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BAB IV INFORMASI YANG DISAMPAIKAN SAAT ADMISI
DAFTAR HARGA PERAWATAN TARIF OPERASI SEDANG (odontektomi 2 gigi)
RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
ODC
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
7,500,000
5,500,000
200,000
500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
3
Sewa Ruang Perawatan Intensif (HCU)
100,000
3,600,000
JUMLAH I
150,000
5,650,000
7,700,000
6,000,000
II. BAHAN HABIS PAKAI
1
Anestesi & Reanimasi
Isofluran / Dexofluran / Cevofluran
1
Jam
Gas Medis
2
Jam
7,000
14,000
Propofol
1
amp
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
ETT
1
pcs
250,000
250,000
Narkotik
1
amp
45,000
45,000
Infus Set
1
pcs
20,000
20,000
300,000
300,000 14,000 76,000 60,000 250,000 45,000 20,000
300,000
300,000
14,000
14,000
76,000
76,000
60,000
60,000
250,000
250,000
45,000
45,000
20,000
20,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
Jarum Infus
1
pcs
10,000
10,000
Cairan Infus 500 cc
5
flush
15,000
75,000
Tampon Pita
1
pcs
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
Mayo
1
pcs
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
Ephedrine
1
amp
50,000
50,000
Lidocaine
1
amp
2,500
2,500
Adrenaline
1
amp
10,000
10,000
Prostigmine
1
amp
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
Spuit 5 cc
2
pcs
4,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
2
pcs
6,000
12,000
1
pcs
20,000
20,000
2
pcs
2,500
5,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
☐ Prostodonsia
Spuit 20 cc
☐ Periodonsia
Spuit 50 cc
☐ Ilmu Penyakit Mulut
10,000 75,000 2,000 9,000 15,000 10,000 6,000 6,000 50,000 2,500 10,000 50,000 5,000 8,000 12,000 12,000 55,000 70,000
12,000
20,000
10,000
10,000
75,000
75,000
2,000
2,000
9,000
9,000
15,000
15,000
10,000
10,000
6,000
6,000
6,000
6,000
50,000
50,000
2,500
2,500
10,000
10,000
50,000
50,000
5,000
5,000
8,000
8,000
12,000
12,000
12,000
12,000
55,000
55,000
70,000
70,000
12,000
12,000
20,000
20,000
5,000
5,000
Surgical Blade #11 Surgical Blade #15
5,000
Needle 24G
2
pcs
5,000
10,000
Lidocaine
4
amp
2,000
8,000
Pehacaine
4
amp
7,500
30,000
Handscoon Non Steril
10
pcs
500
5,000
Handscoon Gamex
3
pasang
20,000
60,000
Masker
5
pcs
500
2,500
Surgical Cap
5
pcs
500
2,500
Apron Plastik
4
pcs
5,000
20,000
Underpad
2
pcs
5,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
Vicryl 3.0
3
pcs
125,000
375,000
Round Bur
2
pcs
50,000
100,000
Fissure Bur
2
pcs
50,000
100,000
Plastik Handstook
3
pcs
500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000
10,000
8,000
8,000
30,000
30,000
5,000
5,000
60,000
60,000
2,500
2,500
2,500
2,500
20,000
20,000
10,000
10,000
3,500
3,500
60,000
60,000
30,000
30,000
375,000
375,000
100,000
100,000
100,000
100,000
1,500
1,500
10,000
10,000
Needle 27G 8,000 30,000 5,000 60,000 2,500 2,500 20,000 10,000 3,500 60,000 30,000 375,000
Vicryl 4.0 Silk 2.0 Silk 3.0 Nylon 5.0
Folley Catheter Urine Bag NGT
100,000 100,000 1,500 10,000
Radon Drain Plester / Hypafix 3
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, …………………………
