Tindakan Umum

DAFTAR TARIF LAYANAN KESEHATAN BLUD PUSKESMAS
A. TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI
SUBSIDI
TARIF PERBUP (PERBUP TARIF LUAR
NO JENIS PELAYANAN 49 TH TARIF BANTUL
NO 45 TH 2016 BANTUL
2016)
A TINDAKAN MEDIS UMUM
1 Injeksi 9,500 3,700 5,800 9,500
2 Injeksi ekstra needle 10,000 3,900 6,100 10,000
3 Skin test 10,500 4,450 6,050 10,500
4 Pasang infus (mikro set) 61,000 26,900 34,100 61,000
5 Pasang infus (makro set) 56,500 0 56,500 56,500
6 Pelepasan infus 8,500 3,300 5,200 8,500
7 Perbaikan infus 18,500 5,050 13,450 18,500
8 Pasang kateter+urinbag 75,500 34,800 40,700 75,500
9 Pelepasan kateter 12,500 350 12,150 12,500
10 Lavement 35,500 12,700 22,800 35,500
11 Resusitasi 59,000 33,750 25,250 59,000
12 Pemasangan Oksigen 15,500 6,900 8,600 15,500
13 Oksigenasi (per liter per menit) 75 35 40 75
14 Pasang NGT 51,000 6,500 44,500 51,000
15 Scorstein 35,000 10,250 24,750 35,000
16 Rectal Toucher 16,500 4,950 11,550 16,500
17 Nebulizer 39,000 14,200 24,800 39,000
18 Perawatan luka (Perda lama : medikasi luka)
a. Kecil 22,000 5,650 16,350 22,000
b, Sedang 33,500 0 33,500 33,500
c. Besar 56,000 0 56,000 56,000
19 Debridemen sederhana 49,000 22,800 26,200 49,000
20 Debridemen kompleks 129,000 54,950 74,050 129,000
21 Hecting 1 sampai 5 61,500 22,450 39,050 61,500
22 Hecting 6 sampai 10 87,500 28,900 58,600 87,500
23 Perjahitan (setelah jahitan ke 10) 5,000 0 5,000 5,000
24 Ambil jahitan 19,000 2,450 16,550 19,000
25 Insisi / Eksisi 59,500 30,500 29,000 59,500
26 Cross incisi 30,500 11,050 19,450 30,500
27 Bilas lambung 152,500 0 152,500 152,500
28 Suction lendir 34,500 0 34,500 34,500
29 Irigasi mata 33,000 0 33,000 33,000
30 Pemberian supositoria 13,000 0 13,000 13,000
31 Pemasangan elastis verban 46,000 0 46,000 46,000
32 Chlorethyl spray 21,700 6,700 15,000 21,700
33 Circumsisi non cauther 134,250 56,400 77,850 134,250
34 Circumsisi cauther 138,500 63,400 75,100 138,500
35 Reposisi Dawir 1 telinga 60,050 19,650 40,400 60,050
36 Reposisi Dawir 2 telinga 99,200 0 99,200 99,200
37 Luka bakar dibawah 10 % tanpa komplikasi 57,500 7,850 49,650 57,500
38 Luka bakar diatas 10 % tanpa komplikasi 143,600 24,300 119,300 143,600
39 Extirpasi (Minor Surgery ) 91,900 40,300 51,600 91,900
40 Ektrasi kuku (Per kuku) 48,200 21,400 26,800 48,200
41 ATS 234,450 0 234,450 234,450
42 Ekstraksi corpus alineum mata (per Mata) 34,100 11,900 22,200 34,100
43 Refraksi Mata 7,500 2,500 5,000 7,500
44 Hordeolum 39,100 12,950 26,150 39,100
45 Tonometri 27,500 9,000 18,500 27,500
46 Cerumen Prop (per Telinga) 17,500 4,550 12,950 17,500
47 Corpus Alienum THT 27,100 10,600 16,500 27,100
SUBSIDI
2016)
48 Pasang Spalk 58,300 19,900 38,400 58,300

49 Pasang Tampon 30,500 0 30,500 30,500
50 Visum di TKP 40,000 20,000 20,000 40,000
51 Visum di Puskesmas 32,500 17,500 15,000 32,500
52 EKG 22,000 4,000 18,000 22,000
B. TINDAKAN KEBIDANAN
1 Partus Normal 345,200 129,100 216,100 345,200
2 Partus Gemelli 478,200 205,400 272,800 478,200
3 Induksi Persalinan 164,100 94,800 69,300 164,100
4 Jahit Luka Perineum (Jelujur) 88,400 48,900 39,500 88,400
5 Evakuasi Digital Placenta 61,700 34,950 26,750 61,700
6 Evakuasi Manual Placenta 96,500 35,000 61,500 96,500
7 Toucher/Kontrol IUD 37,500 11,750 25,750 37,500
8 Pemasangan IUD 76,800 50,550 26,250 76,800
9 Pelepasan IUD 50,300 24,550 25,750 50,300
10 Pemasangan dan Lepas IUD 96,800 50,550 46,250 96,800
11 Pemasangan Inplant 83,300 52,850 30,450 83,300
12 Pelepasan Impant 102,300 71,850 30,450 102,300
13 Pemasangan dan Lepas Inplant/Norplant 142,300 91,850 50,450 142,300
14 Pap Smear (Lab dan Transport) 86,900 65,400 21,500 86,900
14 IVA 29,200 3,700 25,500 29,200
15 Suntik KB 11,400 5,600 5,800 11,400
16 Perawatan Bayi Normal 73,400 21,900 51,500 73,400
17 Tindik 21,700 15,300 6,400 21,700
18 Dopler 10,000 5,000 5,000 10,000
18 Pra Rujukan Perdarahann PP 446,800 0 446,800 446,800
19 Antenatal care 15,000 15,000 0 15,000
20 Post natal care 25,000 0 25,000 25,000
21 Krioterapi 150,000 0 150,000 150,000
TINDAKAN PELAYANAN KESEHATAN GIGI DAN
C. MULUT
1 Oral diagnostik/ konsultasi/ premedikasi 5,000 0 5,000 5,000
Pembersihan Karang Gigi per regio (total RA dan 39,500 25,750 13,750 39,500
2 RB = 6 regio)
3 Tumpatan Amalgam 46,000 27,600 18,400 46,000
4 Tumpatan GIC 1 permukaan 49,500 25,200 24,300 49,500
6 Tumpatan GIC lebih dari 2 permukaan 70,000 45,700 24,300 70,000
7 Tumpatan Komposit Light Cured (kecil/1 52,000 30,450 21,550 52,000

permukaan)
Tumpatan Komposit Light Cured (sedang/2 73,500 34,600 38,900 73,500
8 permukaan)
Tumpatan Komposit Light Cured (besar/lebih
9 dari 86,500 40,550 45,950 86,500
2 permukaan)
10 Perawatan Pulp Capping 26,500 14,300 12,200 26,500
11 Perawatan Syaraf A (Devitalisasi pulpa) 29,000 14,000 15,000 29,000
12 Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 15,700 14,300 30,000
13 Perawatan Syaraf C (Pengisian kamar pulpa) 35,500 19,700 15,800 35,500
14 Trepanasi gigi 19,000 0 19,000 19,000
15 Pengambilan Tumpatan (Up Filling) 17,500 0 17,500 17,500
16 Koreksi Oklusi 30,500 17,700 12,800 30,500
17 Koreksi ulcus Decubitus 20,000 0 20,000 20,000
Pencabutan Gigi Decidui dengan topikal anestesi 20,000 9,400 10,600 20,000
18
SUBSIDI
2016)
19 Pencabutan Gigi Decidui dengan citoject 28,500 17,900 10,600 28,500
Pencabutan Gigi Dewasa dg spuit dispossible 22,500 10,400 12,100 22,500

20
21 Pencabutan Gigi Dewasa dg spuit dispossible 75,500 46,150 29,350 75,500
dengan penyulit
22 Pencabutan Gigi Dewasa dg citoject 50,000 20,650 29,350 50,000
23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 60,650 29,350 90,000

penyulit
24 Incisi Abses per regio 27,000 7,800 19,200 27,000
25 Perawatan Dry Socket 39,000 0 39,000 39,000
26 Operkulektomi 27,000 10,850 16,150 27,000
27 Operasi Gigi 165,000 78,750 86,250 165,000
28 Hecting oral 40,000 0 40,000 40,000
29 Kontrol Post exo / op (Hecting Up) 17,000 0 17,000 17,000
30 Alveolectomy per regio 46,000 0 46,000 46,000
31 Reposisi Mandibula 60,000 15,200 44,800 60,000
32 Imobilisasi dengan komposit (3-5 gigi) 123,000 0 123,000 123,000
33 Gigi Tiruan Sebagian (harga per gigi blm 80,000 14,400 65,600 80,000
termasuk base plate)
34 Jacket Crown Akrilik per unit 215,000 87,900 127,100 215,000
35 Jacket Porcelain fused to metal per unit 545,000 297,900 247,100 545,000
36 Reparasi gigi tiruan akrilik per rahang 140,000 0 140,000 140,000
B. TARIF RETRIBUSI PELAYANAN PENUNJANG DIAGNOSIS
SUBSIDI
2016)
A. RADIOLOGI
1 30X40 1x 52,000 12,000 40,000 52,000
2 30X40 2x 61,000 11,000 50,000 61,000
3 35X35 1x 54,000 19,000 35,000 54,000
4 35X35 2x 63,000 18,000 45,000 63,000
5 24X30 1x 44,000 14,000 30,000 44,000
6 24X30 2x 50,000 10,000 40,000 50,000
7 18X24 1x 41,000 11,000 30,000 41,000
8 18X24 2x 48,000 8,000 40,000 48,000
9 15X30 (OPG) 37,000 13,000 24,000 37,000
10 USG (Print 1 lbr) 51,000 6,000 45,000 51,000
B. LABORATORIUM
1 Hb Sahli 4,000 1,850 2,150 4,000
2 AL 4,000 1,050 2,950 4,000
3 HJL ( Hitung Jenis Leukosit) 10,000 5,300 4,700 10,000
4 Malaria 10,000 5,300 4,700 10,000
5 LPB (Limposit Plasma Biru) 10,000 5,300 4,700 10,000
6 AE 7,500 2,750 4,750 7,500
7 KED 6,000 3,400 2,600 6,000
8 AT Rees Ecker 10,000 3,000 7,000 10,000
9 HMT 5,000 1,950 3,050 5,000
10 CT 7,000 4,000 3,000 7,000
11 BT 4,500 1,950 2,550 4,500
12 Golongan Darah 7,000 2,100 4,900 7,000
13 Protein Urine 5,000 1,400 3,600 5,000
SUBSIDI
2016)
14 Reduksi Urine 5,000 1,400 3,600 5,000
15 Sedimen 5,000 1,150 3,850 5,000
16 Faeses 10,000 5,850 4,150 10,000
17 Glukosa Stik 15,000 2,550 12,450 15,000
18 Asam urat Stik 20,000 1,050 18,950 20,000

19 Kolesterol Stik 25,000 650 24,350 25,000
20 Trigliserid Stik 30,000 2,300 27,700 30,000
21 HBs Ag Rapid Tes 25,000 2,000 23,000 25,000
22 Narkoba (untuk setiap jenis) 30,000 5,650 24,350 30,000
23 PP Test lateks 15,000 1,400 13,600 15,000
24 Hb Spektro 10,000 2,100 7,900 10,000
25 Glukosa spektro 15,000 1,600 13,400 15,000
26 Asam Urat Spektro 22,000 5,100 16,900 22,000
27 Kolesterol Spektro 22,000 4,900 17,100 22,000
28 Trigliserid Spektro 27,000 8,700 18,300 27,000
29 SGOT Spektro 22,000 5,100 16,900 22,000
30 SGPT Spektro 22,000 5,100 16,900 22,000
31 Ureum Spektro 20,000 6,400 13,600 20,000
32 Kreatinin Spektro 20,000 6,400 13,600 20,000
33 Widal 20,000 4,000 16,000 20,000
34 Darah Lengkap Otomatis (DLO) 40,000 0 40,000 40,000
35 Hb/Hmt Stik 15,000 7,000 8,000 15,000
36 Rhesus 7,000 0 7,000 7,000
37 NS1 110,000 0 110,000 110,000
38 IgG/IgM Dengue 110,000 0 110,000 110,000
39 HIV 70,000 0 70,000 70,000
40 syphilis RPR 25,000 0 25,000 25,000
41 syphilis RPR 30,000 0 30,000 30,000
42 Leptotek 80,000 0 80,000 80,000
43 Gonorhoe (GO) 15,000 0 15,000 15,000
44 Jamur 10,000 0 10,000 10,000
45 BTA 20,000 0 20,000 20,000
46 Stik urine 10 P 10,000 0 10,000 10,000
47 Urine Rutin 15,000 0 15,000 15,000
48 Urine Lengkap 20,000 0 20,000 20,000
49 Sampling Darah Kapiler 2,000 0 2,000 2,000
50 Sampling Darah Vena 5,000 0 5,000 5,000
C. TARIF PELAYANAN REHABILITASI MEDIK
SUBSIDI
2016)
1 Terapi Latihan Kecil 8,000 2,500 5,500 8,000
2 Terapi Latihan Sedang 12,000 2,800 9,200 12,000
3 Terapi Latihan Besar 17,000 6,300 10,700 17,000
4 Massage Bayi 12,000 9,050 2,950 12,000
5 Massage dewasa 15,000 12,000 3,000 15,000
6 Infra Red 9,000 1,850 7,150 9,000
7 TENS 10,000 3,800 6,200 10,000
8 Elektrical Stimulation (ES) 10,000 4,000 6,000 10,000
9 Static bycicle lamanya 10,000 2,500 7,500 10,000
11 Senam Hamil/Nifas/asma/DM dll 5,000 1,650 3,350 5,000
12 Ultra Sound (US) 11,500 0 11,500 11,500
SUBSIDI
2016)
13 Chest Therapy 6,000 0 6,000 6,000
14 Short Wave Diathermy 15,150 0 15,150 15,150
15 Micro Wave Diathermy 14,000 0 14,000 14,000
16 Terapi Manipulasi 12,000 1,000 11,000 12,000
17 Ice Massage 10,000 3,000 7,000 10,000
18 Traksi Cervical/Lumbal elektrik 14,000 0 14,000 14,000
19 Cold Pack 13,000 0 13,000 13,000

20 Hot Pack 13,000 0 13,000 13,000
21 Pararel Bar 8,000 0 8,000 8,000
22 Standing Bar 8,000 0 8,000 8,000
23 Shoulder wheel/Pulley/wallbar 8,000 0 8,000 8,000
24 Latihan transfer dan ambulasi menggunakan alat 4,000 0 4,000 4,000
jalan (Kruk/Walker/Tripot)
25 Pemasangan/fitting orthosis 4,500 0 4,500 4,500
26 Parafin bath 22,500 0 22,500 22,500
D. TARIF PELAYANAN KESEHATAN TRADISIONAL
SUBSIDI
2016)
1 Akupresur 17,000 0 17,000 17,000

2 Akupuntur 40,000 0 40,000 40,000
E. TARIF PELAYANAN KESEHATAN INFEKSI MENULAR SEKSUAL (IMS)
SUBSIDI
2016)
A.TINDAKAN
1 inspekulo pervaginam 26,000 0 26,000 26,000
2 Rectal toucher 12,000 0 12,000 12,000
3 pengambilan duh urethra 8,000 0 8,000 8,000
B.PEMERIKSAAN LABORATORIUM
Pemeriksaan basah duh tubuh servik, duh tubuh
1 vagina dan duh tubuh urethra 5,000 0 5,000 5,000
2 Pemeriksaan kering duh tubuh anus 4,500 2,500 2,000 4,500

