Peraturan Daerah ini mulai berlaku pada tanggal diundangkan.
Agar setiap orang mengetahuinya, memerintahkan pengundangan Peraturan Daerah ini dengan penempatannya dalam Lembaran Daerah Kota Madiun.
Ditetapkan di M A D I U N pada tanggal 30 Desember 2011
WALIKOTA MADIUN, ttd H. BAMBANG IRIANTO, SH, MM.
Diundangkan di M A D I U N pada tanggal 30 Desember 2011
SEKRETARIS DAERAH ttd Drs. MAIDI, SH, MM, M.Pd.
LEMBARAN DAERAH KOTA MADIUN TAHUN 2011 NOMOR 8/C
LAMPIRAN :
PERATURAN DAERAH KOTA MADIUN NOMOR : 31 TAHUN 2011 TANGGAL : 30 Desember 2011
A. RETRIBUSI PELAYANAN KESEHATAN
1. Puskesmas
No JENIS PELAYANAN Tarif (Rp) BHPS Jasa Pelayanan Jumlah 1 2 3 4 5 1 Rawat Jalan Umum poliklinik rawat jalan di Puskesmas/ puskesmas pembantu (BP Umum, BP Gigi), penentuan diagnosa dan pemberian obat pada setiap kunjungan 3,000 2,000 5,000 2 Rawat Jalan UGD pertolongan oleh dokter umum 4,000 6,000 10,000 3 Tindakan Medik
a. injeksi 2,000 1,000 3,000
b. tindakan kecil, salah satu di bawah ini:
3,500 1,500 5,000 - rawat luka - rawat luka bakar grade 1 - pasang infus dewasa
c. tindakan sedang, salah satu dibawah ini:
7,000 3,000 10,000 - incisi abses - cross incise - angkat jahitan - rawat luka bakar grade 2, < 10% - jahit luka <5 jahitan - pengambilan cerumen - tindik - pasang infus bayi
d. tindakan besar, salah satu dibawah ini:
9,000 6,000 15,000 - pengambilan benda asing - rawat luka gangren
e. tindakan khusus, salah satu dibawah ini:
21,000 9,000 30,000 - jahit luka >5 jahitan - ekstraksi kuku
f. circumsisi (termasuk perawatan luka) 90,000 60,000 150,000 4 KIA/ KB
a. kunjungan bayi (kunjungan neonatus/DDTK)/bayi sakit/balita sakit/pra sekolah sakit 3,500 1,500 5,000
2 3 4 5
b. kunjungan buteki (konseling) 1,000 1,000 2,000
c. kunjungan KB (konsultasi dan/dengan pemberian pil/kondom) 2,000 3,000 5,000
d. KB suntik (tanpa obat) 2,000 3,000 5,000
e. ANC per kunjungan 3,500 1,500 5,000
f. pengambilan secret vagina 3,000 2,000 5,000
g. kontrol IUD/implant 3,500 1,500 5,000
h. pasang/cabut implant 30,000 20,000 50,000
i. insersi IUD 24,000 16,000 40,000
j. lepas IUD 21,000 9,000 30,000 5 Rawat Inap a visite dokter 15,000 15,000 b visite dokter spesialis 25,000 25,000 c oksigen (O2) (liter per menit) 18 18 6 Pelayanan kebidanan/persalinan
a. pemeriksaan obstetry/ginekologi 6,000 4,000 10,000
b. pertolongan persalinan normal (dokter) 150,000 150,000 300,000 c pertolongan persalinan normal (bidan) 150,000 100,000 250,000 d pertolongan persalinan normal dengan penyulit 300,000 200,000 500,000
e. pertolongan persalinan dengan vacum 360,000 240,000 600,000
f. kuretasi 180,000 120,000 300,000
g. perawatan perinatal 10,000 15,000 25,000
h. infant warmer/incubator per hari 10,000 10,000
i. tindakan - hisap lendir (1 x, max 3x/hari) 3,000 2,000 5,000 - memandikan bayi 3,000 2,000 5,000 - rawat tali pusat 3,000 2,000 5,000 - sibin ibu bayi 3,000 2,000 5,000 - sonde fonding per hari 3,000 2,000 5,000 - terapi solux 6,000 4,000 10,000 - pasang NGT 3,000 2,000 5,000 - infus umbilikus 6,000 4,000 10,000 - fototerapi (paket) 18,000 12,000 30,000 - resusitasi kardiopulmoner tanpa intubasi 6,000 4,000 10,000 7 Rawat Jalan BP gigi
a. pemeriksaan gigi (dengan atau tanpa pengobatan) 3,500 1,500 5,000
b. cabut gigi - cabut gigi susu/ gigi 3,000 2,000 5,000
2 3 4 5 - cabut gigi tetap/ gigi 6,000 4,000 10,000 - cabut gigi tetap dengan penyulit/ gigi 12,000 8,000 20,000
c. tumpat gigi/gigi 1) tumpatan tetap a) tumpatan standart - kecil 6,000 4,000 10,000 - besar 12,000 8,000 20,000 b) tumpatan dengan sinar - kecil 35,000 15,000 50,000 - besar 52,500 22,500 75,000 2) tumpatan sementara 3,500 1,500 5,000
d. perawatan syaraf setiap gigi 3,500 1,500 5,000
e. tindakan lain-lain - pembersihan karang gigi /scaling setiap 3,600 2,400 6,000 regio - operkulektomi/ incisi abses intra oral 6,000 4,000 10,000 8 Uji Kesehatan
a. pemeriksaan kesehatan umum, calon tenaga 2,000 3,000 5,000 kerja, keperluan sekolah, keperluat pendidikan pelatihan, mencari SIM, mendaftar Naik Haji, pertandingan)
b. pemeriksaan (tes) buta warna 4,000 6,000 10,000
c. pemeriksaan Kesehatan Calon Jamaah Haji 30,000 20,000 50,000 standar (diluar pemeriksaan penunjang)
d. pemeriksaan kesehatan pasangan calon 4,000 6,000 10,000 pengantin 9 Pemeriksaan Elektromedik
a. USG 15,000 10,000 25,000
b. EKG 9,000 6,000 15,000
c. nebulizer 6,000 4,000 10,000 10 Pemeriksaan Penunjang Medis (Laboratorium) :
a. direct faeses 7,000 3,000 10,000
b. haemoglobin (Hb) 6,300 2,700 9,000 c leococyt 6,300 2,700 9,000 d defferential count 7,000 3,000 10,000
e. erythrosit 6,300 2,700 9,000 f trombosit 7,000 3,000 10,000 g Laju Endap Darah/LED 3,500 1,500 5,000 h golongan darah 5,250 2,250 7,500 i hematrocit 6,300 2,700 9,000 j urine reduksi 1,400 600 2,000
2 3 4 5 11 k urine protein 1,400 600 2,000
l. sedimen urine 4,200 1,800 6,000 m test kehamilan 5,600 2,400 8,000 n asam urat 10,500 4,500 15,000 o gula darah 7,000 3,000 10,000 p cholesterol 10,500 4,500 15,000 q trigliserid 10,500 4,500 15,000 r SGPT 8,750 3,750 12,500 s SGOT 8,750 3,750 12,500 t pemeriksaan IMS 6,000 4,000 10,000 u testing HIV 17,500 7,500 25,000 v test malaria 3,500 1,500 5,000 Lain-Lain :
a. konsultasi - konsultasi dokter spesialis (on site) - 25,000 25,000 - konsultasi gizi (klinik gizi) 2,000 3,000 5,000 - konsultasi sanitasi (klinik sanitasi) 2,000 3,000 5,000
b. klinik VCT jasa konseling VCT 10,000 10,000
c. deteksi dini dan pengobatan awal kanker leher rahim - I V A 5,000 5,000 10,000 - pengambilan sediaan papsmear 9,000 6,000 15,000 - krio terapi 192,500 82,500 275,000 - follow up post krio terapi 5,000 5,000 10,000
2. Rawat Jalan RSUD
a. Rawat Jalan Poliklinik
