Selamat datang di RSU PKU MUHAMMADIYAH PRAMBANAN
| URS BILATERAL, LITOTRIPSI, INSERSI STENT SINITRA | - | Rp. 4.308.121,- |
| debridement + repair lidah | - | Rp. 3.521.632,- |
| ORIF Metatarsal, digiti, phalang pedis | - | Rp. 4.308.121,- |
| TurBT | - | Rp. 4.308.121,- |
| Sectio Alta | - | Rp. 4.308.121,- |
| Litotripsi | - | Rp. 4.308.121,- |
| Sache | - | Rp. 4.308.121,- |
| Salfingoofrektomy dekstra re laparotomy kistektomi + ekstraksi iud | - | Rp. 4.308.121,- |
| OD ECCE + IOL 9 LA | - | Rp. 4.308.121,- |
| OS ECCE + IOL 9 LA | - | Rp. 4.308.121,- |
| OS PRO EKSTIRPASI PTERIGIUM + GRAFT CONJUCTIVA + SUTURE | - | Rp. 4.308.121,- |
| nefrolitotomi dextra | - | Rp. 4.308.121,- |
| LAPARATOMI RKSPLORASI SALFIGEKTOMI | - | Rp. 3.521.632,- |
| URS Dextra litotrpsi intersi stend dextra | - | Rp. 4.308.121,- |
| Pemasangan CDL | - | Rp. 1.940.940,- |
| Sitoscopy | - | Rp. 4.308.121,- |
| Evaluasi URS aff stent | - | Rp. 4.308.121,- |
| Sectio caesarea. | - | Rp. 3.521.632,- |
| ORIF Ulna | - | Rp. 4.308.121,- |
| ORIF Lunatum | - | Rp. 4.308.121,- |
| ORIF Trabesioit | - | Rp. 4.308.121,- |
| ORIF Metacarpal, Digiti Phalang manus | - | Rp. 4.308.121,- |
| ORIF pelvis | - | Rp. 4.308.121,- |
| ORIF Femur | - | Rp. 4.308.121,- |
| ORIF Patela | - | Rp. 4.308.121,- |
| ORIF Tibia | - | Rp. 4.308.121,- |
| ORIF Fibula | - | Rp. 4.308.121,- |
| ORIF Radius | - | Rp. 4.308.121,- |
| ORIF Humerus | - | Rp. 4.308.121,- |
| ORIF Scapula | - | Rp. 4.308.121,- |
| squestrectomi | - | Rp. 4.308.121,- |
| Sinovitis joint/ sinovectomy | - | Rp. 4.308.121,- |
| Hemartrosis joint / Antrotomy | - | Rp. 4.308.121,- |
| Septic Artritis Joint / Artotromy | - | Rp. 4.308.121,- |
| Neglected Fraktur/ Recontruktion | - | Rp. 4.308.121,- |
| Ruptur Ligamen Joint / Repair Ligamen | - | Rp. 4.308.121,- |
| Ruptur Vaskuler/ Ruptur vaskuler | - | Rp. 4.308.121,- |
| Ruptur Saraf / repair saraf | - | Rp. 4.308.121,- |
| ORIF Clavicula | - | Rp. 4.308.121,- |
| ORIF Ankle | - | Rp. 4.308.121,- |
| ORIF Calcaneus | - | Rp. 4.308.121,- |
| ORIF Naficular | - | Rp. 4.308.121,- |
| ORIF Cunalform | - | Rp. 4.308.121,- |
| Fingertip Injury / recontruksi / Flap | - | Rp. 4.308.121,- |
| ORIF Talus | - | Rp. 4.308.121,- |
| Nailbed Injury / Nailbed Repair | - | Rp. 4.308.121,- |
| Skindegloving / Skidefek / myocutan flap | - | Rp. 4.308.121,- |
| Traumatik Amputatum / Stumpplasty | - | Rp. 4.308.121,- |
| Contractur Deformity / Release fungsi | - | Rp. 4.308.121,- |
| TURP | - | Rp. 4.308.121,- |
| URS | - | Rp. 4.308.121,- |
| ORIF Scapula | - | Rp. 4.308.121,- |
| KURETASE AVM | Kelas 1 | Rp. 3.592.350,- |
| EKSISI BIOPSI | Kelas 1 | Rp. 4.242.818,- |
| KURETASE DIAGNOSTIK | Kelas 1 | Rp. 3.592.350,- |
| LAPARATOMI APENDEKTOMI | Kelas 1 | Rp. 4.242.818,- |
| EKSISI TUMOR | Kelas 1 | Rp. 4.242.818,- |
| MYOCUTAN FLAP, TUTUO DEFEC LUKA | Kelas 1 | Rp. 5.443.759,- |
| SIRKUMSISI | Kelas 1 | Rp. 3.592.350,- |
| KHITAN | Kelas 1 | Rp. 2.446.409,- |
| KISTEKTOMI | Kelas 1 | Rp. 4.242.818,- |
| HERNIOREPAIR | Kelas 1 | Rp. 4.242.818,- |
| HERNIORAPI | Kelas 1 | Rp. 4.242.818,- |
| MYOCUTAN FLAP | Kelas 1 | Rp. 5.443.759,- |
| KISTEKTOMY, EVAKUASI HEMATOMA, REPARASI PERINEUM GR 3 | Kelas 1 | Rp. 4.242.818,- |
| HEMOROIDECTOMI | Kelas 1 | Rp. 4.242.818,- |
| KURETASE | Kelas 1 | Rp. 3.592.350,- |
| KISTEKTOMI + MOW | Kelas 1 | Rp. 4.242.818,- |
| OD PRO EKSTERPASI PTERYGIUM + GRAFT | Kelas 1 | Rp. 3.592.350,- |
| URS DEXTRA, LITOTRIPSI, INSERSI STEND | Kelas 1 | Rp. 5.443.759,- |
| URS DEXTRA, DILATASI OPTIK, INSERSI UK DEXTRA | Kelas 1 | Rp. 5.443.759,- |
| URS DEKSTRA, LITOTRIPSI | Kelas 1 | Rp. 5.443.759,- |
| PARTUS BIDAN | Kelas 1 | Rp. 275.000,- |
| URS DEKSTRA LITOTRIPSI, DILATASI OPTIK, INSERSI STENT DEKSTRA | Kelas 1 | Rp. 5.443.759,- |
| PARTUS DENGAN MANUAL PLACENTA | Kelas 1 | Rp. 585.000,- |
| URS | Kelas 1 | Rp. 5.443.759,- |
| PARTUS DENGAN PENDARAHAN POST PARTUM | Kelas 1 | Rp. 585.000,- |
| URS SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| URS SINISTRA , LITOTRIPSI | Kelas 1 | Rp. 5.443.759,- |
| URS SINISTRA LITOTRIPSI, INSERSI STENT SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| EKSISI MATA | Kelas 1 | Rp. 2.446.409,- |
| INSISI + DRAINASE MATA | Kelas 1 | Rp. 2.446.409,- |
| SICS | Kelas 1 | Rp. 4.242.818,- |
| SICS + IOL | Kelas 1 | Rp. 4.242.818,- |
| URS SINISTRA, LITOTRIPSI | Kelas 1 | Rp. 5.443.759,- |
