I. INSTALASI RAWAT JALAN A. Karcis Harian - Tarif Kelas III RSUP H. Adam Malik ALL

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I. INSTALASI RAWAT JALAN A. Karcis Harian

1. Poliklinik 8,000 2,000 10,000 2. Kartu Identitas Pasien (Embosar) 4,000 1,000 5,000 3. Administrasi Sistem Informasi 1,500 - 1,500 B. Tarif Konsultasi Medis Spesialisasi Rawat Jalan

1. Dokter Spesialis 3,300 13,200 16,500 2. Dokter Gigi 3,300 13,200 16,500 3. Gizi / Farmasi 2,400 9,600 12,000 4. Konsultasi / Konseling HIV/AIDS 3,300 13,200 16,500 5. Psikologi 2,400 9,600 12,000 6. Dll 2,400 9,600 12,000 Keterangan :

a. Tarif Karcis Harian tersebut diatas untuk 1 (satu) kali kunjungan dan berlaku untuk pemeriksaan tindakan standar di Poliklinik. b. Apabila ada pemeriksaan Penunjang Diagnostik, Tindakan Medik dan

Radio Therapi, Rehabilitasi Medik dibayar sesuai dengan tarif RS.

c. Konsultasi Medis Spesialis Pasien Rawat Jalan, harus berdasarkan Rujukan Intern dari Bagian / SMF yang memerlukan hal tersebut ke Bagian / SMF lain, Gizi, Farmasi, Posyansus dan Psikolog untuk keperluan tindak lanjut Observasi, Diagnosa, pengobatan dan pelayanan kesehatan lainnya tanpa tinggal di Ruang Rawat Inap. d. Kartu Identitas pasien (Embosar) hanya dibayar untuk 1 (satu) kali untuk Pasien Umum dan

Askes, tidak berlaku untuk Pasien Jamkesmas. Apabila Kartu Identitas hilang, harus membayar lagi sesuai tarif yang berlaku (berlaku untuk Pasien Umum, Askes & Jamkesmas) e. Pasien Rawat Inap yang dilakukan Pemeriksaan / Tindakan atau Konsultasi di

Instalasi Rawat Jalan maka Tarifnya diberlakukan sesuai dengan Kelas Rawatannya.

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J E N I S P E L A Y A N A N

BESARAN TARIF TA. 2014

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II. TARIF INSTALASI GAWAT DARURAT

A. Karcis Harian 20,000 5,000 25,000 - Administrasi Sistem Informasi 1,500 - 1,500

B. RUANG TRIASE

1. Konsultasi Dokter Spesialis 1x 5,000 20,000 25,000 C. 1. EKG 30,000 20,000 50,000 2. Kumbah Lambung 120,000 80,000 200,000 3. Dilatasi Phimosis 75,000 50,000 125,000 4. Eksisi Clavus 75,000 50,000 125,000 5. Eksisi Condiloma A. 75,000 50,000 125,000 6. Eksisi Keloid 75,000 50,000 125,000 7. Eksisi Veruka Vulgaris 75,000 50,000 125,000 8. Ekstraksi Kuku 42,000 28,000 70,000 9. Ganti Balut (Khusus Gangren Diabetika & Luka ) 24,000 16,000 40,000 10. Insisi Furunkel / Abses 60,000 40,000 100,000 11. Irigasi Telinga 30,000 20,000 50,000 12. Nekrotomi 60,000 40,000 100,000 13. Pasang / Angkat Implant / IUD 42,000 28,000 70,000 14. Tindakan Hecting 42,000 28,000 70,000 15. Pasang Infus Umbilikalis (Pediatric) 108,000 72,000 180,000 16. Pasang Belog Tampon 42,000 28,000 70,000 17. Pasang Kateter (Kasus Non Operasi) 24,000 16,000 40,000 18. Ekstirpasi Corpus Alienum 30,000 20,000 50,000 19. Pengobatan Epistaksis 30,000 20,000 50,000 20. Pungsi Hematoma Telinga 30,000 20,000 50,000 21. Tindakan Businasi 42,000 28,000 70,000 22. Tindakan Cuci Sinus (Perawatan) 24,000 16,000 40,000 23. Tindakan Nebulizer 24,000 16,000 40,000 24. 21,000 14,000 35,000 25. Pasang NGT 24,000 16,000 40,000 26. Pasang ETT 60,000 40,000 100,000 27. Pasang Infus 15,000 10,000 25,000 28. Cuci Luka 24,000 16,000 40,000 29. Tindakan Suction 24,000 16,000 40,000 30. Ganti Balut 24,000 16,000 40,000 31. Pasang Spalk 24,000 16,000 40,000

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32. Tindakan Extubasi 24,000 16,000 40,000 33. Penanganan Luka Bakar < 10% 30,000 20,000 50,000 33. Penanganan Luka Bakar 10% - 30% 60,000 40,000 100,000 34. Penanganan Luka Bakar > 30% 105,000 70,000 175,000 35. Resisutasi Jantung Paru 60,000 40,000 100,000 36. Sirkumsisi 60,000 40,000 100,000 37. Monitor EKG 60,000 40,000 100,000 38. Colar Neck 24,000 16,000 40,000 39. Aspirasi Pneumotoraks 60,000 40,000 100,000 40. Eksisi Khalazion 75,000 50,000 125,000 41. Eksisi Hordeolum / Granuloma 75,000 50,000 125,000 42. Insisi Abses Besar 75,000 50,000 125,000 43. Jahit Luka Palpebra 75,000 50,000 125,000 44. Pasang Gips 60,000 40,000 100,000 45. Pengangkatan Nevus 45,000 30,000 75,000 46. Tindakan Pungsi Lumbal 60,000 40,000 100,000 47. Ekstirpasi Fibroma 75,000 50,000 125,000 48. Injeksi Varises (termasuk obat) 195,000 130,000 325,000 49. Insisi Mucocele 75,000 50,000 125,000 50. Pemasangan WSD 180,000 120,000 300,000 51. Pungsi Pleura 180,000 120,000 300,000 52. Pungsi sum-sum tulang 180,000 120,000 300,000 53. Reposisi dengan Anestesi Lokal 180,000 120,000 300,000 54. Sistostomi dengan Anestesi Lokal 180,000 120,000 300,000 55. Tindakan Manual Plasenta 180,000 120,000 300,000 56. Vena Seksi 180,000 120,000 300,000 D. 1. Ruang Observasi (> 6 Jam tanpa Monitoring) 60,000 40,000 100,000 2. Ruang Resusitasi dengan Monitoring 90,000 60,000 150,000 3. Ruang Observasi Intensive / HCU 150,000 100,000 250,000 4. Ruang Recovery / Intermediate (Post Operatif > 4 jam) 150,000 100,000 250,000 4. Ruang Recovery / Intermediate (Post Operatif > 4 jam) 150,000 100,000 250,000 5. One Day Care 90,000 60,000 150,000 E.

F. 1. Bronchial Provocation Test 102,000 68,000 170,000 2. Bronchoscopy 282,000 188,000 470,000 3. Bronchoscopy + Biopsi 300,000 200,000 500,000 4. Bronchospirometri 342,000 228,000 570,000 5. Laryngoscopy 90,000 60,000 150,000 6. Sinuscopy 45,000 30,000 75,000 7. USG Organ 72,000 48,000 120,000 G. TINDAKAN MEDIS OPERATIF

1. Bedah Digestive

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 5,400,000 3,600,000 9,000,000 e. Khusus II 7,800,000 5,200,000 13,000,000 f. Khusus III 13,500,000 9,000,000 22,500,000 2. Bedah Vaskuler

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 6,000,000 4,000,000 10,000,000 e. Khusus II 9,000,000 6,000,000 15,000,000 f. Khusus III 14,400,000 9,600,000 24,000,000 3. Bedah Orthopedi

a. Sedang II 2,625,000 1,750,000 4,375,000 b. Besar 3,375,000 2,250,000 5,625,000 c. Khusus I 5,400,000 3,600,000 9,000,000 d. Khusus II 9,000,000 6,000,000 15,000,000 e. Khusus III 13,200,000 8,800,000 22,000,000 4. Bedah Gimul

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus 5,400,000 3,600,000 9,000,000 5. Bedah Urologi

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b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 5,400,000 3,600,000 9,000,000 e. Khusus II 7,800,000 5,200,000 13,000,000 f. Khusus III 10,800,000 7,200,000 18,000,000 6. Bedah Onkologi

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 5,400,000 3,600,000 9,000,000 e. Khusus II 7,800,000 5,200,000 13,000,000 7. Bedah Plastik

