| Paket Operasi | Kelas | Tarif Operasi | 
                               
                                                  | Adneosilis | - | Rp. 2.560.000,- | 
                                                  | Angkat Corpus Alineum Cornea | - | Rp. 960.000,- | 
                                                  | Aspirasi/Irigasi/Reformasi COA | - | Rp. 1.540.000,- | 
                                                  | Bilateral repair of inguinal hernia, not otherwise specified | - | Rp. 5.100.000,- | 
                                                  | Biopsi Pembuluh Darah Perifer | - | Rp. 1.540.000,- | 
                                                  | Cholecystectomy | - | Rp. 2.560.000,- | 
                                                  | Corpus Alienum dgn Operating Microscope | - | Rp. 1.540.000,- | 
                                                  | Debridement Nekrotomi Luka Ganggren | - | Rp. 2.560.000,- | 
                                                  | DSAEK (Descemets Stripping Automated Keraoplasty) | - | Rp. 2.560.000,- | 
                                                  | Eksisi Pterigium | - | Rp. 1.540.000,- | 
                                                  | Eksisi Tumor Pembulurh Darah Perifer | - | Rp. 1.540.000,- | 
                                                  | Ekstirpasi Kista | - | Rp. 870.000,- | 
                                                  | Ekstraksi IOL | - | Rp. 2.560.000,- | 
                                                  | Evakuasi Hematom (Pasca pungsi) | - | Rp. 1.540.000,- | 
                                                  | Excision of Perianal Skin Tags | - | Rp. 1.540.000,- | 
                                                  | Fasciotomi | - | Rp. 1.540.000,- | 
                                                  | Fraktur Tripod Multiple | - | Rp. 4.700.000,- | 
                                                  | Hipertropi prostat benigna | - | Rp. 5.100.000,- | 
                                                  | Injeksi Botox pada Strabismus | - | Rp. 1.540.000,- | 
                                                  | Insisi Abses dgn Penyulit | - | Rp. 1.340.000,- | 
                                                  | Katarak ECCE (Tidak Termasuk IOL) | - | Rp. 2.560.000,- | 
                                                  | Kuret Granulasi Care | - | Rp. 870.000,- | 
                                                  | Left Hemikolectomy | - | Rp. 5.100.000,- | 
                                                  | Miomektomi/Kistektomi | - | Rp. 2.560.000,- | 
                                                  | Operasi Perineum | - | Rp. 2.560.000,- | 
                                                  | Orbitotomy Anterior | - | Rp. 2.560.000,- | 
                                                  | Other Incision of Anus | - | Rp. 1.540.000,- | 
                                                  | Other Partial Excesion of Large Intenstine | - | Rp. 2.560.000,- | 
                                                  | Paracentesis | - | Rp. 2.560.000,- | 
                                                  | Pemasangan paritoneal dialisis (PD) catheter (di luar alat) | - | Rp. 5.100.000,- | 
                                                  | Phaco + IOL Multifokal/Torik | - | Rp. 2.560.000,- | 
                                                  | Prosedur Sistrunk Kista Duktus Tiroglosus | - | Rp. 2.560.000,- | 
                                                  | Rekonstruksi Palpebra dgn Flap atau Graft | - | Rp. 2.560.000,- | 
                                                  | Repair Iridodyalisis | - | Rp. 2.560.000,- | 
                                                  | Repair Of Laceration, Cornea, Non Perforating | - | Rp. 2.560.000,- | 
                                                  | Reposisi dislokasi sendi rahang | - | Rp. 5.100.000,- | 
                                                  | Rhitidectomy | - | Rp. 2.560.000,- | 
                                                  | Sekunder IOL | - | Rp. 2.560.000,- | 
                                                  | Subtotal Mastectomy | - | Rp. 2.560.000,- | 
                                                  | Temporary Eleostomy | - | Rp. 2.560.000,- | 
                                                  | Trabekulektomy (pada Anak/Bayi) | - | Rp. 2.560.000,- | 
                                                  | Tubes Implan | - | Rp. 2.560.000,- | 
