Biaya / Tarif Pelayanan
Tarif pelayanan kesehatan di puskesmas
ditetapkan Berdasarkan Peraturan Bupati Tulungagung Nomor 14 Tahun 2021 Tentang
Tarif Layanan Pada Badan Layanan Umum Daerah Unit Pelaksana teknis Pusat
Kesehatan Masyarakat Kabupaten Tulungagung.
Tarif layanan dari jenis-jenis pelayanan kesehatan di puskesmas
|
No |
Jenis Pelayanan |
Satuan |
Jasa Sarana |
Jasa Sarana |
Tarif (Rp) |
|
1. |
Pelayanan rawat jalan |
|
|
|
|
|
|
Pemeriksaan di Poli Puskesmas |
/ kali |
6.000 |
4.000 |
10.000 |
|
|
Pemeriksaan di
Pustu dan Poskesdes |
/ kali |
5.000 |
3.000 |
8.000 |
|
2. |
Pelayanan konsultasi |
|
|
|
|
|
|
Konsultasi Gizi, Sanitasi perorangan, Kesehatan
Reproduksi Remaja, Narkoba bagi pasien dalam keadaan kecanduan, penyakit
menular dan jiwa |
/
Konsultasi |
2,000 |
3,000 |
5,000 |
|
3. |
Pelayanan kesehatan dalam bentuk kunjungan rumah |
|
|
|
|
|
|
a.
Kunjungan kerumah pasien (Home visite) |
/
Kuniungan |
75,000 |
- |
75,000 |
|
|
b. Perawatan di nunah pasien (Horne Care) |
/
Kuniungan |
75,000 |
- |
75,000 |
|
4. |
Pelayaran rawat darurat |
|
|
|
|
|
|
a. Pelayanan Unit Gawat Darurat |
/
Kali |
12.000 |
8.000 , |
20.000 |
|
|
b. Biaya Rawat Sehari (One Day Care) |
/
Kegiatan |
108,000 |
72,000 |
180,000 |
|
|
c. Pelayanan Pengamanan Kesehatan Kegiatan per
8 Jam |
/
Kali |
500.000 |
- |
500,000 |
|
5. |
Pelayanan rawat inap |
|
|
|
|
|
|
a. Paket
Rawat inap |
|
|
|
|
|
|
1.
Kelas 1 |
/
Hari |
150.000 |
100.000 |
250,000 |
|
|
2.
Kelas 11 |
/
Hari |
126.000 |
84,000 |
210,000 |
|
|
3.
Kelas III |
/
Hari |
108.000 |
72.000 |
180,000 |
|
|
4.
ruang isoiasi |
/
Hari |
600.000 |
150.000 |
750.000 |
|
|
b. Paket
Rawat Gabung |
/
Hari |
126,000 |
84,000 |
210,000 |
|
6. |
Pelayanan persalinan dan poned |
|
|
|
|
|
|
a. Persalinan Normal |
/
Paket |
175,000 |
525,000 |
700,000 |
|
|
b.
Persalinan dengan penyulit |
/
Paket |
237,500 |
712,500 |
950,000 |
|
|
c.
Pengambilan sisa placenta di Puskesmas PONED |
/
Paket |
43.750 |
131,250 |
175,000 |
|
|
d.
Perawatan pasca Abortus |
/
Paket |
50.000 |
150,000 |
200.000 |
|
|
e.
Kuretase di Puskesmas PONED |
/
Paket |
125,000 |
375,000 |
500,000 |
|
|
f.
Pertolongan Gadar pada bayi Baru lahir di Puskesmas PONED |
/
Paket |
50,000 |
150,000 |
200,000 |
|
7. |
Pelayanan medik selain rawat inap |
|
|
|
|
|
|
a.
Tindakan Medik Operatif |
|
|
|
|
|
|
1.
Jahit luka per 5 jahitan/ per lokasi |
/
Tindakan |
15,000 |
10.000 |
25,000 |
|
|
2.
Angkat jahitan 1 s/d 5 jahitan |
/
Tindakan |
6,000 |
4,000 |
10.000 |
|
|
3.
Angkat jahitan > 5 jahitan |
/
Tindakan |
9.000 |
6,000 |
15,000 |
|
|
4.