3 Pemeriksaan sipilis Rapid test 25,000 8,000 17,000 25,000
4 Pemeriksaan sipilis RPR 30,000 5,000 25,000 30,000
5 Rapid test HIV 70,000 64,000 6,000 70,000
F. TARIF PELAYANAN AMBULANCE
SUBSIDI
2016)
1 Dalam Kabupaten
sampai dg 5 km pertama 65,000 0 65,000 65,000
> 5 km biaya per kilometer 5,000 5,000 5,000
2 Luar Kabupaten
SUBSIDI
2016)
G. TARIF PELAYANAN KESEHATAN LAINNYA
SUBSIDI
2016)
1 Pemeriksaan Kesehatan 7,500 2,500 5,000 7,500

2 Pemeriksaan Dokter Spesialis 22,500 7,500 15,000 22,500
3 Tes Buta Warna 7,500 2,500 5,000 7,500
4 Konsultasi Kesehatan 7,500 2,500 5,000 7,500
5 BUKU KIA tiap Buku 12,000 5,500 6,500 12,000
6 Home Care (per petugas) 20,000 0 20,000 20,000
7 Tes kebugaran CJH 42,500 0 42,500 42,500
8 Poli Sore 11,000 0 11,000 11,000
H. TARIF PELAYANAN PENDIDIKAN
SUBSIDI
2016)
1 Praktek Klinik per minggu
a. profesi 30,000 0 30,000 30,000
b. D4/S1 26,500 0 26,500 26,500
c. D3 22,500 0 22,500 22,500
2 Praktek non Klinik per minggu
a. profesi 25,000 0 25,000 25,000
b. D4/S1 20,000 0 20,000 20,000
c. D3 18,000 0 18,000 18,000
d SMA/SMK
3 Penelitian
a. Profesi (S2/S3) 250,000 0 250,000 250,000
b. D4/S1 200,000 0 200,000 200,000
c. D3 100,000 0 100,000 100,000
d. Pengambilan data dalam rangka studi
pendahuluan (1 paket) di puskesmas
4 Pelayanan Studi banding
a. narasumber(perJPL/org) 250,000 0 250,000 250,000
b. Sarana Prasarana
- konsumsi/orang 37,000 0 37,000 37,000
- jasa sarana perpaket 200,000 0 200,000 200,000
I. TARIF PELAYANAN RAWAT INAP
SUBSIDI
TARIF PERBUP (PERBUP
JENIS PELAYANAN 49 TH TARIF BANTUL TARIF LUAR
NO 45 TH 2016
NO 2016) BANTUL
SUBSIDI
2016)
SUBSIDI
TARIF PERBUP (PERBUP
JENIS PELAYANAN 49 TH TARIF BANTUL TARIF LUAR
NO 45 TH 2016
NO 2016) BANTUL
1 Rawat Inap Umum 74,000 10,500 63,500 74,000
2 Rawat Inap Utama 185,000 0 185,000 185,000
Kepala Dinas Kesehatan

Kabupaten Bantul
drg. Maya Sintowati Pandji, MM

Pembina Utama Muda/IV.c
NIP. 195911051988032002
TOTAL PENDAPATAN DAN RINCIAN PENGGUNAAN PENDAPATAN PUSKESMAS ( RETRIBUSI UMUM ) TAHUN 2017
DINAS KESEHATAN KABUPATEN BANTUL
Bulan
PENDAPATAN
TARIF
LAYANAN JUMLAH
JASA JASA PENGEMB
NO JENIS PELAYANAN PENDUDUK UNIT COST OBAT
LAYANAN
KUNJUNG PENDAPAT UNIT
OBAT PELAYANA
PUSKESMAS
ANGAN
DINAS KET
LUAR AN AN COST 75% 10%
BANTUL N 15%
A TARIF PELAYANAN RAWAT JALAN

- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- Penduduk luar Bantul 9,000 3,000 6,000 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0
B TARIF PELAYANAN RAWAT INAP
1 Tari Rawat inap utama 185,000 125,000 60,000 0 0 0 0 0 0 0
2 Tari Rawat inap umum 63,500 50,000 13,500 0 0 0 0 0 0 0
C TARIF PELAYANAN RAWAT DARURAT

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0
D TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI

A) TINDAKAN MEDIS UMUM
1 Injeksi 9,500 3,150 6,350 0 0 0 0 0 0 0
2 Injeksi ekstra needle 10,000 3,750 6,250 0 0 0 0 0 0 0
3 Skin test 10,500 3,850 6,650 0 0 0 0 0 0 0
4 Pasang infus (mikro set) 61,000 42,200 18,800 0 0 0 0 0 0 0
5 Pasang infus (makro set) 56,500 37,400 19,100 0 0 0 0 0 0 0
6 Pelepasan infus 8,500 2,150 6,350 0 0 0 0 0 0 0
7 Perbaikan infus 18,500 5,950 12,550 0 0 0 0 0 0 0
8 Pasang kateter+urinbag 75,500 55,600 19,900 0 0 0 0 0 0 0
9 Pelepasan kateter 12,500 6,000 6,500 0 0 0 0 0 0 0
10 Lavement 35,500 16,700 18,800 0 0 0 0 0 0 0
11 Resusitasi 59,000 33,750 25,250 0 0 0 0 0 0 0
12 Pemasangan Oksigen 15,500 9,000 6,500 0 0 0 0 0 0 0
13 Oksigenasi (per liter per menit) 75 75 0 0 0 0 0 0 0 0
14 Pasang NGT 51,000 26,000 25,000 0 0 0 0 0 0 0
15 Scorstein 35,000 22,100 12,900 0 0 0 0 0 0 0
16 Rectal Toucher 16,500 10,250 6,250 0 0 0 0 0 0 0
17 Nebulizer 39,000 20,200 18,800 0 0 0 0 0 0 0
a. Kecil 22,000 11,600 10,400 0 0 0 0 0 0 0
b, Sedang 33,500 21,000 12,500 0 0 0 0 0 0 0
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
19 Debridemen sederhana 49,000 30,000 19,000 0 0 0 0 0 0 0
20 Debridemen kompleks 129,000 66,300 62,700 0 0 0 0 0 0 0
21 Hecting 1 sampai 5 61,500 49,000 12,500 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 87,500 68,400 19,100 0 0 0 0 0 0 0
23 Perjahitan (setelah jahitan ke 10) 5,000 2,500 2,500 0 0 0 0 0 0 0
24 Ambil jahitan 19,000 6,200 12,800 0 0 0 0 0 0 0
25 Insisi / Eksisi 59,500 40,700 18,800 0 0 0 0 0 0 0
26 Cross incisi 30,500 17,800 12,700 0 0 0 0 0 0 0
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
30 Pemberian supositoria 13,000 6,900 6,100 0 0 0 0 0 0 0
31 Pemasangan elastis verban 46,000 40,000 6,000 0 0 0 0 0 0 0
32 Chlorethyl spray 21,700 14,200 7,500 0 0 0 0 0 0 0
33 Circumsisi non cauther 134,250 59,250 75,000 0 0 0 0 0 0 0
34 Circumsisi cauther 138,500 63,500 75,000 0 0 0 0 0 0 0
35 Reposisi Dawir 1 telinga 60,050 37,550 22,500 0 0 0 0 0 0 0
37 Luka bakar dibawah 10 % tanpa komplikasi 57,500 35,000 22,500 0 0 0 0 0 0 0
38 Luka bakar diatas 10 % tanpa komplikasi 143,600 68,600 75,000 0 0 0 0 0 0 0
39 Extirpasi (Minor Surgery ) 91,900 61,900 30,000 0 0 0 0 0 0 0
40 Ektrasi kuku (Per kuku) 48,200 25,700 22,500 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
42 Ekstraksi corpus alineum mata (per Mata) 34,100 11,600 22,500 0 0 0 0 0 0 0
43 Refraksi Mata 7,500 0 7,500 0 0 0 0 0 0 0
44 Hordeolum 39,100 9,100 30,000 0 0 0 0 0 0 0
45 Tonometri 27,500 5,000 22,500 0 0 0 0 0 0 0
46 Cerumen Prop (per Telinga) 17,500 2,500 15,000 0 0 0 0 0 0 0
47 Corpus Alienum THT 27,100 4,600 22,500 0 0 0 0 0 0 0
48 Pasang Spalk 58,300 35,800 22,500 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 40,000 10,000 30,000 0 0 0 0 0 0 0
51 Visum di Puskesmas 32,500 10,000 22,500 0 0 0 0 0 0 0
52 EKG 22,000 10,000 12,000 0 0 0 0 0 0 0
1 Partus Normal 345,200 95,200 250,000 0 0 0 0 0 0 0
2 Partus Gemelli 478,200 128,200 350,000 0 0 0 0 0 0 0
3 Induksi Persalinan 164,100 89,100 75,000 0 0 0 0 0 0 0
4 Jahit Luka Perineum (Jelujur) 88,400 48,400 40,000 0 0 0 0 0 0 0
5 Evakuasi Digital Placenta 61,700 31,700 30,000 0 0 0 0 0 0 0
6 Evakuasi Manual Placenta 96,500 46,500 50,000 0 0 0 0 0 0 0
7 Toucher/Kontrol IUD 37,500 17,500 20,000 0 0 0 0 0 0 0
8 Pemasangan IUD 76,800 26,800 50,000 0 0 0 0 0 0 0
9 Pelepasan IUD 50,300 20,300 30,000 0 0 0 0 0 0 0
10 Pemasangan dan Lepas IUD 96,800 26,800 70,000 0 0 0 0 0 0 0
11 Pemasangan Inplant 83,300 33,300 50,000 0 0 0 0 0 0 0
12 Pelepasan Impant 102,300 42,300 60,000 0 0 0 0 0 0 0
13 Pemasangan dan Lepas Inplant/Norplant 142,300 42,300 100,000 0 0 0 0 0 0 0
14 Pap Smear (Lab dan Transport) 86,900 66,900 20,000 0 0 0 0 0 0 0
14 IVA 29,200 9,200 20,000 0 0 0 0 0 0 0
15 Suntik KB 11,400 3,900 7,500 0 0 0 0 0 0 0
16 Perawatan Bayi Normal 73,400 23,400 50,000 0 0 0 0 0 0 0
17 Tindik 21,700 14,900 6,800 0 0 0 0 0 0 0
18 Dopler 10,000 5,000 5,000 0 0 0 0 0 0 0
18 Pra Rujukan Perdarahann PP 446,800 346,800 100,000 0 0 0 0 0 0 0
19 Antenatal care 15,000 5,000 10,000 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0
C. TINDAKAN PELAYANAN KESEHATAN GIGI DAN MULUT
1 Oral diagnostik/ konsultasi/ premedikasi 5,000 2,500 2,500 0 0 0 0 0 0 0
Pembersihan Karang Gigi per regio (total RA

2 39,500 18,500 21,000 0 0 0 0 0
dan RB = 6 regio) 0 0
3 Tumpatan Amalgam 46,000 33,500 12,500 0 0 0 0 0 0 0
4 Tumpatan GIC 1 permukaan 49,500 37,000 12,500 0 0 0 0 0 0 0
6 Tumpatan GIC lebih dari 2 permukaan 70,000 57,500 12,500 0 0 0 0 0 0 0
7 Tumpatan Komposit Light Cured (kecil/1 52,000 39,500 12,500 0 0 0 0 0

permukaan) 0 0
Tumpatan Komposit Light Cured (sedang/2
8 73,500 48,500 25,000 0 0 0 0 0
permukaan) 0 0
Tumpatan Komposit Light Cured
9 86,500 61,500 25,000 0 0 0 0 0
(besar/lebih dari 2 permukaan) 0 0
10 Perawatan Pulp Capping 26,500 17,750 8,750 0 0 0 0 0 0 0
11 Perawatan Syaraf A (Devitalisasi pulpa) 29,000 20,250 8,750 0 0 0 0 0 0 0
12 Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 21,250 8,750 0 0 0 0 0

0 0
13 Perawatan Syaraf C (Pengisian kamar pulpa) 35,500 26,750 8,750 0 0 0 0 0

0 0
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0
15 Pengambilan Tumpatan (Up Filling) 17,500 8,750 8,750 0 0 0 0 0 0 0
16 Koreksi Oklusi 30,500 18,000 12,500 0 0 0 0 0 0 0
17 Koreksi ulcus Decubitus 20,000 11,250 8,750 0 0 0 0 0 0 0
18 Pencabutan Gigi Decidui dengan topikal 20,000 11,250 8,750 0 0 0 0 0

anestesi 0 0
19 Pencabutan Gigi Decidui dengan citoject 28,500 19,750 8,750 0 0 0 0 0

0 0
20 Pencabutan Gigi Dewasa dg spuit dispossible 22,500 13,750 8,750 0 0 0 0 0

0 0
dengan penyulit 0 0
22 Pencabutan Gigi Dewasa dg citoject 50,000 23,000 27,000 0 0 0 0 0 0 0
23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 36,000 54,000 0 0 0 0 0

penyulit 0 0
24 Incisi Abses per regio 27,000 14,500 12,500 0 0 0 0 0 0 0
25 Perawatan Dry Socket 39,000 26,500 12,500 0 0 0 0 0 0 0
26 Operkulektomi 27,000 14,500 12,500 0 0 0 0 0 0 0
27 Operasi Gigi 165,000 77,500 87,500 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
29 Kontrol Post exo / op (Hecting Up) 17,000 4,500 12,500 0 0 0 0 0 0 0
30 Alveolectomy per regio 46,000 33,500 12,500 0 0 0 0 0 0 0
31 Reposisi Mandibula 60,000 10,000 50,000 0 0 0 0 0 0 0
32 Imobilisasi dengan komposit (3-5 gigi) 123,000 85,500 37,500 0 0 0 0 0 0 0
33 Gigi Tiruan Sebagian (harga per gigi blm 80,000 67,500 12,500 0 0 0 0 0 0 0
34 Jacket Crown Akrilik per unit 215,000 152,500 62,500 0 0 0 0 0 0 0
35 Jacket Porcelain fused to metal per unit 545,000 482,500 62,500 0 0 0 0 0 0 0
36 Reparasi gigi tiruan akrilik per rahang 140,000 115,000 25,000 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 52,000 37,000 15,000 0 0 0 0 0 0 0
2 30X40 2x 61,000 41,000 20,000 0 0 0 0 0 0 0
3 35X35 1x 54,000 39,000 15,000 0 0 0 0 0 0 0
4 35X35 2x 63,000 43,000 20,000 0 0 0 0 0 0 0
5 24X30 1x 44,000 29,000 15,000 0 0 0 0 0 0 0
6 24X30 2x 50,000 30,000 20,000 0 0 0 0 0 0 0
7 18X24 1x 41,000 26,000 15,000 0 0 0 0 0 0 0
8 18X24 2x 48,000 28,000 20,000 0 0 0 0 0 0 0
9 15X30 (OPG) 37,000 29,000 8,000 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 51,000 33,000 18,000 0 0 0 0 0 0 0
B. LABORATORIUM
1 Hb Sahli 4,000 2,000 2,000 0 0 0 0 0 0 0
2 AL 4,000 2,000 2,000 0 0 0 0 0 0 0
3 HJL ( Hitung Jenis Leukosit) 10,000 4,000 6,000 0 0 0 0 0 0 0
4 Malaria 10,000 4,000 6,000 0 0 0 0 0 0 0
5 LPB (Limposit Plasma Biru) 10,000 4,000 6,000 0 0 0 0 0 0 0
6 AE 7,500 3,500 4,000 0 0 0 0 0 0 0
7 KED 6,000 2,000 4,000 0 0 0 0 0 0 0
8 AT Rees Ecker 10,000 6,000 4,000 0 0 0 0 0 0 0
9 HMT 5,000 3,000 2,000 0 0 0 0 0 0 0
10 CT 7,000 3,000 4,000 0 0 0 0 0 0 0
11 BT 4,500 1,500 3,000 0 0 0 0 0 0 0
12 Golongan Darah 7,000 3,500 3,500 0 0 0 0 0 0 0
13 Protein Urine 5,000 3,000 2,000 0 0 0 0 0 0 0
14 Reduksi Urine 5,000 3,000 2,000 0 0 0 0 0 0 0
15 Sedimen 5,000 2,000 3,000 0 0 0 0 0 0 0
16 Faeses 10,000 2,000 8,000 0 0 0 0 0 0 0
17 Glukosa Stik 15,000 10,000 5,000 0 0 0 0 0 0 0
18 Asam urat Stik 20,000 15,000 5,000 0 0 0 0 0 0 0
19 Kolesterol Stik 25,000 20,000 5,000 0 0 0 0 0 0 0
20 Trigliserid Stik 30,000 25,000 5,000 0 0 0 0 0 0 0
21 HBs Ag Rapid Tes 25,000 20,000 5,000 0 0 0 0 0 0 0
22 Narkoba (untuk setiap jenis) 30,000 22,500 7,500 0 0 0 0 0 0 0
23 PP Test lateks 15,000 10,000 5,000 0 0 0 0 0 0 0
24 Hb Spektro 10,000 5,000 5,000 0 0 0 0 0 0 0
25 Glukosa spektro 15,000 8,000 7,000 0 0 0 0 0 0 0
26 Asam Urat Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
27 Kolesterol Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
28 Trigliserid Spektro 27,000 20,000 7,000 0 0 0 0 0 0 0
29 SGOT Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
30 SGPT Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
31 Ureum Spektro 20,000 13,000 7,000 0 0 0 0 0 0 0
32 Kreatinin Spektro 20,000 13,000 7,000 0 0 0 0 0 0 0
33 Widal 20,000 15,000 5,000 0 0 0 0 0 0 0
34 Darah Lengkap Otomatis (DLO) 40,000 20,000 20,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 15,000 10,000 5,000 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 30,000 25,000 5,000 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0
49 Sampling Darah Kapiler 2,000 - 2,000 0 0 0 0 0 0 0
50 Sampling Darah Vena 5,000 - 5,000 0 0 0 0 0 0 0