Jumlah II
2,037,500
Jumlah I + II
5,637,500
2,037,500 7,687,500
2,037,500
2,037,500
9,737,500
8,037,500
3,895,000
3,215,000
1,558,000
1,286,000
155,800
128,600
155,800
128,600
5,764,600
4,758,200
15,502,100
12,795,700
15,600,000
13,000,000
1,560,000
1,300,000
1,950,000
1,625,000
3,510,000
2,925,000
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
2
Dokter Anestesi & Reanimasi
40 % Operator
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
90,200
5
Perawat OK / Bedah / Instrumen
4 % Operator
90,200
6
Dokter HCU
2,255,000 902,000
Jumlah III
3,337,400
Jumlah I + II + III
8,974,900
Pembulatan Jumlah I + II + III
9,200,000
3,075,000 1,230,000
123,000 123,000
4,551,000 12,238,500 12,400,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
2
Lain-lain
12.5 % Jumlah I + II + III Jumlah IV JUMLAH TOTAL
920,000 1,150,000 2,070,000
11,270,000
1,240,000 1,550,000 2,790,000
15,190,000
19,110,000
15,925,000
TARIF OPERASI BESAR (enukleasi kista, osteomyelitis) RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
100,000
150,000
3,600,000
5,650,000
300,000
300,000
7,500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
3
Sewa Ruang Perawatan Intensif (HCU) JUMLAH I
200,000
7,700,000
II. BAHAN HABIS PAKAI
1
Isofluran / Dexofluran / Cevofluran
1
Jam
Gas Medis
3
Jam
7,000
21,000
21,000
Propofol
1
amp
76,000
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
60,000
ETT
1
pcs
250,000
250,000
250,000
Narkotik
1
amp
45,000
45,000
45,000
Infus Set
1
pcs
20,000
20,000
20,000
Jarum Infus
1
pcs
10,000
10,000
10,000
Anestesi & Reanimasi
300,000 21,000 76,000 60,000 250,000 45,000 20,000 10,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
Cairan Infus 500 cc
5
flush
15,000
75,000
75,000
Tampon Pita
1
pcs
2,000
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
9,000
Mayo
1
pcs
15,000
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
6,000
Ephedrine
1
amp
50,000
50,000
50,000
Lidocaine
1
amp
2,500
2,500
2,500
Adrenaline
1
amp
10,000
10,000
10,000
Prostigmine
1
amp
50,000
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
5,000
Spuit 5 cc
2
pcs
4,000
8,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
70,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
2
pcs
6,000
12,000
12,000
☐ Prostodonsia
Spuit 20 cc
1
pcs
12,000
12,000
12,000
☐ Periodonsia
Spuit 50 cc
1
pcs
20,000
20,000
20,000
2
pcs
2,500
5,000
5,000
☐ Ilmu Penyakit Mulut
75,000 2,000 9,000 15,000 10,000 6,000 6,000 50,000 2,500 10,000 50,000 5,000 8,000 12,000 12,000 55,000 70,000
12,000 12,000 20,000
Surgical Blade #11 Surgical Blade #15
5,000
Needle 24G
2
pcs
5,000
10,000
10,000
Needle 27G
2
pcs
7,500
15,000
15,000
Lidocaine
4
amp
2,000
8,000
8,000
Pehacaine
4
amp
7,500
30,000
30,000
Handscoon Non Steril
10
pcs
500
5,000
5,000
Handscoon Gamex
3
pasang
20,000
60,000
60,000
Masker
5
pcs
500
2,500
2,500
Surgical Cap
5
pcs
500
2,500
2,500
Apron Plastik
4
pcs
5,000
20,000
20,000
Underpad
2
pcs
5,000
10,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
30,000
Vicryl 3.0
2
pcs
125,000
250,000