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Besar 3,375,000 2,250,000 5,625,000 c. Khusus 5,400,000 3,600,000 9,000,000 8. Bedah Syaraf

a. Besar 3,375,000 2,250,000 5,625,000 b. Khusus I 5,400,000 3,600,000 9,000,000 c. Khusus II 7,800,000 5,200,000 13,000,000 d. Khusus III 10,800,000 7,200,000 18,000,000 9. Bedah Thorax

a. Besar 3,375,000 2,250,000 5,625,000 b. Khusus I 5,400,000 3,600,000 9,000,000 c. Khusus II 7,800,000 5,200,000 13,000,000 10. Bedah Anak

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus 5,400,000 3,600,000 9,000,000 11. Bedah Mata

11. Bedah Mata

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Besar 3,375,000 2,250,000 5,625,000 c. Khusus I 5,400,000 3,600,000 9,000,000 d. Khusus II 7,800,000 5,200,000 13,000,000 12. Bedah THT

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Besar 3,375,000 2,250,000 5,625,000 c. Khusus I 5,400,000 3,600,000 9,000,000 d. Khusus II 7,800,000 5,200,000 13,000,000 13. Bedah Obgyn

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 5,400,000 3,600,000 9,000,000 14. Bedah Kulit dan Kelamin

a. Sedang I 1,875,000 1,250,000 3,125,000 b. Sedang II 2,625,000 1,750,000 4,375,000 c. Besar 3,375,000 2,250,000 5,625,000 d. Khusus I 5,400,000 3,600,000 9,000,000 Keterangan :

1. Jasa Sarana (JS) sudah termasuk Bahan Habis Pakai tidak termasuk Alat kesehatan. 2. Pelayanan Operasi Komulatif (Multiple / Beberapa operasi dalam satu waktu)

-yang dilakukan oleh satu dokter atau operator : a. 2 (dua) macam operasi :

* tarif operasi utama sesuai tarifnya

* tarif operasi kedua sama dengan 60 % dari tarifnya b. 3 (tiga) macam operasi :

* tarif operasi utama sesuai tarifnya

* tarif operasi selebihnya sama dengan 50 % dari tarifnya 3. Pasien baru yang berobat masuk melalui IGD, tarif Bedah

disesuaikan dengan Tarif IBP Kelas II.

4. Pasien Rawat Inap yang dilakukan tindakan Operasi

di IGD diluar jam kerja maka tarif tindakan operasi untuk pasien Kelas III dikenakan tarif Kelas II dan untuk pasien Kelas II, I, VIP

diberlakukan sesuai dengan kelas perawatannya. 5. Apabila ada dilakukan tindakan selain tindakan tersebut

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Jalan dan Instalasi Penunjang Medik)

6. Tarif tindakan medik operatif dan operatif diatas berlaku untuk bedah elektif. 7. Tarif tindakan medik operatif dan operatif diatas untuk bedah sesuai perjanjian

dengan dokter diberlakukan tarif Kelas II.

H. 1. Persalinan Tanpa Penyulit 210,000 140,000 350,000 2. Persalinan Dengan Penyulit per Vaginam 450,000 300,000 750,000 3. Inspeculo 24,000 16,000 40,000 4. Kuretase tanpa Narkose 180,000 120,000 300,000 I. PELAYANAN GAS MEDIS

1. Oksigen / liter 25 5 30

2. Oksigen Bayi (Perinato) / liter 30 5 35

3. Oksigen Perinato dengan head box / liter 50 15 65

4. Oksigen dengan Ventilator / liter 70 20 90

5. N2O / liter 300 100 400

6. Udara Tekan (UT) / liter 70 10 80 7. CO2 / liter / menit 9,000 3,000 12,000 8. CO2 / Tabung ukuran 2 kg 50,000 10,000 60,000 9. CO2 / Tabung ukuran 5 kg 65,000 20,000 85,000 10. CO2 / Tabung ukuran 25 kg 270,000 80,000 350,000 11. O2 / Tabung 6m3 125,000 - 125,000 12. O2 / Tabung 2m3 50,000 - 50,000 13. O2 / Tabung 1m3 40,000 - 40,000 14. Respiflo / flash 66,000 9,000 75,000

III. A. TARIF RUANGAN RAWAT INAP TERPADU (RINDU) A, B dan KARDIOVASKULER

1. Akomodasi Ruangan 31,500 13,500 45,000 2. Visite / Konsultasi Spesialis 1 kali - 20,000 20,000 3. Visite Tim Spesialis berkelompok 3 orang yang berbeda/1 kali - 40,000 40,000 4. Visite Dokter PPDS - 6,000 6,000 4. Visite Dokter PPDS - 6,000 6,000 5. - 32,000 32,000 6. Konsultasi Gizi/Farmasi 9,000 6,000 15,000 7. Konsultasi/Konseling HIV/AIDS 6,600 9,900 16,500 8. Konsultasi Kemotherapy - 5,000 5,000 Keterangan :

1. Tarif pemeriksaan Penunjang Diagnostik, Tindakan Medik dan Therapy, Rehabilitasi Medik dan pelayanan kesehatan lainnya apabila ada, dibayar terpisah oleh pasien

sesuai tarif pemeriksaan/tindakan sesuai dengan Kelas rawatan. 2. Visite dan Konsultasi Medis dilaksanakan oleh Dokter Spesialis/PPDS

dan disetujui pasien dan atau keluarganya pada setiap pergantian Dokter Spesialis/PPDS. 3. Konseling/konsultasi HIV/AIDS dilakukan oleh Petugas Pusyansus (Pusat Pelayanan Khusus). 4. Visite dan Konsultasi Medis lebih dari 1 (satu) kali per hari maka

dikenakan Tarif tambahan 50 % dari Visite/Konsul terdahulu. 5. JP untuk Visite diatas adalah JDA.

6. Untuk Tarif Pemeriksaan di Poliklinik dan Penunjang Medis jika dilaksanakan di Ruangan Rawat Inap maka dikenakan Biaya Tarif sesuai dengan Kelas rawatan.

B. TINDAKAN DI RINDU A, RINDU B DAN KARDIOVASKULER

1. WSD Continue 74,400 49,600 124,000 2. Punctie Pleura Proef 25,800 17,200 43,000 3. Punctie Pleura Therapi 35,700 23,800 59,500 4. Punctie Ascites 19,200 12,800 32,000 5. Aspirasi Jarum Halus 26,400 17,600 44,000 6. Biopsi 84,000 56,000 140,000 7. Pasang Nebulizer /1x 15,000 10,000 25,000 8. Pasang Gip's 84,000 56,000 140,000 9. Wash Out 18,600 12,400 31,000 10. Penyampuran Obat Kemotherapy 9,000 6,000 15,000 11. Tindakan Kemotherapy 180,000 120,000 300,000 12. Audiometri 36,000 24,000 60,000 13. Timpanometri 36,000 24,000 60,000 14. Timpanometri + Refleks Akustik 54,000 36,000 90,000 15. Timpanometri + Refleks Akustik + Tes Fungsi Tuba 72,000 48,000 120,000 16. BMP 120,000 80,000 200,000 17. Fleurodesis 270,000 180,000 450,000 Catatan :

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sedang, berat; pasang infus; pasang transfusi; pasang kateter urine; pasang NGT;

klisma; suction per hari; ambil sample kultur; aff / cabut hecting; vulva higiene / vaginal swab; perawatan tali pusat; syringe pump; infus pump; light therapy; monitor catheter umbilical; yang dilakukan di ruang rawat, bahan habis pakai obat-obatan yang digunakan pasien di bayar sesuai tarif harga Instalasi Farmasi.

C. TINDAKAN DI RINDU B OBGIN

1. Partus Normal 135,000 90,000 225,000 2. Extrasi Vacum 165,000 110,000 275,000 3. Manual Aid 159,600 106,400 266,000 4. Curetase 180,000 120,000 300,000 5. Abortus 180,000 120,000 300,000 6. Vaginal Touch ( VT) / hari 18,000 12,000 30,000 7. Manual Plasenta 117,000 78,000 195,000 8. USG 36,000 24,000 60,000 9. USG Trans Vagina 60,000 40,000 100,000 10. Pasang Tampon 10,500 7,000 17,500 11. Inspekulo 18,000 12,000 30,000 12. Aspirasi Abdomen 15,000 10,000 25,000 13. Secunder Hecting 105,000 70,000 175,000 14. Ressusitasi Perinatologi 15,000 10,000 25,000 15. Lumbal Fungsi 30,000 20,000 50,000 Keterangan :

1. JDA (Jasa Dokter Ahli) tersebut harus terlebih dahulu disetorkan ke Bendaharawan Penerima melalui Petugas Kasir. 2. Tarif tersebut diatas tidak termasuk alat kesehatan dan obat-obatan standar.

