I. INSTALASI RAWAT JALAN A. Karcis Harian - Tarif Kelas III RSUP H. Adam Malik ALL
- Administrasi Sistem Informasi
17. Pasang Kateter (Kasus Non Operasi) 24,000 16,000 40,000
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
18. Ekstirpasi Corpus Alienum 30,000 20,000 50,000
3. Dilatasi Phimosis 75,000 50,000 125,000
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
4. Eksisi Clavus 75,000 50,000 125,000 5. Eksisi Condiloma A.
2. Kumbah Lambung 120,000 80,000 200,000
J S J P JLH ( Rp ) ( Rp ) ( Rp )
4. Konsultasi / Konseling HIV/AIDS 3,300 13,200 16,500
1
3
4
5 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
5. Psikologi 2,400 9,600 12,000
1. EKG 30,000 20,000 50,000
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.
RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014
NO J E N I S P E L A Y A N A N BESARAN TARIF TA. 20142 II. TARIF INSTALASI GAWAT DARURAT
A. Karcis Harian
20,000 5,000 25,000
1,500 - 1,500
B. RUANG TRIASE
1. Konsultasi Dokter Spesialis 1x 5,000 20,000 25,000 C.
Tindakan pembuatan Visum et Repertum (Korban Hidup / berkaitan dengan tindakan standar di IGD.
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
d. Khusus I 6,000,000 4,000,000 10,000,000
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
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
e. Khusus II 9,000,000 6,000,000 15,000,000
3. Bronchoscopy + Biopsi 300,000 200,000 500,000
a. Sedang I 1,875,000 1,250,000 3,125,000
DC Shock, Defibrilator, Ventilator, Temporary Pace Maker, Incubator, Nebulizer, dll
a. Sedang I 1,875,000 1,250,000 3,125,000
5. Bedah Urologi
d. Khusus 5,400,000 3,600,000 9,000,000
c. Besar 3,375,000 2,250,000 5,625,000
b. Sedang II 2,625,000 1,750,000 4,375,000
4. Bedah Gimul
f. Khusus III 14,400,000 9,600,000 24,000,000
e. Khusus III 13,200,000 8,800,000 22,000,000
d. Khusus II 9,000,000 6,000,000 15,000,000
c. Khusus I 5,400,000 3,600,000 9,000,000
b. Besar 3,375,000 2,250,000 5,625,000
a. Sedang II 2,625,000 1,750,000 4,375,000
3. Bedah Orthopedi
4. Bronchospirometri 342,000 228,000 570,000
2. Bronchoscopy 282,000 188,000 470,000
32. Tindakan Extubasi 24,000 16,000 40,000
39. Aspirasi Pneumotoraks 60,000 40,000 100,000
45. Pengangkatan Nevus 45,000 30,000 75,000
44. Pasang Gips 60,000 40,000 100,000
43. Jahit Luka Palpebra 75,000 50,000 125,000
42. Insisi Abses Besar 75,000 50,000 125,000
41. Eksisi Hordeolum / Granuloma 75,000 50,000 125,000
40. Eksisi Khalazion 75,000 50,000 125,000
38. Colar Neck 24,000 16,000 40,000
47. Ekstirpasi Fibroma 75,000 50,000 125,000
37. Monitor EKG 60,000 40,000 100,000
36. Sirkumsisi 60,000 40,000 100,000
35. Resisutasi Jantung Paru 60,000 40,000 100,000
34. Penanganan Luka Bakar > 30% 105,000 70,000 175,000
33. Penanganan Luka Bakar 10% - 30% 60,000 40,000 100,000
33. Penanganan Luka Bakar < 10% 30,000 20,000 50,000
46. Tindakan Pungsi Lumbal 60,000 40,000 100,000
48. Injeksi Varises (termasuk obat) 195,000 130,000 325,000
1. Bronchial Provocation Test 102,000 68,000 170,000
1. Ruang Observasi (> 6 Jam tanpa Monitoring) 60,000 40,000 100,000
F.