1 Terapi Latihan Kecil 8,000 2,000 6,000 0 0 0 0 0 0 0
2 Terapi Latihan Sedang 12,000 2,000 10,000 0 0 0 0 0 0 0
3 Terapi Latihan Besar 17,000 2,000 15,000 0 0 0 0 0 0 0
4 Massage Bayi 12,000 2,000 10,000 0 0 0 0 0 0 0
5 Massage dewasa 15,000 2,000 13,000 0 0 0 0 0 0 0
6 Infra Red 9,000 6,000 3,000 0 0 0 0 0 0 0
7 TENS 10,000 6,000 4,000 0 0 0 0 0 0 0
8 Elektrical Stimulation (ES) 10,000 6,000 4,000 0 0 0 0 0 0 0
9 Static bycicle lamanya 10,000 5,000 5,000 0 0 0 0 0 0 0
11 Senam Hamil/Nifas/asma/DM dll 5,000 1,000 4,000 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
14 Short Wave Diathermy 15,150 8,150 7,000 0 0 0 0 0 0 0
15 Micro Wave Diathermy 14,000 8,000 6,000 0 0 0 0 0 0 0
16 Terapi Manipulasi 12,000 - 12,000 0 0 0 0 0 0 0
17 Ice Massage 10,000 5,000 5,000 0 0 0 0 0 0 0
18 Traksi Cervical/Lumbal elektrik 14,000 8,000 6,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
23 Shoulder wheel/Pulley/wallbar 8,000 2,000 6,000 0 0 0 0 0 0 0
24 Latihan transfer dan ambulasi menggunakan 4,000 - 4,000 0 0 0 0 0 0 0

alat jalan (Kruk/Walker/Tripot)
25 Pemasangan/fitting orthosis 4,500 1,500 3,000 0 0 0 0 0 0 0

26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0

1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
A. TINDAKAN
1 inspekulo pervaginam 26,000 16,000 10,000 0 0 0 0 0 0 0
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0
3 pengambilan duh urethra 8,000 2,500 5,500 0 0 0 0 0 0 0
B. PEMERIKSAAN LABORATORIUM
1 Pemeriksaan basah duh tubuh servik, duh 5,000 4,000 1,000 0 0 0 0 0 0 0
tubuh vagina dan duh tubuh urethra
2 Pemeriksaan kering duh tubuh anus 4,500 3,000 1,500 0 0 0 0 0 0 0
3 Pemeriksaan sipilis Rapid test 25,000 20,000 5,000 0 0 0 0 0 0 0
4 Pemeriksaan sipilis RPR 30,000 25,000 5,000 0 0 0 0 0 0 0
5 Rapid test HIV 70,000 50,000 20,000 0 0 0 0 0 0 0

1 Dalam Kabupaten
sampai dg 5 km pertama 65,000 35,000 30,000 0 0 0 0 0 0 0
> 5 km biaya per kilometer 5,000 0 0 0 0 0 0 0
2 Luar Kabupaten
1 Pemeriksaan Kesehatan 7,500 7,500 0 0 0 0 0 0 0

2 Pemeriksaan Dokter Spesialis 22,500 22,500 0 0 0 0 0 0 0
3 Tes Buta Warna 7,500 7,500 0 0 0 0 0 0 0
4 Konsultasi Kesehatan 7,500 7,500 0 0 0 0 0 0 0
5 BUKU KIA tiap Buku 12,000 12,000 - 0 0 0 0 0 0 0
6 Home Care (per petugas) 20,000 20,000 0 0 0 0 0 0 0
7 Tes kebugaran CJH 42,500 8,000 34,500 0 0 0 0 0 0 0
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0
1 Praktek Klinik per minggu 0 0 0 0 0 0 0

a. profesi 30,000 Rp 10,500 19,500 0 0 0 0 0 0 0
b. D4/S1 26,500 Rp 9,275 17,225 0 0 0 0 0 0 0
c. D3 22,500 Rp 7,875 14,625 0 0 0 0 0 0 0
2 Praktek non Klinik per minggu 0 0 0 0 0 0 0
a. profesi 25,000 Rp 8,750 16,250 0 0 0 0 0 0 0
b. D4/S1 20,000 Rp 7,000 13,000 0 0 0 0 0 0 0
c. D3 18,000 Rp 6,000 12,000 0 0 0 0 0 0 0
d SMA/SMK
3 Penelitian
a. Profesi (S2/S3) 250,000 Rp 87,500 162,500 0 0 0 0 0 0 0
b. D4/S1 200,000 Rp 70,000 130,000 0 0 0 0 0 0 0
c. D3 100,000 Rp 35,000 65,000 0 0 0 0 0 0 0
pendahuluan (1 paket) di puskesmas -
4 Pelayanan Studi banding 0 0 0 0 0 0 0

a. narasumber(perJPL/org) 250,000 250,000 0 0 0 0 0 0 0
b. Sarana Prasarana 0 0 0 0 0 0 0
- konsumsi/orang 37,000 Rp 37,000.00 0 0 0 0 0 0 0
- jasa sarana perpaket 200,000 Rp 200,000.00 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0
17400
6600
Bulan
TARIF PENDAPATAN
JUMLAH
LAYANAN UNIT JASA JASA
NO JENIS PELAYANAN
PENDUDUK COST
OBAT
LAYANAN
KUNJUNG PENDAPATA UNIT PUSKESMAS PENGEMBA DINAS KET
AN OBAT PELAYANA
BANTUL N COST 75% NGAN 15% 10%
N
- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0

1 Injeksi 5,800 3,150 2,650 0 0 0 0 0 0 0
3 Skin test 6,050 3,850 2,200 0 0 0 0 0 0 0
4 Pasang infus (mikro set) 34,100 42,200 (8,100) 0 0 0 0 0 0 0
6 Pelepasan infus 5,200 2,150 3,050 0 0 0 0 0 0 0
7 Perbaikan infus 13,450 5,950 7,500 0 0 0 0 0 0 0
8 Pasang kateter+urinbag 40,700 55,600 (14,900) 0 0 0 0 0 0 0
10 Lavement 22,800 16,700 6,100 0 0 0 0 0 0 0
11 Resusitasi 25,250 33,750 (8,500) 0 0 0 0 0 0 0
12 Pemasangan Oksigen 8,600 9,000 (400) 0 0 0 0 0 0 0
13 Oksigenasi (per liter per menit) 40 75 (35) 0 0 0 0 0 0 0
14 Pasang NGT 44,500 26,000 18,500 0 0 0 0 0 0 0
15 Scorstein 24,750 22,100 2,650 0 0 0 0 0 0 0
16 Rectal Toucher 11,550 10,250 1,300 0 0 0 0 0 0 0
17 Nebulizer 24,800 20,200 4,600 0 0 0 0 0 0 0
a. Kecil 16,350 11,600 4,750 0 0 0 0 0 0 0
b, Sedang 33,500 21,000 12,500 0 0 0 0 0 0 0
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
19 Debridemen sederhana 26,200 30,000 (3,800) 0 0 0 0 0 0 0
21 Hecting 1 sampai 5 39,050 49,000 (9,950) 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 58,600 68,400 (9,800) 0 0 0 0 0 0 0
24 Ambil jahitan 16,550 6,200 10,350 0 0 0 0 0 0 0
25 Insisi / Eksisi 29,000 40,700 (11,700) 0 0 0 0 0 0 0
26 Cross incisi 19,450 17,800 1,650 0 0 0 0 0 0 0
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
32 Chlorethyl spray 15,000 14,200 800 0 0 0 0 0 0 0
39 Extirpasi (Minor Surgery ) 51,600 61,900 (10,300) 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
43 Refraksi Mata 5,000 0 5,000 0 0 0 0 0 0 0
44 Hordeolum 26,150 9,100 17,050 0 0 0 0 0 0 0
45 Tonometri 18,500 5,000 13,500 0 0 0 0 0 0 0
48 Pasang Spalk 38,400 35,800 2,600 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 20,000 10,000 10,000 0 0 0 0 0 0 0
52 EKG 18,000 10,000 8,000 0 0 0 0 0 0 0
1 Partus Normal 216,100 95,200 120,900 0 0 0 0 0 0 0
2 Partus Gemelli 272,800 128,200 144,600 0 0 0 0 0 0 0
3 Induksi Persalinan 69,300 89,100 (19,800) 0 0 0 0 0 0 0
4 Jahit Luka Perineum (Jelujur) 39,500 48,400 (8,900) 0 0 0 0 0 0 0
5 Evakuasi Digital Placenta 26,750 31,700 (4,950) 0 0 0 0 0 0 0
8 Pemasangan IUD 26,250 26,800 (550) 0 0 0 0 0 0 0
9 Pelepasan IUD 25,750 20,300 5,450 0 0 0 0 0 0 0
11 Pemasangan Inplant 30,450 33,300 (2,850) 0 0 0 0 0 0 0
12 Pelepasan Impant 30,450 42,300 (11,850) 0 0 0 0 0 0 0
14 Pap Smear (Lab dan Transport) 21,500 66,900 (45,400) 0 0 0 0 0 0 0
14 IVA 25,500 9,200 16,300 0 0 0 0 0 0 0
15 Suntik KB 5,800 3,900 1,900 0 0 0 0 0 0 0
17 Tindik 6,400 14,900 (8,500) 0 0 0 0 0 0 0
18 Dopler 5,000 5,000 - 0 0 0 0 0 0 0
19 Antenatal care 0 5,000 (5,000) 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0
2 dan RB = 6 regio) 13,750 18,500 (4,750) 0 0 0 0 0 0 0
3 Tumpatan Amalgam 18,400 33,500 (15,100) 0 0 0 0 0 0 0

4 Tumpatan GIC 1 permukaan 24,300 37,000 (12,700) 0 0 0 0 0 0 0
6 Tumpatan GIC lebih dari 2 permukaan 24,300 57,500 (33,200) 0 0 0 0 0 0 0
7 Tumpatan Komposit Light Cured (kecil/1 21,550 39,500 (17,950) 0 0 0 0 0 0 0

permukaan)
8 Tumpatan Komposit Light Cured (sedang/2 38,900 48,500 (9,600) 0 0 0 0 0 0 0

permukaan)
9 (besar/lebih 45,950 61,500 (15,550) 0 0 0 0 0 0 0
dari 2 permukaan)
10 Perawatan Pulp Capping 12,200 17,750 (5,550) 0 0 0 0 0 0 0
11 Perawatan Syaraf A (Devitalisasi pulpa) 15,000 20,250 (5,250) 0 0 0 0 0 0 0
12 Perawatan Saraf B (Sterilisasi kamar pulpa) 14,300 21,250 (6,950) 0 0 0 0 0 0 0
13 Perawatan Syaraf C (Pengisian kamar pulpa) 15,800 26,750 (10,950) 0 0 0 0 0 0 0
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0

16 Koreksi Oklusi 12,800 18,000 (5,200) 0 0 0 0 0 0 0
18 Pencabutan Gigi Decidui dengan topikal 10,600 11,250 (650) 0 0 0 0 0 0 0

anestesi
19 Pencabutan Gigi Decidui dengan citoject 10,600 19,750 (9,150) 0 0 0 0 0 0 0
20 Pencabutan Gigi Dewasa dg spuit dispossible 12,100 13,750 (1,650) 0 0 0 0 0 0 0
21 Pencabutan Gigi Dewasa dg spuit dispossible 29,350 21,500 7,850 0 0 0 0 0 0 0

dengan penyulit
23 Pencabutan Gigi Dewasa dg citoject dengan 29,350 36,000 (6,650) 0 0 0 0 0 0 0
penyulit
26 Operkulektomi 16,150 14,500 1,650 0 0 0 0 0 0 0
27 Operasi Gigi 86,250 77,500 8,750 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
33 Gigi Tiruan Sebagian (harga per gigi blm 65,600 67,500 (1,900) 0 0 0 0 0 0 0
34 Jacket Crown Akrilik per unit 127,100 152,500 (25,400) 0 0 0 0 0 0 0
35 Jacket Porcelain fused to metal per unit 247,100 482,500 (235,400) 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 40,000 37,000 3,000 0 0 0 0 0 0 0
2 30X40 2x 50,000 41,000 9,000 0 0 0 0 0 0 0
3 35X35 1x 35,000 39,000 (4,000) 0 0 0 0 0 0 0
4 35X35 2x 45,000 43,000 2,000 0 0 0 0 0 0 0
5 24X30 1x 30,000 29,000 1,000 0 0 0 0 0 0 0
6 24X30 2x 40,000 30,000 10,000 0 0 0 0 0 0 0
7 18X24 1x 30,000 26,000 4,000 0 0 0 0 0 0 0
8 18X24 2x 40,000 28,000 12,000 0 0 0 0 0 0 0
9 15X30 (OPG) 24,000 29,000 (5,000) 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 45,000 33,000 12,000 0 0 0 0 0 0 0
B. LABORATORIUM
1 Hb Sahli 2,150 2,000 150 0 0 0 0 0 0 0
2 AL 2,950 2,000 950 0 0 0 0 0 0 0
3 HJL ( Hitung Jenis Leukosit) 4,700 4,000 700 0 0 0 0 0 0 0
4 Malaria 4,700 4,000 700 0 0 0 0 0 0 0
5 LPB (Limposit Plasma Biru) 4,700 4,000 700 0 0 0 0 0 0 0
6 AE 4,750 3,500 1,250 0 0 0 0 0 0 0
7 KED 2,600 2,000 600 0 0 0 0 0 0 0
8 AT Rees Ecker 7,000 6,000 1,000 0 0 0 0 0 0 0
9 HMT 3,050 3,000 50 0 0 0 0 0 0 0
10 CT 3,000 3,000 - 0 0 0 0 0 0 0
11 BT 2,550 1,500 1,050 0 0 0 0 0 0 0
12 Golongan Darah 4,900 3,500 1,400 0 0 0 0 0 0 0
13 Protein Urine 3,600 3,000 600 0 0 0 0 0 0 0
14 Reduksi Urine 3,600 3,000 600 0 0 0 0 0 0 0
15 Sedimen 3,850 2,000 1,850 0 0 0 0 0 0 0
16 Faeses 4,150 2,000 2,150 0 0 0 0 0 0 0
17 Glukosa Stik 12,450 10,000 2,450 0 0 0 0 0 0 0
18 Asam urat Stik 18,950 15,000 3,950 0 0 0 0 0 0 0
19 Kolesterol Stik 24,350 20,000 4,350 0 0 0 0 0 0 0
21 HBs Ag Rapid Tes 23,000 20,000 3,000 0 0 0 0 0 0 0
23 PP Test lateks 13,600 10,000 3,600 0 0 0 0 0 0 0
24 Hb Spektro 7,900 5,000 2,900 0 0 0 0 0 0 0
25 Glukosa spektro 13,400 8,000 5,400 0 0 0 0 0 0 0
28 Trigliserid Spektro 18,300 20,000 (1,700) 0 0 0 0 0 0 0
29 SGOT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
30 SGPT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
31 Ureum Spektro 13,600 13,000 600 0 0 0 0 0 0 0
32 Kreatinin Spektro 13,600 13,000 600 0 0 0 0 0 0 0
33 Widal 16,000 15,000 1,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 8,000 10,000 (2,000) 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 25,000 25,000 - 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0