                                                  | Wide Excision of Soft Tissue tumor | - | Rp. 2.560.000,- | 
                                                  | Amputasi Jari Tangan / Kaki | - | Rp. 1.540.000,- | 
                                                  | Anterior Lamellar Keratoplasty | - | Rp. 2.560.000,- | 
                                                  | Bilateral Radical Mastectomy | - | Rp. 5.100.000,- | 
                                                  | Bilateral Simple Mastectotomy | - | Rp. 2.560.000,- | 
                                                  | Biopsi Tumor Orbita | - | Rp. 2.560.000,- | 
                                                  | Colostomy, not otherwise specified | - | Rp. 2.560.000,- | 
                                                  | CWL (Cold Well Luck) Op. Sinus Maxila | - | Rp. 1.340.000,- | 
                                                  | Deseksi Submandibula | - | Rp. 5.100.000,- | 
                                                  | Eksisi Chalasion/Hordeolum | - | Rp. 1.540.000,- | 
                                                  | Eksisi Tumor jinak | - | Rp. 1.540.000,- | 
                                                  | Eksraksi Ephitelial Downgrowth | - | Rp. 2.560.000,- | 
                                                  | Ekstirpasi Tumor Orbita | - | Rp. 2.560.000,- | 
                                                  | Ekstrerpasi Polip Serviks | - | Rp. 1.540.000,- | 
                                                  | Eviserasi | - | Rp. 2.560.000,- | 
                                                  | Exploration of Common Duct | - | Rp. 5.100.000,- | 
                                                  | Fraktur Antebrachi | - | Rp. 5.100.000,- | 
                                                  | Granuloma Pyogenikum | - | Rp. 990.000,- | 
                                                  | Ileostomy, not otherwise specified | - | Rp. 2.560.000,- | 
                                                  | Insersi Sekunder IOL | - | Rp. 2.560.000,- | 
                                                  | Insisi Hordeolum | - | Rp. 960.000,- | 
                                                  | Keratoprosthesis | - | Rp. 2.560.000,- | 
                                                  | Laparatomy VC | - | Rp. 5.100.000,- | 
                                                  | Limbal Relaxing Incision (LRI) | - | Rp. 2.560.000,- | 
                                                  | Oklusi Punctum Lakrimal | - | Rp. 1.540.000,- | 
                                                  | Orbital Dekompresi 1 Tulang | - | Rp. 2.560.000,- | 
                                                  | other Destrucsion of Lesion of Liver | - | Rp. 2.560.000,- | 
                                                  | Other Local Excisio Destruction of Lesion Tissue of Skin Subcutaneous Tissue | - | Rp. 2.560.000,- | 
                                                  | Other reconstruction of mandible | - | Rp. 5.100.000,- | 
                                                  | Pasang implantable central venous access (di luar alat: port a cath) | - | Rp. 5.100.000,- | 
                                                  | Pericardiocentesis | - | Rp. 5.100.000,- | 
                                                  | Pneumatic Retinopexy | - | Rp. 1.540.000,- | 
                                                  | Punksi Asites | - | Rp. 1.540.000,- | 
                                                  | Rekonstruksi Soket Landai | - | Rp. 2.560.000,- | 
                                                  | Repair of Grastrochisis | - | Rp. 5.100.000,- | 
                                                  | Repair Ruptur Kornea | - | Rp. 2.560.000,- | 
                                                  | Reseksi Adenomiosis | - | Rp. 2.560.000,- | 
                                                  | Ruptur Tendon Achilles | - | Rp. 2.560.000,- | 
                                                  | Sirkumsisi / Phimosis | - | Rp. 1.540.000,- | 
                                                  | Suture of Lasertion of Large Intestine | - | Rp. 2.560.000,- | 
                                                  | Tonsilektomi | - | Rp. 1.340.000,- | 
                                                  | Trakeostomy dengan Penyulit Tumor pada Akses Trakea | - | Rp. 2.560.000,- | 
                                                  | Unilateral radkal madtectomy | - | Rp. 5.100.000,- | 