Insisi |
/
Tindakan |
15,000 |
10,000 |
25,000 |
|
|
5.
Insisi infeksi pada mata |
/
Tindakan |
30,000 |
20,000 |
50.000 |
|
|
6.
Tindik per daun telinga |
/
Tindakan |
9.000 |
6,000 |
15,000 |
|
|
7.
Repair per daun telinga |
/
Tindakan |
60,000 |
40.000 |
100.000 |
|
|
8.
Pemasangan IUD |
/
Tindakan |
40,000 |
160,000 |
200,000 |
|
|
9.
Pencabutan IUD |
/
Tindakan |
20,000 |
80,000 |
100.000 |
|
|
10. Pencabutan dan pemasangan IUD |
/
Tindakan |
40,000 |
210,000 |
250,000 |
|
|
11. Pemasangan Implant |
/
Tindakan |
40,000 |
110,000 |
150,000 |
|
|
12. Pencabutan Implant |
/
Tindakan |
20,000 |
80000 |
100,000 |
|
|
13. Pencabutan dan Pemasangan
Implant |
/
Tindakan |
40,000 |
160.000 |
200,000 |
|
|
14. Pengambilan benda using THT
dan mata |
/
Tindakan |
10,000 |
20.000 |
30.000 |
|
|
15. Pengambilan serumen per
telinga |
/
Tindakan |
10,000 |
15.000 |
25.000 |
|
|
16. Operasi tumor kulit |
/
Tindakan |
20,000 |
30,000 |
50.000 |
|
|
17. Pemasangan kateter |
/
Tindakan |
25,000 |
25.000 |
50.000 |
|
|
18. Pencabutan kateter |
/
Tindakan |
5,000 |
10.000 |
15.000 |
|
|
19. Pencabutan kuku |
/
Tindakan |
20,000 |
10,000 |
30,000 |
|
|
20. Pelayanan kumbah lambung |
/
Tindakan |
24,000 |
16.000 |
40,000 |
|
|
21. Pelayanan Pencahar |
/
Tindakan |
24,000 |
16,000 |
40,000 |
|
|
22. Perawatan Luka ringan |
/
Tindakan |
6,000 |
4,000 |
10000 |
|
|
23. Perawatan Luka sedang |
/ Tindakan |
15,000 |
10,000 |
25,000 |
|
|
24. Reposisi Fraktur/Fiksasi
Fraktur |
/
Tindakan |
30,000 |
20,000 |
50,000 |
|
|
25. Resusitasi anak dan dewasa |
/
Tindakan |
10,000 |
15,000 |
25,000 |
|
|
26. Injeksi |
/
Tindakan |
3,000 |
2.000 |
5,000 |
|
|
27. Pemasangan infus (non rawat
inap) |
/
Tindakan |
20,000 |
15.000 |
35,000 |
|
|
28. Tindakan medis ringan lainnya |
/ Tindakan |
6,000, |
4.000 |
10,000 |
|
|
29. Sircumsisi / khitan |
/
Tindakan |
75,000 |
175.000 |
250,000 |
|
|
30. Swab Naso/Oro Vasektomi |
/
Tindakan |
50,000 |
25.000 |
75,000 |
|
|
b. Tindakan medik non operatif |
|
|
|
|
|
|
1. Pap Smear |
/
Tindakan |
175.000 |
75,000 |
250,000 |
|
|
2. IVA |
/
Tindakan |
20,000 |
30,000 |
50,000 |
|
|
3. Cryo therapy |
/
Tindakan |
250.000 |
50,000 |
300,000 |
|
|
4. Pemakaian oksigen |
/ Liter / Jam |
2.400 |
600 |
3,000 |
|
|
5. Penguapan saluran nafas |
/ Tindakan |
40.000 |
20.000 |
60,000 |
|
8. |
Pelayanan medik gigi dan mulut |
|
|
|
|
|
|
a. Pembersihan karang gigi (per
kuadran) |
/
Tindakan |
12,000 |
18,000, |
30.000 |
|
|
b. Pencabutan gigi sulung |
/
Tindakan |
12.000 |
8,000 |
20,000 . |
|
|
c.