4 Massage Bayi 2,950 2,000 950 0 0 0 0 0 0 0
5 Massage dewasa 3,000 2,000 1,000 0 0 0 0 0 0 0
6 Infra Red 7,150 6,000 1,150 0 0 0 0 0 0 0
7 TENS 6,200 6,000 200 0 0 0 0 0 0 0
8 Elektrical Stimulation (ES) 6,000 6,000 - 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
17 Ice Massage 7,000 5,000 2,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0


26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
A. TINDAKAN
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0

2 Pemeriksaan kering duh tubuh anus 2,000 3,000 (1,000) 0 0 0 0 0 0 0
3 Pemeriksaan sipilis Rapid test 17,000 20,000 (3,000) 0 0 0 0 0 0 0
4 Pemeriksaan sipilis RPR 25,000 25,000 - 0 0 0 0 0 0 0
5 Rapid test HIV 6,000 50,000 (44,000) 0 0 0 0 0 0 0
1 Dalam Kabupaten
> 5 km biaya per kilometer 5,000 - 0 0 0 0 0 0 0
2 Luar Kabupaten -
-
G. TARIF PELAYANAN KESEHATAN LAINNYA -
-
3 Tes Buta Warna 5,000 5,000 0 0 0 0 0 0 0
5 BUKU KIA tiap Buku 6,500 12,000 (5,500) 0 0 0 0 0 0 0
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0

a. profesi 30,000 10,500 19,500 0 0 0 0 0 0 0
b. D4/S1 26,500 9,275 17,225 0 0 0 0 0 0 0
c. D3 22,500 7,875 14,625 0 0 0 0 0 0 0
2 Praktek non Klinik per minggu - -
a. profesi 25,000 8,750 16,250 0 0 0 0 0 0 0
b. D4/S1 20,000 7,000 13,000 0 0 0 0 0 0 0
c. D3 18,000 6,000 12,000 0 0 0 0 0 0 0
d SMA/SMK - - 0 0 0 0 0 0 0
3 Penelitian - -
a. Profesi (S2/S3) 250,000 87,500 162,500 0 0 0 0 0 0 0
b. D4/S1 200,000 70,000 130,000 0 0 0 0 0 0 0
c. D3 100,000 35,000 65,000 0 0 0 0 0 0 0
4 Pelayanan Studi banding - - 0 0 0 0 0 0 0
b. Sarana Prasarana - - 0 0 0 0 0 0 0
- konsumsi/orang 37,000 ### - 0 0 0 0 0 0 0
- jasa sarana perpaket 200,000 ### - 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0
17400
6600
DAFTAR TARIF LAYANAN KESEHATAN BLUD PUSKESMAS
PERBUP BUPATI BANTUL NO 45 TAHUN 2016
A. TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI
TARIF SUBSIDI TARIF TARIF LUAR

NO JENIS PELAYANAN PERBUP NO (PERBUP 49 TH BANTUL BANTUL
45 TH 2016 2016)
A TINDAKAN MEDIS UMUM
1 Injeksi 9,500 3,700 5,800 9,500
3 Skin test 10,500 4,450 6,050 10,500
6 Pelepasan infus 8,500 3,300 5,200 8,500
7 Perbaikan infus 18,500 5,050 13,450 18,500
10 Lavement 35,500 12,700 22,800 35,500
11 Resusitasi 59,000 33,750 25,250 59,000
14 Pasang NGT 51,000 6,500 44,500 51,000
15 Scorstein 35,000 10,250 24,750 35,000
16 Rectal Toucher 16,500 4,950 11,550 16,500
17 Nebulizer 39,000 14,200 24,800 39,000
a. Kecil 22,000 5,650 16,350 22,000
b, Sedang 33,500 0 33,500 33,500
c. Besar 56,000 0 56,000 56,000
21 Hecting 1 sampai 5 61,500 22,450 39,050 61,500
22 Hecting 6 sampai 10 87,500 28,900 58,600 87,500
24 Ambil jahitan 19,000 2,450 16,550 19,000
25 Insisi / Eksisi 59,500 30,500 29,000 59,500
26 Cross incisi 30,500 11,050 19,450 30,500
27 Bilas lambung 152,500 0 152,500 152,500
28 Suction lendir 34,500 0 34,500 34,500
29 Irigasi mata 33,000 0 33,000 33,000
41 ATS 234,450 0 234,450 234,450
43 Refraksi Mata 7,500 2,500 5,000 7,500
44 Hordeolum 39,100 12,950 26,150 39,100
45 Tonometri 27,500 9,000 18,500 27,500
48 Pasang Spalk 58,300 19,900 38,400 58,300
49 Pasang Tampon 30,500 0 30,500 30,500
50 Visum di TKP 40,000 20,000 20,000 40,000
52 EKG 22,000 4,000 18,000 22,000
53 Tes Buta Warna 7,500 2,500 5,000 7,500
56 Poli Sore 11,000 0 11,000 11,000
45 TH 2016 2016)
1 Partus Normal 345,200 129,100 216,100 345,200
2 Partus Gemelli 478,200 205,400 272,800 478,200
3 Induksi Persalinan 164,100 94,800 69,300 164,100
4 Jahit Luka Perineum (Jelujur) 88,400 48,900 39,500 88,400
5 Evakuasi Digital Placenta 61,700 34,950 26,750 61,700
6 Evakuasi Manual Placenta 96,500 35,000 61,500 96,500
8 Pemasangan IUD 76,800 50,550 26,250 76,800
9 Pelepasan IUD 50,300 24,550 25,750 50,300
14 IVA 29,200 3,700 25,500 29,200
15 Suntik KB 11,400 5,600 5,800 11,400
17 Tindik 21,700 15,300 6,400 21,700
18 Dopler 10,000 5,000 5,000 10,000
19 Antenatal care 15,000 15,000 0 15,000
20 Post natal care 25,000 0 25,000 25,000
21 Krioterapi 150,000 0 150,000 150,000
24 Tes Buta Warna 7,500 2,500 5,000 7,500
29 Poli Sore 11,000 0 11,000 11,000
30 Injeksi 9,500 3,700 5,800 9,500
32 Skin test 10,500 4,450 6,050 10,500
35 Hecting 1 sampai 5 61,500 22,450 39,050 61,500
36 Hecting 6 sampai 10 87,500 28,900 58,600 87,500
37 Ambil jahitan 19,000 2,450 16,550 19,000
45 TH 2016 2016)
Pembersihan Karang Gigi per regio (total RA 39,500 25,750 13,750 39,500
2 dan RB = 6 regio)
7 Tumpatan Komposit Light Cured (kecil/1 52,000 30,450 21,550 52,000

permukaan)
Tumpatan Komposit Light Cured (sedang/2 73,500 34,600 38,900 73,500
8 permukaan)
9 dari 86,500 40,550 45,950 86,500
2 permukaan)
Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 15,700 14,300 30,000
12
14 Trepanasi gigi 19,000 0 19,000 19,000

16 Koreksi Oklusi 30,500 17,700 12,800 30,500
Pencabutan Gigi Decidui dengan topikal 20,000 9,400 10,600 20,000
18 anestesi
Pencabutan Gigi Dewasa dg spuit dispossible 22,500 10,400 12,100 22,500

20
dengan penyulit
23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 60,650 29,350 90,000

penyulit
26 Operkulektomi 27,000 10,850 16,150 27,000
27 Operasi Gigi 165,000 78,750 86,250 165,000
28 Hecting oral 40,000 0 40,000 40,000
33 Gigi Tiruan Sebagian (harga per gigi blm 80,000 14,400 65,600 80,000
B. TARIF RETRIBUSI PELAYANAN PENUNJANG DIAGNOSIS

45 TH 2016 2016)
A. RADIOLOGI
1 30X40 1x 52,000 12,000 40,000 52,000
2 30X40 2x 61,000 11,000 50,000 61,000
3 35X35 1x 54,000 19,000 35,000 54,000
4 35X35 2x 63,000 18,000 45,000 63,000
5 24X30 1x 44,000 14,000 30,000 44,000
6 24X30 2x 50,000 10,000 40,000 50,000
7 18X24 1x 41,000 11,000 30,000 41,000
8 18X24 2x 48,000 8,000 40,000 48,000
9 15X30 (OPG) 37,000 13,000 24,000 37,000
10 USG (Print 1 lbr) 51,000 6,000 45,000 51,000

45 TH 2016 2016)
B. LABORATORIUM
1 Hb Sahli 4,000 1,850 2,150 4,000
2 AL 4,000 1,050 2,950 4,000
3 HJL ( Hitung Jenis Leukosit) 10,000 5,300 4,700 10,000
4 Malaria 10,000 5,300 4,700 10,000
5 LPB (Limposit Plasma Biru) 10,000 5,300 4,700 10,000
6 AE 7,500 2,750 4,750 7,500
7 KED 6,000 3,400 2,600 6,000
8 AT Rees Ecker 10,000 3,000 7,000 10,000
9 HMT 5,000 1,950 3,050 5,000
10 CT 7,000 4,000 3,000 7,000
11 BT 4,500 1,950 2,550 4,500
12 Golongan Darah 7,000 2,100 4,900 7,000
13 Protein Urine 5,000 1,400 3,600 5,000
14 Reduksi Urine 5,000 1,400 3,600 5,000
15 Sedimen 5,000 1,150 3,850 5,000
16 Faeses 10,000 5,850 4,150 10,000
17 Glukosa Stik 15,000 2,550 12,450 15,000
18 Asam urat Stik 20,000 1,050 18,950 20,000
19 Kolesterol Stik 25,000 650 24,350 25,000
20 Trigliserid Stik 30,000 2,300 27,700 30,000
21 HBs Ag Rapid Tes 25,000 2,000 23,000 25,000
22 Narkoba (untuk setiap jenis) 30,000 5,650 24,350 30,000
23 PP Test lateks 15,000 1,400 13,600 15,000
24 Hb Spektro 10,000 2,100 7,900 10,000
25 Glukosa spektro 15,000 1,600 13,400 15,000
26 Asam Urat Spektro 22,000 5,100 16,900 22,000
27 Kolesterol Spektro 22,000 4,900 17,100 22,000
28 Trigliserid Spektro 27,000 8,700 18,300 27,000
29 SGOT Spektro 22,000 5,100 16,900 22,000
30 SGPT Spektro 22,000 5,100 16,900 22,000
31 Ureum Spektro 20,000 6,400 13,600 20,000
32 Kreatinin Spektro 20,000 6,400 13,600 20,000

45 TH 2016 2016)
33 Widal 20,000 4,000 16,000 20,000

34 Darah Lengkap Otomatis (DLO) 40,000 0 40,000 40,000
35 Hb/Hmt Stik 15,000 7,000 8,000 15,000
36 Rhesus 7,000 0 7,000 7,000
37 NS1 110,000 0 110,000 110,000
38 IgG/IgM Dengue 110,000 0 110,000 110,000
39 HIV 70,000 0 70,000 70,000
40 syphilis RPR 25,000 0 25,000 25,000
41 syphilis RPR 30,000 0 30,000 30,000
42 Leptotek 80,000 0 80,000 80,000
43 Gonorhoe (GO) 15,000 0 15,000 15,000
44 Jamur 10,000 0 10,000 10,000
45 BTA 20,000 0 20,000 20,000
46 Stik urine 10 P 10,000 0 10,000 10,000
47 Urine Rutin 15,000 0 15,000 15,000
48 Urine Lengkap 20,000 0 20,000 20,000
49 Sampling Darah Kapiler 2,000 0 2,000 2,000
50 Sampling Darah Vena 5,000 0 5,000 5,000

45 TH 2016 2016)
1 Terapi Latihan Kecil 8,000 2,500 5,500 8,000
2 Terapi Latihan Sedang 12,000 2,800 9,200 12,000
3 Terapi Latihan Besar 17,000 6,300 10,700 17,000
4 Massage Bayi 12,000 9,050 2,950 12,000
5 Massage dewasa 15,000 12,000 3,000 15,000
6 Infra Red 9,000 1,850 7,150 9,000
7 TENS 10,000 3,800 6,200 10,000
8 Elektrical Stimulation (ES) 10,000 4,000 6,000 10,000
9 Static bycicle lamanya 10,000 2,500 7,500 10,000
11 Senam Hamil/Nifas/asma/DM dll 5,000 1,650 3,350 5,000
12 Ultra Sound (US) 11,500 0 11,500 11,500
13 Chest Therapy 6,000 0 6,000 6,000
14 Short Wave Diathermy 15,150 0 15,150 15,150
15 Micro Wave Diathermy 14,000 0 14,000 14,000
16 Terapi Manipulasi 12,000 1,000 11,000 12,000
17 Ice Massage 10,000 3,000 7,000 10,000
18 Traksi Cervical/Lumbal elektrik 14,000 0 14,000 14,000
19 Cold Pack 13,000 0 13,000 13,000
20 Hot Pack 13,000 0 13,000 13,000
21 Pararel Bar 8,000 0 8,000 8,000
22 Standing Bar 8,000 0 8,000 8,000
23 Shoulder wheel/Pulley/wallbar 8,000 0 8,000 8,000
24 Latihan transfer dan ambulasi menggunakan 4,000 0 4,000 4,000

25 Pemasangan/fitting orthosis 4,500 0 4,500 4,500

26 Parafin bath 22,500 0 22,500 22,500
TARIF SUBSIDI
PERBUP NO (PERBUP 49 THTARIF BANTULTARIF LUAR
NO JENIS PELAYANAN BANTUL
45 TH 2016 2016)
1 Akupresur 17,000 0 17,000 17,000
2 Akupuntur 40,000 0 40,000 40,000