250,000
2
pcs
50,000
100,000
100,000
Round Bur
2
pcs
50,000
100,000
100,000
Fissure Bur
2
pcs
50,000
100,000
100,000
Plastik Handstook
3
pcs
500
1,500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000 15,000 8,000 30,000 5,000 60,000 2,500 2,500 20,000 10,000 3,500 60,000 30,000 250,000
Vicryl 4.0 Silk 2.0 Silk 3.0
100,000
Nylon 5.0
Folley Catheter Urine Bag
100,000 100,000 1,500 10,000
NGT Radon Drain
3
Plester / Hypafix
1
roll
35,000
35,000
35,000
Spongostan
2
pcs
100,000
200,000
200,000
Kasa Pita
2
pcs
20,000
40,000
40,000
Kalmycetin Salep
2
tube
20,000
40,000
40,000
Carnoy Solution
1
btl
75,000
75,000
75,000
Jumlah II
2,436,500
2,436,500
Jumlah I + II
6,036,500
8,086,500
2,414,600
3,234,600
965,840
1,293,840
35,000 200,000 40,000 40,000 75,000
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, ………………………… 2,436,500 10,136,500
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
2
Dokter Anestesi & Reanimasi
40 % Operator
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
96,584
129,384
5
Perawat OK / Bedah / Instrumen
4 % Operator
96,584
129,384
6
Dokter HCU Jumlah III
3,573,608
4,787,208
Jumlah I + II + III
9,610,108
12,873,708
Pembulatan Jumlah I + II + III
9,800,000
13,000,000
980,000
1,300,000
4,054,600 1,621,840
162,184 162,184
6,000,808 16,137,308 16,200,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
1,620,000
2
Lain-lain
12.5 % Jumlah I + II + III Jumlah IV JUMLAH TOTAL
1,225,000
1,625,000
2,205,000
2,925,000
12,005,000
15,925,000
TARIF OPERASI CANGGIH (bedah ortognatik) RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
7,500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
100,000
150,000
200,000
3
Sewa Ruang Perawatan Intensif (HCU)
500,000
550,000
600,000
JUMLAH I
4,100,000
6,200,000
8,300,000
II. BAHAN HABIS PAKAI
1
Isofluran / Dexofluran / Cevofluran
1
Jam
300,000
300,000
300,000
Gas Medis
6
Jam
7,000
42,000
42,000
42,000
Propofol
1
amp
76,000
76,000
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
60,000
60,000
Anestesi & Reanimasi
2,025,000 3,645,000 19,845,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
ETT
1
pcs
250,000
250,000
250,000
250,000
Narkotik
1
amp
45,000
45,000
45,000
45,000
Infus Set
1
pcs
20,000
20,000
20,000
20,000
Jarum Infus
1
pcs
10,000
10,000
10,000
10,000
Cairan Infus 500 cc
5
flush
15,000
75,000
75,000
75,000
Tampon Pita
1
pcs
2,000
2,000
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
9,000
9,000
Mayo
1
pcs
15,000
15,000
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
6,000
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
6,000
6,000
Ephedrine
1
amp
50,000
50,000
50,000
50,000
Lidocaine
1
amp
2,500
2,500
2,500
2,500
Adrenaline
1
amp
10,000
10,000
10,000
10,000
Prostigmine
1
amp
50,000
50,000
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
5,000
5,000
Spuit 5 cc
2
pcs
4,000
8,000
8,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
12,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
70,000
70,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
2
pcs
4,000
