Selamat datang di RSUD Bayung Lencir
| Uff Arch Barr (Cito) | Rp. 8.007.500,- | |
| Uff Arch Barr dan suspensi maksila (Cito) | Rp. 8.007.500,- | |
| Amputasi jari (phalangs - traumatik) (Cito) | Rp. 8.007.500,- | |
| Amputation of digiti single ** (Cito) | Rp. 8.007.500,- | |
| Anal fistulectomy (Cito) | Rp. 8.007.500,- | |
| Anal fistulotomy (Cito) | Rp. 8.007.500,- | |
| Anterior lamellar keratoplasty (Cito) | Rp. 8.007.500,- | |
| Appendicostomy (Cito) | Rp. 8.007.500,- | |
| Babcock (Cito) | Rp. 8.007.500,- | |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 8.007.500,- | |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Rp. 8.007.500,- | |
| Bilateral multipel excision of lesion of breast with narcose (Cito) | Rp. 8.007.500,- | |
| Bilateral ovariectomy (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of direct inguinal hernia (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of indirect inguinal hernia (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of inguinal hernia, not otherwise specified (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect (Cito) | Rp. 8.007.500,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Rp. 8.007.500,- | |
| Biopsi pembuluh darah perifer * (Cito) | Rp. 8.007.500,- | |
| Biopsi perikardium * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka bronkhus * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka diafragma * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka mediastinum * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka paru * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka pleura * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka pleura dengan VATS * (Cito) | Rp. 8.007.500,- | |
| Biopsi terbuka tumor dinding thoraks * (Cito) | Rp. 8.007.500,- | |
| Caecostomy (Cito) | Rp. 8.007.500,- | |
| Closure of anal fistula (Cito) | Rp. 8.007.500,- | |
| Combustio (luka bakar) * (Cito) | Rp. 8.007.500,- | |
| Compartement excision (Cito) | Rp. 8.007.500,- | |
| Debridement-nekrotomi luka gangren (Cito) | Rp. 8.007.500,- | |
| Deseksi submandibula (Cito) | Rp. 8.007.500,- | |
| Disartikulasi sendi ekstremitas (Cito) | Rp. 8.007.500,- | |
| Dislokasi bahu * (Cito) | Rp. 8.007.500,- | |
| Drainage of appendiceal abscess (Cito) | Rp. 8.007.500,- | |
| Drainage of pancreatic cyst by catheter (Cito) | Rp. 8.007.500,- | |
| DSAEK (Cito) | Rp. 8.007.500,- | |
| ECCE / ICCE / SICS (Cito) | Rp. 8.007.500,- | |
| ECCE / SICS dan IOL (Cito) | Rp. 8.007.500,- | |
| Eksisi biopsi tumor pembuluh darah (Cito) | Rp. 8.007.500,- | |
| Eksisi glandula submandibula (Cito) | Rp. 8.007.500,- | |
| Eksisi higroma leher * (Cito) | Rp. 8.007.500,- | |
| Eksisi kista tiroglosus (Cito) | Rp. 8.007.500,- | |
| Eksisi parsial dan marsupialisasi Ranula (Cito) | Rp. 8.007.500,- | |
| Eksisi Pterigium (Cito) | Rp. 8.007.500,- | |
| Eksisi tumor dinding dada * (Cito) | Rp. 8.007.500,- | |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Cito) | Rp. 8.007.500,- | |
| Eksisi tumor pembuluh darah perifer ** (Cito) | Rp. 8.007.500,- | |
| Ekstirpasi kelainan kornea (Cito) | Rp. 8.007.500,- | |
| Ekstraksi corpus alienum segmen anterior (Cito) | Rp. 8.007.500,- | |
| Ekstraksi IOL (Cito) | Rp. 8.007.500,- | |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Cito) | Rp. 8.007.500,- | |
| Endoskopi - Esofagoskopi dilatasi (Cito) | Rp. 8.007.500,- | |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Cito) | Rp. 8.007.500,- | |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Cito) | Rp. 8.007.500,- | |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Cito) | Rp. 8.007.500,- | |
| Evakuasi silicon oil (Cito) | Rp. 8.007.500,- | |
| Evakuasi silicon oil dan ECCE (Cito) | Rp. 8.007.500,- | |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Cito) | Rp. 8.007.500,- | |
| Exchange IOL (Cito) | Rp. 8.007.500,- | |
| Excision of ectopic breast tissue (Cito) | Rp. 8.007.500,- | |
| excision of lesion of breast with narcose (Cito) | Rp. 8.007.500,- | |
| Excision of thyroglossal duct or trac (Cito) | Rp. 8.007.500,- | |
| Exploratory laparotomy (Cito) | Rp. 8.007.500,- | |
| Extirpasi kista rongga mulut (Cito) | Rp. 8.007.500,- | |
| Extirpasi muoccocele rongga mulut (Cito) | Rp. 8.007.500,- | |
| Fasciotomy * (Cito) | Rp. 8.007.500,- | |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Cito) | Rp. 8.007.500,- | |
| Fiksasi interna fraktur nasal (Cito) | Rp. 8.007.500,- | |
| Flap konjungtiva amnion graft (Cito) | Rp. 8.007.500,- | |
| Fraktur humerus * (Cito) | Rp. 8.007.500,- | |
| Gastrostomi * (Cito) | Rp. 8.007.500,- | |
| GIN -Ekstirpasi polip (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Ekstirpasi Giant Condiloma (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Kistektomi (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Laparotomi Diagnostik (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Pemasangan Implan Tableport (Cito) | Rp. 8.007.500,- | |
| Ginekologi - Salpingo-ooforektomi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Anterior / posterior sklerotomi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Gonioplasty / goniotomy (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Iridektomi perifer (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Paracentesis (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Reformasi COA (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Revisi Bleb (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Tindakan cyclodia termi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Trabekulektomi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Trabekulotomi anak atau bayi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Transkleral Foto Coagulasi (Cito) | Rp. 8.007.500,- | |
| Glaukoma - Tubes implan (Cito) | Rp. 8.007.500,- | |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Cito) | Rp. 8.007.500,- | |
| Hand - Elbow, tennis elbow, release (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Rp. 8.007.500,- | |
| Hand - Jari, crush injuries (complex) wound debridement (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, crush injury (simple), wound debridement (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, deep infection, drainage (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, deformity, instrinsic muscle release (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Rp. 8.007.500,- | |
| Hand - Jari, injury, debridement (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, jaringan lunak tumor, excision (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, macrodactyly, debulking (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, ring construction (single), koreksi (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, superficial infection, drainage (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, syndactili (single) koreksi (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, trauma, terminalisation (multiple) (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, trauma, terminalisation (single) (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, various lesions, amputasi (multiple) (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, various lesions, Ray amputasi (single) (Cito) | Rp. 8.007.500,- | |
| Hand - Jari, wart, com, naevus, excision (Cito) | Rp. 8.007.500,- | |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Cito) | Rp. 8.007.500,- | |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Rp. 8.007.500,- | |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Rp. 8.007.500,- | |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Rp. 8.007.500,- | |
| Hand - Nail bed, Laceration, repair (single) (Cito) | Rp. 8.007.500,- | |
| Hand - Nerve various lesions, primary or secondary suture (Cito) | Rp. 8.007.500,- | |
| Hand - Nerve, Various Lesions, biopsy (Cito) | Rp. 8.007.500,- | |
| Hand - Repair muscle (Cito) | Rp. 8.007.500,- | |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Cito) | Rp. 8.007.500,- | |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Cito) | Rp. 8.007.500,- | |
| Hand - Sendi (wrist), various lesions, arthrodesis (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (Ci | Rp. 8.007.500,- | |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Cit | Rp. 8.007.500,- | |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Rp. 8.007.500,- | |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Cito) | Rp. 8.007.500,- | |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (Ci | Rp. 8.007.500,- | |
| Hidrokel Testis / Funikuli ** (Cito) | Rp. 8.007.500,- | |
| Implantasi iris artifisial (Cito) | Rp. 8.007.500,- | |
| Implantasi piggyback IOL (Cito) | Rp. 8.007.500,- | |
| Incision of perianal abscess (Cito) | Rp. 8.007.500,- | |
| Injeksi intravitreal (Cito) | Rp. 8.007.500,- | |
| Insertion of synthetic implant in facial bone (Cito) | Rp. 8.007.500,- | |
| Insisi atau Eksisi gingiva (Cito) | Rp. 8.007.500,- | |
| Insisi flegmon dasar mulut (Cito) | Rp. 8.007.500,- | |
| Internal Fiksasi fraktur condylus mandibula (Cito) | Rp. 8.007.500,- | |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Cito) | Rp. 8.007.500,- | |
| Internal Fiksasi fraktur Mandibula segmental (Cito) | Rp. 8.007.500,- | |
| Keratoplasty tembus (Cito) | Rp. 8.007.500,- | |
| Keratoprosthesis (Cito) | Rp. 8.007.500,- | |
| Knee - Open knee debridement (Cito) | Rp. 8.007.500,- | |
| Knee - Perypheral nerve ablation (Cito) | Rp. 8.007.500,- | |
| Knee - Perypheral nerve lysis (Cito) | Rp. 8.007.500,- | |
| Kolonoskopi (Cito) | Rp. 8.007.500,- | |
| Labioshisis * (Cito) | Rp. 8.007.500,- | |
| Laring dan Faring - Laringofisure (Cito) | Rp. 8.007.500,- | |
| Laring dan Faring - Pemasangan T-Tube (Cito) | Rp. 8.007.500,- | |
| Left lateral anal sphincterotomy (Cito) | Rp. 8.007.500,- | |
| Ligasi vaskular ekstremitas (Cito) | Rp. 8.007.500,- | |
| Ligation of hemorrhoids (Cito) | Rp. 8.007.500,- | |
| Limbal Relaxing Incision (LRI) (Cito) | Rp. 8.007.500,- | |
| Maksilektomi total dan Rekonstruksi * (Cito) | Rp. 8.007.500,- | |
| Multipel excision of lesion of breast with narcose (Cito) | Rp. 8.007.500,- | |
| Mutilasi digiti ekstremitas (Multiple) (Cito) | Rp. 8.007.500,- | |
| Obstetri - Histerorafi (Cito) | Rp. 8.007.500,- | |
| Obstetri - Kolporafi anterior (Cito) | Rp. 8.007.500,- | |
| Obstetri - Kolporafi posterior (Cito) | Rp. 8.007.500,- | |
| Obstetri - Mioma geburt (Cito) | Rp. 8.007.500,- | |
| Obstetri - Sectio caesaria tanpa penyulit (Cito) | Rp. 8.007.500,- | |
| Odontektomi tingkat I (Cito) | Rp. 8.007.500,- | |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Cito) | Rp. 8.007.500,- | |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Cito) | Rp. 8.007.500,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Cit | Rp. 8.007.500,- | |
| Onkologi - Open biopsy bone tumor (Cito) | Rp. 8.007.500,- | |
| Onkologi - Open biopsy soft tissue (Cito) | Rp. 8.007.500,- | |
| Onkologi - Ray amputation jari (Cito) | Rp. 8.007.500,- | |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Cito) | Rp. 8.007.500,- | |
| Open biopsi of breast (Cito) | Rp. 8.007.500,- | |
| Open biopsy of salivary gland or duct (Cito) | Rp. 8.007.500,- | |
| Open reduction of alveolar fracture * (Cito) | Rp. 8.007.500,- | |
| Osteotomi eksisi tulang maksilofasial (Cito) | Rp. 8.007.500,- | |
| Other appendectomy (elective) * (Cito) | Rp. 8.007.500,- | |
| Other bilateral femoral hernioraphy (Cito) | Rp. 8.007.500,- | |
| Other hernia repair (Cito) | Rp. 8.007.500,- | |
| Other incidental appendectomy * (Cito) | Rp. 8.007.500,- | |
| Other incision of anus (Cito) | Rp. 8.007.500,- | |
| Other lysis of peritoneal adhesions (Cito) | Rp. 8.007.500,- | |
| Other operations on anus (Cito) | Rp. 8.007.500,- | |
| Other operations on trachea (Cito) | Rp. 8.007.500,- | |
| Other procedures on hemorrhoids (Cito) | Rp. 8.007.500,- | |
| Other reconstruction of mandible (Cito) | Rp. 8.007.500,- | |
| Other reconstruction of other facial bone (Cito) | Rp. 8.007.500,- | |
| Other repair and plastic operation of tongue (Cito) | Rp. 8.007.500,- | |
| Other repair of abdominal wall (Cito) | Rp. 8.007.500,- | |
| Other umbilical herniorraphy* (Cito) | Rp. 8.007.500,- | |
| Other unilateral femoral herniorraphy (Cito) | Rp. 8.007.500,- | |
| Otologi - Meatoplasti (Cito) | Rp. 8.007.500,- | |
| Otologi - Miringoplasti (Cito) | Rp. 8.007.500,- | |
| Otologi - Pemasangan grommet (Cito) | Rp. 8.007.500,- | |
| Palatoshisis ** (Cito) | Rp. 8.007.500,- | |
| Partial glossectomy (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Debridement fraktur terbuka anak (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Rp. 8.007.500,- | |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Hemangioma : injeksi intralesi (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Katarak (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Koreksi curly toe (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Koreksi overriding toe polidactili (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Koreksi syndactili kaki (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Nekrotomy (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Open achilles tendon lengthening (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Percutaneous tendon tenotomy (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (Ci | Rp. 8.007.500,- | |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Rp. 8.007.500,- | |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Cito) | Rp. 8.007.500,- | |
| Pediatrik - RetCam and Narkose (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Skin graft (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Rp. 8.007.500,- | |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Rp. 8.007.500,- | |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Cito) | Rp. 8.007.500,- | |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Cito) | Rp. 8.007.500,- | |
| Pembedahan teleangiectasis (Cito) | Rp. 8.007.500,- | |
| Pengangkatan encircling silicone band (Cito) | Rp. 8.007.500,- | |
| Perikardiektomi * (Cito) | Rp. 8.007.500,- | |
| Phaco dan IOL multifokal atau torik (Cito) | Rp. 8.007.500,- | |
| Phakik IOL (Cito) | Rp. 8.007.500,- | |
| Phototherapeutic keratectomy (PTK) (Cito) | Rp. 8.007.500,- | |
| Pionephrosis (Cito) | Rp. 8.007.500,- | |
| Plastik Rekionstruksi - Regional flap tidak luas (Cito) | Rp. 8.007.500,- | |
| Pleural window (eloeser flap) * (Cito) | Rp. 8.007.500,- | |
| Plikasi bulae / bleb emfisematous (Cito) | Rp. 8.007.500,- | |
| Pneumatic retinopexy (Cito) | Rp. 8.007.500,- | |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Rp. 8.007.500,- | |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Cito) | Rp. 8.007.500,- | |
| Prosedur Sistrunk kista duktus tiroglosus (Cito) | Rp. 8.007.500,- | |
| Pulmonary decortication * (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Cryo/cauter pada trichiasis (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Eksternal DCR dan silikon tube (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Ektropion 1 kelopak * (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Entropion 1 kelopak (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Eviserasi / enukleasi (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Koreksi Ptosis * (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Koreksi simblefaron (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Probing (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Repair Ruptur palpebra * (Cito) | Rp. 8.007.500,- | |
| Rekonstruksi - Tarsorafi (Cito) | Rp. 8.007.500,- | |
| Release kontraktur mandibula (Cito) | Rp. 8.007.500,- | |
| Release tortikolis (Cito) | Rp. 8.007.500,- | |
| Removal of foreign body from peritoneal cavity (Cito) | Rp. 8.007.500,- | |
| Removal of foreign body from retro-peritoneal cavity (Cito) | Rp. 8.007.500,- | |
| Repair iridodyalisis (Cito) | Rp. 8.007.500,- | |
| Repair of direct inguinal hernia (Cito) | Rp. 8.007.500,- | |
| Repair of direct inguinal hernia with graft or prosthesis (Cito) | Rp. 8.007.500,- | |
| Repair of indirect inguinal hernia (Cito) | Rp. 8.007.500,- | |
| Repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 8.007.500,- | |
| Repair of laceration, cornea and or sclera, perforating (Cito) | Rp. 8.007.500,- | |
| Repair of laceration, cornea, non perforating (Cito) | Rp. 8.007.500,- | |
| Repair of other hernia of anterior abdominal wall (Cito) | Rp. 8.007.500,- | |
| Repair of other hernia of anterior abdominal wall with prosthesis (Cito) | Rp. 8.007.500,- | |
| Repair of umbilical hernia with prosthesis * (Cito) | Rp. 8.007.500,- | |
| Reposisi IOL (Cito) | Rp. 8.007.500,- | |
| Reposisi Iris (Cito) | Rp. 8.007.500,- | |
| Reposisi tertutup fraktur nasal (Cito) | Rp. 8.007.500,- | |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Cito) | Rp. 8.007.500,- | |
| Rinologi - Konkotomi / Konkoplasti (Cito) | Rp. 8.007.500,- | |
| Rinologi - Nasoendoskopi Dengan tindakan (Cito) | Rp. 8.007.500,- | |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Cito) | Rp. 8.007.500,- | |
| Rupture tendon achiles (Cito) | Rp. 8.007.500,- | |
| Scleral buckle, cryo dan C3F8 (Cito) | Rp. 8.007.500,- | |
| Scleral buckling (Cito) | Rp. 8.007.500,- | |
| Sekunder IOL (Cito) | Rp. 8.007.500,- | |
| Somnoplasty (Cito) | Rp. 8.007.500,- | |
| Spine - Biopsy vertebra (1 level) * (Cito) | Rp. 8.007.500,- | |
| Spine - Plaster application of the spine (Cito) | Rp. 8.007.500,- | |
| Strabismus 1 otot (Cito) | Rp. 8.007.500,- | |
| Strabismus 2 otot (Cito) | Rp. 8.007.500,- | |
| Strabismus 3 otot (Cito) | Rp. 8.007.500,- | |
| Suture of laceration of large intestine (Cito) | Rp. 8.007.500,- | |
| Suture of laceration of small intestine, except duodenum (Cito) | Rp. 8.007.500,- | |
| Suture of peritoneum (Cito) | Rp. 8.007.500,- | |
| Tatto cornea (Cito) | Rp. 8.007.500,- | |
| Torakotomi / sternotomi eksplorasi * (Cito) | Rp. 8.007.500,- | |
| Torsio testis ** (Cito) | Rp. 8.007.500,- | |
| Trakeostomi temporary ** (Cito) | Rp. 8.007.500,- | |
| Trauma - Acute ankle joint dislocation (Cito) | Rp. 8.007.500,- | |
| Trauma - Acute elbow joint dislocation (Cito) | Rp. 8.007.500,- | |
| Trauma - Acute hip joint dislocation (Cito) | Rp. 8.007.500,- | |
| Trauma - Acute knee joint dislocation (Cito) | Rp. 8.007.500,- | |
| Trauma - Closed fraktur shaft femur * (Cito) | Rp. 8.007.500,- | |
| Trauma - Closed fraktur shaft humerus * (Cito) | Rp. 8.007.500,- | |
| Trauma - Closed fraktur shaft radius (Cito) | Rp. 8.007.500,- | |
| Trauma - Closed fraktur shaft tibia (Cito) | Rp. 8.007.500,- | |
| Trauma - Closed fraktur shaft ulna (Cito) | Rp. 8.007.500,- | |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Rp. 8.007.500,- | |
| Trauma - Jaringan granulasi dengan STSG (Cito) | Rp. 8.007.500,- | |
| Trauma - Kompartemen otot (Cito) | Rp. 8.007.500,- | |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Cito) | Rp. 8.007.500,- | |
| Trauma - Nekrotik tissue dengan debridement (Cito) | Rp. 8.007.500,- | |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Cito) | Rp. 8.007.500,- | |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Cito) | Rp. 8.007.500,- | |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Cito) | Rp. 8.007.500,- | |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Cito) | Rp. 8.007.500,- | |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Cito) | Rp. 8.007.500,- | |
| Tumor - Biopsi tumor kelopak (Cito) | Rp. 8.007.500,- | |
| Tumor - Biopsi tumor orbita (Cito) | Rp. 8.007.500,- | |
| Tumor - Eksenterasi (Cito) | Rp. 8.007.500,- | |
| Tumor - Eksisi tumor adneksa (Cito) | Rp. 8.007.500,- | |
| Tumor - Ekstirpasi Tumor Orbita (Cito) | Rp. 8.007.500,- | |
| Tumor - Orbital dekompresi 1 tulang (Cito) | Rp. 8.007.500,- | |
| Tumor - Orbital dekompresi 2 tulang (Cito) | Rp. 8.007.500,- | |
| Tumor - Orbitotomi anterior (Cito) | Rp. 8.007.500,- | |
| Tumor - Orbitotomi lateral (Cito) | Rp. 8.007.500,- | |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 8.007.500,- | |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Rp. 8.007.500,- | |
| Unilateral thyroid lobectomy (Cito) | Rp. 8.007.500,- | |
| Wide excision of soft tissue tumor (Cito) | Rp. 8.007.500,- | |
| Uff Arch Barr (Cito) | Rp. 7.282.400,- | |
| Uff Arch Barr dan suspensi maksila (Cito) | Rp. 7.282.400,- | |
| Amputasi jari (phalangs - traumatik) (Cito) | Rp. 7.282.400,- | |
| Amputation of digiti single ** (Cito) | Rp. 7.282.400,- | |
| Anal fistulectomy (Cito) | Rp. 7.282.400,- | |
| Anal fistulotomy (Cito) | Rp. 7.282.400,- | |
| Anterior lamellar keratoplasty (Cito) | Rp. 7.282.400,- | |
| Appendicostomy (Cito) | Rp. 7.282.400,- | |
| Babcock (Cito) | Rp. 7.282.400,- | |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 7.282.400,- | |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Rp. 7.282.400,- | |
| Bilateral multipel excision of lesion of breast with narcose (Cito) | Rp. 7.282.400,- | |
| Bilateral ovariectomy (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of direct inguinal hernia (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of indirect inguinal hernia (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of inguinal hernia, not otherwise specified (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect (Cito) | Rp. 7.282.400,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Rp. 7.282.400,- | |
| Biopsi pembuluh darah perifer * (Cito) | Rp. 7.282.400,- | |
| Biopsi perikardium * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka bronkhus * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka diafragma * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka mediastinum * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka paru * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka pleura * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka pleura dengan VATS * (Cito) | Rp. 7.282.400,- | |
| Biopsi terbuka tumor dinding thoraks * (Cito) | Rp. 7.282.400,- | |
| Caecostomy (Cito) | Rp. 7.282.400,- | |
| Closure of anal fistula (Cito) | Rp. 7.282.400,- | |
| Combustio (luka bakar) * (Cito) | Rp. 7.282.400,- | |
| Compartement excision (Cito) | Rp. 7.282.400,- | |
| Debridement-nekrotomi luka gangren (Cito) | Rp. 7.282.400,- | |
| Deseksi submandibula (Cito) | Rp. 7.282.400,- | |
| Disartikulasi sendi ekstremitas (Cito) | Rp. 7.282.400,- | |
| Dislokasi bahu * (Cito) | Rp. 7.282.400,- | |
| Drainage of appendiceal abscess (Cito) | Rp. 7.282.400,- | |
| Drainage of pancreatic cyst by catheter (Cito) | Rp. 7.282.400,- | |
| DSAEK (Cito) | Rp. 7.282.400,- | |
| ECCE / ICCE / SICS (Cito) | Rp. 7.282.400,- | |
| ECCE / SICS dan IOL (Cito) | Rp. 7.282.400,- | |
| Eksisi biopsi tumor pembuluh darah (Cito) | Rp. 7.282.400,- | |
| Eksisi glandula submandibula (Cito) | Rp. 7.282.400,- | |
| Eksisi higroma leher * (Cito) | Rp. 7.282.400,- | |
| Eksisi kista tiroglosus (Cito) | Rp. 7.282.400,- | |
| Eksisi parsial dan marsupialisasi Ranula (Cito) | Rp. 7.282.400,- | |
| Eksisi Pterigium (Cito) | Rp. 7.282.400,- | |
| Eksisi tumor dinding dada * (Cito) | Rp. 7.282.400,- | |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Cito) | Rp. 7.282.400,- | |
| Eksisi tumor pembuluh darah perifer ** (Cito) | Rp. 7.282.400,- | |
| Ekstirpasi kelainan kornea (Cito) | Rp. 7.282.400,- | |
| Ekstraksi corpus alienum segmen anterior (Cito) | Rp. 7.282.400,- | |
| Ekstraksi IOL (Cito) | Rp. 7.282.400,- | |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Cito) | Rp. 7.282.400,- | |
| Endoskopi - Esofagoskopi dilatasi (Cito) | Rp. 7.282.400,- | |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Cito) | Rp. 7.282.400,- | |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Cito) | Rp. 7.282.400,- | |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Cito) | Rp. 7.282.400,- | |
| Evakuasi silicon oil (Cito) | Rp. 7.282.400,- | |
| Evakuasi silicon oil dan ECCE (Cito) | Rp. 7.282.400,- | |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Cito) | Rp. 7.282.400,- | |
| Exchange IOL (Cito) | Rp. 7.282.400,- | |
| Excision of ectopic breast tissue (Cito) | Rp. 7.282.400,- | |
| excision of lesion of breast with narcose (Cito) | Rp. 7.282.400,- | |
| Excision of thyroglossal duct or trac (Cito) | Rp. 7.282.400,- | |
| Exploratory laparotomy (Cito) | Rp. 7.282.400,- | |
| Extirpasi kista rongga mulut (Cito) | Rp. 7.282.400,- | |
| Extirpasi muoccocele rongga mulut (Cito) | Rp. 7.282.400,- | |
| Fasciotomy * (Cito) | Rp. 7.282.400,- | |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Cito) | Rp. 7.282.400,- | |
| Fiksasi interna fraktur nasal (Cito) | Rp. 7.282.400,- | |
| Flap konjungtiva amnion graft (Cito) | Rp. 7.282.400,- | |
| Fraktur humerus * (Cito) | Rp. 7.282.400,- | |
| Gastrostomi * (Cito) | Rp. 7.282.400,- | |
| GIN -Ekstirpasi polip (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Ekstirpasi Giant Condiloma (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Kistektomi (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Laparotomi Diagnostik (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Pemasangan Implan Tableport (Cito) | Rp. 7.282.400,- | |
| Ginekologi - Salpingo-ooforektomi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Anterior / posterior sklerotomi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Gonioplasty / goniotomy (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Iridektomi perifer (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Paracentesis (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Reformasi COA (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Revisi Bleb (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Tindakan cyclodia termi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Trabekulektomi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Trabekulotomi anak atau bayi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Transkleral Foto Coagulasi (Cito) | Rp. 7.282.400,- | |
| Glaukoma - Tubes implan (Cito) | Rp. 7.282.400,- | |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Cito) | Rp. 7.282.400,- | |
| Hand - Elbow, tennis elbow, release (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Rp. 7.282.400,- | |
| Hand - Jari, crush injuries (complex) wound debridement (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, crush injury (simple), wound debridement (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, deep infection, drainage (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, deformity, instrinsic muscle release (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Rp. 7.282.400,- | |
| Hand - Jari, injury, debridement (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, jaringan lunak tumor, excision (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, macrodactyly, debulking (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, ring construction (single), koreksi (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, superficial infection, drainage (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, syndactili (single) koreksi (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, trauma, terminalisation (multiple) (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, trauma, terminalisation (single) (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, various lesions, amputasi (multiple) (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, various lesions, Ray amputasi (single) (Cito) | Rp. 7.282.400,- | |
| Hand - Jari, wart, com, naevus, excision (Cito) | Rp. 7.282.400,- | |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Cito) | Rp. 7.282.400,- | |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Rp. 7.282.400,- | |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Rp. 7.282.400,- | |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Rp. 7.282.400,- | |
| Hand - Nail bed, Laceration, repair (single) (Cito) | Rp. 7.282.400,- | |
| Hand - Nerve various lesions, primary or secondary suture (Cito) | Rp. 7.282.400,- | |
| Hand - Nerve, Various Lesions, biopsy (Cito) | Rp. 7.282.400,- | |
| Hand - Repair muscle (Cito) | Rp. 7.282.400,- | |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Cito) | Rp. 7.282.400,- | |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Cito) | Rp. 7.282.400,- | |
| Hand - Sendi (wrist), various lesions, arthrodesis (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (Ci | Rp. 7.282.400,- | |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Cit | Rp. 7.282.400,- | |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Rp. 7.282.400,- | |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Cito) | Rp. 7.282.400,- | |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (Ci | Rp. 7.282.400,- | |
| Hidrokel Testis / Funikuli ** (Cito) | Rp. 7.282.400,- | |
| Implantasi iris artifisial (Cito) | Rp. 7.282.400,- | |
| Implantasi piggyback IOL (Cito) | Rp. 7.282.400,- | |
| Incision of perianal abscess (Cito) | Rp. 7.282.400,- | |
| Injeksi intravitreal (Cito) | Rp. 7.282.400,- | |
| Insertion of synthetic implant in facial bone (Cito) | Rp. 7.282.400,- | |
| Insisi atau Eksisi gingiva (Cito) | Rp. 7.282.400,- | |
| Insisi flegmon dasar mulut (Cito) | Rp. 7.282.400,- | |
| Internal Fiksasi fraktur condylus mandibula (Cito) | Rp. 7.282.400,- | |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Cito) | Rp. 7.282.400,- | |
| Internal Fiksasi fraktur Mandibula segmental (Cito) | Rp. 7.282.400,- | |
| Keratoplasty tembus (Cito) | Rp. 7.282.400,- | |
| Keratoprosthesis (Cito) | Rp. 7.282.400,- | |
| Knee - Open knee debridement (Cito) | Rp. 7.282.400,- | |
| Knee - Perypheral nerve ablation (Cito) | Rp. 7.282.400,- | |
| Knee - Perypheral nerve lysis (Cito) | Rp. 7.282.400,- | |
| Kolonoskopi (Cito) | Rp. 7.282.400,- | |
| Labioshisis * (Cito) | Rp. 7.282.400,- | |
| Laring dan Faring - Laringofisure (Cito) | Rp. 7.282.400,- | |
| Laring dan Faring - Pemasangan T-Tube (Cito) | Rp. 7.282.400,- | |
| Left lateral anal sphincterotomy (Cito) | Rp. 7.282.400,- | |
| Ligasi vaskular ekstremitas (Cito) | Rp. 7.282.400,- | |
| Ligation of hemorrhoids (Cito) | Rp. 7.282.400,- | |
| Limbal Relaxing Incision (LRI) (Cito) | Rp. 7.282.400,- | |
| Maksilektomi total dan Rekonstruksi * (Cito) | Rp. 7.282.400,- | |
| Multipel excision of lesion of breast with narcose (Cito) | Rp. 7.282.400,- | |
| Mutilasi digiti ekstremitas (Multiple) (Cito) | Rp. 7.282.400,- | |
| Obstetri - Histerorafi (Cito) | Rp. 7.282.400,- | |
| Obstetri - Kolporafi anterior (Cito) | Rp. 7.282.400,- | |
| Obstetri - Kolporafi posterior (Cito) | Rp. 7.282.400,- | |
| Obstetri - Mioma geburt (Cito) | Rp. 7.282.400,- | |
| Obstetri - Sectio caesaria tanpa penyulit (Cito) | Rp. 7.282.400,- | |
| Odontektomi tingkat I (Cito) | Rp. 7.282.400,- | |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Cito) | Rp. 7.282.400,- | |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Cito) | Rp. 7.282.400,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Cit | Rp. 7.282.400,- | |
| Onkologi - Open biopsy bone tumor (Cito) | Rp. 7.282.400,- | |
| Onkologi - Open biopsy soft tissue (Cito) | Rp. 7.282.400,- | |
| Onkologi - Ray amputation jari (Cito) | Rp. 7.282.400,- | |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Cito) | Rp. 7.282.400,- | |
| Open biopsi of breast (Cito) | Rp. 7.282.400,- | |
| Open biopsy of salivary gland or duct (Cito) | Rp. 7.282.400,- | |
| Open reduction of alveolar fracture * (Cito) | Rp. 7.282.400,- | |
| Osteotomi eksisi tulang maksilofasial (Cito) | Rp. 7.282.400,- | |
| Other appendectomy (elective) * (Cito) | Rp. 7.282.400,- | |
| Other bilateral femoral hernioraphy (Cito) | Rp. 7.282.400,- | |
| Other hernia repair (Cito) | Rp. 7.282.400,- | |
| Other incidental appendectomy * (Cito) | Rp. 7.282.400,- | |
| Other incision of anus (Cito) | Rp. 7.282.400,- | |
| Other lysis of peritoneal adhesions (Cito) | Rp. 7.282.400,- | |
| Other operations on anus (Cito) | Rp. 7.282.400,- | |
| Other operations on trachea (Cito) | Rp. 7.282.400,- | |
| Other procedures on hemorrhoids (Cito) | Rp. 7.282.400,- | |
| Other reconstruction of mandible (Cito) | Rp. 7.282.400,- | |
| Other reconstruction of other facial bone (Cito) | Rp. 7.282.400,- | |
| Other repair and plastic operation of tongue (Cito) | Rp. 7.282.400,- | |
| Other repair of abdominal wall (Cito) | Rp. 7.282.400,- | |
| Other umbilical herniorraphy* (Cito) | Rp. 7.282.400,- | |
| Other unilateral femoral herniorraphy (Cito) | Rp. 7.282.400,- | |
| Otologi - Meatoplasti (Cito) | Rp. 7.282.400,- | |
| Otologi - Miringoplasti (Cito) | Rp. 7.282.400,- | |
| Otologi - Pemasangan grommet (Cito) | Rp. 7.282.400,- | |
| Palatoshisis ** (Cito) | Rp. 7.282.400,- | |
| Partial glossectomy (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Debridement fraktur terbuka anak (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Rp. 7.282.400,- | |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Hemangioma : injeksi intralesi (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Katarak (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Koreksi curly toe (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Koreksi overriding toe polidactili (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Koreksi syndactili kaki (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Nekrotomy (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Open achilles tendon lengthening (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Percutaneous tendon tenotomy (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (Ci | Rp. 7.282.400,- | |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Rp. 7.282.400,- | |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Cito) | Rp. 7.282.400,- | |
| Pediatrik - RetCam and Narkose (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Skin graft (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Rp. 7.282.400,- | |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Rp. 7.282.400,- | |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Cito) | Rp. 7.282.400,- | |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Cito) | Rp. 7.282.400,- | |
| Pembedahan teleangiectasis (Cito) | Rp. 7.282.400,- | |
| Pengangkatan encircling silicone band (Cito) | Rp. 7.282.400,- | |
| Perikardiektomi * (Cito) | Rp. 7.282.400,- | |
| Phaco dan IOL multifokal atau torik (Cito) | Rp. 7.282.400,- | |
| Phakik IOL (Cito) | Rp. 7.282.400,- | |
| Phototherapeutic keratectomy (PTK) (Cito) | Rp. 7.282.400,- | |
| Pionephrosis (Cito) | Rp. 7.282.400,- | |
| Plastik Rekionstruksi - Regional flap tidak luas (Cito) | Rp. 7.282.400,- | |
| Pleural window (eloeser flap) * (Cito) | Rp. 7.282.400,- | |
| Plikasi bulae / bleb emfisematous (Cito) | Rp. 7.282.400,- | |
| Pneumatic retinopexy (Cito) | Rp. 7.282.400,- | |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Rp. 7.282.400,- | |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Cito) | Rp. 7.282.400,- | |
| Prosedur Sistrunk kista duktus tiroglosus (Cito) | Rp. 7.282.400,- | |
| Pulmonary decortication * (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Cryo/cauter pada trichiasis (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Eksternal DCR dan silikon tube (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Ektropion 1 kelopak * (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Entropion 1 kelopak (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Eviserasi / enukleasi (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Koreksi Ptosis * (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Koreksi simblefaron (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Probing (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Repair Ruptur palpebra * (Cito) | Rp. 7.282.400,- | |
| Rekonstruksi - Tarsorafi (Cito) | Rp. 7.282.400,- | |
| Release kontraktur mandibula (Cito) | Rp. 7.282.400,- | |
| Release tortikolis (Cito) | Rp. 7.282.400,- | |
| Removal of foreign body from peritoneal cavity (Cito) | Rp. 7.282.400,- | |
| Removal of foreign body from retro-peritoneal cavity (Cito) | Rp. 7.282.400,- | |
| Repair iridodyalisis (Cito) | Rp. 7.282.400,- | |
| Repair of direct inguinal hernia (Cito) | Rp. 7.282.400,- | |
| Repair of direct inguinal hernia with graft or prosthesis (Cito) | Rp. 7.282.400,- | |
| Repair of indirect inguinal hernia (Cito) | Rp. 7.282.400,- | |
| Repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 7.282.400,- | |
| Repair of laceration, cornea and or sclera, perforating (Cito) | Rp. 7.282.400,- | |
| Repair of laceration, cornea, non perforating (Cito) | Rp. 7.282.400,- | |
| Repair of other hernia of anterior abdominal wall (Cito) | Rp. 7.282.400,- | |
| Repair of other hernia of anterior abdominal wall with prosthesis (Cito) | Rp. 7.282.400,- | |
| Repair of umbilical hernia with prosthesis * (Cito) | Rp. 7.282.400,- | |
| Reposisi IOL (Cito) | Rp. 7.282.400,- | |
| Reposisi Iris (Cito) | Rp. 7.282.400,- | |
| Reposisi tertutup fraktur nasal (Cito) | Rp. 7.282.400,- | |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Cito) | Rp. 7.282.400,- | |
| Rinologi - Konkotomi / Konkoplasti (Cito) | Rp. 7.282.400,- | |
| Rinologi - Nasoendoskopi Dengan tindakan (Cito) | Rp. 7.282.400,- | |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Cito) | Rp. 7.282.400,- | |
| Rupture tendon achiles (Cito) | Rp. 7.282.400,- | |
| Scleral buckle, cryo dan C3F8 (Cito) | Rp. 7.282.400,- | |
| Scleral buckling (Cito) | Rp. 7.282.400,- | |
| Sekunder IOL (Cito) | Rp. 7.282.400,- | |
| Somnoplasty (Cito) | Rp. 7.282.400,- | |
| Spine - Biopsy vertebra (1 level) * (Cito) | Rp. 7.282.400,- | |
| Spine - Plaster application of the spine (Cito) | Rp. 7.282.400,- | |
| Strabismus 1 otot (Cito) | Rp. 7.282.400,- | |
| Strabismus 2 otot (Cito) | Rp. 7.282.400,- | |
| Strabismus 3 otot (Cito) | Rp. 7.282.400,- | |
| Suture of laceration of large intestine (Cito) | Rp. 7.282.400,- | |
| Suture of laceration of small intestine, except duodenum (Cito) | Rp. 7.282.400,- | |
| Suture of peritoneum (Cito) | Rp. 7.282.400,- | |
| Tatto cornea (Cito) | Rp. 7.282.400,- | |
| Torakotomi / sternotomi eksplorasi * (Cito) | Rp. 7.282.400,- | |
| Torsio testis ** (Cito) | Rp. 7.282.400,- | |
| Trakeostomi temporary ** (Cito) | Rp. 7.282.400,- | |
| Trauma - Acute ankle joint dislocation (Cito) | Rp. 7.282.400,- | |
| Trauma - Acute elbow joint dislocation (Cito) | Rp. 7.282.400,- | |
| Trauma - Acute hip joint dislocation (Cito) | Rp. 7.282.400,- | |
| Trauma - Acute knee joint dislocation (Cito) | Rp. 7.282.400,- | |
| Trauma - Closed fraktur shaft femur * (Cito) | Rp. 7.282.400,- | |
| Trauma - Closed fraktur shaft humerus * (Cito) | Rp. 7.282.400,- | |
| Trauma - Closed fraktur shaft radius (Cito) | Rp. 7.282.400,- | |
| Trauma - Closed fraktur shaft tibia (Cito) | Rp. 7.282.400,- | |
| Trauma - Closed fraktur shaft ulna (Cito) | Rp. 7.282.400,- | |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Rp. 7.282.400,- | |
| Trauma - Jaringan granulasi dengan STSG (Cito) | Rp. 7.282.400,- | |
| Trauma - Kompartemen otot (Cito) | Rp. 7.282.400,- | |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Cito) | Rp. 7.282.400,- | |
| Trauma - Nekrotik tissue dengan debridement (Cito) | Rp. 7.282.400,- | |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Cito) | Rp. 7.282.400,- | |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Cito) | Rp. 7.282.400,- | |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Cito) | Rp. 7.282.400,- | |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Cito) | Rp. 7.282.400,- | |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Cito) | Rp. 7.282.400,- | |
| Tumor - Biopsi tumor kelopak (Cito) | Rp. 7.282.400,- | |
| Tumor - Biopsi tumor orbita (Cito) | Rp. 7.282.400,- | |
| Tumor - Eksenterasi (Cito) | Rp. 7.282.400,- | |
| Tumor - Eksisi tumor adneksa (Cito) | Rp. 7.282.400,- | |
| Tumor - Ekstirpasi Tumor Orbita (Cito) | Rp. 7.282.400,- | |
| Tumor - Orbital dekompresi 1 tulang (Cito) | Rp. 7.282.400,- | |
| Tumor - Orbital dekompresi 2 tulang (Cito) | Rp. 7.282.400,- | |
| Tumor - Orbitotomi anterior (Cito) | Rp. 7.282.400,- | |
| Tumor - Orbitotomi lateral (Cito) | Rp. 7.282.400,- | |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 7.282.400,- | |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Rp. 7.282.400,- | |
| Unilateral thyroid lobectomy (Cito) | Rp. 7.282.400,- | |
| Wide excision of soft tissue tumor (Cito) | Rp. 7.282.400,- | |
| Uff Arch Barr (Cito) | Rp. 6.998.699,- | |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 6.998.699,- | |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Cito) | Rp. 6.998.699,- | |
| Hand - Elbow, tennis elbow, release (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Rp. 6.998.699,- | |
| Hand - Jari, crush injuries (complex) wound debridement (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, crush injury (simple), wound debridement (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, deep infection, drainage (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, deformity, instrinsic muscle release (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Rp. 6.998.699,- | |
| Hand - Jari, injury, debridement (Cito) | Rp. 6.998.699,- | |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Rp. 6.998.699,- | |
| Hand - Jari, jaringan lunak tumor, excision (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, macrodactyly, debulking (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, ring construction (single), koreksi (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, superficial infection, drainage (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, syndactili (single) koreksi (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, trauma, terminalisation (multiple) (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, trauma, terminalisation (single) (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, various lesions, amputasi (multiple) (Cito) | Rp. 6.998.699,- | |
| Bilateral multipel excision of lesion of breast with narcose (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, various lesions, Ray amputasi (single) (Cito) | Rp. 6.998.699,- | |
| Hand - Jari, wart, com, naevus, excision (Cito) | Rp. 6.998.699,- | |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Cito) | Rp. 6.998.699,- | |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Rp. 6.998.699,- | |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Rp. 6.998.699,- | |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Rp. 6.998.699,- | |
| Hand - Nail bed, Laceration, repair (single) (Cito) | Rp. 6.998.699,- | |
| Hand - Nerve various lesions, primary or secondary suture (Cito) | Rp. 6.998.699,- | |
| Hand - Nerve, Various Lesions, biopsy (Cito) | Rp. 6.998.699,- | |
| Hand - Repair muscle (Cito) | Rp. 6.998.699,- | |
| Bilateral ovariectomy (Cito) | Rp. 6.998.699,- | |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Cito) | Rp. 6.998.699,- | |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Cito) | Rp. 6.998.699,- | |
| Hand - Sendi (wrist), various lesions, arthrodesis (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (Ci | Rp. 6.998.699,- | |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Cit | Rp. 6.998.699,- | |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of direct inguinal hernia (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Rp. 6.998.699,- | |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Cito) | Rp. 6.998.699,- | |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (Ci | Rp. 6.998.699,- | |
| Hidrokel Testis / Funikuli ** (Cito) | Rp. 6.998.699,- | |
| Implantasi iris artifisial (Cito) | Rp. 6.998.699,- | |
| Implantasi piggyback IOL (Cito) | Rp. 6.998.699,- | |
| Incision of perianal abscess (Cito) | Rp. 6.998.699,- | |
| Injeksi intravitreal (Cito) | Rp. 6.998.699,- | |
| Insertion of synthetic implant in facial bone (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Cito) | Rp. 6.998.699,- | |
| Insisi atau Eksisi gingiva (Cito) | Rp. 6.998.699,- | |
| Insisi flegmon dasar mulut (Cito) | Rp. 6.998.699,- | |
| Internal Fiksasi fraktur condylus mandibula (Cito) | Rp. 6.998.699,- | |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Cito) | Rp. 6.998.699,- | |
| Internal Fiksasi fraktur Mandibula segmental (Cito) | Rp. 6.998.699,- | |
| Keratoplasty tembus (Cito) | Rp. 6.998.699,- | |
| Keratoprosthesis (Cito) | Rp. 6.998.699,- | |
| Knee - Open knee debridement (Cito) | Rp. 6.998.699,- | |
| Knee - Perypheral nerve ablation (Cito) | Rp. 6.998.699,- | |
| Knee - Perypheral nerve lysis (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Cito) | Rp. 6.998.699,- | |
| Kolonoskopi (Cito) | Rp. 6.998.699,- | |
| Labioshisis * (Cito) | Rp. 6.998.699,- | |
| Laring dan Faring - Laringofisure (Cito) | Rp. 6.998.699,- | |
| Laring dan Faring - Pemasangan T-Tube (Cito) | Rp. 6.998.699,- | |
| Left lateral anal sphincterotomy (Cito) | Rp. 6.998.699,- | |
| Ligasi vaskular ekstremitas (Cito) | Rp. 6.998.699,- | |
| Ligation of hemorrhoids (Cito) | Rp. 6.998.699,- | |
| Limbal Relaxing Incision (LRI) (Cito) | Rp. 6.998.699,- | |
| Maksilektomi total dan Rekonstruksi * (Cito) | Rp. 6.998.699,- | |
| Multipel excision of lesion of breast with narcose (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of indirect inguinal hernia (Cito) | Rp. 6.998.699,- | |
| Mutilasi digiti ekstremitas (Multiple) (Cito) | Rp. 6.998.699,- | |
| Obstetri - Histerorafi (Cito) | Rp. 6.998.699,- | |
| Obstetri - Kolporafi anterior (Cito) | Rp. 6.998.699,- | |
| Obstetri - Kolporafi posterior (Cito) | Rp. 6.998.699,- | |
| Obstetri - Mioma geburt (Cito) | Rp. 6.998.699,- | |
| Obstetri - Sectio caesaria tanpa penyulit (Cito) | Rp. 6.998.699,- | |
| Odontektomi tingkat I (Cito) | Rp. 6.998.699,- | |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Cito) | Rp. 6.998.699,- | |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Cito) | Rp. 6.998.699,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Cit | Rp. 6.998.699,- | |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 6.998.699,- | |
| Onkologi - Open biopsy bone tumor (Cito) | Rp. 6.998.699,- | |
| Onkologi - Open biopsy soft tissue (Cito) | Rp. 6.998.699,- | |
| Onkologi - Ray amputation jari (Cito) | Rp. 6.998.699,- | |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Cito) | Rp. 6.998.699,- | |
| Open biopsi of breast (Cito) | Rp. 6.998.699,- | |
| Open biopsy of salivary gland or duct (Cito) | Rp. 6.998.699,- | |
| Open reduction of alveolar fracture * (Cito) | Rp. 6.998.699,- | |
| Osteotomi eksisi tulang maksilofasial (Cito) | Rp. 6.998.699,- | |
| Other appendectomy (elective) * (Cito) | Rp. 6.998.699,- | |
| Other bilateral femoral hernioraphy (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of inguinal hernia, not otherwise specified (Cito) | Rp. 6.998.699,- | |
| Other hernia repair (Cito) | Rp. 6.998.699,- | |
| Other incidental appendectomy * (Cito) | Rp. 6.998.699,- | |
| Other incision of anus (Cito) | Rp. 6.998.699,- | |
| Other lysis of peritoneal adhesions (Cito) | Rp. 6.998.699,- | |
| Other operations on anus (Cito) | Rp. 6.998.699,- | |
| Other operations on trachea (Cito) | Rp. 6.998.699,- | |
| Other procedures on hemorrhoids (Cito) | Rp. 6.998.699,- | |
| Other reconstruction of mandible (Cito) | Rp. 6.998.699,- | |
| Other reconstruction of other facial bone (Cito) | Rp. 6.998.699,- | |
| Other repair and plastic operation of tongue (Cito) | Rp. 6.998.699,- | |
| Uff Arch Barr dan suspensi maksila (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect (Cito) | Rp. 6.998.699,- | |
| Other repair of abdominal wall (Cito) | Rp. 6.998.699,- | |
| Other umbilical herniorraphy* (Cito) | Rp. 6.998.699,- | |
| Other unilateral femoral herniorraphy (Cito) | Rp. 6.998.699,- | |
| Otologi - Meatoplasti (Cito) | Rp. 6.998.699,- | |
| Otologi - Miringoplasti (Cito) | Rp. 6.998.699,- | |
| Otologi - Pemasangan grommet (Cito) | Rp. 6.998.699,- | |
| Palatoshisis ** (Cito) | Rp. 6.998.699,- | |
| Partial glossectomy (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Cito) | Rp. 6.998.699,- | |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Rp. 6.998.699,- | |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Debridement fraktur terbuka anak (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Rp. 6.998.699,- | |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Hemangioma : injeksi intralesi (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Katarak (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Koreksi curly toe (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Koreksi overriding toe polidactili (Cito) | Rp. 6.998.699,- | |
| Biopsi pembuluh darah perifer * (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Koreksi syndactili kaki (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Nekrotomy (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Open achilles tendon lengthening (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Percutaneous tendon tenotomy (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (Ci | Rp. 6.998.699,- | |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Rp. 6.998.699,- | |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Cito) | Rp. 6.998.699,- | |
| Pediatrik - RetCam and Narkose (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Skin graft (Cito) | Rp. 6.998.699,- | |
| Biopsi perikardium * (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Rp. 6.998.699,- | |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Rp. 6.998.699,- | |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Cito) | Rp. 6.998.699,- | |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Cito) | Rp. 6.998.699,- | |
| Pembedahan teleangiectasis (Cito) | Rp. 6.998.699,- | |
| Pengangkatan encircling silicone band (Cito) | Rp. 6.998.699,- | |
| Perikardiektomi * (Cito) | Rp. 6.998.699,- | |
| Phaco dan IOL multifokal atau torik (Cito) | Rp. 6.998.699,- | |
| Phakik IOL (Cito) | Rp. 6.998.699,- | |
| Phototherapeutic keratectomy (PTK) (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka bronkhus * (Cito) | Rp. 6.998.699,- | |
| Pionephrosis (Cito) | Rp. 6.998.699,- | |
| Plastik Rekionstruksi - Regional flap tidak luas (Cito) | Rp. 6.998.699,- | |
| Pleural window (eloeser flap) * (Cito) | Rp. 6.998.699,- | |
| Plikasi bulae / bleb emfisematous (Cito) | Rp. 6.998.699,- | |
| Pneumatic retinopexy (Cito) | Rp. 6.998.699,- | |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Rp. 6.998.699,- | |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Cito) | Rp. 6.998.699,- | |
| Prosedur Sistrunk kista duktus tiroglosus (Cito) | Rp. 6.998.699,- | |
| Pulmonary decortication * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Cryo/cauter pada trichiasis (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka diafragma * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Eksternal DCR dan silikon tube (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Ektropion 1 kelopak * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Entropion 1 kelopak (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Eviserasi / enukleasi (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Koreksi Ptosis * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Koreksi simblefaron (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Probing (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka mediastinum * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Repair Ruptur palpebra * (Cito) | Rp. 6.998.699,- | |
| Rekonstruksi - Tarsorafi (Cito) | Rp. 6.998.699,- | |
| Release kontraktur mandibula (Cito) | Rp. 6.998.699,- | |
| Release tortikolis (Cito) | Rp. 6.998.699,- | |
| Removal of foreign body from peritoneal cavity (Cito) | Rp. 6.998.699,- | |
| Removal of foreign body from retro-peritoneal cavity (Cito) | Rp. 6.998.699,- | |
| Repair iridodyalisis (Cito) | Rp. 6.998.699,- | |
| Repair of direct inguinal hernia (Cito) | Rp. 6.998.699,- | |
| Repair of direct inguinal hernia with graft or prosthesis (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka paru * (Cito) | Rp. 6.998.699,- | |
| Repair of indirect inguinal hernia (Cito) | Rp. 6.998.699,- | |
| Repair of indirect inguinal hernia with graft or prosthesis (Cito) | Rp. 6.998.699,- | |
| Repair of laceration, cornea and or sclera, perforating (Cito) | Rp. 6.998.699,- | |
| Repair of laceration, cornea, non perforating (Cito) | Rp. 6.998.699,- | |
| Repair of other hernia of anterior abdominal wall (Cito) | Rp. 6.998.699,- | |
| Repair of other hernia of anterior abdominal wall with prosthesis (Cito) | Rp. 6.998.699,- | |
| Repair of umbilical hernia with prosthesis * (Cito) | Rp. 6.998.699,- | |
| Reposisi IOL (Cito) | Rp. 6.998.699,- | |
| Reposisi Iris (Cito) | Rp. 6.998.699,- | |
| Reposisi tertutup fraktur nasal (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka pleura * (Cito) | Rp. 6.998.699,- | |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Cito) | Rp. 6.998.699,- | |
| Rinologi - Konkotomi / Konkoplasti (Cito) | Rp. 6.998.699,- | |
| Rinologi - Nasoendoskopi Dengan tindakan (Cito) | Rp. 6.998.699,- | |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Cito) | Rp. 6.998.699,- | |
| Rupture tendon achiles (Cito) | Rp. 6.998.699,- | |
| Scleral buckle, cryo dan C3F8 (Cito) | Rp. 6.998.699,- | |
| Scleral buckling (Cito) | Rp. 6.998.699,- | |
| Sekunder IOL (Cito) | Rp. 6.998.699,- | |
| Somnoplasty (Cito) | Rp. 6.998.699,- | |
| Spine - Biopsy vertebra (1 level) * (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka pleura dengan VATS * (Cito) | Rp. 6.998.699,- | |
| Spine - Plaster application of the spine (Cito) | Rp. 6.998.699,- | |
| Strabismus 1 otot (Cito) | Rp. 6.998.699,- | |
| Strabismus 2 otot (Cito) | Rp. 6.998.699,- | |
| Strabismus 3 otot (Cito) | Rp. 6.998.699,- | |
| Suture of laceration of large intestine (Cito) | Rp. 6.998.699,- | |
| Suture of laceration of small intestine, except duodenum (Cito) | Rp. 6.998.699,- | |
| Suture of peritoneum (Cito) | Rp. 6.998.699,- | |
| Tatto cornea (Cito) | Rp. 6.998.699,- | |
| Torakotomi / sternotomi eksplorasi * (Cito) | Rp. 6.998.699,- | |
| Torsio testis ** (Cito) | Rp. 6.998.699,- | |
| Amputasi jari (phalangs - traumatik) (Cito) | Rp. 6.998.699,- | |
| Biopsi terbuka tumor dinding thoraks * (Cito) | Rp. 6.998.699,- | |
| Trakeostomi temporary ** (Cito) | Rp. 6.998.699,- | |
| Trauma - Acute ankle joint dislocation (Cito) | Rp. 6.998.699,- | |
| Trauma - Acute elbow joint dislocation (Cito) | Rp. 6.998.699,- | |
| Trauma - Acute hip joint dislocation (Cito) | Rp. 6.998.699,- | |
| Trauma - Acute knee joint dislocation (Cito) | Rp. 6.998.699,- | |
| Trauma - Closed fraktur shaft femur * (Cito) | Rp. 6.998.699,- | |
| Trauma - Closed fraktur shaft humerus * (Cito) | Rp. 6.998.699,- | |
| Trauma - Closed fraktur shaft radius (Cito) | Rp. 6.998.699,- | |
| Trauma - Closed fraktur shaft tibia (Cito) | Rp. 6.998.699,- | |
| Trauma - Closed fraktur shaft ulna (Cito) | Rp. 6.998.699,- | |
| Caecostomy (Cito) | Rp. 6.998.699,- | |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Rp. 6.998.699,- | |
| Trauma - Jaringan granulasi dengan STSG (Cito) | Rp. 6.998.699,- | |
| Trauma - Kompartemen otot (Cito) | Rp. 6.998.699,- | |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Cito) | Rp. 6.998.699,- | |
| Trauma - Nekrotik tissue dengan debridement (Cito) | Rp. 6.998.699,- | |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Cito) | Rp. 6.998.699,- | |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Cito) | Rp. 6.998.699,- | |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Cito) | Rp. 6.998.699,- | |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Cito) | Rp. 6.998.699,- | |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Cito) | Rp. 6.998.699,- | |
| Closure of anal fistula (Cito) | Rp. 6.998.699,- | |
| Tumor - Biopsi tumor kelopak (Cito) | Rp. 6.998.699,- | |
| Tumor - Biopsi tumor orbita (Cito) | Rp. 6.998.699,- | |
| Tumor - Eksenterasi (Cito) | Rp. 6.998.699,- | |
| Tumor - Eksisi tumor adneksa (Cito) | Rp. 6.998.699,- | |
| Tumor - Ekstirpasi Tumor Orbita (Cito) | Rp. 6.998.699,- | |
| Tumor - Orbital dekompresi 1 tulang (Cito) | Rp. 6.998.699,- | |
| Tumor - Orbital dekompresi 2 tulang (Cito) | Rp. 6.998.699,- | |
| Tumor - Orbitotomi anterior (Cito) | Rp. 6.998.699,- | |
| Tumor - Orbitotomi lateral (Cito) | Rp. 6.998.699,- | |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Rp. 6.998.699,- | |
| Combustio (luka bakar) * (Cito) | Rp. 6.998.699,- | |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Rp. 6.998.699,- | |
| Unilateral thyroid lobectomy (Cito) | Rp. 6.998.699,- | |
| Wide excision of soft tissue tumor (Cito) | Rp. 6.998.699,- | |
| Compartement excision (Cito) | Rp. 6.998.699,- | |
| Debridement-nekrotomi luka gangren (Cito) | Rp. 6.998.699,- | |
| Deseksi submandibula (Cito) | Rp. 6.998.699,- | |
| Disartikulasi sendi ekstremitas (Cito) | Rp. 6.998.699,- | |
| Dislokasi bahu * (Cito) | Rp. 6.998.699,- | |
| Drainage of appendiceal abscess (Cito) | Rp. 6.998.699,- | |
| Amputation of digiti single ** (Cito) | Rp. 6.998.699,- | |
| Drainage of pancreatic cyst by catheter (Cito) | Rp. 6.998.699,- | |
| DSAEK (Cito) | Rp. 6.998.699,- | |
| ECCE / ICCE / SICS (Cito) | Rp. 6.998.699,- | |
| ECCE / SICS dan IOL (Cito) | Rp. 6.998.699,- | |
| Eksisi biopsi tumor pembuluh darah (Cito) | Rp. 6.998.699,- | |
| Eksisi glandula submandibula (Cito) | Rp. 6.998.699,- | |
| Eksisi higroma leher * (Cito) | Rp. 6.998.699,- | |
| Eksisi kista tiroglosus (Cito) | Rp. 6.998.699,- | |
| Eksisi parsial dan marsupialisasi Ranula (Cito) | Rp. 6.998.699,- | |
| Eksisi Pterigium (Cito) | Rp. 6.998.699,- | |
| Anal fistulectomy (Cito) | Rp. 6.998.699,- | |
| Eksisi tumor dinding dada * (Cito) | Rp. 6.998.699,- | |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Cito) | Rp. 6.998.699,- | |
| Eksisi tumor pembuluh darah perifer ** (Cito) | Rp. 6.998.699,- | |
| Ekstirpasi kelainan kornea (Cito) | Rp. 6.998.699,- | |
| Ekstraksi corpus alienum segmen anterior (Cito) | Rp. 6.998.699,- | |
| Ekstraksi IOL (Cito) | Rp. 6.998.699,- | |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Cito) | Rp. 6.998.699,- | |
| Endoskopi - Esofagoskopi dilatasi (Cito) | Rp. 6.998.699,- | |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Cito) | Rp. 6.998.699,- | |
| Anal fistulotomy (Cito) | Rp. 6.998.699,- | |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Cito) | Rp. 6.998.699,- | |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Cito) | Rp. 6.998.699,- | |
| Evakuasi silicon oil (Cito) | Rp. 6.998.699,- | |
| Evakuasi silicon oil dan ECCE (Cito) | Rp. 6.998.699,- | |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Cito) | Rp. 6.998.699,- | |
| Exchange IOL (Cito) | Rp. 6.998.699,- | |
| Excision of ectopic breast tissue (Cito) | Rp. 6.998.699,- | |
| excision of lesion of breast with narcose (Cito) | Rp. 6.998.699,- | |
| Excision of thyroglossal duct or trac (Cito) | Rp. 6.998.699,- | |
| Anterior lamellar keratoplasty (Cito) | Rp. 6.998.699,- | |
| Exploratory laparotomy (Cito) | Rp. 6.998.699,- | |
| Extirpasi kista rongga mulut (Cito) | Rp. 6.998.699,- | |
| Extirpasi muoccocele rongga mulut (Cito) | Rp. 6.998.699,- | |
| Fasciotomy * (Cito) | Rp. 6.998.699,- | |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Cito) | Rp. 6.998.699,- | |
| Fiksasi interna fraktur nasal (Cito) | Rp. 6.998.699,- | |
| Flap konjungtiva amnion graft (Cito) | Rp. 6.998.699,- | |
| Fraktur humerus * (Cito) | Rp. 6.998.699,- | |
| Gastrostomi * (Cito) | Rp. 6.998.699,- | |
| GIN -Ekstirpasi polip (Cito) | Rp. 6.998.699,- | |
| Appendicostomy (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Ekstirpasi Giant Condiloma (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Kistektomi (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Laparotomi Diagnostik (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Pemasangan Implan Tableport (Cito) | Rp. 6.998.699,- | |
| Ginekologi - Salpingo-ooforektomi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Anterior / posterior sklerotomi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Gonioplasty / goniotomy (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Iridektomi perifer (Cito) | Rp. 6.998.699,- | |
| Babcock (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Paracentesis (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Reformasi COA (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Revisi Bleb (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Tindakan cyclodia termi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Trabekulektomi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Trabekulotomi anak atau bayi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Transkleral Foto Coagulasi (Cito) | Rp. 6.998.699,- | |
| Glaukoma - Tubes implan (Cito) | Rp. 6.998.699,- | |
| Biopsy insisional dengan anastesi lokal (Cito) | Rp. 2.295.526,- | |
| Biopsy of perianal tissue (Cito) | Rp. 2.295.526,- | |
| Biopsy insisional dengan anastesi lokal (Cito) | Rp. 2.034.526,- | |
| Biopsy of perianal tissue (Cito) | Rp. 2.034.526,- | |
| Biopsy insisional dengan anastesi lokal (Cito) | Rp. 1.932.426,- | |
| Biopsy of perianal tissue (Cito) | Rp. 1.932.426,- | |
| Amputasi above knee (Cito) | Rp. 10.273.026,- | |
| Amputasi below knee (Cito) | Rp. 10.273.026,- | |
| Aneurisma arteri brachialis (Cito) | Rp. 10.273.026,- | |
| Aneurisma arteri femoralis (Cito) | Rp. 10.273.026,- | |
| Axillary dissection (Cito) | Rp. 10.273.026,- | |
| Batu saluran kemih * (Cito) | Rp. 10.273.026,- | |
| Bilateral simple mastectomy (Cito) | Rp. 10.273.026,- | |
| Cholecystectomy (Cito) | Rp. 10.273.026,- | |
| Choledochoplasty (Cito) | Rp. 10.273.026,- | |
| Closure of appendiceal fistula (Cito) | Rp. 10.273.026,- | |
| Closure of cholecystostomy (Cito) | Rp. 10.273.026,- | |
| Closure of fistula of large intestine (Cito) | Rp. 10.273.026,- | |
| Closure of fistula of small intestine, except duodenum (Cito) | Rp. 10.273.026,- | |
| Closure of intestinal stoma (Cito) | Rp. 10.273.026,- | |
| Closure of leceration of liver (Cito) | Rp. 10.273.026,- | |
| Colostomy (not otherwise specified) (Cito) | Rp. 10.273.026,- | |
| Common duct exploration for removal of calculus (Cito) | Rp. 10.273.026,- | |
| Debridement mediastinum (sternotomi) * (Cito) | Rp. 10.273.026,- | |
| Diseksi leher radikal / radikal neck dissection * (Cito) | Rp. 10.273.026,- | |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Cito) | Rp. 10.273.026,- | |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Cito) | Rp. 10.273.026,- | |
| Eksisi pseudoaneurisma (Cito) | Rp. 10.273.026,- | |
| Eksplorasi vaskular (trauma / non trauma) (Cito) | Rp. 10.273.026,- | |
| Ekstraksi corpus alienum di regio toraks * (Cito) | Rp. 10.273.026,- | |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Cito) | Rp. 10.273.026,- | |
| Endoscopic polypectomy of rectum (Cito) | Rp. 10.273.026,- | |
| Endoscopic thyroidectomy (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Pan bronkoskopi (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Pan esofagoskopi (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Sialendoskopi diagnostik (Cito) | Rp. 10.273.026,- | |
| Endoskopi - Sleep nasoendoskopi (Cito) | Rp. 10.273.026,- | |
| Excision of hemorrhoid (Cito) | Rp. 10.273.026,- | |
| Exploration of common duct (Cito) | Rp. 10.273.026,- | |
| Exteriorization of large intestine (Cito) | Rp. 10.273.026,- | |
| Exteriorization of small intestine (Cito) | Rp. 10.273.026,- | |
| Fiksasi sternum (wire, plate) * (Cito) | Rp. 10.273.026,- | |
| Fraktur antebrachi (Cito) | Rp. 10.273.026,- | |
| Fraktur colles dan pergelangan tangan lainnya (Cito) | Rp. 10.273.026,- | |
| Fraktur cruris (Cito) | Rp. 10.273.026,- | |
| Fraktur femur * (Cito) | Rp. 10.273.026,- | |
| Fraktur klavikula (Cito) | Rp. 10.273.026,- | |
| Fraktur olekranon (Cito) | Rp. 10.273.026,- | |
| Fraktur patela (Cito) | Rp. 10.273.026,- | |
| Fraktur suprakondiler humerus (Cito) | Rp. 10.273.026,- | |
| Free skin graft (Cito) | Rp. 10.273.026,- | |
| Full-thickness skin graft to hand (Cito) | Rp. 10.273.026,- | |
| Full-thickness skin graft to other sites * (Cito) | Rp. 10.273.026,- | |
| GIN- Hymenoplasty (Cito) | Rp. 10.273.026,- | |
| Ginekologi - Histerektomi (Cito) | Rp. 10.273.026,- | |
| Ginekologi - Kehamilan ektopik (Cito) | Rp. 10.273.026,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 10.273.026,- | |
| Glaukoma - Tubes implan, Phaco dan IOL (Cito) | Rp. 10.273.026,- | |
| Groin dissection (Cito) | Rp. 10.273.026,- | |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (C | Rp. 10.273.026,- | |
| Hand - Jari, defect or contracture (single) rekonstruksi (Cito) | Rp. 10.273.026,- | |
| Hand - Jari, deformities, koreksi (Cito) | Rp. 10.273.026,- | |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Rp. 10.273.026,- | |
| Hand - Jari, ring constriction (multiple), koreksi (Cito) | Rp. 10.273.026,- | |
| Hand - Jari, syndactili (multiple) (Cito) | Rp. 10.273.026,- | |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (C | Rp. 10.273.026,- | |
| Hand - Nail bed, laceration, Repair (multiple) (Cito) | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Rp. 10.273.026,- | |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Rp. 10.273.026,- | |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Cit | Rp. 10.273.026,- | |
| Hand - Thumb, deformitas, Koreksi (Cito) | Rp. 10.273.026,- | |
| Hemiglosektomi (Cito) | Rp. 10.273.026,- | |
| Hip - Arthroscopy (Cito) | Rp. 10.273.026,- | |
| Hip - Hemiarthroplasty (Cito) | Rp. 10.273.026,- | |
| Hip - ORIF, DHS (Cito) | Rp. 10.273.026,- | |
| Hipertropi Prostat Beningna (BPH) * (Cito) | Rp. 10.273.026,- | |
| Ileostomy (not otherwise specified) * (Cito) | Rp. 10.273.026,- | |
| Incisional hernia repair (Cito) | Rp. 10.273.026,- | |
| Incisional hernia repair with prosthesis (Cito) | Rp. 10.273.026,- | |
| Internal drainage of pancreatic cyst (Cito) | Rp. 10.273.026,- | |
| Knee - Anterior cruciate ligament reconstruction (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy debridement knee (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy debridement shoulder (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy diagnostic (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy diagnostic shoulder (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy meniscus repair (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy remove loose body (Cito) | Rp. 10.273.026,- | |
| Knee - Arthroscopy remove loose body shoulder (Cito) | Rp. 10.273.026,- | |
| Knee - Fibular osteotomy (Cito) | Rp. 10.273.026,- | |
| Knee - Lateral collateral ligament reconstruction (Cito) | Rp. 10.273.026,- | |
| Knee - Medial collateral ligament reconstruction (Cito) | Rp. 10.273.026,- | |
| Knee - Posterior cruciate ligamnet reconstruction (Cito) | Rp. 10.273.026,- | |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Cito) | Rp. 10.273.026,- | |
| Knee - Revisi total knee replacement (Cito) | Rp. 10.273.026,- | |
| Knee - Revisi total shoulder replacement (Cito) | Rp. 10.273.026,- | |
| Knee - Rotator cuff repair by arthroscopy (Cito) | Rp. 10.273.026,- | |
| Knee - Shoulder hemiarthroplasty (Cito) | Rp. 10.273.026,- | |
| Knee - Total shoulder replacement (Cito) | Rp. 10.273.026,- | |
| Kolonoskopi dan Biopsi (Cito) | Rp. 10.273.026,- | |
| Laparoscopic lysis of peritoneal adhesions (Cito) | Rp. 10.273.026,- | |
| Laparoskopi/histeroskopi - ovarian drilling (Cito) | Rp. 10.273.026,- | |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Cito) | Rp. 10.273.026,- | |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Cito) | Rp. 10.273.026,- | |
| Laparskopi / Histereskopi - Second Look (Cito) | Rp. 10.273.026,- | |
| Laparskopi / Histereskopi - Tubektomi (Cito) | Rp. 10.273.026,- | |
| Large to large intestinal anastomosis (Cito) | Rp. 10.273.026,- | |
| Laring dan Faring - Laringektomi * (Cito) | Rp. 10.273.026,- | |
| Laring dan Faring - Laringektomi + RND * (Cito) | Rp. 10.273.026,- | |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Cito) | Rp. 10.273.026,- | |
| Laring dan Faring - RND * (Cito) | Rp. 10.273.026,- | |
| Laringectomi * (Cito) | Rp. 10.273.026,- | |
| Laringectomi dengan diseksi leher * (Cito) | Rp. 10.273.026,- | |
| Lasik 1 (satu) mata (Cito) | Rp. 10.273.026,- | |
| Lobektomi parsial (reseksi paru segmental) * (Cito) | Rp. 10.273.026,- | |
| Muscle flap graft to breast (Cito) | Rp. 10.273.026,- | |
| Muscle flap graft to breast (TRAM flap / LD flap) (Cito) | Rp. 10.273.026,- | |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Cito) | Rp. 10.273.026,- | |
| Obstetri - Partus Dengan Bius ELA (Cito) | Rp. 10.273.026,- | |
| Obstetri - Partus Dengan Bius ILA (Cito) | Rp. 10.273.026,- | |
| Obstetri - Purandare (Cito) | Rp. 10.273.026,- | |
| Obstetri - Rekonstruksi vagina (Cito) | Rp. 10.273.026,- | |
| Obstetri - Repair fistula (Cito) | Rp. 10.273.026,- | |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Cito) | Rp. 10.273.026,- | |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Cito | Rp. 10.273.026,- | |
| Obstetri - Vaginoplasti (Cito) | Rp. 10.273.026,- | |
| Odontektomi tingkat II (Cito) | Rp. 10.273.026,- | |
| Onkologi - Diseksi leher bilateral (Cito) | Rp. 10.273.026,- | |
| Onkologi - Diseksi leher modified (Cito) | Rp. 10.273.026,- | |
| Onkologi - Ligasi arteri karotis eksterna (Cito) | Rp. 10.273.026,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 10.273.026,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 10.273.026,- | |
| Onkologi - Mandibulektomi parsial (Cito) | Rp. 10.273.026,- | |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Rp. 10.273.026,- | |