                                                  | Ekstirpasi FAM | - | Rp. 1.540.000,- | 
                                                  | Ablatio Retina | - | Rp. 4.700.000,- | 
                                                  | Anal Fistulotomyrosthesis, not otherwise spesified | - | Rp. 5.100.000,- | 
                                                  | Appendiktomi Perforasi (Laparotomi) | - | Rp. 2.560.000,- | 
                                                  | Bilateral repair of femoral hernia with/without graft or prosthesis | - | Rp. 5.100.000,- | 
                                                  | Biopsi of Anus | - | Rp. 1.540.000,- | 
                                                  | Canthotomy | - | Rp. 1.540.000,- | 
                                                  | Complete Thyriodectony | - | Rp. 5.100.000,- | 
                                                  | Cyro/Cauter pada Trichiasis | - | Rp. 1.540.000,- | 
                                                  | Drainage of Appendiceal Abcess | - | Rp. 2.560.000,- | 
                                                  | Eksisi Kista Tiroglosus | - | Rp. 2.560.000,- | 
                                                  | Eksisi Tumor Palpebra (> 1/4 margo) | - | Rp. 2.560.000,- | 
                                                  | Ekstirpasi Fibroma | - | Rp. 1.540.000,- | 
                                                  | Ekstraksi Corpus Alineum Nasal dengan general Anastesi | - | Rp. 2.160.000,- | 
                                                  | Ektropion 1 Kelopak | - | Rp. 2.560.000,- | 
                                                  | Excision of Hemmoroids | - | Rp. 2.560.000,- | 
                                                  | Exteriorization of Large Intestine | - | Rp. 2.560.000,- | 
                                                  | Fraktur Fremur | - | Rp. 5.100.000,- | 
                                                  | Hemangioma : Injeksi Intralesi + Narkose Combine Trabulectomy | - | Rp. 2.560.000,- | 
                                                  | Incisional of Perinatal Abcess | - | Rp. 1.540.000,- | 
                                                  | Insisi Abses | - | Rp. 870.000,- | 
                                                  | Jahit Perineum Grade I-II | - | Rp. 990.000,- | 
                                                  | Konka Reduksi | - | Rp. 1.340.000,- | 
                                                  | Laser Katarak Sekunder | - | Rp. 1.540.000,- | 
                                                  | Marsupialisasi | - | Rp. 990.000,- | 
                                                  | Open Biopsi of Rectum | - | Rp. 1.540.000,- | 
                                                  | Orbitotomi Lateral | - | Rp. 4.700.000,- | 
                                                  | Other hernia Repair (Herniotomy - Hernioplasty) | - | Rp. 2.560.000,- | 
                                                  | Other Operation of Intestines | - | Rp. 2.560.000,- | 
                                                  | Other Repair Off Abdominal Wall | - | Rp. 1.540.000,- | 
                                                  | Pemasangan Central Venous Catether (CVC) | - | Rp. 1.540.000,- | 
                                                  | Phaco | - | Rp. 2.560.000,- | 
                                                  | Posterior Vitrectomy + Endo Laser | - | Rp. 4.700.000,- | 
                                                  | Rekonstruksi Fraktur Dasar Orbita | - | Rp. 4.700.000,- | 
                                                  | Reopening of Recent Lapartomy Site | - | Rp. 2.560.000,- | 
                                                  | Repair of Laceration of gallbladder | - | Rp. 5.100.000,- | 
                                                  | Repair Ruptur Palpebra | - | Rp. 2.560.000,- | 
                                                  | Revision of Anastomosis of Small Intestine | - | Rp. 2.560.000,- | 
                                                  | SC Tanpa Penyulit | - | Rp. 2.560.000,- | 
                                                  | Strabismus | - | Rp. 2.560.000,- | 
                                                  | Tatto Kornea | - | Rp. 2.560.000,- | 
                                                  | Trabekulektomi | - | Rp. 2.560.000,- | 
                                                  | Triple Producer Keratiplasty dgn Glaucoma | - | Rp. 4.700.000,- | 