8,000
8,000
8,000
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
2
pcs
6,000
12,000
12,000
12,000
☐ Prostodonsia
Spuit 20 cc
☐ Periodonsia ☐ Ilmu Penyakit Mulut
Spuit 50 cc
1
pcs
20,000
20,000
20,000
20,000
2
pcs
2,500
5,000
5,000
5,000
Needle 27G
2
pcs
7,500
15,000
15,000
15,000
Lidocaine
4
amp
2,000
8,000
8,000
8,000
Pehacaine
4
amp
7,500
30,000
30,000
30,000
Handscoon Non Steril
10
pcs
500
5,000
5,000
5,000
Handscoon Gamex
3
pasang
20,000
60,000
60,000
60,000
Masker
5
pcs
500
2,500
2,500
2,500
Surgical Cap
5
pcs
500
2,500
2,500
2,500
Apron Plastik
4
pcs
5,000
20,000
20,000
20,000
Underpad
2
pcs
5,000
10,000
10,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
3,500
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
60,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
30,000
30,000
Vicryl 3.0
4
pcs
125,000
500,000
500,000
500,000
Round Bur
2
pcs
50,000
100,000
100,000
100,000
Fissure Bur
2
pcs
50,000
100,000
100,000
100,000
Plastik Handstook
3
pcs
500
1,500
1,500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000
Surgical Blade #11 Surgical Blade #15 Needle 24G
Vicryl 4.0 Silk 2.0 Silk 3.0 Nylon 5.0
3
Folley Catheter
1
pcs
125,000
125,000
125,000
125,000
Urine Bag
1
pcs
80,000
80,000
80,000
80,000
NGT
1
pcs
25,000
25,000
25,000
25,000
Radon Drain
2
pcs
200,000
400,000
400,000
400,000
Plester / Hypafix
1
roll
35,000
35,000
35,000
35,000
Linderman Bur Pendek
1
pcs
900,000
900,000
900,000
900,000
Linderman Bur Panjang
1
pcs
900,000
900,000
900,000
900,000
Alginat
1
15,000
15,000
15,000
15,000
Gips
1
15,000
15,000
15,000
15,000
Wafer
1
pcs
250,000
250,000
250,000
250,000
Wire ⌀ 0.4 mm
1
m
30,000
30,000
30,000
30,000
Screw 2 mm
32
pcs
172,000
5,504,000
5,504,000
5,504,000
Plate L Shape 4 Hole 2.0 mm
4
pcs
559,000
2,236,000
2,236,000
2,236,000
Plate 4 Hole w/ Stem 1.7 mm
1
pcs
1,805,000
1,805,000
1,805,000
1,805,000
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, ………………………… Jumlah II
14,523,500
14,523,500
14,523,500
Jumlah I + II
18,623,500
20,723,500
22,823,500
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
7,449,400
8,289,400
9,129,400
2
Dokter Anestesi & Reanimasi
40 % Operator
2,979,760
3,315,760
3,651,760
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
297,976
331,576
365,176
5
Perawat OK / Bedah / Instrumen
4 % Operator
297,976
331,576
365,176
6
Dokter HCU
150,000
200,000
250,000
Jumlah III
11,175,112
12,468,312
13,761,512
Jumlah I + II + III
29,798,612
33,191,812
36,585,012
Pembulatan Jumlah I + II + III
30,000,000
33,400,000
36,800,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
3,000,000
3,340,000
3,680,000
2
Lain-lain
12.5 % Jumlah I + II + III
3,750,000
4,175,000
4,600,000
Jumlah IV
6,750,000
JUMLAH TOTAL
36,750,000
7,515,000 40,915,000
DIREKTUR
Prof. Coen Pramono D, drg.,SU.,SpBM(K)
8,280,000 45,080,000
NIP.19540210.1979011.001
DAFTAR HARGA PERAWATAN TARIF OPERASI SEDANG (odontektomi 2 gigi)
RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
ODC
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
7,500,000