| URS SINISTRA, DILATASI OPTIK EVALUASI DEBRIS , INSERSI STUNT SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| URS SINISTRA, DILATASI OPTIK | Kelas 1 | Rp. 5.443.759,- |
| URETROSKOPI SACHE | Kelas 1 | Rp. 5.443.759,- |
| PARTUS DISTOKIA | Kelas 1 | Rp. 605.000,- |
| PARTUS PRESBO | Kelas 1 | Rp. 605.000,- |
| KISTEKTOMI | Kelas 1 | Rp. 4.242.818,- |
| PARTUS PRETERM/IMMATUR | Kelas 1 | Rp. 585.000,- |
| SCTP | Kelas 1 | Rp. 4.242.818,- |
| PARTUS VE/FORCEP | Kelas 1 | Rp. 605.000,- |
| SC + MOW | Kelas 1 | Rp. 4.242.818,- |
| SC | Kelas 1 | Rp. 4.242.818,- |
| RE SC | Kelas 1 | Rp. 4.242.818,- |
| MIOMEKTOMI | Kelas 1 | Rp. 4.242.818,- |
| PARTUS PACUAN/INDUKSI/SEROTINUS | Kelas 1 | Rp. 585.000,- |
| BATU URETER DEKSTRA | Kelas 1 | Rp. 5.443.759,- |
| TURP | Kelas 1 | Rp. 5.443.759,- |
| PARTUS DOKTER SPESIALIS | Kelas 1 | Rp. 485.000,- |
| SISTOSKOPI TUR BIOPSI BULI | Kelas 1 | Rp. 5.443.759,- |
| PARTUS DOKTER UMUM | Kelas 1 | Rp. 385.000,- |
| SISTOSKOPI LITOTRIPSI | Kelas 1 | Rp. 5.443.759,- |
| PARTUS GEMMELI | Kelas 1 | Rp. 605.000,- |
| PRO URS | Kelas 1 | Rp. 5.443.759,- |
| PARTUS IUFD | Kelas 1 | Rp. 715.000,- |
| LAPARATOMY MIOMEKTOMI | Kelas 1 | Rp. 4.242.818,- |
| ORIF, DEBRIDEMENT DAN FLAP MANUS DEXTRA | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOIN CAPSULE MCP IV DEXTRA | Kelas 1 | Rp. 5.443.759,- |
| ORIF + REKONTRUKSI DRUG | Kelas 1 | Rp. 5.443.759,- |
| ORIF | Kelas 1 | Rp. 5.443.759,- |
| DEBRIDEMENT+ORIF FEMUR S + ORIF RADIUS S | Kelas 1 | Rp. 5.443.759,- |
| FR RADOIUS SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| ORIF + SINOVECTOMY | Kelas 1 | Rp. 5.443.759,- |
| AMPUTATUM + STUMP PLASTY | Kelas 1 | Rp. 5.443.759,- |
| ORIF TIBIA, ORIF FIBULA | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE ANKLE SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| ORIF REKONSTRUKSI | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE ANKLE DEXTRA | Kelas 1 | Rp. 5.443.759,- |
| ORIF RADIUS DAN ULNA | Kelas 1 | Rp. 5.443.759,- |
| EVAKUASI CORPAL | Kelas 1 | Rp. 5.443.759,- |
| DEBRIDEMENT REPAIR | Kelas 1 | Rp. 5.443.759,- |
| CLOSE REDUCTION | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE MCP V | Kelas 1 | Rp. 5.443.759,- |
| BURSITIS BURSECTOMY | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE ELBOW SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| ARTHROTOMY | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE GENU SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| CONTRACTUR ELBOW SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE WRIST DEXTRA | Kelas 1 | Rp. 5.443.759,- |
| DEBRIDEMENT AMPUTASI + MYOCUTAN FLAP | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT KAPSUL WRIST SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| DEBRIDEMENT + MYOCUTAN FLAP | Kelas 1 | Rp. 5.443.759,- |
| DEBRIDEMENT + AMPUTASI JARI | Kelas 1 | Rp. 5.443.759,- |
| TENDON REPAIR | Kelas 1 | Rp. 5.443.759,- |
| REMOVE IMPLANT + OSTEOTOMY | Kelas 1 | Rp. 4.242.818,- |
| DEBRIDEMENT | Kelas 1 | Rp. 4.242.818,- |
| REVISI ORIF | Kelas 1 | Rp. 5.443.759,- |
| ROI | Kelas 1 | Rp. 4.242.818,- |
| ROI + MYOCUTAN FLAP | Kelas 1 | Rp. 4.242.818,- |
| APPENDIKTOMY | Kelas 1 | Rp. 4.242.818,- |
| SINOVECTOMI | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOINT CAPSULE DGT 2 SIN | Kelas 1 | Rp. 5.443.759,- |
| SQUESTRECTOMY | Kelas 1 | Rp. 5.443.759,- |
| REVISI ORIF FIBULA | Kelas 1 | Rp. 5.443.759,- |
| DIVISION JOIN CAPSULE ELBOW SINISTRA | Kelas 1 | Rp. 5.443.759,- |
| PARTIAL OSTEOTOMY | Kelas 1 | Rp. 5.443.759,- |
| RELEASE CONTRACTUR | Kelas 1 | Rp. 5.443.759,- |
| OSTEOMYELITIS | Kelas 1 | Rp. 5.443.759,- |
| EKSISI | Kelas 1 | Rp. 4.242.818,- |
| RELEASE CONTRACTUR + ROI | Kelas 1 | Rp. 4.242.818,- |
| REMOVE IMPLANT | Kelas 1 | Rp. 4.242.818,- |
| Necrotomy | Kelas 2 | Rp. 3.521.632,- |
| Palatoplasti | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi ligament; | Kelas 2 | Rp. 4.308.121,- |
| Cystektomi; | Kelas 2 | Rp. 4.302.121,- |
| Salphinoforektomi; | Kelas 2 | Rp. 3.521.632,- |
| Ovarictomi bilateral; | Kelas 2 | Rp. 3.521.632,- |
| Suspensi Uterus; | Kelas 2 | Rp. 4.308.121,- |
| Mioma gebert dan curetase; | Kelas 2 | Rp. 3.521.632,- |
| Curetase mola hidatidosa pertama; | Kelas 2 | Rp. 3.521.632,- |
| Ext-Kiste Vagina; | Kelas 2 | Rp. 3.521.632,- |
| Laparascopi Ekplorasi; | Kelas 2 | Rp. 3.521.632,- |
| SC dengan gemeli; | Kelas 2 | Rp. 4.308.121,- |
| SC dengan hysterektomi; | Kelas 2 | Rp. 4.308.121,- |
