OBSTETRI DAN GINEKOLOGI

KECIL I 1
2
3
4
5
6
7

SEDANG 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

BESAR 1
2
3
4
5
6
7
8
9
10
11
 12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

KHUSUS I 1
2
3
4
5
6
7
8
9
10
11
12
13

KHUSUS II 1
2
3
 4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

KHUSUS III 1
2
3
4
5
6
7
8
I DAN GINEKOLOGI

culdotomy
diagnostic procedure on vulva ( biopsi vulva)
percutaneus aspiration of bartholin's gland ( cyst)
Incision of Bartholin's gland ( cyst)/ insisi abses bartolin
excision or other destruction of bartholin's
suture of laceration of vulva and perineum
repair of other current obstetric laceration ( episioperineoraphy, perineorafi ruptur perineum)

Other excision or destruction lession of uterus ( pedunculata myoma)

Reclosure of postoperative disruption of abdominal wall
transuretral cystoscopy
Bilateral endoscopic destruction or occlusion of fallopian tubes ( MOW laparoscopic)
other Bilateral endoscopic destruction or occlusion of fallopian tubes ( minilaparatomi sterilisasi)
Unilateral destruction or occlusion of fallopian tube
Repair of internal cervical os ( cerclage of isthmus uteri)
dilation and curettage of uterus
aspiration curettage of uterus
incision of vulva and perineum ( labia & vulva adhesion, enlargement introitus)
removal of cerclage material from cervix
hymenotomy
suture of laceration of vagina
Marsupialization of bartholin's gland (cyst)
pubiotomy to assist delivery
repair of current obstetric laceration of cervix
repair of current obstetric laceration of rectum and spincter ani

Cesarean section and removal of fetus

exploratory lapatomy
reopening of recent laparotomy site
other lapatomy ( drainase of intraperitoneal abses or hematom /TOA)
Delayed closure of granulating abdominal wound
control postoperative hemmorrage of bladder
oophorotomy
diagnostic procedures on ovaries ( aspirasi biopsi, biopsi)
local excision or destruction of ovarian lesion or tissue (cystectomy)
unilateral oophorectomy
unilateral salpingo-oophorectomy
bilateral oophorectomy
bilateral salpingo-oophorectomy
Repair of ovary
lysis of adhesion of ovary and fallopian tube
manual rupture of ovarian cyst
release of torsion of ovary
salpingotomy and salpongostomy
diagnostic procedures on fallopian tubes ( biopsy of fallopian tube)
total unilateral salpingectomy
total bilateral salpingectomy
other salpingectomy ( cautherization, coagulation,excision, electrocoagulation)
aspiration of fallopian tubes
burying of fimbriae in uterine wall
hysterotomy
open biopsy of uterine ligament
other excision or destruction lession of uterus ( uterine myomectomy)
subtotal abdominal hysterectomy
excision or destruction of lession or tissue of uterus and supporting structures
uterine repair( hysteroraphy non obstetric)
caesarean section of unspecified type ( hysterotomy to terminate pregnancy)
repair of current obstetric laceration of uterus
repair of other current obstetric laceration ( blader and uretra)
lysis of intraluminal adhesions of vagina
other vaginotomy ( vaginal septum/ eksisi septum vagina, drainase hematom of vaginal cuff)
other repair of vagina ( colpoperineoplasty, repair old obstetric laceration of vagina

INSUFFLATION OF FALLOPIAN TUBE ( HYDROTUBASI)

conization of cervix excluding electrial/cryo
amputation of cervix (fortegil operation)
closed biopsy of uterine ligament ( laparoscopy biopsy of uterine ligament)
closed biopsy of uterus ( laparoscopy or hysteroscopy)
devision of endometrial synechia
total abdominal hysterectomy
vaginal hysterectomy ( prolap uteri)
other local excision or destruction of vulva and perineum
operations on clitoris
hymenoraphy
other repair of vulva an perineum ( repair of old obstetric laceration of vulva or perineum)
cesarean section with previous C-section or complicated pregnancy

Levator muscle operation for urethrovesical suspension

other ( TOT, TVT-O, TVT)
other and unspesific hysterectomy ( caesarean hysterectomi)
other repair of urinary bladder ( repair fistula involving bladder and intestine/ rectovaginal)
repair of other fistula bladder
other repair of bladder
plication of uterivesical junction
suprapubic sling operation
retropubic uretral suspension
paraurethral suspension
repair of fallopian tube
removal of prosthesis of fallopian tube
hysteroscopy diagnostic
incision or excision of congenital uterus
vaginal hysterectomy
repair of uterine supporting structures
obliteration and total excision of vagina
vaginal construction and reconstruction
removal of extratubalof ectopix pregnancy
other vulvectomy
removal of extratubal of ectopic pregnancy ( abdominal pregnancy)
repair of rectovaginal fistule
vaginal suspension and fixation
repair of fistula of vulva or perineum
amnioscopy ( fetoscopy, laparoamnioscopy)