5,500,000
200,000
500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
3
Sewa Ruang Perawatan Intensif (HCU)
100,000
3,600,000
JUMLAH I
150,000
5,650,000
7,700,000
6,000,000
II. BAHAN HABIS PAKAI
1
Anestesi & Reanimasi
Isofluran / Dexofluran / Cevofluran
1
Jam
Gas Medis
2
Jam
7,000
14,000
Propofol
1
amp
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
ETT
1
pcs
250,000
250,000
Narkotik
1
amp
45,000
45,000
Infus Set
1
pcs
20,000
20,000
300,000
300,000 14,000 76,000 60,000 250,000 45,000 20,000
300,000
300,000
14,000
14,000
76,000
76,000
60,000
60,000
250,000
250,000
45,000
45,000
20,000
20,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
Jarum Infus
1
pcs
10,000
10,000
Cairan Infus 500 cc
5
flush
15,000
75,000
Tampon Pita
1
pcs
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
Mayo
1
pcs
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
Ephedrine
1
amp
50,000
50,000
Lidocaine
1
amp
2,500
2,500
Adrenaline
1
amp
10,000
10,000
Prostigmine
1
amp
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
Spuit 5 cc
2
pcs
4,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
2
pcs
6,000
12,000
1
pcs
20,000
20,000
2
pcs
2,500
5,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
☐ Prostodonsia
Spuit 20 cc
☐ Periodonsia
Spuit 50 cc
☐ Ilmu Penyakit Mulut
10,000 75,000 2,000 9,000 15,000 10,000 6,000 6,000 50,000 2,500 10,000 50,000 5,000 8,000 12,000 12,000 55,000 70,000
12,000
20,000
10,000
10,000
75,000
75,000
2,000
2,000
9,000
9,000
15,000
15,000
10,000
10,000
6,000
6,000
6,000
6,000
50,000
50,000
2,500
2,500
10,000
10,000
50,000
50,000
5,000
5,000
8,000
8,000
12,000
12,000
12,000
12,000
55,000
55,000
70,000
70,000
12,000
12,000
20,000
20,000
5,000
5,000
Surgical Blade #11 Surgical Blade #15
5,000
Needle 24G
2
pcs
5,000
10,000
Lidocaine
4
amp
2,000
8,000
Pehacaine
4
amp
7,500
30,000
Handscoon Non Steril
10
pcs
500
5,000
Handscoon Gamex
3
pasang
20,000
60,000
Masker
5
pcs
500
2,500
Surgical Cap
5
pcs
500
2,500
Apron Plastik
4
pcs
5,000
20,000
Underpad
2
pcs
5,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
Vicryl 3.0
3
pcs
125,000
375,000
Round Bur
2
pcs
50,000
100,000
Fissure Bur
2
pcs
50,000
100,000
Plastik Handstook
3
pcs
500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000
10,000
8,000
8,000
30,000
30,000
5,000
5,000
60,000
60,000
2,500
2,500
2,500
2,500
20,000
20,000
10,000
10,000
3,500
3,500
60,000
60,000
30,000
30,000
375,000
375,000
100,000
100,000
100,000
100,000
1,500
1,500
10,000
10,000
Needle 27G 8,000 30,000 5,000 60,000 2,500 2,500 20,000 10,000 3,500 60,000 30,000 375,000
Vicryl 4.0 Silk 2.0 Silk 3.0 Nylon 5.0
Folley Catheter Urine Bag NGT
100,000 100,000 1,500 10,000
Radon Drain Plester / Hypafix 3
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, …………………………
Jumlah II
2,037,500
Jumlah I + II
5,637,500
2,037,500 7,687,500
2,037,500
2,037,500
9,737,500
8,037,500
3,895,000
3,215,000
1,558,000
1,286,000
155,800
128,600
155,800
128,600
5,764,600
4,758,200
15,502,100
12,795,700
15,600,000
13,000,000
1,560,000
1,300,000
1,950,000
1,625,000
