TARIF RETRIBUSI PELAYANAN KESEHATAN PADA RUMAH SAKIT KHUSUS GIGI DAN MULUT PROVINSI SUMATERA SELATAN. Total

LAMPIRAN I : PERATURAN DAERAH PROVINSI SUMSEL NOMOR... TAHUN 2014 TENTANG PERUBAHAN KEDUA ATAS PERATURAN DAERAH NOMOR 3 TAHUN 2012 TENTANG RETRIBUSI JASA UMUM A. TARIF PELAYANAN PROSTHODONTI RSKGM NO JENIS PELAYANAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 GIGI TIRUAN PENUH: 1 GTP/RAHANG ( BAHAN 210,000 180,000 390,000 350,000 300,000 650,000 210,000 400,000 610,000 350,000 500,000 850,000 ACRYLIC ) 2 GTP/RAHANG ( BAHAN 1,000,000 300,000 1,300,000 600,000 400,000 1,000,000 1,000,000 500,000 1,500,000 VALPLAST ) 3 REPARASI SEDERHANA 48,000 42,000 90,000 80,000 70,000 150,000 48,000 96,000 144,000 80,000 120,000 200,000 4 REPARASI KOMPLEKS 78,000 42,000 120,000 130,000 70,000 200,000 78,000 96,000 174,000 130,000 120,000 250,000 GIGI TIRUAN SEBAGIAN LEPAS: 5 GIGI PERTAMA + BASIS 66,000 60,000 126,000 110,000 100,000 210,000 66,000 160,000 226,000 110,000 200,000 310,000 ACRYLIC 6 GIGI SELANJUTNYA 18,000 15,000 33,000 30,000 25,000 55,000 18,000 28,000 46,000 30,000 35,000 65,000 7 GTSL FRAME 270,000 120,000 390,000 450,000 200,000 650,000 270,000 240,000 510,000 450,000 300,000 750,000 8 GIGI SELANJUTNYA 18,000 15,000 33,000 30,000 25,000 55,000 18,000 28,000 46,000 30,000 35,000 65,000 9 PENAMBAHAN 1 CENGKRAM 6,000 12,000 18,000 10,000 20,000 30,000 6,000 24,000 30,000 10,000 30,000 40,000 10 GIGI PERTAMA +BASIS 180,000 120,000 300,000 300,000 200,000 500,000 180,000 280,000 460,000 300,000 350,000 650,000 VALPLAST 11 GIGI SELANJUTNYA 60,000 30,000 90,000 100,000 50,000 150,000 60,000 80,000 140,000 100,000 100,000 200,000 12 GIGI PERTAMA + BASIS 300,000 120,000 420,000 500,000 200,000 700,000 300,000 280,000 580,000 500,000 350,000 850,000 BAHAN FRS 13 GIGI SELANJUTNYA 42,000 30,000 72,000 70,000 50,000 120,000 42,000 80,000 122,000 70,000 100,000 170,000 14 BASIS + GIGI PERTAMA 60,000 60,000 120,000 100,000 100,000 200,000 60,000 160,000 220,000 110,000 200,000 310,000 IMMEDIATE DENTURE 15 GIGI SELANJUTNYA 18,000 15,000 33,000 30,000 25,000 55,000 18,000 28,000 46,000 30,000 35,000 65,000 KELAINAN TMJ : TARIF RETRIBUSI PELAYANAN KESEHATAN PADA RUMAH SAKIT KHUSUS GIGI DAN MULUT PROVINSI SUMATERA SELATAN Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik 16 OCCLUSAL 15,000 18,000 33,000 25,000 30,000 55,000 15,000 48,000 63,000 25,000 60,000 85,000 ADJUSTMENT 17 MEMBUAT SPLINT 250,000 100,000 350,000 250,000 150,000 400,000 DIAGNOSTIK 18 OBTURATOR 250,000 100,000 350,000 250,000 150,000 400,000 SEMENTARA 19 OBTURATOR 400,000 250,000 650,000 400,000 350,000 750,000 PERMANEN 20 PEMBUATAN MOULAGE 120,000 50,000 170,000 120,000 80,000 200,000 21 ACCURAD/TMJ 36,000 24,000 60,000 60,000 40,000 100,000 36,000 72,000 108,000 60,000 90,000 150,000 Umum VIPUmum 22 NIGHT GUARD/RAHANG GIGI TIRUAN CEKAT: 23 CROWN SEMENTARA ACRYLIC 165,000 60,000 225,000 275,000 100,000 375,000 165,000 160,000 325,000 275,000 200,000 475,000 60,000 90,000 150,000 100,000 150,000 250,000 60,000 200,000 260,000 100,000 250,000 350,000

NO JENIS PELAYANAN Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik 1 2 3 4 5 6 7 8 9 10 11 12 13 14 24 CROWN METAL 350,000 250,000 600,000 210,000 320,000 530,000 350,000 400,000 750,000 PORCELAIN 25 CROWN ALL 650,000 250,000 900,000 390,000 320,000 710,000 650,000 400,000 1,050,000 PORCELAIN /EMPRESS 26 CROWN PORCELAIN 700,000 250,000 950,000 420,000 320,000 740,000 700,000 400,000 1,100,000 EMAX 27 CROWN PORCELAIN 1,000,000 250,000 1,250,000 600,000 320,000 920,000 1,000,000 400,000 1,400,000 ZIRCONIAL 28 PEMBONGKARAN 45,000 45,000 90,000 75,000 75,000 150,000 45,000 140,000 185,000 75,000 175,000 250,000 CROWN 29 INDIRECT LABIAL 390,000 320,000 710,000 650,000 400,000 1,050,000 VENERING COMPOSITE 30 LABIAL VENERING 420,000 240,000 660,000 700,000 300,000 1,000,000 EMAX 31 LABIAL VENERING 1,000,000 440,000 1,440,000 1,000,000 550,000 1,550,000 ZIRCONIAL 32 RESEMENTASI 60,000 40,000 100,000 60,000 40,000 100,000 60,000 72,000 132,000 60,000 90,000 150,000 Umum VIPUmum