45 TH 2016 2016)
A.TINDAKAN
1 inspekulo pervaginam 26,000 0 26,000 26,000
2 Rectal toucher 12,000 0 12,000 12,000
3 pengambilan duh urethra 8,000 0 8,000 8,000
B.PEMERIKSAAN LABORATORIUM
1 Pemeriksaan basah duh tubuh servik, duh 5,000 0 5,000 5,000
2 Pemeriksaan kering duh tubuh anus 4,500 2,500 2,000 4,500
3 Pemeriksaan sipilis Rapid test 25,000 8,000 17,000 25,000
4 Pemeriksaan sipilis RPR 30,000 5,000 25,000 30,000
5 Rapid test HIV 70,000 64,000 6,000 70,000

45 TH 2016 2016)
1 Dalam Kabupaten
2 Luar Kabupaten

45 TH 2016 2016)
3 Tes Buta Warna 7,500 2,500 5,000 7,500
8 Poli Sore 11,000 0 11,000 11,000

45 TH 2016 2016)
a. profesi 30,000 0 30,000 30,000
b. D4/S1 26,500 0 26,500 26,500
c. D3 22,500 0 22,500 22,500
2 Praktek non Klinik per minggu
a. profesi 25,000 0 25,000 25,000
b. D4/S1 20,000 0 20,000 20,000
c. D3 18,000 0 18,000 18,000
d SMA/SMK
3 Penelitian
a. Profesi (S2/S3) 250,000 0 250,000 250,000
b. D4/S1 200,000 0 200,000 200,000
c. D3 100,000 0 100,000 100,000
4 Pelayanan Studi banding
a. narasumber(perJPL/org) 250,000 0 250,000 250,000
b. Sarana Prasarana
- konsumsi/orang 37,000 0 37,000 37,000
- jasa sarana perpaket 200,000 0 200,000 200,000
I. TARIF PELAYANAN RAWAT INAP

JENIS PELAYANAN PERBUP NO (PERBUP 49 TH
NO BANTUL BANTUL
45 TH 2016 2016)
1 Rawat Inap Umum 74,000 10,500 63,500 74,000
2 Rawat Inap Utama 185,000 0 185,000 185,000
l
Bulan
TARIF
LAYANAN JUMLAH PENDAPATAN
JASA
NO JENIS PELAYANAN PENDUDUK UNIT COST OBAT
LAYANAN
KUNJUNG JASA PENGEMB KET
LUAR AN PENDAPAT UNIT PUSKESMAS DINAS
OBAT PELAYANA ANGAN
BANTUL AN COST 75% 10%
N 15%
- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0

1 Injeksi 9,500 3,150 6,350 0 0 0 0 0 0 0
3 Skin test 10,500 3,850 6,650 0 0 0 0 0 0 0
4 Pasang infus (mikro set) 61,000 42,200 18,800 0 0 0 0 0 0 0
6 Pelepasan infus 8,500 2,150 6,350 0 0 0 0 0 0 0
7 Perbaikan infus 18,500 5,950 12,550 0 0 0 0 0 0 0
8 Pasang kateter+urinbag 75,500 55,600 19,900 0 0 0 0 0 0 0
10 Lavement 35,500 16,700 18,800 0 0 0 0 0 0 0
11 Resusitasi 59,000 33,750 25,250 0 0 0 0 0 0 0
12 Pemasangan Oksigen 15,500 9,000 6,500 0 0 0 0 0 0 0
13 Oksigenasi (per liter per menit) 75 75 0 0 0 0 0 0 0 0
14 Pasang NGT 51,000 26,000 25,000 0 0 0 0 0 0 0
15 Scorstein 35,000 22,100 12,900 0 0 0 0 0 0 0
16 Rectal Toucher 16,500 10,250 6,250 0 0 0 0 0 0 0
17 Nebulizer 39,000 20,200 18,800 0 0 0 0 0 0 0
a. Kecil 22,000 11,600 10,400 0 0 0 0 0 0 0
b, Sedang 33,500 21,000 12,500 0 0 0 0 0 0 0
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
19 Debridemen sederhana 49,000 30,000 19,000 0 0 0 0 0 0 0
21 Hecting 1 sampai 5 61,500 49,000 12,500 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 87,500 68,400 19,100 0 0 0 0 0 0 0
24 Ambil jahitan 19,000 6,200 12,800 0 0 0 0 0 0 0
25 Insisi / Eksisi 59,500 40,700 18,800 0 0 0 0 0 0 0
26 Cross incisi 30,500 17,800 12,700 0 0 0 0 0 0 0
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
32 Chlorethyl spray 21,700 14,200 7,500 0 0 0 0 0 0 0
39 Extirpasi (Minor Surgery ) 91,900 61,900 30,000 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
43 Refraksi Mata 7,500 0 7,500 0 0 0 0 0 0 0
44 Hordeolum 39,100 9,100 30,000 0 0 0 0 0 0 0
45 Tonometri 27,500 5,000 22,500 0 0 0 0 0 0 0
48 Pasang Spalk 58,300 35,800 22,500 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 40,000 10,000 30,000 0 0 0 0 0 0 0
52 EKG 22,000 10,000 12,000 0 0 0 0 0 0 0
1 Partus Normal 345,200 95,200 250,000 0 0 0 0 0 0 0
2 Partus Gemelli 478,200 128,200 350,000 0 0 0 0 0 0 0
3 Induksi Persalinan 164,100 89,100 75,000 0 0 0 0 0 0 0
4 Jahit Luka Perineum (Jelujur) 88,400 48,400 40,000 0 0 0 0 0 0 0
5 Evakuasi Digital Placenta 61,700 31,700 30,000 0 0 0 0 0 0 0
8 Pemasangan IUD 76,800 26,800 50,000 0 0 0 0 0 0 0
9 Pelepasan IUD 50,300 20,300 30,000 0 0 0 0 0 0 0
11 Pemasangan Inplant 83,300 33,300 50,000 0 0 0 0 0 0 0
12 Pelepasan Impant 102,300 42,300 60,000 0 0 0 0 0 0 0
14 Pap Smear (Lab dan Transport) 86,900 66,900 20,000 0 0 0 0 0 0 0
14 IVA 29,200 9,200 20,000 0 0 0 0 0 0 0
15 Suntik KB 11,400 3,900 7,500 0 0 0 0 0 0 0
17 Tindik 21,700 14,900 6,800 0 0 0 0 0 0 0
18 Dopler 10,000 5,000 5,000 0 0 0 0 0 0 0
19 Antenatal care 15,000 5,000 10,000 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0

2 39,500 18,500 21,000 0 0 0 0 0
dan RB = 6 regio) 0 0
3 Tumpatan Amalgam 46,000 33,500 12,500 0 0 0 0 0 0 0
6 Tumpatan GIC lebih dari 2 permukaan 70,000 57,500 12,500 0 0 0 0 0 0 0
7 Tumpatan Komposit Light Cured (kecil/1 52,000 39,500 12,500 0 0 0 0 0

permukaan) 0 0
8 73,500 48,500 25,000 0 0 0 0 0
permukaan) 0 0
9 86,500 61,500 25,000 0 0 0 0 0
(besar/lebih dari 2 permukaan) 0 0
10 Perawatan Pulp Capping 26,500 17,750 8,750 0 0 0 0 0 0 0
11 Perawatan Syaraf A (Devitalisasi pulpa) 29,000 20,250 8,750 0 0 0 0 0 0 0
12 Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 21,250 8,750 0 0 0 0 0

0 0
13 Perawatan Syaraf C (Pengisian kamar pulpa) 35,500 26,750 8,750 0 0 0 0 0

0 0
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0
16 Koreksi Oklusi 30,500 18,000 12,500 0 0 0 0 0 0 0
18 Pencabutan Gigi Decidui dengan topikal 20,000 11,250 8,750 0 0 0 0 0

anestesi 0 0
19 Pencabutan Gigi Decidui dengan citoject 28,500 19,750 8,750 0 0 0 0 0

0 0

0 0
dengan penyulit 0 0
23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 36,000 54,000 0 0 0 0 0

penyulit 0 0
26 Operkulektomi 27,000 14,500 12,500 0 0 0 0 0 0 0
27 Operasi Gigi 165,000 77,500 87,500 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
33 Gigi Tiruan Sebagian (harga per gigi blm 80,000 67,500 12,500 0 0 0 0 0 0 0
34 Jacket Crown Akrilik per unit 215,000 152,500 62,500 0 0 0 0 0 0 0
35 Jacket Porcelain fused to metal per unit 545,000 482,500 62,500 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 52,000 37,000 15,000 0 0 0 0 0 0 0
2 30X40 2x 61,000 41,000 20,000 0 0 0 0 0 0 0
3 35X35 1x 54,000 39,000 15,000 0 0 0 0 0 0 0
4 35X35 2x 63,000 43,000 20,000 0 0 0 0 0 0 0
5 24X30 1x 44,000 29,000 15,000 0 0 0 0 0 0 0
6 24X30 2x 50,000 30,000 20,000 0 0 0 0 0 0 0
7 18X24 1x 41,000 26,000 15,000 0 0 0 0 0 0 0
8 18X24 2x 48,000 28,000 20,000 0 0 0 0 0 0 0
9 15X30 (OPG) 37,000 29,000 8,000 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 51,000 33,000 18,000 0 0 0 0 0 0 0
B. LABORATORIUM
1 Hb Sahli 4,000 2,000 2,000 0 0 0 0 0 0 0
2 AL 4,000 2,000 2,000 0 0 0 0 0 0 0
3 HJL ( Hitung Jenis Leukosit) 10,000 4,000 6,000 0 0 0 0 0 0 0
4 Malaria 10,000 4,000 6,000 0 0 0 0 0 0 0
5 LPB (Limposit Plasma Biru) 10,000 4,000 6,000 0 0 0 0 0 0 0
6 AE 7,500 3,500 4,000 0 0 0 0 0 0 0
7 KED 6,000 2,000 4,000 0 0 0 0 0 0 0
8 AT Rees Ecker 10,000 6,000 4,000 0 0 0 0 0 0 0
9 HMT 5,000 3,000 2,000 0 0 0 0 0 0 0
10 CT 7,000 3,000 4,000 0 0 0 0 0 0 0
11 BT 4,500 1,500 3,000 0 0 0 0 0 0 0
12 Golongan Darah 7,000 3,500 3,500 0 0 0 0 0 0 0
13 Protein Urine 5,000 3,000 2,000 0 0 0 0 0 0 0
14 Reduksi Urine 5,000 3,000 2,000 0 0 0 0 0 0 0
15 Sedimen 5,000 2,000 3,000 0 0 0 0 0 0 0
16 Faeses 10,000 2,000 8,000 0 0 0 0 0 0 0
17 Glukosa Stik 15,000 10,000 5,000 0 0 0 0 0 0 0
18 Asam urat Stik 20,000 15,000 5,000 0 0 0 0 0 0 0
19 Kolesterol Stik 25,000 20,000 5,000 0 0 0 0 0 0 0
21 HBs Ag Rapid Tes 25,000 20,000 5,000 0 0 0 0 0 0 0
23 PP Test lateks 15,000 10,000 5,000 0 0 0 0 0 0 0
24 Hb Spektro 10,000 5,000 5,000 0 0 0 0 0 0 0
25 Glukosa spektro 15,000 8,000 7,000 0 0 0 0 0 0 0
28 Trigliserid Spektro 27,000 20,000 7,000 0 0 0 0 0 0 0
29 SGOT Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
30 SGPT Spektro 22,000 15,000 7,000 0 0 0 0 0 0 0
31 Ureum Spektro 20,000 13,000 7,000 0 0 0 0 0 0 0
32 Kreatinin Spektro 20,000 13,000 7,000 0 0 0 0 0 0 0
33 Widal 20,000 15,000 5,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 15,000 10,000 5,000 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 30,000 25,000 5,000 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0

4 Massage Bayi 12,000 2,000 10,000 0 0 0 0 0 0 0
5 Massage dewasa 15,000 2,000 13,000 0 0 0 0 0 0 0
6 Infra Red 9,000 6,000 3,000 0 0 0 0 0 0 0
7 TENS 10,000 6,000 4,000 0 0 0 0 0 0 0
8 Elektrical Stimulation (ES) 10,000 6,000 4,000 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
17 Ice Massage 10,000 5,000 5,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0


26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0

1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
A. TINDAKAN
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0

2 Pemeriksaan kering duh tubuh anus 4,500 3,000 1,500 0 0 0 0 0 0 0

3 Pemeriksaan sipilis Rapid test 25,000 20,000 5,000 0 0 0 0 0 0 0
4 Pemeriksaan sipilis RPR 30,000 25,000 5,000 0 0 0 0 0 0 0
5 Rapid test HIV 70,000 50,000 20,000 0 0 0 0 0 0 0

1 Dalam Kabupaten
2 Luar Kabupaten

3 Tes Buta Warna 7,500 7,500 0 0 0 0 0 0 0
5 BUKU KIA tiap Buku 12,000 12,000 - 0 0 0 0 0 0 0
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0
1 Praktek Klinik per minggu 0 0 0 0 0 0 0

a. profesi 30,000 Rp 10,500 19,500 0 0 0 0 0 0 0
b. D4/S1 26,500 Rp 9,275 17,225 0 0 0 0 0 0 0
c. D3 22,500 Rp 7,875 14,625 0 0 0 0 0 0 0
2 Praktek non Klinik per minggu 0 0 0 0 0 0 0
a. profesi 25,000 Rp 8,750 16,250 0 0 0 0 0 0 0
b. D4/S1 20,000 Rp 7,000 13,000 0 0 0 0 0 0 0
c. D3 18,000 Rp 6,000 12,000 0 0 0 0 0 0 0
d SMA/SMK
3 Penelitian
a. Profesi (S2/S3) 250,000 Rp 87,500 162,500 0 0 0 0 0 0 0
b. D4/S1 200,000 Rp 70,000 130,000 0 0 0 0 0 0 0
c. D3 100,000 Rp 35,000 65,000 0 0 0 0 0 0 0
pendahuluan (1 paket) di puskesmas -
4 Pelayanan Studi banding 0 0 0 0 0 0 0

b. Sarana Prasarana 0 0 0 0 0 0 0
- konsumsi/orang 37,000 Rp 37,000.00 0 0 0 0 0 0 0
- jasa sarana perpaket 200,000 Rp 200,000.00 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0
17400
6600
Bulan
TARIF PENDAPATAN
JUMLAH
NO JENIS PELAYANAN
PENDUDUK COST
OBAT
LAYANAN
KUNJUNG PENDAPAT UNIT PUSKESMAS PENGEMBA KET
AN OBAT PELAYANA DINAS 10%
BANTUL AN COST 75% NGAN 15%
N
- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0