No Jenis Pelayanan (Poliklinik) Komponen Jasa Tarif Retribusi Jasa Sarana Jasa Pelayanan 1 Pemeriksaan Kes. Umum (Klinik Umum) 3,000 8,000 11,000 2 Pemeriksaan Medik Gigi (Klinik Gigi) 3,000 8,000 11,000 3 Pemeriksaan Dokter Spesialis (Klinik Spesialis) 3,000 10,000 13,000 4 Konsultasi Gizi 2,000 4,000 6,000 5 Pelayanan Rekam Medik
a. Pasien Baru 4,000 2,000 6,000
b. Pasien lama - 2,000 2,000
b. Rawat Jalan Instalasi Gawat Darurat
No Jenis Pelayanan Komponen Jasa Tarif Retribusi Jasa Sarana Jasa Pelayanan 1 Dokter Umum 4,000 12,000 16,000 2 Dokter Spesialis 4,000 16,000 20,000 3 Pelayanan Observasi < 6 Jam 4000 12,500 16,500 4 Pelayanan Rekam Medik 2,000 1,000 3,000
B. RETRIBUSI RAWAT INAP
1. Puskesmas No Kelas Perawatan Akomodasi Biaya Makan Jasa Sarana Jumlah Akomodasi 1 Kelas I 45,000 25,000 70,000 2 Kelas II 30,000 10,000 40,000 3 Kelas III 30,000 5,000 35,000
2. RSUD
a. dengan kelas No Uraian Kelas III Kelas II Akomodasi Tarif Retribusi Akomodasi Tarif Retribusi Biaya makan Jasa Sarana Biaya makan Jasa Sarana 1 Pasien diet - Pasien diet biasa 40,000 7,500 47,500 40,000 15,000 55,000 - Pasien diet khusus 45,000 7,500 52,500 45,000 15,000 60,000 2 Pasien non diet 30,000 7,500 37,500 30,000 15,000 45,000
No Uraian Kelas I Kelas VIP Akomodasi Tarif Retribusi Akomodasi Tarif Retribusi Biaya makan Jasa Sarana Biaya makan Jasa Sarana 1 Pasien diet - Pasien diet biasa 40,000 30,000 70,000 40,000 60,000 100,000 - Pasien diet khusus 45,000 29,500 74,500 45,000 60,000 105,000 2 Pasien non diet 50,000 29,500 79,500 50,000 60,000 110,000
b. tanpa kelas No Uraian One Day Care Rawat Intermediate Akomodasi Tarif Retribusi Akomodasi Tarif Retribusi Biaya makan Jasa Sarana Biaya makan Jasa Sarana 1 Pasien diet - Pasien diet biasa 40,000 30,000 70,000 40,000 45,000 85,000 - Pasien diet khusus 45,000 30,000 75,000 45,000 45,000 90,000 2 Pasien non diet 30,000 30,000 60,000 30,000 45,000 75,000 3 Tanpa Makan/Puasa - 30,000 30,000 - 45,000 45,000
No Uraian Perinatologi Rawat Intensif Akomodasi Akomodasi Tarif Retribusi Jasa Sarana tanpa Inkubator Jasa Sarana dengan Inkubator Biaya makan Jasa Sarana 1 Pasien diet - Pasien diet biasa - - 40,000 100,000 140,000 - Pasien diet khusus - - 45,000 100,000 145,000 2 Pasien non diet - - 30,000 100,000 130,000 3 Tanpa Makan/Puasa 20,000 50,000 - 100,000 100,000
3. Visite No Kelas Perawatan Visite Dokter Umum Dokter Spesialis 1 Kelas III 8,000 16,000 2 Kelas II 8,000 16,000 3 Kelas I 35,000 70,000 4 Paviliun 35,000 70,000 5 Perinatologi 8,000 16,000 6 One Day Care 8,000 16,000 7 Rawat intermediate 25,000 50,000 8 Rawat intensif 35,000 70,000
4. Pelayanan Rekam Medis
No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Jumlah 1 Pelayanan Rekam Medis Rawat Inap 5,000 2,500 7,500
C. PELAYANAN MEDIK
1. Jenis-jenis Tindakan Medik Operatif
No Kelompok Jenis Tindakan 1 2 3 1 SEDERHANA 1 Biopsi 2 Cabut Gigi permanen tanpa penyulit 3 Cabut Gigi sulung dengan LA 4 Insisi Abses 5 Nekrotomi dengan komplikasi 6 Parasentense telinga 7 Rawat komplikasi ekstraksi dengan curet dan alvolgyl 1 SEDERHANA 2 Chalazion/ Hordeulum / Granuloma
2 3 2 KECIL 1 Epulis 3 Upperculectomi dengan LA 4 Reposisi dislokasi TMJ 5 Insisi Abses Ekstra Oral 6 Pencabutan Gigi dengan Penyulit 7 Reposisi dislokasi TMJ 1 Fraktur Proc Alveolaris 2 Insisi Abses Septi/ Mastoid/ Peritonsil/ Othematom 3 KECIL 2 Mucocele/Epulis besar 1 Upperculectomy 2 Fistulectomi/Gingivektomi/Alveolectomi/Odontectomy dg LA 3 Pterigium 4 Sirkumsisi dengan anestesi lokal 5 SEDANG 1 Vasektomi 1 Odontectomy dengan komplikasi 2 Pasang WSD 3 Reposisi Fraktur 4 Vena seksi 1 SEDANG 2 Ekstrasi Tumor Jinak 2 Biopsi dalam Narkose umum 3 Cauterisasi 4 Debridement 5 Eksisi / Konisasi 6 Enucleatie/ Extirpasi Kista 7 Extirpasi Polip 8 Fibro Adenom Mamae 9 Ganglion Poplitea 10 Hemoroidektomi 11 Hydrokel 13 Operasi Lipoma 14 Proctoscopy
2 3 15 BESAR 1 Sistotomi 16 Sirkumsisi dengan anestesi umum 17 Pencabutan gigi sulung/permanen dengan GA 18 Tubektomi 19 Tonsilektomi / Turbinektomi 20 Insisi Abses dengan GA 21 Rectosigmoidoscopy 22 Businasi dengan GA 1 Angkat Pen / Screw 2 Apendektomi akut 3 Bronschocopy rigid 4 Eksplorasi abses parafaringeal/ kista 5 Enucleasi/Eviserasi 6 Explorasi vagina 7 Hernia tanpa Komplikasi 8 ICCE / ECCE (tidak termasuk IOL) 9 Laparatomi Percobaan 10 Kehamilan Ektopik terganggu 11 Kistektomi 12 Mastektomi subkutaneus 13 Miomektomi 14 Repair fistel 15 Reposisi fraktur dengan GA 16 Tonsilo adenoidectomy / Trakheostomi 17 Torsio testis 18 Vesicolithotomi (Sectio alta) 1 BESAR 2 Apendektomi perforata 2 Herniotomi bilateral 3 Histerektomi total 4 Hernia Incarcerata/ komplikasi 5 Kolostomi 6 Laparatomi 7 Lensa Tanam (IOL) 8 Mastoidektomi radikal 9 Open reduksi fraktur/ dislokasi lama
2 3 10 CANGGIH 1 Operasi perineum 11 Simple mastectomy 12 Prostatektomi retropubic 13 Reparasi fistula vesiko vaginal 14 Tiroidektomy 15 Colisistectomy 16 Batu Ginjal 1 Ablatio retina 2 Amputasi fore/ handquarter 3 CANGGIH 2 Operasi tumor jinak ovarium 1 Mastektomi radikal 2 Megakolon Hirschprung 3 Operasi tumor ganas ovarium 4 Spleenec/ Gastrec - tomi 1 KHUSUS Histerektomi radikal 2 Reseksi Hepar
2. Retribusi Tindakan Medik Operatif Umum Bedah Non Sectio Caesar
a. Tindakan Medik Operatif Terencana
No Jenis Umum Privat Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Sarana Pelayanan Sarana Pelayanan 1 2 3 4 5 6 7 8 1 Sederhana 1 20,000 20,000 40,000 20,000 64,000 84,000 2 Sederhana 2 50,000 50,000 100,000 50,000 146,000 196,000 3 Kecil 1 104,000 104,000 208,000 104,000 260,000 364,000 4 Kecil 2 225,000 225,000 450,000 225,000 517,000 742,000 5 Sedang 1 424,000 424,000 848,000 424,000 632,250 1,056,250 6 Sedang 2 930,000 930,000 1,860,000 930,000 1,560,770 2,490,770 7 Besar 1 1,268,000 1,268,000 2,536,000 1,268,000 2,246,500 3,514,500 8 Besar 2 1,860,000 1,860,000 3,720,000 1,860,000 3,300,540 5,160,540 9 Canggih 1 2,536,000 2,536,000 5,072,000 2,536,000 3,764,750 6,300,750 10 Canggih 2 3,382,750 3,382,750 6,765,500 3,382,750 4,603,250 7,986,000 11 Khusus 4,228,000 4,228,000 8,456,000 4,228,000 5,629,000 9,857,000