IV. PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK A. KIMIA DARAH

1 Amylase Serum 31,125 10,375 41,500 2 Amylase Urin 24,750 8,250 33,000 2 Amylase Urin 24,750 8,250 33,000 3 Analisa Batu Ginjal 74,250 24,750 99,000 4 Analisa Gas Darah 93,000 31,000 124,000 5 AGDA (iSTAT) 144,375 48,125 192,500 6 AGDA + Na, K, Ion Calcium (iSTAT) 185,625 61,875 247,500 7 Asam Empedu 27,375 9,125 36,500 8 Asam Urat 23,250 7,750 31,000 9 Asam Lactat 41,250 13,750 55,000 10 Calcium Ion 33,000 11,000 44,000 11 Chlorida Darah 18,000 6,000 24,000 12 Chlorida Urin 18,000 6,000 24,000 13 Cholinesterase (Che) 24,750 8,250 33,000 14 CK ( Cratine Kinase ) 69,750 23,250 93,000 15 Ck-MB 69,750 23,250 93,000 16 Pro BNP 286,125 95,375 381,500 17 Serum Protein Elektroforese 109,875 36,625 146,500 18 Fosfatase Asam / Acid Phosphatase 57,750 19,250 77,000 19 LDH 27,375 9,125 36,500 20 Kalium Darah 18,000 6,000 24,000 21 Kalium Urin 18,000 6,000 24,000 22 Kalsium Darah 18,000 6,000 24,000 23 Kalsium Urin 18,000 6,000 24,000 24 Lipase Darah 51,750 17,250 69,000 25 Lipase Urin 51,750 17,250 69,000 26 Magnesium 33,000 11,000 44,000 27 Natrium Darah 18,000 6,000 24,000 28 Natrium Urine 18,000 6,000 24,000 29 Phosphat Darah (Phospor inorganik) 25,500 8,500 34,000 30 Phosphat Urine 25,500 8,500 34,000 31 Troponin T 127,500 42,500 170,000 32 Troponin I 165,000 55,000 220,000 33 Homosystein 132,000 44,000 176,000 34 Vitamin D 231,000 154,000 385,000 35 Vitamin D (untuk Penelitian Peserta Didik/PPDS) 231,000 99,000 330,000 B. DIABETES

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4 Glukosa Darah Puasa 15,375 5,125 20,500 5 Glukosa Darah Sewaktu 15,375 5,125 20,500 6 Glukosa Toleransi Test 51,750 17,250 69,000 7 Urin 4 porsi / kurve harian 25,500 8,500 34,000 8 Insulin 123,750 41,250 165,000 9 C - peptide 144,375 48,125 192,500 C. FUNGSI HATI

1 Albumin 18,750 6,250 25,000 2 Alkali Phospatase 18,750 6,250 25,000 3 Bilirubin Direct/ Indirect 18,000 6,000 24,000 4 Bilirubin Total 20,625 6,875 27,500 5 Gamma GT 36,000 12,000 48,000 6 Globulin 16,500 5,500 22,000 7 Protein Total 18,750 6,250 25,000 8 SGOT 20,625 6,875 27,500 9 SGPT 20,625 6,875 27,500 D. FUNGSI GINJAL

1 Creatinine 19,875 6,625 26,500 2 Creatinine Clearence 36,000 12,000 48,000 3 Urea Clearance 27,375 9,125 36,500 4 Ureum 19,875 6,625 26,500 E. ANALISA LEMAK

1 Cholesterol HDL 23,250 7,750 31,000 2 Cholesterol LDL 18,000 6,000 24,000 3 Cholesterol Total 28,125 9,375 37,500 4 Trigliceride 28,125 9,375 37,500 5 Apo A 99,000 33,000 132,000 6 Apo B 77,625 25,875 103,500 F. HEMATOLOGI

1 Darah Lengkap ( Full Blood Count ) 40,500 13,500 54,000 1 Darah Lengkap ( Full Blood Count ) 40,500 13,500 54,000 2 Hitung Eosinophil 10,875 3,625 14,500 3 Retikulosit 14,625 4,875 19,500 4 Golongan Darah ABO + Rhesus Factor 13,875 4,625 18,500 5 Filaria 14,625 4,875 19,500 6 Malaria 18,375 6,125 24,500 7 Waktu Perdarahan 10,125 3,375 13,500 8 Rumple Leed 10,125 3,375 13,500 9 Asam Folat 149,250 49,750 199,000 10 Elektroforesisi Hb 178,500 59,500 238,000 11 Ferritin 137,250 45,750 183,000 12 G6PD 75,750 25,250 101,000 13 Coomb's Test 28,500 9,500 38,000 14 Ham's Test 27,375 9,125 36,500 15 Hb F 57,375 19,125 76,500 16 Morfologi Apus Darah Tepi 51,375 17,125 68,500 17 Aspirasi sumsum tulang (BMP) dan Morfologi Sum-sum tulang 411,750 137,250 549,000 18 Nerve Action Potential (NAP) 68,625 22,875 91,500 19 Pewarnaan Acid Phophatase 57,375 19,125 76,500 20 Pewarnaan Besi 37,500 12,500 50,000 21 Pewarnaan sum-sum tulang 37,500 12,500 50,000 22 Serum Iron Binding Capacity (SIBC) 49,500 16,500 66,000 23 Sugar Water Test 19,875 6,625 26,500 24 Total Iron Binding Capacity (TIBC) 49,500 16,500 66,000 25 Transferin 109,875 36,625 146,500 G. SEROLOGI

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13 Anti HCV 115,500 38,500 154,000 14 Helicobacter Pylori IgG 68,625 22,875 91,500 15 Helicobacter Pylori IgM 68,625 22,875 91,500 16 Anti HSV I IgG 109,875 36,625 146,500 17 Anti HSV I IgM 109,875 36,625 146,500 18 Anti HSV II IgG 109,875 36,625 146,500 19 Anti HSV II IgM 109,875 36,625 146,500 20 Anti Influenza A-B 274,500 91,500 366,000 21 Anti Japanese B Encephalitis 219,750 73,250 293,000 22 Anti Leptospira 169,500 56,500 226,000 23 Anti Malaria 154,875 51,625 206,500 24 Anti Rubella IgG 109,875 36,625 146,500 25 Anti Rubella IgM 169,500 56,500 226,000 26 Anti TB / IgG TB 169,500 56,500 226,000 27 Anti Toxoplasma IgG 169,500 56,500 226,000 28 Anti Toxoplasma IgM 169,500 56,500 226,000 29 Anti Streptolysin Titer O (ASTO) 50,250 16,750 67,000 30 CMV IgG Avidity 219,750 73,250 293,000 31 Clamydia Ig G 205,875 68,625 274,500 32 Clamydia Ig M 205,875 68,625 274,500 33 C- Reaktif Protein (CRP) 59,625 19,875 79,500 34 hsCRP 91,500 30,500 122,000 35 Antibodi Dengue Ig G / Ig M 114,375 38,125 152,500 36 Faktor Rhematoid 45,750 15,250 61,000 37 FTA - ABS 55,125 18,375 73,500 38 Hainn Test TB 283,875 94,625 378,500 39 HBe Ag 183,000 61,000 244,000 40 HBs Ag 91,500 30,500 122,000 41 IgM Salmonella Typhi ( Tubex TF) 219,750 73,250 293,000 42 NS 1 Ag Dengue 183,000 61,000 244,000 42 NS 1 Ag Dengue 183,000 61,000 244,000 43 PCR Influenza A H1N1 274,500 91,500 366,000 44 PCR Influenza A H1N5 274,500 91,500 366,000 45 Treponema Palidium H Antigen (TPHA) 39,750 13,250 53,000 46 Veneral Disease Research Laboratory (VDRL) 39,750 13,250 53,000 47 Widal 45,750 15,250 61,000 48 Procalcitonin 274,500 91,500 366,000 H. MIKROBIOLOGI