                                                  | Vena Secite (Emergensi) | - | Rp. 2.560.000,- | 
                                                  | Cyclo Cryo | - | Rp. 2.560.000,- | 
                                                  | Aff Arch Bar | - | Rp. 1.540.000,- | 
                                                  | Angkat Jahitan Kornea | - | Rp. 1.540.000,- | 
                                                  | Batu Saluran Kemih/Batu Buli-Buli | - | Rp. 2.560.000,- | 
                                                  | Bilateral repair of inguinal hernia, one direct and one indirect | - | Rp. 5.100.000,- | 
                                                  | Biopsi Terbuka Dinding Thorax | - | Rp. 1.540.000,- | 
                                                  | Closure of Intensial Stoma | - | Rp. 2.560.000,- | 
                                                  | Curet Abortus | - | Rp. 1.540.000,- | 
                                                  | Debridment + Pasang Gips | - | Rp. 1.540.000,- | 
                                                  | ECCE dgn Teknik Fragmentasi dan Aspirasi | - | Rp. 2.560.000,- | 
                                                  | Eksisi Pterigium + Graft | - | Rp. 2.560.000,- | 
                                                  | Eksplorasi Nasofaring | - | Rp. 870.000,- | 
                                                  | Ekstirpasi Kista Ateroma/Lipoma/Ganglion Kcl | - | Rp. 990.000,- | 
                                                  | Ekstraksi Kuku | - | Rp. 990.000,- | 
                                                  | Evakuasi Hematom di Ekstrimitas (Pasca Pungsi HD / Trauma) | - | Rp. 1.540.000,- | 
                                                  | Excision of Thyroglossal Duct or Trac | - | Rp. 2.560.000,- | 
                                                  | Fiksasi Internal Fraktur Nasal | - | Rp. 5.100.000,- | 
                                                  | Geniotomi | - | Rp. 1.540.000,- | 
                                                  | Histerektomi Total/Radikal | - | Rp. 5.100.000,- | 
                                                  | Injeksi Intravitreal | - | Rp. 1.540.000,- | 
                                                  | Insisi Chalasion | - | Rp. 960.000,- | 
                                                  | Katarak Phaco Emulsifikasi (Tdk Termasuk IOL) | - | Rp. 2.560.000,- | 
                                                  | Laparatomi Eksplorasi | - | Rp. 2.560.000,- | 
                                                  | Ligasi Vaskuler Ekstremitas | - | Rp. 1.540.000,- | 
                                                  | Multiple Excision of Lesion of Breast | - | Rp. 2.560.000,- | 
                                                  | Operasi Tumor Ganas Ovarium | - | Rp. 5.100.000,- | 
                                                  | Orbitotomy Lateral | - | Rp. 2.560.000,- | 
                                                  | Other Incision of Skin and Subcutaneus Tissue | - | Rp. 1.540.000,- | 
                                                  | Other partial Thyroidectomy | - | Rp. 5.100.000,- | 
                                                  | Partial Splenoctomy | - | Rp. 5.100.000,- | 
                                                  | pembuatan Thorasic Window | - | Rp. 2.560.000,- | 
                                                  | Phakik IOL | - | Rp. 2.560.000,- | 
                                                  | Pungsi hematom/seroma | - | Rp. 1.540.000,- | 
                                                  | Rekonstruksi Socket Berat | - | Rp. 4.700.000,- | 
                                                  | Repair Luka Kornea + Flap Conjungtiva | - | Rp. 2.560.000,- | 
                                                  | Repair of other hernia of anterior abdominal wall with prosthesis | - | Rp. 5.100.000,- | 
                                                  | Reposisi IOL | - | Rp. 2.560.000,- | 
                                                  | Right Hemicolectomy | - | Rp. 5.100.000,- | 
                                                  | Septum Reposisi | - | Rp. 1.340.000,- | 
                                                  | Surgical Staging Vulvektomy | - | Rp. 5.100.000,- | 
                                                  | Tindakan Cyclodia Termi | - | Rp. 2.560.000,- | 
                                                  | Trabekulektomy + Phaco + IOL | - | Rp. 2.560.000,- | 
