| No | JENIS PELAYANAN | | TARIP |
| 1 | 2 | 3 | 4 |
| A. | PEMERIKSAAN DAN TINDAKAN DI BP UMUM | | |
| 1 | ATS | | 48,300.00 |
| 2 | Bilas Lambung | | 44,800.00 |
| 3 | Cerumen Prop | | 20,000.00 |
| 4 | Circumsisi | | 70,400.00 |
| 5 | Dawir kanan / kiri | | 52,900.00 |
| 6 | Ekstraksi Corpus Alienum di kulit | | 8,000.00 |
| 7 | Ekstraksi Corpus Alienum Mata
| | 30,900.00 |
| 8 | Ekstraksi Corpus Alienum pada Hidung
| | 21,900.00 |
| 9 | Ekstraksi Corpus Alienum pada Telinga
| | 21,900.00 |
| 10 | Exterpasi Nail
| | 44,200.00 |
| 11 | Ganti Cairan Infus | | 8,000.00 |
| 12 | Ganti Verban | | 17,100.00 |
| 13 | Gigitan Binatang | | 19,900.00 |
| 14 | Hordeolum / Chalazion | | 29,900.00 |
| 15 | Imobiliasasi Dislokasi Sederhana | | 86,700.00 |
| 16 | Incisi/Eksisi | | 39,100.00 |
| 17 | Infra Red / Fisio Therafi | | 11,300.00 |
| 18 | Injeksi (tindakan terpisah) | | 8,000.00 |
| 19 | Injeksi ABU / Anti Bisa Ular | | 63,800.00 |
| 20 | Irigasi Mata | | 25,800.00 |
| 21 | Irigasi Telinga | | 21,800.00 |
| 22 | Jahit luka >10 jahitan | | 72,300.00 |
| 23 | Jahit luka 4 jahitan | | 36,700.00 |
| 24 | Jahit luka 5-10 jahitan | | 53,200.00 |
| 25 | Keur Dokter | | 9,300.00 |
| 26 | Lepas Cateter | | 20,800.00 |
| 27 | Lepas Infusan | | 12,000.00 |
| 28 | Lepas Jahitan | | 15,500.00 |
| 29 | Lepas Selang NGT | | 14,300.00 |
| 30 | Nebulizer | | 28,600.00 |
| 31 | Operasi Tumor Jinak | | 62,100.00 |
| 32 | Pasang Infus | | 53,700.00 |
| 33 | Pasang Kateter | | 44,200.00 |
| 34 | Pemasangan Bidai | | 33,800.00 |
| 35 | Pemasangan Gips Spalk | | 125,800.00 |
| 36 | Pemasangan Selang NGT | | 40,300.00 |
| 37 | Pemberian Obat Melalui Anus | | 52,800.00 |
| 38 | Pemberian Oksigen / hari | | 41,200.00 |
| 39 | Pemeriksaan Caten | | 9,300.00 |
| 40 | Pemeriksaan Spinometri / spiro analizer | | 10,300.00 |
| 41 | Perawatan luka bakar <10% | | 48,000.00 |
| 42 | Perawatan luka bakar 10-20% | | 99,400.00 |
| 43 | Perawatan luka DM / Nekrotik | | 36,800.00 |
| 44 | Perawatan luka sobek | | 17,700.00 |
| 45 | Perbaikan Infusan | | 14,300.00 |
| 46 | Rawat Jalan Umum | | 10,800 |
| 47 | Rectal Toucher | | 23,500.00 |
| 48 | Semprot Cutaneus Larva Migrans | | 68,700.00 |
| 49 | Tampon Hidung | | 19,800.00 |
| 50 | Treadmill | | 16,000.00 |
| 51 | Visum luar di Puskesmas | | 23,000.00 |
| 52 | Visum luar di TKP | | 38,000.00 |
| 53 | Pelayanan 24 JAM / UGD TERBATAS DI PUSKESMAS | sesuai tarif + | 20,000.00 |
| 54 | PELAYANAN DI LUAR GEDUNG | sesuai tarif + | 15,000.00 |
| 55 | Pemeriksaan EKG | | 26,900.00 |
| 56 | ROTGEN FOTO UKURAN | 30 X 40 | 42,500.00 |
| 57 | ROTGEN FOTO UKURAN | 30 X 35 | 40,000.00 |
| 58 | ROTGEN FOTO UKURAN | 24 x 30 | 36,000.00 |
| 59 | ROTGEN FOTO UKURAN | 18 x 24 | 34,000.00 |