Pencabutan gigi sulung dengan inieksi |
/
Tindakan |
24,000 |
16,000 |
40.000 |
|
|
d. Pencabutan gigi permanen |
/
Tindakan |
30.000 |
20,000 |
50,000 |
|
|
e.
Pencabutan gigi permanen komplikasi |
/
Tindakan |
32,000 |
48.000 |
80,000 |
|
|
f.
Pencabutan gigi permanen impaksi |
/
Tindakan |
120,000 |
180,000 |
300,000 |
|
|
g.
Insisi abses |
/
Tindakan |
15,000 |
10,000 |
25,000 |
|
|
h. Eksisi jaringan |
/
Tindakan |
15,000 |
10,000 |
25,000 |
|
|
i.
Perawatan PulPa per gigi |
/
Tindakan |
12.000 |
8,000 |
20.000 |
|
|
j.
Tambal gigi tetap per gigi |
/
Tindakan |
24,000 |
16,000 |
40,000 |
|
|
k. Tambal gigi tetap dengan
sinar (light curing) per gigi |
/
Tindakan |
45,000 |
30,000 |
75,000 |
|
|
l.
Trepanasi (open boor)/ oklusal grinding |
/ Tindakan |
6,000 |
4000 |
10,000 |
|
|
m. Perawatan mumifikasi |
/
Tindakan |
15,000 |
10,000 |
25.000 |
|
|
n. Perawatan saraf gigi akar
tunggal |
/
Tindakan |
12,000 |
18.000 |
30,000 |
|
|
o.
Perawatan saraf gigi akar gander |
/
Tindakan |
12,000 |
38,000 |
50,000 |
|
|
p. Perawatan luka di mulut |
/
Tindakan |
15,000 |
10,000 |
25,000 |
|
|
q. jahit luka 1 sid 5 jahitan
per lokasi |
/
Tindakan |
18,000 |
12,000 |
30,000 |
|
|
r.
Anglcat jahitan 1 s/d 5 jahitan |
/
Tindakan |
6,000 |
4.000 |
10,000 |
|
|
s.
Lepas PD cekat |
/
Tindakan |
15,000 |
10,000 |
25,000 |
|
9. |
Pelayanan penunjang diagnosis |
|
|
|
|
|
|
a. PEMERIKSAAN
IABORATORIUM KLINIK |
|
|
|
|
|
|
HEMATOLOGI |
|
|
|
|
|
|
1. Hemoglobin |
/
Tindakan |
11,250 |
3,750 |
15,000 |
|
|
2. Hematokrit |
/
Tindakan |
11,250 |
3.750 |
15,000 |
|
|
3. Eritrosit |
/
Tindakan |
11,250 |
3,750 |
15,000 |
|
|
4. Trombosit |
/
Tindakan |
11.250 |
3.750 |
15,000 |
|
|
5. Lekosit, Hitung jumlah |
/ Tindakan |
11,250 |
3.750 |
15,000 |
|
|
6. Lekosit, hitung jenis |
/
Tindakan |
11.250 |
3,750 |
15,000 |
|
|
7. Laju Endap Darah |
/
Tindakan |
11,250 |
3.750 |
15,000 |
|
|
8. Masa Perdarahan |
/
Tindakan |
11.250 |
3.750 |
15.000 |
|
|
9. Masa Pembekuan |
/
Tindakan |
11,250 |
3,750 |
15,000 |
|
|
10. Darah Lengkap Automatik |
/
Tindakan |
45,000 |
15,000 |
60.000 |
|
|
KIMIA KLINIK |
|
|
|
|
|
|
1. Glukosa |
/
Tindakan |
|
|
|
|
|
Glukosa
metode Elektrometri/Strip |
/
Tindakan |
7,500 |
2,500 |
10,000 |
|
|
Glukosa
metode Fotometri |
/
Tindakan |
15,000 |
5,000 |
20.000 |
|
|
2. Protein |
/
Tindakan |
33,750 |
11,250 |
45,000 |
|
|
3. Albumin |
/
Tindakan |
33,750 |
11,250 |
45,000 |
|
|
4. Bilirubin Total |
/
Tindakan |
33,750 |
11,250 |
45,000 |
|
|
5. Bilirubin Direk |
/
Tindakan |
33,750 |
11,250 |
45,000 |
|
|
6. SGOT |
/
Tindakan |
30.000 |
10.000 |
40,000 |
|
|
7. SGPT |
/
Tindakan |
30,000 |
10,000 |
40,000 |
|
|
8. Alkali fosfatase |
/
Tindakan |
37.500 |
12,500 |
50,000 |
|
|
9. Asam urat |
|
|
|
|
|
|
Asam
urat metode Elelctrometri/Strip |
/
Tindakan |
15,000 |
5,000 |
20,000 |
|
|
Asam
urat metode Fotometri |
/
Tindakan |
18,750 |
6,250 |
25,000 |
|
|
10. Ureum/ BUN |
/
Tindakan |
22,500 |
7,500 |
30,000 |
|
|
1I. Kreatinin |
/ Tindakan |
22,500 |
7,500 |
30,000 |
|
|
12.