1 Injeksi 5,800 3,150 2,650 31 179,800 97,650 0 82,150 61,613 12,323 8,215
3 Skin test 6,050 3,850 2,200 0 0 0 0 0 0 0
6 Pelepasan infus 5,200 2,150 3,050 0 0 0 0 0 0 0
7 Perbaikan infus 13,450 5,950 7,500 0 0 0 0 0 0 0
10 Lavement 22,800 16,700 6,100 0 0 0 0 0 0 0
11 Resusitasi 25,250 33,750 (8,500) 0 0 0 0 0 0 0
14 Pasang NGT 44,500 26,000 18,500 0 0 0 0 0 0 0
15 Scorstein 24,750 22,100 2,650 0 0 0 0 0 0 0
16 Rectal Toucher 11,550 10,250 1,300 0 0 0 0 0 0 0
17 Nebulizer 24,800 20,200 4,600 7 173,600 141,400 0 32,200 24,150 4,830 3,220
a. Kecil 16,350 11,600 4,750 8 130,800 92,800 0 38,000 28,500 5,700 3,800
b, Sedang 33,500 21,000 12,500 10 335,000 210,000 0 125,000 93,750 18,750 12,500
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
19 Debridemen sederhana 26,200 30,000 (3,800) 5 131,000 150,000 0 -19,000 -14,250 -2,850 -1,900
21 Hecting 1 sampai 5 39,050 49,000 (9,950) 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 58,600 68,400 (9,800) 0 0 0 0 0 0 0
24 Ambil jahitan 16,550 6,200 10,350 7 115,850 43,400 0 72,450 54,338 10,868 7,245
25 Insisi / Eksisi 29,000 40,700 (11,700) 0 0 0 0 0 0 0
26 Cross incisi 19,450 17,800 1,650 3 58,350 53,400 0 4,950 3,713 743 495
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
43 Refraksi Mata 5,000 0 5,000 0 0 0 0 0 0 0
44 Hordeolum 26,150 9,100 17,050 0 0 0 0 0 0 0
45 Tonometri 18,500 5,000 13,500 0 0 0 0 0 0 0
48 Pasang Spalk 38,400 35,800 2,600 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 20,000 10,000 10,000 0 0 0 0 0 0 0
52 EKG 18,000 10,000 8,000 0 0 0 0 0 0 0
1 Partus Normal 216,100 95,200 120,900 0 0 0 0 0 0 0
2 Partus Gemelli 272,800 128,200 144,600 0 0 0 0 0 0 0
7 Toucher/Kontrol IUD 25,750 17,500 8,250 2 51,500 35,000 0 16,500 12,375 2,475 1,650
8 Pemasangan IUD 26,250 26,800 (550) 1 26,250 26,800 0 -550 -413 -83 -55
9 Pelepasan IUD 25,750 20,300 5,450 1 25,750 20,300 0 5,450 4,088 818 545
11 Pemasangan Inplant 30,450 33,300 (2,850) 1 30,450 33,300 0 -2,850 -2,138 -428 -285
14 IVA 25,500 9,200 16,300 0 0 0 0 0 0 0
15 Suntik KB 5,800 3,900 1,900 0 0 0 0 0 0 0
17 Tindik 6,400 14,900 (8,500) 10 64,000 149,000 0 -85,000 -63,750 -12,750 -8,500
18 Dopler 5,000 5,000 - 42 210,000 210,000 0 0 0 0 0
19 Antenatal care 0 5,000 (5,000) 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0
1 Oral diagnostik/ konsultasi/ premedikasi 5,000 2,500 2,500 0 0 0

0 0 0 0
2 13,750 18,500 (4,750) 22 302,500 407,000 0 -104,500 -78,375 -15,675 -10,450
dan RB = 6 regio)
4 Tumpatan GIC 1 permukaan 24,300 37,000 (12,700) 8 194,400 296,000 0 -101,600 -76,200 -15,240 -10,160
Tumpatan Komposit Light Cured (kecil/1
7 21,550 39,500 (17,950) 0 0 0 0 0 0 0
permukaan)
8 Tumpatan Komposit Light Cured (sedang/2 38,900 48,500 0 0 0 0 0 0 0

permukaan) (9,600)

9 45,950 61,500 (15,550) 6 275,700 369,000 0 -93,300 -69,975 -13,995 -9,330
(besar/lebih dari 2 permukaan)
10 Perawatan Pulp Capping 12,200 17,750 (5,550) 2 24,400 35,500 0 -11,100 -8,325 -1,665 -1,110
13 Perawatan Syaraf C (Pengisian kamar pulpa) 15,800 26,750 (10,950) 1 15,800 26,750 0 -10,950 -8,213 -1,643 -1,095
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0

16 Koreksi Oklusi 12,800 18,000 (5,200) 2 25,600 36,000 0 -10,400 -7,800 -1,560 -1,040
18 Pencabutan Gigi Decidui dengan topikal 10,600 11,250 (650) 21 222,600 236,250 0 -13,650 -10,238 -2,048 -1,365
anestesi

dengan penyulit
23 Pencabutan Gigi Dewasa dg citoject dengan 29,350 36,000 (6,650) 6 176,100 216,000 0 -39,900 -29,925 -5,985 -3,990
penyulit
26 Operkulektomi 16,150 14,500 1,650 0 0 0 0 0 0 0
27 Operasi Gigi 86,250 77,500 8,750 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 40,000 37,000 3,000 0 0 0 0 0 0 0
2 30X40 2x 50,000 41,000 9,000 0 0 0 0 0 0 0
3 35X35 1x 35,000 39,000 (4,000) 0 0 0 0 0 0 0
4 35X35 2x 45,000 43,000 2,000 0 0 0 0 0 0 0
5 24X30 1x 30,000 29,000 1,000 0 0 0 0 0 0 0
6 24X30 2x 40,000 30,000 10,000 0 0 0 0 0 0 0
7 18X24 1x 30,000 26,000 4,000 0 0 0 0 0 0 0
8 18X24 2x 40,000 28,000 12,000 0 0 0 0 0 0 0
9 15X30 (OPG) 24,000 29,000 (5,000) 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 45,000 33,000 12,000 3 135,000 99,000 0 36,000 27,000 5,400 3,600
B. LABORATORIUM
1 Hb Sahli 2,150 2,000 150 0 0 0 0 0 0 0
2 AL 2,950 2,000 950 1 2,950 2,000 0 950 713 143 95
4 Malaria 4,700 4,000 700 0 0 0 0 0 0 0
6 AE 4,750 3,500 1,250 0 0 0 0 0 0 0
7 KED 2,600 2,000 600 0 0 0 0 0 0 0
8 AT Rees Ecker 7,000 6,000 1,000 0 0 0 0 0 0 0
9 HMT 3,050 3,000 50 0 0 0 0 0 0 0
10 CT 3,000 3,000 - 0 0 0 0 0 0 0
11 BT 2,550 1,500 1,050 0 0 0 0 0 0 0
12 Golongan Darah 4,900 3,500 1,400 9 44,100 31,500 0 12,600 9,450 1,890 1,260
13 Protein Urine 3,600 3,000 600 0 0 0 0 0 0 0
14 Reduksi Urine 3,600 3,000 600 0 0 0 0 0 0 0
15 Sedimen 3,850 2,000 1,850 0 0 0 0 0 0 0
16 Faeses 4,150 2,000 2,150 0 0 0 0 0 0 0
17 Glukosa Stik 12,450 10,000 2,450 58 722,100 580,000 0 142,100 106,575 21,315 14,210
18 Asam urat Stik 18,950 15,000 3,950 27 511,650 405,000 0 106,650 79,988 15,998 10,665
19 Kolesterol Stik 24,350 20,000 4,350 27 657,450 540,000 0 117,450 88,088 17,618 11,745
21 HBs Ag Rapid Tes 23,000 20,000 3,000 13 299,000 260,000 0 39,000 29,250 5,850 3,900
23 PP Test lateks 13,600 10,000 3,600 22 299,200 220,000 0 79,200 59,400 11,880 7,920
24 Hb Spektro 7,900 5,000 2,900 1 7,900 5,000 0 2,900 2,175 435 290
25 Glukosa spektro 13,400 8,000 5,400 0 0 0 0 0 0 0
29 SGOT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
30 SGPT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
31 Ureum Spektro 13,600 13,000 600 0 0 0 0 0 0 0
33 Widal 16,000 15,000 1,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 8,000 10,000 (2,000) 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 25,000 25,000 - 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0

4 Massage Bayi 2,950 2,000 950 0 0 0 0 0 0 0
5 Massage dewasa 3,000 2,000 1,000 0 0 0 0 0 0 0
6 Infra Red 7,150 6,000 1,150 0 0 0 0 0 0 0
7 TENS 6,200 6,000 200 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
17 Ice Massage 7,000 5,000 2,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0


26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
A. TINDAKAN
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0


5 Rapid test HIV 6,000 50,000 (44,000) 0 0 0 0 0 0 0
1 Dalam Kabupaten
2 Luar Kabupaten -
-
-
1 Pemeriksaan Kesehatan 5,000 5,000 17 85,000 0 0 85,000 63,750 12,750 8,500
3 Tes Buta Warna 5,000 5,000 0 0 0 0 0 0 0
4 Konsultasi Kesehatan 5,000 5,000 14 70,000 0 0 70,000 52,500 10,500 7,000
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0
TOTAL 5,603,800 5,028,050 0 575,750 431,813 86,363 57,575
17400
6600
PENGHITUNGAN JASA PELAYANAN PERBUB 45 DAN 49 2016 2017 LUAR WILAYAH
D TARIF PEL TINDAKAN MEDIK DAN TERAPI BULAN
TOTAL
A) TINDAKAN MEDIS UMUM 1 2 3 4 5 6 7 8 9 10 11 12
1 Injeksi 5,800
2 Injeksi dengan ekstra need 6,100
3 Skin test 6,050
4 Pasang infus 34,100
5 Pelepasan infus 5,200
6 Perbaikan infus 13,450
7 Pasang FOLLEY kateter + U 40,700
8 Pelepasan kateter 12,150
9 Lavement 22,800
10 Resusitasi 25,250
11 Pemasangan Oksigen 8,600
12 Oksigenasi / jam 2,350
13 Pasang NGT 44,500
14 Scorstein 24,750
15 Rectal Toucher 11,550
16 Nebulizer 24,800
17 Medikasi luka kecil 16,350
18 Medikasi luka sedang 33,500
19 Medikasi luka besar 56,000
20 Debridemen sederhana 26,200
21 Debridemen kompleks 74,050
22 Hecting 1 sampai 5 39,050
23 Hecting 6 sampai 10 58,600
24 Hecting > 10 jahitan 69,700
25 Penjahitan /setelah jahitan 5,000
26 Ambil jahitan 16,550
27 Insisi / Eksisi 29,000
28 Cross incisi 19,450
29 Bilas lambung 152,500
30 Sukcion lendir 34,500
2017 LUAR WILAYAH
D TARIF PEL TINDAKAN MEDIK DAN TERAPI BULAN
TOTAL
A) TINDAKAN MEDIS UMUM 1 2 3 4 5 6 7 8 9 10 11 12
31 Irigasi mata 33,000
32 Pemberian suspotaria 13,000
33 Pemasangan elastis verban 46,000
34 Chlorethyl spray 15,000
35 Circumsisi non cauther 77,850
36 Circumsisi cauther 75,100
37 Reposisi Dawir I 40,400
38 Reposisi Dawir 2 99,200
39 Extirpasi (Minor Surgery ) 51,600
40 Luka bakar dibawah 10 % 49,650
41 Luka bakar diatas 10 % 119,300
42 Ektraksi kuku 26,800
43 ATS 234,450
44 Refraksi Mata 5,000
45 Ekstraksi corpus alineum m 22,200
46 Hordeolum 26,150
47 Tonometri 18,500
48 Cerumen Prop ( per telinga 12,950
49 Corpus Alienum THT 16,500
50 Pasang spalk 38,400
51 Pasang tampon 30,500
52 Tindik 6,400
53 EKG 15,000
54 USG ( print 1 lbr ) 45,000
55 Dopler 5,000
56 Visum di TKP 20,000
57 Visum di Puskesmas 15,000
58 Pemeriksaan Kesehatan (Ke 5,000
59 Pemeriksaan Dokter Spesial 15,000
60 Tes Buta Warna 5,000
61 Konsultasi Kesehatan 5,000
62 Buku KIA (setiap buku) 6,500
63 Home care per petugas 20,000
64 Tes kebugaran CIH 42,500
2017 LUAR WILAYAH

TARIF PEL TINDAKAN MEDIK DAN TERAPI BULAN
TOTAL
KEBIDANAN 1 2 3 4 5 6 7 8 9 10 11 12
1 Partus Normal 216,100
2 Partus Gemeli 272,800
3 Induksi Persalinan 69,300
4 Jahit Luka Perineum (Jelujur) 39,500
5 Evakuasi Digital Placanta 26,750
6 Evakuasi Manual Placenta 61,500 ;
7 Toucher/Kontrol IUD 25,750
8 Pemasangan IUD 26,250
9 Pelepasan IUD 25,750
10 Pemasangan & Lepas IUD 46,250
11 Pemasangan Implant 30,450
12 Pelepasan Implant 30,450
13 Pasang & Lepas Implant/Norplant 50,450
14 Pap Smear (Pengambilan sampel& Tr 21,500
15 IVA (lengkap) 25,500
17 Tindik 6,400
18 Pra rujukan pendarahan PP 446,800
19 Antenatal Care 0
20 Post natal care 0
21 Perawatan Bayi Normal 51,500
22 IVA 25,500
23 Suntik KB 5,800
24 Krioterapi 150,000
25 Pasang tampon 30,500
26 Tindik 6,400
27 EKG 15,000
28 USG ( print 1 lbr ) 45,000
29 Dopler 5,000
2017 LUAR WILAYAH

TOTAL
C) TINDAKAN PEL KESEHATAN GIGI DAN MULUT 1 2 3 4 5 6 7 8 9 10 11 12
1 Pencabutan Gigi Decidui 10,600
2 Pencabutan Gigi Decidui (dengan komplikasi) 12,100
3 Pencabutan Gigi Dewasa disposible 12,100
4 Pencabutan Gigi Dewasa (dengan komplikasi) 29,350

5 Pencabutan Gigi dengan citoject 29,350
6 Tumpatan Amalgam 18,400
7 Tumpatan GIC 24,300
8 Pembersihan Karang Gigi per regio 13,750
Pembersihan KRG Gigi (Per Regio dgn
9 USS) 23,750
10 Perawatan Pulp Capping 12,200
11 Perawatan Syaraf A 15,000
12 Perawatan Syaraf B 14,300
13 Perawatan Syaraf C 15,800
14 Incisi Abses 19,200
15 Operkulektomi 16,150
16 Koreksi Oklusi 12,800
17 Operasi Gigi 86,250
18 Tumpatan LC (kecil) 21,550
19 Tumpatan LC (sedang) 38,900
20 Tumpatan LC (besar) 45,950
21 Protesa Gigi Lepasan 1 gigi (blm plat) 65,600
22 Jacket Crown Akrilik per unit 127,100
23 Jacket Porcelain per unit 247,100
24 Reposisi tiruan metal 140,000
2017 LUAR WILAYAH
TOTAL
E) LABORATORIUM 1 2 3 4 5 6 7 8 9 10 11 12
1 HB Sahli 2,150
2 AL 2,950
3 HJL /MALARIA/LPG 4,700
4 AE 4,750
5 KED 2,600
6 At Rees Ekker 7,000
7 HMT 3,050
8 CT 3,000
9 BT 2,550
10 Golongan darah 4,900
11 PH/PROTEIN/REDUKSI 3,600
12 Sedimen 3,850
13 Feses 4,150
14 glukosa stik 12,450
15 Asam urat stik 18,950
16 Cholesterol stik 24,350
17 Trigliserit stik 27,700
18 HBsAg stik 23,000
19 Narkoba (untuk setiap jenis) 24,350
20 PP tes latek 13,600
21 HB spektro 7,900
22 Glukosa spektro 13,400
23 Asam urat spektro 16,900
24 Kolesterol spektro 17,100
25 Trigliserit spektro 18,300
26 SGOT spektro 16,900
27 SGPT spektro 16,900
28 Ureum 13,600
2017 LUAR WILAYAH