| Onkologi - Total patellectomy dan rekonstruksi (Cito) | Rp. 10.273.026,- | |
| Open biopsy of gallbladder or bile ducts (Cito) | Rp. 10.273.026,- | |
| Open biopsy of liver (Cito) | Rp. 10.273.026,- | |
| Open biopsy of pancreas (Cito) | Rp. 10.273.026,- | |
| Open reduction of malar and zygomatic fracture (Cito) | Rp. 10.273.026,- | |
| Open reduction of mandibular fractur (Cito) | Rp. 10.273.026,- | |
| Open reduction of maxillary fracture (Cito) | Rp. 10.273.026,- | |
| Other destruction of lesion of liver (Cito) | Rp. 10.273.026,- | |
| Other laparotomy (Cito) | Rp. 10.273.026,- | |
| Other partial excision of large intestine (Cito) | Rp. 10.273.026,- | |
| Other repair of anal sphincter (Cito) | Rp. 10.273.026,- | |
| Other repair of intestine (Cito) | Rp. 10.273.026,- | |
| Other repair of mesentery (Cito) | Rp. 10.273.026,- | |
| Other skin graft to hand (Cito) | Rp. 10.273.026,- | |
| Other skin graft to other sites (Cito) | Rp. 10.273.026,- | |
| Other small to large intestinal anastomosis (Cito) | Rp. 10.273.026,- | |
| Other suture of abdominal wall (Cito) | Rp. 10.273.026,- | |
| Otologi - Dekompresi nervus fasialis (Cito) | Rp. 10.273.026,- | |
| Otologi - Kanaloplasti / kanalomeatoplasty (Cito) | Rp. 10.273.026,- | |
| Otologi - Mastoidektomi radikal (Cito) | Rp. 10.273.026,- | |
| Otologi - Mastoidektomi sederhana (Cito) | Rp. 10.273.026,- | |
| Otologi - Stapedektomi (Cito) | Rp. 10.273.026,- | |
| Parotidektomi superfisial * (Cito) | Rp. 10.273.026,- | |
| Partial splenectomy (Cito) | Rp. 10.273.026,- | |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Rp. 10.273.026,- | |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Cito) | Rp. 10.273.026,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Rp. 10.273.026,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Rp. 10.273.026,- | |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Rp. 10.273.026,- | |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Cito) | Rp. 10.273.026,- | |
| Pedicle or flaps graft (not otherwise specified) (Cito) | Rp. 10.273.026,- | |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Cito) | Rp. 10.273.026,- | |
| Pembuatan thoracic window (Cito) | Rp. 10.273.026,- | |
| Perikardiotomi / pericardial window * (Cito) | Rp. 10.273.026,- | |
| Permanent colostomy (Cito) | Rp. 10.273.026,- | |
| Permanent ileostomy (Cito) | Rp. 10.273.026,- | |
| Phaco (Cito) | Rp. 10.273.026,- | |
| Phaco dan IOL (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Faringeal flap (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Forehead flap (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Otoplasty * (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Revisi parut (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Rinoplasty * (Cito) | Rp. 10.273.026,- | |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Cito) | Rp. 10.273.026,- | |
| Pleurektomi * (Cito) | Rp. 10.273.026,- | |
| Plikasi diafragma * (Cito) | Rp. 10.273.026,- | |
| Pneumonectomy * (Cito) | Rp. 10.273.026,- | |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Cito) | Rp. 10.273.026,- | |
| Posterior vitrectomy, Phaco dan IOL (Cito) | Rp. 10.273.026,- | |
| Radical excision of skin lesion (Cito) | Rp. 10.273.026,- | |
| Reclosure of postoperative disruption of abdominal wall (Cito) | Rp. 10.273.026,- | |
| Rectosigmoidoskopi (Cito) | Rp. 10.273.026,- | |
| Reduction of anal prolapse (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Blefaroplasty 2 kelopak (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Fraktur dasar orbita (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Fraktur Multiple (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Palpebra dengan Graft * (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Soket kontraktur (Cito) | Rp. 10.273.026,- | |
| Rekonstruksi - Soket landai (Cito) | Rp. 10.273.026,- | |
| Reopening of recent laparotomy site (Cito) | Rp. 10.273.026,- | |
| Repair arteri poplitea dan femoralis (Cito) | Rp. 10.273.026,- | |
| Repair of diaphragmatic hernia, abdominal approach (Cito) | Rp. 10.273.026,- | |
| Repair of laceration of gallbladder (Cito) | Rp. 10.273.026,- | |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Cito) | Rp. 10.273.026,- | |
| Resection of transverse colon (Cito) | Rp. 10.273.026,- | |
| Reseksi maksila infrastuktural (Cito) | Rp. 10.273.026,- | |
| Reseksi mandibula tanpa rekonstruksi (Cito) | Rp. 10.273.026,- | |
| Revision of anastomosis of large intestine (Cito) | Rp. 10.273.026,- | |
| Revision of anastomosis of small intestine (Cito) | Rp. 10.273.026,- | |
| Revision of stoma of large intestine (Cito) | Rp. 10.273.026,- | |
| Revision of stoma of small intestine (Cito) | Rp. 10.273.026,- | |
| Revision of tracheostomy (Cito) | Rp. 10.273.026,- | |
| Right hemicolectomy (Cito) | Rp. 10.273.026,- | |
| Rinologi - BSEF / FESS 1 : Mini (Cito) | Rp. 10.273.026,- | |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Cito) | Rp. 10.273.026,- | |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Cito) | Rp. 10.273.026,- | |
| Rupture buli-buli * (Cito) | Rp. 10.273.026,- | |
| Scleral buckling, phaco dan IOL (Cito) | Rp. 10.273.026,- | |
| Sigmoidectomy (Cito) | Rp. 10.273.026,- | |
| Simple suture of common bile duct (Cito) | Rp. 10.273.026,- | |
| Small to small intestinal anastomosis (Cito) | Rp. 10.273.026,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 10.273.026,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 10.273.026,- | |
| Spine - Discograph multilevel * (Cito) | Rp. 10.273.026,- | |
| Spine - Facet block (1 level) (Cito) | Rp. 10.273.026,- | |
| Spine - Facet block multilevel (Cito) | Rp. 10.273.026,- | |
| Spine - Foraminal block (1 level) (Cito) | Rp. 10.273.026,- | |
| Spine - Foraminal block multilevel (Cito) | Rp. 10.273.026,- | |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Rp. 10.273.026,- | |
| Spine - Removal of implants (Plate, Nail, Screw) * (Cito) | Rp. 10.273.026,- | |
| Strabismus 4 otot (Cito) | Rp. 10.273.026,- | |
| Stripping varises ekstremitas inferior (Cito) | Rp. 10.273.026,- | |
| Subtotal mastectomy (Cito) | Rp. 10.273.026,- | |
| Temporary colostomy (Cito) | Rp. 10.273.026,- | |
| Temporary ileostomy * (Cito) | Rp. 10.273.026,- | |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Cito | Rp. 10.273.026,- | |
| Tiroidektomi subtotal / total nodul tiroid ** (Cito) | Rp. 10.273.026,- | |
| Total splenectomy * (Cito) | Rp. 10.273.026,- | |
| Trauma - Closed fraktur distal tibia (Cito) | Rp. 10.273.026,- | |
| Trauma - Closed fraktur intercondylar femur (Cito) | Rp. 10.273.026,- | |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Cito) | Rp. 10.273.026,- | |
| Trauma - Closed fraktur supracondylar femur (Cito) | Rp. 10.273.026,- | |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Cito) | Rp. 10.273.026,- | |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Cito) | Rp. 10.273.026,- | |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur collum femur pada orang tua (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur galeazi (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur intertrochanter femur pada orang tua (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur montegia (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Cito) | Rp. 10.273.026,- | |
| Trauma - Instability joint infection (Cito) | Rp. 10.273.026,- | |
| Trauma - Joint stiffness dengan liberation (Cito) | Rp. 10.273.026,- | |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Rp. 10.273.026,- | |
| Trauma - Non union dengan bone graft (Cito) | Rp. 10.273.026,- | |
| Trauma - Open fraktur shaft femur grade 3 (Cito) | Rp. 10.273.026,- | |
| Trauma - Open fraktur shaft humerus grade 3 (Cito) | Rp. 10.273.026,- | |
| Trauma - Open fraktur shaft radius grade 3 (Cito) | Rp. 10.273.026,- | |
| Trauma - Open fraktur shaft tibia grade 3 (Cito) | Rp. 10.273.026,- | |
| Trauma - Open fraktur shaft ulna grade 3 (Cito) | Rp. 10.273.026,- | |
| Trauma - Osteomyelitis (Cito) | Rp. 10.273.026,- | |
| Tumor - Extended Eksenterasi (Cito) | Rp. 10.273.026,- | |
| Tumor - Orbital dekompresi 3 tulang (Cito) | Rp. 10.273.026,- | |
| Tumor - Orbitotomi lateral and superior (medial) (Cito) | Rp. 10.273.026,- | |
| Unilateral radical mastectomy (Cito) | Rp. 10.273.026,- | |
| Unilateral simple mastectomy (Cito) | Rp. 10.273.026,- | |
| Upper Endoskopi (Cito) | Rp. 10.273.026,- | |
| Upper Endoskopi dan biopsi (Cito) | Rp. 10.273.026,- | |
| Upper Endoskopi dan ekstraksi carpal (Cito) | Rp. 10.273.026,- | |
| Upper Endoskopi dan ligasi (Cito) | Rp. 10.273.026,- | |
| Amputasi above knee (Cito) | Rp. 9.402.825,- | |
| Amputasi below knee (Cito) | Rp. 9.402.825,- | |
| Aneurisma arteri brachialis (Cito) | Rp. 9.402.825,- | |
| Aneurisma arteri femoralis (Cito) | Rp. 9.402.825,- | |
| Axillary dissection (Cito) | Rp. 9.402.825,- | |
| Batu saluran kemih * (Cito) | Rp. 9.402.825,- | |
| Bilateral simple mastectomy (Cito) | Rp. 9.402.825,- | |
| Cholecystectomy (Cito) | Rp. 9.402.825,- | |
| Choledochoplasty (Cito) | Rp. 9.402.825,- | |
| Closure of appendiceal fistula (Cito) | Rp. 9.402.825,- | |
| Closure of cholecystostomy (Cito) | Rp. 9.402.825,- | |
| Closure of fistula of large intestine (Cito) | Rp. 9.402.825,- | |
| Closure of fistula of small intestine, except duodenum (Cito) | Rp. 9.402.825,- | |
| Closure of intestinal stoma (Cito) | Rp. 9.402.825,- | |
| Closure of leceration of liver (Cito) | Rp. 9.402.825,- | |
| Colostomy (not otherwise specified) (Cito) | Rp. 9.402.825,- | |
| Common duct exploration for removal of calculus (Cito) | Rp. 9.402.825,- | |
| Debridement mediastinum (sternotomi) * (Cito) | Rp. 9.402.825,- | |
| Diseksi leher radikal / radikal neck dissection * (Cito) | Rp. 9.402.825,- | |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Cito) | Rp. 9.402.825,- | |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Cito) | Rp. 9.402.825,- | |
| Eksisi pseudoaneurisma (Cito) | Rp. 9.402.825,- | |
| Eksplorasi vaskular (trauma / non trauma) (Cito) | Rp. 9.402.825,- | |
| Ekstraksi corpus alienum di regio toraks * (Cito) | Rp. 9.402.825,- | |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Cito) | Rp. 9.402.825,- | |
| Endoscopic polypectomy of rectum (Cito) | Rp. 9.402.825,- | |
| Endoscopic thyroidectomy (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Pan bronkoskopi (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Pan esofagoskopi (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Sialendoskopi diagnostik (Cito) | Rp. 9.402.825,- | |
| Endoskopi - Sleep nasoendoskopi (Cito) | Rp. 9.402.825,- | |
| Excision of hemorrhoid (Cito) | Rp. 9.402.825,- | |
| Exploration of common duct (Cito) | Rp. 9.402.825,- | |
| Exteriorization of large intestine (Cito) | Rp. 9.402.825,- | |
| Exteriorization of small intestine (Cito) | Rp. 9.402.825,- | |
| Fiksasi sternum (wire, plate) * (Cito) | Rp. 9.402.825,- | |
| Fraktur antebrachi (Cito) | Rp. 9.402.825,- | |
| Fraktur colles dan pergelangan tangan lainnya (Cito) | Rp. 9.402.825,- | |
| Fraktur cruris (Cito) | Rp. 9.402.825,- | |
| Fraktur femur * (Cito) | Rp. 9.402.825,- | |
| Fraktur klavikula (Cito) | Rp. 9.402.825,- | |
| Fraktur olekranon (Cito) | Rp. 9.402.825,- | |
| Fraktur patela (Cito) | Rp. 9.402.825,- | |
| Fraktur suprakondiler humerus (Cito) | Rp. 9.402.825,- | |
| Free skin graft (Cito) | Rp. 9.402.825,- | |
| Full-thickness skin graft to hand (Cito) | Rp. 9.402.825,- | |
| Full-thickness skin graft to other sites * (Cito) | Rp. 9.402.825,- | |
| GIN- Hymenoplasty (Cito) | Rp. 9.402.825,- | |
| Ginekologi - Histerektomi (Cito) | Rp. 9.402.825,- | |
| Ginekologi - Kehamilan ektopik (Cito) | Rp. 9.402.825,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 9.402.825,- | |
| Glaukoma - Tubes implan, Phaco dan IOL (Cito) | Rp. 9.402.825,- | |
| Groin dissection (Cito) | Rp. 9.402.825,- | |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (C | Rp. 9.402.825,- | |
| Hand - Jari, defect or contracture (single) rekonstruksi (Cito) | Rp. 9.402.825,- | |
| Hand - Jari, deformities, koreksi (Cito) | Rp. 9.402.825,- | |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Rp. 9.402.825,- | |
| Hand - Jari, ring constriction (multiple), koreksi (Cito) | Rp. 9.402.825,- | |
| Hand - Jari, syndactili (multiple) (Cito) | Rp. 9.402.825,- | |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (C | Rp. 9.402.825,- | |
| Hand - Nail bed, laceration, Repair (multiple) (Cito) | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Rp. 9.402.825,- | |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Rp. 9.402.825,- | |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Cit | Rp. 9.402.825,- | |
| Hand - Thumb, deformitas, Koreksi (Cito) | Rp. 9.402.825,- | |
| Hemiglosektomi (Cito) | Rp. 9.402.825,- | |
| Hip - Arthroscopy (Cito) | Rp. 9.402.825,- | |
| Hip - Hemiarthroplasty (Cito) | Rp. 9.402.825,- | |
| Hip - ORIF, DHS (Cito) | Rp. 9.402.825,- | |
| Hipertropi Prostat Beningna (BPH) * (Cito) | Rp. 9.402.825,- | |
| Ileostomy (not otherwise specified) * (Cito) | Rp. 9.402.825,- | |
| Incisional hernia repair (Cito) | Rp. 9.402.825,- | |
| Incisional hernia repair with prosthesis (Cito) | Rp. 9.402.825,- | |
| Internal drainage of pancreatic cyst (Cito) | Rp. 9.402.825,- | |
| Knee - Anterior cruciate ligament reconstruction (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy debridement knee (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy debridement shoulder (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy diagnostic (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy diagnostic shoulder (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy meniscus repair (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy remove loose body (Cito) | Rp. 9.402.825,- | |
| Knee - Arthroscopy remove loose body shoulder (Cito) | Rp. 9.402.825,- | |
| Knee - Fibular osteotomy (Cito) | Rp. 9.402.825,- | |
| Knee - Lateral collateral ligament reconstruction (Cito) | Rp. 9.402.825,- | |
| Knee - Medial collateral ligament reconstruction (Cito) | Rp. 9.402.825,- | |
| Knee - Posterior cruciate ligamnet reconstruction (Cito) | Rp. 9.402.825,- | |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Cito) | Rp. 9.402.825,- | |
| Knee - Revisi total knee replacement (Cito) | Rp. 9.402.825,- | |
| Knee - Revisi total shoulder replacement (Cito) | Rp. 9.402.825,- | |
| Knee - Rotator cuff repair by arthroscopy (Cito) | Rp. 9.402.825,- | |
| Knee - Shoulder hemiarthroplasty (Cito) | Rp. 9.402.825,- | |
| Knee - Total shoulder replacement (Cito) | Rp. 9.402.825,- | |
| Kolonoskopi dan Biopsi (Cito) | Rp. 9.402.825,- | |
| Laparoscopic lysis of peritoneal adhesions (Cito) | Rp. 9.402.825,- | |
| Laparoskopi/histeroskopi - ovarian drilling (Cito) | Rp. 9.402.825,- | |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Cito) | Rp. 9.402.825,- | |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Cito) | Rp. 9.402.825,- | |
| Laparskopi / Histereskopi - Second Look (Cito) | Rp. 9.402.825,- | |
| Laparskopi / Histereskopi - Tubektomi (Cito) | Rp. 9.402.825,- | |
| Large to large intestinal anastomosis (Cito) | Rp. 9.402.825,- | |
| Laring dan Faring - Laringektomi * (Cito) | Rp. 9.402.825,- | |
| Laring dan Faring - Laringektomi + RND * (Cito) | Rp. 9.402.825,- | |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Cito) | Rp. 9.402.825,- | |
| Laring dan Faring - RND * (Cito) | Rp. 9.402.825,- | |
| Laringectomi * (Cito) | Rp. 9.402.825,- | |
| Laringectomi dengan diseksi leher * (Cito) | Rp. 9.402.825,- | |
| Lasik 1 (satu) mata (Cito) | Rp. 9.402.825,- | |
| Lobektomi parsial (reseksi paru segmental) * (Cito) | Rp. 9.402.825,- | |
| Muscle flap graft to breast (Cito) | Rp. 9.402.825,- | |
| Muscle flap graft to breast (TRAM flap / LD flap) (Cito) | Rp. 9.402.825,- | |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Cito) | Rp. 9.402.825,- | |
| Obstetri - Partus Dengan Bius ELA (Cito) | Rp. 9.402.825,- | |
| Obstetri - Partus Dengan Bius ILA (Cito) | Rp. 9.402.825,- | |
| Obstetri - Purandare (Cito) | Rp. 9.402.825,- | |
| Obstetri - Rekonstruksi vagina (Cito) | Rp. 9.402.825,- | |
| Obstetri - Repair fistula (Cito) | Rp. 9.402.825,- | |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Cito) | Rp. 9.402.825,- | |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Cito | Rp. 9.402.825,- | |
| Obstetri - Vaginoplasti (Cito) | Rp. 9.402.825,- | |
| Odontektomi tingkat II (Cito) | Rp. 9.402.825,- | |
| Onkologi - Diseksi leher bilateral (Cito) | Rp. 9.402.825,- | |
| Onkologi - Diseksi leher modified (Cito) | Rp. 9.402.825,- | |
| Onkologi - Ligasi arteri karotis eksterna (Cito) | Rp. 9.402.825,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 9.402.825,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 9.402.825,- | |
| Onkologi - Mandibulektomi parsial (Cito) | Rp. 9.402.825,- | |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Rp. 9.402.825,- | |
| Onkologi - Total patellectomy dan rekonstruksi (Cito) | Rp. 9.402.825,- | |
| Open biopsy of gallbladder or bile ducts (Cito) | Rp. 9.402.825,- | |
| Open biopsy of liver (Cito) | Rp. 9.402.825,- | |
| Open biopsy of pancreas (Cito) | Rp. 9.402.825,- | |
| Open reduction of malar and zygomatic fracture (Cito) | Rp. 9.402.825,- | |
| Open reduction of mandibular fractur (Cito) | Rp. 9.402.825,- | |
| Open reduction of maxillary fracture (Cito) | Rp. 9.402.825,- | |
| Other destruction of lesion of liver (Cito) | Rp. 9.402.825,- | |
| Other laparotomy (Cito) | Rp. 9.402.825,- | |
| Other partial excision of large intestine (Cito) | Rp. 9.402.825,- | |
| Other repair of anal sphincter (Cito) | Rp. 9.402.825,- | |
| Other repair of intestine (Cito) | Rp. 9.402.825,- | |
| Other repair of mesentery (Cito) | Rp. 9.402.825,- | |
| Other skin graft to hand (Cito) | Rp. 9.402.825,- | |
| Other skin graft to other sites (Cito) | Rp. 9.402.825,- | |
| Other small to large intestinal anastomosis (Cito) | Rp. 9.402.825,- | |
| Other suture of abdominal wall (Cito) | Rp. 9.402.825,- | |
| Otologi - Dekompresi nervus fasialis (Cito) | Rp. 9.402.825,- | |
| Otologi - Kanaloplasti / kanalomeatoplasty (Cito) | Rp. 9.402.825,- | |
| Otologi - Mastoidektomi radikal (Cito) | Rp. 9.402.825,- | |
| Otologi - Mastoidektomi sederhana (Cito) | Rp. 9.402.825,- | |
| Otologi - Stapedektomi (Cito) | Rp. 9.402.825,- | |
| Parotidektomi superfisial * (Cito) | Rp. 9.402.825,- | |
| Partial splenectomy (Cito) | Rp. 9.402.825,- | |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Rp. 9.402.825,- | |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Cito) | Rp. 9.402.825,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Rp. 9.402.825,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Rp. 9.402.825,- | |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Rp. 9.402.825,- | |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Cito) | Rp. 9.402.825,- | |
| Pedicle or flaps graft (not otherwise specified) (Cito) | Rp. 9.402.825,- | |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Cito) | Rp. 9.402.825,- | |
| Pembuatan thoracic window (Cito) | Rp. 9.402.825,- | |
| Perikardiotomi / pericardial window * (Cito) | Rp. 9.402.825,- | |
| Permanent colostomy (Cito) | Rp. 9.402.825,- | |
| Permanent ileostomy (Cito) | Rp. 9.402.825,- | |
| Phaco (Cito) | Rp. 9.402.825,- | |
| Phaco dan IOL (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Faringeal flap (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Forehead flap (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Otoplasty * (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Revisi parut (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Rinoplasty * (Cito) | Rp. 9.402.825,- | |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Cito) | Rp. 9.402.825,- | |
| Pleurektomi * (Cito) | Rp. 9.402.825,- | |
| Plikasi diafragma * (Cito) | Rp. 9.402.825,- | |
| Pneumonectomy * (Cito) | Rp. 9.402.825,- | |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Cito) | Rp. 9.402.825,- | |
| Posterior vitrectomy, Phaco dan IOL (Cito) | Rp. 9.402.825,- | |
| Radical excision of skin lesion (Cito) | Rp. 9.402.825,- | |
| Reclosure of postoperative disruption of abdominal wall (Cito) | Rp. 9.402.825,- | |
| Rectosigmoidoskopi (Cito) | Rp. 9.402.825,- | |
| Reduction of anal prolapse (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Blefaroplasty 2 kelopak (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Fraktur dasar orbita (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Fraktur Multiple (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Palpebra dengan Graft * (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Soket kontraktur (Cito) | Rp. 9.402.825,- | |
| Rekonstruksi - Soket landai (Cito) | Rp. 9.402.825,- | |
| Reopening of recent laparotomy site (Cito) | Rp. 9.402.825,- | |
| Repair arteri poplitea dan femoralis (Cito) | Rp. 9.402.825,- | |
| Repair of diaphragmatic hernia, abdominal approach (Cito) | Rp. 9.402.825,- | |
| Repair of laceration of gallbladder (Cito) | Rp. 9.402.825,- | |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Cito) | Rp. 9.402.825,- | |
| Resection of transverse colon (Cito) | Rp. 9.402.825,- | |
| Reseksi maksila infrastuktural (Cito) | Rp. 9.402.825,- | |
| Reseksi mandibula tanpa rekonstruksi (Cito) | Rp. 9.402.825,- | |
| Revision of anastomosis of large intestine (Cito) | Rp. 9.402.825,- | |
| Revision of anastomosis of small intestine (Cito) | Rp. 9.402.825,- | |
| Revision of stoma of large intestine (Cito) | Rp. 9.402.825,- | |
| Revision of stoma of small intestine (Cito) | Rp. 9.402.825,- | |
| Revision of tracheostomy (Cito) | Rp. 9.402.825,- | |
| Right hemicolectomy (Cito) | Rp. 9.402.825,- | |
| Rinologi - BSEF / FESS 1 : Mini (Cito) | Rp. 9.402.825,- | |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Cito) | Rp. 9.402.825,- | |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Cito) | Rp. 9.402.825,- | |
| Rupture buli-buli * (Cito) | Rp. 9.402.825,- | |
| Scleral buckling, phaco dan IOL (Cito) | Rp. 9.402.825,- | |
| Sigmoidectomy (Cito) | Rp. 9.402.825,- | |
| Simple suture of common bile duct (Cito) | Rp. 9.402.825,- | |
| Small to small intestinal anastomosis (Cito) | Rp. 9.402.825,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 9.402.825,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 9.402.825,- | |
| Spine - Discograph multilevel * (Cito) | Rp. 9.402.825,- | |
| Spine - Facet block (1 level) (Cito) | Rp. 9.402.825,- | |
| Spine - Facet block multilevel (Cito) | Rp. 9.402.825,- | |
| Spine - Foraminal block (1 level) (Cito) | Rp. 9.402.825,- | |
| Spine - Foraminal block multilevel (Cito) | Rp. 9.402.825,- | |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Rp. 9.402.825,- | |
| Spine - Removal of implants (Plate, Nail, Screw) * (Cito) | Rp. 9.402.825,- | |
| Strabismus 4 otot (Cito) | Rp. 9.402.825,- | |
| Stripping varises ekstremitas inferior (Cito) | Rp. 9.402.825,- | |
| Subtotal mastectomy (Cito) | Rp. 9.402.825,- | |
| Temporary colostomy (Cito) | Rp. 9.402.825,- | |
| Temporary ileostomy * (Cito) | Rp. 9.402.825,- | |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Cito | Rp. 9.402.825,- | |
| Tiroidektomi subtotal / total nodul tiroid ** (Cito) | Rp. 9.402.825,- | |
| Total splenectomy * (Cito) | Rp. 9.402.825,- | |
| Trauma - Closed fraktur distal tibia (Cito) | Rp. 9.402.825,- | |
| Trauma - Closed fraktur intercondylar femur (Cito) | Rp. 9.402.825,- | |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Cito) | Rp. 9.402.825,- | |
| Trauma - Closed fraktur supracondylar femur (Cito) | Rp. 9.402.825,- | |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Cito) | Rp. 9.402.825,- | |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Cito) | Rp. 9.402.825,- | |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur collum femur pada orang tua (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur galeazi (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur intertrochanter femur pada orang tua (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur montegia (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Cito) | Rp. 9.402.825,- | |
| Trauma - Instability joint infection (Cito) | Rp. 9.402.825,- | |
| Trauma - Joint stiffness dengan liberation (Cito) | Rp. 9.402.825,- | |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Rp. 9.402.825,- | |
| Trauma - Non union dengan bone graft (Cito) | Rp. 9.402.825,- | |
| Trauma - Open fraktur shaft femur grade 3 (Cito) | Rp. 9.402.825,- | |
| Trauma - Open fraktur shaft humerus grade 3 (Cito) | Rp. 9.402.825,- | |
| Trauma - Open fraktur shaft radius grade 3 (Cito) | Rp. 9.402.825,- | |
| Trauma - Open fraktur shaft tibia grade 3 (Cito) | Rp. 9.402.825,- | |
| Trauma - Open fraktur shaft ulna grade 3 (Cito) | Rp. 9.402.825,- | |
| Trauma - Osteomyelitis (Cito) | Rp. 9.402.825,- | |
| Tumor - Extended Eksenterasi (Cito) | Rp. 9.402.825,- | |
| Tumor - Orbital dekompresi 3 tulang (Cito) | Rp. 9.402.825,- | |
| Tumor - Orbitotomi lateral and superior (medial) (Cito) | Rp. 9.402.825,- | |
| Unilateral radical mastectomy (Cito) | Rp. 9.402.825,- | |
| Unilateral simple mastectomy (Cito) | Rp. 9.402.825,- | |
| Upper Endoskopi (Cito) | Rp. 9.402.825,- | |
| Upper Endoskopi dan biopsi (Cito) | Rp. 9.402.825,- | |
| Upper Endoskopi dan ekstraksi carpal (Cito) | Rp. 9.402.825,- | |
| Upper Endoskopi dan ligasi (Cito) | Rp. 9.402.825,- | |
| Amputasi above knee (Cito) | Rp. 9.062.526,- | |
| Closure of appendiceal fistula (Cito) | Rp. 9.062.526,- | |
| Knee - Revisi total knee replacement (Cito) | Rp. 9.062.526,- | |
| Knee - Revisi total shoulder replacement (Cito) | Rp. 9.062.526,- | |
| Knee - Rotator cuff repair by arthroscopy (Cito) | Rp. 9.062.526,- | |
| Knee - Shoulder hemiarthroplasty (Cito) | Rp. 9.062.526,- | |
| Knee - Total shoulder replacement (Cito) | Rp. 9.062.526,- | |
| Kolonoskopi dan Biopsi (Cito) | Rp. 9.062.526,- | |
| Laparoscopic lysis of peritoneal adhesions (Cito) | Rp. 9.062.526,- | |
| Laparoskopi/histeroskopi - ovarian drilling (Cito) | Rp. 9.062.526,- | |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Cito) | Rp. 9.062.526,- | |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Cito) | Rp. 9.062.526,- | |
| Closure of cholecystostomy (Cito) | Rp. 9.062.526,- | |
| Laparskopi / Histereskopi - Second Look (Cito) | Rp. 9.062.526,- | |
| Laparskopi / Histereskopi - Tubektomi (Cito) | Rp. 9.062.526,- | |
| Large to large intestinal anastomosis (Cito) | Rp. 9.062.526,- | |
| Laring dan Faring - Laringektomi * (Cito) | Rp. 9.062.526,- | |
| Laring dan Faring - Laringektomi + RND * (Cito) | Rp. 9.062.526,- | |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Cito) | Rp. 9.062.526,- | |
| Laring dan Faring - RND * (Cito) | Rp. 9.062.526,- | |
| Laringectomi * (Cito) | Rp. 9.062.526,- | |
| Laringectomi dengan diseksi leher * (Cito) | Rp. 9.062.526,- | |
| Lasik 1 (satu) mata (Cito) | Rp. 9.062.526,- | |
| Closure of fistula of large intestine (Cito) | Rp. 9.062.526,- | |
| Lobektomi parsial (reseksi paru segmental) * (Cito) | Rp. 9.062.526,- | |
| Muscle flap graft to breast (Cito) | Rp. 9.062.526,- | |
| Muscle flap graft to breast (TRAM flap / LD flap) (Cito) | Rp. 9.062.526,- | |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Cito) | Rp. 9.062.526,- | |
| Obstetri - Partus Dengan Bius ELA (Cito) | Rp. 9.062.526,- | |
| Obstetri - Partus Dengan Bius ILA (Cito) | Rp. 9.062.526,- | |
| Obstetri - Purandare (Cito) | Rp. 9.062.526,- | |
| Obstetri - Rekonstruksi vagina (Cito) | Rp. 9.062.526,- | |
| Obstetri - Repair fistula (Cito) | Rp. 9.062.526,- | |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Cito) | Rp. 9.062.526,- | |
| Closure of fistula of small intestine, except duodenum (Cito) | Rp. 9.062.526,- | |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Cito | Rp. 9.062.526,- | |
| Obstetri - Vaginoplasti (Cito) | Rp. 9.062.526,- | |
| Odontektomi tingkat II (Cito) | Rp. 9.062.526,- | |
| Onkologi - Diseksi leher bilateral (Cito) | Rp. 9.062.526,- | |
| Onkologi - Diseksi leher modified (Cito) | Rp. 9.062.526,- | |
| Onkologi - Ligasi arteri karotis eksterna (Cito) | Rp. 9.062.526,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 9.062.526,- | |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Rp. 9.062.526,- | |
| Onkologi - Mandibulektomi parsial (Cito) | Rp. 9.062.526,- | |
| Closure of intestinal stoma (Cito) | Rp. 9.062.526,- | |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Rp. 9.062.526,- | |
| Onkologi - Total patellectomy dan rekonstruksi (Cito) | Rp. 9.062.526,- | |
| Open biopsy of gallbladder or bile ducts (Cito) | Rp. 9.062.526,- | |
| Open biopsy of liver (Cito) | Rp. 9.062.526,- | |
| Open biopsy of pancreas (Cito) | Rp. 9.062.526,- | |
| Open reduction of malar and zygomatic fracture (Cito) | Rp. 9.062.526,- | |
| Open reduction of mandibular fractur (Cito) | Rp. 9.062.526,- | |
| Open reduction of maxillary fracture (Cito) | Rp. 9.062.526,- | |
| Other destruction of lesion of liver (Cito) | Rp. 9.062.526,- | |
| Other laparotomy (Cito) | Rp. 9.062.526,- | |
| Closure of leceration of liver (Cito) | Rp. 9.062.526,- | |
| Other partial excision of large intestine (Cito) | Rp. 9.062.526,- | |
| Other repair of anal sphincter (Cito) | Rp. 9.062.526,- | |
| Other repair of intestine (Cito) | Rp. 9.062.526,- | |
| Other repair of mesentery (Cito) | Rp. 9.062.526,- | |
| Other skin graft to hand (Cito) | Rp. 9.062.526,- | |
| Other skin graft to other sites (Cito) | Rp. 9.062.526,- | |
| Other small to large intestinal anastomosis (Cito) | Rp. 9.062.526,- | |
| Other suture of abdominal wall (Cito) | Rp. 9.062.526,- | |
| Otologi - Dekompresi nervus fasialis (Cito) | Rp. 9.062.526,- | |
| Otologi - Kanaloplasti / kanalomeatoplasty (Cito) | Rp. 9.062.526,- | |
| Colostomy (not otherwise specified) (Cito) | Rp. 9.062.526,- | |
| Otologi - Mastoidektomi radikal (Cito) | Rp. 9.062.526,- | |
| Otologi - Mastoidektomi sederhana (Cito) | Rp. 9.062.526,- | |
| Otologi - Stapedektomi (Cito) | Rp. 9.062.526,- | |
| Parotidektomi superfisial * (Cito) | Rp. 9.062.526,- | |
| Partial splenectomy (Cito) | Rp. 9.062.526,- | |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Rp. 9.062.526,- | |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Cito) | Rp. 9.062.526,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Rp. 9.062.526,- | |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Rp. 9.062.526,- | |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Rp. 9.062.526,- | |
| Common duct exploration for removal of calculus (Cito) | Rp. 9.062.526,- | |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Cito) | Rp. 9.062.526,- | |
| Pedicle or flaps graft (not otherwise specified) (Cito) | Rp. 9.062.526,- | |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Cito) | Rp. 9.062.526,- | |
| Pembuatan thoracic window (Cito) | Rp. 9.062.526,- | |
| Perikardiotomi / pericardial window * (Cito) | Rp. 9.062.526,- | |
| Permanent colostomy (Cito) | Rp. 9.062.526,- | |
| Permanent ileostomy (Cito) | Rp. 9.062.526,- | |
| Phaco (Cito) | Rp. 9.062.526,- | |
| Phaco dan IOL (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Faringeal flap (Cito) | Rp. 9.062.526,- | |
| Debridement mediastinum (sternotomi) * (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Forehead flap (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Otoplasty * (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Revisi parut (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Rinoplasty * (Cito) | Rp. 9.062.526,- | |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Cito) | Rp. 9.062.526,- | |
| Pleurektomi * (Cito) | Rp. 9.062.526,- | |
| Plikasi diafragma * (Cito) | Rp. 9.062.526,- | |
| Pneumonectomy * (Cito) | Rp. 9.062.526,- | |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Cito) | Rp. 9.062.526,- | |
| Posterior vitrectomy, Phaco dan IOL (Cito) | Rp. 9.062.526,- | |
| Diseksi leher radikal / radikal neck dissection * (Cito) | Rp. 9.062.526,- | |
| Radical excision of skin lesion (Cito) | Rp. 9.062.526,- | |
| Reclosure of postoperative disruption of abdominal wall (Cito) | Rp. 9.062.526,- | |
| Rectosigmoidoskopi (Cito) | Rp. 9.062.526,- | |
| Reduction of anal prolapse (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Blefaroplasty 2 kelopak (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Fraktur dasar orbita (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Fraktur Multiple (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Palpebra dengan Graft * (Cito) | Rp. 9.062.526,- | |
| Amputasi below knee (Cito) | Rp. 9.062.526,- | |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Soket kontraktur (Cito) | Rp. 9.062.526,- | |
| Rekonstruksi - Soket landai (Cito) | Rp. 9.062.526,- | |
| Reopening of recent laparotomy site (Cito) | Rp. 9.062.526,- | |
| Repair arteri poplitea dan femoralis (Cito) | Rp. 9.062.526,- | |
| Repair of diaphragmatic hernia, abdominal approach (Cito) | Rp. 9.062.526,- | |
| Repair of laceration of gallbladder (Cito) | Rp. 9.062.526,- | |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Cito) | Rp. 9.062.526,- | |
| Resection of transverse colon (Cito) | Rp. 9.062.526,- | |
| Reseksi maksila infrastuktural (Cito) | Rp. 9.062.526,- | |
| Reseksi mandibula tanpa rekonstruksi (Cito) | Rp. 9.062.526,- | |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Cito) | Rp. 9.062.526,- | |
| Revision of anastomosis of large intestine (Cito) | Rp. 9.062.526,- | |
| Revision of anastomosis of small intestine (Cito) | Rp. 9.062.526,- | |
| Revision of stoma of large intestine (Cito) | Rp. 9.062.526,- | |
| Revision of stoma of small intestine (Cito) | Rp. 9.062.526,- | |
| Revision of tracheostomy (Cito) | Rp. 9.062.526,- | |
| Right hemicolectomy (Cito) | Rp. 9.062.526,- | |
| Rinologi - BSEF / FESS 1 : Mini (Cito) | Rp. 9.062.526,- | |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Cito) | Rp. 9.062.526,- | |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Cito) | Rp. 9.062.526,- | |
| Rupture buli-buli * (Cito) | Rp. 9.062.526,- | |
| Eksisi pseudoaneurisma (Cito) | Rp. 9.062.526,- | |
| Scleral buckling, phaco dan IOL (Cito) | Rp. 9.062.526,- | |
| Sigmoidectomy (Cito) | Rp. 9.062.526,- | |
| Simple suture of common bile duct (Cito) | Rp. 9.062.526,- | |
| Small to small intestinal anastomosis (Cito) | Rp. 9.062.526,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 9.062.526,- | |
| Spine - Discograph (1 level) * (Cito) | Rp. 9.062.526,- | |
| Spine - Discograph multilevel * (Cito) | Rp. 9.062.526,- | |
| Spine - Facet block (1 level) (Cito) | Rp. 9.062.526,- | |
| Spine - Facet block multilevel (Cito) | Rp. 9.062.526,- | |
| Spine - Foraminal block (1 level) (Cito) | Rp. 9.062.526,- | |
| Eksplorasi vaskular (trauma / non trauma) (Cito) | Rp. 9.062.526,- | |
| Spine - Foraminal block multilevel (Cito) | Rp. 9.062.526,- | |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Rp. 9.062.526,- | |
| Spine - Removal of implants (Plate, Nail, Screw) * (Cito) | Rp. 9.062.526,- | |
| Strabismus 4 otot (Cito) | Rp. 9.062.526,- | |
| Stripping varises ekstremitas inferior (Cito) | Rp. 9.062.526,- | |
| Subtotal mastectomy (Cito) | Rp. 9.062.526,- | |
| Temporary colostomy (Cito) | Rp. 9.062.526,- | |
| Temporary ileostomy * (Cito) | Rp. 9.062.526,- | |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Cito | Rp. 9.062.526,- | |
| Tiroidektomi subtotal / total nodul tiroid ** (Cito) | Rp. 9.062.526,- | |
| Ekstraksi corpus alienum di regio toraks * (Cito) | Rp. 9.062.526,- | |
| Total splenectomy * (Cito) | Rp. 9.062.526,- | |
| Trauma - Closed fraktur distal tibia (Cito) | Rp. 9.062.526,- | |
| Trauma - Closed fraktur intercondylar femur (Cito) | Rp. 9.062.526,- | |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Cito) | Rp. 9.062.526,- | |
| Trauma - Closed fraktur supracondylar femur (Cito) | Rp. 9.062.526,- | |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Cito) | Rp. 9.062.526,- | |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Cito) | Rp. 9.062.526,- | |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur collum femur pada orang tua (Cito) | Rp. 9.062.526,- | |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur galeazi (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur intertrochanter femur pada orang tua (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur montegia (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Cito) | Rp. 9.062.526,- | |
| Trauma - Instability joint infection (Cito) | Rp. 9.062.526,- | |
| Trauma - Joint stiffness dengan liberation (Cito) | Rp. 9.062.526,- | |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Rp. 9.062.526,- | |
| Trauma - Non union dengan bone graft (Cito) | Rp. 9.062.526,- | |
| Trauma - Open fraktur shaft femur grade 3 (Cito) | Rp. 9.062.526,- | |
| Trauma - Open fraktur shaft humerus grade 3 (Cito) | Rp. 9.062.526,- | |
| Trauma - Open fraktur shaft radius grade 3 (Cito) | Rp. 9.062.526,- | |
| Trauma - Open fraktur shaft tibia grade 3 (Cito) | Rp. 9.062.526,- | |
| Trauma - Open fraktur shaft ulna grade 3 (Cito) | Rp. 9.062.526,- | |
| Trauma - Osteomyelitis (Cito) | Rp. 9.062.526,- | |
| Tumor - Extended Eksenterasi (Cito) | Rp. 9.062.526,- | |
| Tumor - Orbital dekompresi 3 tulang (Cito) | Rp. 9.062.526,- | |
| Tumor - Orbitotomi lateral and superior (medial) (Cito) | Rp. 9.062.526,- | |
| Unilateral radical mastectomy (Cito) | Rp. 9.062.526,- | |
| Unilateral simple mastectomy (Cito) | Rp. 9.062.526,- | |
| Upper Endoskopi (Cito) | Rp. 9.062.526,- | |
| Upper Endoskopi dan biopsi (Cito) | Rp. 9.062.526,- | |
| Upper Endoskopi dan ekstraksi carpal (Cito) | Rp. 9.062.526,- | |
| Upper Endoskopi dan ligasi (Cito) | Rp. 9.062.526,- | |
| Aneurisma arteri brachialis (Cito) | Rp. 9.062.526,- | |
| Endoscopic polypectomy of rectum (Cito) | Rp. 9.062.526,- | |
| Endoscopic thyroidectomy (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Pan bronkoskopi (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Pan esofagoskopi (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Sialendoskopi diagnostik (Cito) | Rp. 9.062.526,- | |
| Endoskopi - Sleep nasoendoskopi (Cito) | Rp. 9.062.526,- | |
| Excision of hemorrhoid (Cito) | Rp. 9.062.526,- | |
| Aneurisma arteri femoralis (Cito) | Rp. 9.062.526,- | |
| Exploration of common duct (Cito) | Rp. 9.062.526,- | |
| Exteriorization of large intestine (Cito) | Rp. 9.062.526,- | |
| Exteriorization of small intestine (Cito) | Rp. 9.062.526,- | |
| Fiksasi sternum (wire, plate) * (Cito) | Rp. 9.062.526,- | |
| Fraktur antebrachi (Cito) | Rp. 9.062.526,- | |
| Fraktur colles dan pergelangan tangan lainnya (Cito) | Rp. 9.062.526,- | |
| Fraktur cruris (Cito) | Rp. 9.062.526,- | |
| Fraktur femur * (Cito) | Rp. 9.062.526,- | |
| Fraktur klavikula (Cito) | Rp. 9.062.526,- | |
| Fraktur olekranon (Cito) | Rp. 9.062.526,- | |
| Axillary dissection (Cito) | Rp. 9.062.526,- | |
| Fraktur patela (Cito) | Rp. 9.062.526,- | |
| Fraktur suprakondiler humerus (Cito) | Rp. 9.062.526,- | |
| Free skin graft (Cito) | Rp. 9.062.526,- | |
| Full-thickness skin graft to hand (Cito) | Rp. 9.062.526,- | |
| Full-thickness skin graft to other sites * (Cito) | Rp. 9.062.526,- | |
| GIN- Hymenoplasty (Cito) | Rp. 9.062.526,- | |
| Ginekologi - Histerektomi (Cito) | Rp. 9.062.526,- | |
| Ginekologi - Kehamilan ektopik (Cito) | Rp. 9.062.526,- | |
| Ginekologi - Miomektomi (Cito) | Rp. 9.062.526,- | |
| Glaukoma - Tubes implan, Phaco dan IOL (Cito) | Rp. 9.062.526,- | |
| Batu saluran kemih * (Cito) | Rp. 9.062.526,- | |
| Groin dissection (Cito) | Rp. 9.062.526,- | |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (C | Rp. 9.062.526,- | |
| Hand - Jari, defect or contracture (single) rekonstruksi (Cito) | Rp. 9.062.526,- | |
| Hand - Jari, deformities, koreksi (Cito) | Rp. 9.062.526,- | |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Rp. 9.062.526,- | |
| Hand - Jari, ring constriction (multiple), koreksi (Cito) | Rp. 9.062.526,- | |
| Hand - Jari, syndactili (multiple) (Cito) | Rp. 9.062.526,- | |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (C | Rp. 9.062.526,- | |
| Hand - Nail bed, laceration, Repair (multiple) (Cito) | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Rp. 9.062.526,- | |
| Bilateral simple mastectomy (Cito) | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Rp. 9.062.526,- | |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Rp. 9.062.526,- | |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Cit | Rp. 9.062.526,- | |
| Hand - Thumb, deformitas, Koreksi (Cito) | Rp. 9.062.526,- | |
| Hemiglosektomi (Cito) | Rp. 9.062.526,- | |
| Hip - Arthroscopy (Cito) | Rp. 9.062.526,- | |
| Hip - Hemiarthroplasty (Cito) | Rp. 9.062.526,- | |
| Cholecystectomy (Cito) | Rp. 9.062.526,- | |
| Hip - ORIF, DHS (Cito) | Rp. 9.062.526,- | |
| Hipertropi Prostat Beningna (BPH) * (Cito) | Rp. 9.062.526,- | |
| Ileostomy (not otherwise specified) * (Cito) | Rp. 9.062.526,- | |
| Incisional hernia repair (Cito) | Rp. 9.062.526,- | |
| Incisional hernia repair with prosthesis (Cito) | Rp. 9.062.526,- | |
| Internal drainage of pancreatic cyst (Cito) | Rp. 9.062.526,- | |
| Knee - Anterior cruciate ligament reconstruction (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy debridement knee (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy debridement shoulder (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy diagnostic (Cito) | Rp. 9.062.526,- | |
| Choledochoplasty (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy diagnostic shoulder (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy meniscus repair (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy remove loose body (Cito) | Rp. 9.062.526,- | |
| Knee - Arthroscopy remove loose body shoulder (Cito) | Rp. 9.062.526,- | |
| Knee - Fibular osteotomy (Cito) | Rp. 9.062.526,- | |
| Knee - Lateral collateral ligament reconstruction (Cito) | Rp. 9.062.526,- | |
| Knee - Medial collateral ligament reconstruction (Cito) | Rp. 9.062.526,- | |
| Knee - Posterior cruciate ligamnet reconstruction (Cito) | Rp. 9.062.526,- | |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Cito) | Rp. 9.062.526,- | |
| Clipping costa (Cito) | Rp. 13.379.676,- | |
| Complete thyroidectomy (Cito) | Rp. 13.379.676,- | |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Cito) | Rp. 13.379.676,- | |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Cito) | Rp. 13.379.676,- | |
| Eksisi pada bronkhus (Cito) | Rp. 13.379.676,- | |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Cito) | Rp. 13.379.676,- | |
| Endoskopi - Bronkoskopi diagnostik (Cito) | Rp. 13.379.676,- | |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Cito) | Rp. 13.379.676,- | |
| Endoskopi - Esofagoskopi BA dengan penyulit (Cito) | Rp. 13.379.676,- | |
| Endoskopi - Esofagoskopi diagnostik (Cito) | Rp. 13.379.676,- | |
| Excision of other bile duct (Cito) | Rp. 13.379.676,- | |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Cito) | Rp. 13.379.676,- | |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Cito) | Rp. 13.379.676,- | |
| Ginekologi - Repair tuba (tubaplasti) (Cito) | Rp. 13.379.676,- | |
| Ginekologi - Reseksi adenomiosis (Cito) | Rp. 13.379.676,- | |
| Ginekologi - Transposisi Ovarium (Cito) | Rp. 13.379.676,- | |
| Hand - Artery, large, injury, repair with grafting (Cito) | Rp. 13.379.676,- | |
| Hand - Carpus, delayed (non union), rekonstruksi (Cito) | Rp. 13.379.676,- | |
| Hand - Jari (digit), stump, revision (Cito) | Rp. 13.379.676,- | |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Cito) | Rp. 13.379.676,- | |
| Hand - Jari, deformities, major reconstruction procedure (Cito) | Rp. 13.379.676,- | |
| Hand - Jari, deformities, osteotomy (Cito) | Rp. 13.379.676,- | |
| Hand - Jari, deformity, instrinsic muscle transfer (Cito) | Rp. 13.379.676,- | |
| Hand - Jari, scar, revision osteotomy (Cito) | Rp. 13.379.676,- | |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Rp. 13.379.676,- | |
| Hand - Nerve defect, peripheral graft (Cito) | Rp. 13.379.676,- | |
| Hand - Nerve digital, Injury, microsurgical (single) (Cito) | Rp. 13.379.676,- | |
| Hand - Nerve digital, injury, primary repair (Cito) | Rp. 13.379.676,- | |
| Hand - Nerve ulnar, entrapment, transposition (Cito) | Rp. 13.379.676,- | |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Cito) | Rp. 13.379.676,- | |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Rp. 13.379.676,- | |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Cito) | Rp. 13.379.676,- | |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Cito) | Rp. 13.379.676,- | |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Cito) | Rp. 13.379.676,- | |
| Hand - Thumb, paralysis, oppnens plasty (Cito) | Rp. 13.379.676,- | |
| Hip - Total hip replacement (Cito) | Rp. 13.379.676,- | |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Cito) | Rp. 13.379.676,- | |
| Intra-abdominal manipulation of large intestine (Cito) | Rp. 13.379.676,- | |
| Intra-abdominal manipulation of small intestine (Cito) | Rp. 13.379.676,- | |
| Knee - Total knee replacement (Cito) | Rp. 13.379.676,- | |
| Knee - Uni compartment arthroplasty (Cito) | Rp. 13.379.676,- | |
| Laparoscopic appendectomy (Cito) | Rp. 13.379.676,- | |
| Laparoscopic appendectomy (elective) (Cito) | Rp. 13.379.676,- | |
| Laparoscopic cholecystectomy (Cito) | Rp. 13.379.676,- | |
| Laparoscopic incidental appendectomy (Cito) | Rp. 13.379.676,- | |
| Laparoscopy (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Kistektomi (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Ovareksi (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Salpingoooforektomi (Cito) | Rp. 13.379.676,- | |
| Laparskopi / Histereskopi - Transposisi Ovarium (Cito) | Rp. 13.379.676,- | |
| Laring dan Faring - TA/T dengan Coblation Laser (Cito) | Rp. 13.379.676,- | |
| Laring dan Faring - Tiroidektomi Subtotal ** (Cito) | Rp. 13.379.676,- | |
| Laring dan Faring - Tiroidektomi Total (Cito) | Rp. 13.379.676,- | |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Cito) | Rp. 13.379.676,- | |
| Left hemicolectomy (Cito) | Rp. 13.379.676,- | |
| Mediastinostomy (Cito) | Rp. 13.379.676,- | |
| Obstetri - Operasi plasenta akreta (Cito) | Rp. 13.379.676,- | |
| Odontektomi tingkat III (Cito) | Rp. 13.379.676,- | |
| Onkologi - Belloque tampon dengan narkosis (Cito) | Rp. 13.379.676,- | |
| Onkologi - Diseksi leher radikal * (Cito) | Rp. 13.379.676,- | |
| Onkologi - Eksplorasi nasofaring (Cito) | Rp. 13.379.676,- | |
| Onkologi - Ekstirpasi tumor jinak kel liur (Cito) | Rp. 13.379.676,- | |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Cito) | Rp. 13.379.676,- | |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Cito) | Rp. 13.379.676,- | |
| Onkologi - Hemiglosektomi (Cito) | Rp. 13.379.676,- | |
| Onkologi - Maksilektomi parsial (Cito) | Rp. 13.379.676,- | |
| Onkologi - Maksilektomi total (radikal) (Cito) | Rp. 13.379.676,- | |
| Onkologi - ORIF MBD (Cito) | Rp. 13.379.676,- | |
| Onkologi - Parotidektomi * (Cito) | Rp. 13.379.676,- | |
| Onkologi - Wide excision soft tisue sarcoma (Cito) | Rp. 13.379.676,- | |
| Other operations on intestines (Cito) | Rp. 13.379.676,- | |
| Other operations on the breast (reconstruction of the breast) (Cito) | Rp. 13.379.676,- | |
| Other partial thyroidectomy (Cito) | Rp. 13.379.676,- | |
| Parathyroidectomy subtotal (Cito) | Rp. 13.379.676,- | |
| Parathyroidectomy total (Cito) | Rp. 13.379.676,- | |
| partial mandibulectomy hemimandibulectomy (Cito) | Rp. 13.379.676,- | |
| Pediatrik - Posteromedial soft tissue release CTEV (Cito) | Rp. 13.379.676,- | |
| Pilar Implant (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Labioplasti Bilateral (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Labioplasti unilateral (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Reseksi septum (Cito) | Rp. 13.379.676,- | |
| Plastik Rekionstruksi - Septorinoplasty (Cito) | Rp. 13.379.676,- | |
| Redo torakotomi * (Cito) | Rp. 13.379.676,- | |
| Reduction Neglected Dislocation (Cito) | Rp. 13.379.676,- | |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Cito | Rp. 13.379.676,- | |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Rp. 13.379.676,- | |
| Repair laserasi diafragma * (Cito) | Rp. 13.379.676,- | |
| Reposisi dislokasi rahang (Cito) | Rp. 13.379.676,- | |
| Reseksi maksila suprastuktural (Cito) | Rp. 13.379.676,- | |
| Rinologi - Caldwell Luc (Cito) | Rp. 13.379.676,- | |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Cito) | Rp. 13.379.676,- | |
| Rinologi - Septum Reseksi / SMR (Cito) | Rp. 13.379.676,- | |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Cito) | Rp. 13.379.676,- | |
| Spine - Alar transverse fusion * (Cito) | Rp. 13.379.676,- | |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Cito) | Rp. 13.379.676,- | |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Cito) | Rp. 13.379.676,- | |
| Spine - Debridement and anterior fusion in TB Spine * (Cito) | Rp. 13.379.676,- | |
| Spine - Decompression laminectomy for HNP with stabilization * (Cito) | Rp. 13.379.676,- | |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Cito) | Rp. 13.379.676,- | |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Rp. 13.379.676,- | |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Cito) | Rp. 13.379.676,- | |
| Spine - Mayor desloughing and wound debridement of the spine * (Cito) | Rp. 13.379.676,- | |
| Spine - Micro endoscopic disectomy (1 level) * (Cito) | Rp. 13.379.676,- | |
| Spine - Microscopic disectomy (1 Level) (Cito) | Rp. 13.379.676,- | |
| Spine - Open disectomy multilevel * (Cito) | Rp. 13.379.676,- | |
| Spine - Open disestomy (1 Level) * (Cito) | Rp. 13.379.676,- | |
| Spine - Open reduction and stabilisation of spinal fracture * (Cito) | Rp. 13.379.676,- | |
| Spine - Posterior cervical fusion * (Cito) | Rp. 13.379.676,- | |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Rp. 13.379.676,- | |
| Spine - Posterolateral fusion * (Cito) | Rp. 13.379.676,- | |
| Spine - Total disc replacement (multilevel) * (Cito) | Rp. 13.379.676,- | |
| Split thickness graft to breast (Cito) | Rp. 13.379.676,- | |
| Terapi Slem Cell (Cito) | Rp. 13.379.676,- | |
| Thymectomy dengan VATS (Cito) | Rp. 13.379.676,- | |
| Tiroidektomi total dengan berry picking (Cito) | Rp. 13.379.676,- | |
| Tiroidektomi total dengan diseksi leher fungsional (Cito) | Rp. 13.379.676,- | |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Cito) | Rp. 13.379.676,- | |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Rp. 13.379.676,- | |
| Trauma - Limb leg inequality dengan bone lengthening transport (Cito) | Rp. 13.379.676,- | |
| Turbinoplasty (Cito) | Rp. 13.379.676,- | |
| Clipping costa (Cito) | Rp. 12.364.475,- | |
| Complete thyroidectomy (Cito) | Rp. 12.364.475,- | |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Cito) | Rp. 12.364.475,- | |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Cito) | Rp. 12.364.475,- | |
| Eksisi pada bronkhus (Cito) | Rp. 12.364.475,- | |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Cito) | Rp. 12.364.475,- | |
| Endoskopi - Bronkoskopi diagnostik (Cito) | Rp. 12.364.475,- | |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Cito) | Rp. 12.364.475,- | |
| Endoskopi - Esofagoskopi BA dengan penyulit (Cito) | Rp. 12.364.475,- | |
| Endoskopi - Esofagoskopi diagnostik (Cito) | Rp. 12.364.475,- | |
| Excision of other bile duct (Cito) | Rp. 12.364.475,- | |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Cito) | Rp. 12.364.475,- | |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Cito) | Rp. 12.364.475,- | |
| Ginekologi - Repair tuba (tubaplasti) (Cito) | Rp. 12.364.475,- | |
| Ginekologi - Reseksi adenomiosis (Cito) | Rp. 12.364.475,- | |
| Ginekologi - Transposisi Ovarium (Cito) | Rp. 12.364.475,- | |
| Hand - Artery, large, injury, repair with grafting (Cito) | Rp. 12.364.475,- | |
| Hand - Carpus, delayed (non union), rekonstruksi (Cito) | Rp. 12.364.475,- | |
| Hand - Jari (digit), stump, revision (Cito) | Rp. 12.364.475,- | |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Cito) | Rp. 12.364.475,- | |
| Hand - Jari, deformities, major reconstruction procedure (Cito) | Rp. 12.364.475,- | |
| Hand - Jari, deformities, osteotomy (Cito) | Rp. 12.364.475,- | |
| Hand - Jari, deformity, instrinsic muscle transfer (Cito) | Rp. 12.364.475,- | |
| Hand - Jari, scar, revision osteotomy (Cito) | Rp. 12.364.475,- | |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Rp. 12.364.475,- | |
| Hand - Nerve defect, peripheral graft (Cito) | Rp. 12.364.475,- | |
| Hand - Nerve digital, Injury, microsurgical (single) (Cito) | Rp. 12.364.475,- | |
| Hand - Nerve digital, injury, primary repair (Cito) | Rp. 12.364.475,- | |
| Hand - Nerve ulnar, entrapment, transposition (Cito) | Rp. 12.364.475,- | |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Cito) | Rp. 12.364.475,- | |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Rp. 12.364.475,- | |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Cito) | Rp. 12.364.475,- | |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Cito) | Rp. 12.364.475,- | |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Cito) | Rp. 12.364.475,- | |
| Hand - Thumb, paralysis, oppnens plasty (Cito) | Rp. 12.364.475,- | |
| Hip - Total hip replacement (Cito) | Rp. 12.364.475,- | |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Cito) | Rp. 12.364.475,- | |
| Intra-abdominal manipulation of large intestine (Cito) | Rp. 12.364.475,- | |
| Intra-abdominal manipulation of small intestine (Cito) | Rp. 12.364.475,- | |
| Knee - Total knee replacement (Cito) | Rp. 12.364.475,- | |
| Knee - Uni compartment arthroplasty (Cito) | Rp. 12.364.475,- | |
| Laparoscopic appendectomy (Cito) | Rp. 12.364.475,- | |
| Laparoscopic appendectomy (elective) (Cito) | Rp. 12.364.475,- | |
| Laparoscopic cholecystectomy (Cito) | Rp. 12.364.475,- | |
| Laparoscopic incidental appendectomy (Cito) | Rp. 12.364.475,- | |
| Laparoscopy (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Kistektomi (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Ovareksi (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Salpingoooforektomi (Cito) | Rp. 12.364.475,- | |
| Laparskopi / Histereskopi - Transposisi Ovarium (Cito) | Rp. 12.364.475,- | |
| Laring dan Faring - TA/T dengan Coblation Laser (Cito) | Rp. 12.364.475,- | |
| Laring dan Faring - Tiroidektomi Subtotal ** (Cito) | Rp. 12.364.475,- | |
| Laring dan Faring - Tiroidektomi Total (Cito) | Rp. 12.364.475,- | |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Cito) | Rp. 12.364.475,- | |
| Left hemicolectomy (Cito) | Rp. 12.364.475,- | |
| Mediastinostomy (Cito) | Rp. 12.364.475,- | |
| Obstetri - Operasi plasenta akreta (Cito) | Rp. 12.364.475,- | |
| Odontektomi tingkat III (Cito) | Rp. 12.364.475,- | |
| Onkologi - Belloque tampon dengan narkosis (Cito) | Rp. 12.364.475,- | |
| Onkologi - Diseksi leher radikal * (Cito) | Rp. 12.364.475,- | |
| Onkologi - Eksplorasi nasofaring (Cito) | Rp. 12.364.475,- | |
| Onkologi - Ekstirpasi tumor jinak kel liur (Cito) | Rp. 12.364.475,- | |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Cito) | Rp. 12.364.475,- | |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Cito) | Rp. 12.364.475,- | |
| Onkologi - Hemiglosektomi (Cito) | Rp. 12.364.475,- | |
| Onkologi - Maksilektomi parsial (Cito) | Rp. 12.364.475,- | |
| Onkologi - Maksilektomi total (radikal) (Cito) | Rp. 12.364.475,- | |
| Onkologi - ORIF MBD (Cito) | Rp. 12.364.475,- | |
| Onkologi - Parotidektomi * (Cito) | Rp. 12.364.475,- | |
| Onkologi - Wide excision soft tisue sarcoma (Cito) | Rp. 12.364.475,- | |
| Other operations on intestines (Cito) | Rp. 12.364.475,- | |
| Other operations on the breast (reconstruction of the breast) (Cito) | Rp. 12.364.475,- | |
| Other partial thyroidectomy (Cito) | Rp. 12.364.475,- | |
| Parathyroidectomy subtotal (Cito) | Rp. 12.364.475,- | |
| Parathyroidectomy total (Cito) | Rp. 12.364.475,- | |
| partial mandibulectomy hemimandibulectomy (Cito) | Rp. 12.364.475,- | |
| Pediatrik - Posteromedial soft tissue release CTEV (Cito) | Rp. 12.364.475,- | |
| Pilar Implant (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Labioplasti Bilateral (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Labioplasti unilateral (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Reseksi septum (Cito) | Rp. 12.364.475,- | |
| Plastik Rekionstruksi - Septorinoplasty (Cito) | Rp. 12.364.475,- | |
| Redo torakotomi * (Cito) | Rp. 12.364.475,- | |
| Reduction Neglected Dislocation (Cito) | Rp. 12.364.475,- | |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Cito | Rp. 12.364.475,- | |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Rp. 12.364.475,- | |
| Repair laserasi diafragma * (Cito) | Rp. 12.364.475,- | |
| Reposisi dislokasi rahang (Cito) | Rp. 12.364.475,- | |
| Reseksi maksila suprastuktural (Cito) | Rp. 12.364.475,- | |
| Rinologi - Caldwell Luc (Cito) | Rp. 12.364.475,- | |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Cito) | Rp. 12.364.475,- | |
| Rinologi - Septum Reseksi / SMR (Cito) | Rp. 12.364.475,- | |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Cito) | Rp. 12.364.475,- | |
| Spine - Alar transverse fusion * (Cito) | Rp. 12.364.475,- | |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Cito) | Rp. 12.364.475,- | |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Cito) | Rp. 12.364.475,- | |
| Spine - Debridement and anterior fusion in TB Spine * (Cito) | Rp. 12.364.475,- | |
| Spine - Decompression laminectomy for HNP with stabilization * (Cito) | Rp. 12.364.475,- | |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Cito) | Rp. 12.364.475,- | |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Rp. 12.364.475,- | |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Cito) | Rp. 12.364.475,- | |
| Spine - Mayor desloughing and wound debridement of the spine * (Cito) | Rp. 12.364.475,- | |
| Spine - Micro endoscopic disectomy (1 level) * (Cito) | Rp. 12.364.475,- | |
| Spine - Microscopic disectomy (1 Level) (Cito) | Rp. 12.364.475,- | |
| Spine - Open disectomy multilevel * (Cito) | Rp. 12.364.475,- | |
| Spine - Open disestomy (1 Level) * (Cito) | Rp. 12.364.475,- | |
| Spine - Open reduction and stabilisation of spinal fracture * (Cito) | Rp. 12.364.475,- | |
| Spine - Posterior cervical fusion * (Cito) | Rp. 12.364.475,- | |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Rp. 12.364.475,- | |
| Spine - Posterolateral fusion * (Cito) | Rp. 12.364.475,- | |
| Spine - Total disc replacement (multilevel) * (Cito) | Rp. 12.364.475,- | |
| Split thickness graft to breast (Cito) | Rp. 12.364.475,- | |
| Terapi Slem Cell (Cito) | Rp. 12.364.475,- | |
| Thymectomy dengan VATS (Cito) | Rp. 12.364.475,- | |
| Tiroidektomi total dengan berry picking (Cito) | Rp. 12.364.475,- | |
| Tiroidektomi total dengan diseksi leher fungsional (Cito) | Rp. 12.364.475,- | |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Cito) | Rp. 12.364.475,- | |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Rp. 12.364.475,- | |
| Trauma - Limb leg inequality dengan bone lengthening transport (Cito) | Rp. 12.364.475,- | |
| Turbinoplasty (Cito) | Rp. 12.364.475,- | |
| Clipping costa (Cito) | Rp. 11.967.376,- | |
| Endoskopi - Esofagoskopi diagnostik (Cito) | Rp. 11.967.376,- | |
| Rinologi - Caldwell Luc (Cito) | Rp. 11.967.376,- | |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Cito) | Rp. 11.967.376,- | |
| Rinologi - Septum Reseksi / SMR (Cito) | Rp. 11.967.376,- | |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Cito) | Rp. 11.967.376,- | |
| Spine - Alar transverse fusion * (Cito) | Rp. 11.967.376,- | |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Cito) | Rp. 11.967.376,- | |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Cito) | Rp. 11.967.376,- | |
| Spine - Debridement and anterior fusion in TB Spine * (Cito) | Rp. 11.967.376,- | |
| Spine - Decompression laminectomy for HNP with stabilization * (Cito) | Rp. 11.967.376,- | |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Cito) | Rp. 11.967.376,- | |
| Excision of other bile duct (Cito) | Rp. 11.967.376,- | |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Rp. 11.967.376,- | |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Cito) | Rp. 11.967.376,- | |
| Spine - Mayor desloughing and wound debridement of the spine * (Cito) | Rp. 11.967.376,- | |
| Spine - Micro endoscopic disectomy (1 level) * (Cito) | Rp. 11.967.376,- | |
| Spine - Microscopic disectomy (1 Level) (Cito) | Rp. 11.967.376,- | |
| Spine - Open disectomy multilevel * (Cito) | Rp. 11.967.376,- | |
| Spine - Open disestomy (1 Level) * (Cito) | Rp. 11.967.376,- | |
| Spine - Open reduction and stabilisation of spinal fracture * (Cito) | Rp. 11.967.376,- | |
| Spine - Posterior cervical fusion * (Cito) | Rp. 11.967.376,- | |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Rp. 11.967.376,- | |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Cito) | Rp. 11.967.376,- | |
| Spine - Posterolateral fusion * (Cito) | Rp. 11.967.376,- | |
| Spine - Total disc replacement (multilevel) * (Cito) | Rp. 11.967.376,- | |
| Split thickness graft to breast (Cito) | Rp. 11.967.376,- | |
| Terapi Slem Cell (Cito) | Rp. 11.967.376,- | |
| Thymectomy dengan VATS (Cito) | Rp. 11.967.376,- | |
| Tiroidektomi total dengan berry picking (Cito) | Rp. 11.967.376,- | |
| Tiroidektomi total dengan diseksi leher fungsional (Cito) | Rp. 11.967.376,- | |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Cito) | Rp. 11.967.376,- | |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Rp. 11.967.376,- | |
| Trauma - Limb leg inequality dengan bone lengthening transport (Cito) | Rp. 11.967.376,- | |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Cito) | Rp. 11.967.376,- | |
| Turbinoplasty (Cito) | Rp. 11.967.376,- | |
| Ginekologi - Repair tuba (tubaplasti) (Cito) | Rp. 11.967.376,- | |
| Ginekologi - Reseksi adenomiosis (Cito) | Rp. 11.967.376,- | |
| Ginekologi - Transposisi Ovarium (Cito) | Rp. 11.967.376,- | |
| Hand - Artery, large, injury, repair with grafting (Cito) | Rp. 11.967.376,- | |
| Hand - Carpus, delayed (non union), rekonstruksi (Cito) | Rp. 11.967.376,- | |
| Hand - Jari (digit), stump, revision (Cito) | Rp. 11.967.376,- | |
| Complete thyroidectomy (Cito) | Rp. 11.967.376,- | |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Cito) | Rp. 11.967.376,- | |
| Hand - Jari, deformities, major reconstruction procedure (Cito) | Rp. 11.967.376,- | |
| Hand - Jari, deformities, osteotomy (Cito) | Rp. 11.967.376,- | |
| Hand - Jari, deformity, instrinsic muscle transfer (Cito) | Rp. 11.967.376,- | |
| Hand - Jari, scar, revision osteotomy (Cito) | Rp. 11.967.376,- | |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Rp. 11.967.376,- | |
| Hand - Nerve defect, peripheral graft (Cito) | Rp. 11.967.376,- | |
| Hand - Nerve digital, Injury, microsurgical (single) (Cito) | Rp. 11.967.376,- | |
| Hand - Nerve digital, injury, primary repair (Cito) | Rp. 11.967.376,- | |
| Hand - Nerve ulnar, entrapment, transposition (Cito) | Rp. 11.967.376,- | |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Cito) | Rp. 11.967.376,- | |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Cito) | Rp. 11.967.376,- | |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Rp. 11.967.376,- | |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Cito) | Rp. 11.967.376,- | |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Cito) | Rp. 11.967.376,- | |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Cito) | Rp. 11.967.376,- | |
| Hand - Thumb, paralysis, oppnens plasty (Cito) | Rp. 11.967.376,- | |
| Hip - Total hip replacement (Cito) | Rp. 11.967.376,- | |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Cito) | Rp. 11.967.376,- | |
| Intra-abdominal manipulation of large intestine (Cito) | Rp. 11.967.376,- | |
| Intra-abdominal manipulation of small intestine (Cito) | Rp. 11.967.376,- | |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Cito) | Rp. 11.967.376,- | |
| Knee - Total knee replacement (Cito) | Rp. 11.967.376,- | |
| Knee - Uni compartment arthroplasty (Cito) | Rp. 11.967.376,- | |
| Laparoscopic appendectomy (Cito) | Rp. 11.967.376,- | |
| Laparoscopic appendectomy (elective) (Cito) | Rp. 11.967.376,- | |
| Laparoscopic cholecystectomy (Cito) | Rp. 11.967.376,- | |
| Laparoscopic incidental appendectomy (Cito) | Rp. 11.967.376,- | |
| Laparoscopy (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Cito) | Rp. 11.967.376,- | |
| Eksisi pada bronkhus (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Kistektomi (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Ovareksi (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Salpingoooforektomi (Cito) | Rp. 11.967.376,- | |
| Laparskopi / Histereskopi - Transposisi Ovarium (Cito) | Rp. 11.967.376,- | |
| Laring dan Faring - TA/T dengan Coblation Laser (Cito) | Rp. 11.967.376,- | |
| Laring dan Faring - Tiroidektomi Subtotal ** (Cito) | Rp. 11.967.376,- | |
| Laring dan Faring - Tiroidektomi Total (Cito) | Rp. 11.967.376,- | |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Cito) | Rp. 11.967.376,- | |
| Left hemicolectomy (Cito) | Rp. 11.967.376,- | |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Cito) | Rp. 11.967.376,- | |
| Mediastinostomy (Cito) | Rp. 11.967.376,- | |
| Obstetri - Operasi plasenta akreta (Cito) | Rp. 11.967.376,- | |
| Odontektomi tingkat III (Cito) | Rp. 11.967.376,- | |
| Onkologi - Belloque tampon dengan narkosis (Cito) | Rp. 11.967.376,- | |
| Onkologi - Diseksi leher radikal * (Cito) | Rp. 11.967.376,- | |
| Onkologi - Eksplorasi nasofaring (Cito) | Rp. 11.967.376,- | |
| Onkologi - Ekstirpasi tumor jinak kel liur (Cito) | Rp. 11.967.376,- | |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Cito) | Rp. 11.967.376,- | |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Cito) | Rp. 11.967.376,- | |
| Onkologi - Hemiglosektomi (Cito) | Rp. 11.967.376,- | |
| Endoskopi - Bronkoskopi diagnostik (Cito) | Rp. 11.967.376,- | |
| Onkologi - Maksilektomi parsial (Cito) | Rp. 11.967.376,- | |
| Onkologi - Maksilektomi total (radikal) (Cito) | Rp. 11.967.376,- | |
| Onkologi - ORIF MBD (Cito) | Rp. 11.967.376,- | |
| Onkologi - Parotidektomi * (Cito) | Rp. 11.967.376,- | |
| Onkologi - Wide excision soft tisue sarcoma (Cito) | Rp. 11.967.376,- | |
| Other operations on intestines (Cito) | Rp. 11.967.376,- | |
| Other operations on the breast (reconstruction of the breast) (Cito) | Rp. 11.967.376,- | |
| Other partial thyroidectomy (Cito) | Rp. 11.967.376,- | |
| Parathyroidectomy subtotal (Cito) | Rp. 11.967.376,- | |
| Parathyroidectomy total (Cito) | Rp. 11.967.376,- | |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Cito) | Rp. 11.967.376,- | |
| partial mandibulectomy hemimandibulectomy (Cito) | Rp. 11.967.376,- | |
| Pediatrik - Posteromedial soft tissue release CTEV (Cito) | Rp. 11.967.376,- | |
| Pilar Implant (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Labioplasti Bilateral (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Labioplasti unilateral (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Cito) | Rp. 11.967.376,- | |
| Endoskopi - Esofagoskopi BA dengan penyulit (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Reseksi septum (Cito) | Rp. 11.967.376,- | |
| Plastik Rekionstruksi - Septorinoplasty (Cito) | Rp. 11.967.376,- | |
| Redo torakotomi * (Cito) | Rp. 11.967.376,- | |
| Reduction Neglected Dislocation (Cito) | Rp. 11.967.376,- | |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Cito | Rp. 11.967.376,- | |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Rp. 11.967.376,- | |
| Repair laserasi diafragma * (Cito) | Rp. 11.967.376,- | |
| Reposisi dislokasi rahang (Cito) | Rp. 11.967.376,- | |
| Reseksi maksila suprastuktural (Cito) | Rp. 11.967.376,- | |
| Bilateral radical mastectomy (Cito) | Rp. 19.009.699,- | |
| complete glossectomy (Cito) | Rp. 19.009.699,- | |
| Fiksasi interna fraktur panfacial (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Eksenterasi (Anterior Posterior) (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Histerektomi radikal (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Operasi Frozen Pelvic (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Relaparatomi high risk complication (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Staging Laparatomi (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Trachelectomy Radical Servix (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Ultra Radikal Histerektomi (Cito) | Rp. 19.009.699,- | |
| Ginekologi - Vulvektomi radikal (Cito) | Rp. 19.009.699,- | |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Cito) | Rp. 19.009.699,- | |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Cito) | Rp. 19.009.699,- | |
| Hand - Replantasi (Cito) | Rp. 19.009.699,- | |
| Hip - Revisi THR (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Histerektomi (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Histeroskopi operatif (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Miomektomi (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Onkologi (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Cito) | Rp. 19.009.699,- | |
| Laparskopi / Histereskopi - Reseksi endometriosis (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Eksplorasi Asbes Multiple (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Laringoskopi Diagnostik (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - TA/T (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Trakeostomi ** (Cito) | Rp. 19.009.699,- | |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Cito) | Rp. 19.009.699,- | |
