LAMPIRAN PERATURAN DAERAH KOTA BANJARMASIN NOMOR 16 TAHUN TAHUN 2010 2011
DAFTAR TARIF RETRIBUSI PELAYANAN KESEHATAN DAN PERIZINAN DI BIDANG KESEHATAN
NO . 1 I 1 2 3 4
JENIS PEMERIKSAAN 2 Rawat jalan di Puskesmas dan Pustu Rawat jalan dokter umum Rawat jalan dokter gigi/intra oral camera konsultasi Rawat jalan pelayanan dokter spesialis. Rawat jalan pelayanan dokter spesialis luar.
Jumlah Tarif
Retribusi Jasa Pelayanan
Jasa Sarana
Keterangan
3
4
5
6
5,000 5,000 15,000 20,000
3,000 2,200 9,000 16,000
2,000 2,800 6,000 4,000
6,000 7,500 9,500 30,000 6,000 6,000 7,500 9,000 40,000 15,000 20,000 9,000 12,000 7,500 8,000
3,600 4,500 5,700 13,200 2,640 2,640 3,300 3,960 17,600 9,000 8,800 3,960 5,280 3,300 3,520
2,400 3,000 3,800 16,800 3,360 3,360 4,200 5,040 22,400 6,000 11,200 5,040 6,720 4,200 4,480
10,000
4,400
5,600
10,000 15,000 20,000
6,000 9,000 12,000
4,000 6,000 8,000
25,000 45,000 60,000
15,000 27,000 36,000
10,000 18,000 24,000
5,000 10,000
3,000 6,000
2,000 4,000
20,000 20,000 20,000 15,000 50,000 20,000 30,000 7,000 5,000 7,000 15,000 25,000 20,000
12,000 12,000 12,000 9,000 30,000 8,800 13,200 4,200 3,000 4,200 9,000 15,000 12,000
8,000 8,000 8,000 6,000 20,000 11,200 16,800 2,800 2,000 2,800 6,000 10,000 8,000
10,000 10,000
6,000 6,000
4,000 4,000
II Perawatan gigi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Cabut gigi susu Cabut gigi tetap seri, taring, premolar 1&2 Cabut gigi tetap dengan penyulit Cabut gigi tetap dengan cito jet Perawatan pulp capping dan Trepanasi Tumpatan sementara Tumpatan Amalgam Tumpatan glass ionomer Tumpatan Light cure Buang karang gigi manual Buang karang gigi ultrasonik Incisi abscess Operculectomy Koreksi oklusi Perawatan saluran akar
III Tindakan Medik 1 Debridement 2 Jahit luka luar a.Jahit luka 1-5 jahitan b. Jahit luka 6-10 jahitan c. Jahit luka > 10 jahitan 3 Jahit luka dalam a.Jahit luka 1-5 jahitan b. Jahit luka 6-10 jahitan c. Jahit luka > 10 jahitan 4 Lepas jahitan a. Lepas jahitan 1-5 jahitan b. Lepas jahitan 6-10 jahitan 5 Bedah Minor a.Atheroma b.Lipoma c.Clavus/Callus d.Telinga Dawir e.Circumsisi 6 a. Perawatan luka bakar < 10% b, Perawatan luka bakar > 10% Tidak kompleks 7 Mengobati Luka Excoriasi/lecet 8 Ganti perban 9 Tindik daun telinga 11 Incisi 12 Eksisi 13 Ekstraksi Kuku 14 Ekstrasi corpus alineum a. Telinga b. Hidung
10%
40%
Retribusi NO . 1 15 16 17 18 19 20 22 23
JENIS PEMERIKSAAN
Jumlah Tarif
Jasa Pelayanan
Jasa Sarana
Keterangan
2
3
4
5
6
20,000 7,500 25,000 10,000 15,000 10,000 25,000 35,000
12,000 4,500 15,000 6,000 9,000 6,000 15,000 21,000
8,000 3,000 10,000 4,000 6,000 4,000 10,000 14,000
15,000 10,000 25,000 30,000 500,000
9,000 6,000 15,000 18,000 300,000
6,000 4,000 10,000 12,000 200,000
10,000 10,000
4,400 6,000
5,600 4,000
Tindakan Fisioterapi Tindakan I ( 1 areal yang diterapi ) Tindakan II (2 areal yang diterapi) Tindakan III (2 areal plus manual terapi ) Tindakan IV (>3 areal plus manual terapi ) ASKES (1 paket)
7,500 21,000 27,000 35,000 50,000
3,300 9,240 11,880 15,400 22,000
4,200 11,760 15,120 19,600 28,000
