Sheet1

id_tindakan kode_tm nama_tindakan harga

1477 TM1477 KARTU PASIEN 8250

1478 TM1478 BUKU PASIEN 27500

1479 TM1479 BIAYA ADMINISTRASI RS 20900

1480 TM1480 ADMINISTRASI TANPA BUKU 29150

1481 TM1481 UANG MUKA SUITE ROOM 9500000

1482 TM1482 UANG MUKA SVIP ROOM 8100000

1483 TM1483 UANG MUKA VIP ROOM 7250000

1484 TM1484 UANG MUKA KELAS 1 4250000

1485 TM1485 UANG MUKA KELAS 2 2550000

1486 TM1486 UANG MUKA KELAS 3A 2550000

1487 TM1487 UANG MUKA RAWAT INTENSIF (ICU) 8000000

1488 TM1488 UANG MUKA RAWAT PERINA 3500000

1489 TM1489 REGISTRASI BAYI 16500

1490 TM1490 KAMAR PERAWATAN SUITE ROOM 1430000

1491 TM1491 KAMAR PERAWATAN SVIP ROOM 1078000

1492 TM1492 KAMAR PERAWATAN VIP ROOM 990000

1493 TM1493 KAMAR PERAWATAN KELAS 1 605000

1494 TM1494 KAMAR PERAWATAN KELAS 2 363000

1495 TM1495 KAMAR PERAWATAN KELAS 3 220000

1496 TM1496 KONSULTASI DOKTER UMUM 50000

1497 TM1497 KONSULTASI DOKTER SPESIALIS 121000

1498 TM1498 KONSULTASI DOKTER SUB SPESIALIS/KONSULTASI 137500

1499 TM1499 AFF DRAIN SELANG (ANGKATAN DRAIN) 44000

1500 TM1500 BILAS LAMBUNG 88000

1501 TM1501 BUKA GIPS 1 SISI (IGD) 99000

1502 TM1502 BUKA GIPS 2 SISI (IGD) 165000

1503 TM1503 CIRCUMCISI / SUNAT 440000

Page 1
 Sheet1

1504 TM1504 CLISMA, KOREK SKIBALA 41800

1505 TM1505 DEBRIDEMENT RINGAN (IGD) 88000

1506 TM1506 DEBRIDEMENT SEDANG (IGD) 115500

1507 TM1507 DEBRIDEMENT BERAT (IGD) 147400

1508 TM1508 DILATASI PREPUTIUM 44000

1509 TM1509 EKSPLORASI VULNUS PUNCTUM 36300

1510 TM1510 EKTIRPASI LIPOMA / KISTA / CLAVUS / NEVUS 99000

1511 TM1511 EKSTRASI CORPUS ALIENUM 49500

1512 TM1512 EKSTRASI KUKU 69300

1513 TM1513 GANTI VERBAND (TINDAKAN DOKTER) 33000

1514 TM1514 HECTING 1-3 (IGD) 49500

1515 TM1515 HECTING 4-6 (IGD) 82500

1516 TM1516 HECTING 7-10 (IGD) 132000

1517 TM1517 HECTING 11-15 (IGD) 137500

1518 TM1518 HECTING 15-20 (IGD) 165000

1519 TM1519 HECTING >20 (IGD) 192500

1520 TM1520 INCISI ABSES 1 / < 10CM 41800

1521 TM1521 INCISI ABSES > 1 / > 10CM 99000

1522 TM1522 INJEKSI INTRALASI KELOID 38500

1523 TM1523 INTUBASI / ETT / RESUSITASI (IGD) 159500

1524 TM1524 IRIGASI TELINGA / MATA 29700

1525 TM1525 KOMPRESI JANTUNG PARU (CPR) (IGD) 82500

1526 TM1526 MINI WSD (IGD) 176000

1527 TM1527 OBSERVASI > 3 JAM 33600

1528 TM1528 OBSERVASI 3 - 6 JAM 78000

1529 TM1529 PASANG CATHERER 55000

1530 TM1530 PASANG INFUS DEWASA 18700

1531 TM1531 PASANG IV LINE INTRA OSSEUS (IGD) 110000

1532 TM1532 PASANG IV LINE VENA JUGULARIS (IGD) 110000

1533 TM1533 PASANG IV LINE VENA SECTIE (IGD) 214500

Page 2
 Sheet1

1534 TM1534 PASANG IV LINE PERCUTANEUS CATETER (IGD) 275000

1535 TM1535 PASANG IV LINE VENA SENTRAL (CVC) (IGD) 275000

1536 TM1536 PASANG NASOGASTRIC TUBE (NGT) 30800

1537 TM1537 PASANG RANSEL VERBAND 55000

1538 TM1538 PASANG SPALK / BIDAI 35200

1539 TM1539 PASANG BALON CATETHER 330000

1540 TM1540 PASANG TAMPON HIDUNG 18700