1 Pewarnaan BTA (3x) 48,000 16,000 64,000 2 Pewarnaan Methylen Blue 14,625 4,875 19,500 3 Pemeriksaan Jamur (KOH) 15,750 5,250 21,000 4 Kultur / Sensitivity darah/cairan otak/sendi (Medium Cair) 274,500 91,500 366,000 5 Kultur Sputum, Pus, dll ( Medium Padat) 205,875 68,625 274,500 6 Kultur M. Tuberculose 87,000 29,000 116,000 7 Kultur / Sensitivity TBC / Anaerob 160,125 53,375 213,500 8 Biakan Jamur 50,250 16,750 67,000 9 Biakan Salmonela Shigela (Biakan SS) 78,000 26,000 104,000 10 BTA 3 x Biakan Medium Cair 338,625 112,875 451,500 11 BTA 3 x Biakan Medium Padat 169,500 56,500 226,000 12 Resistensi OAT Lini 1 (SIRE) 169,500 56,500 226,000 13 Resistensi OAT Lini 2 (kana, oflox) 169,500 56,500 226,000 14 Sediaan langsung Pewarnaan BTA 27,375 9,125 36,500 I. URINE

1 Urinalisa 18,375 6,125 24,500 2 Esbach 15,750 5,250 21,000 3 Hemosiderin 32,250 10,750 43,000 4 Oval Fat Body 20,625 6,875 27,500 5 Protein Kwantitatif 18,375 6,125 24,500 6 Protein Urine 24 Jam 22,500 7,500 30,000 7 Protein Bence Jones 6,375 2,125 8,500 J. HORMON

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8 Prolactin 148,500 49,500 198,000 9 T3 72,375 24,125 96,500 10 T4 72,375 24,125 96,500 11 T3 Up Take 57,750 19,250 77,000 12 Testosteron 231,000 77,000 308,000 13 Tiroid Stimulating Hormon (TSH ) 82,500 27,500 110,000 14 Cortisol 142,500 47,500 190,000 15 PTH 162,375 54,125 216,500 16 β HCG 162,375 54,125 216,500 K. CAIRAN TUBUH

1 Analisa Cairan Otak 171,750 57,250 229,000 2 Analisa Cairan Pleura 171,750 57,250 229,000 3 Analisa Cairan Ascites 192,375 64,125 256,500 4 Analisa Cairan Sendi 100,875 33,625 134,500 5 Analisa Sperma 91,500 30,500 122,000 6 Fruktosa Sperma 41,250 13,750 55,000 L. FAECES

1 Analisa Faeces ( pencernaan ) 18,375 6,125 24,500 2 Benzidine Test / Darah Samar 55,125 18,375 73,500 M. DRUG MONITORING

1 Aminophylin 338,625 112,875 451,500 N. HEMOSTASIS

1 Aggregasi Trombosit (ADP) 137,250 45,750 183,000 2 Anti Faktor Xa 201,375 67,125 268,500 3 Anti Trombin III 126,000 42,000 168,000 4 APTT ( Masa Tromboplastin Parsial ) 57,375 19,125 76,500 5 Assay Faktor IX 228,750 76,250 305,000 6 Assay Faktor VIII 228,750 76,250 305,000 7 Beta 2 Glycoprotein 1 (B2GP-1) 507,750 169,250 677,000 8 F. Von Wiilebrands 196,875 65,625 262,500 8 F. Von Wiilebrands 196,875 65,625 262,500 9 FIBRINOGEN 82,500 27,500 110,000 10 D. Dimer 171,750 57,250 229,000 11 Inhibitor VIII 256,125 85,375 341,500 12 Lupus Anticoagulan 192,375 64,125 256,500 13 Masa Iisis Euglobolin 55,125 18,375 73,500 14 PROTEIN S 256,125 85,375 341,500 15 PROTEIN C 256,125 85,375 341,500 16 PT (Prothorombin Time) + INR 56,625 18,875 75,500 17 Tromboplastin Generation Time (TGT) 91,500 30,500 122,000 18 Thrombotest 91,500 30,500 122,000 19 TT(THROMBINE TIME) 57,375 19,125 76,500 20 IT Ratio 21,750 7,250 29,000 O. IMUNOLOGI

1 Alfa 1 Antitrifsin Kwantitatif 81,375 27,125 108,500 2 Alfa 2 Makro Globulin Kwantitatif 57,375 19,125 76,500 3 ANA Test 146,625 48,875 195,500 4 Anti-ds DNA 210,375 70,125 280,500 5 Anti Kappa 64,125 21,375 85,500 6 Anti Lamda 64,125 21,375 85,500 7 Anti HIV (Elisa) 100,875 33,625 134,500 8 Anti Body Sperma 100,875 33,625 134,500 9 Complement C3 67,500 22,500 90,000 10 Complement C4 67,500 22,500 90,000 11 Cryoglobulin 22,875 7,625 30,500 12 IgA / IgG / IgM 87,750 29,250 117,000 13 IgE 82,500 27,500 110,000 14 Imuno Elektroforesisi Anti Ig G / Ig A / Ig M 87,750 29,250 117,000 15 Imuno Elekktroforesis Whole Anti Serum 87,750 29,250 117,000 16 Paket Diagnostik HIV ( 3 metode ) 151,125 50,375 201,500 17 Sel LE 31,125 10,375 41,500 18 SMA (Smooth Muscle Anti Body) 48,375 16,125 64,500 19 T Sel dan B Sel 62,625 20,875 83,500 20 Test Kehamilan 28,500 9,500 38,000 P. TUMOR MARKER

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4 CA 19-9 198,000 66,000 264,000 5 CA 72-4 141,375 47,125 188,500 6 CEA 103,125 34,375 137,500 7 Cyfra 21 478,500 159,500 638,000 8 MCA 74,250 24,750 99,000 9 Neuron Specific Enollase (NSE) 255,750 85,250 341,000 10 Prostat Specific Antigen (PSA) 144,375 48,125 192,500 11 Free PSA 247,500 82,500 330,000 12 Squamous Cell Carcinoma (SCC) 255,750 85,250 341,000 Q. BONE MARKER / PETANDA TULANG

1 N-MID OSTEOCALCIN 165,000 55,000 220,000 R. NARKOBA

1 Methamphetamin 40,500 13,500 54,000 2 Morphin 40,500 13,500 54,000 3 Amphetamine 40,500 13,500 54,000 4 Cocaine 40,500 13,500 54,000 5 Barbiturates 40,500 13,500 54,000 6 THC (Ganja) 40,500 13,500 54,000 7 Benzodiazepine 40,500 13,500 54,000 8 THC + MOP + Met (PAKET) 70,500 23,500 94,000 S. PCR

1 HIV RNA 684,000 228,000 912,000 2 HCV RNA :

a. Kwalitatif 684,000 228,000 912,000 b. Kwantitatif 1,262,625 420,875 1,683,500 3 HBV-DNA Kwantitatif 1,368,000 456,000 1,824,000 4 Mycobacterium TBC DNA 442,875 147,625 590,500 5 CMV DNA Kwantitatif 105,375 35,125 140,500 6 Chlamydia Trachomatis 977,250 325,750 1,303,000 7 Bakteri Gonorhoae (DNA) 371,625 123,875 495,500 7 Bakteri Gonorhoae (DNA) 371,625 123,875 495,500 T. IMMUNOPHENOTYPING FLOWCYTOMETRI

1 CD 4 100,875 33,625 134,500 2 CD 8 100,875 33,625 134,500

V. PEMERIKSAAN MIKROBIOLOGI KLINIK

1. Sediakan Langsung Pewarnaan BTA 19,500 10,500 30,000 2. Sediakan Langsung Pewarnaan Gram 20,150 10,850 31,000 3. Direct Gonorrhoe 20,150 10,850 31,000 4. Direct Difteri 20,150 10,850 31,000 5. Pemeriksaan Jamur (KOH) 20,150 10,850 31,000 6. 195,000 105,000 300,000 7. 195,000 105,000 300,000 8. 195,000 105,000 300,000 9. 31,850 17,150 49,000 10. BTA 3x, Biakan Medium Padat 97,500 52,500 150,000 11. Resistensi OAT Lini 1 (SIRE) 97,500 52,500 150,000 12. Biakan N. Gonorrhoeae dan Uji Resistensi 195,000 105,000 300,000 13. PMDT - - -14. Sediaan Langsung Pewarnaan BTA - TB/HIV - - -15. Pemeriksaan Resistensi OAT - Gene Expert - - -16. Sediaan Langsung Pewarnaan BTA - POLI DOTS - -

-Keterangan:

Pemeriksaan yang berharga 0 (nol) karena dibiayai oleh Program PMDT dan Program TB DOTS Kemenkes RI

