41
h. Clavicula Axila 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Scapula AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
j. Scapula Oblique 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
22
Extrimitas Bawah
a. Pedis AP dan LatObliq 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
b. Calcaneus Axial dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
c. Ankle Joint AP dan lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
d. Cruris AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
e. Genu AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
f. Femur AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
g. Coxea AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Coxea Oblique axial 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
i. Patella axial dan lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
23
Columna Vertebralis
a. Cervical AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
b. Cervical Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
c. Cervical RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
d. Thoracal AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
e. Thoracal Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
f. Thoraco RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
g. Lumbo sacral AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Lumbo sacral Lateral 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Lumbo sacral RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
j. Coxigius AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
k. Coxigius Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
24 Dental Gigi
25,000 40,000
75,000 25,000
30,000 60,000
25,000 25,000
50,000 25
Panoramic 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
26 Ultrasonografi USG
27,500 60,000
100,000 27,500
55,000 85,000
27,500 47,500
75,000
B. Dengan Kontras
1 Intra Vena Pylografi IVP
500,000 425,000
950,000 500,000
400,000 900,000
500,000 385,000
875,000 2
OMD Barium meal 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
3 Maag Deudenum Follow
tr 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
4 Colon In Loop
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 5
Uretrografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
6 Uretro cystografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 7
Cystografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
8 Fistulografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 9
Hystero Salpingografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
10 Colesistografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000
2. Kelas III, ICUneonatal dan Rawat Jalan NO
Jenis Pelayanan
BESAR TARIF Rp KELAS
Kelas III ICU NEONATAL
Rawat Jalan
JS J P
JML JS
J P JML
JS J P
JML
A. Tanpa Kontras
1 Cranium AP PA
40,000 25,000
60,000 40,000
42,500 87,500
40,000 35,000
75,000 2
Cranium Lateral 40,000
15,000 50,000
40,000 30,000
75,000 40,000
21,000 61,000
3 SPN Woters
40,000 25,000
60,000 40,000
42,500 87,500
40,000 35,000
75,000 4
SPN lateral 40,000
15,000 50,000
40,000 30,000
75,000 40,000
21,000 61,000
5 Temporo Madibula Joint
80,000 40,000
110,000 80,000
72,500 162,500
80,000 56,000
136,000
42
6 Mastoid
80,000 40,000
110,000 80,000
72,500 162,500
80,000 56,000
136,000 7
Orbita 80,000
40,000 110,000
80,000 72,500
162,500 80,000
56,000 136,000
8 Maxila dan Zygomaticum
80,000 40,000
110,000 80,000
72,500 162,500
80,000 56,000
136,000 9
Mandibula PA dan Axila 80,000
40,000 110,000
80,000 72,500
162,500 80,000
56,000 136,000
10 Nasal Bone
40,000 25,000
60,000 40,000
42,500 87,500
40,000 35,000
75,000 11
Thorax AP PA 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
12 Thorax Lateral
40,000 25,000
