| A. RAWAT JALAN UMUM |
|
|
|
| No |
Pelayanan |
Jasa Sarana |
Jasa Pelayanan |
Jumlah |
| (Rp.) |
(Rp.) |
(Rp.) |
| 1 |
Prosedur Radioterapi Eksternal Kuratif Definitif |
12.500.000 |
5.800.000 |
18.300.000 |
|
21 – 30 kali tindakan radiasi |
|
|
|
| 2 |
Prosedur Radioterapi Eksternal Kuratif Adjuvan |
9.850.000 |
5.125.000 |
14.975.000 |
|
10 – 20 kali tindakan radiasi |
|
|
|
| 3 |
Prosedur Radioterapi Eksternal Paliatif |
9.200.000 |
4.100.000 |
13.300.000 |
|
1 – 10 kali tindakan radiasi |
|
|
|
| 4 |
Prosedur Radioterapi Eksternal Booster |
400.000 |
325.000 |
725.000 |
| 5 |
Brakiterapi Superficial / Booster |
640.000 |
510.000 |
1.150.000 |
|
1 kali tindakan, 1 kali penyinaran |
|
|
|
| 6 |
Tindakan Lain (perawatan luka/ infus/ transfusi/ |
80.000 |
120.000 |
200.000 |
|
suntik radiosensitiser) per kali tindakan |
|
|
|
|
(tidak termasuk obat yang diresepkan) |
|
|
|
|
|
|
|
|
|
|
|
|
|
| B. RAWAT JALAN SPESIALIS |
|
|
|
| No |
Pelayanan |
Jasa Sarana |
Jasa Pelayanan |
Jumlah |
| (Rp.) |
(Rp.) |
(Rp.) |
| 1 |
Prosedur Radioterapi Eksternal Kuratif Definitif |
13.750.000 |
7.850.000 |
21.600.000 |
|
21 – 30 kali tindakan radiasi |
|
|
|
| 2 |
Prosedur Radioterapi Eksternal Kuratif Adjuvan |
10.850.000 |
7.100.000 |
17.950.000 |
|
10 – 20 kali tindakan radiasi |
|
|
|
| 3 |
Prosedur Radioterapi Eksternal Paliatif |
10.150.000 |
5.600.000 |
15.750.000 |
|
1 – 10 kali tindakan radiasi |
|
|
|
| 4 |
Prosedur Radioterapi Eksternal Booster |
450.000 |
350.000 |
800.000 |
| 5 |
Brakiterapi Superficial / Booster |
800.000 |
600.000 |
1.400.000 |
|
1 kali tindakan, 1 kali penyinaran |
|
|
|
| 6 |
Tindakan Lain (perawatan luka/ infus/ transfusi/ |
125.000 |
175.000 |
300.000 |
|
suntik radiosensitiser) per kali tindakan |
|
|
|
|
(tidak termasuk obat yang diresepkan) |
|
|
|
|
|
|
|
|
| C. RAWAT INAP |
|
|
|
| No |
Pelayanan |
Jasa Sarana |
Jasa Pelayanan |
Jumlah |
| (Rp.) |
(Rp.) |
(Rp.) |
| 1 |
Brakiterapi intracaviter / Ovoid |
|
|
|
|
2 kali tindakan, 2 kali penyinaran |
|
|
|
|
Kelas III |
5.300.000 |
2.275.000 |
7.575.000 |
|
Kelas II |
6.600.000 |
2.550.000 |
9.150.000 |
|
Kelas I |
7.950.000 |
2.750.000 |
10.700.000 |
|
VIP / Utama |
9.250.000 |
3.000.000 |
12.250.000 |
| 2 |
Brakiterapi intracaviter / Ovoid |
|
|
|
|
3 kali tindakan, 3 kali penyinaran |
|
|
|
|
Kelas III |
7.150.000 |
4.550.000 |
11.700.000 |
|
Kelas II |
8.900.000 |
5.000.000 |
13.900.000 |
|
Kelas I |
10.700.000 |
5.500.000 |
16.200.000 |
|
VIP / Utama |
11.575.000 |
6.000.000 |
17.575.000 |
| 3 |
Brakiterapi Microselectron Implan/Intrakaviter/Intraluminal |
|
|
|
1 kali tindakan, 5 kali penyinaran |
|
|
|
|
Kelas III |
10.860.000 |
4.840.000 |
15.700.000 |
|
Kelas II |
13.525.000 |
5.675.000 |
19.200.000 |
|
Kelas I |
16.250.000 |
6.100.000 |
22.350.000 |
|
VIP / Utama |
17.600.000 |
6.600.000 |
24.200.000 |
| Catatan : |
|
|
|
| 1 |
Tarif Brakiterapi belum termasuk Jasa Tindakan Anestesi |
|
|
| 2 |
Tarif Jasa Sarana sudah termasuk Perhitungan Biaya Maintenance Alat Radioterapi . |
|
|
|
|
|
|
