MUDAH 108,000.0006.714.02 GGI084 RELINING KASUS SEDANG 144,000.0006.714.03 GGI085 RELINING KASUS SULIT 270,000.0006.715.01 GGI086 REBASING KASUS MUDAH 99,000.0006.715.02 GGI087 REBASING KASUS SEDANG 144,000.0006.715.03 GGI088 REBASING KASUS SULIT 198,000.0006.716.00 GGI089 BONGKAR CROWN 126,000.0006.801.01 GGI090 SCALING PER RAHANG KELAS I 36,000.0006.801.02 GGI091 SCALING PER RAHANG KELAS II 45,000.0006.801.03 GGI092 SCALING PER RAHANG KELAS III 54,000.0006.802.01 GGI093 KURETASE (1 GIGI) 54,000.0006.802.02 GGI094 KURETASE (> 1 GIGI) 36,000.0006.803.00 GGI095 FLAP (PER REGIO) 180,000.0006.804.01 GGI096 SPLINTING (2 GIGI) 108,000.0006.804.02 GGI097 SPLINTING (> 2 GIGI) 36,000.0006.805.01 GGI098 GINGGIVEKTOMI (1-2 GIGI) 72,000.0006.805.02 GGI099 GINGGIVEKTOMI (> 2 GIGI) 54,000.0006.805.01 GGI100 DESENSITISASI (1 GIGI) 54,000.0006.805.02 GGI101 DESENSITISASI (> 2 GIGI) 36,000.0006.806.00 GGI102 SELECTIVE GRINDING 36,000.0006.807.00 GGI103 RECONTOURING 72,000.0006.901.01 GGI104 FIXED PER RAHANG KASUS MUDAH 900,000.0006.901.02 GGI105 FIXED PER RAHANG KASUS SEDANG 1,170,000.0006.901.03 GGI106 FIXED PER RAHANG KASUS SULIT 1,440,000.00

GGI107 FIXED CERAMIC PER RAHANG 4,320,000.0006.902.00 GGI108 REMOVABLE 324,000.0006.903.00 GGI109 PEMASANGAN BRACKET LEPAS 54,000.0006.904.00 GGI110 AKTIVASI FIXED 54,000.0006.905.00 GGI111 AKTIVASI REMOVABLE 36,000.0024.800.01 HCR001 CREAMBATH TRADITIONAL 25,000.0024.800.02 HCR002 CREAMBATH NR 40,000.0024.800.03 HCR003 HAIR SPA LOREAL 60,000.0024.800.04 HCR004 HAIR MASKER STRUKTURA 70,000.0024.800.05 HCR005 CAT RAMBUT LOREAL 200,000.0024.800.06 HCR006 CUCI RAMBUT 10,000.0024.800.07 HCR007 CUCI BLOW 25,000.0024.800.08 HCR008 BLOW SOFT 10,000.0024.800.09 HCR009 BLOW CATOK 35,000.0024.800.10 HCR010 BLOW VARIASI 35,000.0024.800.11 HCR011 BLOW SPIRAL 35,000.0024.800.12 HCR012 PERAWATAN RAMBUT NUTRIOL 125,000.0024.900.00 HCR013 REFLEKSI 30,000.00

HCR014 CAT RAMBUT MAKARIZO 165,000.00

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HCR015 HIGH LIGTH 200,000.00HCR016 TONING RAMBUT 200,000.00HCR017 SMOOTHING TANPA PRODUK 350,000.00HCR018 BLEACHING 15,000.00HCR019 CREAM BATH TANPA PRODUK 25,000.00HCR020 BILA TANPA CAT 150,000.00HCR021 SMOOTHING TANPA PRODUK 200,000.00HCR022 GUNTING PAKET 35,000.00HCR023 GUNTING RAMBUT 20,000.00HCR024 CABUT ALIS 15,000.00HCR025 CAT RAMBUT PAKET 165,000.00HCR026 TONING RAMBUT PAKET 0.00HCR027 JASA TINDAKAN CAT RAMBUT 60,000.00HCR028 JASA TINDAKAN TONING 0.00HD0001 PAKET TREATMENT 1 (HAEMODIALISA) 830,000.00HD0002 PAKET TREATMENT II ( HAEMODALISA ) 726,000.00

17.001.00 HDR001 CLEANCING COLON 160,000.0017.002.01 HDR002 PAKET CLEANSING COLON 3X 440,000.0017.002.02 HDR003 PAKET CLEANSING COLON 6X 880,000.0017.002.03 HDR004 PAKET CLEANSING COLON 9X 1,320,000.0017.002.04 HDR005 PAKET CLEANSING COLON 10X 1,440,000.00

INJ001 INJEKSI KENACORT 24,000.00JSD001 JASA PEMERIKSAAN - DOKTER UMUM 30,000.00JSD002 JASA PEMERIKSAAN - DOKTER GIGI 20,000.00JSD003 JASA PEMERIKSAAN - DOKTER SPESIALIS ANAK 20,000.00JSD004 JASA PEMERIKSAAN - DOKTER SPESIALIS PENYAKIT DALAM 20,000.00JSD005 JASA PEMERIKSAAN - DOKTER SPESIALIS JANTUNG 20,000.00JSD006 JASA PEMERIKSAAN - DOKTER SPESIALIS MATA 20,000.00JSD007 JASA PEMERIKSAAN - DOKTER SPESIALIS THT 20,000.00JSD008 JASA PEMERIKSAAN - DOKTER SPESIALIS KEBIDANAN 20,000.00JSD009 JASA PEMERIKSAAN - DOKTER GIGI SPESIALIS 20,000.00JSD010 JASA PEMERIKSAAN - DOKTER SPESIALIS SARAF 20,000.00JSD011 JASA PEMERIKSAAN - DOKTER SPESIALIS KESEHATAN JIWA 20,000.00

13.001.00 JTG001 ECG 35,000.0013.002.00 JTG002 PLEURA PUNKSI 50,000.0013.003.00 JTG003 SPIROMETRI 30,000.0013.004.00 JTG004 TREADMILL 175,000.0013.005.01 JTG005 USG (ECHO RADIOGRAPHIC) 125,000.0013.005.02 JTG006 USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER 175,000.0013.006.00 JTG007 JASA SUNTIK (IMUNISASI) 10,000.0013.007.00 JTG008 TEST MANTOUX 50,000.0013.008.00 JTG009 NEBULIZER 60,000.0014.001.00 JWA001 MMPI 52,500.0011.001.00 KBK001 ANGKAT PESARIUM 20,000.0011.002.01 KBK002 CABUT IMPLANON (JASA ) 60,000.0011.002.02 KBK003 CABUT IUD (JASA) 20,000.0011.003.00 KBK004 EKSTIRPASI ( OBSGYN ) 220,000.0011.004.00 KBK005 JASA SUNTIK (IMUNISASI) 10,000.0011.005.00 KBK006 MICRO CURRATAGE / PA 220,000.0011.006.01 KBK007 PASANG IMPLANON (JASA) 80,000.00

TarifKIT

11.006.02 KBK008 PASANG IUD (JASA) 60,000.0011.007.00 KBK009 PAP SMEAR / VAGINAL SMEAR 15,000.0011.008.01 KBK010 PASANG LAMINARIA 60,000.0011.008.02 KBK011 PASANG PESARIUM ( DI LUAR ALKES ) 20,000.0011.009.01 KBK012 USG 2-D & PRINT OUT 32,500.00

KBK013 USG 2-D NON PRINT OUT 19,500.0011.009.02 KBK014 USG 4-D & PRINT OUT 292,500.0011.009.03 KBK015 USG TRANSVAGINAL 97,500.0011.010.00 KBK016 HIDROTUBASI 70,000.0011.011.00 KBK017 CTG 25,000.00

KBK018 BIOPSY SERVIC 280,000.0011.001.00.01KBK019 ANGKAT PESARIUM ( TERMASUK ALKES ) 20,000.0011.002.01.01KBK020 CABUT IMPLANON ( TERMASUK ALKES ) 50,000.0011.002.02.01KBK021 CABUT IUD ( TERMASUK ALKES ) 20,000.0011.003.00.01KBK022 EKSTIRPASI ( OBSGYN )( TERMASUK ALKES ) 220,000.0011.005.00.01KBK023 MICRO CURRATAGE / PA ( TERMASUK ALKES ) 220,000.0011.006.01.01KBK024 PASANG IMPLANON (JASA + ALKES ) 80,000.0011.006.02.01KBK025 PASANG IUD (JASA + ALKES) 50,000.0011.007.00.01KBK026 PAP SMEAR / VAGINAL SMEAR ( TERMASUK ALKES ) 15,000.0011.008.01.01KBK027 PASANG LAMINARIA ( TERMASUK ALKES ) 40,000.0011.008.02.01KBK028 PASANG PESARIUM ( TERMASUK ALKES ) 20,000.0011.010.00.01KBK029 HIDROTUBASI ( TERMASUK ALKES ) 70,000.0011.011.00.01KBK030 CTG ( TERMASUK ALKES ) 25,000.00

KBK031 BIOPSY SERVIC ( TERMASUK ALKES ) 70,000.00KKK001 PEELING KECIL 120,000.00KKK002 PEELING SEDANG 132,000.00KKK003 PEELING BESAR 144,000.00KKK004 CAUTER KECIL 135,000.00KKK005 CAUTER SEDANG 180,000.00KKK006 CAUTER BESAR 240,000.00KKK007 EKSTRAKSI KECIL 75,000.00KKK008 EKSTRAKSI SEDANG 99,000.00KKK009 EKSTRAKSI BESAR 120,000.00KKK010 KIL KECIL 150,000.00KKK011 KIL SEDANG 165,000.00KKK012 INJEKSI KENOCART 24,000.00KKK013 BIOPSY 99,000.00KKK014 ELEKTRO CAUTER BADAN KECIL 42,000.00KKK015 ELEKTRO CAUTER BADAN SEDANG 55,000.00KKK016 ELEKTRO CAUTER BADAN BESAR 80,000.00KKK017 ELEKTRO CAUTER WAJAH KECIL 47,500.00KKK018 ELEKTRO CAUTER WAJAH SEDANG 74,500.00KKK019 ELEKTRO CAUTER WAJAH BESAR 86,300.00KKK020 EKSISI NEVUS 111,000.00KKK021 ENUKKASI KECIL 24,000.00KKK022 ENUKKASI SEDANG 35,000.00KKK023 ENUKKASI BESAR 47,000.00KKK024 EKSTIRPASI LIPOMA 80,000.00KKK025 EKSTRAKSI KOMEDO KECIL 17,000.00KKK026 EKSTRAKSI KOMEDO SEDANG 25,000.00

TarifKIT

KKK027 EKSTRAKSI KOMEDO BESAR 36,000.00KKK028 INSISI ABCESS 65,000.00KKK029 INSISI ABCESS BARTHOLINI 106,000.00KKK030 PEELING NEOSTRATA 20-35% 90,000.00KKK031 PENGOBATAN KONDILOMA (DGN PODOFILLIN) KECIL 36,000.00KKK032 PENGOBATAN KONDILOMA (DGN PODOFILLIN) SEDANG 52,000.00KKK033 PENGOBATAN KONDILOMA (DGN PODOFILLIN) BESAR 66,000.00KKK034 ALKES ELEKTRO CAUTER 60,000.00KKK035 ALKES EKSISI 60,000.00KKK036 ALKES ENUKKASI 60,000.00KKK037 ALKES EKSTIRPASI ( TANPA BENANG ) 65,000.00KKK038 ALKES EKSTRASI KOMEDO 60,000.00KKK039 ALKES INSISI ( DENGAN BENANG ) 75,000.00

31.700.01 KON001 OMNIPAQUE 20 ML 132,000.0031.700.02 KON002 OMNIPAQUE 50 ML 269,500.0031.700.03 KON003 IOPAMIRO 30 ML 220,000.0031.700.04 KON004 IOPAMIRO 50 ML 313,500.00

KRT001 JASA OPERATOR - KURET 0.00KRT002 SHARE OPERATOR - KURET 0.00KRT003 JASA ANASTESI - KURET 0.00KRT004 SHARE ANESTESI - KURET 0.00KRT005 KAMAR BERSALIN - KURET 200,000.00KRT006 KAMAR OBSERVASI - KURET 85,000.00

20.004.01 KTK001 SENSORI INTEGRASI 70,000.0020.004.02.01KTK002 TERAPI (FISIOTERAPI) 45 MENIT - TERAPI 1 SESSION 50,000.0020.004.02.02KTK003 TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 1 BULAN 350,000.0020.004.02.03KTK004 TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 2 BULAN 750,000.0020.004.02.04KTK005 TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 3 BULAN 1,150,000.0020.004.03.01KTK006 TERAPI (OKUPASI TERAPI) - TERAPI 1 SESSION 50,000.0020.004.03.02KTK007 TERAPI (OKUPASI TERAPI) - TERAPI KELAS 1 BULAN 350,000.0020.004.03.03KTK008 TERAPI (OKUPASI TERAPI) - TERAPI KELAS 2 BULAN 750,000.0020.004.03.04KTK009 TERAPI (OKUPASI TERAPI) - TERAPI KELAS 3 BULAN 1,150,000.0020.004.04.01KTK010 TERAPI (SPEECH TERAPI) - TERAPI 1 SESSION 50,000.0020.004.04.02KTK011 TERAPI (SPEECH TERAPI) - TERAPI KELAS 1 BULAN 350,000.0020.004.04.03KTK012 TERAPI (SPEECH TERAPI) - TERAPI KELAS 2 BULAN 750,000.0020.004.04.04KTK013 TERAPI (SPEECH TERAPI) - TERAPI KELAS 3 BULAN 1,150,000.0020.004.04.05KTK014 TERAPI (SPEECH TERAPI) - FEEDING PROBLEM THERAPY 60,000.0020.005.01.01KTK015 PELATIHAN MASSAGE BAYI - TEORI (OLEH DOKTER RM) 0.0020.005.01.02KTK016 PELATIHAN MASSAGE BAYI - PRAKTEK 75,000.00

KTK017 MASSAGE BAYI 50,000.00LAB001 DARAH RUTIN 45,000.00LAB002 DARAH LENGKAP 50,000.00LAB003 PAKET DHF 40,000.00LAB004 HEMOGLOBIN 15,000.00LAB005 HEMATOKRIT 15,000.00LAB006 JUMLAH LEKOSIT 15,000.00LAB007 JUMLAH TROMBOSIT 15,000.00LAB008 JUMLAH RETIKULOSIT 15,000.00LAB009 JUMLAH EOSINOFIL 15,000.00LAB010 MALARIA 25,000.00

TarifKIT

LAB011 GOLONGAN DARAH ABO RHESUS 15,000.00LAB012 GAMBARAN DARAH TEPI 100,000.00LAB013 GAMBARAN SUMSUM TULANG 287,000.00LAB014 RUMPELL LEEDE 15,000.00LAB015 MASA PENDARAHAN / BT 15,000.00LAB016 MASA PROTROMBIN (PT) & INR 93,500.00LAB017 MASA TROMBOPLASTIN PARSIAL / A P I T 85,000.00LAB018 MASA TROMBIN ( TT ) 71,500.00LAB019 MASA TROMBIN SERIAL 236,500.00LAB020 FIBRINOGEN 99,000.00LAB021 D - DIMER 236,500.00LAB022 TROMBOTEST 93,500.00LAB023 ANTI TROMBIN III ( AT III ) 290,500.00LAB024 PROTEIN C 350,000.00LAB025 PROTEIN S 350,000.00LAB026 AGREGASI TROMBOSIT 179,000.00LAB027 SI - TIBC 190,000.00LAB028 FERITIN 160,000.00LAB029 ELEKTROFORESIS HB 160,000.00LAB030 VITAMIN B 12 415,000.00LAB031 ASAM FOLAT 350,000.00LAB032 G6PD ERITROSIT 110,000.00LAB033 RESISTENSI OSMOTIK 44,000.00LAB034 COOMB'S TEST 150,000.00LAB035 HAM'S & SUGAR TEST 0.00LAB036 ANTIBODI TROMBOSIT 111,000.00LAB037 VISKOSITAS DARAH / PLASMA 100,000.00LAB038 SEL LE 35,000.00LAB039 PEWARNAAN SITOKIMIA - NAP 250,000.00LAB040 PEWARNAAN SITOKIMIA - SBB 250,000.00LAB041 PEWARNAAN SITOKIMIA - MGG 270,000.00LAB042 CROSSMATCH 0.00LAB043 PROTEIN TOTAL - ALB - GLOB 50,000.00LAB044 ALBUMIN 30,000.00LAB045 ELEKTROFORESIS PROTEIN 117,000.00LAB046 BILLIRUBIN TOT - DIR - IND 50,000.00LAB047 FOSFATASE ALKALI 49,500.00LAB048 SGOT - SGPT 46,000.00LAB049 GAMMA GT (GGT) 48,000.00LAB050 CHOLISNESTERASE (CHE) 94,000.00LAB051 ASAM EMPEDU 300,000.00LAB052 AMONIA 328,000.00LAB053 TRIGLISERIDA 25,000.00LAB054 KOLESTEROL TOTAL 30,000.00LAB055 HDL KOLESTEROL 30,000.00LAB056 LDL KOLESTEROL 30,000.00LAB057 APO - A 160,000.00LAB058 APO - B 125,000.00LAB059 LP (A) 195,000.00LAB060 LDH 83,000.00

TarifKIT

LAB061 HBDH 104,000.00LAB062 CK TOTAL 101,000.00LAB063 CK - MB 146,000.00LAB064 TROPONIN KUALITATIF 220,000.00LAB065 TROPONIN KUANTITATIF 385,000.00LAB066 HOMOCYSTEIN 275,000.00LAB067 HIGH SENSITIVE C R P 180,000.00LAB068 GLUKOSA SEWAKTU 18,000.00LAB069 GLUKOSA PUASA 18,000.00LAB070 GLUKOSA 2 JAM PP 18,000.00LAB071 KURVA HARIAN GLUKOSA 55,000.00LAB072 TES TOLERANSI GLUKOSA / GTT 75,000.00LAB073 GLIKO HB (HBA 1C) 145,000.00LAB074 FRUKTOSAMIN 176,000.00LAB075 UREUM 23,000.00LAB076 CREATININ 23,000.00LAB077 ASAM URAT 23,000.00LAB078 CREATININ CLEARANCE ( BERSIHAN CLEARANCE ) 55,000.00LAB079 CYSTATIN C 255,000.00LAB080 NATRIUM 37,500.00LAB081 KALIUM URIN 37,500.00LAB082 CHLORIDA 37,500.00LAB083 CALSIUM TOTAL 41,000.00LAB084 CALSIUM ION 225,000.00LAB085 FOSFOR ORGANIK / ANORGANIK 41,000.00LAB086 MAGNESIUM TOTAL 41,000.00LAB087 ANALISA GAS DARAH 140,000.00LAB088 AMILASE 100,000.00LAB089 AMILASE PANKREATIK 154,000.00LAB090 LIPASE 167,000.00LAB091 FOSFATASE ASAM 132,000.00LAB092 FOSFATASE ASAM PROSTAT ( PAP ) 229,000.00LAB093 AMINOPHYLIN / THEOPHILIN 369,000.00LAB094 DIGOXIN 290,000.00LAB095 CLYCOSPORIN 550,000.00LAB096 PHENOBARBITAL 525,000.00LAB097 VDRL / RPR 40,000.00LAB098 TPHA 62,500.00LAB099 WIDAL 65,000.00LAB100 ANTI DENGUE IGG - IGM 260,000.00LAB101 ANTI TB IGG / ICT TB 150,000.00LAB102 HELICOBACTER PYLORI IGG 286,000.00LAB103 ANTI HIV 199,000.00LAB104 WESTERN BLOT 700,000.00LAB105 SERAMOEBA / DT 215,000.00LAB106 CRP KUANTITATIF 82,500.00LAB107 ASTO 115,500.00LAB108 RF 73,000.00LAB109 HBSAG 89,000.00LAB110 ANTI HBS (TITER) 102,000.00