Surat Keterangan Pemeriksaan / Pengujian Kesehatan Pemeriksaan Kesehatan Umum Calon Pengantin Pendidikan/Penataran bagi PNS Surat keterangan sakit Surat Ijin Pengambilan data penelitian Keterangan kehamilan/persalinan Surat keterangan tidak buta warna Surat keterangan tidak bertato Surat keterangan tidak bertindik Surat keterangan bebas narkoba Surat Keterangan Lansia
5,000 10,000 10,000 5,000 5,000 10,000 10,000 10,000 10,000 40,000 5,000
3,000 4,400 6,000 3,000 3,000 6,000 6,000 6,000 6,000 17,600 3,000
2,000 5,600 4,000 2,000 2,000 4,000 4,000 4,000 4,000 22,400 2,000
30,000 20,000 15,000
13,200 8,800 15,000
16,800 11,200 0
15,000
6,600
8,400
15,000 10,000
6,600 10,000
8,400 0
75,000
33,000
42,000
25,000 60,000 60,000 25,000 25,000 30,000 75,000 15,000
11,000 26,400 26,400 11,000 11,000 13,200 33,000 9,000
14,000 33,600 33,600 14,000 14,000 16,800 42,000 6,000
40,000
24,000
16,000
Suntikan ATS/SABU ( tidak termasuk Vaksin ) Pemeriksaan Tonometer Pasang kateter lepas kateter Pasang infuse Pemberian oksigen / Liter / jam Pemasangan spalk Pemakaian Nebulizer
IV. 1 2 3 4 5
Tindakan Obstetri dan Ginekologi Pemasangan IUD Pelepasan IUD Pemasangan implant Pelepasan implant Persalinan normal di Puskesmas dan Jaringannya 6 Biaya pengambilan pap smear / IVA 7 Senam Hamil
V 1 2 3 4 5 VI 1 2 3 4 5 6 7 8 9 10 11
VII Pemeriksaan Penunjang Diagnostik 1 Radiologi a. Film 35 x 35 b. Film 24 x 30 c. Jasa Baca Hasil 2 Radiologi Gigi Film 3 Elektro Kardio Graf (EKG) a. Pemeriksaan EKG b. Jasa Baca Hasil 4 Ultra Sono Grafi ( USG ) Pemeriksaan USG VIII A 1 2 3 4 5 6 7 8
Pelayanan Psikologi Anak dan Remaja Tes kesiapan masuk TK/SD Tes kecerdasan TK 4 ½ - 5 ½ tahun Tes kecerdasan SD-SMP-SLTA Tes bakat Tes minat Pemilihan jurusan pendidikan Tes kepribadian Konsultasi masalah psikologi (1x pertemuan)
9 Konseling /psikoterapi
Retribusi NO . 1 B 1 2 3 4 5 6
JENIS PEMERIKSAAN
2 Dewasa Tes kecerdasan Tes kepribadian Seleksi Promosi,mutasi karyawan biasa Seleksi promosi, mutasi Middle Management Seleksi promosi, mutasi Top Management Konsultasi masalah psikologi (1x pertemuan) 7 Konseling /psikoterapi 8 Pemeriksaan MMPI
IX Pemeriksaan Calon Jamaah Haji Pemeriksaan Kesehatan CJH diluar penunjang X Pelayanan lainnya 1 Konsultasi Sanitasi, Gizi 2 Test Kebugaran 3 Pemakaian Mobil Pusling - Pemakaian s/d 10 Km - Pemakaian > 10 Km (dihitung 4 Surat Keterangan Membawa Mayat Keluar Daerah XI RAWAT INAP 1 Visite dokter spesialis luar 2 Konsul via telpon Dokter spesialis 3 Visite dokter umum 4 Jaga perawat / bidan 5 Akomodasi / hari XII UGD 1 Pemeriksaan dokter jaga
XIII PEMERIKSAAN LABORATORIUM A. KIMIA LINGKUNGAN 1. Kimia dan Fisika Air 1. Bau 2. Rasa 3. Suhu 4. Warna 5. DHL/Daya Hantar Listrik 6. TSS/Zat tersuspensi 7. TDS/Zat Padat Terlarut 8. Kekeruhan 9. Besi terlarut (Fe) 10. Mangan 11. Seng 12. Timbal 13. Tembaga 14. Crom + 6 15. Arsen 16. Raksa 17. Selenium 18. Clorida 19. Magnesium 20. COD 21. BOD 22. Fenol 23. Sianida 24. Aluminium 25. Barium
Jumlah Tarif
Jasa Pelayanan
Jasa Sarana
Keterangan
3
4
5
6
50,000 75,000 60,000 80,000 125,000 18,000
22,000 33,000 26,400 35,200 55,000 7,920