VI. PEMERIKSAAN PATOLOGI ANATOMI A. HISTOPATOLOGI

1. Histopatologi Kecil 178,750 96,250 275,000 2. Histopatologi Sedang 276,250 148,750 425,000 3. Histopatologi Besar 357,500 192,500 550,000 4. Biopsi Khusus (hati, ginjal,sumsum tulang) 260,000 140,000 400,000 5. PA Potong Beku (VC) + imprint 276,250 148,750 425,000 6. Histokimia ( untuk 1 jenis pemeriksaan ) 113,750 61,250 175,000 7. Imunohistokimia ( untuk 1 jenis pemeriksaan ) 195,000 105,000 300,000 8. Visum Jaringan 292,500 157,500 450,000 B. SITOLOGI

1. Hormonal serial 4x 97,500 52,500 150,000 2. Sitologi (pap smear, cairan, dll) 81,250 43,750 125,000 Biakan Mikro Organisme Aerob Medium Cair dengan Resistensi

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3. FNAB (biasa) dengan tindakan 195,000 105,000 300,000 4. FNAB lebih dari 1 lokasi 243,750 131,250 375,000 5. Sitologi 3x serial 61,750 33,250 95,000 6. Sputum 1x 130,000 70,000 200,000 7. Sputum 3x serial, cairan, sikatan, aspirasi 357,500 192,500 550,000 8. Urine serial 3x 65,000 35,000 100,000

VII. PEMERIKSAAN / PELAYANAN DIAGNOSTIK ELEKTROMEDIK A. SEDERHANA

1. Spirometri 90,000 60,000 150,000 2. EKG 18,000 12,000 30,000 B. SEDANG

1. TTLB 360,000 240,000 600,000 2. TTLB dengan USG 450,000 300,000 750,000 3. Biopsi Pleura 300,000 200,000 500,000 4. EMG / Evoke Potensial SSP 165,000 110,000 275,000 5. EEG Mapping 120,000 80,000 200,000 6. Fungsi Cairan Asites 600,000 400,000 1,000,000 7. Fungsi Pluera 516,000 344,000 860,000 8. Biopsi Hati 600,000 400,000 1,000,000 9. USG Color Dopler P. Dalam, Ginjal 150,000 100,000 250,000 10. USG Color Dopler Thorax / Paru 300,000 200,000 500,000 11. USG Tuntunan Biopsi 94,500 63,000 157,500 12. Biopsi Prostat 600,000 400,000 1,000,000 13. Biopsi Ginjal 600,000 400,000 1,000,000 14. Transcranial Dopler (TCD) 180,000 120,000 300,000 C. CANGGIH

1. Skleroterapy Gastroscopy / Varices Esophagus 780,000 520,000 1,300,000 2. Colonoskopy 450,000 300,000 750,000 3. Colonoskopy + Polipeptomy 510,000 340,000 850,000 3. Colonoskopy + Polipeptomy 510,000 340,000 850,000 4. Colonoskopy + Biopsi 510,000 340,000 850,000 5. Colonoskopy dengan Clipping 510,000 340,000 850,000 6. Colonoskopy dengan Anestesi Umum 720,000 1,080,000 1,800,000 7. Gastroskopy 390,000 260,000 650,000 8. Gastroskopy Biopsi 450,000 300,000 750,000 9. Gastroskopy dengan Clipping 480,000 320,000 800,000 10. Gastroskopy Dilatasi Esopagus (Pumping) 2,052,000 1,368,000 3,420,000 11. Gastroskopy dengan Anestesi Umum 720,000 1,080,000 1,800,000 12. Skleroterapy Varices Esophagus 390,000 260,000 650,000 13. Ligasi Varices Esophagus 390,000 260,000 650,000 14. Savary Bougy Esophagus 390,000 260,000 650,000 15. a. ERCP Tidak Berhasil

- ERCP Diagnostik 750,000 500,000 1,250,000 b. ERCP Berhasil

- ERCP Spirinterektomy 1,860,000 1,240,000 3,100,000 - ERCP Stenting 1,860,000 1,240,000 3,100,000 - ERCP Basket 1,860,000 1,240,000 3,100,000

(Seluruh tindakan ERCP memakai anasthesi)

20. Fibroscan 300,000 200,000 500,000 21. Urocystoskopy 150,000 100,000 250,000 22. RPG 600,000 400,000 1,000,000 23. ESWL 1,200,000 1,800,000 3,000,000 24. ESWL Fase II 940,000 1,410,000 2,350,000 25. Bronchoskopy 510,000 340,000 850,000 26. Bronchoskopy + Biopsi 570,000 380,000 950,000 27. Bronchoskopy + Sikatan 570,000 380,000 950,000 28. Bronchoskopy + Bilasan 570,000 380,000 950,000 29. Bronchoskopy dengan Anestesi Umum 720,000 1,080,000 1,800,000 30. Pengambilan Benda Asing dengan Bronchoskopy 720,000 1,080,000 1,800,000 31. Thoracoscopy + Biopsi 1,080,000 1,620,000 2,700,000 32. Treadmill Test 120,000 80,000 200,000 33. Double Lumen Tunnel 1,440,000 960,000 2,400,000 34. Double Lumen Tunnel (Temporer) 900,000 600,000 1,500,000 35. Repair Double Lumen 450,000 300,000 750,000

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1. Scheedel AP / L 58,500 31,500 90,000 2. Sinus Paranasal 58,500 31,500 90,000 3. Mastoid Kiri 58,500 31,500 90,000 4. Mastoid Kanan 58,500 31,500 90,000 5. Mastoid Kiri dan Kanan (Duplex) 97,500 52,500 150,000 6. Mandibula (satu sisi) PA + Eisler 65,000 35,000 100,000 7. Mandibula (dua sisi) PA + Eisler Kiri + Kanan 97,500 52,500 150,000 8. TMJ (Temporo Mandibular Joint ) Kiri 65,000 35,000 100,000 9. TMJ (Temporo Mandibular Joint ) Kanan 65,000 35,000 100,000 10. TMJ ( Dua Sisi) Kiri dan Kanan 97,500 52,500 150,000 11. Scheedel Basis 65,000 35,000 100,000 12. Thorax Anak Ap. 52,000 28,000 80,000 13. Thorax Dewasa PA 52,000 28,000 80,000 14. Manus Kiri AP / Oblique 52,000 28,000 80,000 15. Manus Kanan AP / Oblique 52,000 28,000 80,000 16. Manus Kiri dan Kanan AP / Oblique 78,000 42,000 120,000 17. Wrist Joint Kiri AP / Lateral 52,000 28,000 80,000 18. Wrist Joint Kanan AP / Lateral 52,000 28,000 80,000 19. Wrist Joint Kiri dan Kanan AP / Lateral 78,000 42,000 120,000 20. Ante Brachii Kiri AP / Lateral 52,000 28,000 80,000 21. Ante Brachii Kanan AP / Lateral 52,000 28,000 80,000 22. Ante Brachii Kiri dan Kanan AP / Lateral 78,000 42,000 120,000 23. Elbow Joint Kiri AP / L 52,000 28,000 80,000 24. Elbow Joint Kanan AP / L 52,000 28,000 80,000 25. Humerus Kiri AP / L 52,000 28,000 80,000 26. Humerus Kanan AP / L 52,000 28,000 80,000 27. Articulatio Humerus / Shoulder Joint Kiri 52,000 28,000 80,000 28. Articulatio Humerus / Shoulder Joint Kanan 52,000 28,000 80,000 29. Clavicula Kiri 58,500 31,500 90,000 30. Clavicula Kanan 58,500 31,500 90,000 30. Clavicula Kanan 58,500 31,500 90,000 31. Scapula Kiri 58,500 31,500 90,000 32. Scapula Kanan 58,500 31,500 90,000 33. Sternum 58,500 31,500 90,000 34. Pedis Kiri AP / Oblique 58,500 31,500 90,000 35. Pedis Kanan AP / Oblique 58,500 31,500 90,000 36. Pedis Kiri dan Kanan AP / Oblique 78,000 42,000 120,000 37. Ankle Joint Kiri AP / Lateral 52,000 28,000 80,000 38. Ankle Joint Kanan AP / Lateral 52,000 28,000 80,000 39. Cruris Kiri AP / Lateral 65,000 35,000 100,000 40. Cruris Kanan AP / Lateral 65,000 35,000 100,000 41. Genu (Sendi Lutut) Kiri AP / Lateral 65,000 35,000 100,000 42. Genu (Sendi Lutut) Kanan AP / Lateral 65,000 35,000 100,000 43. Patella Kiri 65,000 35,000 100,000 44. Patella Kanan 65,000 35,000 100,000 45. Femur Kiri AP/Lateral 65,000 35,000 100,000 46. Femur Kanan AP/Lateral 65,000 35,000 100,000 47. Articulatio Coxae / Hip Joint Kiri 52,000 28,000 80,000 48. Articulatio Coxae / Hip Joint Kanan 52,000 28,000 80,000 49. Pelvis 58,500 31,500 90,000 50. BNO / Abdomen 58,500 31,500 90,000 B. SEDANG