TarifKIT

LAB111 HBE AG 250,000.00LAB112 ANTI HBE 295,000.00LAB113 ANTI HBC TOTAL 167,000.00LAB114 ANTI HBC IGM 310,000.00LAB115 HBV - DNA KUALITATIF 800,000.00LAB116 HBV - DNA KUANTITATIF 1,400,000.00LAB117 ANTI HAV IGM 195,000.00LAB118 ANTI HCV TOTAL 230,000.00LAB119 ANTI HCV IGM 564,000.00LAB120 HCV - RNA KUALITATIF 1,000,000.00LAB121 HCV - RNA KUANTITATIF 1,800,000.00LAB122 AFP ( HATI ) 142,500.00LAB123 CEA ( COLON ) 142,500.00LAB124 CA 125 ( OVARIUM ) 275,000.00LAB125 CA 19-9 ( PANKREAS ) 275,000.00LAB126 CA 15-3 ( MAMMA ) 275,000.00LAB127 PSA TOTAL ( PROSTATE ) 199,000.00LAB128 FREE PSA ( PROSTATE ) 420,000.00LAB129 NSE ( PARU ) 330,000.00LAB130 SCC ( CERVIX ) 253,000.00LAB131 ANTI TOKSOPLASMA IGG 155,000.00LAB132 ANTI TOKSOPLASMA IGM 159,000.00LAB133 ANTI RUBELLA IGG 167,000.00LAB134 ANTI RUBELLA IGM 182,000.00LAB135 ANTI CMV IGG 159,000.00LAB136 ANTI CMV IGM 182,000.00LAB137 ANTI HSV I IGG 160,000.00LAB138 ANTI HSV I IGM 164,000.00LAB139 ANTI HSV II IGG 160,000.00LAB140 ANTI HSV II IGM 164,000.00LAB141 ANTI CHLAMYDIA IGG 325,000.00LAB142 ANTI CHLAMYDIA IGM 325,000.00LAB143 IGG 240,000.00LAB144 IGA 240,000.00LAB145 IGM 240,000.00LAB146 IGE TOTAL 170,000.00LAB147 IGE SPESIFIK 750,000.00LAB148 KOMPLEMEN C3 245,000.00LAB149 KOMPLEMEN C4 245,000.00LAB150 ALFA ANTITRIPSIN 115,000.00LAB151 ANA 250,000.00LAB152 ANTI DS DNA 260,000.00LAB153 ACA IGG 330,000.00LAB154 ACA IGM 330,000.00LAB155 AMA 80,000.00LAB156 SMA 80,000.00LAB157 IMUNOFIKSASI 375,000.00LAB158 LIMFOSIT T 350,000.00LAB159 LIMFOSIT SUBSET ( CD4, CD8, CD19, NK ) 360,000.00LAB160 LIMFOSIT B 350,000.00

TarifKIT

LAB161 T4 TOTAL 125,000.00LAB162 T3 TOTAL 125,000.00LAB163 TSH SENSITIF 137,500.00LAB164 T4 BEBAS ( FREE T4 ) 175,000.00LAB165 T3 BEBAS ( FREE T3 ) 200,000.00LAB166 THYROGLOBULIN 357,000.00LAB167 ANTI THYROGLOBULIN 190,000.00LAB168 ANTI T P O 0.00LAB169 TSH NEONATUS 165,000.00LAB170 LH 185,000.00LAB171 FSH 185,000.00LAB172 PROLAKTIN 180,000.00LAB173 ESTRADIOL 220,000.00LAB174 ESTROGEN 1,080,000.00LAB175 PROGESTERON 220,000.00LAB176 TESTOTERON 198,000.00LAB177 B HCG KUANTITATIF 250,000.00LAB178 INSULIN 170,000.00LAB179 VMA 120,000.00LAB180 ACTH 1,440,000.00LAB181 P T H 350,000.00LAB182 URINALISIS LENGKAP 27,500.00LAB183 PROTEIN (ALBUMIN) 12,500.00LAB184 REDUKSI / GLUKOSA - URIN LENGKAP 12,500.00LAB185 SEDIMEN - URIN LENGKAP 15,000.00LAB186 KETON - URIN LENGKAP 15,000.00LAB187 PROTEIN BENCE JONES 33,000.00LAB188 MIKRO ALBUMIN 90,000.00LAB189 TEST KEHAMILAN EIA 55,000.00LAB190 PROTEIN KUANTITATIF 100,000.00LAB191 UREUM - URIN KIMIA 23,000.00LAB192 CREATININ - URIN KIMIA 23,000.00LAB193 NATRIUM - URIN KIMIA 37,500.00LAB194 CLORIDA - URIN KIMIA 37,500.00LAB195 CALSIUM - URIN KIMIA 42,000.00LAB196 MORPHIN 60,000.00LAB197 MARIJUANA / THC 60,000.00LAB198 COCAIN 60,000.00LAB199 BENZODIAZEPIN 60,000.00LAB200 AMPHETAMIN 60,000.00LAB201 TINJA RUTIN 20,000.00LAB202 PENCERNAAN 15,000.00LAB203 DARAH SAMAR 30,000.00LAB204 ANALISA CAIRAN OTAK ( RUTIN ) 100,000.00LAB205 PROTEIN - CAIRAN OTAK 40,000.00LAB206 GLUKOSA - CAIRAN OTAK 20,000.00LAB207 CHLORIDA - CAIRAN OTAK 41,000.00LAB208 CAIRAN TUBUH RUTIN 100,000.00LAB209 RATIO PROTEIN 55,000.00LAB210 RATIO LDH 110,000.00

TarifKIT

LAB211 GLUKOSA CAIRAN TUBUH 35,000.00LAB212 ANALISA SPERMA 165,000.00LAB213 ANALISA BATU GINJAL 125,000.00LAB214 ANALISA CAIRAN SENDI 155,000.00LAB215 PEWARNAAN GRAM 35,000.00LAB216 PEWARNAAN BTA 35,000.00LAB217 BIAKAN KUMAN AEROB 192,500.00LAB218 BIAKAN KUMAN ANAEROB 262,000.00LAB219 RESISTENSI 192,500.00LAB220 BIAKAN MYCOBACTERIUM TB 263,000.00LAB221 PCR MYCOBACTERIUM TB 300,000.00LAB222 PCR SALMONELLA TYPHI 300,000.00LAB223 PAP SMEARS 100,000.00LAB224 P A JARINGAN KECIL 250,000.00LAB225 MASA PEMBEKUAN / CT 15,000.00LAB226 IT RATIO 15,000.00LAB227 BILIRUBIN NEONATUS 50,000.00LAB228 P A JARINGAN BESAR 500,000.00LAB229 175,000.00LAB230 GALL ( EMPEDU ) 192,500.00LAB231 HBA 1C 145,000.00LAB232 275,000.00LAB233 263,000.00LAB234 KETON DARAH 40,000.00LAB235 LAJU ENDAP DARAH (LED) 15,000.00LAB236 HITUNG JENIS (DIFF) 15,000.00LAB237 SGOT 23,000.00LAB238 SGPT 23,000.00LAB239 NILAI ERITROSIT ( MCV, MCH, MCHC ) 15,000.00LAB240 EOSINOFIL INGUS 15,000.00LAB241 G6PD NEONATUS 120,000.00LAB242 LE REAKSI 45,000.00LAB243 TRANSFERIN 162,500.00LAB244 RETRAKSI BEKUAN 12,000.00LAB245 I N R 85,000.00LAB246 S T T 236,500.00LAB247 ASTRUP 140,000.00LAB248 PROTEIN TOTAL 25,000.00LAB249 C - PEPTIDE 210,000.00LAB250 INSULIN PUASA 190,000.00LAB251 LIPID TOTAL 50,000.00LAB252 REDUKSI / GLUKOSA 12,500.00LAB253 METAMPHETAMIN 60,000.00LAB254 CANABIS / MARIYUANA 60,000.00LAB255 ANALISA FECES ANAK 120,000.00LAB256 ANALISA CAIRAN PLEURA ( RUTIN ) 100,000.00LAB257 ANTI HAV TOTAL 239,000.00LAB258 RHEUMATOID FAKTOR 71,500.00LAB259 C - REACTIVE PROTEIN 82,500.00LAB260 ANTI DENGUE IGG 120,000.00

GO / SEKTED / GONORRHOE ???

CA 19-9 ( PAYUDARA ) ---PANKREASMYCOBACTERIUM / BTA ?????

TarifKIT

LAB261 ANTI DENGUE IGM 140,000.00LAB262 HELICOBACTER PYLORI IGM 282,000.00LAB263 ANTI CARDIOLIPIN IGG 330,000.00LAB264 ANTI CARDIOLIPIN IGM 330,000.00LAB265 T3 UPTAKE 195,000.00LAB266 F T I 220,000.00LAB267 CA 72 - 4 525,000.00LAB268 CORTISOL 231,000.00LAB269 JAMUR ????? 192,500.00LAB270 SALMONELLA TYPHI M 165,000.00LAB271 LEPTOSPIROSIS 110,000.00LAB272 LDH CAIRAN TUBUH 55,000.00LAB273 TEST E I A 55,000.00LAB274 SALMONELA IGM/TUBEX 150,000.00LAB275 KALIUM DARAH 37,500.00LAB276 KULTUR JAMUR 192,500.00LAB277 CANDIDA 162,000.00LAB278 ASPERGILLUS 162,000.00LAB279 HITOPLASMA 162,000.00LAB280 KRIPTO COCCUS 162,000.00LAB281 PREPARAT JAMUR 35,000.00LAB282 ICT MALARIA 159,000.00LAB283 MAGNESIUM URIN 38,500.00LAB284 CIFRA 21 360,000.00LAB285 ADINAFIN DIAMINASE 180,000.00LAB286 VIRAL LOAD HIV 1,020,000.00LAB287 PCR MALARIA 300,000.00LAB288 PRACALEITONIN 396,000.00LAB289 ANALISA SPERMA 165,000.00LAB290 IDT AMOEBA 252,000.00LAB291 ANALISA BATU EMPEDU 143,000.00LAB292 LIMFOSIT T SUBSET (CD4, CD8 ) 240,000.00LAB293 CD4 132,000.00LAB294 CD8 132,000.00LAB295 SALMONELLA TYPHI G 165,000.00LAB296 ANALISA CAIRAN LAMBUNG 155,000.00LAB297 ASAM LAKTAT 150,000.00LAB298 MIKROFILARIA 88,000.00LAB299 BARBITURAT 65,000.00LAB300 CHICKUNGUNYA 200,000.00LAB301 NS-1 DENGUE ( RAPID ) 250,000.00MCU001 MCU PURI SILVER 381,000.00MCU002 MCU PURI GOLD 780,000.00MCU003 MCU PURI PLATINUM - PRIA 916,000.00MCU004 MCU PURI PLATINUM - WANITA 1,010,000.00MCU005 MCU PURI DIAMOND - PRIA 1,611,000.00MCU006 MCU PURI DIAMOND - WANITA 2,052,500.00MCU007 MCU PURI COORPORATE STANDAR - DASAR 281,000.00MCU008 MCU PURI COORPORATE STANDAR - PRIMA 741,000.00MCU009 MCU PURI PRE MARITAL - PRIA 716,000.00

TarifKIT

MCU010 MCU PURI GOLD FOR KIDS 0.00MCU011 MCU PURI PLATINUM FOR KIDS 0.00MCU012 MCU CALON KARYAWAN KONTRAK RSPMK 200,000.00MCU013 MCU PURI PRE MARITAL - WANITA 716,000.00MCU014 MCU KARYAWAN TETAP RSPMK 281,500.00MCU015 PRODIA - THORAX 45,000.00MCU016 PAKET MCU 791,500.00

10.001.00 MTA001 ANGKAT JAHITAN (PALPEBRA/KONJUNGTIVA/KORNEA) 20,000.0010.003.00 MTA002 CHALAZION / INCISI 80,000.0010.004.01 MTA003 EKSTRAKSI CORPUS ALIENUM DI KORNEA 25,000.0010.004.02 MTA004 EKSTRAKSI CORPUS ALIENUM DI KONJUNGTIVA 20,000.0010.004.03 MTA005 EKSTRAKSI LITHIASIS 20,000.0010.005.00 MTA006 FITTING LENSA KONTAK 10,000.0010.006.00 MTA007 HORDEOLUM ( INCISI ) 80,000.0010.007.00 MTA008 ANEL TEST 20,000.0010.008.00 MTA009 AVULSI PTERIGIUM / PTERIGIUM KECIL 100,000.0010.009.00 MTA010 TONOMETRI (SCHIOTZ) 6,000.0010.010.00 MTA011 AUTOREF + KOREKSI VISUS 6,000.0010.011.00 MTA012 EPILASI 15,000.0010.012.00 MTA013 OPHTALMOSCOPE INDIRECT W/ MIDRIACYL 6,000.0010.013.00 MTA014 OPHTALMOSCOPE DIRECT W/ MIDRIACYL 5,000.0010.014.00 MTA015 DEBRIDEMENT KORNEA 10,000.0010.015.00 MTA016 SCHIMMER TEST 4,000.0010.016.00 MTA017 ISHIHARA TEST (TEST BUTA WARNA) 6,000.00

MTA018 TRICHIASIS 6,000.00MTA019 INFRAKSI / REFRAKSI 7,000.00MTA020 SLIT LAMP 4,000.00MTA021 LIGASI / SPOOLING 5,000.00MTA022 IRIGASI 30,000.00MTA023 REFRAKSI MATA 13,000.00MTA024 PAKET KOMPLAMI 140,000.00

28.011.01 ODC001 KAMAR TINDAKAN / VK - ODC KURET 200,000.0028.011.02 ODC002 KAMAR OBSEVASI - ODC KURET 150,000.0028.011.03 ODC003 DOKTER KANDUNGAN - ODC KURET 0.0028.011.04 ODC004 DOKTER ANASTESI - ODC KURET 0.0028.012.01 ODC005 KAMAR OK MINOR - ODC STERIL 450,000.0028.012.02 ODC006 KAMAR OBSERVASI - ODC STERIL 150,000.0028.012.03 ODC007 DOKTER KANDUNGAN - ODC STERIL 0.0028.012.04 ODC008 DOKTER ANASTESI - ODC STERIL 0.0028.014.01 ODC009 KAMAR OK MINOR - ODC FAM/HIDROKEL 450,000.0028.014.02 ODC010 KAMAR OBSERVASI - ODC FAM/HIDROKEL 150,000.0028.014.03 ODC011 DOKTER BEDAH - ODC FAM/HIDROKEL 1,500,000.0028.014.04 ODC012 DOKTER ANASTESI - ODC FAM/HIDROKEL 0.0028.015.01 ODC013 JASA DOKTER OPERATOR - ODC CEMINO 0.0028.015.02 ODC014 KAMAR OK MINOR - ODC CEMINO 450,000.0028.015.03 ODC015 KAMAR OBSERVASI - ODC CEMINO 150,000.0028.015.04 ODC016 SEWA ALAT SET BULDOK - ODC CEMINO 300,000.0028.015.01 OKK001 JASA ANESTESI OBS KOND KHUSUS - SC + STERIL / KISTEK 0.0028.015.01 OKK002 JASA DOKTER ANAK OBS KOND KHUSUS - SC + STERIL / KIS 0.0028.015.01 OKK003 JASA OPERATOR OBS KOND KHUSUS - SC + STERIL / KISTEK 0.00

TarifKIT

28.015.01 OKK004 SEWA KAMAR OK OBS KOND KHUSUS - SC + STERIL / KISTE 2,500,000.0028.015.02 OKK005 JASA ANESTESI OBS KOND KHUSUS - SC + CITO / PERMINTA 0.0028.015.02 OKK006 JASA DOKTER ANAK OBS KOND KHUSUS - SC + CITO / PERM 0.0028.015.02 OKK007 JASA OPERATOR OBS KOND KHUSUS - SC + CITO / PERMINT 0.0028.015.02 OKK008 SEWA KAMAR OK OBS KOND KHUSUS - SC + CITO / PERMIN 2,500,000.0028.015.03 OKK009 JASA ANESTESI OBS KOND KHUSUS - SC BEKAS LAPARATOMI 0.0028.015.03 OKK010 JASA DOKTER ANAK OBS KOND KHUSUS - SC BEKAS LAPARA 0.0028.015.03 OKK011 JASA OPERATOR OBS KOND KHUSUS - SC BEKAS LAPARATOM 0.0028.015.03 OKK012 SEWA KAMAR OK OBS KOND KHUSUS - SC BEKAS LAPAROTOM2,500,000.0028.015.04 OKK013 JASA ANESTESI OBS KOND KHUSUS - SC + STERIL + CITO / 0.0028.015.04 OKK014 JASA DOKTER ANAK OBS KOND KHUSUS - SC + STERIL + CI 0.0028.015.04 OKK015 JASA OPERATOR OBS KOND KHUSUS - SC + STERIL + CITO 0.0028.015.04 OKK016 SEWA KAMAR OK OBS KOND KHUSUS - SC + STERIL + CITO 2,500,000.0028.015.05 OKK017 JASA ANESTESI OBS KOND KHUSUS - SC BEKAS LAPAROTOMI 0.0028.015.05 OKK018 JASA DOKTER ANAK OBS KOND KHUSUS - SC BEKAS LAPARO 0.0028.015.05 OKK019 JASA OPERATOR OBS KOND KHUSUS - SC BEKAS LAPAROTOM 0.0028.015.05 OKK020 SEWA KAMAR OK OBS KOND KHUSUS - SC BEKAS LAPAROTO2,500,000.0028.015.06 OKK021 JASA ANESTESI OBS KOND KHUSUS - SC GEMELI + CITO / P 0.0028.015.06 OKK022 JASA DOKTER ANAK OBS KOND KHUSUS - SC GEMELI + CITO 0.0028.015.06 OKK023 JASA OPERATOR OBS KOND KHUSUS - SC GEMELI + CITO / 0.0028.015.06 OKK024 SEWA KAMAR OK OBS KOND KHUSUS - SC GEMELI + CITO / 2,500,000.0028.015.07 OKK025 JASA ANESTESI OBS KOND KHUSUS - SC GEMELI + STERIL 0.0028.015.07 OKK026 JASA DOKTER ANAK OBS KOND KHUSUS - SC GEMELI + STER 0.0028.015.07 OKK027 JASA OPERATOR OBS KOND KHUSUS - SC GEMELI + STERIL 0.0028.015.07 OKK028 SEWA KAMAR OK OBS KOND KHUSUS - SC GEMELI + STERIL2,500,000.0028.015.08 OKK029 JASA ANESTESI OBS KOND KHUSUS - SC + HISTEREKTOMI + 0.0028.015.08 OKK030 JASA DOKTER ANAK OBS KOND KHUSUS - SC + HISTEREKTOM 0.0028.015.08 OKK031 JASA OPERATOR OBS KOND KHUSUS - SC + HISTEREKTOMI + 0.0028.015.08 OKK032 SEWA KAMAR OK OBS KOND KHUSUS - SC + HISTEREKTOMI 2,500,000.0028.015.09 OKK033 JASA ANESTESI OBS KOND KHUSUS - RE SC 0.0028.015.09 OKK034 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC 0.0028.015.09 OKK035 JASA OPERATOR OBS KOND KHUSUS - RE SC 0.0028.015.09 OKK036 SEWA KAMAR OK OBS KOND KHUSUS - RE SC 2,500,000.0028.015.10 OKK037 JASA ANESTESI OBS KOND KHUSUS - RE SC + STERIL 0.0028.015.10 OKK038 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + STERIL 0.0028.015.10 OKK039 JASA OPERATOR OBS KOND KHUSUS - RE SC + STERIL 0.0028.015.10 OKK040 SEWA KAMAR OK OBS KOND KHUSUS - RE SC + STERIL 2,500,000.0028.015.11 OKK041 JASA ANESTESI OBS KOND KHUSUS - RE SC + CITO / PERMI 0.0028.015.11 OKK042 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + CITO / P 0.0028.015.11 OKK043 JASA OPERATOR OBS KOND KHUSUS - RE SC + CITO / PERM 0.0028.015.11 OKK044 SEWA KAMAR OK OBS KOND KHUSUS - RE SC + CITO / PER 2,500,000.0028.015.12 OKK045 JASA ANESTESI OBS KOND KHUSUS - RE SC PADA BEKAS LA 0.0028.015.12 OKK046 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC PADA BEKA 0.0028.015.12 OKK047 JASA OPERATOR OBS KOND KHUSUS - RE SC PADA BEKAS L 0.0028.015.12 OKK048 SEWA KAMAR OK OBS KOND KHUSUS - RE SC PADA BEKAS 2,500,000.0028.015.13 OKK049 JASA ANESTESI OBS KOND KHUSUS - RE SC PADA BEKAS LA 0.0028.015.13 OKK050 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC PADA BEKA 0.0028.015.13 OKK051 JASA OPERATOR OBS KOND KHUSUS - RE SC PADA BEKAS L 0.0028.015.13 OKK052 SEWA KAMAR OK OBS KOND KHUSUS - RE SC PADA BEKAS 2,500,000.0028.015.14 OKK053 JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI 0.00