TOTAL
E) LABORATORIUM 1 2 3 4 5 6 7 8 9 10 11 12
29 Kreatinin 13,600
30 DR = AT= HMT 22,450
30 Widal 16,000
31 Darah lengkap Otomatis 40,000
32 HB / HMT Stik 8,000
33 Rhesus 7,000
34 NS1 110,000
35 Ig G / Ig M dengue 110,000
36 HIV 70,000
37 Sypilis RPR 25,000
38 Sypilis RPR 30,000
39 Leptotek 80,000
40 Gonorrhoe / GO 15,000
41 Jamur 10,000
42 BTA 20,000
43 Stik Urine 10 P 10,000
44 Urin Rutin 15,000
45 Urin lengkap 20,000
46 Sampleng darah kapiler 2,000
47 Sampling darah Vena 5,000
TOTAL PENDAPATAN DAN RINCIAN PENGGUNAAN PENDAPATAN PUSKESMAS ( JAMKESDA ) TAHUN 2017
Bulan
TARIF PENDAPATAN
JUMLAH
NO JENIS PELAYANAN
PENDUDUK COST
OBAT
LAYANAN
AN OBAT PELAYANA
N
- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0

1 Injeksi 5,800 3,150 2,650 0 0 0 0 0 0 0
3 Skin test 6,050 3,850 2,200 0 0 0 0 0 0 0
6 Pelepasan infus 5,200 2,150 3,050 0 0 0 0 0 0 0
7 Perbaikan infus 13,450 5,950 7,500 0 0 0 0 0 0 0
10 Lavement 22,800 16,700 6,100 0 0 0 0 0 0 0
11 Resusitasi 25,250 33,750 (8,500) 0 0 0 0 0 0 0
14 Pasang NGT 44,500 26,000 18,500 0 0 0 0 0 0 0
15 Scorstein 24,750 22,100 2,650 0 0 0 0 0 0 0
16 Rectal Toucher 11,550 10,250 1,300 0 0 0 0 0 0 0
17 Nebulizer 24,800 20,200 4,600 0 0 0 0 0 0 0
a. Kecil 16,350 11,600 4,750 0 0 0 0 0 0 0
b, Sedang 33,500 21,000 12,500 0 0 0 0 0 0 0
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
21 Hecting 1 sampai 5 39,050 49,000 (9,950) 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 58,600 68,400 (9,800) 0 0 0 0 0 0 0
24 Ambil jahitan 16,550 6,200 10,350 0 0 0 0 0 0 0
25 Insisi / Eksisi 29,000 40,700 (11,700) 0 0 0 0 0 0 0
26 Cross incisi 19,450 17,800 1,650 0 0 0 0 0 0 0
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
43 Refraksi Mata 5,000 0 5,000 0 0 0 0 0 0 0
44 Hordeolum 26,150 9,100 17,050 0 0 0 0 0 0 0
45 Tonometri 18,500 5,000 13,500 0 0 0 0 0 0 0
48 Pasang Spalk 38,400 35,800 2,600 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 20,000 10,000 10,000 0 0 0 0 0 0 0
52 EKG 18,000 10,000 8,000 0 0 0 0 0 0 0
1 Partus Normal 216,100 95,200 120,900 0 0 0 0 0 0 0
2 Partus Gemelli 272,800 128,200 144,600 0 0 0 0 0 0 0
8 Pemasangan IUD 26,250 26,800 (550) 0 0 0 0 0 0 0
9 Pelepasan IUD 25,750 20,300 5,450 0 0 0 0 0 0 0
14 IVA 25,500 9,200 16,300 0 0 0 0 0 0 0
15 Suntik KB 5,800 3,900 1,900 0 0 0 0 0 0 0
17 Tindik 6,400 14,900 (8,500) 0 0 0 0 0 0 0
18 Dopler 5,000 5,000 - 0 0 0 0 0 0 0
19 Antenatal care 0 5,000 (5,000) 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0

0 0 0 0
2 Pembersihan Karang Gigi per regio (total RA

dan RB = 6 regio) 13,750 18,500 (4,750) 0 0 0 0 0 0 0


permukaan)

permukaan)
9 (besar/lebih 45,950 61,500 (15,550) 0 0 0 0 0 0 0
dari 2 permukaan)
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0

16 Koreksi Oklusi 12,800 18,000 (5,200) 0 0 0 0 0 0 0

anestesi

dengan penyulit

penyulit
26 Operkulektomi 16,150 14,500 1,650 0 0 0 0 0 0 0
27 Operasi Gigi 86,250 77,500 8,750 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 40,000 37,000 3,000 0 0 0 0 0 0 0
2 30X40 2x 50,000 41,000 9,000 0 0 0 0 0 0 0
3 35X35 1x 35,000 39,000 (4,000) 0 0 0 0 0 0 0
4 35X35 2x 45,000 43,000 2,000 0 0 0 0 0 0 0
5 24X30 1x 30,000 29,000 1,000 0 0 0 0 0 0 0
6 24X30 2x 40,000 30,000 10,000 0 0 0 0 0 0 0
7 18X24 1x 30,000 26,000 4,000 0 0 0 0 0 0 0
8 18X24 2x 40,000 28,000 12,000 0 0 0 0 0 0 0
9 15X30 (OPG) 24,000 29,000 (5,000) 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 45,000 33,000 12,000 0 0 0 0 0 0 0
B. LABORATORIUM
1 Hb Sahli 2,150 2,000 150 0 0 0 0 0 0 0
2 AL 2,950 2,000 950 0 0 0 0 0 0 0
4 Malaria 4,700 4,000 700 0 0 0 0 0 0 0
6 AE 4,750 3,500 1,250 0 0 0 0 0 0 0
7 KED 2,600 2,000 600 0 0 0 0 0 0 0
8 AT Rees Ecker 7,000 6,000 1,000 0 0 0 0 0 0 0
9 HMT 3,050 3,000 50 0 0 0 0 0 0 0
10 CT 3,000 3,000 - 0 0 0 0 0 0 0
11 BT 2,550 1,500 1,050 0 0 0 0 0 0 0
12 Golongan Darah 4,900 3,500 1,400 0 0 0 0 0 0 0
13 Protein Urine 3,600 3,000 600 0 0 0 0 0 0 0
14 Reduksi Urine 3,600 3,000 600 0 0 0 0 0 0 0
15 Sedimen 3,850 2,000 1,850 0 0 0 0 0 0 0
16 Faeses 4,150 2,000 2,150 0 0 0 0 0 0 0
17 Glukosa Stik 12,450 10,000 2,450 0 0 0 0 0 0 0
18 Asam urat Stik 18,950 15,000 3,950 0 0 0 0 0 0 0
19 Kolesterol Stik 24,350 20,000 4,350 0 0 0 0 0 0 0
21 HBs Ag Rapid Tes 23,000 20,000 3,000 0 0 0 0 0 0 0
23 PP Test lateks 13,600 10,000 3,600 0 0 0 0 0 0 0
24 Hb Spektro 7,900 5,000 2,900 0 0 0 0 0 0 0
25 Glukosa spektro 13,400 8,000 5,400 0 0 0 0 0 0 0
29 SGOT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
30 SGPT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
31 Ureum Spektro 13,600 13,000 600 0 0 0 0 0 0 0
33 Widal 16,000 15,000 1,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 8,000 10,000 (2,000) 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 25,000 25,000 - 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0

4 Massage Bayi 2,950 2,000 950 0 0 0 0 0 0 0
5 Massage dewasa 3,000 2,000 1,000 0 0 0 0 0 0 0
6 Infra Red 7,150 6,000 1,150 0 0 0 0 0 0 0
7 TENS 6,200 6,000 200 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
17 Ice Massage 7,000 5,000 2,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0


26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
A. TINDAKAN
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0


5 Rapid test HIV 6,000 50,000 (44,000) 0 0 0 0 0 0 0
1 Dalam Kabupaten
2 Luar Kabupaten -
-
-
3 Tes Buta Warna 5,000 5,000 0 0 0 0 0 0 0
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0

a. profesi 30,000 10,500 19,500 0 0 0 0 0 0 0
b. D4/S1 26,500 9,275 17,225 0 0 0 0 0 0 0
c. D3 22,500 7,875 14,625 0 0 0 0 0 0 0
a. profesi 25,000 8,750 16,250 0 0 0 0 0 0 0
b. D4/S1 20,000 7,000 13,000 0 0 0 0 0 0 0
c. D3 18,000 6,000 12,000 0 0 0 0 0 0 0
d SMA/SMK - - 0 0 0 0 0 0 0
3 Penelitian - -
a. Profesi (S2/S3) 250,000 87,500 162,500 0 0 0 0 0 0 0
b. D4/S1 200,000 70,000 130,000 0 0 0 0 0 0 0
c. D3 100,000 35,000 65,000 0 0 0 0 0 0 0
- konsumsi/orang 37,000 ### - 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0
17400
6600
TOTAL PENDAPATAN DAN RINCIAN PENGGUNAAN PENDAPATAN PUSKESMAS ( JAMKESTA ) TAHUN 2017
Bulan
TARIF PENDAPATAN
JUMLAH
NO JENIS PELAYANAN
PENDUDUK COST
OBAT
LAYANAN
AN OBAT PELAYANA
N
- Penduduk Bantul 5,500 3,000 2,500 0 0 0 0 0 0 0
- UKS 2,750 1,500 1,250 0 0 0 0 0 0 0

- Penduduk Bantul 11,000 6,000 5,000 0 0 0 0 0 0 0

1 Injeksi 5,800 3,150 2,650 0 0 0 0 0 0 0
3 Skin test 6,050 3,850 2,200 0 0 0 0 0 0 0
6 Pelepasan infus 5,200 2,150 3,050 0 0 0 0 0 0 0
7 Perbaikan infus 13,450 5,950 7,500 0 0 0 0 0 0 0
10 Lavement 22,800 16,700 6,100 0 0 0 0 0 0 0
11 Resusitasi 25,250 33,750 (8,500) 0 0 0 0 0 0 0
14 Pasang NGT 44,500 26,000 18,500 0 0 0 0 0 0 0
15 Scorstein 24,750 22,100 2,650 0 0 0 0 0 0 0
16 Rectal Toucher 11,550 10,250 1,300 0 0 0 0 0 0 0
17 Nebulizer 24,800 20,200 4,600 0 0 0 0 0 0 0
a. Kecil 16,350 11,600 4,750 0 0 0 0 0 0 0
b, Sedang 33,500 21,000 12,500 0 0 0 0 0 0 0
c. Besar 56,000 40,600 15,400 0 0 0 0 0 0 0
21 Hecting 1 sampai 5 39,050 49,000 (9,950) 0 0 0 0 0 0 0
22 Hecting 6 sampai 10 58,600 68,400 (9,800) 0 0 0 0 0 0 0
24 Ambil jahitan 16,550 6,200 10,350 0 0 0 0 0 0 0
25 Insisi / Eksisi 29,000 40,700 (11,700) 0 0 0 0 0 0 0
26 Cross incisi 19,450 17,800 1,650 0 0 0 0 0 0 0
27 Bilas lambung 152,500 127,500 25,000 0 0 0 0 0 0 0
28 Suction lendir 34,500 19,400 15,100 0 0 0 0 0 0 0
29 Irigasi mata 33,000 22,700 10,300 0 0 0 0 0 0 0
41 ATS 234,450 226,950 7,500 0 0 0 0 0 0 0
43 Refraksi Mata 5,000 0 5,000 0 0 0 0 0 0 0
44 Hordeolum 26,150 9,100 17,050 0 0 0 0 0 0 0
45 Tonometri 18,500 5,000 13,500 0 0 0 0 0 0 0
48 Pasang Spalk 38,400 35,800 2,600 0 0 0 0 0 0 0
49 Pasang Tampon 30,500 15,500 15,000 0 0 0 0 0 0 0
50 Visum di TKP 20,000 10,000 10,000 0 0 0 0 0 0 0
52 EKG 18,000 10,000 8,000 0 0 0 0 0 0 0
1 Partus Normal 216,100 95,200 120,900 0 0 0 0 0 0 0
2 Partus Gemelli 272,800 128,200 144,600 0 0 0 0 0 0 0
8 Pemasangan IUD 26,250 26,800 (550) 0 0 0 0 0 0 0
9 Pelepasan IUD 25,750 20,300 5,450 0 0 0 0 0 0 0
14 IVA 25,500 9,200 16,300 0 0 0 0 0 0 0
15 Suntik KB 5,800 3,900 1,900 0 0 0 0 0 0 0
17 Tindik 6,400 14,900 (8,500) 0 0 0 0 0 0 0
18 Dopler 5,000 5,000 - 0 0 0 0 0 0 0
19 Antenatal care 0 5,000 (5,000) 0 0 0 0 0 0 0
20 Post natal care 25,000 10,000 15,000 0 0 0 0 0 0 0
21 Krioterapi 150,000 50,000 100,000 0 0 0 0 0 0 0

0 0 0 0
2 Pembersihan Karang Gigi per regio (total RA

dan RB = 6 regio) 13,750 18,500 (4,750) 0 0 0 0 0 0 0


permukaan)

permukaan)
9 (besar/lebih 45,950 61,500 (15,550) 0 0 0 0 0 0 0
dari 2 permukaan)
14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0

16 Koreksi Oklusi 12,800 18,000 (5,200) 0 0 0 0 0 0 0

anestesi

dengan penyulit

penyulit
26 Operkulektomi 16,150 14,500 1,650 0 0 0 0 0 0 0
27 Operasi Gigi 86,250 77,500 8,750 0 0 0 0 0 0 0
28 Hecting oral 40,000 27,500 12,500 0 0 0 0 0 0 0
A. RADIOLOGI
1 30X40 1x 40,000 37,000 3,000 0 0 0 0 0 0 0
2 30X40 2x 50,000 41,000 9,000 0 0 0 0 0 0 0
3 35X35 1x 35,000 39,000 (4,000) 0 0 0 0 0 0 0
4 35X35 2x 45,000 43,000 2,000 0 0 0 0 0 0 0
5 24X30 1x 30,000 29,000 1,000 0 0 0 0 0 0 0
6 24X30 2x 40,000 30,000 10,000 0 0 0 0 0 0 0
7 18X24 1x 30,000 26,000 4,000 0 0 0 0 0 0 0
8 18X24 2x 40,000 28,000 12,000 0 0 0 0 0 0 0
9 15X30 (OPG) 24,000 29,000 (5,000) 0 0 0 0 0 0 0
10 USG (Print 1 lbr) 45,000 33,000 12,000 0 0 0 0 0 0 0
B. LABORATORIUM
1 Hb Sahli 2,150 2,000 150 0 0 0 0 0 0 0
2 AL 2,950 2,000 950 0 0 0 0 0 0 0
4 Malaria 4,700 4,000 700 0 0 0 0 0 0 0
6 AE 4,750 3,500 1,250 0 0 0 0 0 0 0
7 KED 2,600 2,000 600 0 0 0 0 0 0 0
8 AT Rees Ecker 7,000 6,000 1,000 0 0 0 0 0 0 0
9 HMT 3,050 3,000 50 0 0 0 0 0 0 0
10 CT 3,000 3,000 - 0 0 0 0 0 0 0
11 BT 2,550 1,500 1,050 0 0 0 0 0 0 0
12 Golongan Darah 4,900 3,500 1,400 0 0 0 0 0 0 0
13 Protein Urine 3,600 3,000 600 0 0 0 0 0 0 0
14 Reduksi Urine 3,600 3,000 600 0 0 0 0 0 0 0
15 Sedimen 3,850 2,000 1,850 0 0 0 0 0 0 0
16 Faeses 4,150 2,000 2,150 0 0 0 0 0 0 0
17 Glukosa Stik 12,450 10,000 2,450 0 0 0 0 0 0 0
18 Asam urat Stik 18,950 15,000 3,950 0 0 0 0 0 0 0
19 Kolesterol Stik 24,350 20,000 4,350 0 0 0 0 0 0 0
21 HBs Ag Rapid Tes 23,000 20,000 3,000 0 0 0 0 0 0 0
23 PP Test lateks 13,600 10,000 3,600 0 0 0 0 0 0 0
24 Hb Spektro 7,900 5,000 2,900 0 0 0 0 0 0 0
25 Glukosa spektro 13,400 8,000 5,400 0 0 0 0 0 0 0
29 SGOT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
30 SGPT Spektro 16,900 15,000 1,900 0 0 0 0 0 0 0
31 Ureum Spektro 13,600 13,000 600 0 0 0 0 0 0 0
33 Widal 16,000 15,000 1,000 0 0 0 0 0 0 0
35 Hb/Hmt Stik 8,000 10,000 (2,000) 0 0 0 0 0 0 0
36 Rhesus 7,000 3,500 3,500 0 0 0 0 0 0 0
37 NS1 110,000 100,000 10,000 0 0 0 0 0 0 0
38 IgG/IgM Dengue 110,000 100,000 10,000 0 0 0 0 0 0 0
39 HIV 70,000 50,000 20,000 0 0 0 0 0 0 0
40 syphilis RPR 25,000 20,000 5,000 0 0 0 0 0 0 0
41 syphilis RPR 25,000 25,000 - 0 0 0 0 0 0 0
42 Leptotek 80,000 70,000 10,000 0 0 0 0 0 0 0
43 Gonorhoe (GO) 15,000 10,000 5,000 0 0 0 0 0 0 0
44 Jamur 10,000 5,000 5,000 0 0 0 0 0 0 0
45 BTA 20,000 - 20,000 0 0 0 0 0 0 0
46 Stik urine 10 P 10,000 5,000 5,000 0 0 0 0 0 0 0
47 Urine Rutin 15,000 8,000 7,000 0 0 0 0 0 0 0
48 Urine Lengkap 20,000 10,000 10,000 0 0 0 0 0 0 0