| Modifikasi RND / functional neck dissection (Cito) | Rp. 19.009.699,- | |
| Onkologi - Ekstirpasi angiofibroma (Cito) | Rp. 19.009.699,- | |
| Onkologi - Forequarter amputation (Cito) | Rp. 19.009.699,- | |
| Onkologi - Hemipelvectomy (Cito) | Rp. 19.009.699,- | |
| Onkologi - Hemoglosektomi dan diseksi leher (Cito) | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Cito) | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Cito) | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery dengan tumor resection only (Cito) | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery tahap 1 (Cito) | Rp. 19.009.699,- | |
| Onkologi - Limb salvage surgery tahap 2 (Cito) | Rp. 19.009.699,- | |
| Onkologi - Marginal margine excision soft tissue tumor (Cito) | Rp. 19.009.699,- | |
| Onkologi - Tiroidektomi subtotal ** (Cito) | Rp. 19.009.699,- | |
| Onkologi - Tiroidektomi total (Cito) | Rp. 19.009.699,- | |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Cito) | Rp. 19.009.699,- | |
| Operasi Commando (Cito) | Rp. 19.009.699,- | |
| Other operations on pancreas (Cito) | Rp. 19.009.699,- | |
| Other pancreatotomy (Cito) | Rp. 19.009.699,- | |
| Otologi - Implantasi koklea (Cito) | Rp. 19.009.699,- | |
| Otologi - Mastoidektomi radikal dengan penyulit (Cito) | Rp. 19.009.699,- | |
| Otologi - Temporal bone ressection (Cito) | Rp. 19.009.699,- | |
| Otologi - Timpanoplasti (Cito) | Rp. 19.009.699,- | |
| Parotidektomi total (Cito) | Rp. 19.009.699,- | |
| Partial gastrectomy (Cito) | Rp. 19.009.699,- | |
| Partial hepatectomy (Cito) | Rp. 19.009.699,- | |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (C | Rp. 19.009.699,- | |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Cito | Rp. 19.009.699,- | |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Rp. 19.009.699,- | |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Rp. 19.009.699,- | |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Cito) | Rp. 19.009.699,- | |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Rp. 19.009.699,- | |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Cito) | Rp. 19.009.699,- | |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Cito) | Rp. 19.009.699,- | |
| Plastik Rekionstruksi - Palatoplasty * (Cito) | Rp. 19.009.699,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Cito) | Rp. 19.009.699,- | |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Cito) | Rp. 19.009.699,- | |
| Plastik Rekionstruksi - Skingrafting tidak luas (Cito) | Rp. 19.009.699,- | |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Cito) | Rp. 19.009.699,- | |
| Rekonstruksi fraktur blow-out (Cito) | Rp. 19.009.699,- | |
| Rekonstruksi menggunakan flap bebas (Cito) | Rp. 19.009.699,- | |
| Rekonstruksi sternum dan dinding dada (Cito) | Rp. 19.009.699,- | |
| Repair aneurisma aorta abdominalis * (Cito) | Rp. 19.009.699,- | |
| Repair of gastroschisis (Cito) | Rp. 19.009.699,- | |
| Repair of other bile ducts (Cito) | Rp. 19.009.699,- | |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Cito | Rp. 19.009.699,- | |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Rp. 19.009.699,- | |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Rp. 19.009.699,- | |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Rp. 19.009.699,- | |
| Spine - Scoliosis < 70 derajat corrective surgery * (Cito) | Rp. 19.009.699,- | |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Cito) | Rp. 19.009.699,- | |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Rp. 19.009.699,- | |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Cito) | Rp. 19.009.699,- | |
| Total gastrectomy (Cito) | Rp. 19.009.699,- | |
| Trauma - Neglected case dengan bone reconstruction (Cito) | Rp. 19.009.699,- | |
| Vascular shunting (splenorenal shunt, de palma shunt) (Cito) | Rp. 19.009.699,- | |
| Whipple procedure (Cito) | Rp. 19.009.699,- | |
| Arteriovenous shunt (AV Shunt) brakiosefalika (Cito) | Rp. 19.009.699,- | |
| Arteriovenous shunt (AV Shunt) radiosefalika (Cito) | Rp. 19.009.699,- | |
| AV - Shunt dengan lokal anesthesi (Cito) | Rp. 19.009.699,- | |
| Pasang double lumen hemodialysis (HD) (Cito) | Rp. 19.009.699,- | |
| Pemasangan Central Venous Catheter (CVC) (Cito) | Rp. 19.009.699,- | |
| Revisi arteriovenous shunt * (Cito) | Rp. 19.009.699,- | |
| Skleroterapi vena (varises, hemangioma) * (Cito) | Rp. 19.009.699,- | |
| Bilateral radical mastectomy (Cito) | Rp. 17.849.400,- | |
| complete glossectomy (Cito) | Rp. 17.849.400,- | |
| Fiksasi interna fraktur panfacial (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Eksenterasi (Anterior Posterior) (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Histerektomi radikal (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Operasi Frozen Pelvic (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Relaparatomi high risk complication (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Staging Laparatomi (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Trachelectomy Radical Servix (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Ultra Radikal Histerektomi (Cito) | Rp. 17.849.400,- | |
| Ginekologi - Vulvektomi radikal (Cito) | Rp. 17.849.400,- | |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Cito) | Rp. 17.849.400,- | |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Cito) | Rp. 17.849.400,- | |
| Hand - Replantasi (Cito) | Rp. 17.849.400,- | |
| Hip - Revisi THR (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Histerektomi (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Histeroskopi operatif (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Miomektomi (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Onkologi (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Cito) | Rp. 17.849.400,- | |
| Laparskopi / Histereskopi - Reseksi endometriosis (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Eksplorasi Asbes Multiple (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Laringoskopi Diagnostik (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - TA/T (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Trakeostomi ** (Cito) | Rp. 17.849.400,- | |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Cito) | Rp. 17.849.400,- | |
| Modifikasi RND / functional neck dissection (Cito) | Rp. 17.849.400,- | |
| Onkologi - Ekstirpasi angiofibroma (Cito) | Rp. 17.849.400,- | |
| Onkologi - Forequarter amputation (Cito) | Rp. 17.849.400,- | |
| Onkologi - Hemipelvectomy (Cito) | Rp. 17.849.400,- | |
| Onkologi - Hemoglosektomi dan diseksi leher (Cito) | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Cito) | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Cito) | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery dengan tumor resection only (Cito) | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery tahap 1 (Cito) | Rp. 17.849.400,- | |
| Onkologi - Limb salvage surgery tahap 2 (Cito) | Rp. 17.849.400,- | |
| Onkologi - Marginal margine excision soft tissue tumor (Cito) | Rp. 17.849.400,- | |
| Onkologi - Tiroidektomi subtotal ** (Cito) | Rp. 17.849.400,- | |
| Onkologi - Tiroidektomi total (Cito) | Rp. 17.849.400,- | |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Cito) | Rp. 17.849.400,- | |
| Operasi Commando (Cito) | Rp. 17.849.400,- | |
| Other operations on pancreas (Cito) | Rp. 17.849.400,- | |
| Other pancreatotomy (Cito) | Rp. 17.849.400,- | |
| Otologi - Implantasi koklea (Cito) | Rp. 17.849.400,- | |
| Otologi - Mastoidektomi radikal dengan penyulit (Cito) | Rp. 17.849.400,- | |
| Otologi - Temporal bone ressection (Cito) | Rp. 17.849.400,- | |
| Otologi - Timpanoplasti (Cito) | Rp. 17.849.400,- | |
| Parotidektomi total (Cito) | Rp. 17.849.400,- | |
| Partial gastrectomy (Cito) | Rp. 17.849.400,- | |
| Partial hepatectomy (Cito) | Rp. 17.849.400,- | |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (C | Rp. 17.849.400,- | |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Cito | Rp. 17.849.400,- | |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Rp. 17.849.400,- | |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Rp. 17.849.400,- | |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Cito) | Rp. 17.849.400,- | |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Rp. 17.849.400,- | |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Cito) | Rp. 17.849.400,- | |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Cito) | Rp. 17.849.400,- | |
| Plastik Rekionstruksi - Palatoplasty * (Cito) | Rp. 17.849.400,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Cito) | Rp. 17.849.400,- | |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Cito) | Rp. 17.849.400,- | |
| Plastik Rekionstruksi - Skingrafting tidak luas (Cito) | Rp. 17.849.400,- | |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Cito) | Rp. 17.849.400,- | |
| Rekonstruksi fraktur blow-out (Cito) | Rp. 17.849.400,- | |
| Rekonstruksi menggunakan flap bebas (Cito) | Rp. 17.849.400,- | |
| Rekonstruksi sternum dan dinding dada (Cito) | Rp. 17.849.400,- | |
| Repair aneurisma aorta abdominalis * (Cito) | Rp. 17.849.400,- | |
| Repair of gastroschisis (Cito) | Rp. 17.849.400,- | |
| Repair of other bile ducts (Cito) | Rp. 17.849.400,- | |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Cito | Rp. 17.849.400,- | |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Rp. 17.849.400,- | |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Rp. 17.849.400,- | |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Rp. 17.849.400,- | |
| Spine - Scoliosis < 70 derajat corrective surgery * (Cito) | Rp. 17.849.400,- | |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Cito) | Rp. 17.849.400,- | |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Rp. 17.849.400,- | |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Cito) | Rp. 17.849.400,- | |
| Total gastrectomy (Cito) | Rp. 17.849.400,- | |
| Trauma - Neglected case dengan bone reconstruction (Cito) | Rp. 17.849.400,- | |
| Vascular shunting (splenorenal shunt, de palma shunt) (Cito) | Rp. 17.849.400,- | |
| Whipple procedure (Cito) | Rp. 17.849.400,- | |
| Arteriovenous shunt (AV Shunt) brakiosefalika (Cito) | Rp. 17.849.400,- | |
| Arteriovenous shunt (AV Shunt) radiosefalika (Cito) | Rp. 17.849.400,- | |
| AV - Shunt dengan lokal anesthesi (Cito) | Rp. 17.849.400,- | |
| Pasang double lumen hemodialysis (HD) (Cito) | Rp. 17.849.400,- | |
| Pemasangan Central Venous Catheter (CVC) (Cito) | Rp. 17.849.400,- | |
| Revisi arteriovenous shunt * (Cito) | Rp. 17.849.400,- | |
| Skleroterapi vena (varises, hemangioma) * (Cito) | Rp. 17.849.400,- | |
| Bilateral radical mastectomy (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Trachelectomy Radical Servix (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Ultra Radikal Histerektomi (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Vulvektomi radikal (Cito) | Rp. 17.395.600,- | |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Cito) | Rp. 17.395.600,- | |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Cito) | Rp. 17.395.600,- | |
| Hand - Replantasi (Cito) | Rp. 17.395.600,- | |
| Hip - Revisi THR (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Histerektomi (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Histeroskopi operatif (Cito) | Rp. 17.395.600,- | |
| complete glossectomy (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Miomektomi (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Onkologi (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Cito) | Rp. 17.395.600,- | |
| Laparskopi / Histereskopi - Reseksi endometriosis (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Eksplorasi Asbes Multiple (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Cito) | Rp. 17.395.600,- | |
| Fiksasi interna fraktur panfacial (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Laringoskopi Diagnostik (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - TA/T (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Trakeostomi ** (Cito) | Rp. 17.395.600,- | |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Cito) | Rp. 17.395.600,- | |
| Modifikasi RND / functional neck dissection (Cito) | Rp. 17.395.600,- | |
| Onkologi - Ekstirpasi angiofibroma (Cito) | Rp. 17.395.600,- | |
| Onkologi - Forequarter amputation (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Cito) | Rp. 17.395.600,- | |
| Onkologi - Hemipelvectomy (Cito) | Rp. 17.395.600,- | |
| Onkologi - Hemoglosektomi dan diseksi leher (Cito) | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Cito) | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Cito) | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery dengan tumor resection only (Cito) | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery tahap 1 (Cito) | Rp. 17.395.600,- | |
| Onkologi - Limb salvage surgery tahap 2 (Cito) | Rp. 17.395.600,- | |
| Onkologi - Marginal margine excision soft tissue tumor (Cito) | Rp. 17.395.600,- | |
| Onkologi - Tiroidektomi subtotal ** (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Eksenterasi (Anterior Posterior) (Cito) | Rp. 17.395.600,- | |
| Onkologi - Tiroidektomi total (Cito) | Rp. 17.395.600,- | |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Cito) | Rp. 17.395.600,- | |
| Operasi Commando (Cito) | Rp. 17.395.600,- | |
| Other operations on pancreas (Cito) | Rp. 17.395.600,- | |
| Other pancreatotomy (Cito) | Rp. 17.395.600,- | |
| Otologi - Implantasi koklea (Cito) | Rp. 17.395.600,- | |
| Otologi - Mastoidektomi radikal dengan penyulit (Cito) | Rp. 17.395.600,- | |
| Otologi - Temporal bone ressection (Cito) | Rp. 17.395.600,- | |
| Otologi - Timpanoplasti (Cito) | Rp. 17.395.600,- | |
| Parotidektomi total (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Histerektomi radikal (Cito) | Rp. 17.395.600,- | |
| Partial gastrectomy (Cito) | Rp. 17.395.600,- | |
| Partial hepatectomy (Cito) | Rp. 17.395.600,- | |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (C | Rp. 17.395.600,- | |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Cito | Rp. 17.395.600,- | |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Rp. 17.395.600,- | |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Rp. 17.395.600,- | |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Cito) | Rp. 17.395.600,- | |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Rp. 17.395.600,- | |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Cito) | Rp. 17.395.600,- | |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Operasi Frozen Pelvic (Cito) | Rp. 17.395.600,- | |
| Plastik Rekionstruksi - Palatoplasty * (Cito) | Rp. 17.395.600,- | |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Cito) | Rp. 17.395.600,- | |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Cito) | Rp. 17.395.600,- | |
| Plastik Rekionstruksi - Skingrafting tidak luas (Cito) | Rp. 17.395.600,- | |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Cito) | Rp. 17.395.600,- | |
| Rekonstruksi fraktur blow-out (Cito) | Rp. 17.395.600,- | |
| Rekonstruksi menggunakan flap bebas (Cito) | Rp. 17.395.600,- | |
| Rekonstruksi sternum dan dinding dada (Cito) | Rp. 17.395.600,- | |
| Repair aneurisma aorta abdominalis * (Cito) | Rp. 17.395.600,- | |
| Repair of gastroschisis (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Relaparatomi high risk complication (Cito) | Rp. 17.395.600,- | |
| Repair of other bile ducts (Cito) | Rp. 17.395.600,- | |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Cito | Rp. 17.395.600,- | |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Rp. 17.395.600,- | |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Rp. 17.395.600,- | |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Rp. 17.395.600,- | |
| Spine - Scoliosis < 70 derajat corrective surgery * (Cito) | Rp. 17.395.600,- | |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Cito) | Rp. 17.395.600,- | |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Rp. 17.395.600,- | |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Cito) | Rp. 17.395.600,- | |
| Total gastrectomy (Cito) | Rp. 17.395.600,- | |
| Ginekologi - Staging Laparatomi (Cito) | Rp. 17.395.600,- | |
| Trauma - Neglected case dengan bone reconstruction (Cito) | Rp. 17.395.600,- | |
| Vascular shunting (splenorenal shunt, de palma shunt) (Cito) | Rp. 17.395.600,- | |
| Whipple procedure (Cito) | Rp. 17.395.600,- | |
| Arteriovenous shunt (AV Shunt) brakiosefalika (Cito) | Rp. 17.395.600,- | |
| Arteriovenous shunt (AV Shunt) radiosefalika (Cito) | Rp. 17.395.600,- | |
| AV - Shunt dengan lokal anesthesi (Cito) | Rp. 17.395.600,- | |
| Pasang double lumen hemodialysis (HD) (Cito) | Rp. 17.395.600,- | |
| Pemasangan Central Venous Catheter (CVC) (Cito) | Rp. 17.395.600,- | |
| Revisi arteriovenous shunt * (Cito) | Rp. 17.395.600,- | |
| Skleroterapi vena (varises, hemangioma) * (Cito) | Rp. 17.395.600,- | |
| Ekstraksi epithelial downgrowth ( Cito ) | Rp. 5.520.725,- | |
| Evakuasi hematom (pasca pungsi) ( Cito ) | Rp. 5.520.725,- | |
| Excision of perianal skin tags ( Cito ) | Rp. 5.520.725,- | |
| GIN - Insisi Septum Vagina ( Cito ) | Rp. 5.520.725,- | |
| GIN - kromotubasi ( Cito ) | Rp. 5.520.725,- | |
| GIN- Himenectomy ( Cito ) | Rp. 5.520.725,- | |
| GIN- Insisi Drainage ( Cito ) | Rp. 5.520.725,- | |
| GIN- Marsupialisasi ( Cito ) | Rp. 5.520.725,- | |
| Ginekologi - Tubektomi ( Cito ) | Rp. 5.520.725,- | |
| GIN-Kuretase-biopsi PA ( Cito ) | Rp. 5.520.725,- | |
| Glaukoma - Cyclo cryo ( Cito ) | Rp. 5.520.725,- | |
| Hand - Angkat K-Wire with anestesia regional ( Cito ) | Rp. 5.520.725,- | |
| Hand - Jari, extra digit, amputasi ( Cito ) | Rp. 5.520.725,- | |
| Hand - Jari, various, amputation (single) ** ( Cito ) | Rp. 5.520.725,- | |
| Injeksi botox pada strabismus ( Cito ) | Rp. 5.520.725,- | |
| Ligasi Varices Esofgaus (VE) ( Cito ) | Rp. 5.520.725,- | |
| Local excision of lesion of breast ( Cito ) | Rp. 5.520.725,- | |
| Local excision of rectal lesion or tissue ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Drainase abses ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Ekstirpasi ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Ekstraksi IUD dengan anestesi ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Hematoma (ruptur) ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Kauterisasi kondiloma akuminata ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Kista bartholin (kista gartner) ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Kolpotomi pada abses cavum douglas ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Konisasi ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Kuretase abortus ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Kuretase pasca persalinan ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Penjahitan laserasi ringan ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Polip serviks ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Robekan serviks (forniks) ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Shirodkar ( Cito ) | Rp. 5.520.725,- | |
| Obstetri - Sistoskopi LEETZ ( Cito ) | Rp. 5.520.725,- | |
| Onkologi - Insisional biopsi kelenjar leher ( Cito ) | Rp. 5.520.725,- | |
| Open biopsy of rectum ( Cito ) | Rp. 5.520.725,- | |
| Operkulektomi ( Cito ) | Rp. 5.520.725,- | |
| Other diagnostic procedures of abdominal region ( Cito ) | Rp. 5.520.725,- | |
| Other excision of perianal tissue ( Cito ) | Rp. 5.520.725,- | |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Rp. 5.520.725,- | |
| Otologi - Biopsi ( Cito ) | Rp. 5.520.725,- | |
| Otologi - Ekstraksi benda asing ( Cito ) | Rp. 5.520.725,- | |
| Pasang implantable central venous access * ( Cito ) | Rp. 5.520.725,- | |
| Pasang thoraks drain (WSD) * ( Cito ) | Rp. 5.520.725,- | |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih ( Cito ) | Rp. 5.520.725,- | |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat ( Cito ) | Rp. 5.520.725,- | |
| Pemasangan interdental wiring / arch bar ( Cito ) | Rp. 5.520.725,- | |
| Pericardiocentesis * ( Cito ) | Rp. 5.520.725,- | |
| Pleurodesis (pleurosklerosis) * ( Cito ) | Rp. 5.520.725,- | |
| Rekonstruksi - Eksisi tumor kecil kelopak ( Cito ) | Rp. 5.520.725,- | |
| Rekonstruksi - Oklusi punctum lakrimal ( Cito ) | Rp. 5.520.725,- | |
| Release tongue tie * ( Cito ) | Rp. 5.520.725,- | |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * ( Cito ) | Rp. 5.520.725,- | |
| Reposisi tertutup fraktur condilus mandibula ( Cito ) | Rp. 5.520.725,- | |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) ( Cito ) | Rp. 5.520.725,- | |
| Rinologi - Irigasi Sinus / DAWO ( Cito ) | Rp. 5.520.725,- | |
| Scleroterapi dan atau ligasi hemangioma ( Cito ) | Rp. 5.520.725,- | |
| Suture of laceration of anus ( Cito ) | Rp. 5.520.725,- | |
| Thoracocentesis * ( Cito ) | Rp. 5.520.725,- | |
| Trauma - Acute glenohumeral joint dislocation * ( Cito ) | Rp. 5.520.725,- | |
| Tumor jinak kulit dan tumor non neoplastik kulit * ( Cito ) | Rp. 5.520.725,- | |
| Vena punctie - kanulasi - sectie * ( Cito ) | Rp. 5.520.725,- | |
| Glaukoma - Cyclo cryo ( Cito ) | Rp. 4.940.626,- | |
| Hand - Angkat K-Wire with anestesia regional ( Cito ) | Rp. 4.940.626,- | |
| Hand - Jari, extra digit, amputasi ( Cito ) | Rp. 4.940.626,- | |
| Hand - Jari, various, amputation (single) ** ( Cito ) | Rp. 4.940.626,- | |
| Injeksi botox pada strabismus ( Cito ) | Rp. 4.940.626,- | |
| Ligasi Varices Esofgaus (VE) ( Cito ) | Rp. 4.940.626,- | |
| Local excision of lesion of breast ( Cito ) | Rp. 4.940.626,- | |
| Local excision of rectal lesion or tissue ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Drainase abses ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Ekstirpasi ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Ekstraksi IUD dengan anestesi ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Hematoma (ruptur) ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Kauterisasi kondiloma akuminata ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Kista bartholin (kista gartner) ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Kolpotomi pada abses cavum douglas ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Konisasi ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Kuretase abortus ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Kuretase pasca persalinan ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Penjahitan laserasi ringan ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Polip serviks ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Robekan serviks (forniks) ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Shirodkar ( Cito ) | Rp. 4.940.626,- | |
| Obstetri - Sistoskopi LEETZ ( Cito ) | Rp. 4.940.626,- | |
| Onkologi - Insisional biopsi kelenjar leher ( Cito ) | Rp. 4.940.626,- | |
| Open biopsy of rectum ( Cito ) | Rp. 4.940.626,- | |
| Operkulektomi ( Cito ) | Rp. 4.940.626,- | |
| Other diagnostic procedures of abdominal region ( Cito ) | Rp. 4.940.626,- | |
| Other excision of perianal tissue ( Cito ) | Rp. 4.940.626,- | |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Rp. 4.940.626,- | |
| Otologi - Biopsi ( Cito ) | Rp. 4.940.626,- | |
| Otologi - Ekstraksi benda asing ( Cito ) | Rp. 4.940.626,- | |
| Pasang implantable central venous access * ( Cito ) | Rp. 4.940.626,- | |
| Pasang thoraks drain (WSD) * ( Cito ) | Rp. 4.940.626,- | |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih ( Cito ) | Rp. 4.940.626,- | |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat ( Cito ) | Rp. 4.940.626,- | |
| Pemasangan interdental wiring / arch bar ( Cito ) | Rp. 4.940.626,- | |
| Pericardiocentesis * ( Cito ) | Rp. 4.940.626,- | |
| Pleurodesis (pleurosklerosis) * ( Cito ) | Rp. 4.940.626,- | |
| Rekonstruksi - Eksisi tumor kecil kelopak ( Cito ) | Rp. 4.940.626,- | |
| Rekonstruksi - Oklusi punctum lakrimal ( Cito ) | Rp. 4.940.626,- | |
| Release tongue tie * ( Cito ) | Rp. 4.940.626,- | |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * ( Cito ) | Rp. 4.940.626,- | |
| Reposisi tertutup fraktur condilus mandibula ( Cito ) | Rp. 4.940.626,- | |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) ( Cito ) | Rp. 4.940.626,- | |
| Rinologi - Irigasi Sinus / DAWO ( Cito ) | Rp. 4.940.626,- | |
| Scleroterapi dan atau ligasi hemangioma ( Cito ) | Rp. 4.940.626,- | |
| Suture of laceration of anus ( Cito ) | Rp. 4.940.626,- | |
| Thoracocentesis * ( Cito ) | Rp. 4.940.626,- | |
| Trauma - Acute glenohumeral joint dislocation * ( Cito ) | Rp. 4.940.626,- | |
| Tumor jinak kulit dan tumor non neoplastik kulit * ( Cito ) | Rp. 4.940.626,- | |
| Vena punctie - kanulasi - sectie * ( Cito ) | Rp. 4.940.626,- | |
| Ekstraksi epithelial downgrowth ( Cito ) | Rp. 4.940.626,- | |
| Evakuasi hematom (pasca pungsi) ( Cito ) | Rp. 4.940.626,- | |
| Excision of perianal skin tags ( Cito ) | Rp. 4.940.626,- | |
| GIN - Insisi Septum Vagina ( Cito ) | Rp. 4.940.626,- | |
| GIN - kromotubasi ( Cito ) | Rp. 4.940.626,- | |
| GIN- Himenectomy ( Cito ) | Rp. 4.940.626,- | |
| GIN- Insisi Drainage ( Cito ) | Rp. 4.940.626,- | |
| GIN- Marsupialisasi ( Cito ) | Rp. 4.940.626,- | |
| Ginekologi - Tubektomi ( Cito ) | Rp. 4.940.626,- | |
| GIN-Kuretase-biopsi PA ( Cito ) | Rp. 4.940.626,- | |
| Ekstraksi epithelial downgrowth ( Cito ) | Rp. 4.713.725,- | |
| Evakuasi hematom (pasca pungsi) ( Cito ) | Rp. 4.713.725,- | |
| Excision of perianal skin tags ( Cito ) | Rp. 4.713.725,- | |
| GIN - Insisi Septum Vagina ( Cito ) | Rp. 4.713.725,- | |
| GIN - kromotubasi ( Cito ) | Rp. 4.713.725,- | |
| GIN- Himenectomy ( Cito ) | Rp. 4.713.725,- | |
| GIN- Insisi Drainage ( Cito ) | Rp. 4.713.725,- | |
| GIN- Marsupialisasi ( Cito ) | Rp. 4.713.725,- | |
| Ginekologi - Tubektomi ( Cito ) | Rp. 4.713.725,- | |
| GIN-Kuretase-biopsi PA ( Cito ) | Rp. 4.713.725,- | |
| Glaukoma - Cyclo cryo ( Cito ) | Rp. 4.713.725,- | |
| Hand - Angkat K-Wire with anestesia regional ( Cito ) | Rp. 4.713.725,- | |
| Hand - Jari, extra digit, amputasi ( Cito ) | Rp. 4.713.725,- | |
| Hand - Jari, various, amputation (single) ** ( Cito ) | Rp. 4.713.725,- | |
| Injeksi botox pada strabismus ( Cito ) | Rp. 4.713.725,- | |
| Ligasi Varices Esofgaus (VE) ( Cito ) | Rp. 4.713.725,- | |
| Local excision of lesion of breast ( Cito ) | Rp. 4.713.725,- | |
| Local excision of rectal lesion or tissue ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Drainase abses ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Ekstirpasi ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Ekstraksi IUD dengan anestesi ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Hematoma (ruptur) ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Kauterisasi kondiloma akuminata ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Kista bartholin (kista gartner) ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Kolpotomi pada abses cavum douglas ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Konisasi ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Kuretase abortus ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Kuretase pasca persalinan ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Penjahitan laserasi ringan ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Polip serviks ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Robekan serviks (forniks) ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Shirodkar ( Cito ) | Rp. 4.713.725,- | |
| Obstetri - Sistoskopi LEETZ ( Cito ) | Rp. 4.713.725,- | |
| Onkologi - Insisional biopsi kelenjar leher ( Cito ) | Rp. 4.713.725,- | |
| Open biopsy of rectum ( Cito ) | Rp. 4.713.725,- | |
| Operkulektomi ( Cito ) | Rp. 4.713.725,- | |
| Other diagnostic procedures of abdominal region ( Cito ) | Rp. 4.713.725,- | |
| Other excision of perianal tissue ( Cito ) | Rp. 4.713.725,- | |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Rp. 4.713.725,- | |
| Otologi - Biopsi ( Cito ) | Rp. 4.713.725,- | |
| Otologi - Ekstraksi benda asing ( Cito ) | Rp. 4.713.725,- | |
| Pasang implantable central venous access * ( Cito ) | Rp. 4.713.725,- | |
| Pasang thoraks drain (WSD) * ( Cito ) | Rp. 4.713.725,- | |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih ( Cito ) | Rp. 4.713.725,- | |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat ( Cito ) | Rp. 4.713.725,- | |
| Pemasangan interdental wiring / arch bar ( Cito ) | Rp. 4.713.725,- | |
| Pericardiocentesis * ( Cito ) | Rp. 4.713.725,- | |
| Pleurodesis (pleurosklerosis) * ( Cito ) | Rp. 4.713.725,- | |
| Rekonstruksi - Eksisi tumor kecil kelopak ( Cito ) | Rp. 4.713.725,- | |
| Rekonstruksi - Oklusi punctum lakrimal ( Cito ) | Rp. 4.713.725,- | |
| Release tongue tie * ( Cito ) | Rp. 4.713.725,- | |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * ( Cito ) | Rp. 4.713.725,- | |
| Reposisi tertutup fraktur condilus mandibula ( Cito ) | Rp. 4.713.725,- | |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) ( Cito ) | Rp. 4.713.725,- | |
| Rinologi - Irigasi Sinus / DAWO ( Cito ) | Rp. 4.713.725,- | |
| Scleroterapi dan atau ligasi hemangioma ( Cito ) | Rp. 4.713.725,- | |
| Suture of laceration of anus ( Cito ) | Rp. 4.713.725,- | |
| Thoracocentesis * ( Cito ) | Rp. 4.713.725,- | |
| Trauma - Acute glenohumeral joint dislocation * ( Cito ) | Rp. 4.713.725,- | |
| Tumor jinak kulit dan tumor non neoplastik kulit * ( Cito ) | Rp. 4.713.725,- | |
| Vena punctie - kanulasi - sectie * ( Cito ) | Rp. 4.713.725,- | |
| Biopsy of perianal tissue (Elektif) | Rp. 2.022.500,- | |
| Biopsy of perianal tissue (Elektif) | Rp. 1.761.500,- | |
| Biopsy of perianal tissue (Elektif) | Rp. 1.659.400,- | |
| Paket Operasi ( Phaco ) | - | Rp. 7.964.175,- |
| Paket Operasi ( Phaco ) | - | Rp. 6.964.175,- |
| Asuhan pra-anestesi | - | Rp. 45.000,- |
| Asuhan intra-anestesi | - | Rp. 90.000,- |
| Asuhan pasca-anestesi | - | Rp. 45.000,- |
| Asuhan Keperawatan Kamar Operasi | - | Rp. 45.000,- |
| Persalinan Normal | - | Rp. 2.091.100,- |
| Persalinan Dengan Penyulit | - | Rp. 3.326.300,- |
| Hecting Perineum | - | Rp. 1.182.500,- |
| Manual Plasenta | - | Rp. 313.800,- |
| Induksi Persalinan | - | Rp. 522.800,- |
| Embolektomi / trombektomi pembuluh darah arteri abdominal (Cito) | - | Rp. 6.998.700,- |
| RF Dasar Lidah (Cito) | - | Rp. 1.932.425,- |
| Rinologi - Septoplasti (Cito) | - | Rp. 1.932.425,- |
| Sirkumsisi (Cito) | - | Rp. 1.932.425,- |
| Biopsy of anus (Cito) | - | Rp. 1.932.425,- |
| Eksisi tumor jinak dengan anastesi lokal (Cito) | - | Rp. 1.932.425,- |
| Ekstraksi fragmen fraktur gigi dengan flap (Cito) | - | Rp. 1.932.425,- |
| Insisi abses dengan anastesi lokal (Cito) | - | Rp. 1.932.425,- |
| Other incision of skin and subcutaneous tissue (Cito) | - | Rp. 1.932.425,- |
| Pungsi hematom / seroma (Cito) | - | Rp. 1.932.425,- |
| Reposisi dislokasi TMJ tanpa pembiusan (Cito) | - | Rp. 1.932.425,- |
| Embolektomi / trombektomi aorta (Cito) | - | Rp. 9.062.525,- |
| Embolektomi / trombektomi pembuluh darah arteri ekstremitas bawah * (Cito) | - | Rp. 9.062.525,- |
| Embolektomi / trombektomi pembuluh darah ekstremitas atas (Cito) | - | Rp. 9.062.525,- |
| Embolektomi / trombektomi pembuluh darah ekstremitas bawah * (Cito) | - | Rp. 9.062.525,- |
| Alveolektomi (Cito) | - | Rp. 4.713.725,- |
| Ekstirpasi / eksisi tumor jinak jaringan lunak ukuran < 2 cm (Cito) | - | Rp. 4.713.725,- |
| Ekstirpasi kista dermoid * (Cito) | - | Rp. 4.713.725,- |
| Ekstraksi corpus alienum cornea (Cito) | - | Rp. 4.713.725,- |
| Embolektomi (Cito) | - | Rp. 4.713.725,- |
| Angkat jahitan Kornea ( Cito ) | - | Rp. 4.713.724,- |
| Arterial pungsi - kanulasi - sectie (Cito) | - | Rp. 4.713.725,- |
| Aspirasi / Irigasi / Reformasi COA (Cito) | - | Rp. 4.713.725,- |
| Closed reduction of temporomandibular dislocation (Cito) | - | Rp. 4.713.725,- |
| Control of hemorrhage of anus (Cito) | - | Rp. 4.713.725,- |
| Ekskokleasi epulis (Cito) | - | Rp. 4.713.725,- |
| Embolektomi / trombektomi pembuluh darah arteri abdominal (Elektif) | - | Rp. 5.914.100,- |
| Biopsy insisional dengan anastesi lokal (Elektif) | - | Rp. 1.659.400,- |
| Biopsy of anus (Elektif) | - | Rp. 1.659.400,- |
| Eksisi tumor jinak dengan anastesi lokal (Elektif) | - | Rp. 1.659.400,- |
| Ekstraksi fragmen fraktur gigi dengan flap (Elektif) | - | Rp. 1.659.400,- |
| Insisi abses dengan anastesi lokal (Elektif) | - | Rp. 1.659.400,- |
| Other incision of skin and subcutaneous tissue (Elektif) | - | Rp. 1.659.400,- |
| Pungsi hematom / seroma (Elektif) | - | Rp. 1.659.400,- |
| Reposisi dislokasi TMJ tanpa pembiusan (Elektif) | - | Rp. 1.659.400,- |
| RF Dasar Lidah (Elektif) | - | Rp. 1.659.400,- |
| Rinologi - Septoplasti (Elektif) | - | Rp. 1.659.400,- |
| Sirkumsisi (Elektif) | - | Rp. 1.659.400,- |
| Embolektomi / trombektomi aorta (Elektif) | - | Rp. 7.628.199,- |
| Embolektomi / trombektomi pembuluh darah arteri ekstremitas bawah * (Elektif) | - | Rp. 7.628.199,- |
| Embolektomi / trombektomi pembuluh darah ekstremitas atas (Elektif) | - | Rp. 7.628.199,- |
| Embolektomi / trombektomi pembuluh darah ekstremitas bawah * (Elektif) | - | Rp. 7.628.199,- |
| Alveolektomi (Elektif) | - | Rp. 4.023.100,- |
| Ekstirpasi / eksisi tumor jinak jaringan lunak ukuran < 2 cm (Elektif) | - | Rp. 4.023.100,- |
| Ekstirpasi kista dermoid * (Elektif) | - | Rp. 4.023.100,- |
| Ekstraksi corpus alienum cornea (Elektif) | - | Rp. 4.023.100,- |
| Embolektomi (Elektif) | - | Rp. 4.023.100,- |
| Cerclage | - | Rp. 4.023.100,- |
| Angkat jahitan Kornea (Elektif) | - | Rp. 4.023.100,- |
| Arterial pungsi - kanulasi - sectie (Elektif) | - | Rp. 4.023.100,- |
| Aspirasi / Irigasi / Reformasi COA (Elektif) | - | Rp. 4.023.100,- |
| Closed reduction of temporomandibular dislocation (Elektif) | - | Rp. 4.023.100,- |
| Control of hemorrhage of anus (Elektif) | - | Rp. 4.023.100,- |
| Ekskokleasi epulis (Elektif) | - | Rp. 4.023.100,- |
| Kuretase ODS (One Day Surgery) | - | Rp. 1.011.300,- |
| Kuretase | - | Rp. 1.659.400,- |
| Kuretase (Lokal Anestesi) | - | Rp. 829.800,- |
| Robekan Himen + Laserasi Dinding Vagina (Kolporeksis) (cito) | - | Rp. 9.062.526,- |
| Persalinan Normal | Kelas 1 | Rp. 2.091.100,- |
| Persalinan Dengan Penyulit | Kelas 1 | Rp. 3.326.300,- |
| Hecting Perineum | Kelas 1 | Rp. 1.182.500,- |
| Manual Plasenta | Kelas 1 | Rp. 313.800,- |
| Induksi Persalinan | Kelas 1 | Rp. 522.800,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Cito) | Kelas 1 | Rp. 10.273.026,- |
| Ekskokleasi kista folikuler (Cito) | Kelas 1 | Rp. 5.520.725,- |
| Ekskokleasi kista radikuler (Cito) | Kelas 1 | Rp. 5.520.725,- |
| Ekskokleasi kista folikuler (Elektif) | Kelas 1 | Rp. 4.830.100,- |
| Ekskokleasi kista radikuler (Elektif) | Kelas 1 | Rp. 4.830.100,- |
| Uff Arch Barr (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Uff Arch Barr dan suspensi maksila (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Amputasi jari (phalangs - traumatik) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Amputation of digiti single ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Anal fistulectomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Anal fistulotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Anterior lamellar keratoplasty (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Appendicostomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Babcock (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas 1 | Rp. 6.922.900,- |
| Bilateral multipel excision of lesion of breast with narcose (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral ovariectomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of direct inguinal hernia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of indirect inguinal hernia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas 1 | Rp. 6.922.900,- |
| Biopsi pembuluh darah perifer * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi perikardium * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka bronkhus * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka diafragma * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka mediastinum * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka paru * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka pleura * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka pleura dengan VATS * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Biopsi terbuka tumor dinding thoraks * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Caecostomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Closure of anal fistula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Combustio (luka bakar) * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Compartement excision (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Debridement-nekrotomi luka gangren (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Deseksi submandibula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Disartikulasi sendi ekstremitas (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Dislokasi bahu * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Drainage of appendiceal abscess (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Drainage of pancreatic cyst by catheter (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| DSAEK (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| ECCE / ICCE / SICS (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| ECCE / SICS dan IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi biopsi tumor pembuluh darah (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi glandula submandibula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi higroma leher * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi kista tiroglosus (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi parsial dan marsupialisasi Ranula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi Pterigium (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi tumor dinding dada * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Eksisi tumor pembuluh darah perifer ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ekstirpasi kelainan kornea (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ekstraksi corpus alienum segmen anterior (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ekstraksi IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Endoskopi - Esofagoskopi dilatasi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Evakuasi silicon oil (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Evakuasi silicon oil dan ECCE (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Exchange IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Excision of ectopic breast tissue (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| excision of lesion of breast with narcose (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Excision of thyroglossal duct or trac (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Exploratory laparotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Extirpasi kista rongga mulut (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Extirpasi muoccocele rongga mulut (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Fasciotomy * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Fiksasi interna fraktur nasal (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Flap konjungtiva amnion graft (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Fraktur humerus * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Gastrostomi * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| GIN -Ekstirpasi polip (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Kistektomi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Laparotomi Diagnostik (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Pemasangan Implan Tableport (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ginekologi - Salpingo-ooforektomi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Anterior / posterior sklerotomi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Gonioplasty / goniotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Iridektomi perifer (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Paracentesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Reformasi COA (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Revisi Bleb (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Tindakan cyclodia termi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Trabekulektomi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Trabekulotomi anak atau bayi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Transkleral Foto Coagulasi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Glaukoma - Tubes implan (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Elbow, tennis elbow, release (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, crush injuries (complex) wound debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, crush injury (simple), wound debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, deep infection, drainage (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, deformity, instrinsic muscle release (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, injury, debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, jaringan lunak tumor, excision (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, macrodactyly, debulking (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, ring construction (single), koreksi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, superficial infection, drainage (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, syndactili (single) koreksi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, trauma, terminalisation (multiple) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, trauma, terminalisation (single) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, various lesions, amputasi (multiple) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jari, wart, com, naevus, excision (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas 1 | Rp. 6.922.900,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas 1 | Rp. 6.922.900,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas 1 | Rp. 6.922.900,- |
| Hand - Nail bed, Laceration, repair (single) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Nerve various lesions, primary or secondary suture (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Nerve, Various Lesions, biopsy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Repair muscle (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Elektif | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (El | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Ele | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Elekt | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Elekti | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (El | Kelas 1 | Rp. 6.922.900,- |
| Hidrokel Testis / Funikuli ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Implantasi iris artifisial (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Implantasi piggyback IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Incision of perianal abscess (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Injeksi intravitreal (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Insertion of synthetic implant in facial bone (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Insisi atau Eksisi gingiva (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Insisi flegmon dasar mulut (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Internal Fiksasi fraktur condylus mandibula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Internal Fiksasi fraktur Mandibula segmental (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Keratoplasty tembus (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Keratoprosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Knee - Open knee debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Knee - Perypheral nerve ablation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Knee - Perypheral nerve lysis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Kolonoskopi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Labioshisis * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Laring dan Faring - Laringofisure (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Laring dan Faring - Pemasangan T-Tube (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Left lateral anal sphincterotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ligasi vaskular ekstremitas (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Ligation of hemorrhoids (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Limbal Relaxing Incision (LRI) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Maksilektomi total dan Rekonstruksi * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Multipel excision of lesion of breast with narcose (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Mutilasi digiti ekstremitas (Multiple) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Obstetri - Histerorafi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Obstetri - Kolporafi anterior (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Obstetri - Kolporafi posterior (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Obstetri - Mioma geburt (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Obstetri - Sectio caesaria tanpa penyulit (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Odontektomi tingkat I (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Ele | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Open biopsy bone tumor (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Open biopsy soft tissue (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Ray amputation jari (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Open biopsi of breast (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Open biopsy of salivary gland or duct (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Open reduction of alveolar fracture * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Osteotomi eksisi tulang maksilofasial (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other appendectomy (elective) * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other bilateral femoral hernioraphy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other hernia repair (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other incidental appendectomy * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other incision of anus (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other lysis of peritoneal adhesions (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other operations on anus (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other operations on trachea (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other procedures on hemorrhoids (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other reconstruction of mandible (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other reconstruction of other facial bone (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other repair and plastic operation of tongue (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other repair of abdominal wall (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other umbilical herniorraphy* (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Other unilateral femoral herniorraphy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Otologi - Meatoplasti (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Otologi - Miringoplasti (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Otologi - Pemasangan grommet (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Palatoshisis ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Partial glossectomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Debridement fraktur terbuka anak (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Hemangioma : injeksi intralesi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Katarak (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Koreksi curly toe (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Koreksi overriding toe polidactili (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Koreksi syndactili kaki (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Nekrotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Open achilles tendon lengthening (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Percutaneous tendon tenotomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (El | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Elekt | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - RetCam and Narkose (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Skin graft (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pembedahan teleangiectasis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pengangkatan encircling silicone band (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Perikardiektomi * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Phaco dan IOL multifokal atau torik (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Phakik IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Phototherapeutic keratectomy (PTK) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pionephrosis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pleural window (eloeser flap) * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Plikasi bulae / bleb emfisematous (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pneumatic retinopexy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas 1 | Rp. 6.922.900,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Prosedur Sistrunk kista duktus tiroglosus (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Pulmonary decortication * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Ektropion 1 kelopak * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Entropion 1 kelopak (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Eviserasi / enukleasi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Koreksi Ptosis * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Koreksi simblefaron (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Probing (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Elekt | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Repair Ruptur palpebra * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rekonstruksi - Tarsorafi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Release kontraktur mandibula (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Release tortikolis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Removal of foreign body from peritoneal cavity (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Removal of foreign body from retro-peritoneal cavity (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair iridodyalisis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of direct inguinal hernia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of direct inguinal hernia with graft or prosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of indirect inguinal hernia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of laceration, cornea and or sclera, perforating (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of laceration, cornea, non perforating (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of other hernia of anterior abdominal wall (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Repair of umbilical hernia with prosthesis * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Reposisi IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Reposisi Iris (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Reposisi tertutup fraktur nasal (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rinologi - Konkotomi / Konkoplasti (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Rupture tendon achiles (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Scleral buckle, cryo dan C3F8 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Scleral buckling (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Sekunder IOL (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Somnoplasty (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Spine - Biopsy vertebra (1 level) * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Spine - Plaster application of the spine (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Strabismus 1 otot (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Strabismus 2 otot (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Strabismus 3 otot (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Suture of laceration of large intestine (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Suture of laceration of small intestine, except duodenum (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Suture of peritoneum (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tatto cornea (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Torakotomi / sternotomi eksplorasi * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Torsio testis ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trakeostomi temporary ** (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Acute ankle joint dislocation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Acute elbow joint dislocation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Acute hip joint dislocation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Acute knee joint dislocation (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Closed fraktur shaft femur * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Closed fraktur shaft humerus * (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Closed fraktur shaft radius (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Closed fraktur shaft tibia (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Closed fraktur shaft ulna (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Jaringan granulasi dengan STSG (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Kompartemen otot (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Nekrotik tissue dengan debridement (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Biopsi tumor kelopak (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Biopsi tumor orbita (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Eksenterasi (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Eksisi tumor adneksa (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Ekstirpasi Tumor Orbita (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Orbital dekompresi 1 tulang (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Orbital dekompresi 2 tulang (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Orbitotomi anterior (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Tumor - Orbitotomi lateral (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas 1 | Rp. 6.922.900,- |
| Unilateral thyroid lobectomy (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Wide excision of soft tissue tumor (Elektif) | Kelas 1 | Rp. 6.922.900,- |
| Amputasi above knee (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Amputasi below knee (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Aneurisma arteri brachialis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Aneurisma arteri femoralis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Axillary dissection (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Batu saluran kemih * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Bilateral simple mastectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Cholecystectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Choledochoplasty (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of appendiceal fistula (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of cholecystostomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of fistula of large intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of fistula of small intestine, except duodenum (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of intestinal stoma (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Closure of leceration of liver (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Colostomy (not otherwise specified) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Common duct exploration for removal of calculus (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Debridement mediastinum (sternotomi) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Diseksi leher radikal / radikal neck dissection * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Eksisi pseudoaneurisma (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Eksplorasi vaskular (trauma / non trauma) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ekstraksi corpus alienum di regio toraks * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoscopic polypectomy of rectum (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoscopic thyroidectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Pan bronkoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Pan esofagoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Sialendoskopi diagnostik (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Endoskopi - Sleep nasoendoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Excision of hemorrhoid (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Exploration of common duct (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Exteriorization of large intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Exteriorization of small intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fiksasi sternum (wire, plate) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur antebrachi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur colles dan pergelangan tangan lainnya (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur cruris (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur femur * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur klavikula (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur olekranon (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur patela (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Fraktur suprakondiler humerus (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Free skin graft (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Full-thickness skin graft to hand (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Full-thickness skin graft to other sites * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| GIN- Hymenoplasty (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ginekologi - Histerektomi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ginekologi - Kehamilan ektopik (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Groin dissection (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (E | Kelas 1 | Rp. 8.838.699,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Jari, deformities, koreksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas 1 | Rp. 8.838.699,- |
| Hand - Jari, ring constriction (multiple), koreksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Jari, syndactili (multiple) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (E | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nail bed, laceration, Repair (multiple) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas 1 | Rp. 8.838.699,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas 1 | Rp. 8.838.699,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Ele | Kelas 1 | Rp. 8.838.699,- |
| Hand - Thumb, deformitas, Koreksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hemiglosektomi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hip - Arthroscopy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hip - Hemiarthroplasty (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hip - ORIF, DHS (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Hipertropi Prostat Beningna (BPH) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Ileostomy (not otherwise specified) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Incisional hernia repair (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Incisional hernia repair with prosthesis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Internal drainage of pancreatic cyst (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Anterior cruciate ligament reconstruction (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy debridement knee (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy debridement shoulder (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy diagnostic (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy diagnostic shoulder (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy meniscus repair (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy remove loose body (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Arthroscopy remove loose body shoulder (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Fibular osteotomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Lateral collateral ligament reconstruction (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Medial collateral ligament reconstruction (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Posterior cruciate ligamnet reconstruction (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Revisi total knee replacement (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Revisi total shoulder replacement (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Rotator cuff repair by arthroscopy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Shoulder hemiarthroplasty (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Knee - Total shoulder replacement (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Kolonoskopi dan Biopsi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparoscopic lysis of peritoneal adhesions (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparoskopi/histeroskopi - ovarian drilling (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparskopi / Histereskopi - Second Look (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laparskopi / Histereskopi - Tubektomi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Large to large intestinal anastomosis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laring dan Faring - Laringektomi * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laring dan Faring - Laringektomi + RND * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laring dan Faring - RND * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laringectomi * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Laringectomi dengan diseksi leher * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Lasik 1 (satu) mata (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Lobektomi parsial (reseksi paru segmental) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Muscle flap graft to breast (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Partus Dengan Bius ELA (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Partus Dengan Bius ILA (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Purandare (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Rekonstruksi vagina (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Repair fistula (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Elek | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Obstetri - Vaginoplasti (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Odontektomi tingkat II (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Diseksi leher bilateral (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Diseksi leher modified (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Ligasi arteri karotis eksterna (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Mandibulektomi parsial (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas 1 | Rp. 8.838.699,- |
| Onkologi - Total patellectomy dan rekonstruksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open biopsy of gallbladder or bile ducts (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open biopsy of liver (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open biopsy of pancreas (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open reduction of malar and zygomatic fracture (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open reduction of mandibular fractur (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Open reduction of maxillary fracture (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other destruction of lesion of liver (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other laparotomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other partial excision of large intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other repair of anal sphincter (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other repair of intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other repair of mesentery (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other skin graft to hand (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other skin graft to other sites (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other small to large intestinal anastomosis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Other suture of abdominal wall (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Otologi - Dekompresi nervus fasialis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Otologi - Mastoidektomi radikal (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Otologi - Mastoidektomi sederhana (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Otologi - Stapedektomi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Parotidektomi superfisial * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Partial splenectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas 1 | Rp. 8.838.699,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pedicle or flaps graft (not otherwise specified) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pembuatan thoracic window (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Perikardiotomi / pericardial window * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Permanent colostomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Permanent ileostomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Phaco (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Phaco dan IOL (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Faringeal flap (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Forehead flap (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Otoplasty * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Revisi parut (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Rinoplasty * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pleurektomi * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Plikasi diafragma * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Pneumonectomy * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Posterior vitrectomy, Phaco dan IOL (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Radical excision of skin lesion (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Reclosure of postoperative disruption of abdominal wall (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rectosigmoidoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Reduction of anal prolapse (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Fraktur dasar orbita (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Fraktur Multiple (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Palpebra dengan Graft * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Soket kontraktur (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rekonstruksi - Soket landai (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Reopening of recent laparotomy site (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Repair arteri poplitea dan femoralis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Repair of diaphragmatic hernia, abdominal approach (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Repair of laceration of gallbladder (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Resection of transverse colon (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Reseksi maksila infrastuktural (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Reseksi mandibula tanpa rekonstruksi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Revision of anastomosis of large intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Revision of anastomosis of small intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Revision of stoma of large intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Revision of stoma of small intestine (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Revision of tracheostomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Right hemicolectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rinologi - BSEF / FESS 1 : Mini (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Rupture buli-buli * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Scleral buckling, phaco dan IOL (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Sigmoidectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Simple suture of common bile duct (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Small to small intestinal anastomosis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Discograph multilevel * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Facet block (1 level) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Facet block multilevel (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Foraminal block (1 level) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Foraminal block multilevel (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas 1 | Rp. 8.838.699,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Strabismus 4 otot (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Stripping varises ekstremitas inferior (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Subtotal mastectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Temporary colostomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Temporary ileostomy * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Elek | Kelas 1 | Rp. 8.838.699,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Total splenectomy * (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Closed fraktur distal tibia (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Closed fraktur intercondylar femur (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Closed fraktur supracondylar femur (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur collum femur pada orang tua (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur galeazi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur montegia (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Instability joint infection (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Joint stiffness dengan liberation (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Non union dengan bone graft (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Open fraktur shaft femur grade 3 (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Open fraktur shaft humerus grade 3 (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Open fraktur shaft radius grade 3 (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Open fraktur shaft tibia grade 3 (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Open fraktur shaft ulna grade 3 (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Trauma - Osteomyelitis (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Tumor - Extended Eksenterasi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Tumor - Orbital dekompresi 3 tulang (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Tumor - Orbitotomi lateral and superior (medial) (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Unilateral radical mastectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Unilateral simple mastectomy (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Upper Endoskopi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Upper Endoskopi dan biopsi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Upper Endoskopi dan ekstraksi carpal (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Upper Endoskopi dan ligasi (Elektif) | Kelas 1 | Rp. 8.838.699,- |