Trigliserida |
/
Tindakan |
37,500 |
12,500 |
50,000 |
|
|
13.
Kolesterol total |
/
Tindakan |
33.750 |
11,250 |
45,000 |
|
|
14.
Kolesterol HDL |
/
Tindakan |
33,750 |
11.250 |
45,000 |
|
|
15.
Kolesterol LDL |
/
Tindakan |
45,000 |
15,000 |
60000 |
|
|
16. Globulin |
/
Tindakan |
30,000 |
10,000 |
40,000 |
|
|
17. Gamma GT |
/
Tindakan |
82,500 |
27,500 |
110,000 |
|
|
MIKROBIOLOGI DAN PARASITOLOGI |
|
|
|
|
|
|
1. BTA (Mycobacterium tuberculose) |
/
Tindakan |
12,000 |
18.000 |
30000 |
|
|
2. Diplococcus gram negative (Neisseri a
gonnorrhoeae) |
/
Tindakan |
12.000 |
18000 |
30,000 |
|
|
3. Trichomonas vaginalis |
/
Tindakan |
12,000 |
18.000 |
30000 |
|
|
4. Candida albicans |
/
Tindakan |
12,000 |
18,000 |
30000 |
|
|
5. Bacterial vaginosis |
/
Tindakan |
12,000 |
18,000 |
30000 |
|
|
6. Malaria |
|
|
|
|
|
|
Malaria metode Mikroskopis |
/
Tindakan |
12.000 |
18,000 |
30000 |
|
|
Malaria metode Rapid test |
/
Tindakan |
140,000 |
10,000 |
150,000 |
|
|
7. Pewarnaan gram |
/
Tindakan |
9,000 |
6,000 |
15.000 |
|
|
8. Benzidine Teat |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
IMUNOLOGI |
|
|
|
|
|
|
1.
Tes kehamilan |
/
Tindakan |
6,000 |
4.000 |
10,000 |
|
|
2.
Golongan darah |
/
Tindakan |
9,000 |
6.000 |
15,000 |
|
|
3.
W1DAL |
/
Tindakan |
15,000 |
10,000 |
25000 |
|
|
4.
VDRL |
/
Tindakan |
30,000 |
10,000 |
40,000 |
|
|
5.
HBsAg rapid test |
/
Tindakan |
25.000 |
10,000 |
35.000 |
|
|
6.
Anti HIV |
/
Tindakan |
40,000 |
10,000 |
50,000 |
|
|
7.
Antigen / antibodi dengue |
/
Tindakan |
120.000 |
10,000 |
130000 |
|
|
8.
TPHA |
/
Tindakan |
30,000 |
10,000 |
40,000 |
|
|
9.
Narkoba 16 Panel} |
/
Tindakan |
315000 |
10,000 |
325,000 |
|
|
10. Rapid test Covid-19 |
/
Tindakan |
140,000 |
10,000 |
150,000 |
|
|
11. RT- PCR TCM |
/
Tindakan |
720,000 |
180,000 |
900,000 |
|
|
URINALISA |
|
|
|
|
|
|
1.
Makroskopis: Warna, Bau, Keiernihan. Volume |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
2.
pH |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
3.
Berat Janis |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
4.
protein/ Albumin |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
5.
Glukosa/ Reduksi |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
6.