28,000 42,000 33,600 44,800 70,000 10,080
40,000 85,000
24,000 34,000
16,000 51,000
50,000
22,000
28,000
5,000 10,000
3,000 4,400
2,000 5,600
35,000 5,000 100,000
21,000 4,500 60,000
14,000 500 40,000
60,000 20,000 5,000 5,000 35,000
48,000 18,000 3,000 3,000 21,000
12,000 2,000 2,000 2,000 14,000
15,000
9,000
6,000
7,000 7,000 7,000 22,000 22,000 23,000 23,000 28,000 35,000 45,000 45,000 45,000 45,000 45,000 75,000 75,000 75,000 35,000 30,000 56,000 37,000 37,000 27,000 30,000 56,000
2,800 2,800 2,800 8,800 8,800 9,200 9,200 11,200 14,000 18,000 18,000 18,000 18,000 18,000 30,000 30,000 30,000 14,000 12,000 22,400 14,800 14,800 10,800 12,000 22,400
4,200 4,200 4,200 13,200 13,200 13,800 13,800 16,800 21,000 27,000 27,000 27,000 27,000 27,000 45,000 45,000 45,000 21,000 18,000 33,600 22,200 22,200 16,200 18,000 33,600
Retribusi NO . 1
JENIS PEMERIKSAAN 2
Jumlah Tarif
Jasa Pelayanan
Jasa Sarana
3 35,000 35,000 20,000 45,000 45,000 40,000 45,000 15,000 50,000 36,000 30,000 44,200 38,000 95,000 70,000 70,000 25,000 35,000 35,000 44,000 45,000 10,000 45,000
4 14,000 14,000 8,000 18,000 18,000 16,000 18,000 6,000 20,000 14,400 12,000 17,680 15,200 38,000 28,000 28,000 10,000 14,000 14,000 17,600 18,000 4,000 18,000
5 21,000 21,000 12,000 27,000 27,000 24,000 27,000 9,000 30,000 21,600 18,000 26,520 22,800 57,000 42,000 42,000 15,000 21,000 21,000 26,400 27,000 6,000 27,000
2. Biologi dan Bakteriologi Air 1. Bentos 2. Plankton 3. TPC 4. MPN Coliform 5. MPN Coli Tinja 6. E.Coli 7. Salmonella 8. Shigella 9. S.Aureus 10. Strep. Faecalis 11. V. Cholera
60,000 80,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000
24,000 32,000 24,000 24,000 24,000 24,000 24,000 24,000 24,000 24,000 24,000
36,000 48,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000
3. Pemeriksaan Fisika lainnya 1. Pencahayaan 2. kebisingan 3. Geteran
10,000 45,000 125,000
4,000 18,000 50,000
6,000 27,000 75,000
60,000 60,000 60,000 60,000 60,000 60,000 60,000
24,000 24,000 24,000 24,000 24,000 24,000 24,000
36,000 36,000 36,000 36,000 36,000 36,000 36,000
45,000 45,000 45,000 45,000 45,000 45,000 45,000
18,000 18,000 18,000 18,000 18,000 18,000 18,000
27,000 27,000 27,000 27,000 27,000 27,000 27,000
26. Flourida 27. Cadmium 28. Kesadahan CaCO3 29. Natrium 30. Nitrit 31. Nitrat 32. Perak 33. PH 34. Sulfat ( SO4) 35. Sulfida (H2S) 36. DO/Oksigen terlarut 37. TOC 38. Minyak / Lemak 39. Boron 40. Nikel 41. Kobal 42. Sodium Absorbtion Ratio/SAR 43. Zat Organik 44. Amoniak 45. N-Total 46 Formalin 47. Sisa Chlor 48. Ozone
4 Makanan/Minuman a. Bakteriologi 1. Stapylococcus 2. E. Coli 3. V. Cholera 4. Salmonella 5. MPN Coliform 6. MPN Colitinja 7. Angka Kuman b. Kimiawi 1. Methyl Yellow 2. Borax 3. Rhodamin B. 4. Formalin 5. Siklamat 6. Sakarin 7. Arsenic
Keterangan 6