b. Tindakan Medik Operatif Darurat
No Jenis Umum Privat Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Sarana Pelayanan Sarana Pelayanan 1 2 3 4 5 6 7 8 1 Sederhana 1 20,000 26,000 46,000 20,000 83,200 103,200 2 Sederhana 2 50,000 65,000 115,000 50,000 189,800 239,800 3 Kecil 1 104,000 135,200 239,200 104,000 338,000 442,000 4 Kecil 2 225,000 292,500 517,500 225,000 672,100 897,100 5 Sedang 1 424,000 551,200 975,200 424,000 821,925 1,245,925 6 Sedang 2 930,000 1,209,000 2,139,000 930,000 2,029,001 2,959,001 7 Besar 1 1,268,000 1,648,400 2,916,400 1,268,000 2,920,450 4,188,450 8 Besar 2 1,860,000 2,418,000 4,278,000 1,860,000 4,290,702 6,150,702 9 Canggih 1 2,536,000 3,296,800 5,832,800 2,536,000 4,894,175 7,430,175 10 Canggih 2 3,382,750 4,397,575 7,780,325 3,382,750 5,984,225 9,366,975 11 Khusus 4,228,000 5,496,400 9,724,400 4,228,000 7,317,700 11,545,700
3. Retribusi Tindakan Medik Operatif dan Non Operatif Kebidanan
No Jenis Umum Privat Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Sarana Pelayanan Sarana Pelayanan 1 Partus Normal 150,000 250,000 400,000 150,000 600,000 750,000 2 Partus Patologi
a. dengan induksi 325,000 425,000 750,000 325,000 737,500 1,062,500
b. dengan tindakan 300,000 450,000 750,000 300,000 1,050,000 1,350,000
c. SC terencana 1,125,000 1,375,000 2,500,000 1,125,000 2,287,500 3,412,500
d. SC Darurat 1,125,000 1,718,750 2,843,750 1,125,000 2,927,344 4,052,344 3 Curetase
a. manual placenta 318,750 318,750 637,500 318,750 318,750 637,500
b. tanpa penyulit 375,000 375,000 750,000 375,000 375,000 750,000
4. Jenis-jenis Tindakan Medik Non Operatif
No Kelompok Jenis Tindakan 1 2 3 1 SEDERHANA 1 Ambil Darah Vena/Injeksi (maksimal 3 kali per hari) 2 Angkat Drain Post Operasi/Gip/Jahit/Kateter 3 Darm Buis 4 Hisap Lendir (1 kali, maksimal 3 kali per hari) 5 Insulinisasi Paket 6 Memandikan bayi 7 Lepas / Pemasangan Orofaring Tube 8 Rawat Luka Sederhana 9 Rawat tali pusat 10 Sciren 11 Sibin 12 Sonde Fooding per hari 13 Spooling irigasi kateter per hari 14 Suppostaria anus 15 Terapi Solux 16 Test Buta Warna/Garpu Tala 17 Tranfusi Darah 18 Suction (3 kali per hari) 19 Pengukuran Antropometri 20 Pasang Oksigen 21 Setting Inkubator 1 SEDERHANA 2 Angkat Jahitan Mata 2 Digitalisasi 3 Injeksi Keloid/Konjungtiva 4 Open Bur 5 Observasi Pasca Operasi (di Ruang RR) 6 Pasang Infus - Anak /NGT 7 Rawat komplikasi ekstrasi dengan curet dan alvolgyl 8 Rectal Toucher 9 Tindik 10 Vulva Higiene 11 WSD Aff 12 Pasang Head Box
2 3 13 KECIL 1 Pasang Pulse Oxymeter 14 Incubator Transport 15 Infant Warmer per hari 16 Pasang Infus 17 Pasang Mayo 18 Anoscopy 1 Ambil darah arteri 2 Angkat Batu Uretra 3 Angkat jahit perinium 4 Angkat K-Wire 5 Angkat tampon 6 Businasi 7 Ekstraksi Corpus alienum / kuku/ serumen 8 Dilatasi Pimosis 9 Ekstraksi IUD tanpa penyulit 10 Epilasi silia 11 Fiksasi Thorax 12 FNAB 13 Fundoskopi / Refraksi 14 Ganti balut 15 Gastric Cooling (maksimal 3 kali per hari) 16 Irigasi mata/ Telinga 17 Jahit <5 18 Kauteriasi mata 19 Nebulizer 20 Necrotomi tanpa komplikasi 21 Perawatan Tracheostomy 22 Pap Smear 23 Pasang GIP/ Kateter/Pesarium 24 Pasang ransel perban/Spalk 25 Pasang tampon hidung 26 Perawatan saluran akar gigi + pulpa (Mumifikasi) 27 Pengobatan pulpa dengan sitoject 28 Persiapan operasi mata 29 Rawat luka bakar sedang (15 - 30%) 30 Rawat Luka Sedang
2 3 31 KECIL 2 Reposisi Mandibula 32 Regulasi Cepat Gula Darah 33 Regulasi Cepat Tekanan Darah 34 Roozer Plasty 35 Sondase saluran air mata 36 Traksi Dunlop 37 Setting Infus Pump 38 Setting Syringe Pump 39 Setting Monitor 40 Observasi Intensif di Ruang Khusus (rawat intensif, rawat intermediet, Isolasi, Perinatologi, VK) 1 Heparinisasi 2 Irigasi gigi dan mulut (OHI) 3 Jahit < 10 4 Lavement 5 Infus Umbilikus 6 Pasang Glyserin spuit 7 Pasang Infus Pump/hari 8 Pasang Syringe Pump/hari 9 Pasang Monitor/hari 10 Pasang Skin Traction 11 Pasang tampon rooll hidung 12 Pembersihan karang gigi grade 1/per rahang 13 Pengisian saluran akar 14 Cabut Gigi Sulung dengan chlorethyl 15 Pembongkaran tumpatan 16 Rawat luka bakar berat>30% 17 Rawat luka besar 18 Tumpatan Glass ionomer kelas 1, 3, 5 19 Resusitasi Bayi Baru Lahir 1 SEDANG 1 Ekstraksi IUD dengan penyulit 2 Jahit ≥10 3 Pasang tampon uterus 4 Pembersihan karang gigi grade 2 per rahang
2 3 5 SEDANG 2 Proef Pungsi Asites/Pleura 6 Rawat Vital Pulpektomy & Endo Intrakanal 7 Tumpatan Glass ionomer klas 2,4 8 Toilet Oral Cavity 1 Dauglas punctie 2 Pasang/Angkat ETT 3 Jahit Perineum ruptur 4 Pasang CVP Anak/ Dewasa 5 Pasang laminaria 6 Pembongkaran gigi palsu 7 BESAR 1 Tumpatan Light Curing Kl 1,3,5 1 Phlebotomy 2 Tumpatan Light Curing Kl 2,4 3 BESAR 2 Resusitasi Kardiopulmoner tanpa intubasi 1 Aspirasi Cairan Sendi/ Hemarthrosis 2 Fototerapi (paket) 3 Injeksi Intra-artikular 4 KHUSUS 1 Lumbal Punksi 1 Defibrilasi (DC-Shock) 2 Kemoterapi 3 KHUSUS 2 Exchange Transfusion 1 Punksi Cairan Pleura/ Asites 2 Penggunaan/Pemasangan ventilator 3 CPAP / Ventilator 1 KHUSUS 3 Cryo Terapy
5. Retribusi Tindakan Medik Non Operatif