| Hysterektomi totalis; | Kelas 2 | Rp. 4.308.121,- |
| Kistektomi intra ligamen; | Kelas 2 | Rp. 4.308.121,- |
| Tuboplasty; | Kelas 2 | Rp. 4.308.121,- |
| Vaginoplasty; | Kelas 2 | Rp. 4.308.121,- |
| Adnexa perlengketan; | Kelas 2 | Rp. 4.308.121,- |
| Miomectomi; | Kelas 2 | Rp. 4.308.121,- |
| Laparatomi ruptur uteri; | Kelas 2 | Rp. 4.308.121,- |
| Arthrodesis. | Kelas 2 | Rp. 4.308.121,- |
| Kuretase cavum uteri; | Kelas 2 | Rp. 3.521.632,- |
| Cervic inkopeten; | Kelas 2 | Rp. 4.308.121,- |
| Polip dengan kuretase; | Kelas 2 | Rp. 3.521.632,- |
| MOW / MOP; | Kelas 2 | Rp. 3.521.632,- |
| Criyo surgery; | Kelas 2 | Rp. 4.308.121,- |
| Cyste bartolini (marsupialisasi); | Kelas 2 | Rp. 4.308.121,- |
| Curetase mola ke II; | Kelas 2 | Rp. 3.521.632,- |
| Curetase missed aborsi; | Kelas 2 | Rp. 3.521.632,- |
| Pungsi cavum douglas; | Kelas 2 | Rp. 4.308.121,- |
| Microcuret; | Kelas 2 | Rp. 3.521.632,- |
| Ext-Candiloma; | Kelas 2 | Rp. 2.545.222,- |
| Ext-polip; | Kelas 2 | Rp. 2.545.222,- |
| Rehecting. | Kelas 2 | Rp. 4.308.121,- |
| KET / Kehamilan extopik; | Kelas 2 | Rp. 4.308.121,- |
| Cysta ovarii permagna; | Kelas 2 | Rp. 4.308.121,- |
| SC dengan pfanenfpiel | Kelas 2 | Rp. 4.308.121,- |
| Colporasianterior et part on. | Kelas 2 | Rp. 4.308.121,- |
| Mastoidektomy | Kelas 2 | Rp. 4.308.121,- |
| Tymphanoplasty | Kelas 2 | Rp. 4.308.121,- |
| Reposisi os zygoma | Kelas 2 | Rp. 4.308.121,- |
| reposisi os mazilla | Kelas 2 | Rp. 4.308.121,- |
| Radical mastridens | Kelas 2 | Rp. 4.308.121,- |
| ROI | Kelas 2 | Rp. 3.521.632,- |
| Partial Osteotomy | Kelas 2 | Rp. 3.521.632,- |
| Division joint capsule MCP V dextra | Kelas 2 | Rp. 4.308.121,- |
| Division joint capsule ankle dextra | Kelas 2 | Rp. 4.308.121,- |
| Biopsi Sederhana | Kelas 2 | Rp. 2.545.222,- |
| Curetase | Kelas 2 | Rp. 3.521.632,- |
| Debridement | Kelas 2 | Rp. 3.521.632,- |
| Biopsi Sedang | Kelas 2 | Rp. 3.521.632,- |
| Pertubasi | Kelas 2 | Rp. 4.308.121,- |
| Pemasangaan Laminaria | Kelas 2 | Rp. 2.545.222,- |
| Adenotonsilektomi | Kelas 2 | Rp. 3.521.632,- |
| Etmaidektomi | Kelas 2 | Rp. 35.216.320,- |
| Antral window | Kelas 2 | Rp. 2.545.222,- |
| Conchektomi | Kelas 2 | Rp. 2.545.222,- |
| Reposisi os nasale | Kelas 2 | Rp. 2.545.222,- |
| Tampon permanen | Kelas 2 | Rp. 2.545.222,- |
| Granulectomi | Kelas 2 | Rp. 2.545.222,- |
| Tampon supratul | Kelas 2 | Rp. 2.545.222,- |
| Evaluasi cendesteatoma | Kelas 2 | Rp. 2.545.222,- |
| Insisi abses | Kelas 2 | Rp. 3.521.632,- |
| Miningotomi | Kelas 2 | Rp. 2.545.222,- |
| Traccheostomi | Kelas 2 | Rp. 2.545.222,- |
| Tonsilektomi | Kelas 2 | Rp. 2.545.222,- |
| Koreksi Septum Nasi | Kelas 2 | Rp. 3.521.632,- |
| Tonsilo archemoidektomi | Kelas 2 | Rp. 3.521.632,- |
| Maxilextomy | Kelas 2 | Rp. 3.521.632,- |
| Luxatio canal | Kelas 2 | Rp. 35.216.320,- |
| Polipektomi Nasale | Kelas 2 | Rp. 3.521.632,- |
| RE LAPARATOMI KISTEKTOMI | Kelas 2 | Rp. 4.308.121,- |
| Laparatomi Kistektomi Bilateral | Kelas 2 | Rp. 4.308.121,- |
| PARTUS BIDAN | Kelas 2 | Rp. 255.000,- |
| PARTUS DENGAN MANUAL PLACENTA | Kelas 2 | Rp. 510.000,- |
| PARTUS DENGAN PENDARAHAN POST PARTUM | Kelas 2 | Rp. 510.000,- |
| PARTUS DISTOKIA | Kelas 2 | Rp. 545.000,- |
| PARTUS DOKTER SPESIALIS | Kelas 2 | Rp. 425.000,- |
| PARTUS DOKTER UMUM | Kelas 2 | Rp. 335.000,- |
| PARTUS GEMMELI | Kelas 2 | Rp. 545.000,- |
| PARTUS IUFD | Kelas 2 | Rp. 645.000,- |
| PARTUS PACUAN/INDUKSI/SEROTINUS | Kelas 2 | Rp. 510.000,- |
| PARTUS PRESBO | Kelas 2 | Rp. 545.000,- |
| PARTUS PRETERM/IMMATUR | Kelas 2 | Rp. 510.000,- |
| PARTUS VE/FORCEP | Kelas 2 | Rp. 545.000,- |
| tendon ruptur | Kelas 2 | Rp. 4.308.121,- |
| Synovectomy; | Kelas 2 | Rp. 4.308.121,- |
| TURP | Kelas 2 | Rp. 4.943.291,- |
| Sirkumsisi dengan penyulit | Kelas 2 | Rp. 3.521.632,- |
| Jahitan luka dengan debredement fraktur terbuka/tendo putus besar | Kelas 2 | Rp. 2.545.222,- |
| Corpus alienum jaringan dg penyulit | Kelas 2 | Rp. 3.521.632,- |
| Blast punctis | Kelas 2 | Rp. 2.545.222,- |
| Insisi besar | Kelas 2 | Rp. 2.545.222,- |
| Phimosis ( Sirkumsisi dengan anaestesi umum ) | Kelas 2 | Rp. 3.521.632,- |
| Meatotomi dengan GA | Kelas 2 | Rp. 2.545.222,- |
| Biopsi testis, prostat | Kelas 2 | Rp. 2.545.222,- |
| Open Sistostomi / dengan cystofix | Kelas 2 | Rp. 2.545.222,- |
| Insisi abces dengan anaestesi umum | Kelas 2 | Rp. 2.545.222,- |