Retribusi JENIS PEMERIKSAAN NO . 1 2 B BIDANG HEMATOLOGI 1. Eosinofil, hitung jumlah 2. Limposit plasma biru, hitung jumlah 3. Morfologi sel 4. Retikulosit,hitung jumlah 5. Hematokrit, penetapan nilai 6. Hemoglobin eritrosit rata-rata/HER 7 Konsentrasi Hb eritrosit rata- rata/KHER 8. Volume eritrosit rata-rata/VER 9. Hematologi Analizer 10. Thrombosit 11. Pengambilan Sampling Pemeriksaan Laboratorium Dasar 1. Eritrosit, hitung jumlah 2. Lekosit hitung jumlah 3. Lekosit, hitung jenis 4. Hemogloben, penetapan kadar 5. Pembekuan, masa 6. Perdarahan, masa 7. Laju endapan Darah 8. Penetapan Golongan Darah C BIDANG PATOLOGI A. Protien dan NPN 1. Albumin 2. Asam Urat 3. Bilirubin 4. Globulin 5. Kreatinin 6. Nitrit 7. Protien Benco Jones 8. Protien , Penetapan jumlah 9. Urea/Bun 10. Urobilin 11. Urobilinoge B. Karbohidrat 1. Glukosa sewaktu 2. Glukosa Puasa 3. Glukosa, Kurva toleransi Glokusa 3x /5x C. Lipid, Lipoprotien, Apoprotien 1. Fosfolipid/serebrosit, sfingolipid 2. HDL Cholesterol 3. LDL Cholesterol 4. Kolesterol 5. Tringliserid D. Enzim 1. Alkali fosfatase 2. Gamma GT/Glutamil Transferas 3. Glutamat Oksaloasetik Transaminase/GOT 4. Glutamat Viruvat Transminase /SGPT 5. Laktat Dehidrogenase/LDH 6. CK-MB ( Pemeriksaan Jantung ) 7. CK_NAC 8. CPK/CK
Jumlah Tarif
Jasa Pelayanan
Jasa Sarana
Keterangan
3
4
5
6
4,000 4,000 15,000 4,500 15,000 5,000 5,000 5,000 35,000 15,000 4,000
1,600 1,600 6,000 1,800 6,000 2,000 2,000 2,000 14,000 6,000 1,600
2,400 2,400 9,000 2,700 9,000 3,000 3,000 3,000 21,000 9,000 2,400
4,000 4,000 4,000 4,000 7,500 3,000 3,000 3,000
1,600 1,600 1,600 1,600 3,000 1,200 1,200 1,200
2,400 2,400 2,400 2,400 4,500 1,800 1,800 1,800
10,000 10,000 10,000 7,500 10,000 4,000 7,500 7,000 10,000 5,000 5,000
4,000 4,000 4,000 3,000 4,000 1,600 3,000 2,800 4,000 2,000 2,000
6,000 6,000 6,000 4,500 6,000 2,400 4,500 4,200 6,000 3,000 3,000
8,000 8,000 8,000
3,200 3,200 3,200
4,800 4,800 4,800
10,000 15,000 40,000 10,000 17,000
4,000 6,000 16,000 4,000 6,800
6,000 9,000 24,000 6,000 10,200
10,000 20,000 10,000
4,000 8,000 4,000
6,000 12,000 6,000
10,000 20,000 40,000 40,000 40,000
4,000 8,000 16,000 16,000 16,000
6,000 12,000 24,000 24,000 24,000
Retribusi JENIS PEMERIKSAAN NO . 1 2 D BIDANG MIKROBIOLOGI A. Bakteriologi 1. Sputum per slide 2. P. Gram 3. KOH/NaCL/M.Blue 4. Hansen BTA (paket) B. Parasitologi 1. Malaria Mikroskopis 2. Mikrofilaria 3. Malaria Stik E
BIDANG SEROLOGI 1. Widal Test 2. Hepatitis B Aglutinasi (HBs-AG) (HBs-AG) 3. Tes Kehamilan 4. Hepatitis B Antibodi (HBs-AB) 5. Narkoba 6. Cholenesterasi 7. VDRL (Sfilis) 8. HIV 9. TPHA 10. Rheumatoid Faktor (RAF) 11. Anti HCV 12. Asto Pemeriksaan Laboratorium Dasar 1. Analisa Tinja 2. Pemeriksaan Telor Cacing 3. Urin lengkap 4. Analisa Batu 5. Analisa sperma 6. Reduksi.
Jumlah Tarif
Jasa Pelayanan
Jasa Sarana
Keterangan
3
4
5
6
5,000 10,000 10,000 15,000
2,000 4,000 4,000 6,000
3,000 6,000 6,000 9,000
10,000 15,000 20,000
4,000 6,000 8,000
6,000 9,000 12,000
18,000
7,200
10,800
18,000
7,200
10,800
15,000 18,000 40,000 50,000 18,000 20,000 18,000 18,000 50,000 18,000
6,000 7,200 16,000 20,000 7,200 8,000 7,200 7,200 20,000 7,200
9,000 10,800 24,000 30,000 10,800 12,000 10,800 10,800 30,000 10,800
16,000 10,000 10,000 16,000 16,000 2,000
6,400 4,000 4,000 6,400 6,400 800
9,600 6,000 6,000 9,600 9,600 1,200 `
44%
50%
60%
80%
90%