B. TARIF PELAYANAN PEDODONTI RSKGM BESAR TARIF (RUPIAH) Kedokteran Gigi Umum Dokter Kedokteran Gigi Spesialistik NO JENIS PELAYANAN VIP Umum Umum VIP Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 DHE, 18,000 12,000 30,000 30,000 20,000 50,000 30,000 70,000 100,000 PROFILAKSIS/KONTROL 2 APLIKASI FLUOR 24,000 18,000 42,000 40,000 30,000 70,000 90,000 60,000 150,000 3 PIT AND FISSURE SEALANT KONSERVASI GIGI : 4 INLAY / ONLAY LOGAM GIGI SULUNG 5 INLAY / ONLAY PORCELAIN GIGI PSA GIGI SULUNG : 24,000 18,000 42,000 40,000 30,000 70,000 90,000 60,000 150,000 210,000 90,000 300,000 350,000 150,000 500,000 210,000 200,000 410,000 350,000 250,000 600,000 210,000 90,000 300,000 350,000 150,000 500,000 210,000 200,000 410,000 350,000 250,000 600,000 6 1 SALURAN AKAR 24,000 24,000 48,000 40,000 40,000 80,000 24,000 48,000 72,000 40,000 60,000 100,000 7 2 SALURAN AKAR 36,000 30,000 66,000 60,000 50,000 110,000 36,000 56,000 92,000 60,000 70,000 130,000 8 >2 SALURAN AKAR 48,000 64,000 112,000 80,000 80,000 160,000 BEDAH : 9 PENCABUTAN GIGI SUSU TANPA INJEKSI 12,000 18,000 30,000 20,000 30,000 50,000 12,000 40,000 52,000 20,000 50,000 70,000 10 PENCABUTAN GIGI SUSU 18,000 24,000 42,000 30,000 40,000 70,000 18,000 48,000 66,000 30,000 60,000 90,000 DENGAN INJEKSI 11 PENCABUTAN KARENA 36,000 56,000 92,000 60,000 70,000 130,000 KOMPLIKASI 12 INSISI INTRA ORAL 18,000 48,000 66,000 30,000 60,000 90,000 13 GINGIVECTOMY UNTUK 64,000 96,000 160,000 80,000 120,000 200,000 TUMPATAN PENCEGAHAN MALOKLUSI : 14 SPACE MAINTAINER 120,000 60,000 180,000 200,000 100,000 300,000 120,000 120,000 240,000 200,000 150,000 350,000 LEPASAN 15 SPACE MAINTAINER 150,000 60,000 210,000 250,000 100,000 350,000 150,000 120,000 270,000 250,000 150,000 400,000 LEPASAN DENGAN ELEMEN 16 SPACE MAINTAINER 120,000 90,000 210,000 200,000 150,000 350,000 120,000 200,000 320,000 200,000 250,000 450,000 CEKAT INTERSEPTIVE ORTHODONTIC 17 ALAT LEPASAN 300,000 180,000 480,000 500,000 300,000 800,000 300,000 400,000 700,000 500,000 500,000 1,000,000 18 ALAT CEKAT RA & RB a. Non self ligating 1,500,000 2,000,000 3,500,000 (biasa) b. Non Self ligating 3,500,000 2,000,000 5,500,000 (clear) c. Self ligating (DAMON Q) 5,500,000 3,000,000 8,500,000 d. Self Ligating 6,500,000 3,500,000 10,000,000 (DAMON CERAMIK) 19 KONTROL ALAT LEPASAN 30,000 40,000 70,000 20 KONTROL ALAT CEKAT 50,000 100,000 150,000 21 PENGGANTIAN ALAT CEKAT a. Non self ligating 50,000 50,000 100,000 (biasa) b. Non self Ligating (clear) 150,000 50,000 200,000 c. Self ligating 400,000 50,000 450,000

BESAR TARIF (RUPIAH) Kedokteran Gigi Umum Dokter Kedokteran Gigi Spesialistik NO JENIS PELAYANAN Umum Umum VIP VIP Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 (Damon Ceramik ) d. Self ligating (Damon Q ) 400,000 50,000 450,000 22 REPARASI ALAT 18,000 12,000 30,000 80,000 70,000 150,000 64,000 136,000 200,000 80,000 170,000 250,000 LEPASAN SEDERHANA 23 REPARASI ALAT 150,000 70,000 220,000 150,000 150,000 300,000 LEPASAN KOMPLEKS 24 INCLINE BITE PLANE 200,000 160,000 360,000 250,000 200,000 450,000 25 LINGUAL ARCH WIRE 48,000 42,000 90,000 150,000 100,000 250,000 120,000 240,000 360,000 150,000 300,000 450,000 26 PALATAL ARCH WIRE 90,000 42,000 132,000 150,000 100,000 250,000 120,000 240,000 360,000 150,000 300,000 450,000 27 PALATAL CRIB 176,000 144,000 320,000 220,000 180,000 400,000 28 PLAT RETENSI 90,000 60,000 150,000 108,000 72,000 180,000 350,000 250,000 600,000