1541 TM1541 PASANG UMBILICAL CATETER / UMBILICAL LINE 181500

1542 TM1542 COMBUSITO RINGAN 137500

1543 TM1543 COMBUSITO SEDANG 165000

1544 TM1544 COMBUSITO BERAT 192500

1545 TM1545 COMBUSITO LUTUT 137500

1546 TM1546 COMBUSITO PLUERA 220000

1547 TM1547 COMBUSITO PERICARDIAL 275000

1548 TM1548 REPOSISI LUKSASI MANDIBULA 137500

1549 TM1549 REPOSISI DENDI TERTUTUP 40700

1550 TM1550 SUNTIK / SKIN TEST (igd) 23100

1551 TM1551 TINDIK JARUM (IGD) 44000

1552 TM1552 TINDIK ALAT (IGD) 55000

1553 TM1553 BIOPSIS 236500

1554 TM1554 GANTI VERBAND 38500

1555 TM1555 PASANG IMPLANT / NORPLANT 165000

1556 TM1556 AFF IMPLANT / NORPLANT 165000

1557 TM1557 AFF DAN PASANG IMPLANT / NORPLANT 275000

1558 TM1558 PASANG IUD 115500

1559 TM1559 AFF IUD (CABUT) 115500

1560 TM1560 AFF DAN PASANG IUD 151800

1561 TM1561 KOLPOSKOPI 311300

1562 TM1562 KOLPOSKOPI + BIOPSIS 588500

1563 TM1563 PAPSMEAR 148500

Page 3
 Sheet1

1564 TM1564 PAPSMEAR DNA HC2 385000

1565 TM1565 PASANG LAMINARIA 148500

1566 TM1566 PUNGSI DOUGLASH 286000

1567 TM1567 SUNTIK / SKIN TEST 28600

1568 TM1568 TAMPON VAGINA 165000

1569 TM1569 VAGINAL TOILET 220000

1570 TM1570 KOMPRESI JANTUNG PARU (CPR) 448800

1571 TM1571 PASANG IV LINE INTRA OSSEUS (anak) 149600

1572 TM1572 PASANG IV LINE VENA JUGULARIS (anak) 158400

1573 TM1573 PASANG IV LINE VENA SECTIE (anak) 440000

1574 TM1574 PASANG IV LINE PERCUTANEUS CATETER (anak) 440000

1575 TM1575 PASANG IV LINE VENA SENTRAL (CVC) (anak) 422400

1576 TM1576 PASANG NASOGASTRIC TUBE (NGT) 44000

1577 TM1577 PASANG UMBILICAL CATETER / UMBILICAL LINE 308000

1578 TM1578 SURFAKTAN 193600

1579 TM1579 SURFAKTAN + ETT 387200

1580 TM1580 PUNGSI LUMBAL 233200

1581 TM1581 SUNTIK IMUNISASI 22880

1582 TM1582 TINDIK JARUM (anak) 52800

1583 TM1583 TINDIK ALAT (anak) 96800

1584 TM1584 TRANFUSI TUKAR 1 822800

1585 TM1585 TRANFUSI TUKAR 2 536800

1586 TM1586 TRANFUSI TUKAR 3 396000

1587 TM1587 WSD 330000

1588 TM1588 AFF DRAIN SELANG (ANGKATAN DRAIN) 66000

1589 TM1589 CIRCUMCISI (ANASTESI LOKAL) 715000

1590 TM1590 DEBRIDEMENT RINGAN 137500

1591 TM1591 DEBRIDEMENT SEDANG 154000

1592 TM1592 DEBRIDEMENT BERAT 176000

1593 TM1593 DILATASI PREPUTIUM 77000

1594 TM1594 EKSPLORASI VULNUS PUNCTUM 165000

Page 4
 Sheet1

1595 TM1595 EKTIRPASI LIPOMA / KISTA / CLAVUS / NEVUS 280500

1596 TM1596 EKSTRAKSI CORPUS ALIENUM 165000

1597 TM1597 EKSTRAKSI KUKU 220000

1598 TM1598 GANTI VERBAND 38500

1599 TM1599 PASANG GIPS 616000

1600 TM1600 PASANG GIPS + REPOSISI 1001000

1601 TM1601 PASANG GIPS BAYI 825000

1602 TM1602 PASANG GIPS BAYI + REPOSISI 1650000

1603 TM1603 BUKA GIPS 1 SISI 198000

1604 TM1604 BUKA GIPS 2 SISI 330000

1605 TM1605 HECTING 1-3 93500

1606 TM1606 HECTING 4-6 165000

1607 TM1607 HECTING 7-10 264000

1608 TM1608 HECTING 11-15 286000

1609 TM1609 HECTING 15-20 302500

1610 TM1610 HECTING >20 330000

1611 TM1611 HECTING AFF 1-3 60500