1. Thorax PA / L (2 Posisi) 81,250 43,750 125,000 2. Cervical PA / L (2 Posisi) 81,250 43,750 125,000 3. Thoracal PA / L 2 Posisi 81,250 43,750 125,000 4. Lumbal PA / L (2 Posisi) 81,250 43,750 125,000 5. Sacrum PA / L (2 Posisi) 81,250 43,750 125,000 6. Coccygis PA / L (2 Posisi) 81,250 43,750 125,000 7. Pelvimetri 81,250 43,750 125,000 8. Cervical PA / L (4 Posisi) / Oblique ki-ka (4 posisi ) 162,500 87,500 250,000 9. Thoracal PA / L (4Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000 10. Lumbal PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000 11. Sacrum AP / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000 12. Thorax PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000 13. Abdomen 3 Posisi 130,000 70,000 200,000 C. KHUSUS

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3. Panoramic 48,750 26,250 75,000 4. Chepalografi 48,750 26,250 75,000 5. Panoramic + Chepalografi 97,500 52,500 150,000 6. 354,900 191,100 546,000 7. BNO-IVP (Dengan Kontras Intravena) 260,000 140,000 400,000 8. Larynx / Oesophagus (Non Kontras) 64,350 34,650 99,000 9. Dacryografi 162,500 87,500 250,000 D. FLUOROSCOPI

1. Fluoroscopi C - Arm tanpa kontras 2. Fluoroscopi C - Arm dengan kontras 3. Apendix dengan BaSO4 162,500 4. Cholecistografi Oral dengan kontras 5. Cholangiografigrafi T. Tube dengan kontras 6. Urethrografi dengan kontras 7. MDF dengan BaSO4 227,500 8. Usus Halus / Follow Through (kontras BaSO4) 9. Usus Besar / Colon in Loop (kontras BaSO4) 10. Cystografi dengan kontras 11. Barium Oesphagus dengan kontras 12. Myelografi dengan kontras 13. Fistulografi dengan kontras 14. APG / RPG dengan kontras 15. ERCP Fluoroscopy (Tanpa Kontras) 16. ERCP Fluoroscopy (Dengan Kontras) 17. Sialografi dengan kontras 18. HSG / Histero Salphingografi (T. Kontras) 19. Discografi 1,235,000 20. Ductulografi 260,000 21. Fluoroskopi / Spot Fluoroskopi 22. Foto OMD (Osesophagus Maag Duodenum) 162,500 87,500 250,000 276,250 148,750 425,000 87,500 250,000 195,000 105,000 300,000 260,000 140,000 400,000 260,000 140,000 400,000 122,500 350,000 260,000 140,000 400,000 260,000 140,000 400,000 260,000 140,000 400,000 227,500 122,500 350,000 260,000 140,000 400,000 260,000 140,000 400,000 276,250 148,750 425,000 164,450 88,550 253,000 260,000 140,000 400,000 260,000 140,000 400,000 164,450 88,550 253,000 665,000 1,900,000 140,000 400,000 121,875 65,625 187,500 260,000 140,000 400,000

AnteBrachii ka/ki, Femur ka/ki, Cruris ka/ki)

22. Foto OMD (Osesophagus Maag Duodenum) 260,000 140,000 400,000 23. Lopografi 260,000 140,000 400,000 24. Phlebografi dengan pesawat fluoroskopi (1 ekst) 520,000 280,000 800,000 25. Phlebografi dengan pesawat fluoroskopi (2 ekst) 1,040,000 560,000 1,600,000 26. Sacroiliac joint injection 1,235,000 665,000 1,900,000 E. USG

1. USG Liver 104,000 56,000 160,000 2. USG Spleen 104,000 56,000 160,000 3. USG GB / Billary 104,000 56,000 160,000 4. USG Upper Abdomen 227,500 122,500 350,000 5. USG Lower Abdomen / Pelvic 162,500 87,500 250,000 6. USG Upper - Lower Abdomen 325,000 175,000 500,000 7. USG Ginjal/Tract Urinarius 175,500 94,500 270,000 8. USG Thorax 156,000 84,000 240,000 9. USG Small Organ (Breast, Thyroid, Testis) 156,000 84,000 240,000 10. USG Peripheral Vascular 156,000 84,000 240,000 11. USG Organ Superfisial 156,000 84,000 240,000 12. USG Vaskuler Access Dopler 260,000 140,000 400,000 13. Tuntunan USG pada Biopsi 156,000 84,000 240,000 14. USG Kepala Bayi 156,000 84,000 240,000 15. USG Transvaginal / Transrectal 227,500 122,500 350,000 16. Appendix 156,000 84,000 240,000 F. CT SCAN SINGLE SLICE

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16. CT Scan Lower Abdomen dengan I.V Contrast 650,000 350,000 1,000,000 17. CT Scan Whole Abdomen 585,000 315,000 900,000 18. CT Scan Whole Abdomen dengan I.V Contrast 975,000 525,000 1,500,000 19. CT Scan Thorax 455,000 245,000 700,000 20. CT Scan Thorax dengan I.V Contrast 650,000 350,000 1,000,000 21. CT Extermitas 293,150 157,850 451,000 22. CT Extermitas dengan I.V Contrast 464,750 250,250 715,000 23. CT Scan Spine/Vertebra ( 3-4 corpus ) 455,000 245,000 700,000 24. CT Scan Spine/Vertebra dengan I.V Contrast 585,000 315,000 900,000 25. CT Biopsi 1,218,750 656,250 1,875,000 G. CT SCAN MULTI SLICE 64

1. MSCT Scan Head / Brain 474,500 255,500 730,000 2. MSCT Scan Head dengan I.V Contrast 780,000 420,000 1,200,000 3. MSCT Scan Orbita 520,000 280,000 800,000 4. MSCT Scan Orbita dengan I.V Contrast 1,105,000 595,000 1,700,000 5. MSCT Scan Sinus Paranasal 520,000 280,000 800,000 6. MSCT Scan Sinus Paranasal dengan I.V Contrast 1,105,000 595,000 1,700,000 7. MSCT Scan Mastoid / Temporal 520,000 280,000 800,000 8. MSCT Scan Mastoid dengan I.V Contrast 1,105,000 595,000 1,700,000 9. MSCT Scan Thyroid 520,000 280,000 800,000 10. MSCT Scan Thyroid dengan I.V Contrast 1,105,000 595,000 1,700,000 11. MSCT Scan Neck / Larynx 520,000 280,000 800,000 12. MSCT Scan Neck / Larynx dengan I.V Contrast 1,105,000 595,000 1,700,000 13. MSCT Scan Nasoparing 520,000 280,000 800,000 14. MSCT Scan Nasoparing dengan I.V Contrast 1,105,000 595,000 1,700,000 15. MSCT Scan Upper Abdomen 715,000 385,000 1,100,000 16. MSCT Scan Upper Abdomen dengan I.V Contrast 1,072,500 577,500 1,650,000 17. MSCT Scan Lower Abdomen / Pelvic 715,000 385,000 1,100,000 18. MSCT Scan Lower Abdomen dengan I.V Contrast 1,072,500 577,500 1,650,000 19. MSCT Scan Whole Abdomen 845,000 455,000 1,300,000 19. MSCT Scan Whole Abdomen 845,000 455,000 1,300,000 20. MSCT Scan Whole Abdomen dengan I.V Contrast 1,137,500 612,500 1,750,000 21. MSCT Scan Thorax 715,000 385,000 1,100,000 22. MSCT Scan Thorax dengan I.V Contrast 1,072,500 577,500 1,650,000 23. MSCT Extremitas 520,000 280,000 800,000 24. MSCT Extremitas dengan I.V Contrast 975,000 525,000 1,500,000 25. MSCT Myelografi 1,072,500 577,500 1,650,000 26. MSCT Scan Spine / Vertebra ( 3-4 corpus ) 650,000 350,000 1,000,000 27. MSCT Scan Spine / Vertebra dengan I.V Contrast 1,072,500 577,500 1,650,000 MSCT KHUSUS