laparoscopy
vaginal hysterectomy ( laparoscopically assisted vaginal)
vaginal hysterectomy (nondescent due to myoma)
radical vaginal hysterectomy
pelvic eviceration
radical vulvectomy
repair of cystocele and rectocele
other operetion on cervix and uterus
 tarif kelas III tarif kelas II
JS JP jumlah JS
tindakan KECIL 300,000 400,000 700,000 360,000
tindakan SEDANG 750,000 2,100,000 2,850,000 900,000
tindakan BESAR 1,200,000 3,500,000 4,700,000 1,440,000
tindakan KHUSUS I 1,400,000 4,500,000 5,900,000 1,680,000
tindakan KHUSUS II 1,850,000 5,700,000 7,550,000 2,220,000
tindakan KHUSUS III 2,500,000 7,500,000 10,000,000 3,000,000
 tarif kelas II tarif kelas I tarif VIP
JP jumlah JS JP jumlah JS JP
480,000 840,000 390,000 520,000 910,000 435,000 580,000
2,520,000 3,420,000 975,000 2,730,000 3,705,000 1,087,500 3,045,000
4,200,000 5,640,000 1,560,000 4,550,000 6,110,000 1,740,000 5,075,000
5,400,000 7,080,000 1,820,000 5,850,000 7,670,000 2,030,000 6,525,000
6,840,000 9,060,000 2,405,000 7,410,000 9,815,000 2,682,500 8,265,000
9,000,000 11,000,000 3,250,000 9,750,000 13,000,000 3,625,000 10,875,000
tarif VIP
jumlah
1,015,000
4,132,500
6,815,000
8,555,000
10,947,500
14,500,000
 jenis pelayanan JS JP total
Angkat Implant 58,500 31,500 90,000
Angkat IUD 58,500 31,500 90,000
Biopsi Perpaginam 109,200 58,800 168,000
Buka Pessarium 39,000 21,000 60,000
CTG 62,400 33,600 96,000
Diathermi ( satu seri = 6 kali kunjungan ) 58,500 31,500 90,000
Ganti Verban / Buka Jahitan 13,650 7,350 21,000
Kauter Albotyl 13,650 7,350 21,000
Kauter Elektrik 31,200 16,800 48,000
KIE (Komunikasi Informasi Edukasi) 32,500 17,500 50,000
Kolposkopi 487,500 262,500 750,000
Konseling KB 11,700 6,300 18,000
Krayo Terapi 455,000 245,000 700,000

Pap Smear 31,200 16,800 48,000

Pasang Implant 58,500 31,500 90,000
Pasang IUD / AKDR 58,500 31,500 90,000
Pasang pessarium 39,000 21,000 60,000
Pasang/Ganti Tampon 13,650 7,350 21,000
Pemeriksaan Gynekologi 11,700 6,300 18,000
Pemeriksaan IVA 16,250 8,750 25,000
Suntikan KB 23,400 12,600 36,000
Tindakan pasang Infus 7,800 4,200 12,000
Tindakan pasang kateter 19,500 10,500 30,000
USG
- Tampa Print Out 50,700 27,300 78,000
- Dengan Print Out 78,000 42,000 120,000
USG Trans Vaginal
- Tampa Print Out 58,500 31,500 90,000
- Dengan Print Out 97,500 52,500 150,000
ANC 42,000 28,000 70,000
Vaginal Swab 17,160 9,240 26,400
 pelayanan JS JP
Amniotomi 32,500 17,500
CTG 62,400 33,600
Eksplorasi Digital 65,000 35,000
Insersi Misoprosol Pervaginam/1 kali insersi 19,500 10,500
KB Suntik 23,400 12,600
KBI (kompresi Bimanual Internal) 812,500 437,500
KIE (Komunikasi Informasi Edukasi) 32,500 17,500
Kuretase dengan narcosa 1,625,000 875,000
Kuretase tanpa narcosa 812,500 437,500
Menjahit robekan portio 130,000 70,000
Pemasangan AKDR 58,500 31,500
Pemberian Mgso4 (per 1 X pemberian) 65,000 35,000
Pemberian Zalf mata 22,750 12,250
Persalinan Letsu Manual Aid 975,000 525,000
Persalinan spontan dengan bayi gemelli 1,625,000 875,000
Persalinan Sungsang (Bracht) Ringan 812,500 437,500
Persalinan Normal 432,000 368,000
Persalinan dengan penyulit ringan:
a. Oxytosin Drip 720,000 480,000
b. Misoprostal 720,000 480,000
c. Rehidrasi (Pasang Infus) 720,000 480,000
d. Pwerineorafi 720,000 480,000
Persalinan dengan penyulit sedang
a. Ekstraksi Vakum 900,000 600,000
b. HPP 900,000 600,000
c. KDI 900,000 600,000
d. Manual Placenta 1,080,000 720,000
e. Manual AID 1,080,000 720,000
f. Versi Ekstraksi 900,000 600,000
Suction Curetage tanpa narcosa 1,300,000 700,000
Tindakan inspekulo 32,500 17,500
Tindakan Oksitisin Drip (per Botol) 65,000 35,000
Tindakan Oksitisin Drip pada kasus HPP 65,000 35,000
USG kandungan dengan Print Out 78,000 42,000
USG Trans Vaginal dengan Print Out 97,500 52,500
VT (vagina toucher) untuk 1 X VT 13,000 7,000
 total
50,000
96,000
100,000
30,000
36,000
1,250,000
50,000
2,500,000
1,250,000
200,000
90,000
100,000
35,000
1,500,000
2,500,000
1,250,000
800,000

1,200,000
1,200,000
1,200,000
1,200,000

1,500,000
1,500,000
1,500,000
1,800,000
1,800,000
1,500,000
2,000,000
50,000
100,000
100,000
120,000
150,000
20,000