                                                  | Tubes Implan + Phaco + IOL | - | Rp. 4.700.000,- | 
                                                  | Amputasi Above Knee | - | Rp. 5.100.000,- | 
                                                  | Amputasi Trans Medial | - | Rp. 2.560.000,- | 
                                                  | Anterior/Posteorior Sklerotomi | - | Rp. 2.560.000,- | 
                                                  | Bilateral Repair of Direct inguinal hernia | - | Rp. 5.100.000,- | 
                                                  | Biopsi | - | Rp. 1.540.000,- | 
                                                  | Blefarorafi | - | Rp. 1.540.000,- | 
                                                  | Combutsio (Luka Bakar) | - | Rp. 2.560.000,- | 
                                                  | Cyclo Cryo | - | Rp. 2.560.000,- | 
                                                  | Desisi Membran Capsul Katarak Sekunder | - | Rp. 2.560.000,- | 
                                                  | Eksisi Clavus | - | Rp. 990.000,- | 
                                                  | Eksisi Tumor Kecil Kelopak | - | Rp. 2.560.000,- | 
                                                  | Ekstaksi Linear | - | Rp. 2.560.000,- | 
                                                  | Ekstraksi Corpus Alienum Cornea | - | Rp. 1.540.000,- | 
                                                  | Ekstripasi / Eksisi Tumor Jinak Jaringan Lunak Ukuran < 2 cm | - | Rp. 1.540.000,- | 
                                                  | Exchange IOL | - | Rp. 2.560.000,- | 
                                                  | Exploratory Lapartomy | - | Rp. 2.560.000,- | 
                                                  | Fraktur Colles & Pergelangan tangan lainnya | - | Rp. 5.100.000,- | 
                                                  | Grastostomi | - | Rp. 2.560.000,- | 
                                                  | Incisional Hernia Repair | - | Rp. 2.560.000,- | 
                                                  | Insertion of Synthetic Implant in Facial bone | - | Rp. 5.100.000,- | 
                                                  | Iridektomi Perifer | - | Rp. 1.540.000,- | 
                                                  | Kista Ateroma Pada Mata | - | Rp. 1.540.000,- | 
                                                  | Lapartomi Percobaan | - | Rp. 2.560.000,- | 
                                                  | Local Excision of Lesion of Breast | - | Rp. 1.540.000,- | 
                                                  | Open Biopsi of Breast | - | Rp. 1.540.000,- | 
                                                  | Orbital Dekompresi 2 Tulang | - | Rp. 2.560.000,- | 
                                                  | Other Diagnnostic Procedures of Abdominal Region | - | Rp. 2.560.000,- | 
                                                  | Other Lysis of Peritoneal Adhesions | - | Rp. 2.560.000,- | 
                                                  | Other Repair of Intestine | - | Rp. 2.560.000,- | 
                                                  | Pediatric Cataract | - | Rp. 2.560.000,- | 
                                                  | Permanent Colostomy | - | Rp. 2.560.000,- | 
                                                  | Polipektomi | - | Rp. 1.340.000,- | 
                                                  | Punksi Lumbal | - | Rp. 2.560.000,- | 
                                                  | Release Kontraktur Mandibula | - | Rp. 2.560.000,- | 
                                                  | Repair of indirect inguinal hernia | - | Rp. 5.100.000,- | 
                                                  | Repair Ruptur Ocoli Multipel Struktur | - | Rp. 2.560.000,- | 
                                                  | Reseksi Kondiloma | - | Rp. 1.540.000,- | 
                                                  | Salpingo Oophorektomy | - | Rp. 2.560.000,- | 
                                                  | Small to small intestinal anastomosis | - | Rp. 5.100.000,- | 
                                                  | Suture of Periteneum | - | Rp. 2.560.000,- | 
                                                  | Torakoskopi | - | Rp. 2.960.000,- | 
                                                  | Trakeostomy Temporary | - | Rp. 2.560.000,- | 
                                                  | Unilatheral Thyroid lobectomy | - | Rp. 2.560.000,- | 