4 Massage Bayi 2,950 2,000 950 0 0 0 0 0 0 0
5 Massage dewasa 3,000 2,000 1,000 0 0 0 0 0 0 0
6 Infra Red 7,150 6,000 1,150 0 0 0 0 0 0 0
7 TENS 6,200 6,000 200 0 0 0 0 0 0 0
12 Ultra Sound (US) 11,500 6,500 5,000 0 0 0 0 0 0 0
13 Chest Therapy 6,000 1,000 5,000 0 0 0 0 0 0 0
17 Ice Massage 7,000 5,000 2,000 0 0 0 0 0 0 0
19 Cold Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
20 Hot Pack 13,000 3,000 10,000 0 0 0 0 0 0 0
21 Pararel Bar 8,000 2,000 6,000 0 0 0 0 0 0 0
22 Standing Bar 8,000 2,000 6,000 0 0 0 0 0 0 0


26 Parafin bath 22,500 17,500 5,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 Akupresur 17,000 2,000 15,000 0 0 0 0 0 0 0
2 Akupuntur 40,000 20,000 20,000 0 0 0 0 0 0 0
0 0 0 0 0 0 0
A. TINDAKAN
2 Rectal toucher 12,000 6,500 5,500 0 0 0 0 0 0 0


5 Rapid test HIV 6,000 50,000 (44,000) 0 0 0 0 0 0 0
1 Dalam Kabupaten
2 Luar Kabupaten -
-
-
3 Tes Buta Warna 5,000 5,000 0 0 0 0 0 0 0
8 Poli Sore 11,000 6,000 5,000 0 0 0 0 0 0 0

a. profesi 30,000 10,500 19,500 0 0 0 0 0 0 0
b. D4/S1 26,500 9,275 17,225 0 0 0 0 0 0 0
c. D3 22,500 7,875 14,625 0 0 0 0 0 0 0
a. profesi 25,000 8,750 16,250 0 0 0 0 0 0 0
b. D4/S1 20,000 7,000 13,000 0 0 0 0 0 0 0
c. D3 18,000 6,000 12,000 0 0 0 0 0 0 0
d SMA/SMK - - 0 0 0 0 0 0 0
3 Penelitian - -
a. Profesi (S2/S3) 250,000 87,500 162,500 0 0 0 0 0 0 0
b. D4/S1 200,000 70,000 130,000 0 0 0 0 0 0 0
c. D3 100,000 35,000 65,000 0 0 0 0 0 0 0
- konsumsi/orang 37,000 ### - 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0
17400
6600
TOTAL PENDAPATAN DAN RINCIAN PENGGUNAAN PENDAPATAN PUSKESMAS ( PEND
Bulan
PENDAPATAN
UNIT JASA
NO JENIS PELAYANAN TARIF JUMLAH
COST PELAYANAN
KUNJUNGAN
1 Paket Diklat klinik per orang per minggu

a. Profesi 30,000 10,500 19,500
b. Jenjang D4 atau S1 26,500 9,275 17,225
c. Jenjang D3 22,500 7,875 14,625
2 Praktek non klinik per minggu per orang -

a. Profesi 25,000 8,750 16,250
b. Jenjang D4 atau S1 20,000 7,000 13,000
c. Jenjang D3 18,000 6,000 12,000
d. SMA/SMK -
-
3 Penelitian -
a. Profesi (S2/S3) 250,000 87,500 162,500
b. D4/S1 200,000 70,000 130,000
c. D3 100,000 35,000 65,000
d. Pengambilan data dalam rangka studi -
pendahuluan ( 1 paket ) di Puskesmas
-
4 Pelayanan studi banding -
a. Narasumber ( per JPL / org ) 250,000 250,000
b. Sarana prasarana -
- Konsumsi/orang 37,000 37,000 -
- jasa sarana per paket 200,000 200,000 -
JUMLAH
APATAN PUSKESMAS ( PENDIDIKAN ) TAHUN 2017
UPATEN BANTUL
PENDAPATAN
JASA KET
UNIT
TOTAL PELAYANA
COST
N
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
TARIF
SUBSIDI TARIF
PERBUP TARIF
NO JENIS PELAYANAN (PERBUP 49 LUAR BULAN
NO 45 TH BANTUL
TH 2016) BANTUL
2016
C. TINDAKAN PELAYANAN KESEHATAN GIGI DAN MULUT 1 2 3 4 5 6 7 8 9 10 11 12
39,500 25,750 13,750 39,500
2 dan RB = 6 regio)
Tumpatan Komposit Light Cured (kecil/1
7 52,000 30,450 21,550 52,000
permukaan)
73,500 34,600 38,900 73,500
8 permukaan)
9 86,500 40,550 45,950 86,500
dari 2 permukaan)
12 Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 15,700 14,300 30,000
14 Trepanasi gigi 19,000 0 19,000 19,000
16 Koreksi Oklusi 30,500 17,700 12,800 30,500
Pencabutan Gigi Decidui dengan topikal
20,000 9,400 10,600 20,000
18 anestesi
Pencabutan Gigi Dewasa dg spuit dispossible
21 75,500 46,150 29,350 75,500
dengan penyulit
Pencabutan Gigi Dewasa dg citoject dengan
23 90,000 60,650 29,350 90,000
penyulit
26 Operkulektomi 27,000 10,850 16,150 27,000
27 Operasi Gigi 165,000 78,750 86,250 165,000
28 Hecting oral 40,000 0 40,000 40,000
Gigi Tiruan Sebagian (harga per gigi blm
33 80,000 14,400 65,600 80,000
TOTAL
TARIF SUBSIDI
TARIF
PERBUP (PERBUP TARIF
NO JENIS PELAYANAN LUAR BULAN
NO 45 TH 49 TH BANTUL
BANTUL TOTAL
2016 2016)
A TINDAKAN MEDIS UMUM 1 2 3 4 5 6 7 8 9 10 11 12

1 Injeksi 9,500 3,700 5,800 9,500
3 Skin test 10,500 4,450 6,050 10,500
6 Pelepasan infus 8,500 3,300 5,200 8,500
7 Perbaikan infus 18,500 5,050 13,450 18,500
10 Lavement 35,500 12,700 22,800 35,500
11 Resusitasi 59,000 33,750 25,250 59,000
14 Pasang NGT 51,000 6,500 44,500 51,000
15 Scorstein 35,000 10,250 24,750 35,000
16 Rectal Toucher 16,500 4,950 11,550 16,500
17 Nebulizer 39,000 14,200 24,800 39,000
a. Kecil 22,000 5,650 16,350 22,000
b, Sedang 33,500 0 33,500 33,500
c. Besar 56,000 0 56,000 56,000
21 Hecting 1 sampai 5 61,500 22,450 39,050 61,500
22 Hecting 6 sampai 10 87,500 28,900 58,600 87,500
24 Ambil jahitan 19,000 2,450 16,550 19,000
25 Insisi / Eksisi 59,500 30,500 29,000 59,500
26 Cross incisi 30,500 11,050 19,450 30,500
27 Bilas lambung 152,500 0 152,500 152,500
TOTAL
1 2 3 4 5 6 7 8 9 10 11 12
28 Suction lendir 34,500 0 34,500 34,500
29 Irigasi mata 33,000 0 33,000 33,000
41 ATS 234,450 0 234,450 234,450
43 Refraksi Mata 7,500 2,500 5,000 7,500
44 Hordeolum 39,100 12,950 26,150 39,100
45 Tonometri 27,500 9,000 18,500 27,500
48 Pasang Spalk 58,300 19,900 38,400 58,300
49 Pasang Tampon 30,500 0 30,500 30,500
50 Visum di TKP 40,000 20,000 20,000 40,000
52 EKG 22,000 4,000 18,000 22,000
53 Tes Buta Warna 7,500 2,500 5,000 7,500
56 Poli Sore 11,000 0 11,000 11,000
SUBSID
TARIF TARIF
I
PERBUP TARIF LUAR
NO JENIS PELAYANAN (PERBU BULAN
NO 45 TH
P 49 TH
BANTUL BANTU TOTAL
2016 L
2016)
B. TINDAKAN KEBIDANAN 1 2 3 4 5 6 7 8 9 10 11 12
2 Pemasangan IUD 76,800 50,550 26,250 76,800
3 Pelepasan IUD 50,300 24,550 25,750 50,300
9 IVA 29,200 3,700 25,500 29,200
10 Suntik KB 11,400 5,600 5,800 11,400
12 Tindik 21,700 15,300 6,400 21,700
13 Dopler 10,000 5,000 5,000 10,000
15 Antenatal care 15,000 15,000 0 15,000
16 Post natal care 25,000 0 25,000 25,000
17 Krioterapi 150,000 0 150,000 150,000
20 Tes Buta Warna 7,500 2,500 5,000 7,500
25 Poli Sore 11,000 0 11,000 11,000
26 Injeksi 9,500 3,700 5,800 9,500
28 Skin test 10,500 4,450 6,050 10,500
31 Hecting 1 sampai 5 61,500 22,450 39,050 61,500
32 Hecting 6 sampai 10 87,500 28,900 58,600 87,500
33 Ambil jahitan 19,000 2,450 16,550 19,000

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DAFTAR TARIF LAYANAN KESEHATAN BLUD PUSKESMAS

A. TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI

48 Pasang Spalk 58,300 19,900 38,400 58,300

7 Tumpatan Komposit Light Cured (kecil/1 52,000 30,450 21,550 52,000

Pencabutan Gigi Dewasa dg spuit dispossible 22,500 10,400 12,100 22,500

23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 60,650 29,350 90,000

B. TARIF RETRIBUSI PELAYANAN PENUNJANG DIAGNOSIS

18 Asam urat Stik 20,000 1,050 18,950 20,000

C. TARIF PELAYANAN REHABILITASI MEDIK

19 Cold Pack 13,000 0 13,000 13,000

D. TARIF PELAYANAN KESEHATAN TRADISIONAL

1 Akupresur 17,000 0 17,000 17,000

E. TARIF PELAYANAN KESEHATAN INFEKSI MENULAR SEKSUAL (IMS)

2 Pemeriksaan kering duh tubuh anus 4,500 2,500 2,000 4,500

F. TARIF PELAYANAN AMBULANCE

G. TARIF PELAYANAN KESEHATAN LAINNYA

1 Pemeriksaan Kesehatan 7,500 2,500 5,000 7,500

H. TARIF PELAYANAN PENDIDIKAN

I. TARIF PELAYANAN RAWAT INAP

1 Rawat Inap Umum 74,000 10,500 63,500 74,000

2 Rawat Inap Utama 185,000 0 185,000 185,000

Kepala Dinas Kesehatan

drg. Maya Sintowati Pandji, MM

A TARIF PELAYANAN RAWAT JALAN

C TARIF PELAYANAN RAWAT DARURAT

D TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI

1 Oral diagnostik/ konsultasi/ premedikasi 5,000 2,500 2,500 0 0 0 0 0 0 0

Pembersihan Karang Gigi per regio (total RA

7 Tumpatan Komposit Light Cured (kecil/1 52,000 39,500 12,500 0 0 0 0 0

12 Perawatan Saraf B (Sterilisasi kamar pulpa) 30,000 21,250 8,750 0 0 0 0 0

13 Perawatan Syaraf C (Pengisian kamar pulpa) 35,500 26,750 8,750 0 0 0 0 0

18 Pencabutan Gigi Decidui dengan topikal 20,000 11,250 8,750 0 0 0 0 0

19 Pencabutan Gigi Decidui dengan citoject 28,500 19,750 8,750 0 0 0 0 0

20 Pencabutan Gigi Dewasa dg spuit dispossible 22,500 13,750 8,750 0 0 0 0 0

23 Pencabutan Gigi Dewasa dg citoject dengan 90,000 36,000 54,000 0 0 0 0 0

C. TARIF PELAYANAN REHABILITASI MEDIK

24 Latihan transfer dan ambulasi menggunakan 4,000 - 4,000 0 0 0 0 0 0 0

25 Pemasangan/fitting orthosis 4,500 1,500 3,000 0 0 0 0 0 0 0

D. TARIF PELAYANAN KESEHATAN TRADISIONAL

E. TARIF PELAYANAN KESEHATAN INFEKSI MENULAR SEKSUAL (IMS)

F. TARIF PELAYANAN AMBULANCE

G. TARIF PELAYANAN KESEHATAN LAINNYA

1 Pemeriksaan Kesehatan 7,500 7,500 0 0 0 0 0 0 0

H. TARIF PELAYANAN PENDIDIKAN

1 Praktek Klinik per minggu 0 0 0 0 0 0 0

4 Pelayanan Studi banding 0 0 0 0 0 0 0

C TARIF PELAYANAN RAWAT DARURAT

D TARIF PELAYANAN TINDAKAN MEDIK DAN TERAPI

3 Tumpatan Amalgam 18,400 33,500 (15,100) 0 0 0 0 0 0 0

7 Tumpatan Komposit Light Cured (kecil/1 21,550 39,500 (17,950) 0 0 0 0 0 0 0

8 Tumpatan Komposit Light Cured (sedang/2 38,900 48,500 (9,600) 0 0 0 0 0 0 0

12 Perawatan Saraf B (Sterilisasi kamar pulpa) 14,300 21,250 (6,950) 0 0 0 0 0 0 0

13 Perawatan Syaraf C (Pengisian kamar pulpa) 15,800 26,750 (10,950) 0 0 0 0 0 0 0

14 Trepanasi gigi 19,000 10,250 8,750 0 0 0 0 0 0 0

18 Pencabutan Gigi Decidui dengan topikal 10,600 11,250 (650) 0 0 0 0 0 0 0

19 Pencabutan Gigi Decidui dengan citoject 10,600 19,750 (9,150) 0 0 0 0 0 0 0

20 Pencabutan Gigi Dewasa dg spuit dispossible 12,100 13,750 (1,650) 0 0 0 0 0 0 0

21 Pencabutan Gigi Dewasa dg spuit dispossible 29,350 21,500 7,850 0 0 0 0 0 0 0

C. TARIF PELAYANAN REHABILITASI MEDIK