1612 TM1612 HECTING AFF 4-6 88000

1613 TM1613 HECTING AFF 7-10 115500

1614 TM1614 HECTING AFF 11-15 121000

1615 TM1615 HECTING AFF 15-20 132000

1616 TM1616 HECTING AFF >20 143000

1617 TM1617 INCISI ABSES = 1 / < 10CM 137500

1618 TM1618 INCISI ABSES > 1 / > 10CM 242000

1619 TM1619 INJEKSI INTRALASI KELOID 137500

1620 TM1620 INJEKSI INTRATEKAL 330000

1621 TM1621 INTUBASI 297000

1622 TM1622 KOMPRESI JANTUNG PARU (CPR) 330000

1623 TM1623 PASANG BOUGIE 165000

1624 TM1624 PASANG CATHERER 121000

1625 TM1625 PASANG IV LINE INTRA OSSEUS 187000

Page 5
 Sheet1

1626 TM1626 PASANG IV LINE VENA JUGULARIS 198000

1627 TM1627 PASANG IV LINE VENA SECTIE 550000

1628 TM1628 PASANG IV LINE PERCUTANEUS CATETER 550000

1629 TM1629 PASANG IV LINE VENA SENTRAL (CVC) 660000

1630 TM1630 PASANG NASOGASTRIC TUBE (NGT) 55000

1631 TM1631 PASANG RANSEL VERBAND 88000

1632 TM1632 PASANG SKIN TRACTION 55000

1633 TM1633 PASANG SPALK / BIDAI 88000

1634 TM1634 PASANG UMBILICAL CATETER / UMBILICAL LINE 385000

1635 TM1635 COMBUSITO RINGAN 165000

1636 TM1636 COMBUSITO SEDANG 220000

1637 TM1637 COMBUSITO BERAT 275000

1638 TM1638 PUNGSI SUPRA PUBLIC 82500

1639 TM1639 PUNGSI HEMATOMA 137500

1640 TM1640 PUNGSI LUTUT 165000

1641 TM1641 PUNGSI PUNGSI ABDOMEN (ASCITES/BUICK) 220000

1642 TM1642 PUNGSI PLEURA 247500

1643 TM1643 PUNGSI LUMBAL 291500

1644 TM1644 PUNGSI STERNUM (BONE MARROW) 302500

1645 TM1645 PUNGSI PERICARDIAL 220000

1646 TM1646 REPOSISI LUKSASI MANDIBULA 220000

1647 TM1647 REPOSISI SENDI TERTUTUP 275000

1648 TM1648 RESERPLASTY 297000

1649 TM1649 SUNTIK 28600

1650 TM1650 WSD 412500

1651 TM1651 AERONAB (FILTER NEBULIZER) 82500

1652 TM1652 BLUE LIGHT 93500

1653 TM1653 BUBBLE C-PAP 297000

1654 TM1654 DISPOSIBLE / DILUAR ALAT SIRKUIT 121000

1655 TM1655 CTG 1 KALI 74800

1656 TM1656 CTG 2 KALI 148500

Page 6
 Sheet1

1657 TM1657 CTG 3 KALI 209000

1658 TM1658 CTG > 3 KALI/HARI 231000

1659 TM1659 COUVE 74800

1660 TM1660 DEFIBLILATOR 203500

1661 TM1661 ECHOCARDIOGRAPHY 467500

1662 TM1662 EKG 74800

1663 TM1663 KONSUL BACA EKG 33000

1664 TM1664 EEG 247500

1665 TM1665 EEG + BRAIN MAPPING 440000

1666 TM1666 INFUSE PUMP PER JAM 27500

1667 TM1667 INFUSE PUMP > 4 JAM 99000

1668 TM1668 INCUBATOR 187000

1669 TM1669 TINDAKAN MEDIS OPERATIF GOL 1 DAN 2 1100000

1670 TM1670 TINDAKAN MEDIS OPERATIF GOL 3 DAN 4 1760000

1671 TM1671 LARYNGOSCOPE DIRECT 176000

1672 TM1672 MONITOR 176000

1673 TM1673 MONITOR PERINA (LEVEL 2) 88000

1674 TM1674 NEBULIZER 82500

1675 TM1675 OKSIGEN / JAM 33000

1676 TM1676 OKSIGEN / 14 JAM 176000

1677 TM1677 POMPA ELEKTRIK (BREAST PUMP) 23100

1678 TM1678 PULSE SUSU ELEKTRIK 66000

1679 TM1679 SYRINGE PUMP 93500

1680 TM1680 USG KEPALA 2D 165000

1681 TM1681 USG LEHER 3D 275000

1682 TM1682 USG THORAX 3D 275000

1683 TM1683 USG JANTUNG 165000

1684 TM1684 USG ABDOMEN 275000

1685 TM1685 USG 2D (ALAT 3D) 82500