TarifKIT

28.015.14 OKK054 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI 0.0028.015.14 OKK055 JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI 0.0028.015.14 OKK056 SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI 2,500,000.0028.015.15 OKK057 JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI + STER 0.0028.015.15 OKK058 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI + 0.0028.015.15 OKK059 JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI + STE 0.0028.015.15 OKK060 SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI + ST2,500,000.0028.015.16 OKK061 JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI + STE 0.0028.015.16 OKK062 JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI + 0.0028.015.16 OKK063 JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI + ST 0.0028.015.16 OKK064 SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI + ST2,500,000.0028.015.17 OKK065 JASA ANESTESI OBS KOND KHUSUS - RE RE SC 0.0028.015.17 OKK066 JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC 0.0028.015.17 OKK067 JASA OPERATOR OBS KOND KHUSUS - RE RE SC 0.0028.015.17 OKK068 SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC 2,500,000.0028.015.18 OKK069 JASA ANESTESI OBS KOND KHUSUS - RE RE SC + STERIL / K 0.0028.015.18 OKK070 JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC + STERIL 0.0028.015.18 OKK071 JASA OPERATOR OBS KOND KHUSUS - RE RE SC+STERIL / KI 0.0028.015.18 OKK072 SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC + STERIL /2,500,000.0028.015.19 OKK073 JASA ANESTESI OBS KOND KHUSUS - RE RE SC BEKAS LAPA 0.0028.015.19 OKK074 JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC BEKAS L 0.0028.015.19 OKK075 JASA OPERATOR OBS KOND KHUSUS - RE RE SC BEKAS LAPA 0.0028.015.19 OKK076 SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC BEKAS LAP2,500,000.0028.015.20 OKK077 JASA ANESTESI OBS KOND KHUSUS - RE RE SC + STERIL + 0.0028.015.20 OKK078 JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC + STERIL 0.0028.015.20 OKK079 JASA OPERATOR OBS KOND KHUSUS - RE RE SC + STERIL + 0.0028.015.20 OKK080 SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC + STERIL +2,500,000.0028.015.21 OKK081 JASA ANESTESI OBS KOND KHUSUS - KISTEKTOMI BILATERA 0.0028.015.21 OKK082 JASA DOKTER ANAK OBS KOND KHUSUS - KISTEKTOMI BILA 0.0028.015.21 OKK083 JASA OPERATOR OBS KOND KHUSUS - KISTEKTOMI BILATER 0.0028.015.21 OKK084 SEWA KAMAR OK OBS KOND KHUSUS - KISTEKTOMI BILATER2,500,000.0028.015.22 OKK085 JASA ANESTESI OBS KOND KHUSUS - MIOMEKTOMI PADA BE 0.0028.015.22 OKK086 JASA DOKTER ANAK OBS KOND KHUSUS - MIOMEKTOMI PAD 0.0028.015.22 OKK087 JASA OPERATOR OBS KOND KHUSUS - MIOMEKTOMI PADA B 0.0028.015.22 OKK088 SEWA KAMAR OK OBS KOND KHUSUS - MIOMEKTOMI PADA 2,500,000.0028.015.23 OKK089 JASA ANESTESI OBS KOND KHUSUS - RE LAPARATOMI ( MIOM 0.0028.015.23 OKK090 JASA DOKTER ANAK OBS KOND KHUSUS - RE LAPARATOMI ( 0.0028.015.23 OKK091 JASA OPERATOR OBS KOND KHUSUS - RE LAPARATOMI ( MIO 0.0028.015.23 OKK092 SEWA KAMAR OK OBS KOND KHUSUS - RE LAPARATOMI ( MIO2,500,000.00

OOK001 JASA OPERATOR BEDAH OBSGYN - OPERASI KHUSUS 612,500.00OOK002 JASA OPERATOR BEDAH OBSGYN - OPERASI BESAR 490,000.00OOK003 JASA OPERATOR BEDAH OBSGYN - OPERASI SEDANG 400,000.00OOK004 JASA OPERATOR BEDAH OBSGYN - OPERASI KECIL 240,000.00OOK005 JASA OPERATOR BEDAH UMUM - OPERASI KHUSUS 612,500.00OOK006 JASA OPERATOR BEDAH UMUM - OPERASI BESAR 490,000.00OOK007 JASA OPERATOR BEDAH UMUM - OPERASI SEDANG 400,000.00OOK008 JASA OPERATOR BEDAH UMUM - OPERASI KECIL 240,000.00OOK009 JASA OPERATOR BEDAH TULANG - OPERASI KHUSUS 800,000.00OOK010 JASA OPERATOR BEDAH TULANG - OPERASI BESAR 650,000.00OOK011 JASA OPERATOR BEDAH TULANG - OPERASI KECIL 300,000.00

TarifKIT

OOK012 JASA OPERATOR BEDAH TULANG - OPERASI SEDANG 500,000.00OOK013 JASA OPERATOR BEDAH THT - OPERASI KHUSUS 0.00OOK014 JASA OPERATOR BEDAH THT - OPERASI BESAR 0.00OOK015 JASA OPERATOR BEDAH THT - OPERASI SEDANG 0.00OOK016 JASA OPERATOR BEDAH THT - OPERASI KECIL 0.00OOK017 JASA OPERATOR BEDAH MATA - OPERASI KHUSUS 0.00OOK018 JASA OPERATOR BEDAH MATA - OPERASI BESAR 0.00OOK019 JASA OPERATOR BEDAH MATA - OPERASI SEDANG 0.00OOK020 JASA OPERATOR BEDAH MATA - OPERASI KECIL 0.00OOK021 JASA OPERATOR BEDAH SARAF - OPERASI KHUSUS 1,600,000.00OOK022 JASA OPERATOR BEDAH SARAF - OPERASI BESAR 1,200,000.00OOK023 JASA OPERATOR BEDAH SARAF - OPERASI SEDANG 900,000.00OOK024 JASA OPERATOR BEDAH SARAF - OPERASI KECIL 600,000.00OOK025 JASA ANASTESI BEDAH OBSGYN - OPERASI KHUSUS 245,000.00OOK026 JASA ANASTESI BEDAH OBSGYN - OPERASI BESAR 196,000.00OOK027 JASA ANASTESI BEDAH OBSGYN - OPERASI SEDANG 160,000.00OOK028 JASA ANASTESI BEDAH OBSGYN - OPERASI KECIL 96,000.00OOK029 JASA ANASTESI BEDAH UMUM - OPERASI KHUSUS 245,000.00OOK030 JASA ANASTESI BEDAH UMUM - OPERASI BESAR 196,000.00OOK031 JASA ANASTESI BEDAH UMUM - OPERASI SEDANG 160,000.00OOK032 JASA ANASTESI BEDAH UMUM - OPERASI KECIL 96,000.00OOK033 JASA ANASTESI BEDAH TULANG - OPERASI KHUSUS 320,000.00OOK034 JASA ANASTESI BEDAH TULANG - OPERASI BESAR 260,000.00OOK035 JASA ANASTESI BEDAH TULANG - OPERASI SEDANG 200,000.00OOK036 JASA ANASTESI BEDAH TULANG - OPERASI KECIL 120,000.00OOK037 JASA ANASTESI BEDAH THT - OPERASI KHUSUS 0.00OOK038 JASA ANASTESI BEDAH THT - OPERASI BESAR 0.00OOK039 JASA ANASTESI BEDAH THT - OPERASI SEDANG 0.00OOK040 JASA ANASTESI BEDAH THT - OPERASI KECIL 0.00OOK041 JASA ANASTESI BEDAH MATA - OPERASI KHUSUS 0.00OOK042 JASA ANASTESI BEDAH MATA - OPERASI BESAR 0.00OOK043 JASA ANASTESI BEDAH MATA - OPERASI SEDANG 0.00OOK044 JASA ANASTESI BEDAH MATA - OPERASI KECIL 0.00OOK045 JASA ANASTESI BEDAH SARAF - OPERASI KHUSUS 640,000.00OOK046 JASA ANASTESI BEDAH SARAF - OPERASI BESAR 480,000.00OOK047 JASA ANASTESI BEDAH SARAF - OPERASI SEDANG 360,000.00OOK048 JASA ANASTESI BEDAH SARAF - OPERASI KECIL 240,000.00OOK049 SEWA KAMAR OK BEDAH OBSGYN - OPERASI KHUSUS 1,800,000.00OOK050 SEWA KAMAR OK BEDAH OBSGYN - OPERASI BESAR 1,350,000.00OOK051 SEWA KAMAR OK BEDAH OBSGYN - OPERASI SEDANG 1,000,000.00OOK052 SEWA KAMAR OK BEDAH OBSGYN - OPERASI KECIL 700,000.00OOK053 SEWA KAMAR OK BEDAH UMUM - OPERASI KHUSUS 1,800,000.00OOK054 SEWA KAMAR OK BEDAH UMUM - OPERASI BESAR 1,350,000.00OOK055 SEWA KAMAR OK BEDAH UMUM - OPERASI SEDANG 1,000,000.00OOK056 SEWA KAMAR OK BEDAH UMUM - OPERASI KECIL 700,000.00OOK057 SEWA KAMAR OK BEDAH TULANG - OPERASI KECIL 700,000.00OOK058 SEWA KAMAR OK BEDAH THT - OPERASI KECIL 700,000.00OOK059 SEWA KAMAR OK BEDAH MATA - OPERASI KECIL 700,000.00OOK060 SEWA KAMAR OK BEDAH SARAF - OPERASI KECIL 1,000,000.00OOK061 SEWA KAMAR OK BEDAH TULANG - OPERASI KHUSUS 2,000,000.00

TarifKIT

OOK062 SEWA KAMAR OK BEDAH THT - OPERASI KHUSUS 2,000,000.00OOK063 SEWA KAMAR OK BEDAH MATA - OPERASI KHUSUS 2,000,000.00OOK064 SEWA KAMAR OK BEDAH SARAF - OPERASI KHUSUS 2,500,000.00OOK065 SEWA KAMAR OK BEDAH TULANG - OPERASI BESAR 1,500,000.00OOK066 SEWA KAMAR OK BEDAH THT - OPERASI BESAR 1,500,000.00OOK067 SEWA KAMAR OK BEDAH MATA - OPERASI BESAR 1,500,000.00OOK068 SEWA KAMAR OK BEDAH SARAF - OPERASI BESAR 2,000,000.00OOK069 SEWA KAMAR OK BEDAH TULANG - OPERASI SEDANG 1,000,000.00OOK070 SEWA KAMAR OK BEDAH THT - OPERASI SEDANG 1,000,000.00OOK071 SEWA KAMAR OK BEDAH MATA - OPERASI SEDANG 1,000,000.00OOK072 SEWA KAMAR OK BEDAH SARAF - OPERASI SEDANG 1,400,000.00OOK073 JASA DOKTER ANAK BEDAH OBSGYN - OPERASI KHUSUS 0.00OOK074 JASA OPERATOR ANUSCOPY PAKET OK 120,000.00OOK075 JASA ANASTESI ANUSCOPY PAKET OK 48,000.00OOK076 SEWA KAMAR OK ANUSCOPY PAKET OK 350,000.00OOK077 ADMINISTRASI ANUSCOPY PAKET OK 70,000.00

51.001.00 OTR001 SENSORI INTEGRASI 70,000.0051.002.00 OTR002 LATIHAN ADL RINGAN 35,000.0051.003.00 OTR003 LATIHAN ADL GENERAL 60,000.0051.004.00 OTR004 PROPER BODY MEKANIK 35,000.0051.005.00 OTR005 ANALISA PERSIAPAN KERJA 75,000.0051.006.00 OTR006 LATIHAN RELAKSASI RINGAN 35,000.0051.007.00 OTR007 LATIHAN RELAKSASI GENERAL 60,000.0051.008.00 OTR008 ANALISA & INTERVENSI, PERSEPSI, KOGNITIF, PSIKOMOTOR 50,000.0051.009.00 OTR009 JASA PEMBUATAN ALAT SPLINT 150,000.0051.010.00 OTR010 JASA MODIFIKASI / PEMBUATAN ALAT 75,000.0013.001.00 PDL001 ECG 35,000.0013.002.00 PDL002 PLEURA PUNKSI 50,000.0013.003.00 PDL003 SPIROMETRI 30,000.0013.004.00 PDL004 TREADMILL 175,000.0013.005.01 PDL005 USG (ECHO RADIOGRAPHIC) 125,000.0013.005.02 PDL006 USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER 175,000.0013.006.00 PDL007 JASA SUNTIK (IMUNISASI) 10,000.0013.007.00 PDL008 TEST MANTOUX 50,000.0013.008.00 PDL009 NEBULIZER 60,000.00

PRO001 PRODIA - TREADMILL 125,000.00PRO002 PRODIA - USG ABDOMEN ATAS 130,000.00PRO003 PRODIA - ABDOMEN BAWAH 101,000.00PRO004 PRODIA - ABDOMEN ATAS & BAWAH 162,500.00PRO005 PRODIA - USG GYNECOLOGY / TRANSVAGINAL 87,750.00PRO006 PRODIA - USG OBSTETRI 32,500.00PRO007 PRODIA - USG OBSTETRI 4D 227,500.00PRO008 PRODIA - PEMERIKSAAN FISIK DOKTER UMUM 30,000.00

13.001.00 PRU001 ECG 35,000.0013.002.00 PRU002 PLEURA PUNKSI 50,000.0013.003.00 PRU003 SPIROMETRI 30,000.0013.004.00 PRU004 TREADMILL 175,000.0013.005.01 PRU005 USG (ECHO RADIOGRAPHIC) 125,000.0013.005.02 PRU006 USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER 175,000.0013.006.00 PRU007 JASA SUNTIK (IMUNISASI) 10,000.00

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13.007.00 PRU008 TEST MANTOUX 50,000.0013.008.00 PRU009 NEBULIZER 60,000.0031.100.01 RAD001 ANKLE AP/LAT 59,500.0031.100.02 RAD002 ART. HUMERUS 59,500.0031.100.03 RAD003 BASIS CRANII 59,500.0031.100.04 RAD004 BNO/ABDOMEN POLOS 63,750.0031.100.05 RAD005 CALCANEUS LAT/AKSIAL 59,500.0031.100.06 RAD006 CLAVICULA 59,500.0031.100.07 RAD007 COSTAE 59,500.0031.100.08 RAD008 ELBOW/CUBITI 63,750.0031.100.09 RAD009 FORAMEN OPTICUM 59,500.0031.100.10 RAD010 ORBITA 59,500.0031.100.11 RAD011 OS NASAL 59,500.0031.100.12 RAD012 PANORAMIC 68,000.0031.100.13 RAD013 PEDIS AP/LAT 63,750.0031.100.14 RAD014 PELVIS 63,750.0031.100.15 RAD015 RLD THORAX 63,750.0031.100.16 RAD016 STERNUM 59,500.0031.100.17 RAD017 THORAX FOTO (AP / LATERAL) 68,000.0031.100.18 RAD018 THORAX PA + LATERAL 127,500.0031.100.19 RAD019 TMJ SATU SISI 80,750.0031.100.20 RAD020 TOP LORDOTIC 59,500.0031.100.21 RAD021 TOWNE 59,500.0031.100.22 RAD022 WRIST JOIINT 59,500.0031.100.23 RAD023 MANUS AP/LAT 59,500.0031.200.01 RAD024 ABDOMEN 2 POSISI 119,000.0031.200.02 RAD025 ANTEBRACHI AP/LAT 63,750.0031.200.03 RAD026 CEPHALOMETRI 93,500.0031.200.04 RAD027 CERVICAL AP/LAT 93,500.0031.200.05 RAD028 CRURIS AP/LAT 85,000.0031.200.06 RAD029 FEMUR AP/LAT 119,000.0031.200.07 RAD030 GENU AP/LAT 63,750.0031.200.08 RAD031 HUMERUS AP/LAT 85,000.0031.200.09 RAD032 LUMBAL AP/LAT 114,750.0031.200.10 RAD033 MANDIBULA ESHLER KANAN KIRI 85,000.0031.200.11 RAD034 MASTOID KANAN KIRI 102,000.0031.200.12 RAD035 PELVIS AP/LAT 114,750.0031.200.13 RAD036 SACRUM AP/LAT 106,250.0031.200.14 RAD037 SCHEDEL AP/LAT 102,000.0031.200.15 RAD038 SHOULDER EXO/ENDO 102,000.0031.200.16 RAD039 SPN 3 POSISI 106,250.0031.200.17 RAD040 THORACAL AP/LAT 114,750.0031.200.18 RAD041 THORACOLUMBAL AP/LAT 114,750.0031.300.01 RAD042 ABDOMEN 3 POSISI 148,750.0031.300.02 RAD043 ANTEBRACHI 2 POSISI KA/KI 127,500.0031.300.03 RAD044 APPENDICOGRAM 191,250.0031.300.04 RAD045 CERVICAL AP/LAT/OBL 127,500.0031.300.05 RAD046 COR ANALISA 127,500.0031.300.06 RAD047 CRURIS AP/LAT KA-KI 148,750.0031.300.07 RAD048 ESOFAGOGRAM 148,750.00

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31.300.08 RAD049 FEMUR AP/LAT KA-KI 148,750.0031.300.09 RAD050 GENU AP/LAT/SKY LINE 136,000.0031.300.10 RAD051 HUMERUS KA/KI BANDING 127,500.0031.300.11 RAD052 LUMBAL AP/LAT/OBL 153,000.0031.300.12 RAD053 MAMMOGRAFI 153,000.0031.300.13 RAD054 PELVIS DENGAN SONDE 127,500.0031.300.14 RAD055 SHOULDER 2 POSISI ENDING 148,750.0031.300.15 RAD056 THORACAL AP/LAT/OBL 153,000.0031.300.16 RAD057 TMJ KA/KI PERBANDINGAN 148,750.0031.400.01 RAD058 BNO - IVP* 262,500.0031.400.02 RAD059 BONE SURVEY 318,750.0031.400.03 RAD060 COLON IN LOOP* 300,000.0031.400.04 RAD061 CYSTOGRAM 195,000.0031.400.05 RAD062 FISTULOGRAFI* 243,750.0031.400.06 RAD063 FOLLOW THROUGH* 262,500.0031.400.07 RAD064 HSG* 187,500.0031.400.08 RAD065 MD* 225,000.0031.400.09 RAD066 MSU* 281,250.0031.400.10 RAD067 OMD* 281,250.0031.400.11 RAD068 RPG / APG* 262,500.0031.400.12 RAD069 URETHROCYSTOGRAM 262,500.0031.400.13 RAD070 URETHROCYSTOGRAM BIPOLAR 281,250.00

RAD071 GENU BILATERAL 105,000.00RAD072 CEPHALOMETRI PA / LATERAL 52,500.00RAD073 ORDER PEMERIKSAAN RADIOLOGI 0.00RSC001 SEWA OK SC RUJUKAN BIDAN 500,000.00RSC002 JASA TINDAKAN DOKTER OBSGYN SC RUJUKAN BIDAN 0.00RSC003 JASA TINDAKAN DOKTER ANESTESI SC RUJUKAN BIDAN 0.00RSC004 JASA TINDAKAN DOKTER ANAK SC RUJUKAN BIDAN 0.00RSC005 VISITE RUANGAN DOKTER OBSGYN SC RUJUKAN BIDAN 0.00RSC006 VISITE RUANGAN DOKTER ANAK SC RUJUKAN BIDAN 0.00RSC007 SEWA KAMAR IBU SC RUJUKAN BIDAN 240,000.00RSC008 SEWA KAMAR PERAWATAN ANAK SC RUJUKAN BIDAN 150,000.00RSC009 SEWA VK - PAKET OD KURET 200,000.00RSC010 JASA DOKTER OBSGYN - PAKET ODC KURET 0.00RSC011 JASA DOKTER ANESTESI - PAKET ODC KURET 0.00RSC012 SEWA KAMAR OK MINOR - PAKET ODC STERIL 300,000.00RSC013 SEWA KAMAR OBSERVASI - PAKET ODC STERIL 100,000.00RSC014 JASA TINDAKAN DOKTER OBSGYN - PAKET ODC STERIL 0.00RSC015 JASA TINDAKAN DOKTER ANESTESI - PAKET ODC STERIL 0.00RSC016 SEWA VK - PARTUS TINDAKAN NON SC 200,000.00RSC017 JASA TINDAKAN DOKTER OBSGYN - PARTUS TINDAKAN NON 0.00RSC018 JASA TINDAKAN DOKTER ANAK - PARTUS TINDAKAN NON S 0.00RSC019 VISITE RUANGAN DOKTER OBSGYN - PARTUS TINDAKAN NO 0.00RSC020 VISITE RUANGAN DOKTER - PARTUS TINDAKAN NON SC 0.00RSC021 SEWA KAMAR PERAWATAN IBU - PARTUS TINDAKAN NON S 240,000.00RSC022 SEWA KAMAR PERAWATAN ANAK - PARTUS TINDAKAN NON 150,000.00

24.101.00 SPA001 MINI FACIAL 50,000.00SPA002 ELEKTROTERAPI FACIAL 70,000.00SPA003 ACUPRESSURE FACIAL 60,000.00

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SPA004 PAKET PERAWATAN KULIT SENSITIF 125,000.00SPA005 PAKET PERAWATAN KULIT FLEK 160,000.00SPA006 PAKET PERAWATAN KULIT BERMINYAK / BERJERAWAT 140,000.00SPA007 PAKET PERAWATAN KULIT KERING / KUSAM 160,000.00SPA008 PAKET PERAWATAN KULIT BERPORI-PORI BESAR 140,000.00SPA009 PAKET PERAWATAN KULIT NORMAL 140,000.00SPA010 BASIC PEELING / TINDAKAN PEELING WAJAH ( 1 OBAT ) 62,500.00SPA011 INTENSIVE PEELING / TINDAKAN PEELING WAJAH ( 2 OBAT ) 72,500.00

PEELING NEOSTRATA 20%SPA012 PEELING MATA 20,000.00SPA013 INJEKSI JERAWAT 25,000.00SPA014 INJEKSI KELOID 50,000.00SPA015 INJEKSI PEMUTIH DENGAN 1 OBAT 62,500.00SPA016 TINDAKAN CAUTER 50,000.00