| Lipoma besar dengan anaestesi umum | Kelas 2 | Rp. 2.545.222,- |
| Hemangioma dengan anaestesi umum | Kelas 2 | Rp. 2.545.222,- |
| Angkat plat, nail | Kelas 2 | Rp. 2.545.222,- |
| Reposisi dengan anaestesi umum | Kelas 2 | Rp. 2.545.222,- |
| Marsupialisasi Ranula | Kelas 2 | Rp. 2.545.222,- |
| Debrideman, Nekrotopmi, Fasiotomi, amputasi jari dg anaestesi umum/ regional | Kelas 2 | Rp. 2.545.222,- |
| Amputasi jari kaki/tangan | Kelas 2 | Rp. 3.521.632,- |
| OD PRO EKSTERPASI PTERYGIUM + GRAFT | Kelas 2 | Rp. 3.110.859,- |
| URETROSKOPI SACHE | Kelas 2 | Rp. 4.943.291,- |
| URS | Kelas 2 | Rp. 4.943.291,- |
| URS DEKSTRA, LITOTRIPSI | Kelas 2 | Rp. 4.943.291,- |
| URS DEXTRA, DILATASI OPTIK, INSERSI UK DEXTRA | Kelas 2 | Rp. 4.943.291,- |
| URS DEXTRA, LITOTRIPSI, INSERSI STEND | Kelas 2 | Rp. 4.943.291,- |
| KURETASE | Kelas 2 | Rp. 3.110.859,- |
| URS SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| URS SINISTRA , LITOTRIPSI | Kelas 2 | Rp. 4.943.291,- |
| URS SINISTRA LITOTRIPSI, INSERSI STENT SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| URS SINISTRA, DILATASI OPTIK | Kelas 2 | Rp. 4.943.291,- |
| URS SINISTRA, DILATASI OPTIK EVALUASI DEBRIS , INSERSI STUNT SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| URS SINISTRA, LITOTRIPSI | Kelas 2 | Rp. 4.943.291,- |
| SICS + IOL | Kelas 2 | Rp. 3.686.350,- |
| SICS | Kelas 2 | Rp. 3.686.350,- |
| INSISI + DRAINASE MATA | Kelas 2 | Rp. 2.166.182,- |
| EKSISI MATA | Kelas 2 | Rp. 2.166.182,- |
| Eksterpasi kel limfe (limfadenitis/ limfadenopati) | Kelas 2 | Rp. 2.545.222,- |
| Biopsi dlm narkosa umum | Kelas 2 | Rp. 2.545.222,- |
| Eksisi Hygroma / Lymphangioma simple | Kelas 2 | Rp. 2.545.222,- |
| Ligasi hidrokel ( pada anak ) | Kelas 2 | Rp. 3.521.632,- |
| Herniotomi (pada anak / bayi) | Kelas 2 | Rp. 3.521.632,- |
| Repair ruptur blaas/ vesica urinaria | Kelas 2 | Rp. 3.521.632,- |
| Repair defek Hernia Umbilikal | Kelas 2 | Rp. 3.521.632,- |
| Vesikolitektomi | Kelas 2 | Rp. 3.521.632,- |
| Varicocele ( operasi Palomo / Ivanossevich ) | Kelas 2 | Rp. 3.521.632,- |
| Hidrokelektomi ( hidrokel per scrotal ) | Kelas 2 | Rp. 3.521.632,- |
| Orchidectomi subcapsuler ( pada Ca Prostat ) | Kelas 2 | Rp. 3.521.632,- |
| Eksplorasi torsi testis dengan Orchidectomi | Kelas 2 | Rp. 3.521.632,- |
| Lumpektomi pada tumor jinak mamae | Kelas 2 | Rp. 3.521.632,- |
| Fibro Adenoma Mammae multiple/bilateral | Kelas 2 | Rp. 3.521.632,- |
| Eksplorasi Kista Tiroid | Kelas 2 | Rp. 3.521.632,- |
| Fistulektomi besar | Kelas 2 | Rp. 3.521.632,- |
| Appendektomi simpel ( Pada Anak ) | Kelas 2 | Rp. 3.521.632,- |
| Debridement pada luka bakar | Kelas 2 | Rp. 3.521.632,- |
| Vasectomi | Kelas 2 | Rp. 2.545.222,- |
| Hemostasis Saluran Cerna Bagian Atas / Bawah | Kelas 2 | Rp. 2.545.222,- |
| Tracheostomi | Kelas 2 | Rp. 2.545.222,- |
| Pasang Water Seal Drainage / WSD | Kelas 2 | Rp. 2.545.222,- |
| Eksisi luas basalioma tanpa skingraf / flap | Kelas 2 | Rp. 2.545.222,- |
| Fistulektomi | Kelas 2 | Rp. 2.545.222,- |
| Eksterpasi polip recti | Kelas 2 | Rp. 2.545.222,- |
| Pengangkatan ganglion dengan anaestesi umum | Kelas 2 | Rp. 2.545.222,- |
| Fraktur Nasal sederhana | Kelas 2 | Rp. 2.545.222,- |
| Repair luka robek sederhana pd wajah | Kelas 2 | Rp. 2.545.222,- |
| Kelainan jari polidactili, sindactili | Kelas 2 | Rp. 2.545.222,- |
| Eksisi Granuloma umbilicus | Kelas 2 | Rp. 2.545.222,- |
| Eksisi Mucocle | Kelas 2 | Rp. 2.545.222,- |
| Eksterpasi Kista Dermoid | Kelas 2 | Rp. 2.545.222,- |
| Eksisi Fibroma, Nevus | Kelas 2 | Rp. 2.545.222,- |
| Debridement luka | Kelas 2 | Rp. 2.545.222,- |
| Eksisi Tragus Acsesories | Kelas 2 | Rp. 2.545.222,- |
| Eksterpasi / Eksplorasi Benda Asing (corpal)/Hematoma/Rehechting | Kelas 2 | Rp. 2.545.222,- |
| Koreksi kontraktur | Kelas 2 | Rp. 3.521.632,- |
| AMPUTATUM + STUMP PLASTY | Kelas 2 | Rp. 4.943.291,- |
| EVAKUASI CORPAL | Kelas 2 | Rp. 4.943.291,- |
| FR RADOIUS SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| ORIF | Kelas 2 | Rp. 4.943.291,- |
| ORIF + REKONTRUKSI DRUG | Kelas 2 | Rp. 4.943.291,- |
| ORIF + SINOVECTOMY | Kelas 2 | Rp. 4.943.291,- |
| ORIF RADIUS DAN ULNA | Kelas 2 | Rp. 4.943.291,- |
| ORIF REKONSTRUKSI | Kelas 2 | Rp. 4.943.291,- |
| ORIF TIBIA, ORIF FIBULA | Kelas 2 | Rp. 4.943.291,- |
| ORIF, DEBRIDEMENT DAN FLAP MANUS DEXTRA | Kelas 2 | Rp. 4.943.291,- |
| OSTEOMYELITIS | Kelas 2 | Rp. 4.943.291,- |