| Clipping costa (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Complete thyroidectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Eksisi pada bronkhus (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Endoskopi - Bronkoskopi diagnostik (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Endoskopi - Esofagoskopi BA dengan penyulit (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Endoskopi - Esofagoskopi diagnostik (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Excision of other bile duct (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Ginekologi - Repair tuba (tubaplasti) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Ginekologi - Reseksi adenomiosis (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Ginekologi - Transposisi Ovarium (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Artery, large, injury, repair with grafting (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Carpus, delayed (non union), rekonstruksi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari (digit), stump, revision (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari, deformities, major reconstruction procedure (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari, deformities, osteotomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari, deformity, instrinsic muscle transfer (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Jari, scar, revision osteotomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Kelas 1 | Rp. 11.427.400,- |
| Hand - Nerve defect, peripheral graft (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Nerve digital, Injury, microsurgical (single) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Nerve digital, injury, primary repair (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Nerve ulnar, entrapment, transposition (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas 1 | Rp. 11.427.400,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hand - Thumb, paralysis, oppnens plasty (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Hip - Total hip replacement (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Intra-abdominal manipulation of large intestine (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Intra-abdominal manipulation of small intestine (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Knee - Total knee replacement (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Knee - Uni compartment arthroplasty (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparoscopic appendectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparoscopic appendectomy (elective) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparoscopic cholecystectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparoscopic incidental appendectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparoscopy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Kistektomi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Ovareksi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Salpingoooforektomi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laparskopi / Histereskopi - Transposisi Ovarium (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laring dan Faring - TA/T dengan Coblation Laser (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laring dan Faring - Tiroidektomi Subtotal ** (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laring dan Faring - Tiroidektomi Total (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Left hemicolectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Mediastinostomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Obstetri - Operasi plasenta akreta (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Odontektomi tingkat III (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Belloque tampon dengan narkosis (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Diseksi leher radikal * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Eksplorasi nasofaring (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Ekstirpasi tumor jinak kel liur (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Hemiglosektomi (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Maksilektomi parsial (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Maksilektomi total (radikal) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - ORIF MBD (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Parotidektomi * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Onkologi - Wide excision soft tisue sarcoma (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Other operations on intestines (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Other operations on the breast (reconstruction of the breast) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Other partial thyroidectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Parathyroidectomy subtotal (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Parathyroidectomy total (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| partial mandibulectomy hemimandibulectomy (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Pediatrik - Posteromedial soft tissue release CTEV (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Pilar Implant (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Labioplasti Bilateral (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Labioplasti unilateral (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Reseksi septum (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Plastik Rekionstruksi - Septorinoplasty (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Redo torakotomi * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Reduction Neglected Dislocation (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Elek | Kelas 1 | Rp. 11.427.400,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas 1 | Rp. 11.427.400,- |
| Repair laserasi diafragma * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Reposisi dislokasi rahang (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Reseksi maksila suprastuktural (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Rinologi - Caldwell Luc (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Rinologi - Septum Reseksi / SMR (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Alar transverse fusion * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Debridement and anterior fusion in TB Spine * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Decompression laminectomy for HNP with stabilization * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Elektif | Kelas 1 | Rp. 11.427.400,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas 1 | Rp. 11.427.400,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Mayor desloughing and wound debridement of the spine * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Micro endoscopic disectomy (1 level) * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Microscopic disectomy (1 Level) (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Open disectomy multilevel * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Open disestomy (1 Level) * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Open reduction and stabilisation of spinal fracture * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Posterior cervical fusion * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Kelas 1 | Rp. 11.427.400,- |
| Spine - Posterolateral fusion * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Spine - Total disc replacement (multilevel) * (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Split thickness graft to breast (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Terapi Slem Cell (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Thymectomy dengan VATS (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Tiroidektomi total dengan berry picking (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Tiroidektomi total dengan diseksi leher fungsional (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas 1 | Rp. 11.427.400,- |
| Trauma - Limb leg inequality dengan bone lengthening transport (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Turbinoplasty (Elektif) | Kelas 1 | Rp. 11.427.400,- |
| Bilateral radical mastectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| complete glossectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Hand - Replantasi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Hip - Revisi THR (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - TA/T (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Operasi Commando (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Other operations on pancreas (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Other pancreatotomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Otologi - Implantasi koklea (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Otologi - Timpanoplasti (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Parotidektomi total (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Partial gastrectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Partial hepatectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas 1 | Rp. 16.034.801,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Repair of gastroschisis (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Repair of other bile ducts (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas 1 | Rp. 16.034.801,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas 1 | Rp. 16.034.801,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas 1 | Rp. 16.034.801,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas 1 | Rp. 16.034.801,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas 1 | Rp. 16.034.801,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Total gastrectomy (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Whipple procedure (Elektif) | Kelas 1 | Rp. 16.034.801,- |
| Ekstraksi epithelial downgrowth | Kelas 1 | Rp. 4.830.100,- |
| Evakuasi hematom (pasca pungsi) | Kelas 1 | Rp. 4.830.100,- |
| Excision of perianal skin tags | Kelas 1 | Rp. 4.830.100,- |
| GIN - Insisi Septum Vagina | Kelas 1 | Rp. 4.830.100,- |
| GIN - kromotubasi | Kelas 1 | Rp. 4.830.100,- |
| GIN- Himenectomy | Kelas 1 | Rp. 4.830.100,- |
| GIN- Insisi Drainage | Kelas 1 | Rp. 4.830.100,- |
| GIN- Marsupialisasi | Kelas 1 | Rp. 4.830.100,- |
| Ginekologi - Tubektomi | Kelas 1 | Rp. 4.830.100,- |
| GIN-Kuretase-biopsi PA | Kelas 1 | Rp. 4.830.100,- |
| Glaukoma - Cyclo cryo | Kelas 1 | Rp. 4.830.100,- |
| Hand - Angkat K-Wire with anestesia regional | Kelas 1 | Rp. 4.830.100,- |
| Hand - Jari, extra digit, amputasi | Kelas 1 | Rp. 4.830.100,- |
| Hand - Jari, various, amputation (single) ** | Kelas 1 | Rp. 4.830.100,- |
| Injeksi botox pada strabismus | Kelas 1 | Rp. 4.830.100,- |
| Ligasi Varices Esofgaus (VE) | Kelas 1 | Rp. 4.830.100,- |
| Local excision of lesion of breast | Kelas 1 | Rp. 4.830.100,- |
| Local excision of rectal lesion or tissue | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Drainase abses | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Ekstirpasi | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Ekstraksi IUD dengan anestesi | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Hematoma (ruptur) | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Kauterisasi kondiloma akuminata | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Kista bartholin (kista gartner) | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Kolpotomi pada abses cavum douglas | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Konisasi | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Kuretase abortus | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Kuretase pasca persalinan | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Penjahitan laserasi ringan | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Polip serviks | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Robekan serviks (forniks) | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Shirodkar | Kelas 1 | Rp. 4.830.100,- |
| Obstetri - Sistoskopi LEETZ | Kelas 1 | Rp. 4.830.100,- |
| Onkologi - Insisional biopsi kelenjar leher | Kelas 1 | Rp. 4.830.100,- |
| Open biopsy of rectum | Kelas 1 | Rp. 4.830.100,- |
| Operkulektomi | Kelas 1 | Rp. 4.830.100,- |
| Other diagnostic procedures of abdominal region | Kelas 1 | Rp. 4.830.100,- |
| Other excision of perianal tissue | Kelas 1 | Rp. 4.830.100,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas 1 | Rp. 4.830.100,- |
| Otologi - Biopsi | Kelas 1 | Rp. 4.830.100,- |
| Otologi - Ekstraksi benda asing | Kelas 1 | Rp. 4.830.100,- |
| Pasang implantable central venous access * | Kelas 1 | Rp. 4.830.100,- |
| Pasang thoraks drain (WSD) * | Kelas 1 | Rp. 4.830.100,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih | Kelas 1 | Rp. 4.830.100,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat | Kelas 1 | Rp. 4.830.100,- |
| Pemasangan interdental wiring / arch bar | Kelas 1 | Rp. 4.830.100,- |
| Pericardiocentesis * | Kelas 1 | Rp. 4.830.100,- |
| Pleurodesis (pleurosklerosis) * | Kelas 1 | Rp. 4.830.100,- |
| Rekonstruksi - Eksisi tumor kecil kelopak | Kelas 1 | Rp. 4.830.100,- |
| Rekonstruksi - Oklusi punctum lakrimal | Kelas 1 | Rp. 4.830.100,- |
| Release tongue tie * | Kelas 1 | Rp. 4.830.100,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * | Kelas 1 | Rp. 4.830.100,- |
| Reposisi tertutup fraktur condilus mandibula | Kelas 1 | Rp. 4.830.100,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) | Kelas 1 | Rp. 4.830.100,- |
| Rinologi - Irigasi Sinus / DAWO | Kelas 1 | Rp. 4.830.100,- |
| Scleroterapi dan atau ligasi hemangioma | Kelas 1 | Rp. 4.830.100,- |
| Suture of laceration of anus | Kelas 1 | Rp. 4.830.100,- |
| Thoracocentesis * | Kelas 1 | Rp. 4.830.100,- |
| Trauma - Acute glenohumeral joint dislocation * | Kelas 1 | Rp. 4.830.100,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * | Kelas 1 | Rp. 4.830.100,- |
| Vena punctie - kanulasi - sectie * | Kelas 1 | Rp. 4.830.100,- |
| Amputasi above knee (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Amputasi below knee (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Aneurisma arteri brachialis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Aneurisma arteri femoralis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Axillary dissection (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Batu saluran kemih * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Bilateral simple mastectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Cholecystectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Choledochoplasty (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of appendiceal fistula (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of cholecystostomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of fistula of large intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of fistula of small intestine, except duodenum (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of intestinal stoma (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Closure of leceration of liver (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Colostomy (not otherwise specified) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Common duct exploration for removal of calculus (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Debridement mediastinum (sternotomi) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Diseksi leher radikal / radikal neck dissection * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Eksisi pseudoaneurisma (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Eksplorasi vaskular (trauma / non trauma) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ekstraksi corpus alienum di regio toraks * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoscopic polypectomy of rectum (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoscopic thyroidectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Pan bronkoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Pan esofagoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Sialendoskopi diagnostik (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Endoskopi - Sleep nasoendoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Excision of hemorrhoid (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Exploration of common duct (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Exteriorization of large intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Exteriorization of small intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fiksasi sternum (wire, plate) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur antebrachi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur colles dan pergelangan tangan lainnya (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur cruris (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur femur * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur klavikula (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur olekranon (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur patela (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Fraktur suprakondiler humerus (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Free skin graft (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Full-thickness skin graft to hand (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Full-thickness skin graft to other sites * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| GIN- Hymenoplasty (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ginekologi - Histerektomi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ginekologi - Kehamilan ektopik (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Groin dissection (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (E | Kelas 2 | Rp. 7.968.500,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Jari, deformities, koreksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas 2 | Rp. 7.968.500,- |
| Hand - Jari, ring constriction (multiple), koreksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Jari, syndactili (multiple) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (E | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nail bed, laceration, Repair (multiple) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas 2 | Rp. 7.968.500,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas 2 | Rp. 7.968.500,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Ele | Kelas 2 | Rp. 7.968.500,- |
| Hand - Thumb, deformitas, Koreksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hemiglosektomi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hip - Arthroscopy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hip - Hemiarthroplasty (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hip - ORIF, DHS (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Hipertropi Prostat Beningna (BPH) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Ileostomy (not otherwise specified) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Incisional hernia repair (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Incisional hernia repair with prosthesis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Internal drainage of pancreatic cyst (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Anterior cruciate ligament reconstruction (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy debridement knee (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy debridement shoulder (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy diagnostic (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy diagnostic shoulder (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy meniscus repair (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy remove loose body (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Arthroscopy remove loose body shoulder (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Fibular osteotomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Lateral collateral ligament reconstruction (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Medial collateral ligament reconstruction (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Posterior cruciate ligamnet reconstruction (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Revisi total knee replacement (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Revisi total shoulder replacement (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Rotator cuff repair by arthroscopy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Shoulder hemiarthroplasty (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Knee - Total shoulder replacement (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Kolonoskopi dan Biopsi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparoscopic lysis of peritoneal adhesions (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparoskopi/histeroskopi - ovarian drilling (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparskopi / Histereskopi - Second Look (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laparskopi / Histereskopi - Tubektomi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Large to large intestinal anastomosis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laring dan Faring - Laringektomi * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laring dan Faring - Laringektomi + RND * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laring dan Faring - RND * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laringectomi * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Laringectomi dengan diseksi leher * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Lasik 1 (satu) mata (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Lobektomi parsial (reseksi paru segmental) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Muscle flap graft to breast (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Partus Dengan Bius ELA (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Partus Dengan Bius ILA (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Purandare (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Rekonstruksi vagina (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Repair fistula (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Elek | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Obstetri - Vaginoplasti (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Odontektomi tingkat II (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Diseksi leher bilateral (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Diseksi leher modified (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Ligasi arteri karotis eksterna (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Mandibulektomi parsial (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas 2 | Rp. 7.968.500,- |
| Onkologi - Total patellectomy dan rekonstruksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open biopsy of gallbladder or bile ducts (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open biopsy of liver (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open biopsy of pancreas (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open reduction of malar and zygomatic fracture (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open reduction of mandibular fractur (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Open reduction of maxillary fracture (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other destruction of lesion of liver (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other laparotomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other partial excision of large intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other repair of anal sphincter (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other repair of intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other repair of mesentery (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other skin graft to hand (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other skin graft to other sites (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other small to large intestinal anastomosis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Other suture of abdominal wall (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Otologi - Dekompresi nervus fasialis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Otologi - Mastoidektomi radikal (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Otologi - Mastoidektomi sederhana (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Otologi - Stapedektomi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Parotidektomi superfisial * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Partial splenectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas 2 | Rp. 7.968.500,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pedicle or flaps graft (not otherwise specified) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pembuatan thoracic window (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Perikardiotomi / pericardial window * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Permanent colostomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Permanent ileostomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Phaco (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Phaco dan IOL (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Faringeal flap (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Forehead flap (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Otoplasty * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Revisi parut (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Rinoplasty * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pleurektomi * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Plikasi diafragma * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Pneumonectomy * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Posterior vitrectomy, Phaco dan IOL (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Radical excision of skin lesion (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Reclosure of postoperative disruption of abdominal wall (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rectosigmoidoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Reduction of anal prolapse (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Fraktur dasar orbita (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Fraktur Multiple (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Palpebra dengan Graft * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Soket kontraktur (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rekonstruksi - Soket landai (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Reopening of recent laparotomy site (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Repair arteri poplitea dan femoralis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Repair of diaphragmatic hernia, abdominal approach (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Repair of laceration of gallbladder (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Resection of transverse colon (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Reseksi maksila infrastuktural (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Reseksi mandibula tanpa rekonstruksi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Revision of anastomosis of large intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Revision of anastomosis of small intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Revision of stoma of large intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Revision of stoma of small intestine (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Revision of tracheostomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Right hemicolectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rinologi - BSEF / FESS 1 : Mini (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Rupture buli-buli * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Scleral buckling, phaco dan IOL (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Sigmoidectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Simple suture of common bile duct (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Small to small intestinal anastomosis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Discograph multilevel * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Facet block (1 level) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Facet block multilevel (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Foraminal block (1 level) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Foraminal block multilevel (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas 2 | Rp. 7.968.500,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Strabismus 4 otot (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Stripping varises ekstremitas inferior (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Subtotal mastectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Temporary colostomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Temporary ileostomy * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Elek | Kelas 2 | Rp. 7.968.500,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Total splenectomy * (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Closed fraktur distal tibia (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Closed fraktur intercondylar femur (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Closed fraktur supracondylar femur (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur collum femur pada orang tua (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur galeazi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur montegia (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Instability joint infection (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Joint stiffness dengan liberation (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Non union dengan bone graft (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Open fraktur shaft femur grade 3 (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Open fraktur shaft humerus grade 3 (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Open fraktur shaft radius grade 3 (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Open fraktur shaft tibia grade 3 (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Open fraktur shaft ulna grade 3 (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Trauma - Osteomyelitis (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Tumor - Extended Eksenterasi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Tumor - Orbital dekompresi 3 tulang (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Tumor - Orbitotomi lateral and superior (medial) (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Unilateral radical mastectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Unilateral simple mastectomy (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Upper Endoskopi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Upper Endoskopi dan biopsi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Upper Endoskopi dan ekstraksi carpal (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Upper Endoskopi dan ligasi (Elektif) | Kelas 2 | Rp. 7.968.500,- |
| Clipping costa | Kelas 2 | Rp. 10.412.199,- |
| Complete thyroidectomy | Kelas 2 | Rp. 10.412.199,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh | Kelas 2 | Rp. 10.412.199,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal | Kelas 2 | Rp. 10.412.199,- |
| Eksisi pada bronkhus | Kelas 2 | Rp. 10.412.199,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit | Kelas 2 | Rp. 10.412.199,- |
| Endoskopi - Bronkoskopi diagnostik | Kelas 2 | Rp. 10.412.199,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit | Kelas 2 | Rp. 10.412.199,- |
| Endoskopi - Esofagoskopi BA dengan penyulit | Kelas 2 | Rp. 10.412.199,- |
| Endoskopi - Esofagoskopi diagnostik | Kelas 2 | Rp. 10.412.199,- |
| Excision of other bile duct | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Repair tuba (tubaplasti) | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Reseksi adenomiosis | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Transposisi Ovarium | Kelas 2 | Rp. 10.412.199,- |
| Hand - Artery, large, injury, repair with grafting | Kelas 2 | Rp. 10.412.199,- |
| Hand - Carpus, delayed (non union), rekonstruksi | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari (digit), stump, revision | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari, deformities, major reconstruction procedure | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari, deformities, osteotomy | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari, deformity, instrinsic muscle transfer | Kelas 2 | Rp. 10.412.199,- |
| Hand - Jari, scar, revision osteotomy | Kelas 2 | Rp. 10.412.199,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) | Kelas 2 | Rp. 10.412.199,- |
| Hand - Nerve defect, peripheral graft | Kelas 2 | Rp. 10.412.199,- |
| Hand - Nerve digital, Injury, microsurgical (single) | Kelas 2 | Rp. 10.412.199,- |
| Hand - Nerve digital, injury, primary repair | Kelas 2 | Rp. 10.412.199,- |
| Hand - Nerve ulnar, entrapment, transposition | Kelas 2 | Rp. 10.412.199,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty | Kelas 2 | Rp. 10.412.199,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas 2 | Rp. 10.412.199,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) | Kelas 2 | Rp. 10.412.199,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft | Kelas 2 | Rp. 10.412.199,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) | Kelas 2 | Rp. 10.412.199,- |
| Hand - Thumb, paralysis, oppnens plasty | Kelas 2 | Rp. 10.412.199,- |
| Hip - Total hip replacement | Kelas 2 | Rp. 10.412.199,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) | Kelas 2 | Rp. 10.412.199,- |
| Intra-abdominal manipulation of large intestine | Kelas 2 | Rp. 10.412.199,- |
| Intra-abdominal manipulation of small intestine | Kelas 2 | Rp. 10.412.199,- |
| Knee - Total knee replacement | Kelas 2 | Rp. 10.412.199,- |
| Knee - Uni compartment arthroplasty | Kelas 2 | Rp. 10.412.199,- |
| Laparoscopic appendectomy | Kelas 2 | Rp. 10.412.199,- |
| Laparoscopic appendectomy (elective) | Kelas 2 | Rp. 10.412.199,- |
| Laparoscopic cholecystectomy | Kelas 2 | Rp. 10.412.199,- |
| Laparoscopic incidental appendectomy | Kelas 2 | Rp. 10.412.199,- |
| Laparoscopy | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Kistektomi | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Ovareksi | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Salpingoooforektomi | Kelas 2 | Rp. 10.412.199,- |
| Laparskopi / Histereskopi - Transposisi Ovarium | Kelas 2 | Rp. 10.412.199,- |
| Laring dan Faring - TA/T dengan Coblation Laser | Kelas 2 | Rp. 10.412.199,- |
| Laring dan Faring - Tiroidektomi Subtotal ** | Kelas 2 | Rp. 10.412.199,- |
| Laring dan Faring - Tiroidektomi Total | Kelas 2 | Rp. 10.412.199,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) | Kelas 2 | Rp. 10.412.199,- |
| Left hemicolectomy | Kelas 2 | Rp. 10.412.199,- |
| Mediastinostomy | Kelas 2 | Rp. 10.412.199,- |
| Obstetri - Operasi plasenta akreta | Kelas 2 | Rp. 10.412.199,- |
| Odontektomi tingkat III | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Belloque tampon dengan narkosis | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Diseksi leher radikal * | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Eksplorasi nasofaring | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Ekstirpasi tumor jinak kel liur | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Hemiglosektomi | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Maksilektomi parsial | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Maksilektomi total (radikal) | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - ORIF MBD | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Parotidektomi * | Kelas 2 | Rp. 10.412.199,- |
| Onkologi - Wide excision soft tisue sarcoma | Kelas 2 | Rp. 10.412.199,- |
| Other operations on intestines | Kelas 2 | Rp. 10.412.199,- |
| Other operations on the breast (reconstruction of the breast) | Kelas 2 | Rp. 10.412.199,- |
| Other partial thyroidectomy | Kelas 2 | Rp. 10.412.199,- |
| Parathyroidectomy subtotal | Kelas 2 | Rp. 10.412.199,- |
| Parathyroidectomy total | Kelas 2 | Rp. 10.412.199,- |
| partial mandibulectomy hemimandibulectomy | Kelas 2 | Rp. 10.412.199,- |
| Pediatrik - Posteromedial soft tissue release CTEV | Kelas 2 | Rp. 10.412.199,- |
| Pilar Implant | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Labioplasti Bilateral | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Labioplasti unilateral | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Reseksi septum | Kelas 2 | Rp. 10.412.199,- |
| Plastik Rekionstruksi - Septorinoplasty | Kelas 2 | Rp. 10.412.199,- |
| Redo torakotomi * | Kelas 2 | Rp. 10.412.199,- |
| Reduction Neglected Dislocation | Kelas 2 | Rp. 10.412.199,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) | Kelas 2 | Rp. 10.412.199,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas 2 | Rp. 10.412.199,- |
| Repair laserasi diafragma * | Kelas 2 | Rp. 10.412.199,- |
| Reposisi dislokasi rahang | Kelas 2 | Rp. 10.412.199,- |
| Reseksi maksila suprastuktural | Kelas 2 | Rp. 10.412.199,- |
| Rinologi - Caldwell Luc | Kelas 2 | Rp. 10.412.199,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) | Kelas 2 | Rp. 10.412.199,- |
| Rinologi - Septum Reseksi / SMR | Kelas 2 | Rp. 10.412.199,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan | Kelas 2 | Rp. 10.412.199,- |
| Spine - Alar transverse fusion * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Debridement and anterior fusion in TB Spine * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Decompression laminectomy for HNP with stabilization * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas 2 | Rp. 10.412.199,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Mayor desloughing and wound debridement of the spine * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Micro endoscopic disectomy (1 level) * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Microscopic disectomy (1 Level) | Kelas 2 | Rp. 10.412.199,- |
| Spine - Open disectomy multilevel * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Open disestomy (1 Level) * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Open reduction and stabilisation of spinal fracture * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Posterior cervical fusion * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Posterolateral fusion * | Kelas 2 | Rp. 10.412.199,- |
| Spine - Total disc replacement (multilevel) * | Kelas 2 | Rp. 10.412.199,- |
| Split thickness graft to breast | Kelas 2 | Rp. 10.412.199,- |
| Terapi Slem Cell | Kelas 2 | Rp. 10.412.199,- |
| Thymectomy dengan VATS | Kelas 2 | Rp. 10.412.199,- |
| Tiroidektomi total dengan berry picking | Kelas 2 | Rp. 10.412.199,- |
| Tiroidektomi total dengan diseksi leher fungsional | Kelas 2 | Rp. 10.412.199,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** | Kelas 2 | Rp. 10.412.199,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas 2 | Rp. 10.412.199,- |
| Trauma - Limb leg inequality dengan bone lengthening transport | Kelas 2 | Rp. 10.412.199,- |
| Turbinoplasty | Kelas 2 | Rp. 10.412.199,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Hand - Replantasi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Hip - Revisi THR (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - TA/T (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Operasi Commando (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Other operations on pancreas (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Other pancreatotomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Otologi - Implantasi koklea (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Otologi - Timpanoplasti (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Parotidektomi total (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Partial gastrectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Partial hepatectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas 2 | Rp. 14.874.500,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Repair of gastroschisis (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Repair of other bile ducts (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas 2 | Rp. 14.874.500,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas 2 | Rp. 14.874.500,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas 2 | Rp. 14.874.500,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas 2 | Rp. 14.874.500,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas 2 | Rp. 14.874.500,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Total gastrectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Whipple procedure (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Bilateral radical mastectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| complete glossectomy (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas 2 | Rp. 14.874.500,- |
| Glaukoma - Cyclo cryo | Kelas 2 | Rp. 4.250.000,- |
| Hand - Angkat K-Wire with anestesia regional | Kelas 2 | Rp. 4.250.000,- |
| Hand - Jari, extra digit, amputasi | Kelas 2 | Rp. 4.250.000,- |
| Hand - Jari, various, amputation (single) ** | Kelas 2 | Rp. 4.250.000,- |
| Injeksi botox pada strabismus | Kelas 2 | Rp. 4.250.000,- |
| Ligasi Varices Esofgaus (VE) | Kelas 2 | Rp. 4.250.000,- |
| Local excision of lesion of breast | Kelas 2 | Rp. 4.250.000,- |
| Local excision of rectal lesion or tissue | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Drainase abses | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Ekstirpasi | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Ekstraksi IUD dengan anestesi | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Hematoma (ruptur) | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Kauterisasi kondiloma akuminata | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Kista bartholin (kista gartner) | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Kolpotomi pada abses cavum douglas | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Konisasi | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Kuretase abortus | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Kuretase pasca persalinan | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Penjahitan laserasi ringan | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Polip serviks | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Robekan serviks (forniks) | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Shirodkar | Kelas 2 | Rp. 4.250.000,- |
| Obstetri - Sistoskopi LEETZ | Kelas 2 | Rp. 4.250.000,- |
| Onkologi - Insisional biopsi kelenjar leher | Kelas 2 | Rp. 4.250.000,- |
| Open biopsy of rectum | Kelas 2 | Rp. 4.250.000,- |
| Operkulektomi | Kelas 2 | Rp. 4.250.000,- |
| Other diagnostic procedures of abdominal region | Kelas 2 | Rp. 4.250.000,- |
| Other excision of perianal tissue | Kelas 2 | Rp. 4.250.000,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas 2 | Rp. 4.250.000,- |
| Otologi - Biopsi | Kelas 2 | Rp. 4.250.000,- |
| Otologi - Ekstraksi benda asing | Kelas 2 | Rp. 4.250.000,- |
| Pasang implantable central venous access * | Kelas 2 | Rp. 4.250.000,- |
| Pasang thoraks drain (WSD) * | Kelas 2 | Rp. 4.250.000,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih | Kelas 2 | Rp. 4.250.000,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat | Kelas 2 | Rp. 4.250.000,- |
| Pemasangan interdental wiring / arch bar | Kelas 2 | Rp. 4.250.000,- |
| Pericardiocentesis * | Kelas 2 | Rp. 4.250.000,- |
| Pleurodesis (pleurosklerosis) * | Kelas 2 | Rp. 4.250.000,- |
| Rekonstruksi - Eksisi tumor kecil kelopak | Kelas 2 | Rp. 4.250.000,- |
| Rekonstruksi - Oklusi punctum lakrimal | Kelas 2 | Rp. 4.250.000,- |
| Release tongue tie * | Kelas 2 | Rp. 4.250.000,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * | Kelas 2 | Rp. 4.250.000,- |
| Reposisi tertutup fraktur condilus mandibula | Kelas 2 | Rp. 4.250.000,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) | Kelas 2 | Rp. 4.250.000,- |
| Rinologi - Irigasi Sinus / DAWO | Kelas 2 | Rp. 4.250.000,- |
| Scleroterapi dan atau ligasi hemangioma | Kelas 2 | Rp. 4.250.000,- |
| Suture of laceration of anus | Kelas 2 | Rp. 4.250.000,- |
| Thoracocentesis * | Kelas 2 | Rp. 4.250.000,- |
| Trauma - Acute glenohumeral joint dislocation * | Kelas 2 | Rp. 4.250.000,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * | Kelas 2 | Rp. 4.250.000,- |
| Vena punctie - kanulasi - sectie * | Kelas 2 | Rp. 4.250.000,- |
| Ekstraksi epithelial downgrowth | Kelas 2 | Rp. 4.250.000,- |
| Evakuasi hematom (pasca pungsi) | Kelas 2 | Rp. 4.250.000,- |
| Excision of perianal skin tags | Kelas 2 | Rp. 4.250.000,- |
| GIN - Insisi Septum Vagina | Kelas 2 | Rp. 4.250.000,- |
| GIN - kromotubasi | Kelas 2 | Rp. 4.250.000,- |
| GIN- Himenectomy | Kelas 2 | Rp. 4.250.000,- |
| GIN- Insisi Drainage | Kelas 2 | Rp. 4.250.000,- |
| GIN- Marsupialisasi | Kelas 2 | Rp. 4.250.000,- |
| Ginekologi - Tubektomi | Kelas 2 | Rp. 4.250.000,- |
| GIN-Kuretase-biopsi PA | Kelas 2 | Rp. 4.250.000,- |
| Persalinan Normal | Kelas 2 | Rp. 1.642.700,- |
| Persalinan Dengan Penyulit | Kelas 2 | Rp. 2.653.600,- |
| Hecting Perineum | Kelas 2 | Rp. 958.300,- |
| Manual Plasenta | Kelas 2 | Rp. 246.500,- |
| Induksi Persalinan | Kelas 2 | Rp. 410.700,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Cito) | Kelas 2 | Rp. 9.402.825,- |
| Ekskokleasi kista folikuler (Cito) | Kelas 2 | Rp. 4.940.625,- |
| Ekskokleasi kista radikuler (Cito) | Kelas 2 | Rp. 4.940.625,- |
| Ekskokleasi kista folikuler (Elektif) | Kelas 2 | Rp. 4.250.000,- |
| Ekskokleasi kista radikuler (Elektif) | Kelas 2 | Rp. 4.250.000,- |
| Uff Arch Barr (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Uff Arch Barr dan suspensi maksila (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Amputasi jari (phalangs - traumatik) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Amputation of digiti single ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Anal fistulectomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Anal fistulotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Anterior lamellar keratoplasty (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Appendicostomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Babcock (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas 2 | Rp. 6.197.801,- |
| Bilateral multipel excision of lesion of breast with narcose (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral ovariectomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of direct inguinal hernia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of indirect inguinal hernia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas 2 | Rp. 6.197.801,- |
| Biopsi pembuluh darah perifer * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi perikardium * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka bronkhus * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka diafragma * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka mediastinum * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka paru * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka pleura * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka pleura dengan VATS * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Biopsi terbuka tumor dinding thoraks * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Caecostomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Closure of anal fistula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Combustio (luka bakar) * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Compartement excision (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Debridement-nekrotomi luka gangren (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Deseksi submandibula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Disartikulasi sendi ekstremitas (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Dislokasi bahu * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Drainage of appendiceal abscess (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Drainage of pancreatic cyst by catheter (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| DSAEK (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| ECCE / ICCE / SICS (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| ECCE / SICS dan IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi biopsi tumor pembuluh darah (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi glandula submandibula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi higroma leher * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi kista tiroglosus (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi parsial dan marsupialisasi Ranula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi Pterigium (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi tumor dinding dada * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Eksisi tumor pembuluh darah perifer ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ekstirpasi kelainan kornea (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ekstraksi corpus alienum segmen anterior (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ekstraksi IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Endoskopi - Esofagoskopi dilatasi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Evakuasi silicon oil (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Evakuasi silicon oil dan ECCE (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Exchange IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Excision of ectopic breast tissue (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| excision of lesion of breast with narcose (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Excision of thyroglossal duct or trac (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Exploratory laparotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Extirpasi kista rongga mulut (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Extirpasi muoccocele rongga mulut (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Fasciotomy * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Fiksasi interna fraktur nasal (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Flap konjungtiva amnion graft (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Fraktur humerus * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Gastrostomi * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| GIN -Ekstirpasi polip (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Kistektomi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Laparotomi Diagnostik (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Pemasangan Implan Tableport (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ginekologi - Salpingo-ooforektomi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Anterior / posterior sklerotomi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Gonioplasty / goniotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Iridektomi perifer (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Paracentesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Reformasi COA (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Revisi Bleb (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Tindakan cyclodia termi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Trabekulektomi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Trabekulotomi anak atau bayi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Transkleral Foto Coagulasi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Glaukoma - Tubes implan (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Elbow, tennis elbow, release (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, crush injuries (complex) wound debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, crush injury (simple), wound debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, deep infection, drainage (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, deformity, instrinsic muscle release (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, injury, debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, jaringan lunak tumor, excision (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, macrodactyly, debulking (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, ring construction (single), koreksi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, superficial infection, drainage (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, syndactili (single) koreksi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, trauma, terminalisation (multiple) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, trauma, terminalisation (single) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, various lesions, amputasi (multiple) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jari, wart, com, naevus, excision (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas 2 | Rp. 6.197.801,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas 2 | Rp. 6.197.801,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas 2 | Rp. 6.197.801,- |
| Hand - Nail bed, Laceration, repair (single) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Nerve various lesions, primary or secondary suture (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Nerve, Various Lesions, biopsy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Repair muscle (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Elektif | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (El | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Ele | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Elekt | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Elekti | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (El | Kelas 2 | Rp. 6.197.801,- |
| Hidrokel Testis / Funikuli ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Implantasi iris artifisial (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Implantasi piggyback IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Incision of perianal abscess (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Injeksi intravitreal (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Insertion of synthetic implant in facial bone (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Insisi atau Eksisi gingiva (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Insisi flegmon dasar mulut (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Internal Fiksasi fraktur condylus mandibula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Internal Fiksasi fraktur Mandibula segmental (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Keratoplasty tembus (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Keratoprosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Knee - Open knee debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Knee - Perypheral nerve ablation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Knee - Perypheral nerve lysis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Kolonoskopi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Labioshisis * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Laring dan Faring - Laringofisure (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Laring dan Faring - Pemasangan T-Tube (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Left lateral anal sphincterotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ligasi vaskular ekstremitas (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Ligation of hemorrhoids (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Limbal Relaxing Incision (LRI) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Maksilektomi total dan Rekonstruksi * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Multipel excision of lesion of breast with narcose (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Mutilasi digiti ekstremitas (Multiple) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Obstetri - Histerorafi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Obstetri - Kolporafi anterior (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Obstetri - Kolporafi posterior (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Obstetri - Mioma geburt (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Obstetri - Sectio caesaria tanpa penyulit (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Odontektomi tingkat I (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Ele | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Open biopsy bone tumor (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Open biopsy soft tissue (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Ray amputation jari (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Open biopsi of breast (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Open biopsy of salivary gland or duct (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Open reduction of alveolar fracture * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Osteotomi eksisi tulang maksilofasial (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other appendectomy (elective) * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other bilateral femoral hernioraphy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other hernia repair (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other incidental appendectomy * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other incision of anus (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other lysis of peritoneal adhesions (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other operations on anus (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other operations on trachea (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other procedures on hemorrhoids (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other reconstruction of mandible (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other reconstruction of other facial bone (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other repair and plastic operation of tongue (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other repair of abdominal wall (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other umbilical herniorraphy* (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Other unilateral femoral herniorraphy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Otologi - Meatoplasti (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Otologi - Miringoplasti (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Otologi - Pemasangan grommet (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Palatoshisis ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Partial glossectomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Debridement fraktur terbuka anak (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Hemangioma : injeksi intralesi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Katarak (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Koreksi curly toe (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Koreksi overriding toe polidactili (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Koreksi syndactili kaki (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Nekrotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Open achilles tendon lengthening (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Percutaneous tendon tenotomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (El | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Elekt | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - RetCam and Narkose (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Skin graft (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pembedahan teleangiectasis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pengangkatan encircling silicone band (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Perikardiektomi * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Phaco dan IOL multifokal atau torik (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Phakik IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Phototherapeutic keratectomy (PTK) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pionephrosis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pleural window (eloeser flap) * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Plikasi bulae / bleb emfisematous (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pneumatic retinopexy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas 2 | Rp. 6.197.801,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Prosedur Sistrunk kista duktus tiroglosus (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Pulmonary decortication * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Ektropion 1 kelopak * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Entropion 1 kelopak (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Eviserasi / enukleasi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Koreksi Ptosis * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Koreksi simblefaron (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Probing (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Elekt | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Repair Ruptur palpebra * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rekonstruksi - Tarsorafi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Release kontraktur mandibula (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Release tortikolis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Removal of foreign body from peritoneal cavity (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Removal of foreign body from retro-peritoneal cavity (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair iridodyalisis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of direct inguinal hernia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of direct inguinal hernia with graft or prosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of indirect inguinal hernia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of laceration, cornea and or sclera, perforating (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of laceration, cornea, non perforating (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of other hernia of anterior abdominal wall (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Repair of umbilical hernia with prosthesis * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Reposisi IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Reposisi Iris (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Reposisi tertutup fraktur nasal (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rinologi - Konkotomi / Konkoplasti (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Rupture tendon achiles (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Scleral buckle, cryo dan C3F8 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Scleral buckling (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Sekunder IOL (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Somnoplasty (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Spine - Biopsy vertebra (1 level) * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Spine - Plaster application of the spine (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Strabismus 1 otot (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Strabismus 2 otot (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Strabismus 3 otot (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Suture of laceration of large intestine (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Suture of laceration of small intestine, except duodenum (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Suture of peritoneum (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tatto cornea (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Torakotomi / sternotomi eksplorasi * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Torsio testis ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trakeostomi temporary ** (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Acute ankle joint dislocation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Acute elbow joint dislocation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Acute hip joint dislocation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Acute knee joint dislocation (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Closed fraktur shaft femur * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Closed fraktur shaft humerus * (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Closed fraktur shaft radius (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Closed fraktur shaft tibia (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Closed fraktur shaft ulna (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Jaringan granulasi dengan STSG (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Kompartemen otot (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Nekrotik tissue dengan debridement (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Biopsi tumor kelopak (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Biopsi tumor orbita (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Eksenterasi (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Eksisi tumor adneksa (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Ekstirpasi Tumor Orbita (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Orbital dekompresi 1 tulang (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Orbital dekompresi 2 tulang (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Orbitotomi anterior (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Tumor - Orbitotomi lateral (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas 2 | Rp. 6.197.801,- |
| Unilateral thyroid lobectomy (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Wide excision of soft tissue tumor (Elektif) | Kelas 2 | Rp. 6.197.801,- |
| Persalinan Normal | Kelas 3 | Rp. 1.467.300,- |
| Persalinan Dengan Penyulit | Kelas 3 | Rp. 2.390.500,- |
| Hecting Perineum | Kelas 3 | Rp. 870.600,- |
| Manual Plasenta | Kelas 3 | Rp. 220.200,- |
| Induksi Persalinan | Kelas 3 | Rp. 377.600,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Cito) | Kelas 3 | Rp. 9.062.526,- |
| Ekskokleasi kista folikuler (Cito) | Kelas 3 | Rp. 4.713.725,- |
| Ekskokleasi kista radikuler (Cito) | Kelas 3 | Rp. 4.713.725,- |
| Ekskokleasi kista folikuler (Elektif) | Kelas 3 | Rp. 4.023.100,- |
| Ekskokleasi kista radikuler (Elektif) | Kelas 3 | Rp. 4.023.100,- |