1686 TM1686 USG 3D / 4D 242000

1687 TM1687 USG KEBIDANAN 55000

Page 7
 Sheet1

1688 TM1688 USG TRANSVAGINAL 93500

1689 TM1689 USG TESTIS 3D 78100

1690 TM1690 USG EKSTREMITAS 3D 330000

1691 TM1691 USG KULIT 165000

1692 TM1692 USG PRINT / LEMBAR 5500

1693 TM1693 VENTILATOR 495000

1694 TM1694 ALKES NEBULIZER 22500

1695 TM1695 VISIT (suite) by phone 83600

1696 TM1696 VISIT (svip) by phone 69630

1697 TM1697 VISIT (vip) by phone 58080

1698 TM1698 VISIT (utama) by phone 58080

1699 TM1699 VISIT (kls1) by phone 48400

1700 TM1700 VISIT (kls2) by phone 43560

1701 TM1701 VISIT (kls3) by phone 39160

1702 TM1702 VISIT (suite) 209000

1703 TM1703 VISIT (svip) 174240

1704 TM1704 VISIT (vip) 145200

1705 TM1705 VISIT (utama) 135300

1706 TM1706 VISIT (kls1) 121000

1707 TM1707 VISIT (kls2) 108900

1708 TM1708 VISIT (kls3) 98010

1709 TM1709 ABDOMEN 3 POSISI 371000

1710 TM1710 ABDOMEN POLOS 130000

1711 TM1711 APPENDICOGRAM 400000

1712 TM1712 BNO-IVP 1138500

1713 TM1713 ABDOMEN 2 POSISI 241640

1714 TM1714 VET. LUMBOSACRAL AP / LAT 251900

1715 TM1715 VET. LUMBOSACRAL AP / LAT / OBL 262900

1716 TM1716 VET. CERVICAL AP / LAT 251900

1717 TM1717 VET. CERVICAL AP / LAT / OBL 387200

1718 TM1718 VET. THORACOLUMBAL AP / LAT 251900

Page 8
 Sheet1

1719 TM1719 VET. THORACOLUMBAL AP / LAT / OBL 324500

1720 TM1720 PELVIS AP / LAT 211200

1721 TM1721 PELVIS AP / LAT / OBL 245300

1722 TM1722 LUMBAL AP / LAT 214500

1723 TM1723 LUMBAL AP / LAT / OBL 251900

1724 TM1724 SACRAL AP / LAT 171600

1725 TM1725 SACRAL AP / LAT / OBL 262900

1726 TM1726 COCYGEUS AP / LAT 171600

1727 TM1727 COXAE AP 148500

1728 TM1728 COXAE AP / LAT 171600

1729 TM1729 COXAE AP / LAT / OBL 262900

1730 TM1730 HUMERUS AP / LAT 148500

1731 TM1731 HUMERUS BILATERAL 223300

1732 TM1732 MANUS AP / LAT 148500

1733 TM1733 ANTEBRACHII AP / LAT 135300

1734 TM1734 DIGITI AP / LAT 148500

1735 TM1735 DIGITI BILATERAL 190300

1736 TM1736 WRIST JOINT AP / LAT 148500

1737 TM1737 WRIST JOIN BILATERAL 223300

1738 TM1738 ANTEBRACHII BILATERAL 223300

1739 TM1739 ARTIC CUBITI AP / LAT 148500

1740 TM1740 ARTIC CUBITI BILATERAL 223300

1741 TM1741 ANKLE AP/ LAT 148500

1742 TM1742 ART GENU AP/ LAT 148500

1743 TM1743 CALCANEUS AP/ LAT 192500

1744 TM1744 CALCANEUS BILATERAL 258500

1745 TM1745 CRURIS AP/ LAT 148500

1746 TM1746 FEMUR AP/ LAT 148500

1747 TM1747 PEDIS AP/ LAT 148500

1748 TM1748 FEMUR BELATERAL 262900

1749 TM1749 ART GENU BILATERAL 223300

Page 9
 Sheet1

1750 TM1750 CRURIS BILATERAL 223300

1751 TM1751 PEDIS BILATERAL 223300

1752 TM1752 ANKLE BILATERAL 223300

1753 TM1753 CRANIUM 154000

1754 TM1754 MANDIBULA 234300

1755 TM1755 MASTOID 214500

1756 TM1756 ORBITA 206800

1757 TM1757 OS NASAL 198000

1758 TM1758 SPN 2 POSISI 234800

1759 TM1759 TMJ (TEMPOROMANDIBULAJOINT) 148500

1760 TM1760 SPN 3 POSISI 227700

1761 TM1761 TMJ OPEN & CLOSE MOUTH 247500

