Kelas III, ICUneonatal dan Rawat Jalan NO

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