3,510,000
2,925,000
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
2
Dokter Anestesi & Reanimasi
40 % Operator
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
90,200
5
Perawat OK / Bedah / Instrumen
4 % Operator
90,200
6
Dokter HCU
2,255,000 902,000
Jumlah III
3,337,400
Jumlah I + II + III
8,974,900
Pembulatan Jumlah I + II + III
9,200,000
3,075,000 1,230,000
123,000 123,000
4,551,000 12,238,500 12,400,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
2
Lain-lain
12.5 % Jumlah I + II + III Jumlah IV JUMLAH TOTAL
920,000 1,150,000 2,070,000
11,270,000
1,240,000 1,550,000 2,790,000
15,190,000
19,110,000
15,925,000
TARIF OPERASI BESAR (enukleasi kista, osteomyelitis) RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
100,000
150,000
3,600,000
5,650,000
300,000
300,000
7,500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
3
Sewa Ruang Perawatan Intensif (HCU) JUMLAH I
200,000
7,700,000
II. BAHAN HABIS PAKAI
1
Isofluran / Dexofluran / Cevofluran
1
Jam
Gas Medis
3
Jam
7,000
21,000
21,000
Propofol
1
amp
76,000
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
60,000
ETT
1
pcs
250,000
250,000
250,000
Narkotik
1
amp
45,000
45,000
45,000
Infus Set
1
pcs
20,000
20,000
20,000
Jarum Infus
1
pcs
10,000
10,000
10,000
Anestesi & Reanimasi
300,000 21,000 76,000 60,000 250,000 45,000 20,000 10,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
Cairan Infus 500 cc
5
flush
15,000
75,000
75,000
Tampon Pita
1
pcs
2,000
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
9,000
Mayo
1
pcs
15,000
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
6,000
Ephedrine
1
amp
50,000
50,000
50,000
Lidocaine
1
amp
2,500
2,500
2,500
Adrenaline
1
amp
10,000
10,000
10,000
Prostigmine
1
amp
50,000
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
5,000
Spuit 5 cc
2
pcs
4,000
8,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
70,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
2
pcs
6,000
12,000
12,000
☐ Prostodonsia
Spuit 20 cc
1
pcs
12,000
12,000
12,000
☐ Periodonsia
Spuit 50 cc
1
pcs
20,000
20,000
20,000
2
pcs
2,500
5,000
5,000
☐ Ilmu Penyakit Mulut
75,000 2,000 9,000 15,000 10,000 6,000 6,000 50,000 2,500 10,000 50,000 5,000 8,000 12,000 12,000 55,000 70,000
12,000 12,000 20,000
Surgical Blade #11 Surgical Blade #15
5,000
Needle 24G
2
pcs
5,000
10,000
10,000
Needle 27G
2
pcs
7,500
15,000
15,000
Lidocaine
4
amp
2,000
8,000
8,000
Pehacaine
4
amp
7,500
30,000
30,000
Handscoon Non Steril
10
pcs
500
5,000
5,000
Handscoon Gamex
3
pasang
20,000
60,000
60,000
Masker
5
pcs
500
2,500
2,500
Surgical Cap
5
pcs
500
2,500
2,500
Apron Plastik
4
pcs
5,000
20,000
20,000
Underpad
2
pcs
5,000
10,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
30,000
Vicryl 3.0
2
pcs
125,000
250,000
250,000
2
pcs
50,000
100,000
100,000
Round Bur
2
pcs
50,000
100,000
100,000
Fissure Bur
2
pcs
50,000
100,000
100,000
Plastik Handstook
3
pcs
500
1,500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000 15,000 8,000 30,000 5,000 60,000 2,500 2,500 20,000 10,000 3,500 60,000 30,000 250,000