No Jenis Umum Privat ICU/ICCU VK/Perinatologi/Rawat Jalan HCU/IGD BHPS JP Jumlah BHPS JP Jumlah BHPS JP Jumlah BHPS JP Jumlah BHPS JP Jumlah 1 Sederhana 1 6,500 4,000 10,500 6,500 8,085 14,585 6,500 8,085 14,585 6,500 4,000 10,500 7,700 4,900 12,600 2 Sederhana 2 10,200 6,800 17,000 10,200 13,090 23,290 10,200 13,090 23,290 10,200 6,800 17,000 12,300 8,100 20,400 3 Kecil 1 16,200 10,800 27,000 16,200 20,790 36,990 16,200 20,790 36,990 16,200 10,800 27,000 19,400 13,000 32,400 4 Kecil 2 22,700 14,800 37,500 22,700 28,875 51,575 22,700 28,875 51,575 22,700 14,800 37,500 27,200 17,800 45,000 5 Sedang 1 30,800 20,200 51,000 30,800 39,270 70,070 30,800 39,270 70,070 30,800 20,200 51,000 36,900 24,300 61,200 6 Sedang 2 38,900 25,600 64,500 38,900 49,665 88,565 38,900 49,665 88,565 38,900 25,600 64,500 46,600 30,800 77,400 7 Besar 1 48,600 32,400 81,000 48,600 56,700 105,300 48,600 56,700 105,300 48,600 32,400 81,000 58,300 38,900 97,200 8 Besar 2 58,800 39,200 98,000 58,800 68,600 127,400 58,800 68,600 127,400 58,800 39,200 98,000 70,600 47,000 117,600 7 Khusus 1 126,000 84,000 210,000 126,000 147,000 273,000 126,000 147,000 273,000 126,000 84,000 210,000 156,000 96,000 252,000 8 Khusus 2 150,000 100,000 250,000 150,000 175,000 325,000 150,000 175,000 325,000 150,000 100,000 250,000 184,800 115,200 300,000 9 Khusus 3 562,500 375,000 937,500 562,500 656,250 1,218,750 562,500 656,250 1,218,750 914,063 609,375 1,523,438 675,000 450,000 1,125,000
D. RETRIBUSI PELAYANAN PENUNJANG MEDIK
1. Retribusi Pelayanan Laboratorium Patologi Klinik No Jenis Pemeriksaan/Parameter Umum Privat Darurat Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Jasa Sarana Jasa Pelayanan Jasa Sarana Jasa Pelayanan Jasa Sarana Jasa Pelayanan 1 2 3 4 5 6 7 8 9 10 11 I. DARAH A. Hematologi 1 Darah Lengkap Rutin (Otomatis) 32,500 2,500 35,000 36,000 6,000 42,000 42,250 3,250 45,500 2 Gol Darah A B O 7,500 2,500 10,000 8,500 3,500 12,000 9,750 3,250 13,000
2 3 4 5 6 7 8 9 10 11 3 Gol Darah Rhesus 7,500 2,500 10,000 8,500 3,500 12,000 9,750 3,250 13,000 4 HDT 10,000 50,000 60,000 16,000 56,000 72,000 13,000 65,000 78,000 5 APPT 24,000 5,000 29,000 26,900 7,900 34,800 31,200 6,500 37,700 6 PPT 29,000 6,000 35,000 32,500 9,500 42,000 37,700 7,800 45,500 7 LED Automatic 20,900 1,100 22,000 23,100 3,300 26,400 27,170 1,430 28,600 B. Parasitologi 8 MALARIA (IGG/IGM) 78,900 1,100 80,000 86,900 9,100 96,000 102,570 1,430 104,000 C. Gula Darah 9 GDP/ 2 J PP/ Acak (Stik) 7,000 3,000 10,000 8,000 4,000 12,000 9,100 3,900 13,000 D. Ginjal 10 BUN 10,900 1,100 12,000 12,100 2,300 14,400 14,170 1,430 15,600 11 Creatinin 10,900 1,100 12,000 12,100 2,300 14,400 14,170 1,430 15,600 12 Uric Acid Otomatis 10,900 1,100 12,000 12,100 2,300 14,400 14,170 1,430 15,600 13 Uric Acid Stik 10,500 4,500 15,000 12,000 6,000 18,000 13,650 5,850 19,500 E. Hati 14 Alkali Phosphatase 11,900 1,100 13,000 13,200 2,400 15,600 15,470 1,430 16,900 15 Bill. Direct 8,900 1,100 10,000 9,900 2,100 12,000 11,570 1,430 13,000 16 Bill. Total 12,900 1,100 14,000 14,300 2,500 16,800 16,770 1,430 18,200 17 Gamma GT 15,900 1,100 17,000 17,600 2,800 20,400 20,670 1,430 22,100
2 3 4 5 6 7 8 9 10 11 18 Prot -Albumin 8,900 1,100 10,000 9,900 2,100 12,000 11,570 1,430 13,000 19 Protein-Total 10,900 1,100 12,000 12,100 2,300 14,400 14,170 1,430 15,600 20 SGOT Otomatis 11,900 1,100 13,000 13,200 2,400 15,600 15,470 1,430 16,900 21 SGOT Manual 8,750 3,750 12,500 10,000 5,000 15,000 11,375 4,875 16,250 22 SGPT Otomatis 11,900 1,100 13,000 13,200 2,400 15,600 15,470 1,430 16,900 23 SGPT Manual 8,750 3,750 12,500 10,000 5,000 15,000 11,375 4,875 16,250 24 Neonatal Bilirubin 14,900 1,100 16,000 16,500 2,700 19,200 19,370 1,430 20,800 F. Lemak 25 Cholesterol (Fotometer) 10,900 1,100 12,000 12,100 2,300 14,400 14,170 1,430 15,600 26 Cholesterol (Stik) 10,500 4,500 15,000 12,000 6,000 18,000 13,650 5,850 19,500 27 HDL 19,900 1,100 21,000 22,000 3,200 25,200 25,870 1,430 27,300 28 LDL 15,900 1,100 17,000 17,600 2,800 20,400 20,670 1,430 22,100 29 Trigliserid (Fotometer) 15,900 1,100 17,000 17,600 2,800 20,400 20,670 1,430 22,100 30 Trigliserid (Stik) 10,500 4,500 15,000 12,000 6,000 18,000 13,650 5,850 19,500 G. Imunologi 31 Rheumatoid Faktor Manual 22,900 2,500 25,400 25,440 5,040 30,480 29,770 3,250 33,020 32 VDRL Manual 18,900 2,500 21,400 21,040 4,640 25,680 24,570 3,250 27,820 33 Widal Manual 15,900 2,500 18,400 17,740 4,340 22,080 20,670 3,250 23,920 34 Dengue Test (IGG/IGM) Manual 78,900 2,500 81,400 87,040 10,640 97,680 102,570 3,250 105,820
2 3 4 5 6 7 8 9 10 11 35 HBs Antibody Manual 45,900 2,500 48,400 50,740 7,340 58,080 59,670 3,250 62,920 36 HBs Antigen Manual 39,900 2,500 42,400 44,140 6,740 50,880 51,870 3,250 55,120 37 ASTO Manual 30,900 2,500 33,400 34,240 5,840 40,080 40,170 3,250 43,420 38 CRP Manual 30,900 2,500 33,400 34,240 5,840 40,080 40,170 3,250 43,420 39 Hbe Ag Manual 134,900 2,500 137,400 148,640 16,240 164,880 175,370 3,250 178,620 40 Anti HCV Manual 116,900 2,500 119,400 128,840 14,440 143,280 151,970 3,250 155,220 41 Anti Hbe Manual 134,900 2,500 137,400 148,640 16,240 164,880 175,370 3,250 178,620 42 Hba Ic Manual 99,900 2,500 102,400 110,140 12,740 122,880 129,870 3,250 133,120 43 Troponin I Manual 127,900 2,500 130,400 140,940 15,540 156,480 166,270 3,250 169,520 44 HBs Antibody Otomatis 45,900 1,100 47,000 50,600 5,800 56,400 59,670 1,430 61,100 45 HBs Antigen Otomatis 39,900 1,100 41,000 44,000 5,200 49,200 51,870 1,430 53,300 46 ASTO Otomatis 30,900 1,100 32,000 34,100 4,300 38,400 40,170 1,430 41,600 47 CRP Otomatis 30,900 1,100 32,000 34,100 4,300 38,400 40,170 1,430 41,600 48 Hbe Ag Otomatis 134,900 1,100 136,000 148,500 14,700 163,200 175,370 1,430 176,800 49 Anti HCV Otomatis 116,900 1,100 118,000 128,700 12,900 141,600 151,970 1,430 153,400 50 Anti Hbe Otomatis 134,900 1,100 136,000 148,500 14,700 163,200 175,370 1,430 176,800 51 Hba Ic Otomatis 99,900 1,100 101,000 110,000 11,200 121,200 129,870 1,430 131,300 52 Troponin I Otomatis 127,900 1,100 129,000 140,800 14,000 154,800 166,270 1,430 167,700