24.200.01 SPA017 SIMPLE MASSAGE 120,000.0024.200.02 SPA018 SIMPLE MASSAGE + SCUB 150,000.0024.200.03 SPA019 SIMPLE MASSAGE + ALAT UMDT 225,000.0024.200.04 SPA020 SIMPLE MASSAGE + STEAM BLANKET 225,000.0024.200.05 SPA021 MASSAGE LENGKAP 250,000.0024.300.00 SPA022 EAR WAX CANDLE 50,000.0024.400.01 SPA023 MANICURE 75,000.0024.400.02 SPA024 PEDICURE 75,000.0024.400.03 SPA025 MANICURE - PEDICURE 140,000.0024.500.01 SPA026 KAKI BAU / FOOT ODOR 90,000.0024.500.02 SPA027 KAPALAN / CALLUSE 90,000.0024.500.03 SPA028 KAKI KERING / DRY FOOT 90,000.0024.500.04 SPA029 PECAH - PECAH / CRACKS SKIN 90,000.0024.500.05 SPA030 LETIH / RELAXATION 90,000.0024.600.00 SPA031 EYE TREATMENT 35,000.0024.102.00 SPA032 FACE LIFT FACIAL 100,000.0024.103.00 SPA033 DETOX & SPA FACIAL 100,000.0024.104.01 SPA034 PERAWATAN KULIT ACNE 100,000.0024.104.02 SPA035 PERAWATAN KULIT KOMEDOGENIC 100,000.0024.105.00 SPA036 FLEK - FLEK HITAM ( TPW CARE ) 200,000.0024.600.00 SPA037 EYE COMPLEX 20,000.0024.700.00 SPA038 NAIL ART 25,000.00

SPA039 JASA TINDAKAN SCUB 15,000.00SPA040 INJEKSI PEMUTIH DENGAN 2 OBAT 87,500.00SPA041 INJEKSI PEMUTIH DENGAN 3 OBAT 112,500.00SPA042 INJEKSI PEMUTIH DENGAN 4 OBAT 137,500.00SPA043 PRODUC CAT MAKARIZO 65,000.00SPA044 PRODUC CAT LORPAL 75,000.00SPA43 INJEKSI SLIMING 1 OBAT 35,000.00

15.001.00 SRF001 EEG 100,000.0016.001.01 THT001 ANGKAT SERUMEN TANPA PENYULIT 10,000.0016.001.02 THT002 ANGKAT SERUMEN DENGAN PENYULIT 25,000.0016.002.01 THT003 ASPIRASI ABSES PERITONSIL / DI TEMPAT LAIN 35,000.0016.002.02 THT004 ASPIRASI PSEUDOKISTA DAUN TELINGA 35,000.0016.003.00 THT005 AUDIOMETRI/AUDIOGRAM KLINIK 35,000.0016.004.00 THT006 BELLOQUE TAMPON 40,000.00

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16.005.01 THT007 CAUSTIK FARING 10,000.0016.005.02 THT008 CAUSTIK HIDUNG 10,000.0016.005.03 THT009 CAUSTIK TELINGA 10,000.0016.006.01 THT010 CORPUS ALIENUM HIDUNG 30,000.0016.006.02 THT011 CORPUS ALIENUM TELINGA 30,000.0016.006.03 THT012 CORPUS ALIENUM TENGGOROK 30,000.0016.007.00 THT013 ENDOSCOPY NASOFARING 125,000.0016.008.01 THT014 INCISI ABSES HIDUNG 40,000.0016.008.02 THT015 INCISI ABSES PERITONSILER 40,000.0016.008.03 THT016 INCISI ABSES PRE AURICULER 40,000.0016.008.04 THT017 INCISI ABSES RETRO AURICULER 40,000.0016.008.05 THT018 INCISI ABSES RETRO FARINGEAL 90,000.0016.009.00 THT019 INHALASI 30,000.0016.010.01 THT020 IRIGASI SINUS MAKSILARIS 50,000.0016.010.02 THT021 IRIGASI SINUS MAKSILARIS DUPLEKS 60,000.0016.011.00 THT022 PARACENTASE MEMBRAN TIMPANI 40,000.0016.012.00 THT023 PERIKONDRITIS/ABSES DAUN TELINGA 40,000.0016.013.00 THT024 PUNGSI & IRIGASI SINUS MAKSILARIS 80,000.0016.014.00 THT025 TAMPON HIDUNG (SATU LUBANG) 10,000.0016.015.00 THT026 TIMPANOMETRI 15,000.0016.016.00 THT027 AFF TAMPON 8,000.00

THT028 IRIGASI TELINGA / EAR TOILET 10,000.00THT029 ENDOSCOPY INTIP 62,500.00

28.016.01 TOK001 JASA OPERATOR - KURET NORMAL 240,000.0028.016.01 TOK002 JASA ANASTESI - KURET NORMAL 96,000.0028.016.01 TOK003 KAMAR BERSALIN - KURET NORMAL 200,000.0028.016.01 TOK004 KAMAR OBSERVASI - KURET NORMAL 150,000.0028.016.02 TOK005 JASA OPERATOR - KURET PLASENTA 300,000.0028.016.02 TOK006 JASA ANESTESI - KURET PLASENTA 120,000.0028.016.02 TOK007 KAMAR BERSALIN - KURET PLASENTA 200,000.0028.016.02 TOK008 KAMAR OBSERVASI - KURET PLASENTA 150,000.0030.001.01 TRI001 AF HECHTING (1 - 5) 11,500.0030.001.02 TRI002 AF HECHTING (6 -10) 18,000.0030.001.03 TRI003 AF HECHTING (> 10) 23,000.0030.002.00 TRI004 CLYSMA 12,000.0030.003.00 TRI005 ECG 12,000.0030.004.00 TRI006 EEG 46,000.0030.005.00 TRI007 INTUBASI 60,000.0030.006.01 TRI008 PUNGSI LUMBAL 60,000.0030.006.02 TRI009 PUNGSI FLEURA 60,000.0030.006.03 TRI010 PUNGSI ASCITES 60,000.0030.007.00 TRI011 PASANG FOLLEY CATHETER 11,500.0030.008.00 TRI012 PASANG INFUS 11,500.0030.009.00 TRI013 PASANG NGT 11,500.0030.010.00 TRI014 SITOSTATIKA 140,000.0030.011.00 TRI015 SPIROMETRI 14,000.0030.012.00 TRI016 VENA SEKSI 46,000.0030.013.00 TRI017 TINDIK TELINGA BAYI 18,000.0030.014.00 TRI018 SUNAT BAYI PEREMPUAN 14,000.0030.015.00 TRI019 PEMASANGAN UMBILICAL CATHETER 46,000.00

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30.016.00 TRI020 EXCHANGE TRANSFUSI 92,000.0030.017.00 TRI021 SPOOL DRAIN 9,000.0030.018.00 TRI022 AF WSD 19,000.0030.019.01 TRI023 AF DRAIN NON CRANIOTOMI 19,000.0030.019.02 TRI024 AF DRAIN CRANIOTOMI 23,000.00

TRI025 PASANG CATHETER DG MANDREN 58,000.00TRI026 PUNGSI PUS 11,500.00TRI027 NEKROTOMI KECIL 23,000.00TRI028 NEKROTOMI SEDANG 35,000.00TRI029 NEKROTOMI BESAR 46,000.00TRI030 PASANG CVP 70,000.00

30.015.00 TRI031 MERAWAT DECUBITUS / HARI 23,000.0030.016.00 TRI032 MERAWAT GANGRENE / HARI 23,000.0030.017.01 TRI033 LUKA BAKAR RINGAN ( < 20% ) 17,500.0030.017.02 TRI034 LUKA BAKAR SEDANG (20-40%) 29,000.0030.017.03 TRI035 LUKA BAKAR BERAT ( >40% ) 41,000.0030.018.00 TRI036 LABU DARAH / KANTONG 210,000.00

TRI037 PENGELOLAAN 1 KANTONG LABU DARAH 35,000.0030.019.01 TRI038 PEMBUATAN AKTE KELAHIRAN - WNI 145,000.0030.019.02 TRI039 PEMBUATAN AKTE KELAHIRAN - WNI KETURUNAN 215,000.0052.001.00 TWC001 FUNGSI BICARA ( DEWASA ) 35,000.0052.002.00 TWC002 FUNGSI BICARA ( ANAK ) 50,000.0052.003.00 TWC003 FUNGSI BAHASA / LAKU ( DEWASA ) 35,000.0052.004.00 TWC004 FUNGSI BAHASA / LAKU ( ANAK ) 50,000.0052.005.00 TWC005 FUNGSI MENELAN ( DEWASA ) 40,000.0052.006.00 TWC006 FUNGSI MENELAN ( ANAK ) 60,000.0001.001.01 UGD001 AF HECTING (1 - 5) 10,000.0001.001.02 UGD002 AF HECTING (6 - 10) 15,000.0001.001.03 UGD003 AF HECTING (>10) 20,000.0001.002.01 UGD004 AMPUTASI JARI RUAS I 40,000.0001.002.02 UGD005 AMPUTASI JARI RUAS II 60,000.0001.003.00 UGD006 BILAS LAMBUNG (Intoksikasi Baygon/Drug) 40,000.0001.004.01 UGD007 CORPUS ALIENUM HIDUNG 40,000.0001.004.02 UGD008 CORPUS ALIENUM MATA (Satu mata) 40,000.0001.004.03 UGD009 CORPUS ALIENUM TELINGA (Satu telinga) 40,000.0001.004.04 UGD010 CORPUS ALIENUM TENGGOROK 40,000.0001.005.01 UGD011 DEBRIDEMENT LUKA BAKAR BERAT 80,000.0001.005.02 UGD012 DEBRIDEMENT LUKA BAKAR RINGAN 24,000.0001.005.03 UGD013 DEBRIDEMENT LUKA BAKAR SEDANG 40,000.0001.006.01 UGD014 DEFIBRILATOR (= 3 kali) 40,000.0001.006.02 UGD015 DEFIBRILATOR (> 3 kali) 80,000.0001.007.01 UGD016 ECG 35,000.0001.008.00 UGD017 EKSPLORASI / CROSS INCISI 40,000.0001.009.00 UGD018 EKSTIRPASI KECIL 50,000.0001.010.00 UGD019 EKSTRAKSI KUKU ( 1 KUKU ) 50,000.00

UGD020 GANTI VERBAN (Incl alkes : max 10-15 pcs kasa) 25,000.00UGD021 GANTI VERBAN (Incl alkes : 15 - 20 pcs kasa) 25,000.00

01.011.00 UGD022 GANTI VERBAN KECIL 10,000.0001.011.00 UGD023 GANTI VERBAN SEDANG 12,500.0001.011.00 UGD024 GANTI VERBAN BESAR 12,000.00

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01.012.01 UGD025 HECHTING BESAR ( > 10 ) 36,000.0001.012.02 UGD026 HECHTING KECIL ( 1 - 5 ) 24,000.0001.012.03 UGD027 HECHTING SEDANG ( 6 - 10 ) 30,000.0001.013.00 UGD028 INCISI ABSES 50,000.0001.014.00 UGD029 INHALASI TANPA OBAT 12,000.0001.015.00 UGD030 INTUBASI 80,000.0001.016.00 UGD031 IRIGASI MATA 40,000.0001.017.01 UGD032 JAHIT OTOT DENGAN EKSPLORASI ( BESAR ) 80,000.0001.017.02 UGD033 JAHIT OTOT DENGAN EKSPLORASI ( KECIL ) 40,000.0001.017.03 UGD034 JAHIT OTOT DENGAN EKSPLORASI ( SEDANG ) 60,000.0001.018.00 UGD035 LAVAMENT / CLYSMA 50,000.0001.019.00 UGD036 O2 / 3 JAM 10,000.0001.020.00 UGD037 RUANG OBSERVASI S/D 8 JAM 120,000.0001.021.00 UGD038 PASANG CATHETER 14,000.0001.022.00 UGD039 PASANG CVP 160,000.0001.023.00 UGD040 PASANG INFUS 10,000.0001.024.00 UGD041 ANGKAT SERUMEN TANPA PENYULIT 20,000.0001.025.00 UGD042 PASANG NGT 15,000.0001.026.00 UGD043 PASANG SPALK 50,000.0001.027.00 UGD044 PASANG TAMPON (HIDUNG DAN TELINGA) 8,000.0001.028.00 UGD045 PLEURA PUNKSI / WSD MINI 60,000.0001.029.00 UGD046 SPOOLING / IRIGASI TELINGA 12,000.0001.030.00 UGD047 SUNTIK 7,500.0001.031.00 UGD048 TAMPON POSTERIOR EPISTAKSIS 24,000.0001.032.00 UGD049 VENA SEKSI 60,000.0001.033.00 UGD050 CPR 40,000.00

UGD051 CIRCUMSISI ANAK ( < 15 TAHUN ) 250,000.00UGD052 CIRCUMSISI DEWASA 400,000.00UGD053 WOUND TOILET KECIL 15,000.00UGD054 WOUND TOILET SEDANG 15,000.00UGD055 WOUND TOILET BESAR 25,000.00UGD056 ECG MONITOR PER 3 JAM 100,000.00UGD057 IRIGASI TELINGA / EAR TOILET 30,000.00

01.001.01 UMM001 AF HECTING (1 - 5) 10,000.0001.001.02 UMM002 AF HECTING (6 - 10) 15,000.0001.001.03 UMM003 AF HECTING (>10) 20,000.0001.002.01 UMM004 AMPUTASI JARI RUAS I 40,000.0001.002.02 UMM005 AMPUTASI JARI RUAS II 60,000.0001.003.00 UMM006 BILAS LAMBUNG (Intoksikasi Baygon/Drug) 40,000.0001.004.01 UMM007 CORPUS ALIENUM HIDUNG 40,000.0001.004.02 UMM008 CORPUS ALIENUM MATA (Satu mata) 40,000.0001.004.03 UMM009 CORPUS ALIENUM TELINGA (Satu telinga) 40,000.0001.004.04 UMM010 CORPUS ALIENUM TENGGOROK 40,000.0001.005.01 UMM011 DEBRIDEMENT LUKA BAKAR BERAT 80,000.0001.005.02 UMM012 DEBRIDEMENT LUKA BAKAR RINGAN 24,000.0001.005.03 UMM013 DEBRIDEMENT LUKA BAKAR SEDANG 40,000.0001.006.01 UMM014 DEFIBRILATOR (= 3 kali) 40,000.0001.006.02 UMM015 DEFIBRILATOR (> 3 kali) 80,000.0001.007.01 UMM016 ECG 35,000.0001.008.00 UMM017 EKSPLORASI / CROSS INCISI 40,000.00

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01.009.00 UMM018 EKSTIRPASI KECIL 50,000.0001.010.00 UMM019 EKSTRAKSI KUKU ( 1 KUKU ) 50,000.00

UMM020 GANTI VERBAN (Incl alkes : max 10-15 pcs kasa) 20,000.00UMM021 GANTI VERBAN (Incl alkes : 15 - 20 pcs kasa) 25,000.00

01.011.00 UMM022 GANTI VERBAN KECIL 10,000.0001.011.00 UMM023 GANTI VERBAN SEDANG 12,500.0001.011.00 UMM024 GANTI VERBAN BESAR 12,000.0001.012.01 UMM025 HECHTING BESAR ( > 10 ) 36,000.0001.012.02 UMM026 HECHTING KECIL ( 1 - 5 ) 24,000.0001.012.03 UMM027 HECHTING SEDANG ( 6 - 10 ) 30,000.0001.013.00 UMM028 INCISI ABSES 50,000.0001.014.00 UMM029 INHALASI TANPA OBAT 12,000.0001.015.00 UMM030 INTUBASI 80,000.0001.016.00 UMM031 IRIGASI MATA 40,000.0001.017.01 UMM032 JAHIT OTOT DENGAN EKSPLORASI ( BESAR ) 80,000.0001.017.02 UMM033 JAHIT OTOT DENGAN EKSPLORASI ( KECIL ) 40,000.0001.017.03 UMM034 JAHIT OTOT DENGAN EKSPLORASI ( SEDANG ) 60,000.0001.018.00 UMM035 LAVAMENT / CLYSMA 50,000.0001.019.00 UMM036 O2 / 3 JAM 10,000.0001.020.00 UMM037 RUANG OBSERVASI S/D 8 JAM 120,000.0001.021.00 UMM038 PASANG CATHETER 14,000.0001.022.00 UMM039 PASANG CVP 160,000.0001.023.00 UMM040 PASANG INFUS 10,000.0001.024.00 UMM041 ANGKAT SERUMEN TANPA PENYULIT 20,000.0001.025.00 UMM042 PASANG NGT 15,000.0001.026.00 UMM043 PASANG SPALK 50,000.0001.027.00 UMM044 PASANG TAMPON (HIDUNG DAN TELINGA) 8,000.0001.028.00 UMM045 PLEURA PUNKSI / WSD MINI 60,000.0001.029.00 UMM046 SPOOLING / IRIGASI TELINGA 12,000.0001.030.00 UMM047 SUNTIK 7,500.0001.031.00 UMM048 TAMPON POSTERIOR EPISTAKSIS 24,000.0001.032.00 UMM049 VENA SEKSI 60,000.0001.033.00 UMM050 CPR 40,000.00

UMM051 CIRCUMSISI ANAK ( < 15 TAHUN ) 250,000.00UMM052 CIRCUMSISI DEWASA 400,000.00UMM053 ECG MONITOR PER 3 JAM 100,000.00

31.600.01 USG001 USG ABDOMEN ATAS 172,500.0031.600.02 USG002 USG ABDOMEN PELVIS 131,250.0031.600.03 USG003 USG ABDOMEN ATAS & BAWAH 225,000.0031.600.04 USG004 USG - MAMMAE 168,750.0031.600.05 USG005 USG - THYROID 168,750.0031.600.06 USG006 USG KEPALA 131,250.0031.600.07.01USG007 USG - GYNEKOLOGY / TRANSVAGINAL 112,500.0031.600.07.02USG008 USG - OBSTETRI 2D 37,500.0031.600.07.03USG009 USG - OBSTETRI 4D 337,500.0031.600.08.01USG010 USG - TESTIS ANAK 150,000.0031.600.08.02USG011 USG - SOFT TISSUE/MUSC. SKELETAL 150,000.0031.600.09.01USG012 USG KHUSUS - THORAX 150,000.0031.600.09.02USG013 USG - GUIDE BIOPSI 187,500.0031.600.09.03USG014 USG VASKULER/DOPPLER 281,250.00

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31.600.09.04USG015 USG (ECHO RADIOGRAPHIC) 187,500.0031.600.09.05USG016 USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER 262,500.00

VAG001 VAGINA TOILET 37,500.00VKN001 KAMAR BERSALIN 200,000.00VKN002 RUANG OBSERVASI KEBIDANAN 150,000.00VKN003 RUANG OK MINOR 450,000.00VKN004 ONE DAY CARE 150,000.00VKN005 KAMAR VK PARTUS NORMAL DENGAN DOKTER 200,000.00VKN006 JASA DOKTER OBSGYN PARTUS NORMAL 0.00VKN007 JASA DOKTER ANAK PARTUS NORMAL 0.00VKN008 KAMAR VK PARTUS NORMAL DENGAN BIDAN 200,000.00VKN009 JASA BIDAN PARTUS NORMAL 0.00VKN010 SHARE OPERATOR PARTUS NORMAL 0.00VKN011 SHARE DOKTER ANAK PARTUS NORMAL 0.00VKN012 SHARE BIDAN PARTUS NORMAL 0.00

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PHDR PHSU PHNMTotal Total BaruDokter Obat Alkes

0.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 5,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 7,500.00 0.00

18,000.00 0.00 0.00 30,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0048,000.00 0.00 0.00 80,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0093,000.00 0.00 0.00 155,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0093,000.00 0.00 0.00 155,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0093,000.00 0.00 0.00 155,000.00 0.0093,000.00 0.00 0.00 155,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.00

123,000.00 0.00 0.00 205,000.00 0.0042,000.00 0.00 0.00 70,000.00 0.00

360,000.00 0.00 0.00 600,000.00 0.00720,000.00 0.00 0.00 1,200,000.00 0.00

0.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 400,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 500,000.00 0.00

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0.00 0.00 0.00 10,000.00 0.0060,000.00 0.00 0.00 75,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.00

0.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 60,000.00 0.00

40,000.00 0.00 0.00 50,000.00 70,000.0060,000.00 0.00 0.00 75,000.00 95,000.0080,000.00 0.00 0.00 100,000.00 120,000.00

120,000.00 0.00 0.00 150,000.00 230,000.00320,000.00 0.00 0.00 400,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00

80,000.00 0.00 0.00 100,000.00 0.00300,000.00 0.00 0.00 600,000.00 0.00400,000.00 0.00 0.00 800,000.00 0.00100,000.00 0.00 0.00 125,000.00 0.00400,000.00 0.00 0.00 500,000.00 600,000.00320,000.00 0.00 0.00 400,000.00 96,000.00200,000.00 0.00 0.00 250,000.00 300,000.00480,000.00 0.00 0.00 600,000.00 500,000.00320,000.00 0.00 0.00 400,000.00 580,000.00