C. TARIF PELAYANAN PERIODONTIA RSKGM NO JENIS PELAYANAN Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 SCALING RINGAN 48,000 42,000 90,000 80,000 70,000 150,000 80,000 120,000 200,000 (RA+RB) 2 SCALING SEDANG 48,000 66,000 114,000 80,000 110,000 190,000 80,000 140,000 220,000 (RA+RB) 3 SCALING BERAT (RA+RB) 48,000 84,000 132,000 80,000 140,000 220,000 80,000 170,000 250,000 4 KURETASE SEDERHANA/REGIO 48,000 42,000 90,000 80,000 70,000 150,000 80,000 120,000 200,000 5 KURETASE 120,000 120,000 100,000 150,000 250,000 KOMPLEKS/REGIO 6 KONTROL KURETASE 12,000 6,000 18,000 20,000 10,000 30,000 12,000 24,000 36,000 20,000 30,000 50,000 7 SPLINTING (WIRE) 78,000 72,000 150,000 130,000 120,000 250,000 78,000 120,000 198,000 130,000 150,000 280,000 /REGIO 8 SPLINTING (COMPOSIT) /REGIO 150,000 90,000 240,000 250,000 150,000 400,000 150,000 200,000 350,000 250,000 250,000 500,000 9 MOUNTH GUARD 400,000 150,000 550,000 400,000 300,000 700,000 10 SPLINTING PERMANEN 600,000 250,000 850,000 600,000 400,000 1,000,000 LOGAM / PORSELEN 11 KONTROL SPLINTING 12,000 18,000 30,000 20,000 30,000 50,000 12,000 48,000 60,000 20,000 60,000 80,000 12 BIOPSI PERIO 136,000 104,000 240,000 170,000 130,000 300,000 13 GINGIVOPLASTY/GINGIV 400,000 300,000 700,000 500,000 500,000 1,000,000 ECTOMY/ ABLASI 14 GINGIVAL GRAFT 600,000 500,000 1,100,000 600,000 900,000 1,500,000 DENGAN PROTEKSI 15 KONTROL PASCA BEDAH 40,000 30,000 70,000 60,000 40,000 100,000 / TERAPI PEMELIHARAAN 16 PEMASANGAN 300,000 100,000 400,000 300,000 200,000 500,000 MEMBRANE 17 PEMASANGAN 300,000 100,000 400,000 300,000 200,000 500,000 BONEGRAFT BATAN 18 PEMASANGAN BONEGRAFT CALSITEK 600,000 200,000 800,000 600,000 400,000 1,000,000 19 OPER CULECTOMY 150,000 70,000 220,000 180,000 120,000 300,000 Umum Umum VIP 20 OPER CULECTOMY (TAMBAHAN/GIGI) 21 OPERASI FLAP (PERAWATAN POKET) 22 KONTROL OPERASI FLAP (PERAWATAN POKET) 70,000 30,000 100,000 90,000 60,000 150,000 150,000 150,000 300,000 250,000 200,000 450,000 24,000 32,000 56,000 30,000 40,000 70,000

D. TARIF PELAYANAN BEDAH MULUT RSKGM NO JENIS PELAYANAN Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 JAHITAN < 3 LUKA 21,000 15,000 36,000 35,000 25,000 60,000 21,000 32,000 53,000 60,000 40,000 100,000 2 BUKA JAHITAN + SPOOLING 6,000 12,000 18,000 10,000 20,000 30,000 6,000 40,000 46,000 10,000 50,000 60,000 3 EXSTRASI GIGI ANTERIOR 24,000 18,000 42,000 40,000 30,000 70,000 24,000 48,000 72,000 40,000 60,000 100,000 4 EXSTRASI GIGI POSTERIOR 36,000 24,000 60,000 60,000 40,000 100,000 36,000 64,000 100,000 60,000 80,000 140,000 5 EXTRASI GIGI KOMPLIKASI 48,000 72,000 120,000 80,000 120,000 200,000 48,000 120,000 168,000 80,000 150,000 230,000 6 ODONTECTOMY KLS.I 180,000 270,000 450,000 300,000 450,000 750,000 180,000 640,000 820,000 300,000 800,000 1,100,000 7 ODONTECTOMY DENGAN KOMPLIKASI KLS. II,KLS. III 300,000 550,000 850,000 500,000 1,000,000 1,500,000 8 FRENECTOMY 150,000 200,000 350,000 200,000 350,000 550,000 9 INCISI ABSES INTRA ORAL 18,000 24,000 42,000 30,000 40,000 70,000 18,000 56,000 74,000 30,000 70,000 100,000 10 INCISI ABSES EXTRA ORAL 80,000 120,000 200,000 100,000 150,000 250,000 11 EXCISI BIOPSI 104,000 136,000 240,000 130,000 170,000 300,000 12 INCISI BIOPSI 104,000 136,000 240,000 130,000 170,000 300,000 13 ALVEOCLECTOMY/REGIO 60,000 90,000 150,000 100,000 150,000 250,000 60,000 320,000 380,000 100,000 400,000 500,000 14 DEBRIMENT 24,000 36,000 60,000 40,000 60,000 100,000 24,000 88,000 112,000 40,000 110,000 150,000 15 REPOSISI/FIKSASI 400,000 400,000 800,000 320,000 240,000 560,000 400,000 600,000 1,000,000 SEDERHANA 16 BUKA FIKSASI 36,000 24,000 60,000 60,000 40,000 100,000 36,000 112,000 148,000 60,000 140,000 200,000 17 PEMASANGAN IMPLANT / 6,000,000 4,000,000 10,000,000 UNIT 18 INSISI EPULIS 150,000 200,000 350,000 200,000 300,000 500,000 19 MOCOCEL 70,000 130,000 200,000 100,000 150,000 250,000 20 RANULA 300,000 400,000 700,000 400,000 600,000 1,000,000 21 KISTA < 2 CM (ENUKLEASI) 150,000 150,000 300,000 150,000 250,000 400,000 22 KISTA > 2 CM (ENUKLEASI) 150,000 350,000 500,000 200,000 500,000 700,000 23 REPLANTASI/TRANSPLANTASI 300,000 450,000 750,000 300,000 700,000 1,000,000 DENGAN FIX SEDERHANA 24 FRAK. RB 1,000,000 1,000,000 2,000,000 1,000,000 2,000,000 3,000,000 SEDERHANA/PROC. ALV 25 FRAK. RB KOMP./MULTI FRAKTUR 1,000,000 1,000,000 2,000,000 1,000,000 2,500,000 3,500,000 26 FRAK. Zyg. KOMPLEK 500,000 1,000,000 1,500,000 500,000 2,000,000 2,500,000 27 KELAINAN TMJ ->reposisi 500,000 1,500,000 2,000,000 500,000 2,000,000 2,500,000 terbuka 28 FRAKTUR TMJ ->reposisi 500,000 1,000,000 1,500,000 500,000 1,500,000 2,000,000 tertutup 29 KISTA/TUMOR/Ca. KEL. PAROTIS 500,000 1,500,000 2,000,000 500,000 2,500,000 3,000,000 30 OROANTRAL SINUS 300,000 500,000 800,000 300,000 700,000 1,000,000 Umum VIP Umum