| PARTIAL OSTEOTOMY | Kelas 2 | Rp. 4.943.291,- |
| RELEASE CONTRACTUR | Kelas 2 | Rp. 4.943.291,- |
| RELEASE CONTRACTUR + ROI | Kelas 2 | Rp. 3.686.350,- |
| REMOVE IMPLANT | Kelas 2 | Rp. 3.686.350,- |
| REMOVE IMPLANT + OSTEOTOMY | Kelas 2 | Rp. 3.686.350,- |
| REVISI ORIF | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT KAPSUL WRIST SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE MCP V | Kelas 2 | Rp. 4.943.291,- |
| ARTHROTOMY | Kelas 2 | Rp. 4.943.291,- |
| BURSITIS BURSECTOMY | Kelas 2 | Rp. 4.943.291,- |
| CLOSE REDUCTION | Kelas 2 | Rp. 4.943.291,- |
| CONTRACTUR ELBOW SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| DEBRIDEMENT + AMPUTASI JARI | Kelas 2 | Rp. 4.943.291,- |
| DEBRIDEMENT + MYOCUTAN FLAP | Kelas 2 | Rp. 4.943.291,- |
| DEBRIDEMENT AMPUTASI + MYOCUTAN FLAP | Kelas 2 | Rp. 4.943.291,- |
| DEBRIDEMENT REPAIR | Kelas 2 | Rp. 4.943.291,- |
| DEBRIDEMENT+ORIF FEMUR S + ORIF RADIUS S | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOIN CAPSULE ELBOW SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOIN CAPSULE MCP IV DEXTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE ANKLE DEXTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE ANKLE SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE DGT 2 SIN | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE ELBOW SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE GENU SINISTRA | Kelas 2 | Rp. 4.943.291,- |
| REVISI ORIF FIBULA | Kelas 2 | Rp. 4.943.291,- |
| DIVISION JOINT CAPSULE WRIST DEXTRA | Kelas 2 | Rp. 4.943.291,- |
| KISTEKTOMI | Kelas 2 | Rp. 3.686.350,- |
| KISTEKTOMI + MOW | Kelas 2 | Rp. 3.686.350,- |
| KISTEKTOMY, EVAKUASI HEMATOMA, REPARASI PERINEUM GR 4 | Kelas 2 | Rp. 3.686.350,- |
| KURETASE AVM | Kelas 2 | Rp. 3.110.859,- |
| KURETASE DIAGNOSTIK | Kelas 2 | Rp. 3.110.859,- |
| LAPARATOMI APENDEKTOMI | Kelas 2 | Rp. 3.686.350,- |
| LAPARATOMY MIOMEKTOMI | Kelas 2 | Rp. 3.686.350,- |
| RE SC | Kelas 2 | Rp. 3.686.350,- |
| SC | Kelas 2 | Rp. 3.686.350,- |
| SC + MOW | Kelas 2 | Rp. 3.686.350,- |
| SCTP | Kelas 2 | Rp. 3.686.350,- |
| KISTEKTOMI | Kelas 2 | Rp. 3.686.350,- |
| MIOMEKTOMI | Kelas 2 | Rp. 3.686.350,- |
| BATU URETER DEKSTRA | Kelas 2 | Rp. 4.943.291,- |
| PRO URS | Kelas 2 | Rp. 4.943.291,- |
| SISTOSKOPI LITOTRIPSI | Kelas 2 | Rp. 4.943.291,- |
| SIRKUMSISI | Kelas 2 | Rp. 3.110.859,- |
| MYOCUTAN FLAP, TUTUO DEFEC LUKA | Kelas 2 | Rp. 4.943.291,- |
| ROI | Kelas 2 | Rp. 3.686.350,- |
| URS DEKSTRA LITOTRIPSI, DILATASI OPTIK, INSERSI STENT DEKSTRA | Kelas 2 | Rp. 4.943.291,- |
| ROI + MYOCUTAN FLAP | Kelas 2 | Rp. 3.686.350,- |
| SINOVECTOMI | Kelas 2 | Rp. 4.943.291,- |
| SQUESTRECTOMY | Kelas 2 | Rp. 4.943.291,- |
| TENDON REPAIR | Kelas 2 | Rp. 4.943.291,- |
| APPENDIKTOMY | Kelas 2 | Rp. 3.686.350,- |
| DEBRIDEMENT | Kelas 2 | Rp. 3.686.350,- |
| EKSISI | Kelas 2 | Rp. 3.686.350,- |
| EKSISI BIOPSI | Kelas 2 | Rp. 3.686.350,- |
| EKSISI TUMOR | Kelas 2 | Rp. 3.686.350,- |
| HEMOROIDECTOMI | Kelas 2 | Rp. 3.686.350,- |
| HERNIORAPI | Kelas 2 | Rp. 3.686.350,- |
| HERNIOREPAIR | Kelas 2 | Rp. 3.686.350,- |
| KHITAN | Kelas 2 | Rp. 2.166.182,- |
| MYOCUTAN FLAP | Kelas 2 | Rp. 4.943.291,- |
| SISTOSKOPI TUR BIOPSI BULI | Kelas 2 | Rp. 4.943.291,- |
| Parasintesa | Kelas 2 | Rp. 2.545.222,- |
| Orbitotomi | Kelas 2 | Rp. 2.545.222,- |
| Eksisi luas tumor jinak; | Kelas 2 | Rp. 4.308.121,- |
| Catarak dengan pasang IOL | Kelas 2 | Rp. 4.308.121,- |
| Tendon lengthening; | Kelas 2 | Rp. 4.308.121,- |
| Eksenterasi | Kelas 2 | Rp. 4.308.121,- |
| Katarak dengan faleoemulsifikasi | Kelas 2 | Rp. 4.308.121,- |
| Rekanalisasi ruptur kanalis | Kelas 2 | Rp. 2.545.222,- |
| Disisi katarak sekunder | Kelas 2 | Rp. 2.545.222,- |
| Repair tendo 2 jari atau lebih; | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi ruptur trans kornea | Kelas 2 | Rp. 2.545.222,- |
| Whyler | Kelas 2 | Rp. 2.545.222,- |
| Repair tendo Achilles; | Kelas 2 | Rp. 4.308.121,- |
| Eksterpasi pterigium | Kelas 2 | Rp. 2.545.222,- |
| Laminectomy; | Kelas 2 | Rp. 4.308.121,- |
| Trabe kulektomi | Kelas 2 | Rp. 2.545.222,- |
| Aff implant K-wire | Kelas 2 | Rp. 3.521.632,- |
| CTEV soft tissue procedure; | Kelas 2 | Rp. 4.308.121,- |
| Sklerotonil | Kelas 2 | Rp. 2.545.222,- |
| Koreksi strabismus | Kelas 2 | Rp. 2.545.222,- |
| Iridektomi | Kelas 2 | Rp. 2.545.222,- |
| Eviscerasi | Kelas 2 | Rp. 2.545.222,- |
| Enukleasi | Kelas 2 | Rp. 2.545.222,- |