15,000.00 0.00 0.00 25,000.00 35,000.0024,000.00 0.00 0.00 40,000.00 50,000.00

0.00 0.00 0.00 25,000.00 50,000.000.00 0.00 0.00 30,000.00 75,000.00

45,000.00 0.00 0.00 75,000.00 75,000.00120,000.00 0.00 0.00 150,000.00 200,000.00200,000.00 0.00 0.00 250,000.00 500,000.00120,000.00 0.00 0.00 150,000.00 500,000.00120,000.00 0.00 0.00 150,000.00 200,000.00160,000.00 0.00 0.00 200,000.00 0.00400,000.00 0.00 0.00 500,000.00 0.00

15,000.00 0.00 0.00 50,000.00 100,000.00560,000.00 0.00 0.00 700,000.00 0.00280,000.00 0.00 0.00 350,000.00 0.00160,000.00 0.00 0.00 200,000.00 250,000.00240,000.00 0.00 0.00 300,000.00 1,000,000.00240,000.00 0.00 0.00 300,000.00 500,000.00

80,000.00 0.00 0.00 100,000.00 0.00120,000.00 0.00 0.00 150,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00

80,000.00 0.00 0.00 100,000.00 150,000.0080,000.00 0.00 0.00 100,000.00 150,000.00

280,000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 5,000.00 0.00

TarifKIT

75,000.00 0.00 0.00 125,000.00 0.0015,000.00 0.00 0.00 50,000.00 0.0015,000.00 0.00 0.00 55,000.00 0.0024,000.00 0.00 0.00 65,000.00 75,000.0024,000.00 0.00 0.00 70,000.00 75,000.0045,000.00 0.00 0.00 100,000.00 0.0045,000.00 0.00 0.00 105,000.00 0.00

0.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 375,000.00 0.000.00 0.00 0.00 395,000.00 0.00

175,000.00 0.00 0.00 550,000.00 0.0090,000.00 0.00 0.00 90,000.00 0.0030,000.00 0.00 0.00 60,000.00 0.0035,000.00 0.00 0.00 70,000.00 0.0035,000.00 0.00 0.00 70,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0030,000.00 0.00 0.00 60,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.00

0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00

120,000.00 0.00 0.00 150,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0090,000.00 0.00 0.00 90,000.00 0.0080,000.00 0.00 0.00 80,000.00 0.0080,000.00 0.00 0.00 80,000.00 0.0060,000.00 0.00 0.00 60,000.00 0.00

125,000.00 0.00 0.00 125,000.00 0.00

TarifKIT

110,000.00 0.00 0.00 110,000.00 0.0090,000.00 0.00 0.00 90,000.00 0.00

0.00 0.00 0.00 0.00 0.007,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.00

12,000.00 0.00 0.00 60,000.00 0.0020,000.00 0.00 0.00 100,000.00 0.00

6,000.00 0.00 0.00 30,000.00 0.007,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.00

13,000.00 0.00 0.00 65,000.00 0.0019,000.00 0.00 0.00 95,000.00 0.0025,000.00 0.00 0.00 125,000.00 0.0012,000.00 0.00 0.00 60,000.00 0.0016,000.00 0.00 0.00 80,000.00 0.0014,000.00 0.00 0.00 70,000.00 0.00

7,000.00 0.00 0.00 35,000.00 0.007,000.00 0.00 0.00 35,000.00 0.006,000.00 0.00 0.00 30,000.00 0.006,000.00 0.00 0.00 30,000.00 0.006,000.00 0.00 0.00 30,000.00 0.00

0.00 0.00 0.00 25,000.00 0.0030,600.00 0.00 0.00 51,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.0032,400.00 0.00 0.00 54,000.00 0.0064,800.00 0.00 0.00 108,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.0032,400.00 0.00 0.00 54,000.00 0.0032,400.00 0.00 0.00 54,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

378,000.00 0.00 270,000.00 540,000.00 0.0032,400.00 0.00 0.00 54,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.00135,000.00 0.00 0.00 225,000.00 0.00

81,000.00 0.00 0.00 135,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00135,000.00 0.00 0.00 225,000.00 0.00

54,000.00 0.00 0.00 90,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

TarifKIT

81,000.00 0.00 0.00 135,000.00 0.00189,000.00 0.00 225,000.00 315,000.00 0.00

81,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00135,000.00 0.00 0.00 225,000.00 0.00162,000.00 0.00 0.00 270,000.00 0.00351,000.00 0.00 180,000.00 585,000.00 0.00486,000.00 0.00 315,000.00 810,000.00 0.00

1,350,000.00 0.00 0.00 2,250,000.00 0.002,160,000.00 0.00 0.00 3,600,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.00162,000.00 0.00 0.00 270,000.00 0.00189,000.00 0.00 0.00 315,000.00 0.00216,000.00 0.00 0.00 360,000.00 0.00810,000.00 0.00 0.00 1,350,000.00 0.00

1,080,000.00 0.00 0.00 1,800,000.00 0.001,350,000.00 0.00 0.00 2,250,000.00 0.00

270,000.00 0.00 0.00 450,000.00 0.009,720,000.00 0.00 0.00 16,200,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.00324,000.00 0.00 0.00 540,000.00 0.00405,000.00 0.00 0.00 675,000.00 0.00810,000.00 0.00 0.00 1,350,000.00 0.00270,000.00 0.00 0.00 450,000.00 0.00405,000.00 0.00 0.00 675,000.00 0.00

3,240,000.00 0.00 0.00 5,400,000.00 0.00810,000.00 0.00 0.00 1,350,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00324,000.00 0.00 0.00 540,000.00 0.00675,000.00 0.00 0.00 1,125,000.00 0.00216,000.00 0.00 0.00 360,000.00 0.00

1,080,000.00 0.00 0.00 1,800,000.00 0.00297,000.00 0.00 0.00 495,000.00 0.00

1,350,000.00 0.00 0.00 2,250,000.00 0.00810,000.00 0.00 0.00 1,350,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00

81,000.00 0.00 0.00 135,000.00 0.00297,000.00 0.00 0.00 495,000.00 0.00432,000.00 0.00 0.00 720,000.00 0.00810,000.00 0.00 0.00 1,350,000.00 0.00540,000.00 0.00 0.00 900,000.00 0.00540,000.00 0.00 0.00 900,000.00 0.00

1,188,000.00 0.00 720,000.00 1,980,000.00 0.001,485,000.00 0.00 1,125,000.00 2,475,000.00 0.002,376,000.00 0.00 1,440,000.00 3,960,000.00 0.002,700,000.00 0.00 2,250,000.00 4,500,000.00 0.00

TarifKIT

94,500.00 0.00 67,500.00 157,500.00 0.00135,000.00 0.00 135,000.00 225,000.00 0.00

81,000.00 0.00 135,000.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

108,000.00 0.00 90,000.00 180,000.00 0.00135,000.00 0.00 135,000.00 225,000.00 0.00162,000.00 0.00 0.00 450,000.00 0.00162,000.00 0.00 90,000.00 270,000.00 0.00216,000.00 0.00 180,000.00 360,000.00 0.00405,000.00 0.00 225,000.00 675,000.00 0.00148,500.00 0.00 157,500.00 247,500.00 0.00216,000.00 0.00 225,000.00 360,000.00 0.00297,000.00 0.00 315,000.00 495,000.00 0.00189,000.00 0.00 0.00 315,000.00 0.00

54,000.00 0.00 0.00 90,000.00 0.0067,500.00 0.00 0.00 112,500.00 0.0081,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

270,000.00 0.00 0.00 450,000.00 0.00162,000.00 0.00 0.00 270,000.00 0.00

54,000.00 0.00 0.00 90,000.00 0.00108,000.00 0.00 0.00 180,000.00 0.00

81,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

108,000.00 0.00 0.00 180,000.00 0.001,350,000.00 0.00 1,350,000.00 2,250,000.00 0.001,755,000.00 0.00 1,575,000.00 2,925,000.00 0.002,160,000.00 0.00 1,800,000.00 3,600,000.00 0.006,480,000.00 0.00 2,700,000.00 10,800,000.00 0.00

486,000.00 0.00 315,000.00 810,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0081,000.00 0.00 0.00 135,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.00

0.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 40,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 70,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 125,000.00 0.000.00 0.00 0.00 30,000.00 0.000.00 0.00 0.00 165,000.00 0.00

TarifKIT

0.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 830,000.00 0.000.00 0.00 0.00 726,000.00 0.00

40,000.00 0.00 0.00 200,000.00 0.00110,000.00 0.00 0.00 550,000.00 0.00220,000.00 0.00 0.00 1,100,000.00 0.00330,000.00 0.00 0.00 1,650,000.00 0.00360,000.00 0.00 0.00 1,800,000.00 0.00

96,000.00 0.00 0.00 120,000.00 0.0030,000.00 0.00 0.00 60,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0085,000.00 0.00 0.00 105,000.00 0.0015,000.00 0.00 0.00 50,000.00 0.00

200,000.00 0.00 0.00 250,000.00 0.0030,000.00 0.00 0.00 60,000.00 0.00

175,000.00 0.00 0.00 350,000.00 0.00125,000.00 0.00 0.00 250,000.00 0.00175,000.00 0.00 0.00 350,000.00 0.00

0.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 60,000.00 0.00

122,500.00 0.00 0.00 175,000.00 0.0080,000.00 0.00 0.00 100,000.00 0.00

240,000.00 0.00 0.00 300,000.00 0.0080,000.00 0.00 0.00 100,000.00 0.00

880,000.00 0.00 0.00 1,100,000.00 0.000.00 0.00 0.00 10,000.00 0.00

880,000.00 0.00 0.00 1,100,000.00 0.00320,000.00 0.00 0.00 400,000.00 0.00

TarifKIT

240,000.00 0.00 0.00 300,000.00 0.0060,000.00 0.00 0.00 75,000.00 0.00

240,000.00 0.00 0.00 300,000.00 0.0080,000.00 0.00 0.00 100,000.00 0.0017,500.00 0.00 0.00 50,000.00 0.0010,500.00 0.00 0.00 30,000.00 0.00

157,500.00 0.00 0.00 450,000.00 0.0052,500.00 0.00 0.00 150,000.00 0.00

280,000.00 0.00 0.00 350,000.00 0.0025,000.00 0.00 0.00 50,000.00 0.0070,000.00 0.00 0.00 350,000.00 0.0080,000.00 0.00 30,000.00 100,000.00 0.00

200,000.00 0.00 65,000.00 250,000.00 0.0080,000.00 0.00 30,000.00 100,000.00 0.00

880,000.00 0.00 30,000.00 1,100,000.00 0.00880,000.00 0.00 30,000.00 1,100,000.00 0.00320,000.00 0.00 65,000.00 400,000.00 0.00200,000.00 0.00 30,000.00 250,000.00 0.00

60,000.00 0.00 30,000.00 75,000.00 0.00160,000.00 0.00 30,000.00 200,000.00 0.00

80,000.00 0.00 30,000.00 100,000.00 0.00280,000.00 0.00 30,000.00 350,000.00 0.00

25,000.00 0.00 30,000.00 50,000.00 0.00280,000.00 0.00 30,000.00 350,000.00 0.00

80,000.00 0.00 0.00 200,000.00 0.0088,000.00 0.00 0.00 220,000.00 0.0096,000.00 0.00 0.00 240,000.00 0.0090,000.00 0.00 0.00 225,000.00 0.00

120,000.00 0.00 0.00 300,000.00 0.00160,000.00 0.00 0.00 400,000.00 0.00

50,000.00 0.00 0.00 125,000.00 0.0066,000.00 0.00 0.00 165,000.00 0.0080,000.00 0.00 0.00 200,000.00 0.00

100,000.00 0.00 0.00 250,000.00 0.00110,000.00 0.00 0.00 275,000.00 0.00

96,000.00 0.00 0.00 120,000.00 0.00396,000.00 0.00 0.00 495,000.00 0.00168,000.00 0.00 0.00 210,000.00 0.00220,000.00 0.00 0.00 275,000.00 0.00320,000.00 0.00 0.00 400,000.00 0.00190,000.00 0.00 0.00 237,500.00 0.00298,000.00 0.00 0.00 372,500.00 0.00345,200.00 0.00 0.00 431,500.00 0.00444,000.00 0.00 0.00 555,000.00 0.00

96,000.00 0.00 0.00 120,000.00 0.00140,000.00 0.00 0.00 175,000.00 0.00188,000.00 0.00 0.00 235,000.00 0.00320,000.00 0.00 0.00 400,000.00 0.00

68,000.00 0.00 0.00 85,000.00 0.00100,000.00 0.00 0.00 125,000.00 0.00

TarifKIT

144,000.00 0.00 0.00 180,000.00 0.00260,000.00 0.00 0.00 325,000.00 0.00424,000.00 0.00 0.00 530,000.00 0.00135,000.00 0.00 0.00 225,000.00 0.00

54,000.00 0.00 0.00 90,000.00 0.0078,000.00 0.00 0.00 130,000.00 0.0099,000.00 0.00 0.00 165,000.00 0.00

0.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 65,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 132,000.00 0.000.00 0.00 0.00 269,500.00 0.000.00 0.00 0.00 220,000.00 0.000.00 0.00 0.00 313,500.00 0.00

1,500,000.00 0.00 0.00 1,500,000.00 0.001,200,000.00 0.00 0.00 1,200,000.00 0.00

600,000.00 0.00 0.00 600,000.00 0.00480,000.00 0.00 0.00 480,000.00 0.00

0.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 85,000.00 0.000.00 0.00 0.00 70,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 750,000.00 0.000.00 0.00 0.00 1,150,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 750,000.00 0.000.00 0.00 0.00 1,150,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 750,000.00 0.000.00 0.00 0.00 1,150,000.00 0.000.00 0.00 0.00 60,000.00 0.00

100,000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 45,000.00 0.000.00 0.00 0.00 50,000.00 55,000.000.00 0.00 0.00 40,000.00 0.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 25,000.00 35,000.00

TarifKIT

0.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 287,000.00 230,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 93,500.00 100,000.000.00 0.00 0.00 85,000.00 0.000.00 0.00 0.00 71,500.00 100,000.000.00 0.00 0.00 236,500.00 250,000.000.00 0.00 0.00 99,000.00 120,000.000.00 0.00 0.00 236,500.00 240,000.000.00 0.00 0.00 93,500.00 110,000.000.00 0.00 0.00 290,500.00 0.000.00 0.00 0.00 350,000.00 450,000.000.00 0.00 0.00 350,000.00 450,000.000.00 0.00 0.00 179,000.00 180,000.000.00 0.00 0.00 190,000.00 160,000.000.00 0.00 0.00 160,000.00 0.000.00 0.00 0.00 160,000.00 250,000.000.00 0.00 0.00 415,000.00 445,000.000.00 0.00 0.00 350,000.00 425,000.000.00 0.00 0.00 110,000.00 132,000.000.00 0.00 0.00 44,000.00 100,000.000.00 0.00 0.00 150,000.00 182,000.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 111,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 35,000.00 40,000.000.00 0.00 0.00 250,000.00 350,000.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 270,000.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 50,000.00 55,000.000.00 0.00 0.00 30,000.00 0.000.00 0.00 0.00 117,000.00 120,000.000.00 0.00 0.00 50,000.00 55,000.000.00 0.00 0.00 49,500.00 49,500.000.00 0.00 0.00 46,000.00 50,000.000.00 0.00 0.00 48,000.00 0.000.00 0.00 0.00 94,000.00 0.000.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 328,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 30,000.00 0.000.00 0.00 0.00 30,000.00 35,000.000.00 0.00 0.00 30,000.00 0.000.00 0.00 0.00 160,000.00 0.000.00 0.00 0.00 125,000.00 0.000.00 0.00 0.00 195,000.00 0.000.00 0.00 0.00 83,000.00 0.00

TarifKIT

0.00 0.00 0.00 104,000.00 0.000.00 0.00 0.00 101,000.00 0.000.00 0.00 0.00 146,000.00 0.000.00 0.00 0.00 220,000.00 0.000.00 0.00 0.00 385,000.00 0.000.00 0.00 0.00 275,000.00 300,000.000.00 0.00 0.00 180,000.00 0.000.00 0.00 0.00 18,000.00 20,000.000.00 0.00 0.00 18,000.00 20,000.000.00 0.00 0.00 18,000.00 20,000.000.00 0.00 0.00 55,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 145,000.00 0.000.00 0.00 0.00 176,000.00 0.000.00 0.00 0.00 23,000.00 25,000.000.00 0.00 0.00 23,000.00 25,000.000.00 0.00 0.00 23,000.00 25,000.000.00 0.00 0.00 55,000.00 60,000.000.00 0.00 0.00 255,000.00 0.000.00 0.00 0.00 37,500.00 50,000.000.00 0.00 0.00 37,500.00 0.000.00 0.00 0.00 37,500.00 50,000.000.00 0.00 0.00 41,000.00 45,000.000.00 0.00 0.00 225,000.00 0.000.00 0.00 0.00 41,000.00 50,000.000.00 0.00 0.00 41,000.00 50,000.000.00 0.00 0.00 140,000.00 200,000.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 154,000.00 0.000.00 0.00 0.00 167,000.00 0.000.00 0.00 0.00 132,000.00 150,000.000.00 0.00 0.00 229,000.00 0.000.00 0.00 0.00 369,000.00 0.000.00 0.00 0.00 290,000.00 0.000.00 0.00 0.00 550,000.00 0.000.00 0.00 0.00 525,000.00 0.000.00 0.00 0.00 40,000.00 0.000.00 0.00 0.00 62,500.00 0.000.00 0.00 0.00 65,000.00 0.000.00 0.00 0.00 260,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 286,000.00 0.000.00 0.00 0.00 199,000.00 0.000.00 0.00 0.00 700,000.00 750,000.000.00 0.00 0.00 215,000.00 0.000.00 0.00 0.00 82,500.00 110,000.000.00 0.00 0.00 115,500.00 0.000.00 0.00 0.00 73,000.00 0.000.00 0.00 0.00 89,000.00 0.000.00 0.00 0.00 102,000.00 0.00

TarifKIT

0.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 295,000.00 0.000.00 0.00 0.00 167,000.00 0.000.00 0.00 0.00 310,000.00 0.000.00 0.00 0.00 800,000.00 0.000.00 0.00 0.00 1,400,000.00 0.000.00 0.00 0.00 195,000.00 0.000.00 0.00 0.00 230,000.00 240,000.000.00 0.00 0.00 564,000.00 650,000.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 1,800,000.00 0.000.00 0.00 0.00 142,500.00 155,000.000.00 0.00 0.00 142,500.00 155,000.000.00 0.00 0.00 275,000.00 310,000.000.00 0.00 0.00 275,000.00 310,000.000.00 0.00 0.00 275,000.00 285,000.000.00 0.00 0.00 199,000.00 200,000.000.00 0.00 0.00 420,000.00 450,000.000.00 0.00 0.00 330,000.00 350,000.000.00 0.00 0.00 253,000.00 260,000.000.00 0.00 0.00 155,000.00 0.000.00 0.00 0.00 159,000.00 0.000.00 0.00 0.00 167,000.00 170,000.000.00 0.00 0.00 182,000.00 215,000.000.00 0.00 0.00 159,000.00 0.000.00 0.00 0.00 182,000.00 0.000.00 0.00 0.00 160,000.00 178,000.000.00 0.00 0.00 164,000.00 178,000.000.00 0.00 0.00 160,000.00 168,000.000.00 0.00 0.00 164,000.00 168,000.000.00 0.00 0.00 325,000.00 0.000.00 0.00 0.00 325,000.00 0.000.00 0.00 0.00 240,000.00 0.000.00 0.00 0.00 240,000.00 0.000.00 0.00 0.00 240,000.00 0.000.00 0.00 0.00 170,000.00 0.000.00 0.00 0.00 750,000.00 0.000.00 0.00 0.00 245,000.00 0.000.00 0.00 0.00 245,000.00 0.000.00 0.00 0.00 115,000.00 0.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 260,000.00 0.000.00 0.00 0.00 330,000.00 0.000.00 0.00 0.00 330,000.00 0.000.00 0.00 0.00 80,000.00 120,000.000.00 0.00 0.00 80,000.00 125,000.000.00 0.00 0.00 375,000.00 0.000.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 360,000.00 0.000.00 0.00 0.00 350,000.00 0.00