E. TARIF PELAYANAN RADIOLOGI RSKGM NO JENIS PELAYANAN Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik Sarana 1 DENTAL/PA 12,000 12,000 24,000 20,000 15,000 35,000 12,000 15,000 27,000 20,000 15,000 35,000 2 PANORAMIC 36,000 36,000 72,000 60,000 20,000 80,000 36,000 20,000 56,000 60,000 20,000 80,000 3 SEFALOMETRI 36,000 36,000 72,000 60,000 40,000 100,000 36,000 40,000 76,000 60,000 40,000 100,000 4 CONDY-RAY/TMJ 48,000 48,000 96,000 80,000 40,000 120,000 48,000 40,000 88,000 80,000 40,000 120,000 5 OCCLUSAL 24,000 24,000 48,000 40,000 35,000 75,000 24,000 35,000 59,000 40,000 35,000 75,000 6 KARPAL/EISLER 36,000 36,000 72,000 60,000 40,000 100,000 36,000 40,000 76,000 60,000 40,000 100,000 7 BITEWING 18,000 18,000 36,000 30,000 20,000 50,000 18,000 20,000 38,000 30,000 20,000 50,000 8 SINUS 36,000 36,000 72,000 60,000 20,000 80,000 36,000 20,000 56,000 60,000 20,000 80,000 9 3D SINGLE 60,000 60,000 120,000 100,000 50,000 150,000 60,000 50,000 110,000 100,000 50,000 150,000 10 3D FULL 90,000 90,000 180,000 150,000 50,000 200,000 90,000 50,000 140,000 150,000 50,000 200,000 Umum VIPUmum

F. TARIF PELAYANAN ORAL MEDICINE RSKGM NO JENIS PELAYANAN PEMERIKSAAN 1 COMPREHENSIVE PEMERIKSAAN 2 DENGAN KOH PEMERIKSAAN 3 SITOLOGI PEMERIKSAAN SALIVA 4 CHECK MUTAN Sarana Kedokteran Gigi Umum Sarana VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik Umum VIPUmum 40,000 30,000 70,000 60,000 40,000 100,000 60,000 20,000 80,000 60,000 40,000 100,000 50,000 50,000 100,000 80,000 70,000 150,000 80,000 50,000 130,000 80,000 70,000 150,000