| Release nerve entrapment; | Kelas 2 | Rp. 4.308.121,- |
| Soft tissue release Cerebral palsy; | Kelas 2 | Rp. 4.308.121,- |
| Whyler | Kelas 2 | Rp. 2.545.222,- |
| Eksterpasi pterigium | Kelas 2 | Rp. 2.545.222,- |
| Wide/radical exicision tumor ganas; | Kelas 2 | Rp. 4.308.121,- |
| Ekstraksi katarak | Kelas 2 | Rp. 2.545.222,- |
| Soft tissue reconstruction (flap, skin graft luas); | Kelas 2 | Rp. 4.775.843,- |
| Trabe kulektomi | Kelas 2 | Rp. 2.545.222,- |
| Ekstraksi korpal intra okuler | Kelas 2 | Rp. 2.545.222,- |
| Amputasi jari & ray amputation 3 jari atau lebih; | Kelas 2 | Rp. 4.308.121,- |
| Ablatio retina | Kelas 2 | Rp. 2.545.222,- |
| Parasintesa | Kelas 2 | Rp. 2.545.222,- |
| Amputasi forequarter, hindquarter, disartikulasi shoulder/hip, hemipelvectomy; | Kelas 2 | Rp. 4.308.121,- |
| Extirpasi tumor jinak; | Kelas 2 | Rp. 3.521.632,- |
| Debridement spine; | Kelas 2 | Rp. 4.308.121,- |
| Debridement sedang | Kelas 2 | Rp. 3.521.632,- |
| intertrochanter femur, supracondylar femur); | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi pulley tendon; | Kelas 2 | Rp. 4.308.121,- |
| Debridement luas, degloving injury; | Kelas 2 | Rp. 4.308.121,- |
| Debridement osteomyelitis + saucerization; | Kelas 2 | Rp. 4.308.121,- |
| Skin grafting sedang; | Kelas 2 | Rp. 4.308.121,- |
| collum femur; | Kelas 2 | Rp. 4.308.121,- |
| Curettage + bonegrafting; | Kelas 2 | Rp. 4.308.121,- |
| ORIF periartikuler (fraktur collum humeri, supracondylar humeri, Smith, | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi dengan bone grafting; | Kelas 2 | Rp. 4.308.121,- |
| Arthroscopy diagnostic/debridement; | Kelas 2 | Rp. 3.521.632,- |
| intercondyar femur, intercondylar humeri, olecranon, patella, maleolus medial); | Kelas 2 | Rp. 4.308.121,- |
| Biopsy vertebra; | Kelas 2 | Rp. 3.521.632,- |
| ORIF fraktur intraartikuler (fraktur Barton, Pillon, tibial plateau, | Kelas 2 | Rp. 4.308.121,- |
| Foraminal dan facet block vertebra; | Kelas 2 | Rp. 4.308.121,- |
| Percutaneus tendon tenotomy; | Kelas 2 | Rp. 4.308.121,- |
| Drainage infeksi manus | Kelas 2 | Rp. 3.521.632,- |
| Repair tendo 1-2 jari; | Kelas 2 | Rp. 4.308.121,- |
| Amputasi jari & ray amputation 1-2 jari; | Kelas 2 | Rp. 4.308.121,- |
| ORIF plate & screw, nailing; | Kelas 2 | Rp. 4.308.121,- |
| Open biopsy | Kelas 2 | Rp. 3.521.632,- |
| Nekrotomi | Kelas 2 | Rp. 3.521.632,- |
| Open reduction neglected dislocation; | Kelas 2 | Rp. 4.308.121,- |
| Fasciotomy | Kelas 2 | Rp. 4.308.121,- |
| Release DeQuervain, trigger finger | Kelas 2 | Rp. 4.308.121,- |
| ORIF pinning | Kelas 2 | Rp. 4.308.121,- |
| Closed reduction + percutaneus pinning dg guiding fluoroskopi; | Kelas 2 | Rp. 4.308.121,- |
| ORIF metapercal, metatarsall, phalanx, 1-2 jari | Kelas 2 | Rp. 4.308.121,- |
| Aff implant plate & screw, nail, TBW | Kelas 2 | Rp. 1.308.121,- |
| Open Reduction & Fiksasi External; | Kelas 2 | Rp. 4.308.121,- |
| Closed reduction dengan narkose | Kelas 2 | Rp. 3.521.632,- |
| ORIF metacarpal, metatarsal, phalanx 3 jari atau lebih; | Kelas 2 | Rp. 4.308.121,- |
| Closed reduction + peercutaneus pinning tanpa fluoroskopi guilding | Kelas 2 | Rp. 3.521.632,- |
| Closed reduction + skeletal traksi | Kelas 2 | Rp. 3.521.632,- |
| ORIF fraktur dislokasi (Monteggia, Galeazzi, Essex Lopresty); | Kelas 2 | Rp. 4.308.121,- |
| Amputasi transmeduller long bone ( humerus, antebrachii, femur, cruris) | Kelas 2 | Rp. 3.521.632,- |
| Soft tissue release kontraktur | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi ruptur trans kornea | Kelas 2 | Rp. 2.545.222,- |
| Odontektomi 1 gigi dengan penyulit | Kelas 2 | Rp. 3.521.632,- |
| Alveolectomi 1 regio | Kelas 2 | Rp. 2.545.222,- |
| Apikoektomi | Kelas 2 | Rp. 2.545.222,- |
| Fiksasi 1 regio rahang dengan kawat fiksasi | Kelas 2 | Rp. 2.545.222,- |
| Odontektomi 1 gigi posisi ringan | Kelas 2 | Rp. 2.545.222,- |
| Ekstirpasi tumor 2-4 cm | Kelas 2 | Rp. 2.545.222,- |
| Eksisi tumor 2-4 cm | Kelas 2 | Rp. 2.545.222,- |
| Biopsi tumor 2-4 cm | Kelas 2 | Rp. 2.545.222,- |
| Ekstrasi lebih dari 2 gigi tanpa komplikasi | Kelas 2 | Rp. 2.545.222,- |
| Ekstrasi 1 gigi dengan komplikasi | Kelas 2 | Rp. 2.545.222,- |
| Fistulectomi kecil | Kelas 2 | Rp. 2.545.222,- |
| Gingivectomi 1 regio | Kelas 2 | Rp. 2.545.222,- |
| Insisi abses intra oral | Kelas 2 | Rp. 2.545.222,- |
| Incisi abses besar / ekstra oral | Kelas 2 | Rp. 3.521.632,- |