2 3 4 5 6 7 8 9 10 11 H. Elektrolit 53 Kalium 22,900 1,100 24,000 25,300 3,500 28,800 29,770 1,430 31,200 54 Natrium 22,900 1,100 24,000 25,300 3,500 28,800 29,770 1,430 31,200 55 Klorida 22,900 1,100 24,000 25,300 3,500 28,800 29,770 1,430 31,200 56 Kalsium 22,900 1,100 24,000 25,300 3,500 28,800 29,770 1,430 31,200 I. Khusus 57 HIV 36,500 2,500 39,000 40,400 6,400 46,800 47,450 3,250 50,700 58 Narkoba 5 panel 151,500 2,500 154,000 166,900 17,900 184,800 196,950 3,250 200,200 J. Kimia Klinik 59 LDH 11,900 1,100 13,000 13,200 2,400 15,600 15,470 1,430 16,900 60 BUBC 18,900 1,100 20,000 20,900 3,100 24,000 24,570 1,430 26,000 61 Phosporus 7,900 1,100 9,000 8,800 2,000 10,800 10,270 1,430 11,700 62 Amylase 13,900 1,100 15,000 15,400 2,600 18,000 18,070 1,430 19,500 63 CK 12,900 1,100 14,000 14,300 2,500 16,800 16,770 1,430 18,200 64 CKMB 44,900 1,100 46,000 49,500 5,700 55,200 58,370 1,430 59,800 65 Iron (Fee) 13,900 1,100 15,000 15,400 2,600 18,000 18,070 1,430 19,500 66 Lipase 2,900 1,100 34,000 36,300 4,500 40,800 42,770 1,430 44,200 67 Magnesium 25,900 1,100 27,000 28,600 3,800 32,400 33,670 1,430 35,100
2 3 4 5 6 7 8 9 10 11 II. URINE A. Rutin
68. Urine Lengkap 13,500 2,500 16,000 15,100 4,100 19,200 17,550 3,250 20,800
69. Sedimen Urine 4,200 1,800 6,000 4,800 2,400 7,200 5,460 2,340 7,800 B. Khusus
70. Test Kehamilan 12,500 2,500 15,000 14,000 4,000 18,000 16,250 3,250 19,500 III. TINJA A. Rutin
71. Tinja Lengkap 7,000 3,000 10,000 8,000 4,000 12,000 9,100 3,900 13,000 B. Lainnya IV. CAIRAN TUBUH A. Mikrobiologi
72. BTA 15,000 4,000 19,000 16,900 5,900 22,800 19,500 5,200 24,700
73. GRAM 6,000 4,000 10,000 7,000 5,000 12,000 7,800 5,200 13,000 B. Lainnya V. LAIN - LAIN
74. A. Tumor Marker CEA 113,000 12,000 125,000 125,500 24,500 150,000 146,900 15,600 162,500
2 3 4 5 6 7 8 9 10 11
75. PSA 113,000 12,000 125,000 125,500 24,500 150,000 146,900 15,600 162,500
76. AFP 128,000 8,000 136,000 141,600 21,600 163,200 166,400 10,400 176,800 B. Hormon Tyroid
77. T3 82,500 2,500 85,000 91,000 11,000 102,000 107,250 3,250 110,500
78. T4 82,500 2,500 85,000 91,000 11,000 102,000 107,250 3,250 110,500
79. TSH 96,500 2,500 99,000 106,400 12,400 118,800 125,450 3,250 128,700 C. Pengambilan Sample/Orang - 4,000 4,000 - 5,000 5,000 - 4,000 4,000
2. Retribusi Pelayanan Radiologi
No Jenis Pemeriksaan Umum Privat Cito Bed Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Jasa Sarana Jasa Pelayanan Jasa Sarana Jasa Pelayanan Jasa
Pelayanan Jasa
Pelayanan 1 2 3 4 5 6 7 8 9 10 11 1 Ankle 41,500 16,500 58,000 47,300 24,400 71,700 41,500 31,000 72,500 2 Antebrachii 58,500 16,500 75,000 66,000 25,250 91,250 58,500 35,250 93,750 3 BOF 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500 4 Calcaneus 41,500 16,500 58,000 47,300 24,400 71,700 41,500 31,000 72,500
2 3 4 5 6 7 8 9 10 11 5 Cervical 58,500 20,000 78,500 66,350 28,925 95,275 58,500 39,625 98,125 6 Clavicula 36,500 16,500 53,000 41,800 24,150 65,950 36,500 29,750 66,250 7 Colon* 295,000 54,000 349,000 329,900 76,450 406,350 295,000 141,250 436,250 8 Cruris 58,500 16,500 75,000 66,000 25,250 91,250 58,500 35,250 93,750 9 Elbow 41,500 16,500 58,000 47,300 24,400 71,700 41,500 31,000 72,500 10 Femur 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500 11 Genu 58,500 16,500 75,000 66,000 25,250 91,250 58,500 35,250 93,750 12 Gigi* 11,000 9,000 20,000 13,000 15,000 28,000 11,000 14,000 25,000 13 Humerus 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500 14 IVP** 148,000 54,000 202,000 168,200 69,100 237,300 148,000 104,500 252,500 15 Lumbosacral/ Thoracolumbal 75,500 20,000 95,500 85,050 29,775 114,825 75,500 43,875 119,375 16 Mammo 135,000 54,000 189,000 153,900 68,450 222,350 135,000 101,250 236,250 17 Manus 41,500 16,500 58,000 47,300 24,400 71,700 41,500 31,000 72,500 18 Panoramik 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500 19 Pedis 58,500 16,500 75,000 66,000 25,250 91,250 58,500 35,250 93,750 20 Pelvis 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500 22 Shoulder 58,500 16,500 75,000 66,000 25,250 91,250 58,500 35,250 93,750 23 Skull 58,500 20,000 78,500 66,350 28,925 95,275 58,500 39,625 98,125 24 Thorax 53,500 16,500 70,000 60,500 25,000 85,500 53,500 34,000 87,500
2 3 4 5 6 7 8 9 10 11 25 TMJ 68,500 16,500 85,000 77,000 25,750 102,750 68,500 37,750 106,250 26 Uretro 105,000 65,000 170,000 122,000 78,500 200,500 105,000 107,500 212,500 27 Uretro Cysto 120,000 80,000 200,000 140,000 95,000 235,000 120,000 130,000 250,000 28 USG 50,000 50,000 100,000 60,000 60,000 120,000 50,000 75,000 125,000 29 USG 4D 100,000 100,000 200,000 120,000 115,000 235,000 100,000 150,000 250,000 30 USG Transvaginal 60,000 60,000 120,000 72,000 71,000 143,000 60,000 90,000 150,000 31 Waters 36,500 16,500 53,000 41,800 24,150 65,950 36,500 29,750 66,250 32 Wrist 41,500 16,500 58,000 47,300 24,400 71,700 41,500 31,000 72,500
3. Retribusi Pelayanan Diagnostik Elektromedik
No Kelompok Tindakan Umum Privat Komponen Jasa Tarif Retribusi Komponen Jasa Tarif Retribusi Jasa Sarana Jasa Pelayanan Jasa Sarana Jasa Pelayanan 1 SEDERHANA : E C G 10,000 10,000 20,000 10,000 20,000 30,000 2 SEDANG : E E G 100,000 50,000 150,000 125,000 75,000 200,000 3 CANGGIH : E M G 100,000 50,000 150,000 125,000 75,000 200,000
E. RETRIBUSI PELAYANAN KEPERAWATAN RSUD
No Kelas Perawatan Tarif Retribusi 1 Kelas 3 5,000 2 Kelas 2 5,000 3 Kelas 1 6,900 4 Paviliun 15,000 5 Perinatologi 15,000 6 One Day Care 5,000 7 Rawat intermediate 15,000 8 Rawat intensif 15,000
F. PELAYANAN REHABILITASI MEDIK (FISIOTERAPI)
1. Jenis Tindakan
No Kelompok Jenis Tindakan 1 Sederhana Tindakan dengan memakai 1 alat, meliputi:
a. infra red/diathermi/paraffin;
b. electro therapy; atau
c. traksi.
2 Sedang Tindakan dengan memakai 2 alat, meliputi:
a. infra red/diathermi/paraffin dan electro therapy;
b. infra red/diathermi/paraffin dan traksi; atau
c. electro therapy dan traksi.