28. MSCT Cardiac dengan I.V Contrast 2,080,000 1,120,000 3,200,000 29. MSCT Urologi 1,137,500 612,500 1,750,000 30. MSCT Angiografi dengan I.V Contrast 1,690,000 910,000 2,600,000 31. MSCT Virtual Colonoscopy 1,755,000 945,000 2,700,000 32. MSCT Muskuloskeletal 975,000 525,000 1,500,000 33. Guiding MSCT Biopsi 1,218,750 656,250 1,875,000 34. 3D Kontras (Bahu-Muka-Pelvic-Lumbal) 1,170,000 630,000 1,800,000 35. 3D Kontras Karotis 1,040,000 560,000 1,600,000 36. Whole Body 3 Phase (Thorax-Abdomen) dengan Kontras 1,755,000 945,000 2,700,000 37. CT Perfusion 1,040,000 560,000 1,600,000

H. PEMERIKSAAN GAMMA CAMERA / KEDOKTERAN NUKLIR H.1. DIAGNOSTIK IN VIVO

PEMERIKSAAN KELENJAR TIROID

1. Thyroid scan dengan Tc-99m 292,500 157,500 450,000 2. Thyroid uptake & scan 325,000 175,000 500,000 3. Whole body scan dengan Nal-131 390,000 210,000 600,000 4. Whole body scan dengan MIBI 1,300,000 700,000 2,000,000 5. Paratiroid scan dengan MIBI 1,300,000 700,000 2,000,000 PEMERIKSAAN FUNGSI JANTUNG

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PEMERIKSAAN FUNGSI GINJAL DAN SALURAN KEMIH

1. Renal scan/renogram dengan Tc-99m cuplikan plasma 520,000 280,000 800,000 2. Renal scan/renogram dengan Tc-99m pemantauan eksternal 520,000 280,000 800,000 3. Renogram dengan Tc-99m pemantauan eksternal :

- Konvensional 650,000 350,000 1,000,000 - Diuresis 975,000 525,000 1,500,000 - Kaptopril 975,000 525,000 1,500,000 4. Renogram/ERPF dengan Tc-99m 650,000 350,000 1,000,000 5. Renal scan (DMSA) dengan hippuran I-131 650,000 350,000 1,000,000 6. Cystography 455,000 245,000 700,000 7. Scrotal Scan 975,000 525,000 1,500,000 PEMERIKSAAN FUNGSI TULANG

1. Bone scanning dengan Tc-99m + kit :

- Statik (1 fase) 1,040,000 560,000 1,600,000 - Dinamik (3 fase) 1,300,000 700,000 2,000,000 - SPECT 1,625,000 875,000 2,500,000 PEMERIKSAAN GASTROINTESTINAL

1. Gastric Emptying Time 1,625,000 875,000 2,500,000 2. Oesopagus motility scan 1,625,000 875,000 2,500,000 3. Oesopagus feflux scan 1,625,000 875,000 2,500,000 4. Divertikulum Meckel scan 975,000 525,000 1,500,000 5. Intestinal bleeding scan 1,950,000 1,050,000 3,000,000 PEMERIKSAAN HEPATOBILIER

1. Liver scanning dengan Tc-99m sulfur colloid 1,625,000 875,000 2,500,000 2. Hepatobiliary scan 1,625,000 875,000 2,500,000 3. Hepatogram 1,625,000 875,000 2,500,000 4. Limpa/spleen scanning dengan Tc-99m sulfur colloid 1,625,000 875,000 2,500,000 PEMERIKSAAN PARU

1. Perfusion lung scan 975,000 525,000 1,500,000 2. Ventilation lung scan Tc-99m 1,300,000 700,000 2,000,000 2. Ventilation lung scan Tc-99m 1,300,000 700,000 2,000,000 3. Ventilation perfusion scan (V/Q scan) 1,625,000 875,000 2,500,000 LAIN - LAIN

1. Brain scan dengan Tc-99m + kit (HMPAO) 2,600,000 1,400,000 4,000,000 2. Brain spect 2,925,000 1,575,000 4,500,000 3. Cysternogram dengan Tc-99m + kit 1,300,000 700,000 2,000,000 4. Phlebografi 975,000 525,000 1,500,000 5. Venography 1,105,000 595,000 1,700,000 6. Lymphoskintigrafi 1,300,000 700,000 2,000,000 7. Skintimammografi 2,275,000 1,225,000 3,500,000 8. Infeksi scan dengan infekton 1,300,000 700,000 2,000,000 9. Sentinel node/gamma probe detection 1,300,000 700,000 2,000,000 10. Dakriosistografi 325,000 175,000 500,000 H.2 DIAGNOSTIK IN VITRO

1. T3 RIA 97,500 52,500 150,000 2. T4 RIA 97,500 52,500 150,000 3. TSHS IRMA 113,750 61,250 175,000 4. ANTITIROGLOBULIN 260,000 140,000 400,000 5. TIROGLOBULIN 260,000 140,000 400,000 6. TERAPI :

1) Hipertiroid

- < 5 mCi 357,500 192,500 550,000 - 5-10 mCi 520,000 280,000 800,000 - 11-15 mCi 650,000 350,000 1,000,000 - 16-20 mCi 780,000 420,000 1,200,000 - 21-30 mCi 975,000 525,000 1,500,000 - 40-50 mCi 1,300,000 700,000 2,000,000 2) Ablasi karsinoma tiroid

- 80-100 mCi 2,600,000 1,400,000 4,000,000 - 100-150 mCi 3,250,000 1,750,000 5,000,000 - 150-200 mCi 3,900,000 2,100,000 6,000,000 - 200-300 mCi 4,550,000 2,450,000 7,000,000 3) Paliatif

- Samarium 2,600,000 1,400,000 4,000,000 - Rhenium 2,600,000 1,400,000 4,000,000 4) Terapi hemangioma.keloid 975,000 525,000 1,500,000 5) Permintaan tambahan film

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- Copy film bone scanning 65,000 35,000 100,000 - Copy film renogram/renmal scan 65,000 35,000 100,000 - Copy film cardioscintigraphy 130,000 70,000 200,000 - Copy film pemeriksaan lainnya 97,500 52,500 150,000

IX. PELAYANAN TINDAKAN RADIASI EKSTERNA (UMUM) UNIT RADIOTHERAPY 1. PESAWAT + SIMULATOR

Kuratif 5,586,000 3,724,000 9,310,000 Defenitif 6,384,000 4,256,000 10,640,000 Paliatif 3,192,000 2,128,000 5,320,000 2. PESAWAT + SIMULATOR + TPS

Kuratif 6,384,000 4,256,000 10,640,000 Defenitif 7,980,000 5,320,000 13,300,000 Paliatif 4,788,000 3,192,000 7,980,000 Rad. Kastrasi / Non Keganasan 2,793,000 1,862,000 4,655,000 3. PESAWAT + SIMULATOR + TPS + ALAT BANTU

Kuratif 7,980,000 5,320,000 13,300,000 Defenitif 9,576,000 6,384,000 15,960,000 Paliatif 5,586,000 3,724,000 9,310,000 3. 3 D

Kuratif 9,576,000 6,384,000 15,960,000 Defenitif 12,000,000 8,000,000 20,000,000 Paliatif 6,702,000 4,468,000 11,170,000

4. CONFORMAL 1,350,000 900,000 2,250,000

5. Konsul Dokter & Follow Up / 1 (satu) kali - 80,000 100,000 Keterangan :

Untuk tindakan pelayanan di unit Radiotherapy adalah merupakan Pelayanan Paket : a. Kuratif = Penyinaran yang dilakukan sebanyak 25 kali (25 kali penyinaran)

b. Defenitif = Penyinaran yang dilakukan lebih dari 25 kali ( > 25 kali penyinaran) c. Paliatif = Penyinaran yang dilakukan kurang dari 25 kali ( < 25 kali penyinaran) c. Paliatif = Penyinaran yang dilakukan kurang dari 25 kali ( < 25 kali penyinaran)

X. PELAYANAN BRACHITERAPI A. Ovoid

1. 2x Tindakan + 2x Penyinaran + 2x Anastesi 7,800,000 5,200,000 13,000,000 2. 3x Tindakan + 3x Penyinaran + 3x Anastesi 8,580,000 5,720,000 14,300,000 B. Cervix Intra Caviter Lengkap

1. 2x Tindakan + 2x Penyinaran + 2x Anastesi 9,000,000 6,000,000 15,000,000 2. 3x Tindakan + 3x Penyinaran + 3x Anastesi 10,140,000 6,760,000 16,900,000 C. Nasopharing Intralumen

1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 9,000,000 6,000,000 15,000,000 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi 11,700,000 7,800,000 19,500,000 D. Perineal Inplantasi

1. 1x Tindakan + 1x Penyinaran + 1x Anastesi 7,800,000 5,200,000 13,000,000 2. 1x Tindakan + 2x Penyinaran + 1x Anastesi 8,580,000 5,720,000 14,300,000 3. 1x Tindakan + 3x Penyinaran + 1x Anastesi 9,000,000 6,000,000 15,000,000 E. Cervix Inplant