TarifKIT

0.00 0.00 0.00 125,000.00 0.000.00 0.00 0.00 125,000.00 0.000.00 0.00 0.00 137,500.00 0.000.00 0.00 0.00 175,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 357,000.00 0.000.00 0.00 0.00 190,000.00 0.000.00 0.00 0.00 0.00 0.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 185,000.00 0.000.00 0.00 0.00 185,000.00 0.000.00 0.00 0.00 180,000.00 0.000.00 0.00 0.00 220,000.00 225,000.000.00 0.00 0.00 1,080,000.00 0.000.00 0.00 0.00 220,000.00 225,000.000.00 0.00 0.00 198,000.00 200,000.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 170,000.00 190,000.000.00 0.00 0.00 120,000.00 0.000.00 0.00 0.00 1,440,000.00 0.000.00 0.00 0.00 350,000.00 375,000.000.00 0.00 0.00 27,500.00 30,000.000.00 0.00 0.00 12,500.00 15,000.000.00 0.00 0.00 12,500.00 15,000.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 33,000.00 0.000.00 0.00 0.00 90,000.00 95,000.000.00 0.00 0.00 55,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 23,000.00 41,000.000.00 0.00 0.00 23,000.00 41,000.000.00 0.00 0.00 37,500.00 58,000.000.00 0.00 0.00 37,500.00 58,000.000.00 0.00 0.00 42,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 20,000.00 25,000.000.00 0.00 0.00 15,000.00 25,000.000.00 0.00 0.00 30,000.00 40,000.000.00 0.00 0.00 100,000.00 200,000.000.00 0.00 0.00 40,000.00 0.000.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 41,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 55,000.00 0.000.00 0.00 0.00 110,000.00 0.00

TarifKIT

0.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 125,000.00 0.000.00 0.00 0.00 155,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 192,500.00 200,000.000.00 0.00 0.00 262,000.00 0.000.00 0.00 0.00 192,500.00 200,000.000.00 0.00 0.00 263,000.00 0.000.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 50,000.00 55,000.000.00 0.00 0.00 500,000.00 0.000.00 0.00 0.00 175,000.00 0.000.00 0.00 0.00 192,500.00 200,000.000.00 0.00 0.00 145,000.00 0.000.00 0.00 0.00 275,000.00 310,000.000.00 0.00 0.00 263,000.00 0.000.00 0.00 0.00 40,000.00 75,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 15,000.00 20,000.000.00 0.00 0.00 23,000.00 0.000.00 0.00 0.00 23,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 120,000.00 132,000.000.00 0.00 0.00 45,000.00 51,000.000.00 0.00 0.00 162,500.00 180,000.000.00 0.00 0.00 12,000.00 0.000.00 0.00 0.00 85,000.00 100,000.000.00 0.00 0.00 236,500.00 0.000.00 0.00 0.00 140,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 210,000.00 0.000.00 0.00 0.00 190,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 12,500.00 15,000.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 120,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 239,000.00 0.000.00 0.00 0.00 71,500.00 0.000.00 0.00 0.00 82,500.00 0.000.00 0.00 0.00 120,000.00 0.00

TarifKIT

0.00 0.00 0.00 140,000.00 0.000.00 0.00 0.00 282,000.00 0.000.00 0.00 0.00 330,000.00 0.000.00 0.00 0.00 330,000.00 0.000.00 0.00 0.00 195,000.00 0.000.00 0.00 0.00 220,000.00 323,000.000.00 0.00 0.00 525,000.00 475,000.000.00 0.00 0.00 231,000.00 0.000.00 0.00 0.00 192,500.00 200,000.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 110,000.00 130,000.000.00 0.00 0.00 55,000.00 0.000.00 0.00 0.00 55,000.00 0.000.00 0.00 0.00 150,000.00 160,000.000.00 0.00 0.00 37,500.00 50,000.000.00 0.00 0.00 192,500.00 200,000.000.00 0.00 0.00 162,000.00 0.000.00 0.00 0.00 162,000.00 0.000.00 0.00 0.00 162,000.00 0.000.00 0.00 0.00 162,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 159,000.00 0.000.00 0.00 0.00 38,500.00 0.000.00 0.00 0.00 360,000.00 450,000.000.00 0.00 0.00 180,000.00 200,000.000.00 0.00 0.00 1,020,000.00 0.000.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 396,000.00 0.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 252,000.00 0.000.00 0.00 0.00 143,000.00 0.000.00 0.00 0.00 240,000.00 250,000.000.00 0.00 0.00 132,000.00 140,000.000.00 0.00 0.00 132,000.00 140,000.000.00 0.00 0.00 165,000.00 0.000.00 0.00 0.00 155,000.00 0.000.00 0.00 0.00 150,000.00 280,000.000.00 0.00 0.00 88,000.00 0.000.00 0.00 0.00 65,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 250,000.00 0.00

69,000.00 0.00 0.00 450,000.00 0.00119,000.00 0.00 0.00 899,000.00 0.00384,000.00 0.00 0.00 1,300,000.00 0.00454,000.00 0.00 0.00 1,464,000.00 0.00588,000.00 0.00 0.00 2,199,000.00 0.00658,000.00 0.00 0.00 2,710,500.00 0.00

69,000.00 0.00 0.00 350,000.00 0.00109,000.00 0.00 0.00 850,000.00 0.00159,000.00 0.00 0.00 875,000.00 0.00

TarifKIT

0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00

50,000.00 0.00 0.00 250,000.00 0.00159,000.00 0.00 0.00 875,000.00 0.00

50,000.00 0.00 0.00 331,500.00 0.0015,000.00 0.00 0.00 60,000.00 0.00

290,000.00 0.00 0.00 1,081,500.00 0.0080,000.00 0.00 0.00 100,000.00 0.00

320,000.00 0.00 0.00 400,000.00 0.00100,000.00 0.00 0.00 125,000.00 0.00

80,000.00 0.00 0.00 100,000.00 0.0080,000.00 0.00 0.00 100,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.00

320,000.00 0.00 0.00 400,000.00 0.0080,000.00 0.00 0.00 100,000.00 0.00

400,000.00 0.00 0.00 500,000.00 0.0024,000.00 0.00 0.00 30,000.00 0.0024,000.00 0.00 0.00 30,000.00 0.0060,000.00 0.00 0.00 75,000.00 0.0024,000.00 0.00 0.00 30,000.00 0.0020,000.00 0.00 0.00 25,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.0016,000.00 0.00 0.00 20,000.00 0.0024,000.00 0.00 0.00 30,000.00 0.0024,000.00 0.00 0.00 30,000.00 0.0028,000.00 0.00 0.00 35,000.00 0.0016,000.00 0.00 0.00 20,000.00 0.0020,000.00 0.00 0.00 25,000.00 0.00

120,000.00 0.00 0.00 150,000.00 0.0052,000.00 0.00 0.00 65,000.00 0.00

0.00 0.00 0.00 140,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 150,000.00 0.00

1,250,000.00 0.00 0.00 1,250,000.00 0.00500,000.00 0.00 0.00 500,000.00 0.00

0.00 0.00 0.00 450,000.00 0.000.00 0.00 0.00 150,000.00 0.00

1,400,000.00 0.00 0.00 1,400,000.00 0.00560,000.00 0.00 0.00 560,000.00 0.00

0.00 0.00 0.00 450,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 1,500,000.00 0.00

600,000.00 0.00 0.00 600,000.00 0.001,500,000.00 0.00 0.00 1,500,000.00 0.00

0.00 0.00 0.00 450,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 300,000.00 0.00

1,600,000.00 0.00 0.00 1,600,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.004,000,000.00 0.00 0.00 4,000,000.00 0.00

TarifKIT

0.00 0.00 0.00 2,500,000.00 0.001,500,000.00 0.00 0.00 1,500,000.00 0.00

750,000.00 0.00 0.00 750,000.00 0.003,750,000.00 0.00 0.00 3,750,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,240,000.00 0.00 0.00 2,240,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,600,000.00 0.00 0.00 5,600,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.001,600,000.00 0.00 0.00 1,600,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.004,000,000.00 0.00 0.00 4,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,400,000.00 0.00 0.00 2,400,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,000,000.00 0.00 0.00 6,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.00

TarifKIT

1,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,400,000.00 0.00 0.00 2,400,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,000,000.00 0.00 0.00 6,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,720,000.00 0.00 0.00 2,720,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,800,000.00 0.00 0.00 6,800,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,400,000.00 0.00 0.00 2,400,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,000,000.00 0.00 0.00 6,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,560,000.00 0.00 0.00 2,560,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,400,000.00 0.00 0.00 6,400,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,720,000.00 0.00 0.00 2,720,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,800,000.00 0.00 0.00 6,800,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.00

0.00 0.00 0.00 0.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.00

0.00 0.00 0.00 0.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,000,000.00 0.00 0.00 2,000,000.00 0.00

0.00 0.00 0.00 0.00 0.005,000,000.00 0.00 0.00 5,000,000.00 0.00

0.00 0.00 0.00 2,500,000.00 0.002,450,000.00 0.00 0.00 3,062,500.00 0.001,960,000.00 0.00 0.00 2,450,000.00 0.001,600,000.00 0.00 0.00 2,000,000.00 0.00

960,000.00 0.00 0.00 1,200,000.00 0.002,450,000.00 0.00 0.00 3,062,500.00 0.001,960,000.00 0.00 0.00 2,450,000.00 0.001,600,000.00 0.00 0.00 2,000,000.00 0.00

960,000.00 0.00 0.00 1,200,000.00 0.003,200,000.00 0.00 0.00 4,000,000.00 0.002,600,000.00 0.00 0.00 3,250,000.00 0.001,200,000.00 0.00 0.00 1,500,000.00 0.00

TarifKIT

2,000,000.00 0.00 0.00 2,500,000.00 0.003,000,000.00 0.00 0.00 3,000,000.00 0.002,200,000.00 0.00 0.00 2,200,000.00 0.001,700,000.00 0.00 0.00 1,700,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.003,000,000.00 0.00 0.00 3,000,000.00 0.002,200,000.00 0.00 0.00 2,200,000.00 0.001,700,000.00 0.00 0.00 1,700,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.006,400,000.00 0.00 0.00 8,000,000.00 0.004,800,000.00 0.00 0.00 6,000,000.00 0.003,600,000.00 0.00 0.00 4,500,000.00 0.002,400,000.00 0.00 0.00 3,000,000.00 0.00

980,000.00 0.00 0.00 1,225,000.00 0.00784,000.00 0.00 0.00 980,000.00 0.00640,000.00 0.00 0.00 800,000.00 0.00384,000.00 0.00 0.00 480,000.00 0.00980,000.00 0.00 0.00 1,225,000.00 0.00784,000.00 0.00 0.00 980,000.00 0.00640,000.00 0.00 0.00 800,000.00 0.00384,000.00 0.00 0.00 480,000.00 0.00

1,280,000.00 0.00 0.00 1,600,000.00 0.001,040,000.00 0.00 0.00 1,300,000.00 0.00

800,000.00 0.00 0.00 1,000,000.00 0.00480,000.00 0.00 0.00 600,000.00 0.00

1,200,000.00 0.00 0.00 1,200,000.00 0.00880,000.00 0.00 0.00 880,000.00 0.00680,000.00 0.00 0.00 680,000.00 0.00400,000.00 0.00 0.00 400,000.00 0.00

1,200,000.00 0.00 0.00 1,200,000.00 0.00880,000.00 0.00 0.00 880,000.00 0.00680,000.00 0.00 0.00 680,000.00 0.00400,000.00 0.00 0.00 400,000.00 0.00

2,560,000.00 0.00 0.00 3,200,000.00 0.001,920,000.00 0.00 0.00 2,400,000.00 0.001,440,000.00 0.00 0.00 1,800,000.00 0.00

960,000.00 0.00 0.00 1,200,000.00 0.000.00 0.00 0.00 1,800,000.00 0.000.00 0.00 0.00 1,350,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 700,000.00 0.000.00 0.00 0.00 1,800,000.00 0.000.00 0.00 0.00 1,350,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 700,000.00 0.000.00 0.00 0.00 700,000.00 0.000.00 0.00 0.00 700,000.00 0.000.00 0.00 0.00 700,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 2,000,000.00 0.00

TarifKIT

0.00 0.00 0.00 2,000,000.00 0.000.00 0.00 0.00 2,000,000.00 0.000.00 0.00 0.00 2,500,000.00 0.000.00 0.00 0.00 1,500,000.00 0.000.00 0.00 0.00 1,500,000.00 0.000.00 0.00 0.00 1,500,000.00 0.000.00 0.00 0.00 2,000,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 1,000,000.00 0.000.00 0.00 0.00 1,400,000.00 0.000.00 0.00 0.00 0.00 0.00

480,000.00 0.00 0.00 600,000.00 0.00192,000.00 0.00 0.00 240,000.00 0.00

0.00 0.00 0.00 350,000.00 0.000.00 0.00 0.00 70,000.00 0.000.00 0.00 0.00 70,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 60,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 75,000.00 0.00

15,000.00 0.00 0.00 50,000.00 60,000.00200,000.00 0.00 0.00 250,000.00 0.00

30,000.00 0.00 0.00 60,000.00 70,000.00175,000.00 0.00 0.00 350,000.00 0.00125,000.00 0.00 0.00 250,000.00 0.00175,000.00 0.00 0.00 350,000.00 0.00

0.00 0.00 0.00 10,000.00 25,000.000.00 0.00 0.00 50,000.00 65,000.000.00 0.00 0.00 60,000.00 0.00

125,000.00 0.00 0.00 250,000.00 0.0070,000.00 0.00 0.00 200,000.00 0.0054,000.00 0.00 0.00 155,000.00 0.0087,500.00 0.00 0.00 250,000.00 0.0047,250.00 0.00 0.00 135,000.00 0.0017,500.00 0.00 0.00 50,000.00 0.00

122,500.00 0.00 0.00 350,000.00 0.0030,000.00 0.00 0.00 60,000.00 0.0015,000.00 0.00 0.00 50,000.00 60,000.00

200,000.00 0.00 0.00 250,000.00 0.0030,000.00 0.00 0.00 60,000.00 70,000.00

175,000.00 0.00 0.00 350,000.00 0.00125,000.00 0.00 0.00 250,000.00 0.00175,000.00 0.00 0.00 350,000.00 0.00

0.00 0.00 0.00 10,000.00 15,000.00

TarifKIT

0.00 0.00 0.00 50,000.00 15,000.000.00 0.00 0.00 60,000.00 0.00

17,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0018,750.00 0.00 0.00 82,500.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0018,750.00 0.00 0.00 82,500.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0020,000.00 0.00 0.00 88,000.00 0.0018,750.00 0.00 0.00 82,500.00 0.0018,750.00 0.00 0.00 82,500.00 0.0018,750.00 0.00 0.00 82,500.00 0.0017,500.00 0.00 0.00 77,000.00 0.0020,000.00 0.00 0.00 88,000.00 0.0037,500.00 0.00 0.00 165,000.00 0.0023,750.00 0.00 0.00 104,500.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0017,500.00 0.00 0.00 77,000.00 0.0035,000.00 0.00 0.00 154,000.00 0.0018,750.00 0.00 0.00 82,500.00 0.0027,500.00 0.00 0.00 121,000.00 0.0027,500.00 0.00 0.00 121,000.00 0.0025,000.00 0.00 0.00 110,000.00 0.0035,000.00 0.00 0.00 154,000.00 0.0018,750.00 0.00 0.00 82,500.00 0.0025,000.00 0.00 0.00 110,000.00 0.0033,750.00 0.00 0.00 148,500.00 0.0025,000.00 0.00 0.00 110,000.00 0.0030,000.00 0.00 0.00 132,000.00 0.0033,750.00 0.00 0.00 148,500.00 0.0031,250.00 0.00 0.00 137,500.00 0.0030,000.00 0.00 0.00 132,000.00 0.0030,000.00 0.00 0.00 132,000.00 0.0031,250.00 0.00 0.00 137,500.00 0.0033,750.00 0.00 0.00 148,500.00 0.0033,750.00 0.00 0.00 148,500.00 0.0043,750.00 0.00 0.00 192,500.00 0.0037,500.00 0.00 0.00 165,000.00 0.0056,250.00 0.00 0.00 247,500.00 0.0037,500.00 0.00 0.00 165,000.00 0.0037,500.00 0.00 0.00 165,000.00 0.0043,750.00 0.00 0.00 192,500.00 0.0043,750.00 0.00 0.00 192,500.00 0.00

TarifKIT

43,750.00 0.00 0.00 192,500.00 0.0040,000.00 0.00 0.00 176,000.00 0.0037,500.00 0.00 0.00 165,000.00 0.0045,000.00 0.00 0.00 198,000.00 0.0045,000.00 0.00 0.00 198,000.00 0.0037,500.00 0.00 0.00 165,000.00 0.0043,750.00 0.00 0.00 192,500.00 0.0045,000.00 0.00 0.00 198,000.00 0.0043,750.00 0.00 0.00 192,500.00 0.00

122,500.00 0.00 0.00 385,000.00 0.00148,750.00 0.00 0.00 467,500.00 0.00140,000.00 0.00 0.00 440,000.00 0.00

91,000.00 0.00 0.00 286,000.00 0.00113,750.00 0.00 0.00 357,500.00 0.00122,500.00 0.00 0.00 385,000.00 0.00

87,500.00 0.00 0.00 275,000.00 0.00105,000.00 0.00 0.00 330,000.00 0.00131,250.00 0.00 0.00 412,500.00 0.00131,250.00 0.00 0.00 412,500.00 0.00122,500.00 0.00 0.00 385,000.00 0.00122,500.00 0.00 0.00 385,000.00 0.00131,250.00 0.00 0.00 412,500.00 0.00

45,000.00 0.00 0.00 150,000.00 0.0022,500.00 0.00 0.00 75,000.00 0.00

0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 500,000.00 0.00

1,750,000.00 0.00 0.00 1,750,000.00 0.00612,500.00 0.00 0.00 612,500.00 0.00437,500.00 0.00 0.00 437,500.00 0.00180,000.00 0.00 0.00 180,000.00 0.00180,000.00 0.00 0.00 180,000.00 0.00

0.00 0.00 0.00 240,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 200,000.00 0.00

1,200,000.00 0.00 0.00 1,200,000.00 0.00420,000.00 0.00 0.00 420,000.00 0.00

0.00 0.00 0.00 300,000.00 0.000.00 0.00 0.00 100,000.00 0.00

1,200,000.00 0.00 0.00 1,200,000.00 0.00420,000.00 0.00 0.00 420,000.00 0.00

0.00 0.00 0.00 200,000.00 0.001,000,000.00 0.00 0.00 1,000,000.00 0.00

250,000.00 0.00 0.00 250,000.00 0.00180,000.00 0.00 0.00 180,000.00 0.00180,000.00 0.00 0.00 180,000.00 0.00

0.00 0.00 0.00 240,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 50,000.00 60,000.000.00 0.00 0.00 70,000.00 80,000.000.00 0.00 0.00 60,000.00 70,000.00

TarifKIT

0.00 0.00 0.00 125,000.00 135,000.000.00 0.00 0.00 160,000.00 170,000.000.00 0.00 0.00 140,000.00 150,000.000.00 0.00 0.00 160,000.00 170,000.000.00 0.00 0.00 140,000.00 150,000.000.00 0.00 0.00 140,000.00 150,000.00

47,500.00 0.00 0.00 110,000.00 120,000.0067,500.00 0.00 0.00 140,000.00 150,000.00

0.00 200,000.0020,000.00 0.00 0.00 40,000.00 50,000.0025,000.00 0.00 0.00 50,000.00 60,000.0050,000.00 0.00 0.00 100,000.00 110,000.0062,500.00 0.00 0.00 125,000.00 150,000.0050,000.00 0.00 0.00 100,000.00 0.00

0.00 0.00 0.00 120,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 225,000.00 0.000.00 0.00 0.00 225,000.00 0.000.00 0.00 0.00 250,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 140,000.00 0.000.00 0.00 0.00 90,000.00 0.000.00 0.00 0.00 90,000.00 0.000.00 0.00 0.00 90,000.00 0.000.00 0.00 0.00 90,000.00 0.000.00 0.00 0.00 90,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 100,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 15,000.00 0.00

62,500.00 0.00 0.00 150,000.00 160,000.0062,500.00 0.00 0.00 175,000.00 180,000.0062,500.00 0.00 0.00 200,000.00 0.00

0.00 0.00 0.00 65,000.00 0.000.00 0.00 0.00 75,000.00 0.00

35,000.00 0.00 0.00 70,000.00 80,000.00100,000.00 0.00 0.00 200,000.00 0.00

40,000.00 0.00 0.00 50,000.00 0.00100,000.00 0.00 0.00 125,000.00 0.00140,000.00 0.00 0.00 175,000.00 0.00140,000.00 0.00 0.00 175,000.00 0.00

35,000.00 0.00 0.00 70,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00

TarifKIT

40,000.00 0.00 0.00 50,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.00

120,000.00 0.00 0.00 150,000.00 0.00120,000.00 0.00 0.00 150,000.00 0.00120,000.00 0.00 0.00 150,000.00 0.00125,000.00 0.00 0.00 250,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00360,000.00 0.00 0.00 450,000.00 0.00

0.00 0.00 0.00 30,000.00 0.00200,000.00 0.00 0.00 250,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00160,000.00 0.00 0.00 200,000.00 0.00320,000.00 0.00 0.00 400,000.00 0.00

40,000.00 0.00 0.00 50,000.00 0.0060,000.00 0.00 0.00 75,000.00 0.0032,000.00 0.00 0.00 40,000.00 0.0040,000.00 0.00 0.00 50,000.00 0.0062,500.00 0.00 0.00 125,000.00 0.00