                                                  | Eksisi / Konisasi dengan GA | - | Rp. 1.540.000,- | 
                                                  | Adenotonsilektomi | - | Rp. 1.340.000,- | 
                                                  | Angkat Corpus Alienum Orbita | - | Rp. 1.540.000,- | 
                                                  | Appendiktomi Tanpa Penyulit | - | Rp. 1.540.000,- | 
                                                  | Bilateral repair of indirect inguinal hernia with graft or prothesis | - | Rp. 5.100.000,- | 
                                                  | Biopsi of Perinal Tissue | - | Rp. 1.540.000,- | 
                                                  | Cantoplasty | - | Rp. 1.540.000,- | 
                                                  | Coreoplasty Jahit Membrana Pupilaris | - | Rp. 2.560.000,- | 
                                                  | Cystotomi (Emergensi) | - | Rp. 2.560.000,- | 
                                                  | Dry Needling | - | Rp. 2.560.000,- | 
                                                  | Eksisi Prolaps Iris | - | Rp. 1.540.000,- | 
                                                  | Eksisi Tumor Pembuluh Darah Perifer (Hemangioma) | - | Rp. 2.560.000,- | 
                                                  | Ekstirpasi Kelainan Kornea | - | Rp. 2.560.000,- | 
                                                  | Ekstraksi Corpus Alineum Telingan dengan General Anastesi | - | Rp. 2.160.000,- | 
                                                  | Entropion 1 Kelopak | - | Rp. 2.560.000,- | 
                                                  | Excision of Lesion of Breast | - | Rp. 2.560.000,- | 
                                                  | Exxteriorization of Small Intestine | - | Rp. 2.560.000,- | 
                                                  | Fraktur Hummerus | - | Rp. 5.100.000,- | 
                                                  | Hidrokel Testis/Funikuli | - | Rp. 2.560.000,- | 
                                                  | Injeksi Botox pada Blefarospasme | - | Rp. 1.540.000,- | 
                                                  | Insisi Abses | - | Rp. 1.540.000,- | 
                                                  | Jahit Perineum Grade III-IV | - | Rp. 2.560.000,- | 
                                                  | Konkotomi | - | Rp. 1.340.000,- | 
                                                  | Lasik 1 (Satu) Mata | - | Rp. 2.560.000,- | 
                                                  | ME / Mastoidektomi Simple | - | Rp. 2.160.000,- | 
                                                  | Open Biopsi of Salivary Gland or Duct | - | Rp. 1.540.000,- | 
                                                  | Orbitotomi Lateral + Superior/Medial | - | Rp. 4.700.000,- | 
                                                  | Other Incidental Appendictomy | - | Rp. 2.560.000,- | 
                                                  | Other Operation on Trachea | - | Rp. 5.100.000,- | 
                                                  | Other small to large intestinal anastomsis | - | Rp. 5.100.000,- | 
                                                  | Pemasangan Interdental Wiring / Arch Bar | - | Rp. 2.560.000,- | 
                                                  | Phaco + IOL | - | Rp. 2.560.000,- | 
                                                  | Probing | - | Rp. 2.560.000,- | 
                                                  | Rekonstruksi Kelopak Berat | - | Rp. 4.700.000,- | 
                                                  | Repair Dehisensi Pasca Operasi Kornea | - | Rp. 2.560.000,- | 
                                                  | Repair Of Laceration, Cornea, And/Or Screra, Perforating | - | Rp. 2.560.000,- | 
                                                  | Repair Ruptur Sclera | - | Rp. 2.560.000,- | 
                                                  | Revision of anastomsis of Lare Instestine | - | Rp. 2.560.000,- | 
                                                  | Scleral Buckling + Phaco + IOL | - | Rp. 4.700.000,- | 
                                                  | Strabismus 1,2,3,4 Otot | - | Rp. 2.560.000,- | 
                                                  | Temporary Colostomy | - | Rp. 2.560.000,- | 
                                                  | Trabekulektomy | - | Rp. 2.560.000,- | 
                                                  | Tubectomy | - | Rp. 1.540.000,- | 