| Uff Arch Barr (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Uff Arch Barr dan suspensi maksila (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Amputasi jari (phalangs - traumatik) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Amputation of digiti single ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Anal fistulectomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Anal fistulotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Anterior lamellar keratoplasty (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Appendicostomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Babcock (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Elbow, tennis elbow, release (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, crush injuries (complex) wound debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, crush injury (simple), wound debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, deep infection, drainage (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, deformity, instrinsic muscle release (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, injury, debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, jaringan lunak tumor, excision (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, macrodactyly, debulking (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, ring construction (single), koreksi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, superficial infection, drainage (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, syndactili (single) koreksi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, trauma, terminalisation (multiple) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, trauma, terminalisation (single) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, various lesions, amputasi (multiple) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral multipel excision of lesion of breast with narcose (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jari, wart, com, naevus, excision (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas 3 | Rp. 5.914.100,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas 3 | Rp. 5.914.100,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas 3 | Rp. 5.914.100,- |
| Hand - Nail bed, Laceration, repair (single) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Nerve various lesions, primary or secondary suture (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Nerve, Various Lesions, biopsy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Repair muscle (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral ovariectomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Elektif | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (El | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Ele | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Elekt | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of direct inguinal hernia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Elekti | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (El | Kelas 3 | Rp. 5.914.100,- |
| Hidrokel Testis / Funikuli ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Implantasi iris artifisial (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Implantasi piggyback IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Incision of perianal abscess (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Injeksi intravitreal (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Insertion of synthetic implant in facial bone (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Insisi atau Eksisi gingiva (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Insisi flegmon dasar mulut (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Internal Fiksasi fraktur condylus mandibula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Internal Fiksasi fraktur Mandibula segmental (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Keratoplasty tembus (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Keratoprosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Knee - Open knee debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Knee - Perypheral nerve ablation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Knee - Perypheral nerve lysis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Kolonoskopi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Labioshisis * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Laring dan Faring - Laringofisure (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Laring dan Faring - Pemasangan T-Tube (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Left lateral anal sphincterotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ligasi vaskular ekstremitas (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ligation of hemorrhoids (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Limbal Relaxing Incision (LRI) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Maksilektomi total dan Rekonstruksi * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Multipel excision of lesion of breast with narcose (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of indirect inguinal hernia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Mutilasi digiti ekstremitas (Multiple) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Obstetri - Histerorafi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Obstetri - Kolporafi anterior (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Obstetri - Kolporafi posterior (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Obstetri - Mioma geburt (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Obstetri - Sectio caesaria tanpa penyulit (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Odontektomi tingkat I (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Ele | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Open biopsy bone tumor (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Open biopsy soft tissue (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Ray amputation jari (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Open biopsi of breast (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Open biopsy of salivary gland or duct (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Open reduction of alveolar fracture * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Osteotomi eksisi tulang maksilofasial (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other appendectomy (elective) * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other bilateral femoral hernioraphy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other hernia repair (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other incidental appendectomy * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other incision of anus (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other lysis of peritoneal adhesions (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other operations on anus (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other operations on trachea (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other procedures on hemorrhoids (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other reconstruction of mandible (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other reconstruction of other facial bone (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other repair and plastic operation of tongue (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other repair of abdominal wall (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other umbilical herniorraphy* (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Other unilateral femoral herniorraphy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Otologi - Meatoplasti (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Otologi - Miringoplasti (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Otologi - Pemasangan grommet (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Palatoshisis ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Partial glossectomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Debridement fraktur terbuka anak (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Hemangioma : injeksi intralesi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Katarak (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Koreksi curly toe (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Koreksi overriding toe polidactili (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi pembuluh darah perifer * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Koreksi syndactili kaki (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Nekrotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Open achilles tendon lengthening (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Percutaneous tendon tenotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (El | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Elekt | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - RetCam and Narkose (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Skin graft (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi perikardium * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pembedahan teleangiectasis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pengangkatan encircling silicone band (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Perikardiektomi * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Phaco dan IOL multifokal atau torik (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Phakik IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Phototherapeutic keratectomy (PTK) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka bronkhus * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pionephrosis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pleural window (eloeser flap) * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Plikasi bulae / bleb emfisematous (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pneumatic retinopexy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas 3 | Rp. 5.914.100,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Prosedur Sistrunk kista duktus tiroglosus (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Pulmonary decortication * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka diafragma * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Ektropion 1 kelopak * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Entropion 1 kelopak (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Eviserasi / enukleasi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Koreksi Ptosis * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Koreksi simblefaron (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Probing (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka mediastinum * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Elekt | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Repair Ruptur palpebra * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rekonstruksi - Tarsorafi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Release kontraktur mandibula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Release tortikolis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Removal of foreign body from peritoneal cavity (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Removal of foreign body from retro-peritoneal cavity (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair iridodyalisis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of direct inguinal hernia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of direct inguinal hernia with graft or prosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka paru * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of indirect inguinal hernia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of laceration, cornea and or sclera, perforating (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of laceration, cornea, non perforating (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of other hernia of anterior abdominal wall (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Repair of umbilical hernia with prosthesis * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Reposisi IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Reposisi Iris (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Reposisi tertutup fraktur nasal (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka pleura * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rinologi - Konkotomi / Konkoplasti (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Rupture tendon achiles (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Scleral buckle, cryo dan C3F8 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Scleral buckling (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Sekunder IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Somnoplasty (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Spine - Biopsy vertebra (1 level) * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka pleura dengan VATS * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Spine - Plaster application of the spine (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Strabismus 1 otot (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Strabismus 2 otot (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Strabismus 3 otot (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Suture of laceration of large intestine (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Suture of laceration of small intestine, except duodenum (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Suture of peritoneum (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tatto cornea (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Torakotomi / sternotomi eksplorasi * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Torsio testis ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Biopsi terbuka tumor dinding thoraks * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trakeostomi temporary ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Acute ankle joint dislocation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Acute elbow joint dislocation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Acute hip joint dislocation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Acute knee joint dislocation (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Closed fraktur shaft femur * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Closed fraktur shaft humerus * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Closed fraktur shaft radius (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Closed fraktur shaft tibia (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Closed fraktur shaft ulna (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Caecostomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Jaringan granulasi dengan STSG (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Kompartemen otot (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Nekrotik tissue dengan debridement (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Closure of anal fistula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Biopsi tumor kelopak (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Biopsi tumor orbita (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Eksenterasi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Eksisi tumor adneksa (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Ekstirpasi Tumor Orbita (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Orbital dekompresi 1 tulang (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Orbital dekompresi 2 tulang (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Orbitotomi anterior (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Tumor - Orbitotomi lateral (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Combustio (luka bakar) * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas 3 | Rp. 5.914.100,- |
| Unilateral thyroid lobectomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Wide excision of soft tissue tumor (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Compartement excision (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Debridement-nekrotomi luka gangren (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Deseksi submandibula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Disartikulasi sendi ekstremitas (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Dislokasi bahu * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Drainage of appendiceal abscess (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Drainage of pancreatic cyst by catheter (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| DSAEK (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| ECCE / ICCE / SICS (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| ECCE / SICS dan IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi biopsi tumor pembuluh darah (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi glandula submandibula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi higroma leher * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi kista tiroglosus (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi parsial dan marsupialisasi Ranula (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi Pterigium (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi tumor dinding dada * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Eksisi tumor pembuluh darah perifer ** (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ekstirpasi kelainan kornea (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ekstraksi corpus alienum segmen anterior (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ekstraksi IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Endoskopi - Esofagoskopi dilatasi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Evakuasi silicon oil (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Evakuasi silicon oil dan ECCE (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Exchange IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Excision of ectopic breast tissue (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| excision of lesion of breast with narcose (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Excision of thyroglossal duct or trac (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Exploratory laparotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Extirpasi kista rongga mulut (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Extirpasi muoccocele rongga mulut (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Fasciotomy * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Fiksasi interna fraktur nasal (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Flap konjungtiva amnion graft (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Fraktur humerus * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Gastrostomi * (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| GIN -Ekstirpasi polip (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Kistektomi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Laparotomi Diagnostik (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Pemasangan Implan Tableport (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Ginekologi - Salpingo-ooforektomi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Anterior / posterior sklerotomi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Gonioplasty / goniotomy (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Iridektomi perifer (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Paracentesis (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Reformasi COA (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Revisi Bleb (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Tindakan cyclodia termi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Trabekulektomi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Trabekulotomi anak atau bayi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Transkleral Foto Coagulasi (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Glaukoma - Tubes implan (Elektif) | Kelas 3 | Rp. 5.914.100,- |
| Amputasi above knee (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Amputasi below knee (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Aneurisma arteri brachialis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Aneurisma arteri femoralis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Axillary dissection (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Batu saluran kemih * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Bilateral simple mastectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Cholecystectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Choledochoplasty (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of appendiceal fistula (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Revisi total knee replacement (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Revisi total shoulder replacement (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Rotator cuff repair by arthroscopy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Shoulder hemiarthroplasty (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Total shoulder replacement (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Kolonoskopi dan Biopsi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparoscopic lysis of peritoneal adhesions (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparoskopi/histeroskopi - ovarian drilling (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of cholecystostomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparskopi / Histereskopi - Second Look (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laparskopi / Histereskopi - Tubektomi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Large to large intestinal anastomosis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laring dan Faring - Laringektomi * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laring dan Faring - Laringektomi + RND * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laring dan Faring - RND * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laringectomi * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Laringectomi dengan diseksi leher * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Lasik 1 (satu) mata (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of fistula of large intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Lobektomi parsial (reseksi paru segmental) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Muscle flap graft to breast (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Partus Dengan Bius ELA (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Partus Dengan Bius ILA (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Purandare (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Rekonstruksi vagina (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Repair fistula (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of fistula of small intestine, except duodenum (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Elek | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Obstetri - Vaginoplasti (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Odontektomi tingkat II (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Diseksi leher bilateral (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Diseksi leher modified (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Ligasi arteri karotis eksterna (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Mandibulektomi parsial (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of intestinal stoma (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas 3 | Rp. 7.628.199,- |
| Onkologi - Total patellectomy dan rekonstruksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open biopsy of gallbladder or bile ducts (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open biopsy of liver (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open biopsy of pancreas (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open reduction of malar and zygomatic fracture (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open reduction of mandibular fractur (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Open reduction of maxillary fracture (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other destruction of lesion of liver (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other laparotomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Closure of leceration of liver (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other partial excision of large intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other repair of anal sphincter (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other repair of intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other repair of mesentery (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other skin graft to hand (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other skin graft to other sites (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other small to large intestinal anastomosis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Other suture of abdominal wall (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Otologi - Dekompresi nervus fasialis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Colostomy (not otherwise specified) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Otologi - Mastoidektomi radikal (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Otologi - Mastoidektomi sederhana (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Otologi - Stapedektomi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Parotidektomi superfisial * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Partial splenectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas 3 | Rp. 7.628.199,- |
| Common duct exploration for removal of calculus (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pedicle or flaps graft (not otherwise specified) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pembuatan thoracic window (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Perikardiotomi / pericardial window * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Permanent colostomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Permanent ileostomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Phaco (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Phaco dan IOL (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Faringeal flap (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Debridement mediastinum (sternotomi) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Forehead flap (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Otoplasty * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Revisi parut (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Rinoplasty * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pleurektomi * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Plikasi diafragma * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Pneumonectomy * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Posterior vitrectomy, Phaco dan IOL (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Diseksi leher radikal / radikal neck dissection * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Radical excision of skin lesion (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Reclosure of postoperative disruption of abdominal wall (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rectosigmoidoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Reduction of anal prolapse (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Fraktur dasar orbita (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Fraktur Multiple (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Palpebra dengan Graft * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Soket kontraktur (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rekonstruksi - Soket landai (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Reopening of recent laparotomy site (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Repair arteri poplitea dan femoralis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Repair of diaphragmatic hernia, abdominal approach (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Repair of laceration of gallbladder (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Resection of transverse colon (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Reseksi maksila infrastuktural (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Reseksi mandibula tanpa rekonstruksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Revision of anastomosis of large intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Revision of anastomosis of small intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Revision of stoma of large intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Revision of stoma of small intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Revision of tracheostomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Right hemicolectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rinologi - BSEF / FESS 1 : Mini (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Rupture buli-buli * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Eksisi pseudoaneurisma (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Scleral buckling, phaco dan IOL (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Sigmoidectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Simple suture of common bile duct (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Small to small intestinal anastomosis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Discograph multilevel * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Facet block (1 level) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Facet block multilevel (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Foraminal block (1 level) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Eksplorasi vaskular (trauma / non trauma) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Foraminal block multilevel (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas 3 | Rp. 7.628.199,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Strabismus 4 otot (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Stripping varises ekstremitas inferior (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Subtotal mastectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Temporary colostomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Temporary ileostomy * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Elek | Kelas 3 | Rp. 7.628.199,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ekstraksi corpus alienum di regio toraks * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Total splenectomy * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Closed fraktur distal tibia (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Closed fraktur intercondylar femur (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Closed fraktur supracondylar femur (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur collum femur pada orang tua (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur galeazi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur montegia (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Instability joint infection (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Joint stiffness dengan liberation (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Non union dengan bone graft (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Open fraktur shaft femur grade 3 (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Open fraktur shaft humerus grade 3 (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Open fraktur shaft radius grade 3 (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Open fraktur shaft tibia grade 3 (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Open fraktur shaft ulna grade 3 (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Trauma - Osteomyelitis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Tumor - Extended Eksenterasi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Tumor - Orbital dekompresi 3 tulang (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Tumor - Orbitotomi lateral and superior (medial) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Unilateral radical mastectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Unilateral simple mastectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Upper Endoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Upper Endoskopi dan biopsi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Upper Endoskopi dan ekstraksi carpal (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Upper Endoskopi dan ligasi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoscopic polypectomy of rectum (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoscopic thyroidectomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Pan bronkoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Pan esofagoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Sialendoskopi diagnostik (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Endoskopi - Sleep nasoendoskopi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Excision of hemorrhoid (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Exploration of common duct (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Exteriorization of large intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Exteriorization of small intestine (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fiksasi sternum (wire, plate) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur antebrachi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur colles dan pergelangan tangan lainnya (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur cruris (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur femur * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur klavikula (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur olekranon (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur patela (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Fraktur suprakondiler humerus (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Free skin graft (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Full-thickness skin graft to hand (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Full-thickness skin graft to other sites * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| GIN- Hymenoplasty (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ginekologi - Histerektomi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ginekologi - Kehamilan ektopik (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ginekologi - Miomektomi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Groin dissection (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (E | Kelas 3 | Rp. 7.628.199,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Jari, deformities, koreksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas 3 | Rp. 7.628.199,- |
| Hand - Jari, ring constriction (multiple), koreksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Jari, syndactili (multiple) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (E | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nail bed, laceration, Repair (multiple) (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas 3 | Rp. 7.628.199,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas 3 | Rp. 7.628.199,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Ele | Kelas 3 | Rp. 7.628.199,- |
| Hand - Thumb, deformitas, Koreksi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hemiglosektomi (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hip - Arthroscopy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hip - Hemiarthroplasty (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hip - ORIF, DHS (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Hipertropi Prostat Beningna (BPH) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Ileostomy (not otherwise specified) * (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Incisional hernia repair (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Incisional hernia repair with prosthesis (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Internal drainage of pancreatic cyst (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Anterior cruciate ligament reconstruction (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy debridement knee (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy debridement shoulder (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy diagnostic (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy diagnostic shoulder (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy meniscus repair (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy remove loose body (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Arthroscopy remove loose body shoulder (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Fibular osteotomy (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Lateral collateral ligament reconstruction (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Medial collateral ligament reconstruction (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Posterior cruciate ligamnet reconstruction (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Elektif) | Kelas 3 | Rp. 7.628.199,- |
| Clipping costa (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Complete thyroidectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Eksisi pada bronkhus (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Endoskopi - Bronkoskopi diagnostik (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Endoskopi - Esofagoskopi BA dengan penyulit (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Endoskopi - Esofagoskopi diagnostik (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Rinologi - Caldwell Luc (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Rinologi - Septum Reseksi / SMR (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Alar transverse fusion * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Debridement and anterior fusion in TB Spine * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Decompression laminectomy for HNP with stabilization * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Elektif | Kelas 3 | Rp. 10.015.100,- |
| Excision of other bile duct (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas 3 | Rp. 10.015.100,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Mayor desloughing and wound debridement of the spine * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Micro endoscopic disectomy (1 level) * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Microscopic disectomy (1 Level) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Open disectomy multilevel * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Open disestomy (1 Level) * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Open reduction and stabilisation of spinal fracture * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Posterior cervical fusion * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Kelas 3 | Rp. 10.015.100,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Posterolateral fusion * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Spine - Total disc replacement (multilevel) * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Split thickness graft to breast (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Terapi Slem Cell (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Thymectomy dengan VATS (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Tiroidektomi total dengan berry picking (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Tiroidektomi total dengan diseksi leher fungsional (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas 3 | Rp. 10.015.100,- |
| Trauma - Limb leg inequality dengan bone lengthening transport (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Turbinoplasty (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Ginekologi - Repair tuba (tubaplasti) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Ginekologi - Reseksi adenomiosis (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Ginekologi - Transposisi Ovarium (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Artery, large, injury, repair with grafting (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Carpus, delayed (non union), rekonstruksi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari (digit), stump, revision (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari, deformities, major reconstruction procedure (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari, deformities, osteotomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari, deformity, instrinsic muscle transfer (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Jari, scar, revision osteotomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Kelas 3 | Rp. 10.015.100,- |
| Hand - Nerve defect, peripheral graft (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Nerve digital, Injury, microsurgical (single) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Nerve digital, injury, primary repair (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Nerve ulnar, entrapment, transposition (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas 3 | Rp. 10.015.100,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hand - Thumb, paralysis, oppnens plasty (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Hip - Total hip replacement (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Intra-abdominal manipulation of large intestine (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Intra-abdominal manipulation of small intestine (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Knee - Total knee replacement (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Knee - Uni compartment arthroplasty (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparoscopic appendectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparoscopic appendectomy (elective) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparoscopic cholecystectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparoscopic incidental appendectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparoscopy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Kistektomi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Ovareksi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Salpingoooforektomi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laparskopi / Histereskopi - Transposisi Ovarium (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laring dan Faring - TA/T dengan Coblation Laser (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laring dan Faring - Tiroidektomi Subtotal ** (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laring dan Faring - Tiroidektomi Total (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Left hemicolectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Mediastinostomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Obstetri - Operasi plasenta akreta (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Odontektomi tingkat III (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Belloque tampon dengan narkosis (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Diseksi leher radikal * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Eksplorasi nasofaring (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Ekstirpasi tumor jinak kel liur (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Hemiglosektomi (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Maksilektomi parsial (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Maksilektomi total (radikal) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - ORIF MBD (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Parotidektomi * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Onkologi - Wide excision soft tisue sarcoma (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Other operations on intestines (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Other operations on the breast (reconstruction of the breast) (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Other partial thyroidectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Parathyroidectomy subtotal (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Parathyroidectomy total (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| partial mandibulectomy hemimandibulectomy (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Pediatrik - Posteromedial soft tissue release CTEV (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Pilar Implant (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Labioplasti Bilateral (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Labioplasti unilateral (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Reseksi septum (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Plastik Rekionstruksi - Septorinoplasty (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Redo torakotomi * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Reduction Neglected Dislocation (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Elek | Kelas 3 | Rp. 10.015.100,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas 3 | Rp. 10.015.100,- |
| Repair laserasi diafragma * (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Reposisi dislokasi rahang (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Reseksi maksila suprastuktural (Elektif) | Kelas 3 | Rp. 10.015.100,- |
| Bilateral radical mastectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| complete glossectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Hand - Replantasi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Hip - Revisi THR (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - TA/T (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Operasi Commando (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Other operations on pancreas (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Other pancreatotomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Otologi - Implantasi koklea (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Otologi - Timpanoplasti (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Parotidektomi total (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Partial gastrectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Partial hepatectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas 3 | Rp. 14.420.699,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Repair of gastroschisis (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Repair of other bile ducts (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas 3 | Rp. 14.420.699,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas 3 | Rp. 14.420.699,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas 3 | Rp. 14.420.699,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas 3 | Rp. 14.420.699,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas 3 | Rp. 14.420.699,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Total gastrectomy (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Whipple procedure (Elektif) | Kelas 3 | Rp. 14.420.699,- |
| Ekstraksi epithelial downgrowth | Kelas 3 | Rp. 4.023.100,- |
| Evakuasi hematom (pasca pungsi) | Kelas 3 | Rp. 4.023.100,- |
| Excision of perianal skin tags | Kelas 3 | Rp. 4.023.100,- |
| GIN - Insisi Septum Vagina | Kelas 3 | Rp. 4.023.100,- |
| GIN - kromotubasi | Kelas 3 | Rp. 4.023.100,- |
| GIN- Himenectomy | Kelas 3 | Rp. 4.023.100,- |
| GIN- Insisi Drainage | Kelas 3 | Rp. 4.023.100,- |
| GIN- Marsupialisasi | Kelas 3 | Rp. 4.023.100,- |
| Ginekologi - Tubektomi | Kelas 3 | Rp. 4.023.100,- |
| GIN-Kuretase-biopsi PA | Kelas 3 | Rp. 4.023.100,- |
| Glaukoma - Cyclo cryo | Kelas 3 | Rp. 4.023.100,- |
| Hand - Angkat K-Wire with anestesia regional | Kelas 3 | Rp. 4.023.100,- |
| Hand - Jari, extra digit, amputasi | Kelas 3 | Rp. 4.023.100,- |
| Hand - Jari, various, amputation (single) ** | Kelas 3 | Rp. 4.023.100,- |
| Injeksi botox pada strabismus | Kelas 3 | Rp. 4.023.100,- |
| Ligasi Varices Esofgaus (VE) | Kelas 3 | Rp. 4.023.100,- |
| Local excision of lesion of breast | Kelas 3 | Rp. 4.023.100,- |
| Local excision of rectal lesion or tissue | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Drainase abses | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Ekstirpasi | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Ekstraksi IUD dengan anestesi | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Hematoma (ruptur) | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Kauterisasi kondiloma akuminata | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Kista bartholin (kista gartner) | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Kolpotomi pada abses cavum douglas | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Konisasi | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Kuretase abortus | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Kuretase pasca persalinan | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Penjahitan laserasi ringan | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Polip serviks | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Robekan serviks (forniks) | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Shirodkar | Kelas 3 | Rp. 4.023.100,- |
| Obstetri - Sistoskopi LEETZ | Kelas 3 | Rp. 4.023.100,- |
| Onkologi - Insisional biopsi kelenjar leher | Kelas 3 | Rp. 4.023.100,- |
| Open biopsy of rectum | Kelas 3 | Rp. 4.023.100,- |
| Operkulektomi | Kelas 3 | Rp. 4.023.100,- |
| Other diagnostic procedures of abdominal region | Kelas 3 | Rp. 4.023.100,- |
| Other excision of perianal tissue | Kelas 3 | Rp. 4.023.100,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas 3 | Rp. 4.023.100,- |
| Otologi - Biopsi | Kelas 3 | Rp. 4.023.100,- |
| Otologi - Ekstraksi benda asing | Kelas 3 | Rp. 4.023.100,- |
| Pasang implantable central venous access * | Kelas 3 | Rp. 4.023.100,- |
| Pasang thoraks drain (WSD) * | Kelas 3 | Rp. 4.023.100,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih | Kelas 3 | Rp. 4.023.100,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat | Kelas 3 | Rp. 4.023.100,- |
| Pemasangan interdental wiring / arch bar | Kelas 3 | Rp. 4.023.100,- |
| Pericardiocentesis * | Kelas 3 | Rp. 4.023.100,- |
| Pleurodesis (pleurosklerosis) * | Kelas 3 | Rp. 4.023.100,- |
| Rekonstruksi - Eksisi tumor kecil kelopak | Kelas 3 | Rp. 4.023.100,- |
| Rekonstruksi - Oklusi punctum lakrimal | Kelas 3 | Rp. 4.023.100,- |
| Release tongue tie * | Kelas 3 | Rp. 4.023.100,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * | Kelas 3 | Rp. 4.023.100,- |
| Reposisi tertutup fraktur condilus mandibula | Kelas 3 | Rp. 4.023.100,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) | Kelas 3 | Rp. 4.023.100,- |
| Rinologi - Irigasi Sinus / DAWO | Kelas 3 | Rp. 4.023.100,- |
| Scleroterapi dan atau ligasi hemangioma | Kelas 3 | Rp. 4.023.100,- |
| Suture of laceration of anus | Kelas 3 | Rp. 4.023.100,- |
| Thoracocentesis * | Kelas 3 | Rp. 4.023.100,- |
| Trauma - Acute glenohumeral joint dislocation * | Kelas 3 | Rp. 4.023.100,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * | Kelas 3 | Rp. 4.023.100,- |
| Vena punctie - kanulasi - sectie * | Kelas 3 | Rp. 4.023.100,- |
| Suture of peritoneum (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tatto cornea (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Torakotomi / sternotomi eksplorasi * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Torsio testis ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trakeostomi temporary ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Acute ankle joint dislocation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Acute elbow joint dislocation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Acute hip joint dislocation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Acute knee joint dislocation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Closed fraktur shaft femur * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Closed fraktur shaft humerus * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Closed fraktur shaft radius (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Closed fraktur shaft tibia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Closed fraktur shaft ulna (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Jaringan granulasi dengan STSG (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Kompartemen otot (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Nekrotik tissue dengan debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Biopsi tumor kelopak (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Biopsi tumor orbita (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Eksenterasi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Eksisi tumor adneksa (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Ekstirpasi Tumor Orbita (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Orbital dekompresi 1 tulang (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Orbital dekompresi 2 tulang (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Orbitotomi anterior (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Tumor - Orbitotomi lateral (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas VIP | Rp. 8.019.900,- |
| Unilateral thyroid lobectomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Wide excision of soft tissue tumor (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Uff Arch Barr (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Uff Arch Barr dan suspensi maksila (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Amputasi jari (phalangs - traumatik) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsy of perianal tissue (Elektif) | Kelas VIP | Rp. 2.347.099,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas VIP | Rp. 10.234.801,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pedicle or flaps graft (not otherwise specified) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pembuatan thoracic window (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Perikardiotomi / pericardial window * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Permanent colostomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Permanent ileostomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Phaco (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Phaco dan IOL (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Faringeal flap (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Forehead flap (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Otoplasty * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Revisi parut (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Rinoplasty * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pleurektomi * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Plikasi diafragma * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pneumonectomy * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Posterior vitrectomy, Phaco dan IOL (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Radical excision of skin lesion (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Reclosure of postoperative disruption of abdominal wall (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rectosigmoidoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Reduction of anal prolapse (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Fraktur dasar orbita (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Fraktur Multiple (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Palpebra dengan Graft * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Soket kontraktur (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rekonstruksi - Soket landai (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Reopening of recent laparotomy site (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Repair arteri poplitea dan femoralis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Repair of diaphragmatic hernia, abdominal approach (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Repair of laceration of gallbladder (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Resection of transverse colon (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Reseksi maksila infrastuktural (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Reseksi mandibula tanpa rekonstruksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Revision of anastomosis of large intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Revision of anastomosis of small intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Revision of stoma of large intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Revision of stoma of small intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Revision of tracheostomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Right hemicolectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rinologi - BSEF / FESS 1 : Mini (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Rupture buli-buli * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Scleral buckling, phaco dan IOL (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Sigmoidectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Simple suture of common bile duct (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Small to small intestinal anastomosis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Discograph multilevel * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Facet block (1 level) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Facet block multilevel (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Foraminal block (1 level) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Foraminal block multilevel (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas VIP | Rp. 10.234.801,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Strabismus 4 otot (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Stripping varises ekstremitas inferior (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Subtotal mastectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Temporary colostomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Temporary ileostomy * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Elek | Kelas VIP | Rp. 10.234.801,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Total splenectomy * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Closed fraktur distal tibia (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Closed fraktur intercondylar femur (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Closed fraktur supracondylar femur (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur collum femur pada orang tua (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur galeazi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur montegia (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Instability joint infection (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Joint stiffness dengan liberation (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Non union dengan bone graft (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Open fraktur shaft femur grade 3 (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Open fraktur shaft humerus grade 3 (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Open fraktur shaft radius grade 3 (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Open fraktur shaft tibia grade 3 (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Open fraktur shaft ulna grade 3 (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Trauma - Osteomyelitis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Tumor - Extended Eksenterasi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Tumor - Orbital dekompresi 3 tulang (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Tumor - Orbitotomi lateral and superior (medial) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Unilateral radical mastectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Unilateral simple mastectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Upper Endoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Upper Endoskopi dan biopsi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Upper Endoskopi dan ekstraksi carpal (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Upper Endoskopi dan ligasi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Amputasi above knee (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Amputasi below knee (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Aneurisma arteri brachialis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Aneurisma arteri femoralis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Axillary dissection (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Batu saluran kemih * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Bilateral simple mastectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Cholecystectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Choledochoplasty (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of appendiceal fistula (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of cholecystostomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of fistula of large intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of fistula of small intestine, except duodenum (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of intestinal stoma (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Closure of leceration of liver (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Colostomy (not otherwise specified) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Common duct exploration for removal of calculus (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Debridement mediastinum (sternotomi) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Diseksi leher radikal / radikal neck dissection * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Eksisi pseudoaneurisma (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Eksplorasi vaskular (trauma / non trauma) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ekstraksi corpus alienum di regio toraks * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoscopic polypectomy of rectum (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoscopic thyroidectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Pan bronkoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Pan esofagoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Sialendoskopi diagnostik (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Endoskopi - Sleep nasoendoskopi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Excision of hemorrhoid (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Exploration of common duct (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Exteriorization of large intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Exteriorization of small intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fiksasi sternum (wire, plate) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur antebrachi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur colles dan pergelangan tangan lainnya (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur cruris (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur femur * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur klavikula (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur olekranon (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur patela (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Fraktur suprakondiler humerus (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Free skin graft (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Full-thickness skin graft to hand (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Full-thickness skin graft to other sites * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| GIN- Hymenoplasty (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ginekologi - Histerektomi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ginekologi - Kehamilan ektopik (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ginekologi - Miomektomi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Groin dissection (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (E | Kelas VIP | Rp. 10.234.801,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Jari, deformities, koreksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas VIP | Rp. 10.234.801,- |
| Hand - Jari, ring constriction (multiple), koreksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Jari, syndactili (multiple) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (E | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nail bed, laceration, Repair (multiple) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas VIP | Rp. 10.234.801,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas VIP | Rp. 10.234.801,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Ele | Kelas VIP | Rp. 10.234.801,- |
| Hand - Thumb, deformitas, Koreksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hemiglosektomi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hip - Arthroscopy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hip - Hemiarthroplasty (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hip - ORIF, DHS (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Hipertropi Prostat Beningna (BPH) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Ileostomy (not otherwise specified) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Incisional hernia repair (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Incisional hernia repair with prosthesis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Internal drainage of pancreatic cyst (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Anterior cruciate ligament reconstruction (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy debridement knee (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy debridement shoulder (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy diagnostic (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy diagnostic shoulder (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy meniscus repair (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy remove loose body (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Arthroscopy remove loose body shoulder (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Fibular osteotomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Lateral collateral ligament reconstruction (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Medial collateral ligament reconstruction (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Posterior cruciate ligamnet reconstruction (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Revisi total knee replacement (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Revisi total shoulder replacement (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Rotator cuff repair by arthroscopy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Shoulder hemiarthroplasty (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Knee - Total shoulder replacement (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Kolonoskopi dan Biopsi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparoscopic lysis of peritoneal adhesions (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparoskopi/histeroskopi - ovarian drilling (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparskopi / Histereskopi - Second Look (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laparskopi / Histereskopi - Tubektomi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Large to large intestinal anastomosis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laring dan Faring - Laringektomi * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laring dan Faring - Laringektomi + RND * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laring dan Faring - RND * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laringectomi * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Laringectomi dengan diseksi leher * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Lasik 1 (satu) mata (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Lobektomi parsial (reseksi paru segmental) * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Muscle flap graft to breast (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Partus Dengan Bius ELA (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Partus Dengan Bius ILA (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Purandare (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Rekonstruksi vagina (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Repair fistula (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Elek | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Obstetri - Vaginoplasti (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Odontektomi tingkat II (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Diseksi leher bilateral (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Diseksi leher modified (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Ligasi arteri karotis eksterna (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Mandibulektomi parsial (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas VIP | Rp. 10.234.801,- |