1762 TM1762 ELBOW JOINT AP/LAT 192500

1763 TM1763 ELBOW JOINT BILATERAL 258500

1764 TM1764 CLAVICULA 136400

1765 TM1765 SCAPULA 136400

1766 TM1766 SHOULDER 170500

1767 TM1767 STRENUM 154500

1768 TM1768 THORAX LAT 126500

1769 TM1769 THORAX AP / PA 135300

1770 TM1770 THORAX AP / LAT 247500

1771 TM1771 TORAX ANAK 135000

1772 TM1772 COSTEA 143000

1773 TM1773 SHOULDER BILATERAL 200200

1774 TM1774 CLAVICULA BILATERAL 171600

1775 TM1775 SCAPULA BILATERAL 171600

1776 TM1776 TENS 50050

1777 TM1777 DIATHERMY 91050

1778 TM1778 EXERCISE 100100

1779 TM1779 NEBULIZER (fisio) 100100

1780 TM1780 ULTRASOUND 57200

Page 10
 Sheet1

1781 TM1781 PARAFINBATH 50050

1782 TM1782 INFRA RED 42900

1783 TM1783 MANIPULASI (MASSAGE) 143000

1784 TM1784 MANUAL TERAPI 143000

1785 TM1785 LASER 143000

1786 TM1786 TENS (kls1) 77000

1787 TM1787 DIATHERMY (kls1) 77000

1788 TM1788 EXERCISE (kls1) 112000

1789 TM1789 NEBULIZER (kls1) 119000

1790 TM1790 ULTRASOUND (kls1) 84000

1791 TM1791 PARAFINBATH (kls1) 77000

1792 TM1792 INFRA RED (kls1) 70000

1793 TM1793 TENS (kls2) 63000

1794 TM1794 DIATHERMY (kls2) 63000

1795 TM1795 EXERCISE (kls2) 91000

1796 TM1796 NEBULIZER (kls2) 105000

1797 TM1797 ULTRASOUND (kls2) 70000

1798 TM1798 PARAFINBATH (kls2) 63000

1799 TM1799 INFRA RED (kls2) 56000

1800 TM1800 TENS (kls3) 49000

1801 TM1801 DIATHERMY (kls3) 49000

1802 TM1802 EXERCISE (kls3) 70000

1803 TM1803 NEBULIZER (kls3) 91000

1804 TM1804 ULTRASOUND (kls3) 56000

1805 TM1805 PARAFINBATH (kls3) 49000

1806 TM1806 INFRA RED (kls3) 42000

1807 TM1807 TENS (vip) 91000

1808 TM1808 DIATHERMY (vip) 91000

1809 TM1809 EXERCISE (vip) 133000

1810 TM1810 NEBULIZER (vip) 119000

1811 TM1811 ULTRASOUND (vip) 98000

Page 11
 Sheet1

1812 TM1812 PARAFINBATH (vip) 91000

1813 TM1813 INFRA RED (vip) 91000

1814 TM1814 BHP USG ABDOMEN / USG 2D 6875

1815 TM1815 BHP CTG 17875

1816 TM1816 BHP EKG 37125

1817 TM1817 BHP AFF HECTING (ANGKAT/BUKA JAHITAN) 21725

1818 TM1818 BHP HECTING KECIL (3-5 JAHITAN) 41112

1819 TM1819 BHP HECTING SEDANG (5-10 JAHITAN) 62837

1820 TM1820 BHP HECTING BESAR (>10 JAHITAN) 69850

1821 TM1821 BHP GANTI VERBAND (GV) KECIL 29975

1822 TM1822 BHP GANTI VERBAND (GV) SEDANG DAN BESAR 43037

1823 TM1823 BHP LUKA BAKAR RINGAN 25162

1824 TM1824 BHP LUKA BAKAR SEDANG 39600

1825 TM1825 BHP LUKA BAKAR BERAT 82325

1826 TM1826 BHP VULVA HYGIENE 23925

1827 TM1827 BHP PASANG IUD 32175

1828 TM1828 BHP PAPSMEAR 47437

1829 TM1829 BHP SUNTIK IMUNISASI 10038

1830 TM1830 BHP PASANG CATHETER 26675

1831 TM1831 BHP PASANG NGT / OGT 9350

1832 TM1832 BHP PASANG INFUS DEWASA 10725

1833 TM1833 BHP PASANG INFUS ANAK 40975

1834 TM1834 BHP CUKUR 11550

1835 TM1835 BHP NEBULIZER 22550

1836 TM1836 BHP USG TRANSVAGINAL 23100

1837 TM1837 PASANG INFUS ANAK 27500

1839 TM1838 JASA PARAMEDIS 11000

1840 TM1839 INSPEKULO 27500

1841 TM1840 BHP INSPEKULO 23925