                                                  | Vitrectomy | - | Rp. 4.700.000,- | 
                                                  | Aff Arch Barr dan Suspensi Maksila | - | Rp. 1.540.000,- | 
                                                  | Angkat Pterigium dan Graft | - | Rp. 1.540.000,- | 
                                                  | Bilateral Multiple Excision of Lesion of Breast | - | Rp. 1.540.000,- | 
                                                  | Bilateral repair of inguinal, one direct one indirect, with graft or prothesis | - | Rp. 5.100.000,- | 
                                                  | Biopsi Tumor Kelopak | - | Rp. 2.560.000,- | 
                                                  | Closure of Lesteration of Liver | - | Rp. 2.560.000,- | 
                                                  | Curet Malohidatidosa | - | Rp. 2.560.000,- | 
                                                  | Dekompresi | - | Rp. 4.700.000,- | 
                                                  | Eksenterasi | - | Rp. 2.560.000,- | 
                                                  | Eksisi Tumor Adneksa | - | Rp. 2.560.000,- | 
                                                  | Eksplorasi Vaskular Trauma | - | Rp. 2.560.000,- | 
                                                  | Ekstirpasi Tumor Adneksi + Rekonstruksi | - | Rp. 4.700.000,- | 
                                                  | Ekstraksi Lithiasis | - | Rp. 1.540.000,- | 
                                                  | Evakuasi Silicon Oil + Phaco/ECCE + IOL | - | Rp. 2.560.000,- | 
                                                  | Explorasi | - | Rp. 870.000,- | 
                                                  | Flap Conjunctiva/Amnion Graf | - | Rp. 2.560.000,- | 
                                                  | Gonioplasty/Goniotomy | - | Rp. 2.560.000,- | 
                                                  | Hymenectomy | - | Rp. 1.540.000,- | 
                                                  | Insersi IOL | - | Rp. 2.560.000,- | 
                                                  | Insisi Flegmon Dasar Mulut | - | Rp. 2.560.000,- | 
                                                  | Keratoplasty Tembus | - | Rp. 2.560.000,- | 
                                                  | Laparatomi Percobaan | - | Rp. 2.560.000,- | 
                                                  | Ligation of Hemorrhoids | - | Rp. 2.560.000,- | 
                                                  | Mutilasi Digiti Ekstremitas (Multiple) | - | Rp. 1.540.000,- | 
                                                  | Operasi Tumor Jinak Ovarium | - | Rp. 2.560.000,- | 
                                                  | Other Appendictomy | - | Rp. 2.560.000,- | 
                                                  | Other Lapartomy | - | Rp. 2.560.000,- | 
                                                  | Other Procedures on Homorroids | - | Rp. 5.100.000,- | 
                                                  | Pasang double lumen hemodialysis (HD) (di  luar alat) | - | Rp. 5.100.000,- | 
                                                  | Pengangkatan Encircling Silicone Band | - | Rp. 2.560.000,- | 
                                                  | Pleurodesis | - | Rp. 600.000,- | 
                                                  | Pungsi pleura | - | Rp. 560.000,- | 
                                                  | Rekonstruksi Socket Kontraktur | - | Rp. 4.700.000,- | 
                                                  | Repair of direct inguinal hernia with graft or prosthesis | - | Rp. 5.100.000,- | 
                                                  | Repair Ruptur Canalis Lacrimalis | - | Rp. 2.560.000,- | 
                                                  | Reposisi Iris | - | Rp. 2.560.000,- | 
                                                  | Ruptur Buli-buli | - | Rp. 2.560.000,- | 
                                                  | Sigmoidectomy | - | Rp. 2.560.000,- | 
                                                  | Suture of Laceration of Small Intestine, except Duodenum | - | Rp. 2.560.000,- | 
                                                  | Tiroidectomy subtotal/total nodul tiroid | - | Rp. 5.100.000,- | 
                                                  | Tracheostomy | - | Rp. 1.340.000,- | 
                                                  | Tumor Ganas/Adnesa Luas Dgn Rekonstruksi | - | Rp. 2.560.000,- | 