60,000 40,000
42,500 87,500
40,000 35,000
75,000 13
Thorax Top Lordotic 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
14 Sternum Oblique
40,000 40,000
75,000 40,000
52,500 97,500
40,000 50,000
90,000 15
Sternum Lateral 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
16 Abdoment BNO Polos
40,000 25,000
60,000 40,000
42,500 87,500
40,000 35,000
75,000 17
BNO 3 POSISI 120,000
50,000 155,000
120,000 85,000
220,000 120,000
70,000 190,000
18 BNO 2 POSISI Wongstan
80,000 50,000
120,000 80,000
85,000 175,000
80,000 70,000
150,000 19
Pelvic AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
20 Pelvic Axial
40,000 40,000
75,000 40,000
52,500 97,500
40,000 50,000
90,000
21
Extrimitas Atas
a. Manus AP dan LatOblq 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
b. Wrist Joint AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
c. Antebrachi AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
d. Elbow Joint AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
e. Humerus AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
f. Shoulder Joint AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
g. Shoulder Joint Axila 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
h. Clavicula Axila 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Scapula AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
j. Scapula Oblique 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
22
Extrimitas Bawah
a. Pedis AP dan LatObliq 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
b. Calcaneus Axial dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
c. Ankle Joint AP dan lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
d. Cruris AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
e. Genu AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
f. Femur AP dan Lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
g. Coxea AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Coxea Oblique axial 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
i. Patella axial dan lat 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
23
Columna Vertebralis
a. Cervical AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
b. Cervical Lateral 40,000
15,000 50,000
40,000 30,000
75,000 40,000
21,000 61,000
c. Cervical RAO LAO 80,000
40,000 110,000
80,000 72,500
162,500 80,000
56,000 136,000
d. Thoracal AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
e. Thoracal Lateral 40,000
15,000 50,000
40,000 30,000
75,000 40,000
21,000 61,000
f. Thoraco RAO LAO 80,000
40,000 110,000
80,000 72,500
162,500 80,000
56,000 136,000
g. Lumbo sacral AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Lumbo sacral Lateral 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Lumbo sacral RAO LAO 80,000
40,000 110,000
80,000 72,500
162,500 80,000
56,000 136,000
j. Coxigius AP 40,000
25,000 60,000
40,000 42,500
87,500 40,000
35,000 75,000
k. Coxigius Lateral 40,000
15,000 50,000
40,000 30,000
75,000 40,000
21,000 61,000
24 Dental Gigi
25,000 20,000
40,000 25,000
30,000 60,000
25,000 25,000
50,000 25
Panoramic 40,000
40,000 75,000
40,000 52,500
97,500 40,000
50,000 90,000
26 Ultrasonografi USG
27,500 45,000
70,000 27,500
55,000 85,000
27,500 47,500
75,000
43
B. Dengan Kontras
1 Intra Vena Pylografi IVP
500,000 325,000
800,000 500,000
400,000 900,000
500,000 385,000
875,000 2
OMD Barium meal 300,000
200,000 475,000
300,000 235,000
535,000 300,000
210,000 500,000
3 Maag Deudenum Follow
tr 300,000
200,000 475,000
300,000 235,000
535,000 300,000
210,000 500,000
4 Colon In Loop
300,000 200,000
475,000 300,000
235,000 535,000
300,000 210,000
500,000 5
Uretrografi 300,000
200,000 475,000
300,000 235,000
535,000 300,000
210,000 500,000
6 Uretro cystografi