1842 TM1841 BHP VT 23925

1843 TM1842 BHP AVV IUD 32175

Page 12
 Sheet1

1844 TM1843 WONT TOILET (WT) (igd) 44000

1845 TM1844 NEOPUFF 165000

1846 TM1845 BHP AFF IUD 32175

1847 TM1846 JASA DOKTER NEBULIZER (igd) 27500

1848 TM1847 BIAYA SC + STERIL (suite) 5527500

1849 TM1848 BIAYA SC + STERIL (svip) 4576000

1850 TM1849 BIAYA SC + STERIL (vip) 3826900

1851 TM1850 BIAYA SC + STERIL (kls1) 3619000

1852 TM1851 BIAYA SC + STERIL (kls2) 3151225

1853 TM1852 BIAYA SC + STERIL (kls3) 2727725

1854 TM1853 INDUKSI (suite) 1425600

1855 TM1854 INDUKSI (svip) 1211650

1856 TM1855 INDUKSI (vip) 1111550

1857 TM1856 INDUKSI (utama) 975150

1858 TM1857 INDUKSI (kls1) 840950

1859 TM1858 INDUKSI (ksl2) 657250

1860 TM1859 INDUKSI (kls3) 470250

1861 TM1860 ALAT VAKUM 220000

1862 TM1861 VAKUM (suite) 1425600

1863 TM1862 VAKUM (svip) 1211650

1864 TM1863 VAKUM (vip) 1111550

1865 TM1864 VAKUM (utama) 975150

1866 TM1865 VAKUM (kls1) 840950

1867 TM1866 VAKUM (kls2) 657250

1868 TM1867 VAKUM (kls3) 470250

1869 TM1868 BHP GANTI VERBAN (poli) 43038

1870 TM1869 KONSULTASI GIGI (anak) 90000

1871 TM1870 KONSULTASI GIGI (dewasa) 90000

1872 TM1871 OBAT TANPA TINDAKAN GIGI 120000

1873 TM1872 PERAWATAN ULKUS/INFEKSI/RADANG/DRAINASE 160000

1874 TM1873 BONGKAR TAMBALAN 150000

Page 13
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1875 TM1874 POLISHING/ GRINDING 100000

1876 TM1875 EUGENOL + TS 150000

1877 TM1876 PULPCAPPING TS 200000

1878 TM1877 DEVITAL + EUGENOL + TS 200000

1879 TM1878 ROCKLESS TS 200000

1880 TM1879 3MIX + TS 150000

1881 TM1880 TAMBAL COMPOSITE PERMANEN KECIL (anak) 200000

1882 TM1881 TAMBAL COMPOSITE PERMANEN SEDANG (anak) 250000

1883 TM1882 TAMBAL COMPOSITE PERMANEN BESAR (anak) 300000

1884 TM1883 TAMBAL COMPOSITE PERMANEN KECIL (dewasa) 250000

1885 TM1884 TAMBAL COMPOSITE PERMANEN SEDANG (dewasa) 300000

1886 TM1885 TAMBAL COMPOSITE PERMANEN BESAR (dewasa) 400000

1887 TM1886 TAMBAL GIC PERMANEN KECIL (anak) 150000

1888 TM1887 TAMBAL GIC PERMANEN SEDANG (anak) 200000

1889 TM1888 TAMBAL GIC PERMANEN BESAR (anak) 250000

1890 TM1889 TAMBAL GIC PERMANEN KECIL (dewasa) 200000

1891 TM1890 TAMBAL GIC PERMANEN SEDANG (dewasa) 250000

1892 TM1891 TAMBAL GIC PERMANEN BESAR (dewasa) 300000

1893 TM1892 PSA I/C (anak) 50000

1894 TM1893 PSA M (anak) 100000

1895 TM1894 PSA I/C (dewasa) 100000

1896 TM1895 PSA P (dewasa) 125000

1897 TM1896 PSA M (dewasa) 150000

1898 TM1897 PENGISIAN I/ C (anak) 100000

1899 TM1898 PENGISIAN M (anak) 150000

1900 TM1899 PENGISIAN I/ C (dewasa) 150000

1901 TM1900 PENGISIAN P (dewasa) 175000

1902 TM1901 PENGISIAN M (dewasa) 200000

1903 TM1902 SCALLING KALKULUS TYPE 1 (anak) 125000

1904 TM1903 SCALLING KALKULUS TYPE 2 (anak) 150000

1905 TM1904 SCALLING KALKULUS TYPE 3 (anak) 200000

Page 14
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1906 TM1905 SCALLING KALKULUS TYPE 1 (dewasa) 250000