960,000.00 0.00 0.00 1,200,000.00 0.00384,000.00 0.00 0.00 480,000.00 0.00

0.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 150,000.00 0.00

1,200,000.00 0.00 0.00 1,500,000.00 0.00480,000.00 0.00 0.00 600,000.00 0.00

0.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 150,000.00 0.00

46,000.00 0.00 0.00 57,500.00 0.0072,000.00 0.00 0.00 90,000.00 0.0092,000.00 0.00 0.00 115,000.00 0.0048,000.00 0.00 0.00 60,000.00 0.0048,000.00 0.00 0.00 60,000.00 0.00

184,000.00 0.00 0.00 230,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00240,000.00 0.00 0.00 300,000.00 0.00

46,000.00 0.00 0.00 57,500.00 0.0046,000.00 0.00 0.00 57,500.00 0.0046,000.00 0.00 0.00 57,500.00 0.00

560,000.00 0.00 0.00 700,000.00 0.0056,000.00 0.00 0.00 70,000.00 0.00

184,000.00 0.00 0.00 230,000.00 0.0072,000.00 0.00 0.00 90,000.00 0.0056,000.00 0.00 0.00 70,000.00 0.00

184,000.00 0.00 0.00 230,000.00 0.00

TarifKIT

368,000.00 0.00 0.00 460,000.00 0.0036,000.00 0.00 0.00 45,000.00 0.0076,000.00 0.00 0.00 95,000.00 0.0076,000.00 0.00 0.00 95,000.00 0.0092,000.00 0.00 0.00 115,000.00 0.00

232,000.00 0.00 0.00 290,000.00 0.0046,000.00 0.00 0.00 57,500.00 0.0092,000.00 0.00 0.00 115,000.00 0.00

140,000.00 0.00 0.00 175,000.00 0.00184,000.00 0.00 0.00 230,000.00 0.00280,000.00 0.00 0.00 350,000.00 400,000.00

92,000.00 0.00 0.00 115,000.00 0.0092,000.00 0.00 0.00 115,000.00 0.0070,000.00 0.00 0.00 87,500.00 0.00

116,000.00 0.00 0.00 145,000.00 0.000.00 0.00 0.00 41,000.00 0.000.00 0.00 0.00 210,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 145,000.00 0.000.00 0.00 0.00 215,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 35,000.00 0.000.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 40,000.00 0.000.00 0.00 0.00 60,000.00 0.00

15,000.00 0.00 0.00 25,000.00 0.0022,500.00 0.00 0.00 37,500.00 0.0030,000.00 0.00 0.00 50,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0015,000.00 0.00 0.00 50,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0075,000.00 0.00 0.00 125,000.00 0.0075,000.00 0.00 0.00 125,000.00 0.00

0.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 25,000.00 0.00

10,000.00 0.00 0.00 20,000.00 0.0012,500.00 0.00 0.00 25,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.00

TarifKIT

54,000.00 0.00 0.00 90,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.0045,000.00 0.00 0.00 75,000.00 0.0075,000.00 0.00 0.00 125,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.00

120,000.00 0.00 0.00 200,000.00 250,000.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.00

0.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 120,000.00 0.00

21,000.00 0.00 0.00 35,000.00 0.00240,000.00 0.00 0.00 400,000.00 0.00

0.00 0.00 0.00 10,000.00 0.0030,000.00 0.00 0.00 50,000.00 0.00

0.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 50,000.00 0.00

12,000.00 0.00 0.00 20,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.00

0.00 0.00 0.00 7,500.00 0.0036,000.00 0.00 0.00 60,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

150,000.00 0.00 0.00 400,000.00 0.00200,000.00 0.00 0.00 600,000.00 0.00

0.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 25,000.00 0.000.00 0.00 0.00 100,000.00 0.00

20,000.00 0.00 0.00 50,000.00 0.0015,000.00 0.00 0.00 25,000.00 0.0022,500.00 0.00 0.00 37,500.00 0.0030,000.00 0.00 0.00 50,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0015,000.00 0.00 0.00 50,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

TarifKIT

75,000.00 0.00 0.00 125,000.00 0.0075,000.00 0.00 0.00 125,000.00 0.00

0.00 0.00 0.00 20,000.00 0.000.00 0.00 0.00 25,000.00 0.00

10,000.00 0.00 0.00 20,000.00 0.0012,500.00 0.00 0.00 25,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.0054,000.00 0.00 0.00 90,000.00 0.0036,000.00 0.00 0.00 60,000.00 0.0045,000.00 0.00 0.00 75,000.00 0.0075,000.00 0.00 0.00 125,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

120,000.00 0.00 0.00 200,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.00

0.00 0.00 0.00 50,000.00 0.000.00 0.00 0.00 10,000.00 0.000.00 0.00 0.00 120,000.00 0.00

21,000.00 0.00 0.00 35,000.00 0.00240,000.00 0.00 0.00 400,000.00 0.00

0.00 0.00 0.00 10,000.00 0.0030,000.00 0.00 0.00 50,000.00 0.00

0.00 0.00 0.00 15,000.00 0.000.00 0.00 0.00 50,000.00 0.00

12,000.00 0.00 0.00 20,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0018,000.00 0.00 0.00 30,000.00 0.00

0.00 0.00 0.00 7,500.00 0.0036,000.00 0.00 0.00 60,000.00 0.0090,000.00 0.00 0.00 150,000.00 0.0060,000.00 0.00 0.00 100,000.00 0.00

150,000.00 0.00 0.00 400,000.00 0.00200,000.00 0.00 0.00 600,000.00 0.00

0.00 0.00 0.00 100,000.00 0.0080,500.00 0.00 0.00 253,000.00 0.0061,250.00 0.00 0.00 192,500.00 0.00

105,000.00 0.00 0.00 330,000.00 0.0078,750.00 0.00 0.00 247,500.00 0.0078,750.00 0.00 0.00 247,500.00 0.0061,250.00 0.00 0.00 192,500.00 0.0052,500.00 0.00 0.00 165,000.00 0.0017,500.00 0.00 0.00 55,000.00 0.00

157,500.00 0.00 0.00 495,000.00 0.0070,000.00 0.00 0.00 220,000.00 0.0070,000.00 0.00 0.00 220,000.00 0.0070,000.00 0.00 0.00 220,000.00 0.0087,500.00 0.00 0.00 275,000.00 0.00

131,250.00 0.00 0.00 412,500.00 0.00

TarifKIT

87,500.00 0.00 0.00 275,000.00 0.00122,500.00 0.00 0.00 385,000.00 0.00

37,500.00 0.00 0.00 75,000.00 0.000.00 0.00 0.00 200,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 450,000.00 0.000.00 0.00 0.00 150,000.00 0.000.00 0.00 0.00 200,000.00 0.00

1,800,000.00 0.00 0.00 1,800,000.00 0.00450,000.00 0.00 0.00 450,000.00 0.00

0.00 0.00 0.00 200,000.00 0.00720,000.00 0.00 0.00 720,000.00 0.00

1,440,000.00 0.00 0.00 1,440,000.00 0.00360,000.00 0.00 0.00 360,000.00 0.00360,000.00 0.00 0.00 360,000.00 0.00

A.ADMINISTRASI

NO KETERANGAN1 RAWAT JALAN

a. Dokter Umum b. Dokter spesialis & Gigi c. Bidan c. Penunjang medis ( Laboratorium,.Radiologi,Fisiotherapi,Elektromedik,dll)

2 Observasi Ruang observasi s/d 8 Jam

3 RAWAT INAP

4 TAMBAHAN Kartu Kunjungan Pasien Buku Catatan Pasien Kebidanan dan Kandungan

5 Jasa Service

A.ADMINISTRASI

TARIF ( RP.)

15,000 20,000 15,000 10,000

100,000

5% dari Sub Total

5,000 10,000

10% dari Tarif Kamar

1

B. KONSULTASI RAWAT JALAN

NO KETERANGAN TARIF ( RP,)

1 DOKTER SPESIALIS

Konsultasi 100,000 2 DOKTER UMUM

Konsultasi

Pukul 08.00-21.00 WIB 40,000

Pukul 21.00-08.00 WIB 50,000

Sabtu - Minggu / Libur Nasional 50,000 3 BIDAN

Konsultasi 20,000

KB 10,000 4 Dokter GIGI

Konsultasi Gigi Umum 60,000

Konsultasi Gigi Spesialis 90,000

2

C.TARIF RAWAT JALAN POLI UMUM & UGDTOTAL

01.001.03 UGD003 AF HECTING (>10) 50,000.00AF HECTING (-10) 35,000.00

01.002.01 UGD004 AMPUTASI JARI RUAS I 100,000.0001.002.02 UGD005 AMPUTASI JARI RUAS II 150,000.0001.003.00 UGD006 BILAS LAMBUNG (Intoksikasi Baygon/Drug) 100,000.0001.004.01 UGD007 CORPUS ALIENUM HIDUNG 100,000.0001.004.02 UGD008 CORPUS ALIENUM MATA (Satu mata) 100,000.0001.004.03 UGD009 CORPUS ALIENUM TELINGA (Satu telinga) 100,000.0001.004.04 UGD010 CORPUS ALIENUM TENGGOROK 100,000.0001.005.01 UGD011 DEBRIDEMENT LUKA BAKAR BERAT 200,000.0001.005.02 UGD012 DEBRIDEMENT LUKA BAKAR RINGAN 100,000.0001.005.03 UGD013 DEBRIDEMENT LUKA BAKAR SEDANG 150,000.0001.007.01 UGD016 ECG 60,000.0001.008.00 UGD017 EKSPLORASI / CROSS INCISI 100,000.0001.009.00 UGD018 EKSTIRPASI KECIL 125,000.0001.010.00 UGD019 EKSTRAKSI KUKU ( 1 KUKU ) 125,000.0001.011.00 UGD022 GANTI VERBAN KECIL 25,000.0001.011.00 UGD023 GANTI VERBAN SEDANG 30,000.0001.011.00 UGD024 GANTI VERBAN BESAR 40,000.0001.012.01 UGD025 HECHTING BESAR ( > 10 ) 90,000.0001.012.02 UGD026 HECHTING KECIL ( 1 - 5 ) 60,000.0001.012.03 UGD027 HECHTING SEDANG ( 6 - 10 ) 75,000.0001.013.00 UGD028 INCISI ABSES 125,000.0001.014.00 UGD029 INHALASI TANPA OBAT 30,000.0001.015.00 UGD030 INTUBASI 180,000.0001.016.00 UGD031 IRIGASI MATA 100,000.0001.017.01 UGD032 JAHIT OTOT KESULITAN TINGGI 250,000.0001.017.02 UGD033 JAHIT OTOT KESULITAN RENDAH 125,000.0001.017.03 UGD034 JAHIT OTOT KESULITAN SEDANG 175,000.0001.018.00 UGD035 LAVAMENT / CLYSMA 50,000.0001.019.00 UGD036 O2 /1- 3 JAM 50,000.00

O2/3-8 JAM 100,000.00O2/8-24 JAM 150,000.00

01.020.00 UGD037 RUANG OBSERVASI S/D 8 JAM 100,000.0001.021.00 UGD038 PASANG CATHETER 35,000.0001.022.00 UGD039 PASANG CVP 400,000.0001.023.00 UGD040 PASANG INFUS 15,000.0001.024.00 UGD041 ANGKAT SERUMEN TANPA PENYULIT 50,000.0001.025.00 UGD042 PASANG NGT 15,000.0001.026.00 UGD043 PASANG SPALK 30,000.0001.027.00 UGD044 PASANG TAMPON (HIDUNG DAN TELINGA) 30,000.0001.028.00 UGD045 PLEURA PUNKSI / WSD MINI ( DR SPESIALIS ) 300,000.0001.029.00 UGD046 SPOOLING TELINGA 30,000.0001.030.00 UGD047 SUNTIK 7,500.0001.031.00 UGD048 TAMPON POSTERIOR EPISTAKSIS 60,000.0001.032.00 UGD049 VENA SEKSI 250,000.0001.033.00 UGD050 CPR 100,000.0001.034.00 UGD051 CIRCUMSISI ANAK ( < 15 TAHUN ) 150,000.0001.035.00 UGD052 CIRCUMSISI DEWASA 300,000.0001.036.00 UGD053 WOUND TOILET KECIL 25,000.0001.036.00 UGD054 WOUND TOILET SEDANG 30,000.0001.037.00 UGD055 WOUND TOILET BESAR 40,000.0001.038.00 UGD056 ECG MONITOR PER 3 JAM 100,000.0001.039.00 UGD057 IRIGASI TELINGA / EAR TOILET 50,000.0001.040.00 UGD058 VISUM 15,000.00

3

D.TINDAKAN RAWAT JALAN POLI KEBIDANAN

11.001.00 KBK001 ANGKAT PESARIUM 100,000

11.002.01 KBK002 CABUT IMPLANON (JASA ) 200,000

11.002.02 KBK003 CABUT IUD (JASA) 200,000

11.003.00 KBK004 EKSTIRPASI ( OBSGYN ) 1,000,000

11.004.00 KBK005 JASA SUNTIK (IMUNISASI) 20,000

11.005.00 KBK006 MICRO CURRATAGE (JASA) 800,000

11.006.01 KBK007 PASANG IMPLANON (JASA) 250,000

11.006.02 KBK008 PASANG IUD (JASA) 250,000

11.007.00 KBK009 PAP SMEAR / VAGINAL SMEAR (JASA) 75,000

11.008.01 KBK010 PASANG LAMINARIA 300,000

11.008.02 KBK011 PASANG PESARIUM ( DI LUAR ALKES ) 100,000

11.009.01 KBK012 USG 2-D & PRINT OUT 105,000

KBK013 USG 2-D NON PRINT OUT 90,000

11.010.00 KBK016 HIDROTUBASI 350,000

11.011.00 KBK017 CTG 75,000

11.012.00 KBK018 VAGINA TOILET 80,000

4

E.TINDAKAN RAWAT JALAN POLI ANAK

13.001.00 ANK001 ECG 75,000.00

13.002.00 ANK002 PLEURA PUNKSI 300,000.00

13.006.00 ANK003 JASA SUNTIK (IMUNISASI) 20,000.00

13.007.00 ANK004 TEST MANTOUX (JASA) 40,000.00

13.008.00 ANK005 IMUNISASI POLIO 10,000.00

13.009.00 ANK006 HEPASTITIS B 15,000.00

13.010.00 ANK007 NEBULIZER 65,000.00

5

F.TINDAKAN RAWAT JALAN POLI PENYAKIT DALAM

13.001.00 PDL001 ECG

13.002.00 PDL002 PLEURA PUNKSI

13.003.00 PDL003 SPIROMETRI

13.005.01 PDL005 USG (ABDOMEN ATAS)

13.005.02 PDL006 USG (ABDOMEN BAWAH)

USG (ABDOMEN ATAS & BAWAH)

13.006.00 PDL007 JASA SUNTIK (IMUNISASI)

13.007.00 PDL008 TEST MANTOUX (JASA)

13.008.00 PDL009 NEBULIZER

75,000.00

300,000.00

75,000.00

150,000.00

150,000.00

275,000.00

20,000.00

40,000.00

65,000.00

6

G.POLI GIGI

KODE JENIS PELAYANAN TARIF

UMUM

PGM.U.01 Konsultasi drg. Umum 60,000

PGM.S.02 Konsultasi drg. Spesialis 110,000

PGM.U.03 Buka Jahitan 110,000

PGM.U.04 Kontrol Paska Operasi 60,000

PGM.U.05 Cetak Model Gigi / Rahang 75,000

PGM.U.06 Mouth Guard 1 Rahang 900,000

RONTGEN

PGM.U.07 Foto Dental (Per Foto) 60,000

PREVENTIF

PGM.U.08 Fluoridasi Topikal / Gigi 50,000

PGM.U.09 Pit & Fissure Sealant * 165,000

PEDODONTI

Tumpatan GIC

PGM.U.10 Tumpatan GIC Kecil 165,000

PGM.U.11 Tumpatan GIC Sedang 220,000

PGM.U.12 Tumpatan GIC Besar 275,000

PGM.U.13 Pulpotomi 110,000

PGM.U.14 Endodontik Gigi Susu 110,000

Ekstraksi Gigi Susu

PGM.U.15 Ekstraksi Gigi Susu Tanpa Injeksi * 100,000

PGM.U.16 Ekstraksi Gigi Susu Dengan Injeksi * 150,000

PGM.U.17 Space Maintainer ** 660,000

KONSERVASI

PGM.U.18 Tumpatan Sementara * 100,000

PGM.U.19 Pulp Capping * 100,000

PGM.U.20 Perawatan Endodontik 165,000

PGM.U.21 Tumpatan Komposit Lokal 150,000

PGM.U.22 Tumpatan Komposit Kecil 200,000

PGM.U.23 Tumpatan Komposit Sedang 225,000

PGM.U.24 Tumpatan Komposit Besar 300,000

PGM.U.25 Veneering Komposit 350,000

PGM.U.26 Inlay / Onlay / Uplay Metal * 930,000

PGM.U.27 Inlay / Onlay / Uplay Keramik * 1,375,000

PGM.S.28 Home Bleacing 2,200,000

PGM.S.29 Office Bleaching 4,400,000

BEDAH MULUT

PGM.S.30 Ekstraksi Gigi Kasus Mudah 150,000

PGM.S.31 Ekstraksi Gigi Kasus Sedang 200,000

PGM.S.32 Ekstraksi Gigi Permanen Komplikasi Kasus Mudah 330,000

PGM.S.33 Ekstraksi Gigi Permanen Komplikasi Kasus Sedang 385,000

PGM.S.34 Ekstraksi Gigi Permanen Komplikasi Kasus Sulit 440,000

PGM.S.35 Odontectomy Kelas I 1,100,000

PGM.S.36 Odontectomy Kelas II 2,200,000

PGM.S.37 Odontectomy Kelas III 2,750,000

PGM.S.38 Alveolectomy Per Regio *** 550,000

PGM.S.39 Implant * 19,800,000

PGM.S.40 Insisi Abses Intra Oral 150,000

PGM.S.41 Insisi Abses Ekstra Oral 300,000

PGM.S.42 Apex Reseksi Per Gigi 1,650,000

PGM.S.43 Operculetomy 550,000

PGM.S.44 Ekstirpasi Mucocel 825,000

PGM.S.45 Bone Graft 6,600,000

PGM.S.46 Fiksasi Fraktur 1,650,000

PGM.S.47 Kuret Dry Socket 150,000

PROSTODONTI

Jacket Crown

PGM.S.48 Jacket Crown Metal Acrylic * 660,000

PGM.S.49 Jacket Crown Metal Porcelain * 1,375,000

PGM.S.50 Jacket Crown All Acrylic * 440,000

PGM.S.51 Jacket Crown All Porcelain * 2,200,000

PGM.S.52 Jacket Crown All Metal * 605,000

PGM.S.53 Pin Fiber & Crown * 2,200,000

PGM.S.54 Pin Metal & Crown * 1,650,000

PGM.S.55 Mahkota Sementara * 220,000

Plat Akrilik

PGM.S.56 Plat Akrilik & 1 Gigi Akrilik ** 605,000

PGM.S.57 Plat Akrilik & 1 Gigi Porselen ** 880,000

PGM.S.58 Plat Frame ** 1,650,000

Flexy Denture

PGM.S.59 Flexy Denture Saddle & 1 Gigi ** 1,100,000

PGM.S.60 Flexy Denture Bilateral & 1 Gigi ** 1,100,000

Single Complete Denture

PGM.S.61 Single Complete Denture Akrilik ** 3,300,000

PGM.S.62 Single Complete Denture Porselen ** 4,400,000

Full Denture Akrilik

PGM.S.63 Full Denture Akrilik RA & RB 6,600,000

PGM.S.64 Full Denture Porselen RA & RB 8,250,000

Elemen Gigi Tiruan

PGM.S.65 Elemen Gigi Tiruan Akrilik * 150,000

PGM.S.66 Elemen Gigi Tiruan Porselen * 175,000

PGM.S.67 Elemen Gigi Tiruan Flexy Denture * 225,000

Reparasi

PGM.S.68 Reparasi Kasus Mudah ** 330,000

PGM.S.69 Reparasi Kasus Sedang ** 440,000

PGM.S.70 Reparasi Kasus Sulit ** 550,000

Relining

PGM.S.71 Relining Kasus Mudah ** 440,000

PGM.S.72 Relining Kasus Sedang ** 660,000

PGM.S.73 Relining Kasus Sulit ** 1,100,000

Rebasing

PGM.S.74 Rebasing Kasus Mudah ** 400,000

PGM.S.75 Rebasing Kasus Sedang ** 600,000

PGM.S.76 Rebasing Kasus Sulit ** 800,000

PGM.S.77 Bongkar Crown * 350,000

PERIODONTI

PGM.U.78 Scaling Per Rahang Lokal 75,000

PGM.U.79 Scaling Per Rahang Kelas I 110,000

PGM.U.80 Scaling Per Rahang Kelas II 130,000

PGM.U.81 Scaling Per Rahang Kelas III 250,000

Kuretase

PGM.U.82 Kuretase (1 Gigi) * 150,000

PGM.U.83 Kuretase (>1 Gigi) * 100,000

PGM.S.84 Flap (Per Regio) *** 550,000

Splinting

PGM.S.85 Splinting (2 Gigi) 330,000

PGM.S.86 Splinting (>2 Gigi) 110,000

Ginggivektomi

PGM.U.87 Ginggivektomi (1-2 Gigi) * 220,000

PGM.U.88 Ginggivektomi (>1 Gigi) * 165,000

Desensitisasi

PGM.U.89 Desensitisasi (1 Gigi) * 50,000

PGM.U.90 Selective Grinding * 110,000

PGM.U.91 Recontouring * 220,000

ORTHODONTI

Fixed Per Rahang

PGM.S.92 Fixed Per Rahang Kasus Mudah 4,000,000

PGM.S.93 Fixed Per Rahang Kasus Sedang 5,000,000

PGM.S.94 Fixed Per Rahang Kasus Sulit 6,000,000

Fixed Ceramic Per Rahang 16,500,000

PGM.S.95 Removable ** 1,000,000

PGM.S.96 Pemasangan Bracket Lepas **** 100,000

PGM.S.97 Aktivasi Fixed 100,000

PGM.S.98 Aktivasi Removable 100,000

Keterangan :* Per Gigi** Per Rahang*** Per Regio**** Per Bracket 7

H.LABORATORIUM

KODE KETERANGAN

HEMATOLOGI

Darah Lengkap

Hemoglobin

Leukosit

Trombosit

Hematokrit

Hitung Jenis/Diff Count

Darah Rutin 1 (Hb, Leuko, Trombo, Ht)