| Onkologi - Total patellectomy dan rekonstruksi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open biopsy of gallbladder or bile ducts (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open biopsy of liver (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open biopsy of pancreas (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open reduction of malar and zygomatic fracture (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open reduction of mandibular fractur (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Open reduction of maxillary fracture (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other destruction of lesion of liver (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other laparotomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other partial excision of large intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other repair of anal sphincter (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other repair of intestine (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other repair of mesentery (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other skin graft to hand (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other skin graft to other sites (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other small to large intestinal anastomosis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Other suture of abdominal wall (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Otologi - Dekompresi nervus fasialis (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Otologi - Mastoidektomi radikal (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Otologi - Mastoidektomi sederhana (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Otologi - Stapedektomi (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Parotidektomi superfisial * (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Partial splenectomy (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas VIP | Rp. 10.234.801,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Elektif) | Kelas VIP | Rp. 10.234.801,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas VIP | Rp. 10.234.801,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas VIP | Rp. 10.234.801,- |
| Clipping costa (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Complete thyroidectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Eksisi pada bronkhus (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Endoskopi - Bronkoskopi diagnostik (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Endoskopi - Esofagoskopi BA dengan penyulit (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Endoskopi - Esofagoskopi diagnostik (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Excision of other bile duct (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Ginekologi - Repair tuba (tubaplasti) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Ginekologi - Reseksi adenomiosis (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Ginekologi - Transposisi Ovarium (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Artery, large, injury, repair with grafting (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Carpus, delayed (non union), rekonstruksi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari (digit), stump, revision (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari, deformities, major reconstruction procedure (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari, deformities, osteotomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari, deformity, instrinsic muscle transfer (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Jari, scar, revision osteotomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Kelas VIP | Rp. 13.223.500,- |
| Hand - Nerve defect, peripheral graft (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Nerve digital, Injury, microsurgical (single) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Nerve digital, injury, primary repair (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Nerve ulnar, entrapment, transposition (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas VIP | Rp. 13.223.500,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hand - Thumb, paralysis, oppnens plasty (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Hip - Total hip replacement (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Intra-abdominal manipulation of large intestine (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Intra-abdominal manipulation of small intestine (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Knee - Total knee replacement (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Knee - Uni compartment arthroplasty (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparoscopic appendectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparoscopic appendectomy (elective) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparoscopic cholecystectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparoscopic incidental appendectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparoscopy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Kistektomi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Ovareksi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Salpingoooforektomi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laparskopi / Histereskopi - Transposisi Ovarium (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laring dan Faring - TA/T dengan Coblation Laser (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laring dan Faring - Tiroidektomi Subtotal ** (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laring dan Faring - Tiroidektomi Total (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Left hemicolectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Mediastinostomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Obstetri - Operasi plasenta akreta (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Odontektomi tingkat III (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Belloque tampon dengan narkosis (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Diseksi leher radikal * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Eksplorasi nasofaring (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Ekstirpasi tumor jinak kel liur (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Hemiglosektomi (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Maksilektomi parsial (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Maksilektomi total (radikal) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - ORIF MBD (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Parotidektomi * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Onkologi - Wide excision soft tisue sarcoma (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Other operations on intestines (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Other operations on the breast (reconstruction of the breast) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Other partial thyroidectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Parathyroidectomy subtotal (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Parathyroidectomy total (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| partial mandibulectomy hemimandibulectomy (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Pediatrik - Posteromedial soft tissue release CTEV (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Pilar Implant (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Labioplasti Bilateral (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Labioplasti unilateral (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Reseksi septum (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Plastik Rekionstruksi - Septorinoplasty (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Redo torakotomi * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Reduction Neglected Dislocation (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Elek | Kelas VIP | Rp. 13.223.500,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas VIP | Rp. 13.223.500,- |
| Repair laserasi diafragma * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Reposisi dislokasi rahang (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Reseksi maksila suprastuktural (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Rinologi - Caldwell Luc (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Rinologi - Septum Reseksi / SMR (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Alar transverse fusion * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Debridement and anterior fusion in TB Spine * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Decompression laminectomy for HNP with stabilization * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Elektif | Kelas VIP | Rp. 13.223.500,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas VIP | Rp. 13.223.500,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Mayor desloughing and wound debridement of the spine * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Micro endoscopic disectomy (1 level) * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Microscopic disectomy (1 Level) (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Open disectomy multilevel * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Open disestomy (1 Level) * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Open reduction and stabilisation of spinal fracture * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Posterior cervical fusion * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Kelas VIP | Rp. 13.223.500,- |
| Spine - Posterolateral fusion * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Spine - Total disc replacement (multilevel) * (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Split thickness graft to breast (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Terapi Slem Cell (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Thymectomy dengan VATS (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Tiroidektomi total dengan berry picking (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Tiroidektomi total dengan diseksi leher fungsional (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas VIP | Rp. 13.223.500,- |
| Trauma - Limb leg inequality dengan bone lengthening transport (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Turbinoplasty (Elektif) | Kelas VIP | Rp. 13.223.500,- |
| Bilateral radical mastectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| complete glossectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Replantasi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hip - Revisi THR (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - TA/T (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Operasi Commando (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Other operations on pancreas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Other pancreatotomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Implantasi koklea (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Timpanoplasti (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Parotidektomi total (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Partial gastrectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Partial hepatectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair of gastroschisis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair of other bile ducts (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas VIP | Rp. 18.533.699,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas VIP | Rp. 18.533.699,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas VIP | Rp. 18.533.699,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas VIP | Rp. 18.533.699,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas VIP | Rp. 18.533.699,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Total gastrectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Whipple procedure (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Bilateral radical mastectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| complete glossectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hand - Replantasi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Hip - Revisi THR (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - TA/T (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Operasi Commando (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Other operations on pancreas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Other pancreatotomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Implantasi koklea (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Otologi - Timpanoplasti (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Parotidektomi total (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Partial gastrectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Partial hepatectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas VIP | Rp. 18.533.699,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair of gastroschisis (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Repair of other bile ducts (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas VIP | Rp. 18.533.699,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas VIP | Rp. 18.533.699,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas VIP | Rp. 18.533.699,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas VIP | Rp. 18.533.699,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas VIP | Rp. 18.533.699,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Total gastrectomy (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Whipple procedure (Elektif) | Kelas VIP | Rp. 18.533.699,- |
| Evakuasi hematom (pasca pungsi) | Kelas VIP | Rp. 5.601.400,- |
| Excision of perianal skin tags | Kelas VIP | Rp. 5.601.400,- |
| GIN - Insisi Septum Vagina | Kelas VIP | Rp. 5.601.400,- |
| GIN - kromotubasi | Kelas VIP | Rp. 5.601.400,- |
| GIN- Himenectomy | Kelas VIP | Rp. 5.601.400,- |
| GIN- Insisi Drainage | Kelas VIP | Rp. 5.601.400,- |
| GIN- Marsupialisasi | Kelas VIP | Rp. 5.601.400,- |
| Ginekologi - Tubektomi | Kelas VIP | Rp. 5.601.400,- |
| GIN-Kuretase-biopsi PA | Kelas VIP | Rp. 5.601.400,- |
| Glaukoma - Cyclo cryo | Kelas VIP | Rp. 5.601.400,- |
| Hand - Angkat K-Wire with anestesia regional | Kelas VIP | Rp. 5.601.400,- |
| Hand - Jari, extra digit, amputasi | Kelas VIP | Rp. 5.601.400,- |
| Hand - Jari, various, amputation (single) ** | Kelas VIP | Rp. 5.601.400,- |
| Injeksi botox pada strabismus | Kelas VIP | Rp. 5.601.400,- |
| Ligasi Varices Esofgaus (VE) | Kelas VIP | Rp. 5.601.400,- |
| Local excision of lesion of breast | Kelas VIP | Rp. 5.601.400,- |
| Local excision of rectal lesion or tissue | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Drainase abses | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Ekstirpasi | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Ekstraksi IUD dengan anestesi | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Hematoma (ruptur) | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Kauterisasi kondiloma akuminata | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Kista bartholin (kista gartner) | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Kolpotomi pada abses cavum douglas | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Konisasi | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Kuretase abortus | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Kuretase pasca persalinan | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Penjahitan laserasi ringan | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Polip serviks | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Robekan serviks (forniks) | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Shirodkar | Kelas VIP | Rp. 5.601.400,- |
| Obstetri - Sistoskopi LEETZ | Kelas VIP | Rp. 5.601.400,- |
| Onkologi - Insisional biopsi kelenjar leher | Kelas VIP | Rp. 5.601.400,- |
| Open biopsy of rectum | Kelas VIP | Rp. 5.601.400,- |
| Operkulektomi | Kelas VIP | Rp. 5.601.400,- |
| Other diagnostic procedures of abdominal region | Kelas VIP | Rp. 5.601.400,- |
| Other excision of perianal tissue | Kelas VIP | Rp. 5.601.400,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas VIP | Rp. 5.601.400,- |
| Otologi - Biopsi | Kelas VIP | Rp. 5.601.400,- |
| Otologi - Ekstraksi benda asing | Kelas VIP | Rp. 5.601.400,- |
| Pasang implantable central venous access * | Kelas VIP | Rp. 5.601.400,- |
| Pasang thoraks drain (WSD) * | Kelas VIP | Rp. 5.601.400,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih | Kelas VIP | Rp. 5.601.400,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat | Kelas VIP | Rp. 5.601.400,- |
| Pemasangan interdental wiring / arch bar | Kelas VIP | Rp. 5.601.400,- |
| Pericardiocentesis * | Kelas VIP | Rp. 5.601.400,- |
| Pleurodesis (pleurosklerosis) * | Kelas VIP | Rp. 5.601.400,- |
| Rekonstruksi - Eksisi tumor kecil kelopak | Kelas VIP | Rp. 5.601.400,- |
| Rekonstruksi - Oklusi punctum lakrimal | Kelas VIP | Rp. 5.601.400,- |
| Release tongue tie * | Kelas VIP | Rp. 5.601.400,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * | Kelas VIP | Rp. 5.601.400,- |
| Reposisi tertutup fraktur condilus mandibula | Kelas VIP | Rp. 5.601.400,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) | Kelas VIP | Rp. 5.601.400,- |
| Rinologi - Irigasi Sinus / DAWO | Kelas VIP | Rp. 5.601.400,- |
| Scleroterapi dan atau ligasi hemangioma | Kelas VIP | Rp. 5.601.400,- |
| Suture of laceration of anus | Kelas VIP | Rp. 5.601.400,- |
| Thoracocentesis * | Kelas VIP | Rp. 5.601.400,- |
| Trauma - Acute glenohumeral joint dislocation * | Kelas VIP | Rp. 5.601.400,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * | Kelas VIP | Rp. 5.601.400,- |
| Vena punctie - kanulasi - sectie * | Kelas VIP | Rp. 5.601.400,- |
| Persalinan Normal | Kelas VIP | Rp. 2.441.100,- |
| Persalinan Dengan Penyulit | Kelas VIP | Rp. 3.879.500,- |
| Hecting Perineum | Kelas VIP | Rp. 1.378.000,- |
| Manual Plasenta | Kelas VIP | Rp. 366.300,- |
| Induksi Persalinan | Kelas VIP | Rp. 610.300,- |
| Amputation of digiti single ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Anal fistulectomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Anal fistulotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Anterior lamellar keratoplasty (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Appendicostomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Babcock (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas VIP | Rp. 9.267.199,- |
| Bilateral multipel excision of lesion of breast with narcose (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral ovariectomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of direct inguinal hernia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of indirect inguinal hernia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas VIP | Rp. 9.267.199,- |
| Biopsi pembuluh darah perifer * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi perikardium * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka bronkhus * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka diafragma * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka mediastinum * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka paru * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka pleura * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka pleura dengan VATS * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsi terbuka tumor dinding thoraks * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Caecostomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Closure of anal fistula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Combustio (luka bakar) * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Compartement excision (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Debridement-nekrotomi luka gangren (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Deseksi submandibula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Disartikulasi sendi ekstremitas (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Dislokasi bahu * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Drainage of appendiceal abscess (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Drainage of pancreatic cyst by catheter (Cito) | Kelas VIP | Rp. 9.267.199,- |
| DSAEK (Cito) | Kelas VIP | Rp. 9.267.199,- |
| ECCE / ICCE / SICS (Cito) | Kelas VIP | Rp. 9.267.199,- |
| ECCE / SICS dan IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi biopsi tumor pembuluh darah (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi glandula submandibula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi higroma leher * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi kista tiroglosus (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi parsial dan marsupialisasi Ranula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi Pterigium (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi tumor dinding dada * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Eksisi tumor pembuluh darah perifer ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ekstirpasi kelainan kornea (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ekstraksi corpus alienum segmen anterior (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ekstraksi IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Endoskopi - Esofagoskopi dilatasi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Evakuasi silicon oil (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Evakuasi silicon oil dan ECCE (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Exchange IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Excision of ectopic breast tissue (Cito) | Kelas VIP | Rp. 9.267.199,- |
| excision of lesion of breast with narcose (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Excision of thyroglossal duct or trac (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Exploratory laparotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Extirpasi kista rongga mulut (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Extirpasi muoccocele rongga mulut (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Fasciotomy * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Fiksasi interna fraktur nasal (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Flap konjungtiva amnion graft (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Fraktur humerus * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Gastrostomi * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| GIN -Ekstirpasi polip (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Kistektomi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Laparotomi Diagnostik (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Miomektomi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Pemasangan Implan Tableport (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ginekologi - Salpingo-ooforektomi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Anterior / posterior sklerotomi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Gonioplasty / goniotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Iridektomi perifer (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Paracentesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Reformasi COA (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Revisi Bleb (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Tindakan cyclodia termi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Trabekulektomi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Trabekulotomi anak atau bayi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Transkleral Foto Coagulasi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Glaukoma - Tubes implan (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Elbow, tennis elbow, release (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, crush injuries (complex) wound debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, crush injury (simple), wound debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, deep infection, drainage (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, deformity, instrinsic muscle release (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, injury, debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, jaringan lunak tumor, excision (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, macrodactyly, debulking (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, ring construction (single), koreksi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, superficial infection, drainage (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, syndactili (single) koreksi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, trauma, terminalisation (multiple) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, trauma, terminalisation (single) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, various lesions, amputasi (multiple) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jari, wart, com, naevus, excision (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas VIP | Rp. 9.267.199,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas VIP | Rp. 9.267.199,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas VIP | Rp. 9.267.199,- |
| Hand - Nail bed, Laceration, repair (single) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Nerve various lesions, primary or secondary suture (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Nerve, Various Lesions, biopsy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Repair muscle (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (Ci | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Cit | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (Ci | Kelas VIP | Rp. 9.267.199,- |
| Hidrokel Testis / Funikuli ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Implantasi iris artifisial (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Implantasi piggyback IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Incision of perianal abscess (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Injeksi intravitreal (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Insertion of synthetic implant in facial bone (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Insisi atau Eksisi gingiva (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Insisi flegmon dasar mulut (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Internal Fiksasi fraktur condylus mandibula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Internal Fiksasi fraktur Mandibula segmental (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Keratoplasty tembus (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Keratoprosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Knee - Open knee debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Knee - Perypheral nerve ablation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Knee - Perypheral nerve lysis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Kolonoskopi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Labioshisis * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Laring dan Faring - Laringofisure (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Laring dan Faring - Pemasangan T-Tube (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Left lateral anal sphincterotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ligasi vaskular ekstremitas (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Ligation of hemorrhoids (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Limbal Relaxing Incision (LRI) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Maksilektomi total dan Rekonstruksi * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Multipel excision of lesion of breast with narcose (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Mutilasi digiti ekstremitas (Multiple) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Obstetri - Histerorafi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Obstetri - Kolporafi anterior (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Obstetri - Kolporafi posterior (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Obstetri - Mioma geburt (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Obstetri - Sectio caesaria tanpa penyulit (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Odontektomi tingkat I (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Cit | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Open biopsy bone tumor (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Open biopsy soft tissue (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Ray amputation jari (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Open biopsi of breast (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Open biopsy of salivary gland or duct (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Open reduction of alveolar fracture * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Osteotomi eksisi tulang maksilofasial (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other appendectomy (elective) * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other bilateral femoral hernioraphy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other hernia repair (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other incidental appendectomy * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other incision of anus (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other lysis of peritoneal adhesions (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other operations on anus (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other operations on trachea (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other procedures on hemorrhoids (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other reconstruction of mandible (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other reconstruction of other facial bone (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other repair and plastic operation of tongue (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other repair of abdominal wall (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other umbilical herniorraphy* (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Other unilateral femoral herniorraphy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Otologi - Meatoplasti (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Otologi - Miringoplasti (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Otologi - Pemasangan grommet (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Palatoshisis ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Partial glossectomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Debridement fraktur terbuka anak (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Hemangioma : injeksi intralesi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Katarak (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Koreksi curly toe (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Koreksi overriding toe polidactili (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Koreksi syndactili kaki (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Nekrotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Open achilles tendon lengthening (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Percutaneous tendon tenotomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (Ci | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - RetCam and Narkose (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Skin graft (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pembedahan teleangiectasis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pengangkatan encircling silicone band (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Perikardiektomi * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Phaco dan IOL multifokal atau torik (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Phakik IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Phototherapeutic keratectomy (PTK) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pionephrosis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pleural window (eloeser flap) * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Plikasi bulae / bleb emfisematous (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pneumatic retinopexy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas VIP | Rp. 9.267.199,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Prosedur Sistrunk kista duktus tiroglosus (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Pulmonary decortication * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Ektropion 1 kelopak * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Entropion 1 kelopak (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Eviserasi / enukleasi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Koreksi Ptosis * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Koreksi simblefaron (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Probing (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Repair Ruptur palpebra * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rekonstruksi - Tarsorafi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Release kontraktur mandibula (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Release tortikolis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Removal of foreign body from peritoneal cavity (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Removal of foreign body from retro-peritoneal cavity (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair iridodyalisis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of direct inguinal hernia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of direct inguinal hernia with graft or prosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of indirect inguinal hernia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of laceration, cornea and or sclera, perforating (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of laceration, cornea, non perforating (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of other hernia of anterior abdominal wall (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Repair of umbilical hernia with prosthesis * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Reposisi IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Reposisi Iris (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Reposisi tertutup fraktur nasal (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rinologi - Konkotomi / Konkoplasti (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Rupture tendon achiles (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Scleral buckle, cryo dan C3F8 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Scleral buckling (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Sekunder IOL (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Somnoplasty (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Spine - Biopsy vertebra (1 level) * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Spine - Plaster application of the spine (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Strabismus 1 otot (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Strabismus 2 otot (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Strabismus 3 otot (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Suture of laceration of large intestine (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Suture of laceration of small intestine, except duodenum (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Suture of peritoneum (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tatto cornea (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Torakotomi / sternotomi eksplorasi * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Torsio testis ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trakeostomi temporary ** (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Acute ankle joint dislocation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Acute elbow joint dislocation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Acute hip joint dislocation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Acute knee joint dislocation (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Closed fraktur shaft femur * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Closed fraktur shaft humerus * (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Closed fraktur shaft radius (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Closed fraktur shaft tibia (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Closed fraktur shaft ulna (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Jaringan granulasi dengan STSG (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Kompartemen otot (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Nekrotik tissue dengan debridement (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Biopsi tumor kelopak (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Biopsi tumor orbita (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Eksenterasi (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Eksisi tumor adneksa (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Ekstirpasi Tumor Orbita (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Orbital dekompresi 1 tulang (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Orbital dekompresi 2 tulang (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Orbitotomi anterior (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Tumor - Orbitotomi lateral (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas VIP | Rp. 9.267.199,- |
| Unilateral thyroid lobectomy (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Wide excision of soft tissue tumor (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Uff Arch Barr (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Uff Arch Barr dan suspensi maksila (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Amputasi jari (phalangs - traumatik) (Cito) | Kelas VIP | Rp. 9.267.199,- |
| Biopsy insisional dengan anastesi lokal (Cito) | Kelas VIP | Rp. 2.661.100,- |
| Biopsy of perianal tissue (Cito) | Kelas VIP | Rp. 2.661.100,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas VIP | Rp. 11.884.276,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pedicle or flaps graft (not otherwise specified) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pembuatan thoracic window (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Perikardiotomi / pericardial window * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Permanent colostomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Permanent ileostomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Phaco (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Phaco dan IOL (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Faringeal flap (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Forehead flap (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Otoplasty * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Revisi parut (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Rinoplasty * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pleurektomi * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Plikasi diafragma * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pneumonectomy * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Posterior vitrectomy, Phaco dan IOL (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Radical excision of skin lesion (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Reclosure of postoperative disruption of abdominal wall (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rectosigmoidoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Reduction of anal prolapse (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Fraktur dasar orbita (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Fraktur Multiple (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Palpebra dengan Graft * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Soket kontraktur (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rekonstruksi - Soket landai (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Reopening of recent laparotomy site (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Repair arteri poplitea dan femoralis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Repair of diaphragmatic hernia, abdominal approach (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Repair of laceration of gallbladder (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Resection of transverse colon (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Reseksi maksila infrastuktural (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Reseksi mandibula tanpa rekonstruksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Revision of anastomosis of large intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Revision of anastomosis of small intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Revision of stoma of large intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Revision of stoma of small intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Revision of tracheostomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Right hemicolectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rinologi - BSEF / FESS 1 : Mini (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Rupture buli-buli * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Scleral buckling, phaco dan IOL (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Sigmoidectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Simple suture of common bile duct (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Small to small intestinal anastomosis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Discograph (1 level) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Discograph (1 level) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Discograph multilevel * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Facet block (1 level) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Facet block multilevel (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Foraminal block (1 level) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Foraminal block multilevel (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas VIP | Rp. 11.884.276,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Strabismus 4 otot (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Stripping varises ekstremitas inferior (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Subtotal mastectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Temporary colostomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Temporary ileostomy * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Cito | Kelas VIP | Rp. 11.884.276,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Total splenectomy * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Closed fraktur distal tibia (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Closed fraktur intercondylar femur (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Closed fraktur supracondylar femur (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur collum femur pada orang tua (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur galeazi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur montegia (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Instability joint infection (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Joint stiffness dengan liberation (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Non union dengan bone graft (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Open fraktur shaft femur grade 3 (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Open fraktur shaft humerus grade 3 (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Open fraktur shaft radius grade 3 (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Open fraktur shaft tibia grade 3 (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Open fraktur shaft ulna grade 3 (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Trauma - Osteomyelitis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Tumor - Extended Eksenterasi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Tumor - Orbital dekompresi 3 tulang (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Tumor - Orbitotomi lateral and superior (medial) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Unilateral radical mastectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Unilateral simple mastectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Upper Endoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Upper Endoskopi dan biopsi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Upper Endoskopi dan ekstraksi carpal (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Upper Endoskopi dan ligasi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Amputasi above knee (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Amputasi below knee (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Aneurisma arteri brachialis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Aneurisma arteri femoralis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Axillary dissection (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Batu saluran kemih * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Bilateral simple mastectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Cholecystectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Choledochoplasty (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of appendiceal fistula (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of cholecystostomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of fistula of large intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of fistula of small intestine, except duodenum (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of intestinal stoma (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Closure of leceration of liver (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Colostomy (not otherwise specified) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Common duct exploration for removal of calculus (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Debridement mediastinum (sternotomi) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Diseksi leher radikal / radikal neck dissection * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Eksisi pseudoaneurisma (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Eksplorasi vaskular (trauma / non trauma) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ekstraksi corpus alienum di regio toraks * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoscopic polypectomy of rectum (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoscopic thyroidectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Pan bronkoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Pan esofagoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Sialendoskopi diagnostik (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Endoskopi - Sleep nasoendoskopi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Excision of hemorrhoid (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Exploration of common duct (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Exteriorization of large intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Exteriorization of small intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fiksasi sternum (wire, plate) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur antebrachi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur colles dan pergelangan tangan lainnya (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur cruris (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur femur * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur klavikula (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur olekranon (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur patela (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Fraktur suprakondiler humerus (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Free skin graft (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Full-thickness skin graft to hand (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Full-thickness skin graft to other sites * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| GIN- Hymenoplasty (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ginekologi - Histerektomi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ginekologi - Kehamilan ektopik (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ginekologi - Miomektomi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Groin dissection (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (C | Kelas VIP | Rp. 11.884.276,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Jari, deformities, koreksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas VIP | Rp. 11.884.276,- |
| Hand - Jari, ring constriction (multiple), koreksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Jari, syndactili (multiple) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (C | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nail bed, laceration, Repair (multiple) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas VIP | Rp. 11.884.276,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas VIP | Rp. 11.884.276,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Cit | Kelas VIP | Rp. 11.884.276,- |
| Hand - Thumb, deformitas, Koreksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hemiglosektomi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hip - Arthroscopy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hip - Hemiarthroplasty (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hip - ORIF, DHS (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Hipertropi Prostat Beningna (BPH) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Ileostomy (not otherwise specified) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Incisional hernia repair (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Incisional hernia repair with prosthesis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Internal drainage of pancreatic cyst (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Anterior cruciate ligament reconstruction (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy debridement knee (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy debridement shoulder (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy diagnostic (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy diagnostic shoulder (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy meniscus repair (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy remove loose body (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Arthroscopy remove loose body shoulder (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Fibular osteotomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Lateral collateral ligament reconstruction (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Medial collateral ligament reconstruction (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Posterior cruciate ligamnet reconstruction (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Revisi total knee replacement (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Revisi total shoulder replacement (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Rotator cuff repair by arthroscopy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Shoulder hemiarthroplasty (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Knee - Total shoulder replacement (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Kolonoskopi dan Biopsi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparoscopic lysis of peritoneal adhesions (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparoskopi/histeroskopi - ovarian drilling (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparskopi / Histereskopi - Second Look (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laparskopi / Histereskopi - Tubektomi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Large to large intestinal anastomosis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laring dan Faring - Laringektomi * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laring dan Faring - Laringektomi + RND * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laring dan Faring - RND * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laringectomi * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Laringectomi dengan diseksi leher * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Lasik 1 (satu) mata (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Lobektomi parsial (reseksi paru segmental) * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Muscle flap graft to breast (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Partus Dengan Bius ELA (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Partus Dengan Bius ILA (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Purandare (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Rekonstruksi vagina (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Repair fistula (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Cito | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Obstetri - Vaginoplasti (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Odontektomi tingkat II (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Diseksi leher bilateral (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Diseksi leher modified (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Ligasi arteri karotis eksterna (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Mandibulektomi parsial (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas VIP | Rp. 11.884.276,- |
| Onkologi - Total patellectomy dan rekonstruksi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open biopsy of gallbladder or bile ducts (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open biopsy of liver (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open biopsy of pancreas (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open reduction of malar and zygomatic fracture (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open reduction of mandibular fractur (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Open reduction of maxillary fracture (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other destruction of lesion of liver (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other laparotomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other partial excision of large intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other repair of anal sphincter (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other repair of intestine (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other repair of mesentery (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other skin graft to hand (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other skin graft to other sites (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other small to large intestinal anastomosis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Other suture of abdominal wall (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Otologi - Dekompresi nervus fasialis (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Otologi - Mastoidektomi radikal (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Otologi - Mastoidektomi sederhana (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Otologi - Stapedektomi (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Parotidektomi superfisial * (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Partial splenectomy (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas VIP | Rp. 11.884.276,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Cito) | Kelas VIP | Rp. 11.884.276,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas VIP | Rp. 11.884.276,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas VIP | Rp. 11.884.276,- |
| Clipping costa (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Complete thyroidectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Eksisi pada bronkhus (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Endoskopi - Bronkoskopi diagnostik (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Endoskopi - Esofagoskopi BA dengan penyulit (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Endoskopi - Esofagoskopi diagnostik (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Excision of other bile duct (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Ginekologi - Repair tuba (tubaplasti) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Ginekologi - Reseksi adenomiosis (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Ginekologi - Transposisi Ovarium (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Artery, large, injury, repair with grafting (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Carpus, delayed (non union), rekonstruksi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari (digit), stump, revision (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari, deformities, major reconstruction procedure (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari, deformities, osteotomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari, deformity, instrinsic muscle transfer (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Jari, scar, revision osteotomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Kelas VIP | Rp. 15.468.626,- |
| Hand - Nerve defect, peripheral graft (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Nerve digital, Injury, microsurgical (single) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Nerve digital, injury, primary repair (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Nerve ulnar, entrapment, transposition (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas VIP | Rp. 15.468.626,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hand - Thumb, paralysis, oppnens plasty (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Hip - Total hip replacement (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Intra-abdominal manipulation of large intestine (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Intra-abdominal manipulation of small intestine (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Knee - Total knee replacement (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Knee - Uni compartment arthroplasty (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparoscopic appendectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparoscopic appendectomy (elective) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparoscopic cholecystectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparoscopic incidental appendectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparoscopy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Kistektomi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Ovareksi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Salpingoooforektomi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laparskopi / Histereskopi - Transposisi Ovarium (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laring dan Faring - TA/T dengan Coblation Laser (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laring dan Faring - Tiroidektomi Subtotal ** (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laring dan Faring - Tiroidektomi Total (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Left hemicolectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Mediastinostomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Obstetri - Operasi plasenta akreta (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Odontektomi tingkat III (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Belloque tampon dengan narkosis (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Diseksi leher radikal * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Eksplorasi nasofaring (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Ekstirpasi tumor jinak kel liur (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Hemiglosektomi (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Maksilektomi parsial (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Maksilektomi total (radikal) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - ORIF MBD (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Parotidektomi * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Onkologi - Wide excision soft tisue sarcoma (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Other operations on intestines (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Other operations on the breast (reconstruction of the breast) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Other partial thyroidectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Parathyroidectomy subtotal (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Parathyroidectomy total (Cito) | Kelas VIP | Rp. 15.468.626,- |
| partial mandibulectomy hemimandibulectomy (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Pediatrik - Posteromedial soft tissue release CTEV (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Pilar Implant (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Labioplasti Bilateral (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Labioplasti unilateral (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Reseksi septum (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Plastik Rekionstruksi - Septorinoplasty (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Redo torakotomi * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Reduction Neglected Dislocation (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Cito | Kelas VIP | Rp. 15.468.626,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas VIP | Rp. 15.468.626,- |
| Repair laserasi diafragma * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Reposisi dislokasi rahang (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Reseksi maksila suprastuktural (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Rinologi - Caldwell Luc (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Rinologi - Septum Reseksi / SMR (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Alar transverse fusion * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Debridement and anterior fusion in TB Spine * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Decompression laminectomy for HNP with stabilization * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas VIP | Rp. 15.468.626,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Mayor desloughing and wound debridement of the spine * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Micro endoscopic disectomy (1 level) * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Microscopic disectomy (1 Level) (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Open disectomy multilevel * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Open disestomy (1 Level) * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Open reduction and stabilisation of spinal fracture * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Posterior cervical fusion * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Kelas VIP | Rp. 15.468.626,- |
| Spine - Posterolateral fusion * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Spine - Total disc replacement (multilevel) * (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Split thickness graft to breast (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Terapi Slem Cell (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Thymectomy dengan VATS (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Tiroidektomi total dengan berry picking (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Tiroidektomi total dengan diseksi leher fungsional (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas VIP | Rp. 15.468.626,- |
| Trauma - Limb leg inequality dengan bone lengthening transport (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Turbinoplasty (Cito) | Kelas VIP | Rp. 15.468.626,- |
| Bilateral radical mastectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| complete glossectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Fiksasi interna fraktur panfacial (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Histerektomi radikal (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Operasi Frozen Pelvic (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Relaparatomi high risk complication (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Staging Laparatomi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Trachelectomy Radical Servix (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Ultra Radikal Histerektomi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Ginekologi - Vulvektomi radikal (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Hand - Replantasi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Hip - Revisi THR (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Histerektomi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Miomektomi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Onkologi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Laringoskopi Diagnostik (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - TA/T (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Trakeostomi ** (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Modifikasi RND / functional neck dissection (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Ekstirpasi angiofibroma (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Forequarter amputation (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Hemipelvectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery tahap 1 (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Limb salvage surgery tahap 2 (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Marginal margine excision soft tissue tumor (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Tiroidektomi subtotal ** (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Tiroidektomi total (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Operasi Commando (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Other operations on pancreas (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Other pancreatotomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Otologi - Implantasi koklea (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Otologi - Temporal bone ressection (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Otologi - Timpanoplasti (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Parotidektomi total (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Partial gastrectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Partial hepatectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (C | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Cito | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas VIP | Rp. 21.954.850,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Plastik Rekionstruksi - Palatoplasty * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Rekonstruksi fraktur blow-out (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Rekonstruksi menggunakan flap bebas (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Rekonstruksi sternum dan dinding dada (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Repair aneurisma aorta abdominalis * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Repair of gastroschisis (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Repair of other bile ducts (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Cito | Kelas VIP | Rp. 21.954.850,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas VIP | Rp. 21.954.850,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas VIP | Rp. 21.954.850,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas VIP | Rp. 21.954.850,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas VIP | Rp. 21.954.850,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Total gastrectomy (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Trauma - Neglected case dengan bone reconstruction (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Whipple procedure (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Arteriovenous shunt (AV Shunt) brakiosefalika (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Arteriovenous shunt (AV Shunt) radiosefalika (Cito) | Kelas VIP | Rp. 21.954.850,- |
| AV - Shunt dengan lokal anesthesi (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Pasang double lumen hemodialysis (HD) (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Pemasangan Central Venous Catheter (CVC) (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Revisi arteriovenous shunt * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Skleroterapi vena (varises, hemangioma) * (Cito) | Kelas VIP | Rp. 21.954.850,- |