1907 TM1906 SCALLING KALKULUS TYPE 2 (dewasa) 350000

1908 TM1907 SCALLING KALKULUS TYPE 3 (dewasa) 450000

1909 TM1908 CURRETAGE/ ROOT PLANNING PER GIGI 150000

1910 TM1909 SPLINTING PER REGIO 400000

1911 TM1910 OCCLUSAL ADJUSTMENT PER GIGI 100000

1912 TM1911 CABUT GIGI SULUNG TOPIKAL 150000

1913 TM1912 CABUT GIGI SULUNG CITOJEK 200000

1914 TM1913 CABUT GIGI DEWASA KASUS 1 250000

1915 TM1914 CABUT GIGI DEWASA KASUS 2 350000

1916 TM1915 CABUT GIGI DEWASA KASUS 3 450000

1917 TM1916 CABUT GIGI KOMPILASI KOMPLIKASI 600000

1918 TM1917 CABUT GIGI OLEH SP.BM 1500000

1919 TM1918 GIGI IMPAKSI OLEH DOKTER GIGI 2000000

1920 TM1919 GIGI IMPAKSI OLEH SPESIALIS BEDAH MULUT 3500000

1921 TM1920 ALVEOLECTOMY PER REGIO 500000

1922 TM1921 GINGIVECTOMY PER GIGI 250000

1923 TM1922 INSISI ABSES INTRAORAL 250000

1924 TM1923 KONTROL PASCA BEDAH (ANGKAT HECTING) 200000

1925 TM1924 HOME BLEACHING 2500000

1926 TM1925 IN OFFICE BLEACHING 3000000

1927 TM1926 APLIKASI DENGAN FLOUR PER KUNJUNGAN 250000

1928 TM1927 DIRECT LABIAL VENEER PER 1 GIGI 550000

1929 TM1928 INDIRECT LANIAL VENEER PER 1 GIGI PORCELAIN EMAX 3200000

1930 TM1929 CETAK ALGINATE RA & RB 250000

1931 TM1930 CETAK DOUBLE IMPRESSION RA & RB 300000

1932 TM1931 ALAT ORTHO CEKAT BAHAN METAL KASUS RINGAN 5500000

1933 TM1932 ALAT ORTHO CEKAT BAHAN METAL KASUS SEDANG 7500000

1934 TM1933 ALAT ORTHO CEKAT BAHAN METAL KASUS SULIT 8500000

1935 TM1934 ALAT ORTHO CEKAT BAHAN CERAMIC KASUS RINGAN 9500000

1936 TM1935 ALAT ORTHO CEKAT BAHAN CERAMIC KASUS SEDANG 11000000

Page 15
 Sheet1

1937 TM1936 ALAT ORTHO CEKAT BAHAN CERAMIC KASUS SULIT 13000000

1938 TM1937 ALAT ORTHO CEKAT BAHAN SAPHIRE KASUS RINGAN 13500000

1939 TM1938 ALAT ORTHO CEKAT BAHAN SAPHIRE KASUS SEDANG 15000000

1940 TM1939 ALAT ORTHO CEKAT BAHAN SAPHIRE KASUS SULIT 16000000

1941 TM1940 ALAT ORTHO CEKAT DAMOND METAL 22000000

1942 TM1941 ALAT ORTHO LEPASAN RA & RB 2000000

1943 TM1942 PINDAH KONTROL ORTHO 2500000

1944 TM1943 KONTROL BRACKET 250000

1945 TM1944 RECEMENT 1 BRACKET/BUCCAL TUBE 80000

1946 TM1945 GANTI 1 BRACKET 140000

1947 TM1946 GANTI 1 BUCCAL TUBE 180000

1948 TM1947 RETAINER VACUUM PER RAHANG 1500000

1949 TM1948 BUKA BRACKET PER RAHANG 200000

1950 TM1949 WIRE PER RAHANG 150000

1951 TM1950 GTSL KERANGKA AKRILIK (PAKE KAWAT)+ 1 GIGI PERTAMA 1100000

1952 TM1951 GTSL VALPLAST (TIDAK PAKE KAWAT) + 1 GIGI PERTAMA (BILAT 1750000

1953 TM1952 GTSL VERTEX THERMOSEN/FRS +1 GIGI PERTAMA (BILATERAL)1850000

1954 TM1953 GTSL VALPLAST (TIDAK PAKE KAWAT) + 1 GIGI PERTAMA (SADD1500000

1955 TM1954 GTSL VERTEX THERMOSEN/FRS +1 GIGI PERTAMA (SADDLE) 1650000

1956 TM1955 GIGI KEDUA DAN SETERUSNYA 180000

1957 TM1956 GTP AKRILIK PER RAHANG 3300000

1958 TM1957 GTP VALPLAST PER RAHANG 3000000

1959 TM1958 GTP KERANGKA LOGAMPER RAHANG 2300000

1960 TM1959 KONTROL PASCA INSERSI 150000

1961 TM1960 REPARASI PROTESA PATAH/RETAK + 1GIGI PERTAMA 550000

1962 TM1961 REPARASI PROTESA PATAH/RETAK + 1GIGI PERTAMA (HEAD CU700000

1963 TM1962 REBASING PER RAHANG 650000

1964 TM1963 SENDOK CETAK INDIVIDUAL 500000

1965 TM1964 BONGKAR/ BUKA CROWN PER-1 UNIT 250000