                                                  | Amputasi Bellow Knee | - | Rp. 5.100.000,- | 
                                                  | Anal Fistulectomy | - | Rp. 5.100.000,- | 
                                                  | Anterior/Posterior Sklerotomi | - | Rp. 2.560.000,- | 
                                                  | Bilateral repair of direct inguinal hernia with graft or prosthesis | - | Rp. 5.100.000,- | 
                                                  | Biopsi Insisional | - | Rp. 1.540.000,- | 
                                                  | Canthorafi | - | Rp. 1.540.000,- | 
                                                  | Compartemen Excision | - | Rp. 2.560.000,- | 
                                                  | Cyclodialysa | - | Rp. 2.560.000,- | 
                                                  | Dislokasi Bahu | - | Rp. 2.560.000,- | 
                                                  | Eksisi Keloid < 5 cm | - | Rp. 990.000,- | 
                                                  | Eksisi Tumor Palpebra | - | Rp. 1.540.000,- | 
                                                  | Eksternal DCR + Silicone Tube | - | Rp. 2.560.000,- | 
                                                  | Ekstraksi Corpus Alienum Segmen Anterior | - | Rp. 2.560.000,- | 
                                                  | Ekstripasi Kista Demorid | - | Rp. 1.540.000,- | 
                                                  | Excision of Etopic Breast Tissue | - | Rp. 1.540.000,- | 
                                                  | Extended Eksenterasi | - | Rp. 4.700.000,- | 
                                                  | Fraktur Cruris | - | Rp. 5.100.000,- | 
                                                  | Haemoroidectomy | - | Rp. 2.560.000,- | 
                                                  | Incisional hernia repair with prosthesis | - | Rp. 5.100.000,- | 
                                                  | Insisi Abses | - | Rp. 990.000,- | 
                                                  | Jahit Palpebra | - | Rp. 1.540.000,- | 
                                                  | Kolostomi | - | Rp. 2.560.000,- | 
                                                  | Large to large intensial anastomsis | - | Rp. 5.100.000,- | 
                                                  | Local Excision of Rectal Lesion or tissue | - | Rp. 1.540.000,- | 
                                                  | Open Biopsi of Liver | - | Rp. 2.560.000,- | 
                                                  | Orbital Dekompresi 3 Tulang | - | Rp. 4.700.000,- | 
                                                  | Other Excision of Perianal Tissue | - | Rp. 1.540.000,- | 
                                                  | Other Operaion on the breast/ reconstruction of the breast | - | Rp. 5.100.000,- | 
                                                  | Other Repair of Mesentery | - | Rp. 2.560.000,- | 
                                                  | Pelepasan Plat & Skrup Maksilofasial 3 Tempat atau Lebih | - | Rp. 1.540.000,- | 
                                                  | Permanent Ileostomy | - | Rp. 2.560.000,- | 
                                                  | Posterior Vitectomy | - | Rp. 4.700.000,- | 
                                                  | Radikal Excision of Skin Lesion | - | Rp. 2.560.000,- | 
                                                  | Removal of Foreign Body from Periotenal Cavity | - | Rp. 2.560.000,- | 
                                                  | Repair of indirect inguinal with graft or prosthesis | - | Rp. 5.100.000,- | 
                                                  | Repair Ruptur Orbita | - | Rp. 2.560.000,- | 
                                                  | Revisi Blab | - | Rp. 1.540.000,- | 
                                                  | SC Dengan Penyulit | - | Rp. 5.100.000,- | 
                                                  | Spirometri | - | Rp. 180.000,- | 
                                                  | Tarsorafi | - | Rp. 1.540.000,- | 
                                                  | Total Splenoctomy | - | Rp. 2.560.000,- | 
                                                  | Transkleral Foto Cagulasi | - | Rp. 2.560.000,- | 
                                                  | Vasektomi | - | Rp. 1.540.000,- | 
                                                  | Relaparatomy Debridement | - | Rp. 2.560.000,- |