Vicryl 4.0 Silk 2.0 Silk 3.0
100,000
Nylon 5.0
Folley Catheter Urine Bag
100,000 100,000 1,500 10,000
NGT Radon Drain
3
Plester / Hypafix
1
roll
35,000
35,000
35,000
Spongostan
2
pcs
100,000
200,000
200,000
Kasa Pita
2
pcs
20,000
40,000
40,000
Kalmycetin Salep
2
tube
20,000
40,000
40,000
Carnoy Solution
1
btl
75,000
75,000
75,000
Jumlah II
2,436,500
2,436,500
Jumlah I + II
6,036,500
8,086,500
2,414,600
3,234,600
965,840
1,293,840
35,000 200,000 40,000 40,000 75,000
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, ………………………… 2,436,500 10,136,500
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
2
Dokter Anestesi & Reanimasi
40 % Operator
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
96,584
129,384
5
Perawat OK / Bedah / Instrumen
4 % Operator
96,584
129,384
6
Dokter HCU Jumlah III
3,573,608
4,787,208
Jumlah I + II + III
9,610,108
12,873,708
Pembulatan Jumlah I + II + III
9,800,000
13,000,000
980,000
1,300,000
4,054,600 1,621,840
162,184 162,184
6,000,808 16,137,308 16,200,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
1,620,000
2
Lain-lain
12.5 % Jumlah I + II + III Jumlah IV JUMLAH TOTAL
1,225,000
1,625,000
2,205,000
2,925,000
12,005,000
15,925,000
TARIF OPERASI CANGGIH (bedah ortognatik) RUMAH SAKIT GIGI DAN MULUT UNIVERSITAS AIRLANGGA JUMLAH No
JENIS PELAYANAN
RINCIAN
HARGA
TARIF
SATUAN KEPERLUAN
SATUAN
KELAS 3
KELAS 2
KELAS 1
I. SARANA & PRASARANA 1. Mesin Anestesi, Syringe Pump, Monitor 2. Instrumen Bedah & Anestesi 1
Sewa Kamar Operasi (OK)
3. Listrik & Pendingin Ruangan
3,500,000
5,500,000
7,500,000
4. CSSD + Linen + Laundry 5. Maintenance 2
Sewa Ruang Pulih Sadar (RR)
100,000
150,000
200,000
3
Sewa Ruang Perawatan Intensif (HCU)
500,000
550,000
600,000
JUMLAH I
4,100,000
6,200,000
8,300,000
II. BAHAN HABIS PAKAI
1
Isofluran / Dexofluran / Cevofluran
1
Jam
300,000
300,000
300,000
Gas Medis
6
Jam
7,000
42,000
42,000
42,000
Propofol
1
amp
76,000
76,000
76,000
76,000
Muscle Relaxant
2
amp
30,000
60,000
60,000
60,000
Anestesi & Reanimasi
2,025,000 3,645,000 19,845,000
2
Operator RSGM (salah satu) ☐ Bedah Mulut dan Maksilofasial
ETT
1
pcs
250,000
250,000
250,000
250,000
Narkotik
1
amp
45,000
45,000
45,000
45,000
Infus Set
1
pcs
20,000
20,000
20,000
20,000
Jarum Infus
1
pcs
10,000
10,000
10,000
10,000
Cairan Infus 500 cc
5
flush
15,000
75,000
75,000
75,000
Tampon Pita
1
pcs
2,000
2,000
2,000
2,000
ECG Electrode
3
pcs
3,000
9,000
9,000
9,000
Mayo
1
pcs
15,000
15,000
15,000
15,000
Suction Catheter
1
pcs
10,000
10,000
10,000
10,000
Handscoon Non Steril
12
pcs
500
6,000
6,000
6,000
Atrophin / Sulfas Atrophin
1
amp
6,000
6,000
6,000
6,000
Ephedrine
1
amp
50,000
50,000
50,000
50,000
Lidocaine
1
amp
2,500
2,500
2,500
2,500
Adrenaline
1
amp
10,000
10,000
10,000
10,000
Prostigmine
1
amp
50,000
50,000
50,000
50,000
Spuit 3 cc
2
pcs
2,500
5,000
5,000
5,000
Spuit 5 cc
2
pcs
4,000
8,000
8,000
8,000
Spuit 10 cc
2
pcs
6,000
12,000
12,000
12,000
Spuit 20 cc
1
pcs
12,000
12,000
12,000
12,000
Povidon Iodine 10 % 100 ml
1
btl
55,000
55,000
55,000
55,000