3 Canggih Tindakan dengan memakai 3 alat, meliputi infra red/diathermi/ paraffin, electro therapy dan traksi.
4 Khusus 1 Latihan dengan alat.
5 Khusus 2 Latihan tanpa alat.
2. Retribusi
No Kelompok Umum Privat Jasa Sarana Jasa Pelayanan Jumlah Jasa Sarana Jasa Pelayanan Jumlah 1 Sederhana 14,400 9,600 24,000 18,000 12,000 30,000 2 Sedang 16,800 11,200 28,000 24,000 16,000 40,000 3 Canggih 19,200 12,800 32,000 30,000 20,000 50,000 4 Khusus 1 16,800 11,200 28,000 28,000 24,000 52,000 5 Khusus 2 11,200 16,800 28,000 24,000 28,000 52,000
G. RETRIBUSI PEMAKAIAN OKSIGEN RSUD
No Pemakaian Tarif Liter per menit 1 Oksigen (O2) 18
H. RETRIBUSI GIZI KLINIK
No Jenis Pelayanan Jasa Pelayanan 1 Konsultasi Gizi Rawat Inap 4,000 2 Pelayanan Makanan Non Diet 2,000 3 Pelayanan Makanan Diet 4,000
I. RETRIBUSI PELAYANAN KONSULTASI GIZI
No Jenis Pelayanan BHP Jasa sarana Jasa Konsultasi Jumlah 1 Konsultasi Gizi 4,500 3,000 7,500 15,000
J. RETRIBUSI PELAYANAN MEDICOL LEGAL
No Paket Pelayanan Jasa Pelayanan 1 Pelayanan Visum Et Repertum korban Hidup
a. Pemeriksaan Luar 100,000
b. Pemeriksaan Dalam 150,000 2 Pelayanan Resume Medis 20,000
K. RETRIBUSI PEMULASARAN JENAZAH
No Jenis Layanan Jasa Sarana Jasa Pelayanan Jumlah 1 Perawatan Jenazah 45,000 50,000 95,000 2 Penyimpanan Jenazah per hari 100,000 - 100,000 3 Konservasi Jenazah 60,000 40,000 100,000
L. RETRIBUSI PELAYANAN TRANSPORTASI
1. MOBIL AMBULANS
a. Dalam Daerah
No Tujuan Jasa Sarana (BBMS) Jasa Pelayanan Sopir Pembantu Sopir Dokter Perawat 1 Lumpsum 22,500 17,000 - 28,000 25,000
b. Luar Daerah
No Jarak Tujuan (Km) Jasa Sarana (BBMS) Jasa Pelayanan 0,5 x jarak (km) x harga BBM Sopir Pembantu Sopir Dokter Keperawatan 45% x BBMS 20% x BBMS 70% x BBMS 60% x BBMS 1 2 3 4 5 6 7 1 1 Km 2,250 1,013 - 1,575 1,350 2 2 Km 4,500 2,025 - 3,150 2,700 3 3 Km 6,750 3,038 - 4,725 4,050 4 4 Km 9,000 4,050 - 6,300 5,400 5 5 Km 11,250 5,063 - 7,875 6,750 6 6 Km 13,500 6,075 - 9,450 8,100 7 7 Km 15,750 7,088 - 11,025 9,450 8 8 Km 18,000 8,100 - 12,600 10,800 9 9 Km 20,250 9,113 - 14,175 12,150 10 10 Km 22,500 10,125 - 15,750 13,500 11 11 Km 24,750 11,138 - 17,325 14,850 12 12 Km 27,000 12,150 - 18,900 16,200 13 13 Km 29,250 13,163 - 20,475 17,550 14 14 Km 31,500 14,175 - 22,050 18,900 15 15 Km 33,750 15,188 - 23,625 20,250 16 16 Km 36,000 16,200 - 25,200 21,600 17 17 Km 38,250 17,213 - 26,775 22,950 18 18 Km 40,500 18,225 - 28,350 24,300 19 19 Km 42,750 19,238 - 29,925 25,650 20 20 Km 45,000 20,250 - 31,500 27,000 21 21 Km 47,250 21,263 - 33,075 28,350 22 22 Km 49,500 22,275 - 34,650 29,700 23 23 Km 51,750 23,288 - 36,225 31,050 24 24 Km 54,000 24,300 - 37,800 32,400 25 25 Km 56,250 25,313 - 39,375 33,750 26 26 Km 58,500 26,325 - 40,950 35,100 27 27 Km 60,750 27,338 - 42,525 36,450 28 28 Km 63,000 28,350 - 44,100 37,800 29 29 Km 65,250 29,363 - 45,675 39,150
3 4 5 6 7 30 30 Km 67,500 30,375 - 47,250 40,500 31 31 Km 69,750 31,388 - 48,825 41,850 32 32 Km 72,000 32,400 - 50,400 43,200 33 33 Km 74,250 33,413 - 51,975 44,550 34 34 Km 76,500 34,425 - 53,550 45,900 35 35 Km 78,750 35,438 - 55,125 47,250 36 36 Km 81,000 36,450 - 56,700 48,600 37 37 Km 83,250 37,463 - 58,275 49,950 38 38 Km 85,500 38,475 - 59,850 51,300 39 39 Km 87,750 39,488 - 61,425 52,650 40 40 Km 90,000 40,500 - 63,000 54,000 41 41 Km 92,250 41,513 - 64,575 55,350 42 42 Km 94,500 42,525 - 66,150 56,700 43 43 Km 96,750 43,538 - 67,725 58,050 44 44 Km 99,000 44,550 - 69,300 59,400 45 45 Km 101,250 45,563 - 70,875 60,750 46 46 Km 103,500 46,575 - 72,450 62,100 47 47 Km 105,750 47,588 - 74,025 63,450 48 48 Km 108,000 48,600 - 75,600 64,800 49 49 Km 110,250 49,613 - 77,175 66,150 50 50 Km 112,500 50,625 - 78,750 67,500 51 51 Km 114,750 51,638 - 80,325 68,850 52 52 Km 117,000 52,650 - 81,900 70,200 53 53 Km 119,250 53,663 - 83,475 71,550 54 54 Km 121,500 54,675 - 85,050 72,900 55 55 Km 123,750 55,688 - 86,625 74,250 56 56 Km 126,000 56,700 - 88,200 75,600 57 57 Km 128,250 57,713 - 89,775 76,950 58 58 Km 130,500 58,725 - 91,350 78,300 59 59 Km 132,750 59,738 - 92,925 79,650 60 60 Km 135,000 60,750 - 94,500 81,000 61 61 Km 137,250 61,763 - 96,075 82,350 62 62 Km 139,500 62,775 - 97,650 83,700 63 63 Km 141,750 63,788 - 99,225 85,050 64 64 Km 144,000 64,800 - 100,800 86,400
3 4 5 6 7 65 65 Km 146,250 65,813 - 102,375 87,750 66 66 Km 148,500 66,825 - 103,950 89,100 67 67 Km 150,750 67,838 - 105,525 90,450 68 68 Km 153,000 68,850 - 107,100 91,800 69 69 Km 155,250 69,863 - 108,675 93,150 70 70 Km 157,500 70,875 - 110,250 94,500 71 71 Km 159,750 71,888 - 111,825 95,850 72 72 Km 162,000 72,900 - 113,400 97,200 73 73 Km 164,250 73,913 - 114,975 98,550 74 74 Km 166,500 74,925 - 116,550 99,900 75 75 Km 168,750 75,938 - 118,125 101,250 76 76 Km 171,000 76,950 - 119,700 102,600 77 77 Km 173,250 77,963 - 121,275 103,950 78 78 Km 175,500 78,975 - 122,850 105,300 79 79 Km 177,750 79,988 - 124,425 106,650 80 80 Km 180,000 81,000 - 126,000 108,000 81 81 Km 182,250 82,013 - 127,575 109,350 82 82 Km 184,500 83,025 - 129,150 110,700 83 83 Km 186,750 84,038 - 130,725 112,050 84 84 Km 189,000 85,050 - 132,300 113,400 85 85 Km 191,250 86,063 - 133,875 114,750 86 86 Km 193,500 87,075 - 135,450 116,100 87 87 Km 195,750 88,088 - 137,025 117,450 88 88 Km 198,000 89,100 - 138,600 118,800 89 89 Km 200,250 90,113 - 140,175 120,150 90 90 Km 202,500 91,125 - 141,750 121,500 91 91 Km 204,750 92,138 - 143,325 122,850 92 92 Km 207,000 93,150 - 144,900 124,200 93 93 Km 209,250 94,163 - 146,475 125,550 94 94 Km 211,500 95,175 - 148,050 126,900 95 95 Km 213,750 96,188 - 149,625 128,250 96 96 Km 216,000 97,200 - 151,200 129,600 97 97 Km 218,250 98,213 - 152,775 130,950 98 98 Km 220,500 99,225 - 154,350 132,300 99 99 Km 222,750 100,238 - 155,925 133,650