1. 1x Tindakan + 2x Penyinaran + 1x Anastesi 8,580,000 5,720,000 14,300,000 2. 1x Tindakan + 4x Penyinaran + 1x Anastesi 10,140,000 6,760,000 16,900,000 3. 1x Tindakan + 6x Penyinaran + 1x Anastesi 12,480,000 8,320,000 20,800,000 F. Lidah Anterior

1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 12,480,000 8,320,000 20,800,000 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi 14,820,000 9,880,000 24,700,000 G. Base of Tongue

1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 14,820,000 9,880,000 24,700,000 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi 17,940,000 11,960,000 29,900,000

XI. PEMERIKSAAN INTERVENSI RADIOLOGI

Tindakan Angiography tanpa menggunakan Micro Cateter

1 DSA / Angiografi (Tanpa menggunakan microcateter) 7,605,000 4,095,000 11,700,000 2 TACI/TACE/TAE (Angiografi tanpa menggunakan mikrocateter) 7,605,000 4,095,000 11,700,000

Keterangan :

1. Tarif tersebut diatas sudah termasuk seluruh AKHP dan obat-obatan yang dibutuhkan (Paket) tidak termasuk micro cateter 2.7 2. Tarif diatas sudah termasuk pemeriksaan penunjang (Lab. Klinik) yang dibutuhkan yaitu :

- Pungsi Hepar (Hbs Ag, SGOT, SGPT) - Pungsi Ginjal

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3. JDA (Jasa Dokter Ahli) terlebih dahulu disetorkan ke Bendahara Penerima melalui Petugas Kasir.

4. Tarif diatas hanya untuk tindakan Angiografi, belum termasuk ruang rawat inap, ICCU, HCU bila diperlukan. 5. Apabila dilakukan pemeriksaan penunjang diluar butir 2 (dua) maka dikenakan biaya pemeriksaan

yang dilakukan sesuai dengan tarif kelas II yang berlaku.

6. Pasien yang berasal dari rujukan prakter dokter, rujukan dari RS luar dikenakan tambahan biaya 25% dari tarif tindakan yang dilakukan.

7. Bahan Habis Pakai dan Obat-obatan (Paket) diatas telah disediakan oleh Inst. Farmasi.

XII. REHABILITASI MEDIS

A. DOKTER REHABILITASI MEDIK

1. Pemeriksaan Physik Diagnostik 21,000 14,000 35,000 B. FISIOTERAPI

1. ASSESMENT

a. Assesment Fleksibilitas dan Lingkup Gerak 21,000 14,000 35,000 b. Assesment Fungsi Eksekusi Gerak 21,000 14,000 35,000 c. Assesment Fungsi Kardiorespirasi 21,000 14,000 35,000 d. Assesment Fungsi Lokomotor 21,000 14,000 35,000 e. Assesment Fungsi Integral Sensori Motor 21,000 14,000 35,000 f. Assesment Fungsi Kebugaran 21,000 14,000 35,000 g. Assesment Fungsi Kekuatan Otot 21,000 14,000 35,000 h. Assesment Fungsi Keseimbangan Statik dan Dinamik 21,000 14,000 35,000 i. Assesment motorik Halus 21,000 14,000 35,000 j. Assesment Pola Jalan 21,000 14,000 35,000 k. Assesment Fungsi Postur Control 21,000 14,000 35,000 l. Assesment Sensibilitas 21,000 14,000 35,000 2. TINDAKAN

a. Sederhana

1). Infra Red 15,000 10,000 25,000 2). Massage / Vibrator 15,000 10,000 25,000 b. Sedang

b. Sedang

1). Chest Fisioterapi 15,000 10,000 25,000 2). Manual Therapy 15,000 10,000 25,000 3). Exercise Therapy 18,000 12,000 30,000 4). MWD / SWD 18,000 12,000 30,000 5). IT/ TENS / FARADIK 18,000 12,000 30,000 6). Traksi L/C 18,000 12,000 30,000 7). Nebulizer 18,000 12,000 30,000 8). Crio Jet Therapy 18,000 12,000 30,000 9). Vacuum Unit Therapy 18,000 12,000 30,000 10). Parafin Bath 18,000 12,000 30,000 11). Magnetic Therapy 18,000 12,000 30,000 12). Ultra Sound 18,000 12,000 30,000 13). Stimulasi Sensory (Tumbuh Kembang) 21,000 14,000 35,000 c. Canggih

1). Endolaser Therapy 21,000 14,000 35,000 2). EMG Bio Feedback 21,000 14,000 35,000 C. TERAPI WICARA

1. ASSESMENT

a. Assesment Umum 21,000 14,000 35,000 b. Assesment Komunikasi 21,000 14,000 35,000 c. Assesment Fungsi Menelan 21,000 14,000 35,000 d. Assesment Fungsi Kognisi 21,000 14,000 35,000 e. Assesment Memory 21,000 14,000 35,000 2. TERAPI WICARA

a. Speech Defect Training 18,000 12,000 30,000 b. Other Speech Training 18,000 12,000 30,000 c. Training in use of lead dog for the blind 18,000 12,000 30,000 3. TERAPI FUNGSI BAHASA

a. Dysphasia Training 18,000 12,000 30,000 b. Play Therapy 18,000 12,000 30,000 4. TERAPI FUNGSI MENELAN

a. Eshopageal Speech Training (Voca Stimulation) 21,000 14,000 35,000 D. PELAYANAN OKUPASI TERAPI

1. ASSESMENT

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a. Edukasi 15,000 10,000 25,000 b. Home Program 15,000 10,000 25,000 3. Tindakan Sedang

a. ADL 18,000 12,000 30,000 b. Produktivity 18,000 12,000 30,000 c. Leisure 18,000 12,000 30,000 d. Terapi Kelompok 18,000 12,000 30,000 4. Tindakan Khusus

a. Snoezelen 24,000 16,000 40,000 b. Sensori Integrasi 27,000 18,000 45,000 c. Behavior Therapy 24,000 16,000 40,000 d. Relaksasi 24,000 16,000 40,000 E. ORTOTIK PROSTETIK

1. Assesment

a. Assesment Umum 18,000 12,000 30,000 b. Fitting and Chech Out Ortosis and Protesis 18,000 12,000 30,000 2. Tindakan Sederhana

a. Stik 192,500 5,000 197,500 b. Tripot 229,000 5,000 234,000 c. Axilla Cruches Aluminium / Kruk 315,000 35,000 350,000 d. Cervical Collar

1). Anak 78,500 5,000 83,500 2). Dewasa 89,500 5,000 94,500 e. Mallet Splint/ 1 Jari 63,000 5,000 68,000 f. Arch Support

1). Anak 48,500 5,000 53,500 2). Dewasa 56,500 5,000 61,500 g. Cock Up Splint Aluminium

1). Anak 122,500 5,000 127,500 2). Dewasa 133,500 5,000 138,500 2). Dewasa 133,500 5,000 138,500 h. Resting Splint Aluminium

1). Anak 139,000 5,000 144,000 2). Dewasa 150,000 5,000 155,000 i. Splint Siku Aluminium

1). Anak 160,000 5,000 165,000 2). Dewasa 211,000 5,000 216,000 j. Splint Lutut Aluminium

1). Anak 166,500 5,000 171,500 2). Dewasa 254,500 5,000 259,500 3. Tindakan Sedang Aluminium

a. Walker

1). Anak 394,000 10,000 404,000 2). Dewasa 394,000 10,000 404,000 b. Lumbal Korset

1). Kecil 164,000 10,000 174,000 2). Sedang 189,500 10,000 199,500 3). Besar 194,000 10,000 204,000 4). Elastis 340,000 10,000 350,000 c. Thoracolumbal Karset

1). Kecil 193,000 10,000 203,000 2). Sedang 204,000 10,000 214,000 3). Besar 221,000 10,000 231,000 d. Lumbal Ortosis Chair Back

1). Anak 335,000 10,000 345,000 2). Dewasa 368,500 10,000 378,500 c. Thoracolumbel Ortosis

1). Knight Taylor Brace

a). Anak 415,000 10,000 425,000 b). Dewasa 431,500 10,000 441,500 2). Taylor Brace Dural + AL

a). Anak 244,000 10,000 254,000 b). Dewasa 259,500 10,000 269,500 3). Extension Brace Dural + AL

a). Anak 214,000 10,000 224,000 b). Dewasa 315,000 10,000 325,000 d. Long Leg Brace