Alkohol 70 % 100 ml
1
btl
70,000
70,000
70,000
70,000
☐ Ortodonsia
Spuit 3 cc
☐ Konservasi Gigi
Spuit 5 cc
2
pcs
4,000
8,000
8,000
8,000
☐ Ilmu Kedokteran Gigi Anak
Spuit 10 cc
2
pcs
6,000
12,000
12,000
12,000
☐ Prostodonsia
Spuit 20 cc
☐ Periodonsia ☐ Ilmu Penyakit Mulut
Spuit 50 cc
1
pcs
20,000
20,000
20,000
20,000
2
pcs
2,500
5,000
5,000
5,000
Needle 27G
2
pcs
7,500
15,000
15,000
15,000
Lidocaine
4
amp
2,000
8,000
8,000
8,000
Pehacaine
4
amp
7,500
30,000
30,000
30,000
Handscoon Non Steril
10
pcs
500
5,000
5,000
5,000
Handscoon Gamex
3
pasang
20,000
60,000
60,000
60,000
Masker
5
pcs
500
2,500
2,500
2,500
Surgical Cap
5
pcs
500
2,500
2,500
2,500
Apron Plastik
4
pcs
5,000
20,000
20,000
20,000
Underpad
2
pcs
5,000
10,000
10,000
10,000
Kasa Tampon / Kasa Steril
20
pcs
175
3,500
3,500
3,500
Pz / NaCl 500 cc
4
flush
15,000
60,000
60,000
60,000
Gentamycin Salep
2
tube
15,000
30,000
30,000
30,000
Vicryl 3.0
4
pcs
125,000
500,000
500,000
500,000
Round Bur
2
pcs
50,000
100,000
100,000
100,000
Fissure Bur
2
pcs
50,000
100,000
100,000
100,000
Plastik Handstook
3
pcs
500
1,500
1,500
1,500
Suction Tip Plastik
1
pcs
10,000
10,000
10,000
10,000
Surgical Blade #11 Surgical Blade #15 Needle 24G
Vicryl 4.0 Silk 2.0 Silk 3.0 Nylon 5.0
3
Folley Catheter
1
pcs
125,000
125,000
125,000
125,000
Urine Bag
1
pcs
80,000
80,000
80,000
80,000
NGT
1
pcs
25,000
25,000
25,000
25,000
Radon Drain
2
pcs
200,000
400,000
400,000
400,000
Plester / Hypafix
1
roll
35,000
35,000
35,000
35,000
Linderman Bur Pendek
1
pcs
900,000
900,000
900,000
900,000
Linderman Bur Panjang
1
pcs
900,000
900,000
900,000
900,000
Alginat
1
15,000
15,000
15,000
15,000
Gips
1
15,000
15,000
15,000
15,000
Wafer
1
pcs
250,000
250,000
250,000
250,000
Wire ⌀ 0.4 mm
1
m
30,000
30,000
30,000
30,000
Screw 2 mm
32
pcs
172,000
5,504,000
5,504,000
5,504,000
Plate L Shape 4 Hole 2.0 mm
4
pcs
559,000
2,236,000
2,236,000
2,236,000
Plate 4 Hole w/ Stem 1.7 mm
1
pcs
1,805,000
1,805,000
1,805,000
1,805,000
Operator Non RSGM (salah satu) ☐ Bedah Umum ☐ Lain-lain, ………………………… Jumlah II
14,523,500
14,523,500
14,523,500
Jumlah I + II
18,623,500
20,723,500
22,823,500
III. TIM 1
Dokter Operator RSGM
40 % Jumlah I + II
7,449,400
8,289,400
9,129,400
2
Dokter Anestesi & Reanimasi
40 % Operator
2,979,760
3,315,760
3,651,760
3
Dokter Operator Non RSGM
25 % Operator
4
Perawat Anestesi & Reanimasi
4 % Operator
297,976
331,576
365,176
5
Perawat OK / Bedah / Instrumen
4 % Operator
297,976
331,576
365,176
6
Dokter HCU
150,000
200,000
250,000
Jumlah III
11,175,112
12,468,312
13,761,512
Jumlah I + II + III
29,798,612
33,191,812
36,585,012
Pembulatan Jumlah I + II + III
30,000,000
33,400,000
36,800,000
IV. ADMINISTRASI 1
Administrasi Rumah Sakit
10 % Jumlah I + II + III
3,000,000
3,340,000
3,680,000
2
Lain-lain
12.5 % Jumlah I + II + III
3,750,000
4,175,000
4,600,000
Jumlah IV
6,750,000
JUMLAH TOTAL
36,750,000
7,515,000 40,915,000
DIREKTUR
Prof. Coen Pramono D, drg.,SU.,SpBM(K)
8,280,000 45,080,000
NIP.19540210.1979011.001
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