3 4 5 6 7 100 100 Km 225,000 101,250 45,000 157,500 135,000 101 101 Km 227,250 102,263 45,450 159,075 136,350 102 102 Km 229,500 103,275 45,900 160,650 137,700 103 103 Km 231,750 104,288 46,350 162,225 139,050 104 104 Km 234,000 105,300 46,800 163,800 140,400 105 105 Km 236,250 106,313 47,250 165,375 141,750 106 106 Km 238,500 107,325 47,700 166,950 143,100 107 107 Km 240,750 108,338 48,150 168,525 144,450 108 108 Km 243,000 109,350 48,600 170,100 145,800 109 109 Km 245,250 110,363 49,050 171,675 147,150 110 110 Km 247,500 111,375 49,500 173,250 148,500 111 111 Km 249,750 112,388 49,950 174,825 149,850 112 112 Km 252,000 113,400 50,400 176,400 151,200 113 113 Km 254,250 114,413 50,850 177,975 152,550 114 114 Km 256,500 115,425 51,300 179,550 153,900 115 115 Km 258,750 116,438 51,750 181,125 155,250 116 116 Km 261,000 117,450 52,200 182,700 156,600 117 117 Km 263,250 118,463 52,650 184,275 157,950 118 118 Km 265,500 119,475 53,100 185,850 159,300 119 119 Km 267,750 120,488 53,550 187,425 160,650 120 120 Km 270,000 121,500 54,000 189,000 162,000 121 121 Km 272,250 122,513 54,450 190,575 163,350 122 122 Km 274,500 123,525 54,900 192,150 164,700 123 123 Km 276,750 124,538 55,350 193,725 166,050 124 124 Km 279,000 125,550 55,800 195,300 167,400 125 125 Km 281,250 126,563 56,250 196,875 168,750 126 126 Km 283,500 127,575 56,700 198,450 170,100 127 127 Km 285,750 128,588 57,150 200,025 171,450 128 128 Km 288,000 129,600 57,600 201,600 172,800 129 129 Km 290,250 130,613 58,050 203,175 174,150 130 130 Km 292,500 131,625 58,500 204,750 175,500 131 131 Km 294,750 132,638 58,950 206,325 176,850 132 132 Km 297,000 133,650 59,400 207,900 178,200 133 133 Km 299,250 134,663 59,850 209,475 179,550 134 134 Km 301,500 135,675 60,300 211,050 180,900
3 4 5 6 7 135 135 Km 303,750 136,688 60,750 212,625 182,250 136 136 Km 306,000 137,700 61,200 214,200 183,600 137 137 Km 308,250 138,713 61,650 215,775 184,950 138 138 Km 310,500 139,725 62,100 217,350 186,300 139 139 Km 312,750 140,738 62,550 218,925 187,650 140 140 Km 315,000 141,750 63,000 220,500 189,000 141 141 Km 317,250 142,763 63,450 222,075 190,350 142 142 Km 319,500 143,775 63,900 223,650 191,700 143 143 Km 321,750 144,788 64,350 225,225 193,050 144 144 Km 324,000 145,800 64,800 226,800 194,400 145 145 Km 326,250 146,813 65,250 228,375 195,750 146 146 Km 328,500 147,825 65,700 229,950 197,100 147 147 Km 330,750 148,838 66,150 231,525 198,450 148 148 Km 333,000 149,850 66,600 233,100 199,800 149 149 Km 335,250 150,863 67,050 234,675 201,150 150 150 Km 337,500 151,875 67,500 236,250 202,500 151 151 Km 339,750 152,888 67,950 237,825 203,850 152 152 Km 342,000 153,900 68,400 239,400 205,200 153 153 Km 344,250 154,913 68,850 240,975 206,550 154 154 Km 346,500 155,925 69,300 242,550 207,900 155 155 Km 348,750 156,938 69,750 244,125 209,250 156 156 Km 351,000 157,950 70,200 245,700 210,600 157 157 Km 353,250 158,963 70,650 247,275 211,950 158 158 Km 355,500 159,975 71,100 248,850 213,300 159 159 Km 357,750 160,988 71,550 250,425 214,650 160 160 Km 360,000 162,000 72,000 252,000 216,000 161 161 Km 362,250 163,013 72,450 253,575 217,350 162 162 Km 364,500 164,025 72,900 255,150 218,700 163 163 Km 366,750 165,038 73,350 256,725 220,050 164 164 Km 369,000 166,050 73,800 258,300 221,400 165 165 Km 371,250 167,063 74,250 259,875 222,750 166 166 Km 373,500 168,075 74,700 261,450 224,100 167 167 Km 375,750 169,088 75,150 263,025 225,450 168 168 Km 378,000 170,100 75,600 264,600 226,800 169 169 Km 380,250 171,113 76,050 266,175 228,150
3 4 5 6 7 170 170 Km 382,500 172,125 76,500 267,750 229,500 171 171 Km 384,750 173,138 76,950 269,325 230,850 172 172 Km 387,000 174,150 77,400 270,900 232,200 173 173 Km 389,250 175,163 77,850 272,475 233,550 174 174 Km 391,500 176,175 78,300 274,050 234,900 175 175 Km 393,750 177,188 78,750 275,625 236,250 176 176 Km 396,000 178,200 79,200 277,200 237,600 177 177 Km 398,250 179,213 79,650 278,775 238,950 178 178 Km 400,500 180,225 80,100 280,350 240,300 179 179 Km 402,750 181,238 80,550 281,925 241,650 180 180 Km 405,000 182,250 81,000 283,500 243,000 181 181 Km 407,250 183,263 81,450 285,075 244,350 182 182 Km 409,500 184,275 81,900 286,650 245,700 183 183 Km 411,750 185,288 82,350 288,225 247,050 184 184 Km 414,000 186,300 82,800 289,800 248,400 185 185 Km 416,250 187,313 83,250 291,375 249,750 186 186 Km 418,500 188,325 83,700 292,950 251,100 187 187 Km 420,750 189,338 84,150 294,525 252,450 188 188 Km 423,000 190,350 84,600 296,100 253,800 189 189 Km 425,250 191,363 85,050 297,675 255,150 190 190 Km 427,500 192,375 85,500 299,250 256,500 191 191 Km 429,750 193,388 85,950 300,825 257,850 192 192 Km 432,000 194,400 86,400 302,400 259,200 193 193 Km 434,250 195,413 86,850 303,975 260,550 194 194 Km 436,500 196,425 87,300 305,550 261,900 195 195 Km 438,750 197,438 87,750 307,125 263,250 196 196 Km 441,000 198,450 88,200 308,700 264,600 197 197 Km 443,250 199,463 88,650 310,275 265,950 198 198 Km 445,500 200,475 89,100 311,850 267,300 199 199 Km 447,750 201,488 89,550 313,425 268,650 200 200 Km 450,000 202,500 90,000 315,000 270,000
2. MOBIL JENAZAH
a. Dalam Daerah
No Jarak Tujuan (km) Jasa Sarana (BBMS) Jasa Pelayanan Sopir Pembantu Sopir 50% x BBMS 20% x BBMS 1 Dalam Kota 5 kilometer pertama (Lumpsum) 33,750 28,000 -
b. Luar Daerah
No Jarak Tujuan (Km) Jasa Sarana (BBMS) Jasa Pelayanan Sopir Pembantu Sopir 50% x BBMS 20% x BBMS 1 2 3 4 5 Setiap penambahan dari 5 km pertama 1 1 Km 3,375 1,688 675 2 2 Km 6,750 3,375 1,350 3 3 Km 10,125 5,063 2,025 4 4 Km 13,500 6,750 2,700 5 5 Km 16,875 8,438 3,375 6 6 Km 20,250 10,125 4,050 7 7 Km 23,625 11,813 4,725 8 8 Km 27,000 13,500 5,400 9 9 Km 30,375 15,188 6,075 10 10 Km 33,750 16,875 6,750 11 11 Km 37,125 18,563 7,425 12 12 Km 40,500 20,250 8,100 13 13 Km 43,875 21,938 8,775 14 14 Km 47,250 23,625 9,450 15 15 Km 50,625 25,313 10,125 16 16 Km 54,000 27,000 10,800 17 17 Km 57,375 28,688 11,475 18 18 Km 60,750 30,375 12,150 19 19 Km 64,125 32,063 12,825 20 20 Km 67,500 33,750 13,500 21 21 Km 70,875 35,438 14,175 22 22 Km 74,250 37,125 14,850