1966 TM1965 INLAY/ONLAY METAL 1150000

1967 TM1966 INLAY/ONLAY ALL PORCELAIN EMAX 3000000

Page 16
 Sheet1

1968 TM1967 INLAY/ONLAY ALL PORCELINE ZIRCONE 4500000

1969 TM1968 PROVISORIS 150000

1970 TM1969 NIGHT GUARD 1200000

1971 TM1970 HAWLEY RETAINER PER RAHANG 1300000

1972 TM1971 CENGKRAM/KAWAT 140000

1973 TM1972 INVISIBLE RETAINER PER RAHANG 1800000

1974 TM1973 JACKET/BRIDGE CROWN PFM (PORCELAIN FUSED METAL) 2000000

1975 TM1974 JACKET/BRIDGE CROEN EMAX 3000000

1976 TM1975 JACKET/BRIDGE CROWN ZICRONE 4500000

1977 TM1976 JACKET/BRIDGE CROWN METAL PER 1 GIGI 1400000

1978 TM1977 JACKET/BRIDGE CROWN ACRYLIC PER 1 GIGI 850000

1979 TM1978 PIN CORE METAL/ POST CORE 2000000

1980 TM1979 PIN FIBER CORE 600000

1981 TM1980 BREAST CARE 33000

1986 TM1981 VISIT (perina) 137500

1987 TM1982 VISIT (nicu/picu) 187500

1988 TM1983 VISIT (vk/ok) 108900

VISIT HCU

VISIT DOKTER UMUM

Page 17
 Sheet1

ANAK IGD IBU PICU NICU HCU PERINA BAYI POLI VK OK ADM DEPOSIT

√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √
√ √

√ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √
√ √ √ √ √
√

Page 18
 Sheet1

√ √ √ √ √ √ √
√
√
√
√
√
√
√
√ 1
√ 1 1 1 1 1
√
√
√
√
√
√
√
√
√
√ 1 1 1
√
√
√
√
√
√ 1 1 1 1 1 1
√ 1 1 1 1
√ 1 1 1 1 1
√ 1 1 1 1 1
√ 1 1 1 1 1
Page 19
 Sheet1

√ 1 1 1 1 1
√ 1 1 1 1 1
1 √ 1 1 1
√
1 √ 1 1 1 1
√ 1
1 √ 1 1
√ 1 1
√
√
√
√
√
√
√
√
1 √ 1 1 1 1 1
√ 1
√
√ 1
1 1
1
1
1
1 1
1 1
1 1
1
1
1

Page 20
 Sheet1

1
1
1 1
1 1 1 1 1 1 1 1
1 1
1 1 1
1 1 1 1 1 1 1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1
1
1
1
1 1 1
1 1
1
1 1 1
1 1 1
1 1 1
1 1
1 1 1
1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1
1
Page 21
 Sheet1

1 1
1 1 1

1
1
1
1
1
1
1
1
1
1
1
1
1 1
1 1
1 1 1
1
1 1 1 1
1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1
Page 22
 Sheet1

1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1 1 1 1 1 1

1
1 1
1 1
1 1
1 1

1 1 1 1 1 1 1 1 1 1 1
1 1
1 1 1 1 1 1 1 1 1
1 1
1 1
1
1
1
Page 23
 Sheet1

1
1

1 1 1 1 1
1 1 1 1 1

1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1
1
1
1 1 1 1
1 1 1 1 1 1 1 1
1 1
1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1

1
1
1
1 1 1
Page 24
 Sheet1

1 1 1

1
1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1

1
1
1
1
1
1
Page 25
Sheet1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 26
Sheet1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 27
 Sheet1

1
1

1 1
1 1

1 1
1 1

1 1

1 1
1

1 1

1 1
1 1
1 1
Page 28
 Sheet1

1 1
1 1 1
1 1 1
1 1
1 1
1 1
1 1
1 1
1 1 1 1
1 1 1
1 1
1 1
1 1
1 1 1 1
1 1
1
1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1
1 1 1
1 1 1
1 1 1 1 1 1 1 1 1 1
1
1 1 1
1 1 1 1 1 1 1 1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1
Page 29
 Sheet1

1
1 1 1 1 1 1 1 1 1 1
1 1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 1
1 1
1
1
1
Page 30
Sheet1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 31
 Sheet1

1
1
1
1

1
1
1
1
1
1
1
1
1
1

1
1 1
1 1
1
1
1
1
1
1
1
1
1
1
1
1
Page 32
Sheet1

1
1
1
1
1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 33
 Sheet1

1
1
1
1
1
1
1
1
1
1
1
1
1
1 1 1
1
1 1
1
1
1 1 1 1 1 1 1 1 1

Page 34