G. TARIF PELAYANAN KONSERVASI RSKGM Sarana Sarana Sarana Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 1 BIDANG : 2 2 BIDANG a. Bahan Hybrid 30,000 54,000 84,000 50,000 90,000 140,000 30,000 96,000 126,000 50,000 120,000 170,000 b. Bahan Nano 48,000 54,000 102,000 80,000 90,000 170,000 48,000 96,000 144,000 80,000 120,000 200,000 a. Bahan Hybrid 42,000 60,000 102,000 70,000 100,000 170,000 42,000 104,000 146,000 70,000 130,000 200,000 b. Bahan Nano 72,000 60,000 132,000 120,000 100,000 220,000 72,000 104,000 176,000 120,000 130,000 250,000 3 >2 BIDANG Kedokteran Gigi Umum NO JENIS PELAYANAN VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik a. Bahan Hybrid 60,000 72,000 132,000 100,000 120,000 220,000 60,000 120,000 180,000 100,000 150,000 250,000 b. Bahan Nano 90,000 72,000 162,000 150,000 120,000 270,000 90,000 120,000 210,000 150,000 150,000 300,000 4 DIRECT VENEER COMPOSITE 250,000 250,000 500,000 200,000 320,000 520,000 250,000 400,000 650,000 AMALGAM GLASS IONOMER CEMENT/BIDANG : 5 KAVITAS KECIL 24,000 18,000 42,000 40,000 30,000 70,000 24,000 48,000 72,000 40,000 60,000 100,000 6 KAVITAS BESAR 36,000 18,000 54,000 60,000 30,000 90,000 48,000 48,000 96,000 60,000 60,000 120,000 7 PULP CAPPING 36,000 24,000 60,000 60,000 40,000 100,000 48,000 72,000 120,000 60,000 90,000 150,000 8 TREPANASI 12,000 24,000 36,000 20,000 40,000 60,000 16,000 40,000 56,000 20,000 50,000 70,000 Umum Umum Kelas PERAWATAN SALURAN AKAR/ ENDODONTIK: 9 1 SALURAN AKAR a. Alat manual 24,000 24,000 48,000 40,000 40,000 80,000 32,000 48,000 80,000 40,000 60,000 100,000 b. Alat Rotary 70,000 60,000 130,000 70,000 80,000 150,000 10 2 SALURAN AKAR a. Alat Manual 42,000 36,000 78,000 60,000 60,000 120,000 48,000 72,000 120,000 60,000 90,000 150,000 b. Alat Rotary 90,000 80,000 170,000 90,000 110,000 200,000 11 >2 SALURAN AKAR a. Alat Manual 36,000 48,000 84,000 70,000 80,000 150,000 80,000 80,000 160,000 100,000 100,000 200,000 b. Alat Rotary 100,000 100,000 200,000 120,000 130,000 250,000 12 PENGISIAN GIGI 1 SALURAN AKAR a. Endometasone 40,000 60,000 100,000 32,000 88,000 120,000 40,000 110,000 150,000 b. Resin 60,000 60,000 120,000 48,000 88,000 136,000 60,000 110,000 170,000 c. MTA 80,000 60,000 140,000 80,000 110,000 190,000 13 PENGISIAN GIGI 2 SALURAN AKAR a. Endometason 24,000 36,000 60,000 50,000 80,000 130,000 40,000 80,000 120,000 50,000 100,000 150,000

Sarana Kedokteran Gigi Umum NO JENIS PELAYANAN VIP Sarana BESAR TARIF (RUPIAH) Sarana Dokter Kedokteran Gigi Spesialistik Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Umum Umum Kelas b. Resin 36,000 36,000 72,000 80,000 80,000 160,000 64,000 80,000 144,000 80,000 100,000 180,000 c. MTA 110,000 80,000 190,000 110,000 100,000 210,000 14 BLEACHING EKTERNAL a. Chemical 750,000 150,000 900,000 750,000 250,000 1,000,000 b. Light cure 2,000,000 500,000 2,500,000 15 BLEACHING INTERNAL/VISIT 66,000 48,000 114,000 200,000 150,000 350,000 160,000 240,000 400,000 200,000 300,000 500,000 INLAY / ONLAY 16 METAL 450,000 90,000 540,000 450,000 150,000 600,000 360,000 240,000 600,000 450,000 300,000 750,000 17 PORCELAIN 450,000 150,000 600,000 450,000 300,000 750,000 18 COMPOSITE 240,000 260,000 500,000 350,000 350,000 700,000 19 EMAX 850,000 150,000 1,000,000 850,000 300,000 1,150,000 20 ZIRCONIAL 1,300,000 150,000 1,450,000 1,300,000 300,000 1,600,000 21 DOWEL + CETAK a. Metal post 200,000 150,000 350,000 160,000 160,000 320,000 200,000 200,000 400,000 b. Fiber post 400,000 150,000 550,000 400,000 300,000 700,000 BEDAH ENDO : 22 APEK RESEKSI/APIKOEKTOMI (1 GIGI 960,000 400,000 1,360,000 1,200,000 500,000 1,700,000 23 KONTROL PASCA PSA/BEDAH 16,000 32,000 48,000 20,000 40,000 60,000 24 HEMISEKSI/BICUSPIDISASI 240,000 160,000 400,000 300,000 200,000 500,000