| Fistulektomi luas/besar | Kelas 2 | Rp. 3.521.632,- |
| Gingivektomi lebih dari 1 regio | Kelas 2 | Rp. 3.521.632,- |
| Alveolektomi lebih dari 1 regio | Kelas 2 | Rp. 3.521.632,- |
| Debridement luka terbuaka luas | Kelas 2 | Rp. 3.521.632,- |
| Ekstrasi > 2 gigi dengan penyulit | Kelas 2 | Rp. 3.521.632,- |
| Debridement luka terbuka kecil | Kelas 2 | Rp. 2.545.222,- |
| Frenektomi | Kelas 2 | Rp. 2.545.222,- |
| Ankilotomi | Kelas 2 | Rp. 2.545.222,- |
| AV Shunt | Kelas 2 | Rp. 4.308.121,- |
| Hemoroidektomi | Kelas 2 | Rp. 4.308.121,- |
| Herniotomi dengan mesh ( pada dewasa ) | Kelas 2 | Rp. 4.308.121,- |
| Nefrostomi open | Kelas 2 | Rp. 4.308.121,- |
| Anoplasti sederhana ( cut back ) | Kelas 2 | Rp. 4.308.121,- |
| Hypospadia distal/ chordektomi | Kelas 2 | Rp. 4.308.121,- |
| Detorsi testis dg orchidopeksi | Kelas 2 | Rp. 4.308.121,- |
| Open prostatektomi | Kelas 2 | Rp. 4.308.121,- |
| Herniotomi tanpa komplikasi ( pada dewasa ) | Kelas 2 | Rp. 3.521.632,- |
| Appendektomi simple ( akut, kronis ) pada dewasa | Kelas 2 | Rp. 3.521.632,- |
| Colostomi | Kelas 2 | Rp. 3.521.632,- |
| Amputasi | Kelas 2 | Rp. 3.521.632,- |
| Eksisi Mammae Aberans | Kelas 2 | Rp. 4.308.121,- |
| Isthmolobektomi | Kelas 2 | Rp. 4.308.121,- |
| Skingraf yang luas | Kelas 2 | Rp. 4.308.121,- |
| Appendiktomi dengan penyulit(perfotasi, pelengketan) | Kelas 2 | Rp. 4.308.121,- |
| Ekplorasi kiste ductus tiroglosus | Kelas 2 | Rp. 4.308.121,- |
| Labioplasti | Kelas 2 | Rp. 3.521.632,- |
| Mastektomi supcutan (ginekomasti) | Kelas 2 | Rp. 4.308.121,- |
| Herniotomi pada hernia inkarserata/residif/dengan penyulit | Kelas 2 | Rp. 4.308.121,- |
| Reposisi , fiksasi fraktur maxilla / mandibula | Kelas 2 | Rp. 4.308.121,- |
| Orchidopexi pada UDT | Kelas 2 | Rp. 4.308.121,- |
| Muscle Group Excision | Kelas 2 | Rp. 4.308.121,- |
| Laparatomi eksplorasi | Kelas 2 | Rp. 4.308.121,- |
| Repair luka pada wajah komplek | Kelas 2 | Rp. 3.521.632,- |
| Odontektomi ringan lebih dari 2 gigi | Kelas 2 | Rp. 3.521.632,- |
| Flap konjungtiva | Kelas 2 | Rp. 2.545.222,- |
| Koreksi entropion/ektrapion | Kelas 2 | Rp. 2.545.222,- |
| Labioplasty unilateral | Kelas 2 | Rp. 4.308.121,- |
| Ekstirpasi tumor lebih dari 5 cm (besar) | Kelas 2 | Rp. 3.521.632,- |
| Enukleasi Kista | Kelas 2 | Rp. 3.521.632,- |
| Marsupilisasi kista | Kelas 2 | Rp. 3.521.632,- |
| Odontektomi berat lebih dari 2 gigi dengan posisi sulit | Kelas 2 | Rp. 4.308.121,- |
| Debridement arthrotomy; | Kelas 2 | Rp. 4.308.121,- |
| Fiksasi rahang IDW dan IMW | Kelas 2 | Rp. 3.521.632,- |
| Vestibuloplasty | Kelas 2 | Rp. 3.521.632,- |
| Eksisi tumor lebih dari 5 cm | Kelas 2 | Rp. 3.521.632,- |
| Rekanalisasi ruptur kanalis | Kelas 2 | Rp. 2.545.222,- |
| Biopsi eksisi tumor besar lebih dari 5 cm | Kelas 2 | Rp. 3.521.632,- |
| Patellectomy; | Kelas 2 | Rp. 4.308.121,- |
| Rekonstruksi deformitas manus (Mallet, Boutoniere, Swan neck, syndactyly | Kelas 2 | Rp. 4.308.121,- |
| Disisi katarak sekunder | Kelas 2 | Rp. 2.545.222,- |
| Fikasasi zygoma dengan kawat fiksasi | Kelas 2 | Rp. 4.308.121,- |
| Reposisi dislokasi mandibula | Kelas 2 | Rp. 3.521.632,- |
| Rekonstruksi deformitas pedis (hallux valgus); | Kelas 2 | Rp. 4.308.121,- |
| Fiksasi rahang dengan IOW | Kelas 2 | Rp. 4.308.121,- |
| DEBRIDEMENT + MYOCUTAN FLAP | Kelas 3 | Rp. 4.442.818,- |
| DEBRIDEMENT AMPUTASI + MYOCUTAN FLAP | Kelas 3 | Rp. 4.442.818,- |
| ORIF + REKONTRUKSI DRUG | Kelas 3 | Rp. 4.442.818,- |
| ARTHROTOMY | Kelas 3 | Rp. 4.442.818,- |
| DEBRIDEMENT + AMPUTASI JARI | Kelas 3 | Rp. 4.442.818,- |
| OSTEOMYELITIS | Kelas 3 | Rp. 4.442.818,- |
| ORIF, DEBRIDEMENT DAN FLAP MANUS DEXTRA | Kelas 3 | Rp. 4.442.818,- |
| CLOSE REDUCTION | Kelas 3 | Rp. 4.442.818,- |
| ORIF TIBIA, ORIF FIBULA | Kelas 3 | Rp. 4.442.818,- |
| BURSITIS BURSECTOMY | Kelas 3 | Rp. 4.442.818,- |
| ORIF REKONSTRUKSI | Kelas 3 | Rp. 4.442.818,- |
| CONTRACTUR ELBOW SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| ORIF RADIUS DAN ULNA | Kelas 3 | Rp. 4.442.818,- |
| ORIF | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE GENU SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOIN CAPSULE MCP IV DEXTRA | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE ELBOW SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| ORIF + SINOVECTOMY | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE DGT 2 SIN | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE ANKLE DEXTRA | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE ANKLE SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOIN CAPSULE ELBOW SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE MCP V | Kelas 3 | Rp. 4.442.818,- |