300,000 200,000
475,000 300,000
235,000 535,000
300,000 210,000
500,000 7
Cystografi 300,000
200,000 475,000
300,000 235,000
535,000 300,000
210,000 500,000
8 Fistulografi
300,000 200,000
475,000 300,000
235,000 535,000
300,000 210,000
500,000 9
Hystero Salpingografi 300,000
200,000 475,000
300,000 235,000
535,000 300,000
210,000 500,000
10 Colesistografi
300,000 200,000
475,000 300,000
235,000 535,000
300,000 210,000
500,000
XI. Pelayanan Pemeriksaan Laboratorium 1. VIP
No Jenis Pemeriksaan
Jasa Sarana Jasa Pelayanan
Jumlah A. KIMIA KLINIK I
1 Asam urat darah
Rp 22,000 Rp 18,000
Rp 40,000 2
Creatinine darah Rp 22,000
Rp 18,000 Rp 40,000
3 Cholesterol
Rp 22,000 Rp 18,000
Rp 40,000 4
Bilirubin total Rp 22,000
Rp 18,000 Rp 40,000
5 Bilirubin direct
Rp 22,000 Rp 18,000
Rp 40,000 6
Protein total Rp 22,000
Rp 18,000 Rp 40,000
B. KIMIA KLINIK II
1 SGOT
Rp 22,000 Rp 18,000
Rp 40,000 2
SGPT Rp 22,000
Rp 18,000 Rp 40,000
3 HDL Cholesterol
Rp 22,000 Rp 18,000
Rp 40,000 4
LDL Cholesterol Rp 22,000
Rp 18,000 Rp 40,000
5 Albumin
Rp 22,000 Rp 18,000
Rp 40,000 6
Globulin Rp 22,000
Rp 18,000 Rp 40,000
7 Urea
Rp 22,000 Rp 18,000
Rp 40,000 8
Natrium darah Rp 22,000
Rp 18,000 Rp 40,000
9 Kalium darah
Rp 22,000 Rp 18,000
Rp 40,000 10
Chlorida darah Rp 22,000
Rp 18,000 Rp 40,000
11 Triglycerida
Rp 22,000 Rp 18,000
Rp 40,000 12
Alkaline Phospatase Rp 22,000
Rp 18,000 Rp 40,000
C. GULA DARAH
1 Nuchter
Rp 22,000 Rp 18,000
Rp 40,000 2
Post prandial Rp 22,000
Rp 18,000 Rp 40,000
3 Sewaktu
Rp 22,000 Rp 18,000
Rp 40,000
D. HEMATOLOGI I
1 Laju end. darah LED
Rp 10,000 Rp 5,000
Rp 15,000 2
Hematokrit Rp 10,000
Rp 5,000 Rp 15,000
3 Hb
Rp 10,000 Rp 5,000
Rp 15,000 4
Eritrosit AE Rp 10,000
Rp 5,000 Rp 15,000
5 Retikulosit
Rp 10,000 Rp 5,000
Rp 15,000 6
Lekosit AL Rp 10,000
Rp 5,000 Rp 15,000
7 Hit. Jns. Lekosit Diftel
Rp 10,000 Rp 5,000
Rp 15,000 8
Trombosit Rp 10,000
Rp 5,000 Rp 15,000
9 Golongan darah
Rp 10,000 Rp 5,000
Rp 15,000 10
Malaria Filaria Rp 10,000
Rp 5,000 Rp 15,000
E. HEMATOLOGI II
1 Masa Pendarahan
Rp 10,000 Rp 5,000
Rp 15,000
44
2 Masa Pembekuan
Rp 10,000 Rp 5,000
Rp 15,000
F. SEROLOGI IMUNOLOGI
1 VDOKTERL RPR
Rp 22,000 Rp 18,000
Rp 40,000 2
Widal Rp 22,000
Rp 18,000 Rp 40,000
3 ASTO
Rp 22,000 Rp 18,000
Rp 40,000 4
CRP Rp 22,000
Rp 18,000 Rp 40,000
5 HBS Ag Ab RPHA
Rp 22,000 Rp 18,000
Rp 40,000 6
Anti HBsAg Rp 22,000
Rp 18,000 Rp 40,000
G. BAKTERIOLOGI
1 Preparat BTA
Rp 25,000 Rp 25,000
Rp 50,000 2
Preparat jamur spr Rp 25,000
Rp 25,000 Rp 50,000
3 Preparat gram
Rp 25,000 Rp 25,000
Rp 50,000 4
Preparat GO Rp 25,000
Rp 25,000 Rp 50,000
5 Preparat Diphteri
Rp 25,000 Rp 25,000
Rp 50,000 6
Preparat Trichom Rp 25,000
Rp 25,000 Rp 50,000
7 Candida Albicans
Rp 25,000 Rp 25,000
Rp 50,000
H. LIQUOR
1 Jumlah sel
Rp 10,000 Rp 5,000
Rp 15,000 2
Hitung jenis Rp 10,000
Rp 5,000 Rp 15,000
3 Protein
Rp 10,000 Rp 5,000
Rp 15,000 4
Glukosa Rp 10,000
Rp 5,000 Rp 15,000
I. ANALISA SEMEN
1 Bau, Warna, Volume
Rp 10,000 Rp 5,000
Rp 15,000 2
Morfologi Rp 10,000
Rp 5,000 Rp 15,000
3 Gerak
Rp 10,000 Rp 5,000
Rp 15,000 4
Jumlah Rp 10,000
Rp 5,000 Rp 15,000
5 Koagulum, Leg
Rp 10,000 Rp 5,000
Rp 15,000
J. URINE
1 PH
Rp 10,000 Rp 5,000
Rp 15,000 2
Berat jenis Rp 10,000
Rp 5,000 Rp 15,000
3 Protein
Rp 10,000 Rp 5,000
Rp 15,000 4
Reduksi Glukose Rp 10,000
Rp 5,000 Rp 15,000
5 Urobilinogen
Rp 10,000 Rp 5,000
Rp 15,000 6
Ketone Rp 10,000
Rp 5,000 Rp 15,000
7 Leukosit
Rp 10,000 Rp 5,000
Rp 15,000 8
Bilirubin Rp 10,000
Rp 5,000 Rp 15,000
9 Esbach
Rp 10,000 Rp 5,000
Rp 15,000 10
Sedimen Rp 10,000
Rp 5,000 Rp 15,000
11 Nitrit
Rp 10,000 Rp 5,000
Rp 15,000
K. TINJA
1 Darah Samar
Rp 10,000 Rp 5,000
Rp 15,000 2
Rutin Rp 10,000
Rp 5,000 Rp 15,000
2. Kelas III,II,I,ICU dan Rawat Jalan No