H. TARIF PELAYANAN ORTHODONTI RSKGM NO JENIS PELAYANAN Sarana Sarana Sarana Sarana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 PERAWATAN DGN ALAT 900,000 3,600,000 4,500,000 1,500,000 4,500,000 6,000,000 CEKAT NON SELF LIGATING RA & RB ( Bahan Titanium ) 2 PERAWATAN DGN ALAT CEKAT NON SELF LIGATING RA & RB (Bahan Safir Transparant) 3 PERAWATAN DGN ALAT CEKAT SELF LIGATING / DAMON ( Bahan Titanium ) 4 PERAWATAN DGN ALAT CEKAT SELF LIGATING / DAMON (Clear) 5 FIXED RETAINER /RAHANG 6 BIAYA PERAWATAN DGN ALAT REMOVABLE TANPA 7 BIAYA PERAWATAN DGN ALAT REMOVABLE DGN 8 REMOVABLE RETAINER / RAHANG BIAYA PENAMBAHAN /PENGGANTIAN ALAT : Kedokteran Gigi Umum VIP BESAR TARIF (RUPIAH) Dokter Kedokteran Gigi Spesialistik 2,400,000 2,800,000 5,200,000 4,000,000 3,500,000 7,500,000 6,000,000 5,000,000 11,000,000 7,000,000 5,000,000 12,000,000 120,000 240,000 360,000 200,000 300,000 500,000 240,000 240,000 480,000 400,000 400,000 800,000 240,000 640,000 880,000 400,000 800,000 1,200,000 300,000 240,000 540,000 500,000 400,000 900,000 300,000 480,000 780,000 400,000 600,000 1,000,000 180,000 120,000 300,000 300,000 200,000 500,000 180,000 320,000 500,000 300,000 400,000 700,000 9 ALAT MYOFUNCTIONAL 700,000 300,000 1,000,000 420,000 400,000 820,000 700,000 500,000 1,200,000 10 BUCCAL TUBE HILANG/ 24,000 32,000 56,000 40,000 40,000 80,000 BUAH 11 BUCCAL TUBE LEPAS/ 12,000 16,000 28,000 30,000 20,000 50,000 BUAH 12 BRACKET NON SELF 30,000 40,000 70,000 50,000 50,000 100,000 LIGATING HILANG/ BUAH 13 BRACKET SELF LIGATING HILANG/BUAH 300,000 80,000 380,000 500,000 100,000 600,000 14 BRACKET LEPAS/ BUAH 12,000 16,000 28,000 30,000 20,000 50,000 15 LIP BUMPER 270,000 520,000 790,000 450,000 650,000 1,100,000 Umum Umum Kelas 16 HEAD GEAR 1,500,000 400,000 1,900,000 1,900,000 600,000 2,500,000 17 CHIN CAP 1,500,000 500,000 2,000,000 1,900,000 600,000 2,500,000 18 FACE MASK 1,250,000 750,000 2,000,000 1,800,000 1,200,000 3,000,000 19 NANCE HOLDER 500,000 250,000 750,000 720,000 480,000 1,200,000 20 TRANS PALATAR BAR 350,000 240,000 590,000 450,000 300,000 750,000 21 QUAD HELIX 900,000 600,000 1,500,000 22 RPE ( RAPID PALATAL 720,000 420,000 1,140,000 900,000 600,000 1,500,000 EXPANDER) 23 KONTROL REMOVABLE 12,000 18,000 30,000 20,000 30,000 50,000 12,000 40,000 52,000 20,000 50,000 70,000 /RAHANG 24 KONTROL FIXED/ RAHANG 24,000 48,000 72,000 40,000 60,000 100,000

I. TARIF PELAYANAN UGD BESARNYA TARIF JENIS (RUPIAH) NO KONSULTASI JASA SARANA TOTAL PELAYANAN 1 Pemeriksaan Dokter 7,500 7,500 Jaga 2 Konsultasi Dokter 1,500 1,500 Spesialis 3 Tindakan Perawatan 7,500 7,500 4 Pemeriksaan ECG 50,000 25,000 75,000 J. PELAYANAN RAWAT INAP BESAR TARIF (RUPIAH) NO JENIS PELAYANAN JASA KETERANGAN JASA SARANA TOTAL PELAYANAN 1 2 3 4 5 6 1 RAWAT INAP/HARI a. Kelas 240,000 160,000 400,000 Sewa kamar inap

2 SEWA KAMAR OPERASI b. Kelas 220,000 130,000 350,000 c. Kelas I 140,000 85,000 225,000 d. Kelas II 95,000 55,000 150,000 e. Kelas III 35,000 20,000 55,000 1,000,000 1,000,000 Untuk dokter spesialis gigi tamu (bukan dokter gigi dari RSGM yang ingin menyewa 3 ANASTESI UMUM 450,000 450,000 tenaga dari anestesi dari luar RSGM 4 JASA DOKTER KONSULTAN 5 JASA DOKTER VISIT untuk pasien RSGM yang memerlukan Perawatan intensif 100,000 100,000 dokter konsultan untuk pasien yang dioperasi dengan 25,000 25,000 anastersi Tarif untuk umum dokter dalam melakukan visite pasien rawat inap (per visit)

K. TARIF KONSULTASI DOKTER / DOKTER GIGI NO JENIS KONSULTASI SARANA BESARNYA TARIF (RUPIAH) JASA PELAYANAN TOTAL 1 Konsultasi spesialis 15,000 50,000 65,000 - Konsultasi spesialis penyakit dalam - Konsultas spesialis anak - Konsultasi spesialis anestesi - Konsultasi dokter gigi spesialis 2 Konsultasi dokter umum / dokter 15,000 15,000 30,000 3 gigi umum Konsultasi Gigi 5,000 15,000 20,000 L. TARIF LABORATORIUM DARAH DAN BIOPSI NO JENIS KONSULTASI PEMERIKSAAN LAB sederhana SARANA BESARNYA TARIF (RUPIAH) JASA PELAYANAN TOTAL 1 Darah Rutin 24,000 6,000 30,000 2 Haemoglobin 6,000 4,000 10,000 3 LED 4,000 4,000 8,000 4 Waktu Perdarahan (BT) 2,000 5,000 7,000 5 Waktu Pembekuan (CT) 4,000 4,000 8,000 6 Waktu Protrombin (PT) 40,000 5,000 45,000 7 UPTT 30,000 5,000 35,000 8 Golongan Darah 4,000 6,000 10,000 9 Urine Lengkap 5,000 5,000 10,000 10 Widal 30,000 5,000 35,000 11 HbsAg (Rapid Test) 15,000 5,000 20,000