| Evakuasi hematom (pasca pungsi) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Excision of perianal skin tags ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN - Insisi Septum Vagina ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN - kromotubasi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN- Himenectomy ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN- Insisi Drainage ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN- Marsupialisasi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Ginekologi - Tubektomi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| GIN-Kuretase-biopsi PA ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Glaukoma - Cyclo cryo ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Hand - Angkat K-Wire with anestesia regional ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Hand - Jari, extra digit, amputasi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Hand - Jari, various, amputation (single) ** ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Injeksi botox pada strabismus ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Ligasi Varices Esofgaus (VE) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Local excision of lesion of breast ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Local excision of rectal lesion or tissue ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Drainase abses ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Ekstirpasi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Ekstraksi IUD dengan anestesi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Hematoma (ruptur) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Kauterisasi kondiloma akuminata ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Kista bartholin (kista gartner) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Kolpotomi pada abses cavum douglas ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Konisasi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Kuretase abortus ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Kuretase pasca persalinan ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Penjahitan laserasi ringan ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Polip serviks ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Robekan serviks (forniks) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Shirodkar ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Obstetri - Sistoskopi LEETZ ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Onkologi - Insisional biopsi kelenjar leher ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Open biopsy of rectum ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Operkulektomi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Other diagnostic procedures of abdominal region ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Other excision of perianal tissue ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas VIP | Rp. 6.395.600,- |
| Otologi - Biopsi ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Otologi - Ekstraksi benda asing ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pasang implantable central venous access * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pasang thoraks drain (WSD) * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pemasangan interdental wiring / arch bar ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pericardiocentesis * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Pleurodesis (pleurosklerosis) * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Rekonstruksi - Eksisi tumor kecil kelopak ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Rekonstruksi - Oklusi punctum lakrimal ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Release tongue tie * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Reposisi tertutup fraktur condilus mandibula ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Rinologi - Irigasi Sinus / DAWO ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Scleroterapi dan atau ligasi hemangioma ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Suture of laceration of anus ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Thoracocentesis * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Trauma - Acute glenohumeral joint dislocation * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Vena punctie - kanulasi - sectie * ( Cito ) | Kelas VIP | Rp. 6.395.600,- |
| Amputation of digiti single ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Anal fistulectomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Anal fistulotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Anterior lamellar keratoplasty (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Appendicostomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Babcock (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas VIP | Rp. 8.019.900,- |
| Bilateral multipel excision of lesion of breast with narcose (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral ovariectomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of direct inguinal hernia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of indirect inguinal hernia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas VIP | Rp. 8.019.900,- |
| Biopsi pembuluh darah perifer * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi perikardium * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka bronkhus * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka diafragma * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka mediastinum * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka paru * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka pleura * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka pleura dengan VATS * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Biopsi terbuka tumor dinding thoraks * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Caecostomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Closure of anal fistula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Combustio (luka bakar) * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Compartement excision (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Debridement-nekrotomi luka gangren (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Deseksi submandibula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Disartikulasi sendi ekstremitas (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Dislokasi bahu * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Drainage of appendiceal abscess (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Drainage of pancreatic cyst by catheter (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| DSAEK (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| ECCE / ICCE / SICS (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| ECCE / SICS dan IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi biopsi tumor pembuluh darah (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi glandula submandibula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi higroma leher * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi kista tiroglosus (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi parsial dan marsupialisasi Ranula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi Pterigium (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi tumor dinding dada * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Eksisi tumor pembuluh darah perifer ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ekstirpasi kelainan kornea (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ekstraksi corpus alienum segmen anterior (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ekstraksi IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Endoskopi - Esofagoskopi dilatasi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Evakuasi silicon oil (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Evakuasi silicon oil dan ECCE (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Exchange IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Excision of ectopic breast tissue (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| excision of lesion of breast with narcose (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Excision of thyroglossal duct or trac (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Exploratory laparotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Extirpasi kista rongga mulut (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Extirpasi muoccocele rongga mulut (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Fasciotomy * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Fiksasi interna fraktur nasal (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Flap konjungtiva amnion graft (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Fraktur humerus * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Gastrostomi * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| GIN -Ekstirpasi polip (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Kistektomi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Laparotomi Diagnostik (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Miomektomi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Pemasangan Implan Tableport (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ginekologi - Salpingo-ooforektomi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Anterior / posterior sklerotomi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Gonioplasty / goniotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Iridektomi perifer (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Paracentesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Reformasi COA (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Revisi Bleb (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Tindakan cyclodia termi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Trabekulektomi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Trabekulotomi anak atau bayi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Transkleral Foto Coagulasi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Glaukoma - Tubes implan (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Elbow, tennis elbow, release (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, crush injuries (complex) wound debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, crush injury (simple), wound debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, deep infection, drainage (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, deformity, instrinsic muscle release (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, injury, debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, jaringan lunak tumor, excision (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, macrodactyly, debulking (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, ring construction (single), koreksi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, superficial infection, drainage (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, syndactili (single) koreksi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, trauma, terminalisation (multiple) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, trauma, terminalisation (single) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, various lesions, amputasi (multiple) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jari, wart, com, naevus, excision (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas VIP | Rp. 8.019.900,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas VIP | Rp. 8.019.900,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas VIP | Rp. 8.019.900,- |
| Hand - Nail bed, Laceration, repair (single) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Nerve various lesions, primary or secondary suture (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Nerve, Various Lesions, biopsy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Repair muscle (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Elektif | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (El | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Ele | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Elekt | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Elekti | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (El | Kelas VIP | Rp. 8.019.900,- |
| Hidrokel Testis / Funikuli ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Implantasi iris artifisial (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Implantasi piggyback IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Incision of perianal abscess (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Injeksi intravitreal (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Insertion of synthetic implant in facial bone (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Insisi atau Eksisi gingiva (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Insisi flegmon dasar mulut (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Internal Fiksasi fraktur condylus mandibula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Internal Fiksasi fraktur Mandibula segmental (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Keratoplasty tembus (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Keratoprosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Knee - Open knee debridement (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Knee - Perypheral nerve ablation (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Knee - Perypheral nerve lysis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Kolonoskopi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Labioshisis * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Laring dan Faring - Laringofisure (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Laring dan Faring - Pemasangan T-Tube (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Left lateral anal sphincterotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ligasi vaskular ekstremitas (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Ligation of hemorrhoids (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Limbal Relaxing Incision (LRI) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Maksilektomi total dan Rekonstruksi * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Multipel excision of lesion of breast with narcose (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Mutilasi digiti ekstremitas (Multiple) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Obstetri - Histerorafi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Obstetri - Kolporafi anterior (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Obstetri - Kolporafi posterior (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Obstetri - Mioma geburt (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Obstetri - Sectio caesaria tanpa penyulit (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Odontektomi tingkat I (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Ele | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Open biopsy bone tumor (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Open biopsy soft tissue (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Ray amputation jari (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Open biopsi of breast (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Open biopsy of salivary gland or duct (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Open reduction of alveolar fracture * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Osteotomi eksisi tulang maksilofasial (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other appendectomy (elective) * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other bilateral femoral hernioraphy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other hernia repair (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other incidental appendectomy * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other incision of anus (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other lysis of peritoneal adhesions (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other operations on anus (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other operations on trachea (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other procedures on hemorrhoids (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other reconstruction of mandible (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other reconstruction of other facial bone (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other repair and plastic operation of tongue (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other repair of abdominal wall (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other umbilical herniorraphy* (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Other unilateral femoral herniorraphy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Otologi - Meatoplasti (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Otologi - Miringoplasti (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Otologi - Pemasangan grommet (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Palatoshisis ** (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Partial glossectomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Debridement fraktur terbuka anak (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Hemangioma : injeksi intralesi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Katarak (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Koreksi curly toe (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Koreksi overriding toe polidactili (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Koreksi syndactili kaki (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Nekrotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Open achilles tendon lengthening (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Percutaneous tendon tenotomy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (El | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Elekt | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - RetCam and Narkose (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Skin graft (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pembedahan teleangiectasis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pengangkatan encircling silicone band (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Perikardiektomi * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Phaco dan IOL multifokal atau torik (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Phakik IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Phototherapeutic keratectomy (PTK) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pionephrosis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pleural window (eloeser flap) * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Plikasi bulae / bleb emfisematous (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pneumatic retinopexy (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas VIP | Rp. 8.019.900,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Prosedur Sistrunk kista duktus tiroglosus (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Pulmonary decortication * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Ektropion 1 kelopak * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Entropion 1 kelopak (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Eviserasi / enukleasi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Koreksi Ptosis * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Koreksi simblefaron (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Probing (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Elekt | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Repair Ruptur palpebra * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rekonstruksi - Tarsorafi (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Release kontraktur mandibula (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Release tortikolis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Removal of foreign body from peritoneal cavity (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Removal of foreign body from retro-peritoneal cavity (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair iridodyalisis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of direct inguinal hernia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of direct inguinal hernia with graft or prosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of indirect inguinal hernia (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of laceration, cornea and or sclera, perforating (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of laceration, cornea, non perforating (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of other hernia of anterior abdominal wall (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Repair of umbilical hernia with prosthesis * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Reposisi IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Reposisi Iris (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Reposisi tertutup fraktur nasal (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rinologi - Konkotomi / Konkoplasti (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Rupture tendon achiles (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Scleral buckle, cryo dan C3F8 (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Scleral buckling (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Sekunder IOL (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Somnoplasty (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Spine - Biopsy vertebra (1 level) * (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Spine - Plaster application of the spine (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Strabismus 1 otot (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Strabismus 2 otot (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Strabismus 3 otot (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Suture of laceration of large intestine (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Suture of laceration of small intestine, except duodenum (Elektif) | Kelas VIP | Rp. 8.019.900,- |
| Persalinan Normal | Kelas VVIP | Rp. 2.544.600,- |
| Persalinan Dengan Penyulit | Kelas VVIP | Rp. 4.034.800,- |
| Hecting Perineum | Kelas VVIP | Rp. 1.429.700,- |
| Manual Plasenta | Kelas VVIP | Rp. 381.800,- |
| Induksi Persalinan | Kelas VVIP | Rp. 636.200,- |
| Uff Arch Barr (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Uff Arch Barr dan suspensi maksila (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Amputasi jari (phalangs - traumatik) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Amputation of digiti single ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Anal fistulectomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Anal fistulotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Anterior lamellar keratoplasty (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Appendicostomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Babcock (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral multipel excision of lesion of breast with narcose (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral ovariectomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of direct inguinal hernia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of indirect inguinal hernia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi pembuluh darah perifer * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi perikardium * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka bronkhus * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka diafragma * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka mediastinum * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka paru * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka pleura * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka pleura dengan VATS * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsi terbuka tumor dinding thoraks * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Caecostomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Closure of anal fistula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Combustio (luka bakar) * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Compartement excision (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Debridement-nekrotomi luka gangren (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Deseksi submandibula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Disartikulasi sendi ekstremitas (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Dislokasi bahu * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Drainage of appendiceal abscess (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Drainage of pancreatic cyst by catheter (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| DSAEK (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| ECCE / ICCE / SICS (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| ECCE / SICS dan IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi biopsi tumor pembuluh darah (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi glandula submandibula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi higroma leher * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi kista tiroglosus (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi parsial dan marsupialisasi Ranula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi Pterigium (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi tumor dinding dada * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Eksisi tumor pembuluh darah perifer ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ekstirpasi kelainan kornea (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ekstraksi corpus alienum segmen anterior (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ekstraksi IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Endoskopi - Esofagoskopi dilatasi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Evakuasi silicon oil (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Evakuasi silicon oil dan ECCE (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Exchange IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Excision of ectopic breast tissue (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| excision of lesion of breast with narcose (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Excision of thyroglossal duct or trac (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Exploratory laparotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Extirpasi kista rongga mulut (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Extirpasi muoccocele rongga mulut (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Fasciotomy * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Fiksasi interna fraktur nasal (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Flap konjungtiva amnion graft (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Fraktur humerus * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Gastrostomi * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| GIN -Ekstirpasi polip (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Kistektomi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Laparotomi Diagnostik (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Miomektomi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Pemasangan Implan Tableport (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ginekologi - Salpingo-ooforektomi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Anterior / posterior sklerotomi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Gonioplasty / goniotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Iridektomi perifer (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Paracentesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Reformasi COA (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Revisi Bleb (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Tindakan cyclodia termi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Trabekulektomi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Trabekulotomi anak atau bayi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Transkleral Foto Coagulasi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Glaukoma - Tubes implan (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Elbow, tennis elbow, release (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, crush injuries (complex) wound debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, crush injury (simple), wound debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, deep infection, drainage (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, deformity, instrinsic muscle release (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, injury, debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, jaringan lunak tumor, excision (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, macrodactyly, debulking (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, ring construction (single), koreksi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, superficial infection, drainage (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, syndactili (single) koreksi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, trauma, terminalisation (multiple) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, trauma, terminalisation (single) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, various lesions, amputasi (multiple) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jari, wart, com, naevus, excision (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Nail bed, Laceration, repair (single) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Nerve various lesions, primary or secondary suture (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Nerve, Various Lesions, biopsy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Repair muscle (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (Ci | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Cit | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (Ci | Kelas VVIP | Rp. 9.434.600,- |
| Hidrokel Testis / Funikuli ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Implantasi iris artifisial (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Implantasi piggyback IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Incision of perianal abscess (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Injeksi intravitreal (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Insertion of synthetic implant in facial bone (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Insisi atau Eksisi gingiva (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Insisi flegmon dasar mulut (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Internal Fiksasi fraktur condylus mandibula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Internal Fiksasi fraktur Mandibula segmental (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Keratoplasty tembus (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Keratoprosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Knee - Open knee debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Knee - Perypheral nerve ablation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Knee - Perypheral nerve lysis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Kolonoskopi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Labioshisis * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Laring dan Faring - Laringofisure (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Laring dan Faring - Pemasangan T-Tube (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Left lateral anal sphincterotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ligasi vaskular ekstremitas (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Ligation of hemorrhoids (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Limbal Relaxing Incision (LRI) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Maksilektomi total dan Rekonstruksi * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Multipel excision of lesion of breast with narcose (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Mutilasi digiti ekstremitas (Multiple) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Obstetri - Histerorafi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Obstetri - Kolporafi anterior (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Obstetri - Kolporafi posterior (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Obstetri - Mioma geburt (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Obstetri - Sectio caesaria tanpa penyulit (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Odontektomi tingkat I (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Cit | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Open biopsy bone tumor (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Open biopsy soft tissue (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Ray amputation jari (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Open biopsi of breast (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Open biopsy of salivary gland or duct (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Open reduction of alveolar fracture * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Osteotomi eksisi tulang maksilofasial (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other appendectomy (elective) * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other bilateral femoral hernioraphy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other hernia repair (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other incidental appendectomy * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other incision of anus (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other lysis of peritoneal adhesions (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other operations on anus (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other operations on trachea (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other procedures on hemorrhoids (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other reconstruction of mandible (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other reconstruction of other facial bone (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other repair and plastic operation of tongue (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other repair of abdominal wall (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other umbilical herniorraphy* (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Other unilateral femoral herniorraphy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Otologi - Meatoplasti (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Otologi - Miringoplasti (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Otologi - Pemasangan grommet (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Palatoshisis ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Partial glossectomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Debridement fraktur terbuka anak (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Hemangioma : injeksi intralesi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Katarak (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Koreksi curly toe (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Koreksi overriding toe polidactili (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Koreksi syndactili kaki (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Nekrotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Open achilles tendon lengthening (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Percutaneous tendon tenotomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (Ci | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - RetCam and Narkose (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Skin graft (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pembedahan teleangiectasis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pengangkatan encircling silicone band (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Perikardiektomi * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Phaco dan IOL multifokal atau torik (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Phakik IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Phototherapeutic keratectomy (PTK) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pionephrosis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pleural window (eloeser flap) * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Plikasi bulae / bleb emfisematous (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pneumatic retinopexy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas VVIP | Rp. 9.434.600,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Prosedur Sistrunk kista duktus tiroglosus (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Pulmonary decortication * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Ektropion 1 kelopak * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Entropion 1 kelopak (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Eviserasi / enukleasi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Koreksi Ptosis * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Koreksi simblefaron (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Probing (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Repair Ruptur palpebra * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rekonstruksi - Tarsorafi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Release kontraktur mandibula (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Release tortikolis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Removal of foreign body from peritoneal cavity (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Removal of foreign body from retro-peritoneal cavity (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair iridodyalisis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of direct inguinal hernia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of direct inguinal hernia with graft or prosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of indirect inguinal hernia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of laceration, cornea and or sclera, perforating (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of laceration, cornea, non perforating (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of other hernia of anterior abdominal wall (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Repair of umbilical hernia with prosthesis * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Reposisi IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Reposisi Iris (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Reposisi tertutup fraktur nasal (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rinologi - Konkotomi / Konkoplasti (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Rupture tendon achiles (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Scleral buckle, cryo dan C3F8 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Scleral buckling (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Sekunder IOL (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Somnoplasty (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Spine - Biopsy vertebra (1 level) * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Spine - Plaster application of the spine (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Strabismus 1 otot (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Strabismus 2 otot (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Strabismus 3 otot (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Suture of laceration of large intestine (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Suture of laceration of small intestine, except duodenum (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Suture of peritoneum (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tatto cornea (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Torakotomi / sternotomi eksplorasi * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Torsio testis ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trakeostomi temporary ** (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Acute ankle joint dislocation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Acute elbow joint dislocation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Acute hip joint dislocation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Acute knee joint dislocation (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Closed fraktur shaft femur * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Closed fraktur shaft humerus * (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Closed fraktur shaft radius (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Closed fraktur shaft tibia (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Closed fraktur shaft ulna (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Jaringan granulasi dengan STSG (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Kompartemen otot (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Nekrotik tissue dengan debridement (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Biopsi tumor kelopak (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Biopsi tumor orbita (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Eksenterasi (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Eksisi tumor adneksa (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Ekstirpasi Tumor Orbita (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Orbital dekompresi 1 tulang (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Orbital dekompresi 2 tulang (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Orbitotomi anterior (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Tumor - Orbitotomi lateral (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas VVIP | Rp. 9.434.600,- |
| Unilateral thyroid lobectomy (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Wide excision of soft tissue tumor (Cito) | Kelas VVIP | Rp. 9.434.600,- |
| Biopsy insisional dengan anastesi lokal (Cito) | Kelas VVIP | Rp. 2.721.301,- |
| Biopsy of perianal tissue (Cito) | Kelas VVIP | Rp. 2.721.301,- |
| Amputasi above knee (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Amputasi below knee (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Aneurisma arteri brachialis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Aneurisma arteri femoralis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Axillary dissection (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Batu saluran kemih * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Bilateral simple mastectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Cholecystectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Choledochoplasty (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of appendiceal fistula (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of cholecystostomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of fistula of large intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of fistula of small intestine, except duodenum (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of intestinal stoma (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Closure of leceration of liver (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Colostomy (not otherwise specified) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Common duct exploration for removal of calculus (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Debridement mediastinum (sternotomi) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Diseksi leher radikal / radikal neck dissection * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Eksisi pseudoaneurisma (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Eksplorasi vaskular (trauma / non trauma) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ekstraksi corpus alienum di regio toraks * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoscopic polypectomy of rectum (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoscopic thyroidectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Pan bronkoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Pan esofagoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Sialendoskopi diagnostik (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Endoskopi - Sleep nasoendoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Excision of hemorrhoid (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Exploration of common duct (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Exteriorization of large intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Exteriorization of small intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fiksasi sternum (wire, plate) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur antebrachi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur colles dan pergelangan tangan lainnya (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur cruris (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur femur * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur klavikula (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur olekranon (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur patela (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Fraktur suprakondiler humerus (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Free skin graft (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Full-thickness skin graft to hand (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Full-thickness skin graft to other sites * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| GIN- Hymenoplasty (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ginekologi - Histerektomi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ginekologi - Kehamilan ektopik (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ginekologi - Miomektomi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Groin dissection (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (C | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Jari, deformities, koreksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Jari, ring constriction (multiple), koreksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Jari, syndactili (multiple) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (C | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nail bed, laceration, Repair (multiple) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Cit | Kelas VVIP | Rp. 12.085.075,- |
| Hand - Thumb, deformitas, Koreksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hemiglosektomi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hip - Arthroscopy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hip - Hemiarthroplasty (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hip - ORIF, DHS (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Hipertropi Prostat Beningna (BPH) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Ileostomy (not otherwise specified) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Incisional hernia repair (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Incisional hernia repair with prosthesis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Internal drainage of pancreatic cyst (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Anterior cruciate ligament reconstruction (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy debridement knee (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy debridement shoulder (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy diagnostic (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy diagnostic shoulder (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy meniscus repair (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy remove loose body (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Arthroscopy remove loose body shoulder (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Fibular osteotomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Lateral collateral ligament reconstruction (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Medial collateral ligament reconstruction (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Posterior cruciate ligamnet reconstruction (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Revisi total knee replacement (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Revisi total shoulder replacement (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Rotator cuff repair by arthroscopy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Shoulder hemiarthroplasty (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Knee - Total shoulder replacement (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Kolonoskopi dan Biopsi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparoscopic lysis of peritoneal adhesions (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparoskopi/histeroskopi - ovarian drilling (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparskopi / Histereskopi - Second Look (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laparskopi / Histereskopi - Tubektomi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Large to large intestinal anastomosis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laring dan Faring - Laringektomi * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laring dan Faring - Laringektomi + RND * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laring dan Faring - RND * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laringectomi * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Laringectomi dengan diseksi leher * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Lasik 1 (satu) mata (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Lobektomi parsial (reseksi paru segmental) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Muscle flap graft to breast (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Partus Dengan Bius ELA (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Partus Dengan Bius ILA (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Purandare (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Rekonstruksi vagina (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Repair fistula (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Cito | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Obstetri - Vaginoplasti (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Odontektomi tingkat II (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Diseksi leher bilateral (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Diseksi leher modified (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Ligasi arteri karotis eksterna (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Mandibulektomi parsial (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas VVIP | Rp. 12.085.075,- |
| Onkologi - Total patellectomy dan rekonstruksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open biopsy of gallbladder or bile ducts (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open biopsy of liver (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open biopsy of pancreas (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open reduction of malar and zygomatic fracture (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open reduction of mandibular fractur (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Open reduction of maxillary fracture (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other destruction of lesion of liver (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other laparotomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other partial excision of large intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other repair of anal sphincter (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other repair of intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other repair of mesentery (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other skin graft to hand (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other skin graft to other sites (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other small to large intestinal anastomosis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Other suture of abdominal wall (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Otologi - Dekompresi nervus fasialis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Otologi - Mastoidektomi radikal (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Otologi - Mastoidektomi sederhana (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Otologi - Stapedektomi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Parotidektomi superfisial * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Partial splenectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas VVIP | Rp. 12.085.075,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pedicle or flaps graft (not otherwise specified) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pembuatan thoracic window (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Perikardiotomi / pericardial window * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Permanent colostomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Permanent ileostomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Phaco (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Phaco dan IOL (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Faringeal flap (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Forehead flap (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Otoplasty * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Revisi parut (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Rinoplasty * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pleurektomi * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Plikasi diafragma * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Pneumonectomy * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Posterior vitrectomy, Phaco dan IOL (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Radical excision of skin lesion (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Reclosure of postoperative disruption of abdominal wall (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rectosigmoidoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Reduction of anal prolapse (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Fraktur dasar orbita (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Fraktur Multiple (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Palpebra dengan Graft * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Soket kontraktur (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rekonstruksi - Soket landai (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Reopening of recent laparotomy site (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Repair arteri poplitea dan femoralis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Repair of diaphragmatic hernia, abdominal approach (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Repair of laceration of gallbladder (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Resection of transverse colon (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Reseksi maksila infrastuktural (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Reseksi mandibula tanpa rekonstruksi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Revision of anastomosis of large intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Revision of anastomosis of small intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Revision of stoma of large intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Revision of stoma of small intestine (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Revision of tracheostomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Right hemicolectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rinologi - BSEF / FESS 1 : Mini (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Rupture buli-buli * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Scleral buckling, phaco dan IOL (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Sigmoidectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Simple suture of common bile duct (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Small to small intestinal anastomosis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Discograph (1 level) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Discograph (1 level) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Discograph multilevel * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Facet block (1 level) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Facet block multilevel (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Foraminal block (1 level) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Foraminal block multilevel (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas VVIP | Rp. 12.085.075,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Strabismus 4 otot (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Stripping varises ekstremitas inferior (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Subtotal mastectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Temporary colostomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Temporary ileostomy * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Cito | Kelas VVIP | Rp. 12.085.075,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Total splenectomy * (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Closed fraktur distal tibia (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Closed fraktur intercondylar femur (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Closed fraktur supracondylar femur (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur collum femur pada orang tua (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur galeazi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur montegia (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Instability joint infection (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Joint stiffness dengan liberation (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Non union dengan bone graft (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Open fraktur shaft femur grade 3 (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Open fraktur shaft humerus grade 3 (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Open fraktur shaft radius grade 3 (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Open fraktur shaft tibia grade 3 (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Open fraktur shaft ulna grade 3 (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Trauma - Osteomyelitis (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Tumor - Extended Eksenterasi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Tumor - Orbital dekompresi 3 tulang (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Tumor - Orbitotomi lateral and superior (medial) (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Unilateral radical mastectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Unilateral simple mastectomy (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Upper Endoskopi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Upper Endoskopi dan biopsi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Upper Endoskopi dan ekstraksi carpal (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Upper Endoskopi dan ligasi (Cito) | Kelas VVIP | Rp. 12.085.075,- |
| Clipping costa (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Complete thyroidectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Eksisi luas tumor ganas dengan rekonstruksi flap jauh (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Eksisi pada bronkhus (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Eksisi tumor ganas kulit dengan flap local atau graft kulit (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Endoskopi - Bronkoskopi diagnostik (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Endoskopi - Bronkoskopi ekstraksi tanpa penyulit (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Endoskopi - Esofagoskopi BA dengan penyulit (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Endoskopi - Esofagoskopi diagnostik (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Excision of other bile duct (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Ginekologi - Adhesiolisis perlekatan berat pelvik (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Ginekologi - Infeksi panggul/PUS dengan perlekatan (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Ginekologi - Repair tuba (tubaplasti) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Ginekologi - Reseksi adenomiosis (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Ginekologi - Transposisi Ovarium (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Artery, large, injury, repair with grafting (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Carpus, delayed (non union), rekonstruksi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari (digit), stump, revision (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari, defect or contracture (multiple) rekonstruksi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari, deformities, major reconstruction procedure (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari, deformities, osteotomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari, deformity, instrinsic muscle transfer (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Jari, scar, revision osteotomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) ( | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Nerve defect, peripheral graft (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Nerve digital, Injury, microsurgical (single) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Nerve digital, injury, primary repair (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Nerve ulnar, entrapment, transposition (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Sendi (jari), various lesions, replacement arthoplasty (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Tendon (ekstremitas atas), bowstringing (entrapment), pulley rekonstruksi | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Tendon extensor (ekstremitas atas) injury, repair (multiple) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Tendon flexor (ekstremitas atas) injury, tendon graft (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Tendon flexor (ekstremitas atas), defect grafting (single) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hand - Thumb, paralysis, oppnens plasty (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Hip - Total hip replacement (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Intra-abdominal manipulation of intestine (not otherwise specified) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Intra-abdominal manipulation of large intestine (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Intra-abdominal manipulation of small intestine (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Knee - Total knee replacement (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Knee - Uni compartment arthroplasty (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparoscopic appendectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparoscopic appendectomy (elective) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparoscopic cholecystectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparoscopic incidental appendectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparoscopy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan Ringan (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Eksplorasi dan ektraksi IUD translokasi. (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Kasus dengan penyulit (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Kistektomi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Ooforektomi/salpingektomi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Ovareksi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Salpingoooforektomi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laparskopi / Histereskopi - Transposisi Ovarium (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laring dan Faring - TA/T dengan Coblation Laser (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laring dan Faring - Tiroidektomi Subtotal ** (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laring dan Faring - Tiroidektomi Total (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Laring dan Faring - UPPP (Uvulo Palatopharyngo Plasty) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Left hemicolectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Mediastinostomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Obstetri - Operasi plasenta akreta (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Odontektomi tingkat III (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Belloque tampon dengan narkosis (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Diseksi leher radikal * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Eksplorasi nasofaring (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Ekstirpasi tumor jinak kel liur (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Ekstirpasi tumor jinak sinonasal, oral cavity (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Hemiartroplasty pada metastatic bone disease (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Hemiglosektomi (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Maksilektomi parsial (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Maksilektomi total (radikal) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - ORIF MBD (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Parotidektomi * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Onkologi - Wide excision soft tisue sarcoma (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Other operations on intestines (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Other operations on the breast (reconstruction of the breast) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Other partial thyroidectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Parathyroidectomy subtotal (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Parathyroidectomy total (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| partial mandibulectomy hemimandibulectomy (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Pediatrik - Posteromedial soft tissue release CTEV (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Pilar Implant (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Labioplasti Bilateral (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Labioplasti unilateral (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Pembukaan lubang hidung (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur rahang (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Rekonstruksi hidung dengan defek (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Rekonstruksi mandibula ** (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 1 (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Rekonstruksi telinga (mirotia) tahap 2 (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Reseksi septum (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Plastik Rekionstruksi - Septorinoplasty (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Redo torakotomi * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Reduction Neglected Dislocation (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Rekonstruksi vaskular ekstremitas inferior (arteri femoralis dan poplitea) (Cito | Kelas VVIP | Rp. 15.702.925,- |
| Rekonstruksi vaskular ekstremitas superior (arteri brakialis, radialis dan ulnar | Kelas VVIP | Rp. 15.702.925,- |
| Repair laserasi diafragma * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Reposisi dislokasi rahang (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Reseksi maksila suprastuktural (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Rinologi - Caldwell Luc (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Rinologi - Ekstraksi Benda Asing (Narkosis) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Rinologi - Septum Reseksi / SMR (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Rinologi - Sinuskopi / Sinoskopi Dengan Tindakan (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Alar transverse fusion * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Anterior cervcal discetomy dan Fusion (ACDF) * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Anterior cervical corpectomy dan Fusion (ACCF) * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Debridement and anterior fusion in TB Spine * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Decompression laminectomy for HNP with stabilization * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Decompression laminectomy for spondilolisthesis stabilization * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Decompression laminectomy for tumor and spinal stenosis with stabilizati | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Laminectomy (1 Level) pada simple spine stenosis * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Mayor desloughing and wound debridement of the spine * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Micro endoscopic disectomy (1 level) * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Microscopic disectomy (1 Level) (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Open disectomy multilevel * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Open disestomy (1 Level) * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Open reduction and stabilisation of spinal fracture * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Posterior cervical fusion * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Posterior lumbar interbody fusion (FLIF) dan posterior stabilisation * ( | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Posterolateral fusion * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Spine - Total disc replacement (multilevel) * (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Split thickness graft to breast (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Terapi Slem Cell (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Thymectomy dengan VATS (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Tiroidektomi total dengan berry picking (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Tiroidektomi total dengan diseksi leher fungsional (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Trakeostomi dengan penyulit tumor pada akses trakea *** (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Trauma - Joint kompleks destruction / OA post trauma (total joint arthroplasty) | Kelas VVIP | Rp. 15.702.925,- |