| FR RADOIUS SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| DEBRIDEMENT REPAIR | Kelas 3 | Rp. 4.442.818,- |
| EVAKUASI CORPAL | Kelas 3 | Rp. 4.442.818,- |
| AMPUTATUM + STUMP PLASTY | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT KAPSUL WRIST SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| DEBRIDEMENT+ORIF FEMUR S + ORIF RADIUS S | Kelas 3 | Rp. 4.442.818,- |
| DIVISION JOINT CAPSULE WRIST DEXTRA | Kelas 3 | Rp. 4.442.818,- |
| REVISI ORIF FIBULA | Kelas 3 | Rp. 4.442.818,- |
| URS DEXTRA, LITOTRIPSI, INSERSI STEND | Kelas 3 | Rp. 4.442.818,- |
| PARTUS PACUAN/INDUKSI/SEROTINUS | Kelas 3 | Rp. 455.000,- |
| KISTEKTOMI | Kelas 3 | Rp. 3.242.209,- |
| PARTUS IUFD | Kelas 3 | Rp. 575.000,- |
| MIOMEKTOMI | Kelas 3 | Rp. 3.242.209,- |
| PARTUS GEMMELI | Kelas 3 | Rp. 485.000,- |
| BATU URETER DEKSTRA | Kelas 3 | Rp. 4.442.818,- |
| PARTUS DOKTER UMUM | Kelas 3 | Rp. 295.000,- |
| PRO URS | Kelas 3 | Rp. 4.442.818,- |
| PARTUS DOKTER SPESIALIS | Kelas 3 | Rp. 365.000,- |
| PARTUS PRESBO | Kelas 3 | Rp. 485.000,- |
| SC + MOW | Kelas 3 | Rp. 3.242.209,- |
| KURETASE | Kelas 3 | Rp. 2.591.409,- |
| KURETASE AVM | Kelas 3 | Rp. 2.591.409,- |
| KURETASE DIAGNOSTIK | Kelas 3 | Rp. 2.591.409,- |
| LAPARATOMI APENDEKTOMI | Kelas 3 | Rp. 3.242.209,- |
| LAPARATOMY MIOMEKTOMI | Kelas 3 | Rp. 3.242.209,- |
| RE SC | Kelas 3 | Rp. 3.242.209,- |
| PARTUS VE/FORCEP | Kelas 3 | Rp. 485.000,- |
| SC | Kelas 3 | Rp. 3.242.209,- |
| PARTUS PRETERM/IMMATUR | Kelas 3 | Rp. 455.000,- |
| SISTOSKOPI LITOTRIPSI | Kelas 3 | Rp. 4.442.818,- |
| PARTUS DISTOKIA | Kelas 3 | Rp. 485.000,- |
| SISTOSKOPI TUR BIOPSI BULI | Kelas 3 | Rp. 4.442.818,- |
| URS SINISTRA , LITOTRIPSI | Kelas 3 | Rp. 4.442.818,- |
| URS SINISTRA LITOTRIPSI, INSERSI STENT SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| URS SINISTRA, DILATASI OPTIK | Kelas 3 | Rp. 4.442.818,- |
| URS SINISTRA, DILATASI OPTIK EVALUASI DEBRIS , INSERSI STUNT SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| URS SINISTRA, LITOTRIPSI | Kelas 3 | Rp. 4.442.818,- |
| SICS + IOL | Kelas 3 | Rp. 3.242.209,- |
| SICS | Kelas 3 | Rp. 3.242.209,- |
| INSISI + DRAINASE MATA | Kelas 3 | Rp. 1.940.941,- |
| EKSISI MATA | Kelas 3 | Rp. 1.940.941,- |
| URS SINISTRA | Kelas 3 | Rp. 4.442.818,- |
| URS DEXTRA, DILATASI OPTIK, INSERSI UK DEXTRA | Kelas 3 | Rp. 4.442.818,- |
| PARTUS DENGAN PENDARAHAN POST PARTUM | Kelas 3 | Rp. 455.000,- |
| TURP | Kelas 3 | Rp. 4.442.818,- |
| PARTUS DENGAN MANUAL PLACENTA | Kelas 3 | Rp. 455.000,- |
| URETROSKOPI SACHE | Kelas 3 | Rp. 4.442.818,- |
| PARTUS BIDAN | Kelas 3 | Rp. 235.000,- |
| URS | Kelas 3 | Rp. 4.442.818,- |
| ROI | Kelas 3 | Rp. 3.242.209,- |
| URS DEKSTRA LITOTRIPSI, DILATASI OPTIK, INSERSI STENT DEKSTRA | Kelas 3 | Rp. 4.442.818,- |
| URS DEKSTRA, LITOTRIPSI | Kelas 3 | Rp. 4.442.818,- |
| OD PRO EKSTERPASI PTERYGIUM + GRAFT | Kelas 3 | Rp. 2.591.409,- |
| PARTIAL OSTEOTOMY | Kelas 3 | Rp. 4.442.818,- |
| ROI + MYOCUTAN FLAP | Kelas 3 | Rp. 3.242.209,- |
| SINOVECTOMI | Kelas 3 | Rp. 4.442.818,- |
| SQUESTRECTOMY | Kelas 3 | Rp. 4.442.818,- |
| TENDON REPAIR | Kelas 3 | Rp. 4.442.818,- |
| REVISI ORIF | Kelas 3 | Rp. 4.442.818,- |
| RELEASE CONTRACTUR | Kelas 3 | Rp. 4.442.818,- |
| RELEASE CONTRACTUR + ROI | Kelas 3 | Rp. 3.242.209,- |
| REMOVE IMPLANT | Kelas 3 | Rp. 3.242.209,- |
| REMOVE IMPLANT + OSTEOTOMY | Kelas 3 | Rp. 3.242.209,- |
| APPENDIKTOMY | Kelas 3 | Rp. 3.242.209,- |
| SCTP | Kelas 3 | Rp. 3.242.209,- |
| HERNIOREPAIR | Kelas 3 | Rp. 3.242.209,- |
| KHITAN | Kelas 3 | Rp. 1.940.941,- |
| MYOCUTAN FLAP | Kelas 3 | Rp. 4.442.818,- |
| MYOCUTAN FLAP, TUTUO DEFEC LUKA | Kelas 3 | Rp. 4.442.818,- |
| SIRKUMSISI | Kelas 3 | Rp. 2.591.409,- |
| KISTEKTOMI | Kelas 3 | Rp. 3.242.209,- |
| KISTEKTOMI + MOW | Kelas 3 | Rp. 3.242.209,- |
| HERNIORAPI | Kelas 3 | Rp. 3.242.209,- |
| KISTEKTOMY, EVAKUASI HEMATOMA, REPARASI PERINEUM GR 5 | Kelas 3 | Rp. 3.242.209,- |
| DEBRIDEMENT | Kelas 3 | Rp. 3.242.209,- |
| EKSISI | Kelas 3 | Rp. 3.242.209,- |
| EKSISI BIOPSI | Kelas 3 | Rp. 3.242.209,- |
| EKSISI TUMOR | Kelas 3 | Rp. 3.242.209,- |
| HEMOROIDECTOMI | Kelas 3 | Rp. 3.242.209,- |