NO JENIS KONSULTASI SARANA BESARNYA TARIF (RUPIAH) JASA PELAYANAN TOTAL 12 Anti HBs (Rapid Test) 20,000 5,000 25,000 13 Gram 5,000 5,000 10,000 14 Jamur 5,000 5,000 10,000 15 Glukosa 9,000 6,000 15,000 16 BSN/BSPP 18,000 7,000 25,000 17 HBATC 125,000 5,000 130,000 18 Triglycerid 12,000 4,000 16,000 19 Cholesterol 12,000 4,000 16,000 20 WDL Cholesterol 15,000 5,000 20,000 21 Ureum 12,000 4,000 16,000 22 Creatinin 12,000 4,000 16,000 23 Asam Urat 12,000 4,000 16,000 24 Bilirubin 12,000 4,000 16,000 25 Bilirubin Direk 12,000 4,000 16,000 26 Bilirubin Indirek 12,000 4,000 16,000 27 SGOT 12,000 4,000 16,000 28 SGPT 12,000 4,000 16,000 29 GGT 12,000 4,000 16,000 30 Alkalina Phosphatase 12,000 4,000 16,000 31 Protein 10,000 4,000 14,000 32 Albumin 10,000 4,000 14,000 33 Giobulin 10,000 4,000 14,000 34 CK 30,000 5,000 35,000

M. TARIF LABORATORIUM TEKNIK GIGI No Jenis perawatan Tarif 1 Porcelain Fuse Metal 250,000 2 Crown Implant Semen type 350,000 3 Crown Implant Screw type 650,000 4 Crown porcelain + pin core 400,000 5 Inlay/onlay PFM 150,000 6 Porcelain margin 100,000 7 Pin porcelain 100,000 8 Pin crown/post core 75,000 9 Post core magnetic attachment 200,000 10 Maryland bridge 190,000 11 Onlay/inlay metal 75,000 12 Attachment/key and key 250,000 13 Full metal 200,000 14 Rest/wing 25,000 15 Full Denture lepasan akrilik/rahang 300,000 16 Full Denture lepasan valplast/rahang 900,000 17 Ortho Removable/rahang 115,000 18 Simple spring 10,000 19 C-Clasp 10,000 20 Valplast gigi pertama RA/RB 225,000 21 Valplast gigi selanjutnya 35,000 22 GTSL akrilik gigi pertama 60,000 23 GTSL akrilik gigi selanjutnya 30,000 24 Klamer 10,000 25 Split labial bow 10,000 26 Jacket akrilik 80,000 27 Reparasi 30,000 28 Rebasing 60,000

No Jenis perawatan Tarif 31 All Porcelain - Zirconia 900,000 32 Cr/Br/Inlay/Onlay/Veneer All porc - Emax 600,000 33 Cr/Br/Inlay/Onlay/Veneer All porc- Empress 550,000 34 Ceramage Crown/Inlay/onlay/uplay 300,000 35 Frame Full 400,000 36 Frame bilateral 250,000 37 Frame sadle 225,000 38 FRS Bilateral unit ke-1 400,000 39 FRS Sadle Unit ke-1 300,000 40 FRS Unit Selanjutnya 70,000 41 FRS Full 1,250,000 42 FRS kombinasi frame unit ke-1 350,000 43 FRS-Clear Clasp 150,000 44 Estetik Retainer/Rahang 120,000 45 Bleaching Tray/Rahang 80,000 46 Surgical Template/Rahang 70,000 47 Individual Mouthguard Standard/Rahang 225,000 48 Individual Mouthguard Standard Heavy-freestyle 450,000 GUBERNUR SUMATERA SELATAN, ALEX NOERDIN

LAMPIRAN II : PERATURAN DAERAH PROVINSI SUMSEL NOMOR TAHUN 2014 TENTANG PERUBAHAN KEDUA ATAS PERATURAN DAERAH NOMOR 3 TAHUN 2012 TENTANG RETRIBUSI JASA UMUM TARIF RETRIBUSI PENYELENGGARAAN PELAYANAN PENDIDIKAN PADA RUMAH SAKIT KHUSUS GIGI DAN MULUT PROVINSI SUMATERA SELATAN Besaran Tarif No. Jenis JASA SARANA JASA PELAYANAN JUMLAH KETERANGAN (Rp) (Rp) (Rp) 1 2 3 4 5 6 Pendidikan dan Pelatihan (Diklat) 1 Praktek / Orientasi a. Praktek per org/hari b. Praktek per org/minggu 2 Magang a. Magang per org/minggu b. Magang per org / bulan 3 Penelitian a. Pra penelitian (per kegiatan) b. Penelitian (per kegiatan) 2,000 3,000 5,000 12,000 18,000 30,000 14,000 21,000 35,000 60,000 90,000 150,000 20,000 30,000 50,000 30,000 45,000 75,000 GUBERNUR SUMATERA SELATAN, ALEX NOERDIN