Bilirubin |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
7.
Urobilinogen |
/ Tindakan |
6,000 |
4,000 |
10,000 |
|
|
8.
Keton |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
9.
Nitrit |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
10. Sedimen |
/
Tindakan |
9,000 |
6,000 |
15,000 |
|
|
11. Lekosit, Penetapan semi
kuantitatif |
/
Tindakan |
6,000 |
4,000 |
10,000 |
|
|
12. Eritront, Penetapan
semikuantitatif |
/ Tindakan |
6,000 |
4,000 |
10,000 |
|
|
13. urin Lengkap |
/
Tindakan |
15,000 |
10,000 |
25.000 |
|
|
a.
PEMER1KSAAN PENUNJANG DIAGNOSTIK LAINNYA |
|
|
|
|
|
|
1.
Elektrokardiogram (EKG) |
/ Tindakan |
15,000 |
10.000 |
25,000 |
|
|
2.
Ultrosonography (USG) |
|
|
|
|
|
|
a.
Tanpa Print out |
/
Tindakan |
10,000 |
15.000 |
25,000 |
|
|
b.
Dengan Print Out |
/
Tindakan |
30,000 |
15,000 |
45,000 |
|
|
3. Doppler |
/
Tindakan |
3,000 |
2,000 |
5,000 |
|
10. |
PELAYANAN
PENGUJIAN KESEHATAN |
|
|
|
|
|
|
SURAT KETERANGAN
SEHAT |
|
|
|
|
|
|
a. Pelajar |
/
Dokumen |
2,000 |
3,000 |
5,000 |
|
|
b.
Masyarakat Umum |
/
Dokumen |
2,000 |
3,000 |
5,000 |
|
|
c.
Calon Jamaah HaP |
/
Dokumen |
2,000 |
3,000 |
5,000 |
|
|
d.
Calon Pengantin |
/
Dokumen |
2,000 |
3,000 |
5,000 |
|
11. |
PELAYANAN MEDIKO
LEGAL |
|
|
|
|
|
|
a. Visum et repertum korban hidup
(pemeriksaan luar) |
/
Dokumen |
12,000 |
8,000 |
20,000 |
|
|
b. Resume Medis |
/
Dokumen |
9,000 |
6,000 |
15,000 |
|
12. |
PELAYANAN FARMASI |
|
|
|
|
|
|
a. Pembuatan sediaan Puyer |
/Resep |
3,000 |
2,000 |
5,000 |
|
|
b. Pembuatan sediaan Kapsul |
/Resep |
6,000 |
4,000 |
10.000 |
|
13. |
PELAYANAN
PENUNJANG KESEHATAN |
|
|
|
|
|
|
a. PRAKTIK PENDIDIKAN |
|
|
|
|
|
|
1. I.
SMK (Kesehatanl |
/
Orang/ |
6,000 |
4,000 |
10.000 |
|
|
2. 03 |
/
Orang/ |
9,000 |
6,000 |
15.000 |
|
|
3. D4, 81. 32, 33 |
/
Orang/ |
12,000 |
8,000 |
20,000 |
|
|
4. Profesi |
/
Orang/ |
15,000 |
10,000 |
25,000 |
|
|
b. KAJI BANDING |
|
|
|
|
|
|
1. Biaya narasumber |
/ Orang/ jam |
- |
100,000 |
100,000 |
|
|
2. Jasa Sarana |
/ Kegiatan |
200,000 |
- |
200,000 |
|
14. |
PELAYANAN
TRANSPORTASI MOBIL AMBULANCE DAN MOBIL JENAZAH |
|
|
|
|
|
|
a.
Transportasi Pasien |
|
|
|
|
|
|
I. 5
Km Pertama |
/ 5
Km |
- |
- |
50,000 |
|
|
2.
Selanjutnya (per Km) |
/ Km |
- |
- |
1,5 x harga |
|
|
|
|
|
|
|
|
|
b.
Transportass Jenazah |
|
|
|
|
|
|
1. 5
Km Pertama |
/ 5
Km |
- |
- |
70,000 |
|
|
2.
Selanjutnya (per Km) |
/ Km |
- |
- |
2 x harga BBM |
|
|
|
|
|
|
|