3 4 5 23 23 Km 77,625 38,813 15,525 24 24 Km 81,000 40,500 16,200 25 25 Km 84,375 42,188 16,875 26 26 Km 87,750 43,875 17,550 27 27 Km 91,125 45,563 18,225 28 28 Km 94,500 47,250 18,900 29 29 Km 97,875 48,938 19,575 30 30 Km 101,250 50,625 20,250 31 31 Km 104,625 52,313 20,925 32 32 Km 108,000 54,000 21,600 33 33 Km 111,375 55,688 22,275 34 34 Km 114,750 57,375 22,950 35 35 Km 118,125 59,063 23,625 36 36 Km 121,500 60,750 24,300 37 37 Km 124,875 62,438 24,975 38 38 Km 128,250 64,125 25,650 39 39 Km 131,625 65,813 26,325 40 40 Km 135,000 67,500 27,000 41 41 Km 138,375 69,188 27,675 42 42 Km 141,750 70,875 28,350 43 43 Km 145,125 72,563 29,025 44 44 Km 148,500 74,250 29,700 45 45 Km 151,875 75,938 30,375 46 46 Km 155,250 77,625 31,050 47 47 Km 158,625 79,313 31,725 48 48 Km 162,000 81,000 32,400 49 49 Km 165,375 82,688 33,075 50 50 Km 168,750 84,375 33,750 51 51 Km 172,125 86,063 34,425 52 52 Km 175,500 87,750 35,100 53 53 Km 178,875 89,438 35,775 54 54 Km 182,250 91,125 36,450 55 55 Km 185,625 92,813 37,125 56 56 Km 189,000 94,500 37,800 57 57 Km 192,375 96,188 38,475
3 4 5 58 58 Km 195,750 97,875 39,150 59 59 Km 199,125 99,563 39,825 60 60 Km 202,500 101,250 40,500 61 61 Km 205,875 102,938 41,175 62 62 Km 209,250 104,625 41,850 63 63 Km 212,625 106,313 42,525 64 64 Km 216,000 108,000 43,200 65 65 Km 219,375 109,688 43,875 66 66 Km 222,750 111,375 44,550 67 67 Km 226,125 113,063 45,225 68 68 Km 229,500 114,750 45,900 69 69 Km 232,875 116,438 46,575 70 70 Km 236,250 118,125 47,250 71 71 Km 239,625 119,813 47,925 72 72 Km 243,000 121,500 48,600 73 73 Km 246,375 123,188 49,275 74 74 Km 249,750 124,875 49,950 75 75 Km 253,125 126,563 50,625 76 76 Km 256,500 128,250 51,300 77 77 Km 259,875 129,938 51,975 78 78 Km 263,250 131,625 52,650 79 79 Km 266,625 133,313 53,325 80 80 Km 270,000 135,000 54,000 81 81 Km 273,375 136,688 54,675 82 82 Km 276,750 138,375 55,350 83 83 Km 280,125 140,063 56,025 84 84 Km 283,500 141,750 56,700 85 85 Km 286,875 143,438 57,375 86 86 Km 290,250 145,125 58,050 87 87 Km 293,625 146,813 58,725 88 88 Km 297,000 148,500 59,400 89 89 Km 300,375 150,188 60,075 90 90 Km 303,750 151,875 60,750 91 91 Km 307,125 153,563 61,425 92 92 Km 310,500 155,250 62,100
3 4 5 93 93 Km 313,875 156,938 62,775 94 94 Km 317,250 158,625 63,450 95 95 Km 320,625 160,313 64,125 96 96 Km 324,000 162,000 64,800 97 97 Km 327,375 163,688 65,475 98 98 Km 330,750 165,375 66,150 99 99 Km 334,125 167,063 66,825 100 100 Km 337,500 168,750 67,500 101 101 Km 340,875 170,438 68,175 102 102 Km 344,250 172,125 68,850 103 103 Km 347,625 173,813 69,525 104 104 Km 351,000 175,500 70,200 105 105 Km 354,375 177,188 70,875 106 106 Km 357,750 178,875 71,550 107 107 Km 361,125 180,563 72,225 108 108 Km 364,500 182,250 72,900 109 109 Km 367,875 183,938 73,575 110 110 Km 371,250 185,625 74,250 111 111 Km 374,625 187,313 74,925 112 112 Km 378,000 189,000 75,600 113 113 Km 381,375 190,688 76,275 114 114 Km 384,750 192,375 76,950 115 115 Km 388,125 194,063 77,625 116 116 Km 391,500 195,750 78,300 117 117 Km 394,875 197,438 78,975 118 118 Km 398,250 199,125 79,650 119 119 Km 401,625 200,813 80,325 120 120 Km 405,000 202,500 81,000 121 121 Km 408,375 204,188 81,675 122 122 Km 411,750 205,875 82,350 123 123 Km 415,125 207,563 83,025 124 124 Km 418,500 209,250 83,700 125 125 Km 421,875 210,938 84,375 126 126 Km 425,250 212,625 85,050 127 127 Km 428,625 214,313 85,725 128 128 Km 432,000 216,000 86,400
3 4 5 129 129 Km 435,375 217,688 87,075 130 130 Km 438,750 219,375 87,750 131 131 Km 442,125 221,063 88,425 132 132 Km 445,500 222,750 89,100 133 133 Km 448,875 224,438 89,775 134 134 Km 452,250 226,125 90,450 135 135 Km 455,625 227,813 91,125 136 136 Km 459,000 229,500 91,800 137 137 Km 462,375 231,188 92,475 138 138 Km 465,750 232,875 93,150 139 139 Km 469,125 234,563 93,825 140 140 Km 472,500 236,250 94,500 141 141 Km 475,875 237,938 95,175 142 142 Km 479,250 239,625 95,850 143 143 Km 482,625 241,313 96,525 144 144 Km 486,000 243,000 97,200 145 145 Km 489,375 244,688 97,875 146 146 Km 492,750 246,375 98,550 147 147 Km 496,125 248,063 99,225 148 148 Km 499,500 249,750 99,900 149 149 Km 502,875 251,438 100,575 150 150 Km 506,250 253,125 101,250 151 151 Km 509,625 254,813 101,925 152 152 Km 513,000 256,500 102,600 153 153 Km 516,375 258,188 103,275 154 154 Km 519,750 259,875 103,950 155 155 Km 523,125 261,563 104,625 156 156 Km 526,500 263,250 105,300 157 157 Km 529,875 264,938 105,975 158 158 Km 533,250 266,625 106,650 159 159 Km 536,625 268,313 107,325 160 160 Km 540,000 270,000 108,000 161 161 Km 543,375 271,688 108,675 162 162 Km 546,750 273,375 109,350 163 163 Km 550,125 275,063 110,025 164 164 Km 553,500 276,750 110,700
3 4 5 165 165 Km 556,875 278,438 111,375 166 166 Km 560,250 280,125 112,050 167 167 Km 563,625 281,813 112,725 168 168 Km 567,000 283,500 113,400 169 169 Km 570,375 285,188 114,075 170 170 Km 573,750 286,875 114,750 171 171 Km 577,125 288,563 115,425 172 172 Km 580,500 290,250 116,100 173 173 Km 583,875 291,938 116,775 174 174 Km 587,250 293,625 117,450 175 175 Km 590,625 295,313 118,125 176 176 Km 594,000 297,000 118,800 177 177 Km 597,375 298,688 119,475 178 178 Km 600,750 300,375 120,150 179 179 Km 604,125 302,063 120,825 180 180 Km 607,500 303,750 121,500 181 181 Km 610,875 305,438 122,175 182 182 Km 614,250 307,125 122,850 183 183 Km 617,625 308,813 123,525 184 184 Km 621,000 310,500 124,200 185 185 Km 624,375 312,188 124,875 186 186 Km 627,750 313,875 125,550 187 187 Km 631,125 315,563 126,225 188 188 Km 634,500 317,250 126,900 189 189 Km 637,875 318,938 127,575 190 190 Km 641,250 320,625 128,250 191 191 Km 644,625 322,313 128,925 192 192 Km 648,000 324,000 129,600 193 193 Km 651,375 325,688 130,275 194 194 Km 654,750 327,375 130,950 195 195 Km 658,125 329,063 131,625 196 196 Km 661,500 330,750 132,300 197 197 Km 664,875 332,438 132,975 198 198 Km 668,250 334,125 133,650 199 199 Km 671,625 335,813 134,325 200 200 Km 675,000 337,500 135,000
M. RETRIBUSI PELAYANAN PEMBAKARAN LIMBAH MEDIS PADAT (INCENERATOR)
No Jenis Pelayanan BHP Jasa sarana Jasa Pelayanan Jumlah 1 Pembakaran limbah medis per 2 (dua) kilogram 22,500 3,500 9,000 35,000
WALIKOTA MADIUN, ttd H. BAMBANG IRIANTO, SH, MM.