USULAN TARIF LABORATORIUM TEKNIK GIGI RSK. GIGI DAN MULUT PROVINSI SUMATERA SELATAN Tarif pembanding Tarif yang di usulkan No Jenis perawatan Asia RSKGM QTA Afrika Age Prov. Sum- PERSADA Dental Sel 1 Porcelain Fuse Metal 300,000 260,000 190,000 250,000 2 Crown Implant Semen type 400,000 350,000 3 Crown Implant Screw type 700,000 650,000 4 Crown porcelain + pin core 450,000 400,000 5 Inlay/onlay PFM 225,000 500,000 150,000 150,000 6 Porcelain margin 100,000 100,000 7 Pin porcelain 100,000 100,000 8 Pin crown/post core 200,000 75,000 50,000 75,000 9 Post core magnetic attachment 225,000 200,000 200,000 10 Maryland bridge 450,000 400,000 195,000 190,000 11 Onlay/inlay metal 150,000 135,000 50,000 75,000 12 Attachment/key and key 300,000 250,000 13 Full metal 220,000 200,000 14 Rest/wing 50,000 25,000 25,000 15 Full Denture lepasan akrilik/rahang 450,000 400,000 300,000 300,000 16 Full Denture lepasan valplast/rahang 1,000,000 900,000 17 Ortho Removable/rahang 120,000 115,000 125,000 115,000 18 Simple spring 10,000 10,000 19 C-Clasp 10,000 13,000 10,000

No Jenis perawatan QTA PERSADA Tarif pembanding Asia Afrika Dental Age Tarif yang di usulkan RSKGM Prov. Sum- Sel 20 Valplast gigi pertama RA/RB 270,000 400,000 225,000 225,000 21 Valplast gigi selanjutnya 35,000 60,000 25,000 35,000 22 GTSL akrilik gigi pertama 60,000 75,000 90,000 60,000 23 GTSL akrilik gigi selanjutnya 30,000 25,000 10,000 30,000 24 Klamer 10,000 13,000 10,000 25 Split labial bow 10,000 10,000 26 Jacket akrilik Rp. 100.000 200,000 Rp. 50.000 80,000 27 Reparasi Rp. 30,000 30.000 28 Rebasing Rp. 60,000 60.000 29 Profisoris Rp. 45,000 45,000 50.000 30 Sendok cetak perseorangan Rp. 60.000 60,000 31 All Porcelain - Zirconia 1,100,000 950,000 900,000 32 Cr/Br/Inlay/Onlay/Veneer All porc - 650,000 600,000 Emax 33 Cr/Br/Inlay/Onlay/Veneer All porc- 600,000 550,000 Empress 34 Ceramage Crown/Inlay/onlay/uplay 500,000 300,000 35 Frame Full 450,000 300,000 400,000 36 Frame bilateral 400,000 250,000 250,000 37 Frame sadle 350,000 225,000 225,000 38 FRS Bilateral unit ke-1 450,000 400,000 39 FRS Sadle Unit ke-1 350,000 300,000

No Jenis perawatan QTA PERSADA Tarif pembanding Asia Afrika Dental Age Tarif yang di usulkan RSKGM Prov. Sum- Sel 40 FRS Unit Selanjutnya 75,000 70,000 41 FRS Full 1,300,000 1,250,000 42 FRS kombinasi frame unit ke-1 375,000 350,000 43 FRS-Clear Clasp 175,000 150,000 44 Estetik Retainer/Rahang 125,000 120,000 45 Bleaching Tray/Rahang 10,000 80,000 46 Surgical Template/Rahang 75,000 70,000 47 Individual Mouthguard Standard/Rahang 48 Individual Mouthguard Standard Heavyfreestyle 250,000 225,000 500,000 450,000

USULAN TARIF LABORATORIUM TEKNIK GIGI RSK. GIGI DAN MULUT PROVINSI SUMATERA SELATAN No Jenis perawatan Tarif yang di usulkan No Jenis perawatan Tarif yang di usulkan 1 Porcelain Fuse Metal 250,000 25 Split labial bow 10,000 2 Crown Implant Semen type 350,000 26 Jacket akrilik 80,000 3 Crown Implant Screw type 650,000 27 Reparasi 30,000 4 Crown porcelain + pin core 400,000 28 Rebasing 60,000 5 Inlay/onlay PFM 150,000 29 Profisoris 45,000 6 Porcelain margin 100,000 30 Sendok cetak perseorangan 60,000 7 Pin porcelain 100,000 31 All Porcelain - Zirconia 900,000 8 Pin crown/post core 75,000 32 Cr/Br/Inlay/Onlay/Veneer All porc - Emax 600,000 9 Post core magnetic attachment 200,000 33 Cr/Br/Inlay/Onlay/Veneer All porc- Empress 550,000 10 Maryland bridge 190,000 34 Ceramage Crown/Inlay/onlay/uplay 300,000 11 Onlay/inlay metal 75,000 35 Frame Full 400,000 12 Attachment/key and key 250,000 36 Frame bilateral 250,000 13 Full metal 200,000 37 Frame sadle 225,000 14 Rest/wing 25,000 38 FRS Bilateral unit ke-1 400,000 15 Full Denture lepasan akrilik/rahang 300,000 39 FRS Sadle Unit ke-1 300,000 16 Full Denture lepasan valplast/rahang 900,000 40 FRS Unit Selanjutnya 70,000 17 Ortho Removable/rahang 115,000 41 FRS Full 1,250,000 18 Simple spring 10,000 42 FRS kombinasi frame unit ke-1 350,000 19 C-Clasp 10,000 43 FRS-Clear Clasp 150,000 20 Valplast gigi pertama RA/RB 225,000 44 Estetik Retainer/Rahang 120,000 21 Valplast gigi selanjutnya 35,000 45 Bleaching Tray/Rahang 80,000 22 GTSL akrilik gigi pertama 60,000 46 Surgical Template/Rahang 70,000 23 GTSL akrilik gigi selanjutnya 30,000 47 Individual Mouthguard Standard/Rahang 225,000 24 Klamer 10,000 48 Individual Mouthguard Standard Heavy-freestyle 450,000