Darah Rutin 2 (Hb, Leuko, Diff Count, LED)

Darah Rutin 3 (Hb, Diff Count, Trombo, LED, Ht)

DPL (Hb, Diff Count, Eri, Trombo, LED)

APT/Masa Protrombin

Elektroforesa

Feritin

Fibrinogen

Gambaran Darah Tepi

Golongan Darah/Rhesus

Hitung Eosinofil

LED / Laju Endap Darah

Masa Pembekuan (CT)

Masa Perdarahan (BT)

Mikrofilaria

Reaksi LE

Resistensi Osmotik

Retikulosit

Retraksi Bekuan

Rumpell Leed

Sel LE

Serum Iron

Tes Comb Direct/Indirect

TIBC

Trombo Test/INR

URINE

Urine Rutin/Lengkap

Darah Samar

Protein Bence Jones

Tes Kehamilan

HEMOSTASIS

Waktu pembekuan perdarahan

KIMIA DARAH

GDS/Puasa/2 jam PP @

Alkali Fosfatase

APTT

Asam Urat

Bilirubin total : direct/indirect

CPK

Elektrolit/Na/K/Cl/Ca

Gamma GT

HDL & LDL Kolesterol

Kolesterol Total

Kurva Harian

LDH

Lipase

Protein Total : Albumin & Globulin

SGOT & SGPT

Trigliserida

Ureum & Creatinin

SEROLOGI / IMUNOLOGI

Widal CRP

Anti HBs

Anti HIV

HBsAg

Malaria

Papsmear

T3 uptake/ T3 / T4 total

Tes Mantoux

FAECES

Rutin / Lengkap

Darah Samar

CATATAN

**Cito/Panggilan/Libur Tarif + 25%**Pemeriksaan di atas jam 21.00 WIB + 25%**Tarif dikenakan biaya administrasi penunjang sebesar 10% dari pemeriksaaan**Untuk pasien tanpa pemeriksaan dokter dikenakan tambahan biaya administrasi sebesar Rp. 5.000,-/orang

TARIF

55,000

12,500

12,500

12,500

12,500

12,500

50,000

45,000

50,000

55,000

60,000

200,000

190,000

60,000

55,000

25,000

30,000

15,000

15,000

15,000

25,000

40,000

200,000

30,000

20,000

15,000

40,000

80,000

200,000

80,000

60,000

30,000

70,000

20,000

40,000

30,000

75,000 30,000 60,000 60,000 80,000 70,000 120,000 40,000 80,000 30,000 75,000 70,000 120,000 80,000 60,000 30,000 60,000

50,000 120,000 135,000 85,000 25,000 75,000 500,000 70,000

25,000 30,000

8

I.RADIOLOGI

NO KETERANGAN TARIF

1

KepalaSchedell 110,000Sinus Paranasal 120,000Mandibula 120,000

2

TruncusCervical AP/Lat/Oblique 110,000Thoracal AP/Lat 120,000Thoracal PA/Lat 150,000Lumbal AP/Lat 120,000Lumbo Sacral 120,000Sacral AP/Lat 120,000

3

Anggota GerakExtremitas Atas AP/Lat 100,000Extremitas Bawah Ap/Lat 100,000Persendian/Articulatio/Joint 100,000Antebrachii 100,000

4AbdomenAbdomen/BNO 100,000

USG

NO KETERANGAN TARIFA USG KEBIDANAN

1. USG Kebidanan 90,000 Print per gambar @ 15,0002. USG Transvaginal 100,000 Print per gambar @ 15,000

B USG PENY.DALAM/BEDAH/LAINUSG AbdomenAbdomen Atas/Bawah @ 150,000Whole Abdomen 275,000USG Mammae/Thyroid 150,000USG Pelvis 150,000Print per gambar @ 15,000

CATATAN** Cito/panggilan/libur tarif + 25%** Tarif di atas belum termasuk cairan kontras/obat-obatan** Tarif dikenakan tambahan biaya administrasi penunjang sebesar Rp.10.000,-/orang

J.TARIF FISOTERAPI

NO JENIS TINDAKAN1 MWD ( Micro Wave Diathermy )

2 US ( Ultra Sound )

3 Tens / ES

4 IR ( Infra Red )

5 Nebulizer :

Inhalasi + Chest Terapi

Inhalasi + IR + Chest Terapi

Inhalasi + MWD + Chest Terapi

6 Exercise Terapi :

Ringan waktunya 15 menit

Sedang waktunya 30 menit

Berat waktunya 45 menit

7 Massage

8 MWD + Tens / ES + Exercise

9 MED + Tens / ES + US + Exercise

10 IR + Exercise

11 Paket :

dengan 2 alat yang berbeda untuk area yang sama

dengan 3 alat yang berbeda untuk area yang sama

12 Paket Nebulizer ( Inhalasi ) :

3 X Terapi ( Inhalasi + Chest Terapi )

3 X Terapi ( Inhalasi + IR + Chest Terapi )

3 X Terapi ( Inhalasi + MWD + Chest Terapi )

13 Pakt Elektro Terapi :

3 X Terapi ( MWD + Tens / ES + Exercise

3 X Terapi ( MWD + Tens / ES + US + Exercise

3 X Terapi ( IR + Exercise )

Keterangan 1. Tarif inhalasi sudah termasuk obat untuk inhalasi 2. Tarif dikenakan biaya tambahan administrasi penunjang sebesar Rp.15.000,- per orang 3. Tarif paket nebulizer dan paket elektro terapi di atas sudah ditambahkan biaya administrasi ( Paket 3 X Terapi -> diskon 10 % administrasi Rp. 15.000 )

J.TARIF FISOTERAPI

TARIF 35,000

35,000

35,000

30,000

65,000

75,000

85,000

35,000

50,000

65,000

50,000

75,000

100,000

60,000

70,000

100,000

229,500

262,500

295,000

262,500

345,000

213,000

2. Tarif dikenakan biaya tambahan administrasi penunjang sebesar Rp.15.000,- per orang 3. Tarif paket nebulizer dan paket elektro terapi di atas sudah ditambahkan biaya administrasi

10

K.TINDAKAN TARIF RAWAT INAP

KELAS III & II

30.001.01 TRI001 AF HECHTING (< 10 ) 35,000.00

30.001.03 TRI003 AF HECHTING (> 10 ) 50,000.00

30.002.00 TRI004 CLYSMA 60,000.00

30.003.00 TRI005 ECG 75,000.00

30.005.00 TRI007 INTUBASI 300,000.00

30.006.01 TRI008 PUNGSI LUMBAL 300,000.00

30.006.02 TRI009 PUNGSI FLEURA 300,000.00

30.006.03 TRI010 PUNGSI ASCITES 300,000.00

30.007.00 TRI011 PASANG FOLLEY CATHETER 50,000.00

30.008.00 TRI012 PASANG INFUS 50,000.00

30.009.00 TRI013 PASANG NGT 50,000.00

30.012.00 TRI016 VENA SEKSI 225,000.00

30.013.00 TRI017 TINDIK TELINGA BAYI 75,000.00

30.015.00 TRI019 PEMASANGAN UMBILICAL CATHETER 230,000.00

30.016.00 TRI020 EXCHANGE TRANSFUSI 400,000.00

30.017.00 TRI021 SPOOL DRAIN 50,000.00

30.018.00 TRI022 AF WSD 90,000.00

TRI026 PUNGSI PUS 75,000.00

TRI027 NEKROTOMI KECIL 130,000.00

TRI028 NEKROTOMI SEDANG 160,000.00

TRI029 NEKROTOMI BESAR 200,000.00

TRI030 PASANG CVP 350,000.00

30.015.00 TRI031 MERAWAT DECUBITUS / HARI 100,000.00

30.016.00 TRI032 MERAWAT GANGRENE / HARI 125,000.00

30.017.01 TRI033 LUKA BAKAR RINGAN ( < 20% ) 90,000.00

30.017.02 TRI034 LUKA BAKAR SEDANG (20-40%) 125,000.00

30.017.03 TRI035 LUKA BAKAR BERAT ( >40% ) 150,000.00

30.018.00 TRI036 LABU DARAH / KANTONG ( Biaya transport/1 X ) 100,000.0030.020.00 TRI037 O2 /1- 3 JAM 50,000.00

TRI038 O2/3-8 JAM 100,000.00TRI039 O2/8-24 JAM 150,000.00

KELAS 1&VIP

50,000.00

70,000.00

85,000.00

100,000.00

400,000.00

400,000.00

400,000.00

400,000.00

50,000.00

50,000.00

50,000.00

300,000.00

75,000.00

275,000.00

500,000.00

75,000.00

120,000.00

100,000.00

165,000.00

200,000.00

240,000.00

400,000.00

125,000.00

150,000.00

120,000.00

150,000.00

180,000.00

100,000.0050,000.00

100,000.00150,000.00

11

L.TARIF KAMAR

NO KAMAR KELAS 3 KELAS 2 KELAS 1

1 LANTAI 1 85,000 150,000 225,000

2 LANTAI 2 85,000 125,000 175,000

3 R.I ANAK LANTAI 2 85,000

* INKUBATOR ( PER HARI ) 75,000

* BLUE LIGHT ( PER HARI ) 75,000

4 JASA VISITE SPESIALIS 70,000 80,000 90,000

5 Dr. UMUM 25,000 25,000 40,000

NO KETERANGAN KAMAR BERSALIN ( VK ) KAMAR OPERASI ( OK )

KELAS 3 & 2 KELAS 1 & VIP KELAS 3 & 2

1 PARTUS 350,000 350,000

2 TINDAKAN KECIL 500,000

3 TINDAKAN SEDANG 600,000

4 TINDAKAN BESAR 750,000

5 TINDAKAN KHUSUS 1,000,000

V I P

350,000

100,000

40,000

KAMAR OPERASI ( OK ) KELAS 1 & VIP

700,000

850,000

1,000,000

1,400,000

12

M. TARIF JASA TINDAKAN

NO KETERANGAN V I P KELAS 1 KELAS 2 KELAS 31 JASA OPERATOR

DOKTER SPESIALIS OBGYN / BEDAH UMUMTINDAKAN KECIL 1,500,000 1,250,000 1,000,000 800,000 TINDAKAN SEDANG 2,500,000 2,250,000 2,000,000 1,800,000 TINDAKAN BESAR 3,000,000 2,750,000 2,500,000 2,250,000 TINDAKAN KHUSUS 4,000,000 3,500,000 3,000,000 2,500,000 PARTUS NORMAL 1,500,000 1,200,000 900,000 700,000 SECTIO CAESARIA 2,000,000 1,800,000 1,550,000 1,200,000

DOKTER UMUMPARTUS NORMAL 50% dari Operator UtamaTINDAKAN KECILTINDAKAN SEDANG

2 JASA RESUSITASIDOKTER SPESIALIS 2X dari nilai visite sesuai kamar perawatanDOKTER UMUM 2X dari nilai visite sesuai kamar perawatan

3 JASA ANESTESIDOKTER SPESIALIS 40% dari Operator Utama

Jasa Operator dg penyulit/diluar jam kerja naik 20%Bila ada kenaikan tarif Jasa Operator maka Tarif Kamar OK naik sebesar 20%Dokter Anestesi 40% dari OperatorDokter Anak 25% dari Operator

Macam TindakanOBGYN Bedah Umum

Kuret/Retensio Plasenta Incisi Abses/Mata IkanAppendictomy

13

N.TARIF TINDAKAN PAKET

TINDAKAN UTAMA KELAS I KELAS II KELAS III

KURET 4,250,000 3,800,000 3,200,000 2,850,000

KURET PLASENTA 5,000,000 4,500,000 3,500,000 3,050,000

PARTUS NORMAL 6,200,000 5,200,000 4,200,000 3,200,000

SECTIO CESARIA 10,800,000 9,500,000 7,750,000 6,500,000

Keterangan :Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIBBila diluar hari dan jam kerja, maka tarif naik sebesar 12% dari totalTarif hanya berlaku untuk SC tanpa penyulit,non gemelli dllBila terdapat penyulit, maka tarif di atas tidak berlakuTarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RSObat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

14

O.AMBULANCE

KODE KETERANGAN TARIFAntar atau Jemput

Radius < 5 km 100,000 Radius > 5 km, per km + 10,000 Antar dan Jemput

Radius < 5 km 150,000 Radius > 5 km, per km + 15,000 Rujuk Pemeriksaan

Radius < 5 km 50,000 Radius > 5 km, per km + 5,000 Pengambilan Darah

PMI Jakarta 150,000

Keterangan :** Tarif di atas belum termasuk bahan habis pakai/obat-obatan, jasa tenaga medis, administrasi

Tarif di atas belum termasuk bahan habis pakai/obat-obatan, jasa tenaga medis, administrasi

BREAK DOWN PAKET KURET

KODE JENIS PELAYANANTARIF

UTAMA KELAS I KELAS IIKURETPemeriksaan Awal 90,000 90,000 90,000 Jasa Operator(100%) 1,200,000 1,000,000 800,000

Jasa Anestesi(100%) 480,000 400,000 320,000 JASA ASISTEN 120,000 100,000 80,000 Sewa OK 700,000 700,000 500,000 Sewa Alat Kuret - - - Sewa Kmr Perawatan 300,000 200,000 150,000 Laboratorium

- Drh lengkap 55,000 55,000 55,000 - CT 20,000 20,000 20,000 - BT 20,000 20,000 20,000 - GDS 20,000 20,000 20,000 Farmasi (obat2an & alkes) 600,000 600,000 600,000 Jasa service (10% dari kmr perawatan) 30,000 20,000 15,000 Subtotal 3,635,000 3,225,000 2,670,000 Adm (5% dari subtotal) 181,750 161,250 133,500 Marketing Fee (10% dari subtotal) 545,250 483,750 400,500 TOTAL 4,362,000 3,870,000 3,204,000

USULAN TARIF 4,250,000 3,800,000 3,200,000

Keterangan :Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIBBila diluar hari dan jam kerja, maka tarif naik sebesar 12%Bila terdapat penyulit, maka tarif di atas tidak berlakuObat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

TARIFKELAS III

KURET 90,000 640,000

256,000 64,000 500,000 - 75,000

55,000 20,000 20,000 20,000 600,000 7,500 2,347,500 117,375 352,125 2,817,000

2,850,000


BREAK DOWN KURET PLASENTA

KODE JENIS PELAYANANTARIF

UTAMA KELAS IKURETPemeriksaan Awal 90,000 90,000 Jasa Operator(100%) 1,300,000 1,100,000

Jasa Anestesi(100%) 520,000 440,000 JASA ASISTEN 130,000 110,000 Sewa OK 700,000 700,000 Sewa Alat Kuret - - Sewa Kmr Perawatan 300,000 200,000 Laboratorium

- Drh lengkap 55,000 55,000 - CT 20,000 20,000 - BT 20,000 20,000 - GDS 20,000 20,000 Farmasi (obat2an & alkes) 900,000 900,000 Jasa service (10% dari kmr perawatan) 30,000 20,000 Subtotal 4,085,000 3,675,000 Adm (5% dari subtotal) 204,250 183,750 Marketing Fee (15% dari subtotal) 612,750 551,250 TOTAL 4,902,000 4,410,000

USULAN TARIF 5,000,000 4,500,000

Keterangan :Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIBBila terdapat penyulit, maka tarif di atas tidak berlakuObat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

TARIFKELAS II KELAS III

KURET 90,000 90,000 900,000 700,000

360,000 280,000 90,000 70,000 500,000 500,000 - - 150,000 75,000

55,000 55,000 20,000 20,000 20,000 20,000 20,000 20,000 700,000 700,000 15,000 7,500 2,920,000 2,537,500 146,000 126,875 438,000 380,625 3,504,000 3,045,000

3,500,000 3,050,000

Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB


BREAK DOWN PARTUS NORMAL

KODE JENIS PELAYANAN TARIFUTAMA KELAS I KELAS II

PARTUS NORMAL (2 hari 1 malam)

Sewa VK 350,000 350,000 350,000

Jasa SpOG 2,000,000 1,600,000 1,300,000 Jasa Bidan (asisten operator) 200,000 160,000 130,000 Jasa Dokter Anak 500,000 400,000 325,000 Kamar Perawatan Ibu 600,000 400,000 300,000 Kamar Bayi (50% dr kamar Ibu) 300,000 200,000 150,000 Visite dr SpOG 200,000 180,000 160,000 Visite dr SpA 200,000 180,000 160,000 Laboratorium :

Ibu :- darah lengkap 55,000 55,000 55,000 - CT 20,000 20,000 20,000 - BT 20,000 20,000 20,000

Anak :

- golongan darah 25,000 25,000 25,000 Farmasi (obat2an & alkes) 700,000 700,000 500,000 Jasa service (10% dari kmr perawatan) 90,000 60,000 45,000 Subtotal 5,260,000 4,350,000 3,540,000 Adm (5% dari sub total) 263,000 217,500 177,000 Marketing Fee (5% dari sub total) 263,000 217,500 177,000 TOTAL 5,786,000 4,785,000 3,894,000

HARGA JUAL 6,200,000 5,200,000 4,200,000

Keterangan :Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIBBila diluar hari dan jam kerja, maka tarif naik sebesar 12%Bila terdapat penyulit, maka tarif di atas tidak berlakuTarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RSObat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

TARIFKELAS III

350,000

1,000,000 100,000 250,000 150,000 75,000 140,000 140,000

55,000 20,000 20,000

500,000 22,500 2,822,500 141,125 141,125 3,104,750

3,200,000


BREAK DOWN TARIF SECTIO CAESAREA

KODE JENIS PELAYANAN TARIF ShareKELAS III Dokter Rs.

SECTIO CAESAREA (3 HARI 2 MALAM)Sewa OK 750,000 750,000 Jasa Operator 1,250,000 1,250,000 Jasa Dokter Anestesi 500,000 500,000

Jasa Dokter Anak 312,500 312,500 Jasa Paramdis 187,500 187,500 Kamar Perawatan Ibu 225,000 225,000 225,000 Kamar Bayi ( 50% dari kamar Ibu ) 112,500 112,500 112,500 Visite dr.SpOG 210,000 210,000 210,000 Visite dr.SpA 210,000 210,000 210,000 Visite dr.SpAn 70,000 70,000 70,000

Laboratorium Ibu :

-Darah Lengkap 50,000 50,000 50,000 -Masa pendarahan 20,000 20,000 20,000 -Masa Pembekuan 20,000 20,000 20,000 -GDS 25,000 25,000 25,000 CTG - - - Anak:-Golongan Darah - - - -Billirubin Neonatus - - -

Farmasi ( Obat-obatan dan Alkes ) 1,500,000 1,500,000 1,500,000 Jasa Service ( 10% dari kamar perawatan ) 33,750 33,750 33,750

Subtotal 5,476,250 4,726,250 3,226,250 Adm ( 5% dari sub total ) 273,813 236,313 161,313 Marketing fee ( 10% dari sub total ) 547,625 472,625 322,625

TOTAL 6,297,688 5,435,188 3,710,188

USULAN TARIF 6,500,000

Keterangan :Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIBBila diluar hari dan jam kerja, maka tarif naik sebesar 12%Tarif hanya berlaku untuk SC tanpa penyulit,non gemelli dllBila terdapat penyulit, maka tarif di atas tidak berlakuTarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RSObat-obat yang diresepkan diluar paket dan yang dibawa pulang tida 0

tarif bsm 2012 ( siti )

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