| Trauma - Limb leg inequality dengan bone lengthening transport (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Turbinoplasty (Cito) | Kelas VVIP | Rp. 15.702.925,- |
| Evakuasi hematom (pasca pungsi) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Excision of perianal skin tags ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN - Insisi Septum Vagina ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN - kromotubasi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN- Himenectomy ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN- Insisi Drainage ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN- Marsupialisasi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Ginekologi - Tubektomi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| GIN-Kuretase-biopsi PA ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Glaukoma - Cyclo cryo ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Hand - Angkat K-Wire with anestesia regional ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Hand - Jari, extra digit, amputasi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Hand - Jari, various, amputation (single) ** ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Injeksi botox pada strabismus ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Ligasi Varices Esofgaus (VE) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Local excision of lesion of breast ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Local excision of rectal lesion or tissue ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Drainase abses ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Ekstirpasi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Ekstraksi IUD dengan anestesi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Hematoma (ruptur) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Kauterisasi kondiloma akuminata ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Kista bartholin (kista gartner) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Kolpotomi pada abses cavum douglas ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Konisasi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Kuretase abortus ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Kuretase pasca persalinan ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Penjahitan laserasi ringan ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Polip serviks ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Robekan serviks (forniks) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Shirodkar ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Obstetri - Sistoskopi LEETZ ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Onkologi - Insisional biopsi kelenjar leher ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Open biopsy of rectum ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Operkulektomi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Other diagnostic procedures of abdominal region ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Other excision of perianal tissue ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas VVIP | Rp. 6.529.500,- |
| Otologi - Biopsi ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Otologi - Ekstraksi benda asing ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pasang implantable central venous access * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pasang thoraks drain (WSD) * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pemasangan interdental wiring / arch bar ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pericardiocentesis * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Pleurodesis (pleurosklerosis) * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Rekonstruksi - Eksisi tumor kecil kelopak ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Rekonstruksi - Oklusi punctum lakrimal ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Release tongue tie * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Reposisi tertutup fraktur condilus mandibula ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Rinologi - Irigasi Sinus / DAWO ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Scleroterapi dan atau ligasi hemangioma ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Suture of laceration of anus ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Thoracocentesis * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Trauma - Acute glenohumeral joint dislocation * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Vena punctie - kanulasi - sectie * ( Cito ) | Kelas VVIP | Rp. 6.529.500,- |
| Uff Arch Barr (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Uff Arch Barr dan suspensi maksila (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Amputasi jari (phalangs - traumatik) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Amputation of digiti single ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Anal fistulectomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Anal fistulotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Anterior lamellar keratoplasty (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Appendicostomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Babcock (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral inguinal hernia repair with graft or prosthesis (not otherwise specifi | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral multipel excision of lesion of breast with narcose (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral ovariectomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of direct inguinal hernia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of direct inguinal hernia with graft or prosthetis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of femoral hernia with/without graft of prosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of indirect inguinal hernia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of inguinal hernia, not otherwise specified (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of inguinal hernia, one direct and one indirect (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Bilateral repair of inguinal hernia, one direct and one indirect, with graft or | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi pembuluh darah perifer * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi perikardium * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka bronkhus * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka diafragma * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka mediastinum * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka paru * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka pleura * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka pleura dengan VATS * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsi terbuka tumor dinding thoraks * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Caecostomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Closure of anal fistula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Combustio (luka bakar) * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Compartement excision (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Debridement-nekrotomi luka gangren (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Deseksi submandibula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Disartikulasi sendi ekstremitas (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Dislokasi bahu * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Drainage of appendiceal abscess (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Drainage of pancreatic cyst by catheter (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| DSAEK (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| ECCE / ICCE / SICS (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| ECCE / SICS dan IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi biopsi tumor pembuluh darah (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi glandula submandibula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi higroma leher * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi kista tiroglosus (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi parsial dan marsupialisasi Ranula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi Pterigium (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi tumor dinding dada * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi tumor pembuluh darah perifer (hemangioma) ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Eksisi tumor pembuluh darah perifer ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ekstirpasi kelainan kornea (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ekstraksi corpus alienum segmen anterior (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ekstraksi IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Endoskopi - Esofagoskopi BA tanpa penyulit (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Endoskopi - Esofagoskopi dilatasi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Endoskopi - Sialendoskopi diagnostik dan dilatasi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Endoskopi - Sialendoskopi diagnostik dan terapeutik (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Evakuasi hematom di ekstremitas (pasca pungsi HD / traumatik) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Evakuasi silicon oil (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Evakuasi silicon oil dan ECCE (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Evakuasi silicon oil, Phaco / ECCE dan IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Exchange IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Excision of ectopic breast tissue (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| excision of lesion of breast with narcose (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Excision of thyroglossal duct or trac (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Exploratory laparotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Extirpasi kista rongga mulut (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Extirpasi muoccocele rongga mulut (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Fasciotomy * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Fiksasi interna fraktur nasal (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Flap konjungtiva amnion graft (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Fraktur humerus * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Gastrostomi * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| GIN -Ekstirpasi polip (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Ekstirpasi Giant Condiloma (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Kistektomi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Laparotomi Diagnostik (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Ligasi Arteri Hipogastrica / Uterina (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Miomektomi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Pemasangan Implan Tableport (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ginekologi - Salpingo-ooforektomi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Anterior / posterior sklerotomi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Gonioplasty / goniotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Iridektomi perifer (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Paracentesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Reformasi COA (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Revisi Bleb (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Tindakan cyclodia termi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Trabekulektomi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Trabekulektomi, Phaco dan IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Trabekulotomi anak atau bayi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Trabekulotomi dan trabekulektomi anak atau bayi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Transkleral Foto Coagulasi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Glaukoma - Tubes implan (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Elbow (medical epicondyle), fracture, excision bony fragment (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Elbow, tennis elbow, release (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, closed fracture or dislocation, reduksi terbuka dan fixation (singl | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, crush injuries (complex) wound debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, crush injury (simple), wound debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, deep infection, drainage (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, deformity, instrinsic muscle extensor relocation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, deformity, instrinsic muscle release (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, foreign body (superficial), removal with mobilization of neurovascu | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, injury, debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, jaringan lunak tumor, excision (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, macrodactyly, debulking (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, polydactyly, amputasi with rekonstruksi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, ring construction (single), koreksi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, superficial infection, drainage (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, syndactili (single) koreksi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, trauma, terminalisation (multiple) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, trauma, terminalisation (single) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, tumors, excision with dissection of neurovasculer bundle (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, various lesions, amputasi (multiple) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, various lesions, Ray amputasi (single) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jari, wart, com, naevus, excision (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Jaringan lunak (palmar space), abscess, drainage (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Kulit dan jaringan subkultis, defect (single digit), free full thickness | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Kulit dan jaringan subkus, defect (deep) staged distant flap (division) ( | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Kulit dan jaringan subkutis, defect (multiple digits) staged local flap ( | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Nail bed, Laceration, repair (single) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Nerve various lesions, primary or secondary suture (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Nerve, Various Lesions, biopsy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Repair muscle (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Sendi (extremitas atas) rush rods / wires / screw removal (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Sendi (jari), contracture, capsulectomy (capsulotomy) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Sendi (wrist), various lesions, arthrodesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon (ekstremitas atas) , contracture, tenotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon extensor (extremitas atas) injury, repair (single) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon flexor (ekstremitas atas) adhesion, tenolysis (single) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon flexor (ekstremitas atas), adhesion, tenolysis (multiple) (Elektif | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (ekstremitas atas), De Quervain's (unilateral), Release (El | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage (Ele | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (ekstremitas atas), Trigger Jari (multiple), Release (Elekt | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (extremitas atas) ganglion atau villo nodular synovitis, ex | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (extremitas atas), tenosynovitis (single), drainage (Elekti | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath (extremitas atas), trigger jari (single) release (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Hand - Tendon sheath dan jaringan subkutis, ganglion (small bursa), excision (El | Kelas VVIP | Rp. 8.187.300,- |
| Hidrokel Testis / Funikuli ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Implantasi iris artifisial (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Implantasi piggyback IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Incision of perianal abscess (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Injeksi intravitreal (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Insertion of synthetic implant in facial bone (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Insisi atau Eksisi gingiva (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Insisi flegmon dasar mulut (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Internal Fiksasi fraktur condylus mandibula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Internal fiksasi fraktur maksilofasial 5 tempat patahan atau lebih (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Internal Fiksasi fraktur Mandibula segmental (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Keratoplasty tembus (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Keratoprosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Knee - Open knee debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Knee - Perypheral nerve ablation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Knee - Perypheral nerve lysis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Kolonoskopi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Labioshisis * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Laring dan Faring - Laringofisure (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Laring dan Faring - Pemasangan T-Tube (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Left lateral anal sphincterotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ligasi vaskular ekstremitas (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Ligation of hemorrhoids (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Limbal Relaxing Incision (LRI) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Maksilektomi total dan Rekonstruksi * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Multipel excision of lesion of breast with narcose (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Mutilasi digiti ekstremitas (Multiple) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Obstetri - Histerorafi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Obstetri - Kolporafi anterior (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Obstetri - Kolporafi posterior (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Obstetri - Mioma geburt (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Obstetri - Sectio caesaria tanpa penyulit (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Odontektomi tingkat I (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Biopsi tumor hidung, lidah, nasofaring (narkosis) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Excision soft tissue tumor < 5 cm (kecil) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Limb ablation dengan above atau below knee amputation bone tumor (Ele | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Open biopsy bone tumor (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Open biopsy soft tissue (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Ray amputation jari (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Onkologi - Tumor jinak tulang (curettage dan bonegraft) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Open biopsi of breast (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Open biopsy of salivary gland or duct (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Open reduction of alveolar fracture * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Osteotomi eksisi tulang maksilofasial (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other appendectomy (elective) * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other bilateral femoral hernioraphy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other hernia repair (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other incidental appendectomy * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other incision of anus (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other lysis of peritoneal adhesions (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other operations on anus (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other operations on trachea (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other procedures on hemorrhoids (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other reconstruction of mandible (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other reconstruction of other facial bone (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other repair and plastic operation of tongue (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other repair of abdominal wall (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other umbilical herniorraphy* (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Other unilateral femoral herniorraphy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Otologi - Meatoplasti (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Otologi - Miringoplasti (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Otologi - Pemasangan grommet (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Palatoshisis ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Partial glossectomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Bony bridge release pada kasus tarsal coalition (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Closed reduction dan pemasangan gips fraktur femur anak (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Combined Trabeculotomy dan trabeculectomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Debridement dan soft tissue release pada infeksi sendi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Debridement fraktur terbuka anak (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Debridement, nekrotomy dan saucerization pada chronic osteomyelits ( | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Fiksasi cannualted screw pada SCFE (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Hemangioma : injeksi intralesi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Injeksi botoks kasus Cerebral Palsy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Katarak (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Koreksi curly toe (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Koreksi overriding toe polidactili (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Koreksi syndactili kaki (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Nekrotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Open achilles tendon lengthening (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Percutaneous tendon tenotomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL (El | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Reposisi tertutup dan gips fraktur anak kecuali fraktur femur (Elekt | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Reposisi tertutup dan percutaneous pinning fraktur seputar sendi sik | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Reposisi tertutup, arthrogram dan hemispica DDH (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - RetCam and Narkose (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Skin graft (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Soft tissue release and enhancement kasus habitual dislokasi lutut a | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Soft tissue release kelainan Cerebral Palsy, Arthrogryposis, Spina B | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Synovectomy arthroscopy pada penderita hemofilia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pediatrik - Trabeculotomy pada glaucoma congenital (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pembedahan teleangiectasis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pengangkatan encircling silicone band (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Perikardiektomi * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Phaco dan IOL multifokal atau torik (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Phakik IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Phototherapeutic keratectomy (PTK) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pionephrosis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Plastik Rekionstruksi - Regional flap tidak luas (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pleural window (eloeser flap) * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Plikasi bulae / bleb emfisematous (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pneumatic retinopexy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Posterior vitrectomy dan endo laser dengan atau tanpa Silikon Oil / Gas dan inje | Kelas VVIP | Rp. 8.187.300,- |
| Posterior vitrectomy dengaan atau tanpa Sceral buckling (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Prosedur Sistrunk kista duktus tiroglosus (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Pulmonary decortication * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Cryo/cauter pada trichiasis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Eksternal DCR dan silikon tube (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Ektropion 1 kelopak * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Entropion 1 kelopak (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Eviserasi / enukleasi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Eviserasi / enukleasi dan implan (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Graft Bibir pada Ptisis Bulbi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Koreksi Lagoftalmos dengan beban emas (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Koreksi Ptosis * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Koreksi simblefaron (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Probing (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Repair Ruptur palpebra (dengan rupture canalis lacrimalis) (Elekt | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Repair Ruptur palpebra * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rekonstruksi - Tarsorafi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Release kontraktur mandibula (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Release tortikolis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Removal of foreign body from peritoneal cavity (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Removal of foreign body from retro-peritoneal cavity (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair iridodyalisis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of direct inguinal hernia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of direct inguinal hernia with graft or prosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of indirect inguinal hernia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of indirect inguinal hernia with graft or prosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of laceration, cornea and or sclera, perforating (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of laceration, cornea, non perforating (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of other hernia of anterior abdominal wall (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of other hernia of anterior abdominal wall with prosthesis (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Repair of umbilical hernia with prosthesis * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Reposisi IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Reposisi Iris (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Reposisi tertutup fraktur nasal (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Reseksi mandibula dengan rekonstruksi graft tulang / K-wire (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rinologi - Konkotomi / Konkoplasti (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rinologi - Nasoendoskopi Dengan tindakan (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rinologi - Sinuskopi / Sinoskopi (Narkosis) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Rupture tendon achiles (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Scleral buckle, cryo dan C3F8 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Scleral buckling (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Sekunder IOL (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Somnoplasty (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Spine - Biopsy vertebra (1 level) * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Spine - Plaster application of the spine (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Strabismus 1 otot (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Strabismus 2 otot (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Strabismus 3 otot (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Suture of laceration of large intestine (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Suture of laceration of small intestine, except duodenum (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Suture of peritoneum (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tatto cornea (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Torakotomi / sternotomi eksplorasi * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Torsio testis ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trakeostomi temporary ** (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Acute ankle joint dislocation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Acute elbow joint dislocation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Acute hip joint dislocation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Acute knee joint dislocation (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Closed fraktur shaft femur * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Closed fraktur shaft humerus * (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Closed fraktur shaft radius (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Closed fraktur shaft tibia (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Closed fraktur shaft ulna (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Fraktur tulang panjang dengan MIPO atau ORIF dan implant removal (long | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Jaringan granulasi dengan STSG (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Kompartemen otot (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Nekrotik tissue > 1 kompartemen dengan debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Nekrotik tissue dengan debridement (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Open fraktur shaft femur grade 1 dan 2 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Open fraktur shaft humerus grade 1 dan 2 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Open fraktur shaft radius grade 1 dan 2 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Open fraktur shaft tibia grade 1 dan 2 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Trauma - Open fraktur shaft ulna grade 1 dan 2 (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Biopsi tumor kelopak (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Biopsi tumor orbita (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Eksenterasi (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Eksisi tumor adneksa (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Ekstirpasi Tumor Orbita (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Orbital dekompresi 1 tulang (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Orbital dekompresi 2 tulang (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Orbitotomi anterior (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Tumor - Orbitotomi lateral (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Unilateral excision of ectopic breast tissue (mamma aberans) (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Unilateral repair of femoral atau inguinal hernia with or without graft or prost | Kelas VVIP | Rp. 8.187.300,- |
| Unilateral thyroid lobectomy (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Wide excision of soft tissue tumor (Elektif) | Kelas VVIP | Rp. 8.187.300,- |
| Biopsy of perianal tissue (Elektif) | Kelas VVIP | Rp. 2.407.298,- |
| Amputasi above knee (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Amputasi below knee (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Aneurisma arteri brachialis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Aneurisma arteri femoralis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Axillary dissection (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Batu saluran kemih * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Bilateral simple mastectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Cholecystectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Choledochoplasty (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of appendiceal fistula (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of cholecystostomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of fistula of large intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of fistula of small intestine, except duodenum (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of intestinal stoma (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Closure of leceration of liver (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Colostomy (not otherwise specified) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Common duct exploration for removal of calculus (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Debridement mediastinum (sternotomi) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Diseksi leher radikal / radikal neck dissection * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Eksisi luas tumor ganas kulit tanpa rekonstruksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Eksisi pseudoaneurisma (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Eksplorasi vaskular (trauma / non trauma) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ekstraksi corpus alienum di regio toraks * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ekstraksi corpus alienum di regio toraks dengan VATS * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoscopic polypectomy of rectum (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoscopic thyroidectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Bronkoskopi ekstraksi dengan penyulit (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Intubasi dengan flexible bronkoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Pan bronkoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Pan esofagoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Sialendoskopi diagnostik (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Endoskopi - Sleep nasoendoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Excision of hemorrhoid (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Exploration of common duct (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Exteriorization of large intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Exteriorization of small intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fiksasi sternum (wire, plate) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur antebrachi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur colles dan pergelangan tangan lainnya (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur cruris (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur femur * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur klavikula (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur olekranon (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur patela (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Fraktur suprakondiler humerus (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Free skin graft (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Full-thickness skin graft to hand (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Full-thickness skin graft to other sites * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| GIN- Hymenoplasty (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ginekologi - Histerektomi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ginekologi - Kehamilan ektopik (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ginekologi - Miomektomi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Glaukoma - Tubes implan, Phaco dan IOL (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Groin dissection (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Carpus, fracture or dislocation, reduksi terbuka dan fiksasi interna * (E | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Jari, defect or contracture (single) rekonstruksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Jari, deformities, koreksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Jari, fracture or dislocation, reduksi terbuka dan fiksasi interna (multi | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Jari, ring constriction (multiple), koreksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Jari, syndactili (multiple) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Kulit dan Jaringan subkutis, laceration (superficial ) > 7 cm , repair (E | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nail bed, laceration, Repair (multiple) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bila | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other) decompression with | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), entrapment syndrome (other), decompression (uni | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral wit | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Nerve (ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) ( | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release (Ele | Kelas VVIP | Rp. 10.435.600,- |
| Hand - Thumb, deformitas, Koreksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hemiglosektomi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hip - Arthroscopy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hip - Hemiarthroplasty (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hip - ORIF, DHS (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Hipertropi Prostat Beningna (BPH) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Ileostomy (not otherwise specified) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Incisional hernia repair (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Incisional hernia repair with prosthesis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Internal drainage of pancreatic cyst (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Anterior cruciate ligament reconstruction (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy debridement knee (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy debridement shoulder (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy diagnostic (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy diagnostic shoulder (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy meniscus repair (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy minisectomy, arthroscopy synevectomy knee (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy remove loose body (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Arthroscopy remove loose body shoulder (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Fibular osteotomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Lateral collateral ligament reconstruction (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Medial collateral ligament reconstruction (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Posterior cruciate ligamnet reconstruction (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Recurrent shoulder dislocation repair TUBS and AMBRI (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Revisi total knee replacement (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Revisi total shoulder replacement (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Rotator cuff repair by arthroscopy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Shoulder hemiarthroplasty (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Knee - Total shoulder replacement (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Kolonoskopi dan Biopsi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparoscopic lysis of peritoneal adhesions (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparoskopi/histeroskopi - ovarian drilling (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparskopi / Histereskopi - Histeroskopi diagnostik (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparskopi / Histereskopi - Laparoskopi diagnostik (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparskopi / Histereskopi - Second Look (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laparskopi / Histereskopi - Tubektomi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Large to large intestinal anastomosis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laring dan Faring - Laringektomi * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laring dan Faring - Laringektomi + RND * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laring dan Faring - Laringoskopi dengan Ekstirpasi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laring dan Faring - RND * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laringectomi * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Laringectomi dengan diseksi leher * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Lasik 1 (satu) mata (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Lobektomi parsial (reseksi paru segmental) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Muscle flap graft to breast (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Muscle flap graft to breast (TRAM flap / LD flap) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Histerektomi pervaginam dan kolpoperineoplasti (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Partus Dengan Bius ELA (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Partus Dengan Bius ILA (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Purandare (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Rekonstruksi vagina (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Repair fistula (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Sectio caesaria dan histerektomi obstetri (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Sectio caesaria dengan penyulit (perlekatan berat, histerorafi) (Elek | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Sectio Cesaria (SC) dengan ERACS (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Obstetri - Vaginoplasti (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Odontektomi tingkat II (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Diseksi leher bilateral (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Diseksi leher modified (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Ligasi arteri karotis eksterna (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Limb ablation dengan above atau below knee amputation soft tissue tum | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Mandibulektomi parsial (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Panendoskopi (eksplorasi NF, laringoskopi, esofagoskopi, bronkoskopi | Kelas VVIP | Rp. 10.435.600,- |
| Onkologi - Total patellectomy dan rekonstruksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open biopsy of gallbladder or bile ducts (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open biopsy of liver (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open biopsy of pancreas (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open reduction of malar and zygomatic fracture (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open reduction of mandibular fractur (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Open reduction of maxillary fracture (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other destruction of lesion of liver (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other laparotomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other partial excision of large intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other repair of anal sphincter (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other repair of intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other repair of mesentery (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other skin graft to hand (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other skin graft to other sites (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other small to large intestinal anastomosis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Other suture of abdominal wall (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Otologi - Dekompresi nervus fasialis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Otologi - Kanaloplasti / kanalomeatoplasty (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Otologi - Mastoidektomi radikal (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Otologi - Mastoidektomi sederhana (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Otologi - Stapedektomi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Parotidektomi superfisial * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Partial splenectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Open reduction dislokasi panggul dengan Acetabuloplasty dan Femoral | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Operasi rekonstruksi ibu jari kaki pada Hallux Valgus (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada ana | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular a | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Reposisi terbuka dan fiksasi Interna pada kasus fraktur Salter Harri | Kelas VVIP | Rp. 10.435.600,- |
| Pediatrik - Tendon transfer ekstremitas bawah kasus neuromuskular anak (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pedicle or flaps graft (not otherwise specified) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pemasangan Peritoneal Dialysis (PD) Catheter (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pembuatan thoracic window (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Perikardiotomi / pericardial window * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Permanent colostomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Permanent ileostomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Phaco (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Phaco dan IOL (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Faringeal flap (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Forehead flap (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Otoplasty * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Revisi parut (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Rinoplasty * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plastik Rekionstruksi - Rinoplasty dengan augmentasi tulang rawan (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pleurektomi * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Plikasi diafragma * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Pneumonectomy * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Posterior vitektomi, SB, Endo laser, Silikon Oil / Gas, Phaco dan IOL (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Posterior vitrectomy, Phaco dan IOL (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Radical excision of skin lesion (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Reclosure of postoperative disruption of abdominal wall (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rectosigmoidoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Reduction of anal prolapse (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Blefaroplasty 2 kelopak (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Ekstirpasi Tumor Adneksa (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Endoskopi DCR dan silikon tube (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Fraktur dasar orbita (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Fraktur Multiple (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Palpebra dengan Graft * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Soket kontraktur (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rekonstruksi - Soket landai (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Reopening of recent laparotomy site (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Repair arteri poplitea dan femoralis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Repair of diaphragmatic hernia, abdominal approach (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Repair of laceration of gallbladder (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Repair pembuluh darah regio servikal (karotis, jugular) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Resection of transverse colon (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Reseksi maksila infrastuktural (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Reseksi mandibula tanpa rekonstruksi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Revision of anastomosis of large intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Revision of anastomosis of small intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Revision of stoma of large intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Revision of stoma of small intestine (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Revision of tracheostomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Right hemicolectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rinologi - BSEF / FESS 1 : Mini (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rinologi - BSEF / FESS 2 : Mini dan Maksila / etmoid (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rinologi - BSEF / FESS 3 : Mini dan frontal / sfenoid (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Rupture buli-buli * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Scleral buckling, phaco dan IOL (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Sigmoidectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Simple suture of common bile duct (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Small to small intestinal anastomosis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Discograph (1 level) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Discograph multilevel * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Facet block (1 level) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Facet block multilevel (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Foraminal block (1 level) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Foraminal block multilevel (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Manipulation, reduction of simple fracture and dislocation with general | Kelas VVIP | Rp. 10.435.600,- |
| Spine - Removal of implants (Plate, Nail, Screw) * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Strabismus 4 otot (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Stripping varises ekstremitas inferior (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Subtotal mastectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Temporary colostomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Temporary ileostomy * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Thoracal symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) (Elek | Kelas VVIP | Rp. 10.435.600,- |
| Tiroidektomi subtotal / total nodul tiroid ** (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Total splenectomy * (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Closed fraktur distal tibia (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Closed fraktur intercondylar femur (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Closed fraktur proksimal tibia involve intraartikular (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Closed fraktur supracondylar femur (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fracture acetabulum 1 collum dengan ORIF (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fracture artikuler dengan MIPO atau ORIF Artikuler (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fracture pelvis simple dengan fiksasi eksterna pelvic (ORIF) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur acetabulum dan pelvic dengan ORIF (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur collum femur pada orang tua (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur collum femur pada usia < 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur galeazi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur intertrochanter femur pada orang tua (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur intertrochanter femur pada usia < 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur montegia (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur neck humerus pada usia < 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur neck humerus pada usia > 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur subtrochanter femur pada usia < 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Fraktur subtrochanter femur pada usia > 60 tahun (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Instability joint infection (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Joint stiffness dengan liberation (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Multiple fracture tulang panjang dengan MIPO atau ORIF dan removal impl | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Non union dengan bone graft (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Open fraktur shaft femur grade 3 (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Open fraktur shaft humerus grade 3 (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Open fraktur shaft radius grade 3 (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Open fraktur shaft tibia grade 3 (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Open fraktur shaft ulna grade 3 (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Trauma - Osteomyelitis (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Tumor - Extended Eksenterasi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Tumor - Orbital dekompresi 3 tulang (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Tumor - Orbitotomi lateral and superior (medial) (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Unilateral radical mastectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Unilateral simple mastectomy (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Upper Endoskopi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Upper Endoskopi dan biopsi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Upper Endoskopi dan ekstraksi carpal (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Upper Endoskopi dan ligasi (Elektif) | Kelas VVIP | Rp. 10.435.600,- |
| Bilateral radical mastectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| complete glossectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Replantasi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hip - Revisi THR (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - TA/T (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Operasi Commando (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Other operations on pancreas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Other pancreatotomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Implantasi koklea (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Timpanoplasti (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Parotidektomi total (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Partial gastrectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Partial hepatectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair of gastroschisis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair of other bile ducts (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas VVIP | Rp. 18.801.500,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Total gastrectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Whipple procedure (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Bilateral radical mastectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| complete glossectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Fiksasi interna fraktur panfacial (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Debulking Kanker Ovarium Lanjut (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Eksenterasi (Anterior Posterior) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Histerektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Operasi Frozen Pelvic (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Relaparatomi high risk complication (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Staging Laparatomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Trachelectomy Radical Servix (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Ultra Radikal Histerektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Ginekologi - Vulvektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Jari, swan neck or boutonniere deformity (single), koreksi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Nerve-digital, injury, microsurgical repair (multiple) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hand - Replantasi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Hip - Revisi THR (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Adhesiolisis Perlekatan berat (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Histerektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Histeroskopi operatif (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Kistektomi / Adesiolisis Berat (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Laparaskopi histerektomi radikal (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Miomektomi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Onkologi (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Rekanalisasi tuba (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Reseksi adenomiosis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laparskopi / Histereskopi - Reseksi endometriosis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Multiple (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Parafaring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Eksplorasi Asbes Submandibula (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstirpasi Kista Bronchialis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstirpasi Papiloma Laring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Ekstsisi Ca Laring dengan Laser (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Laringoskopi Diagnostik (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - TA/T (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Trakeostomi ** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Laring dan Faring - Trakeostomi dengan penyulit *** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Modifikasi RND / functional neck dissection (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Ekstirpasi angiofibroma (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Forequarter amputation (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Hemipelvectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Hemoglosektomi dan diseksi leher (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dan rekonstruksi dengan artrodesis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan resection dan rekonstruksi dengan fibular | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan scapular reconstruction (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery dengan tumor resection only (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery tahap 1 (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Limb salvage surgery tahap 2 (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Marginal margine excision soft tissue tumor (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Tiroidektomi subtotal ** (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Tiroidektomi total (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Onkologi - Wide eksisi tumor tonsil, orofaring (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Operasi Commando (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Other operations on pancreas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Other pancreatotomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Implantasi koklea (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Mastoidektomi radikal dengan penyulit (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Temporal bone ressection (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Otologi - Timpanoplasti (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Parotidektomi total (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Partial gastrectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Partial hepatectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Acetabuloplasty (salter innominate, pemberton, dega) pada panggul (E | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Arthrodesis sendi (panggul, wrist, ankle , triple arthrodesis) (Elek | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Bony reconstruction ekstremitas atas anak (malunion fraktur supracon | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Bony reconstruction ekstremitas bawah anak (CTEV, Blount disease, ke | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Double osteotomy pelvis pada exstrophy bladder (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Limb lengthening (operasi rekonstruksi pada anak dengan alat khusus) | Kelas VVIP | Rp. 18.801.500,- |
| Pediatrik - Open reduction dislokasi panggul tanpa acetabuloplasty (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Ekstirpasi preaurikuler fistel (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Palatoplasty * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Rekonstruksi fraktur muka dengan plate screw (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Septoplasty e.c trauma hidung (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Plastik Rekionstruksi - Skingrafting tidak luas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi arteri ekstremitas dengan by-pass graft synthetic (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi fraktur blow-out (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi menggunakan flap bebas (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rekonstruksi sternum dan dinding dada (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair aneurisma aorta abdominalis * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair of gastroschisis (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Repair of other bile ducts (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Rinologi - BSEF / FESS 4 : Mini dan maksila / etmoid dan frontal / sfenoid (Elek | Kelas VVIP | Rp. 18.801.500,- |
| Rinologi - BSEF / FESS Lanjut : Ekstirpasi Tumor, penutupan defek intrakranial ( | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Anterior dan posterior surgery in deformity with stabilization (Instrume | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Anterior dan posterior surgery in spinal disease with stabilization (ins | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Scoliosis < 70 derajat corrective surgery * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Scoliosis kurva > 70 derajat corrective surgery * (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Spinal osteotomy for ankylossing spondylitis dengan forward gaze kurang | Kelas VVIP | Rp. 18.801.500,- |
| Spine - Spinal osteotomy for Ankylossing Spondylitis* (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Total gastrectomy (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Trauma - Neglected case dengan bone reconstruction (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Vascular shunting (splenorenal shunt, de palma shunt) (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Whipple procedure (Elektif) | Kelas VVIP | Rp. 18.801.500,- |
| Evakuasi hematom (pasca pungsi) | Kelas VVIP | Rp. 5.735.300,- |
| Excision of perianal skin tags | Kelas VVIP | Rp. 5.735.300,- |
| GIN - Insisi Septum Vagina | Kelas VVIP | Rp. 5.735.300,- |
| GIN - kromotubasi | Kelas VVIP | Rp. 5.735.300,- |
| GIN- Himenectomy | Kelas VVIP | Rp. 5.735.300,- |
| GIN- Insisi Drainage | Kelas VVIP | Rp. 5.735.300,- |
| GIN- Marsupialisasi | Kelas VVIP | Rp. 5.735.300,- |
| Ginekologi - Tubektomi | Kelas VVIP | Rp. 5.735.300,- |
| GIN-Kuretase-biopsi PA | Kelas VVIP | Rp. 5.735.300,- |
| Glaukoma - Cyclo cryo | Kelas VVIP | Rp. 5.735.300,- |
| Hand - Angkat K-Wire with anestesia regional | Kelas VVIP | Rp. 5.735.300,- |
| Hand - Jari, extra digit, amputasi | Kelas VVIP | Rp. 5.735.300,- |
| Hand - Jari, various, amputation (single) ** | Kelas VVIP | Rp. 5.735.300,- |
| Injeksi botox pada strabismus | Kelas VVIP | Rp. 5.735.300,- |
| Ligasi Varices Esofgaus (VE) | Kelas VVIP | Rp. 5.735.300,- |
| Local excision of lesion of breast | Kelas VVIP | Rp. 5.735.300,- |
| Local excision of rectal lesion or tissue | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Drainase abses | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Ekstirpasi | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Ekstraksi IUD dengan anestesi | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Hematoma (ruptur) | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Kauterisasi kondiloma akuminata | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Kista bartholin (kista gartner) | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Kolpotomi pada abses cavum douglas | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Konisasi | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Kuretase abortus | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Kuretase pasca persalinan | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Penjahitan laserasi ringan | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Polip serviks | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Robekan serviks (forniks) | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Shirodkar | Kelas VVIP | Rp. 5.735.300,- |
| Obstetri - Sistoskopi LEETZ | Kelas VVIP | Rp. 5.735.300,- |
| Onkologi - Insisional biopsi kelenjar leher | Kelas VVIP | Rp. 5.735.300,- |
| Open biopsy of rectum | Kelas VVIP | Rp. 5.735.300,- |
| Operkulektomi | Kelas VVIP | Rp. 5.735.300,- |
| Other diagnostic procedures of abdominal region | Kelas VVIP | Rp. 5.735.300,- |
| Other excision of perianal tissue | Kelas VVIP | Rp. 5.735.300,- |
| Other local excision or destruction of lesion or tissue of skin and subcutaneous | Kelas VVIP | Rp. 5.735.300,- |
| Otologi - Biopsi | Kelas VVIP | Rp. 5.735.300,- |
| Otologi - Ekstraksi benda asing | Kelas VVIP | Rp. 5.735.300,- |
| Pasang implantable central venous access * | Kelas VVIP | Rp. 5.735.300,- |
| Pasang thoraks drain (WSD) * | Kelas VVIP | Rp. 5.735.300,- |
| Pelepasan plat dan skrup maksilofasial 3 tempat atau lebih | Kelas VVIP | Rp. 5.735.300,- |
| Pelepasan plat dan skrup tulang maksilofasial 1-2 tempat | Kelas VVIP | Rp. 5.735.300,- |
| Pemasangan interdental wiring / arch bar | Kelas VVIP | Rp. 5.735.300,- |
| Pericardiocentesis * | Kelas VVIP | Rp. 5.735.300,- |
| Pleurodesis (pleurosklerosis) * | Kelas VVIP | Rp. 5.735.300,- |
| Rekonstruksi - Eksisi tumor kecil kelopak | Kelas VVIP | Rp. 5.735.300,- |
| Rekonstruksi - Oklusi punctum lakrimal | Kelas VVIP | Rp. 5.735.300,- |
| Release tongue tie * | Kelas VVIP | Rp. 5.735.300,- |
| Reposisi dislokasi sendi rahang dengan pembiusan (TMJ) * | Kelas VVIP | Rp. 5.735.300,- |
| Reposisi tertutup fraktur condilus mandibula | Kelas VVIP | Rp. 5.735.300,- |
| Revisi thoraks drain/ Water Sealed Drainage (WSD) | Kelas VVIP | Rp. 5.735.300,- |
| Rinologi - Irigasi Sinus / DAWO | Kelas VVIP | Rp. 5.735.300,- |
| Scleroterapi dan atau ligasi hemangioma | Kelas VVIP | Rp. 5.735.300,- |
| Suture of laceration of anus | Kelas VVIP | Rp. 5.735.300,- |
| Thoracocentesis * | Kelas VVIP | Rp. 5.735.300,- |
| Trauma - Acute glenohumeral joint dislocation * | Kelas VVIP | Rp. 5.735.300,- |
| Tumor jinak kulit dan tumor non neoplastik kulit * | Kelas VVIP | Rp. 5.735.300,- |
| Vena punctie - kanulasi - sectie * | Kelas VVIP | Rp. 5.735.300,- |