5. One Day Care 90,000 60,000 150,000 E.
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
3. Ruang Observasi Intensive / HCU 150,000 100,000 250,000
2. Ruang Resusitasi dengan Monitoring 90,000 60,000 150,000
56. Vena Seksi 180,000 120,000 300,000 D.
49. Insisi Mucocele 75,000 50,000 125,000
55. Tindakan Manual Plasenta 180,000 120,000 300,000
54. Sistostomi dengan Anestesi Lokal 180,000 120,000 300,000
53. Reposisi dengan Anestesi Lokal 180,000 120,000 300,000
52. Pungsi sum-sum tulang 180,000 120,000 300,000
51. Pungsi Pleura 180,000 120,000 300,000
50. Pemasangan WSD 180,000 120,000 300,000
G. TINDAKAN MEDIS OPERATIF
5. Apabila ada dilakukan tindakan selain tindakan tersebut diatas, maka dihitung Tarif Tindakan Kelas II (Poli Rawat
a. Sedang I 1,875,000 1,250,000 3,125,000
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
b. Sedang II 2,625,000 1,750,000 4,375,000
d. Khusus 5,400,000 3,600,000 9,000,000
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 :
b. 3 (tiga) macam operasi :
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.
11. Bedah Mata
c. Besar 3,375,000 2,250,000 5,625,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
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 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
b. Besar 3,375,000 2,250,000 5,625,000
b. Sedang II 2,625,000 1,750,000 4,375,000
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
- tarif operasi utama sesuai tarifnya
- tarif operasi kedua sama dengan 60 % dari tarifnya
- tarif operasi utama sesuai tarifnya
- tarif operasi selebihnya sama dengan 50 % dari tarifnya
I. PELAYANAN GAS MEDIS
13. O2 / Tabung 1m3 40,000 - 40,000
10
4. Oksigen dengan Ventilator / liter
70
20
90
5. N2O / liter 300 100 400
6. Udara Tekan (UT) / liter
70
80
15
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
14. Respiflo / flash 66,000 9,000 75,000 III.
65
50
2. Visite / Konsultasi Spesialis 1 kali
3. Oksigen Perinato dengan head box / liter
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
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
1. Oksigen / liter
25
5
30
2. Oksigen Bayi (Perinato) / liter
30
5
35
A. TARIF RUANGAN RAWAT INAP TERPADU (RINDU) A, B dan KARDIOVASKULER
1. Akomodasi Ruangan 31,500 13,500 45,000
- 20,000 20,000
3. Visite Tim Spesialis berkelompok 3 orang yang berbeda/1 kali - 40,000 40,000
4. Visite Dokter PPDS
4. Visite Dokter PPDS
- 6,000 6,000 5.
- 32,000 32,000
- 6,000 6,000
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
4. Punctie Ascites 19,200 12,800 32,000
14. Timpanometri + Refleks Akustik 54,000 36,000 90,000
1. WSD Continue 74,400 49,600 124,000
2. Punctie Pleura Proef 25,800 17,200 43,000
Untuk tindakan keperawatan seperti : ganti verban kecil, sedang , besar; ganti luka bakar ringan, Visite/Konsultasi oleh Dokter Spesialis untuk pasien kiriman RS swasta atau
Catatan :
17. Fleurodesis 270,000 180,000 450,000
16. BMP 120,000 80,000 200,000
15. Timpanometri + Refleks Akustik + Tes Fungsi Tuba 72,000 48,000 120,000
13. Timpanometri 36,000 24,000 60,000
3. Punctie Pleura Therapi 35,700 23,800 59,500
12. Audiometri 36,000 24,000 60,000
11. Tindakan Kemotherapy 180,000 120,000 300,000
10. Penyampuran Obat Kemotherapy 9,000 6,000 15,000
9. Wash Out 18,600 12,400 31,000
8. Pasang Gip's 84,000 56,000 140,000
7. Pasang Nebulizer /1x 15,000 10,000 25,000
6. Biopsi 84,000 56,000 140,000
5. Aspirasi Jarum Halus 26,400 17,600 44,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
C. TINDAKAN DI RINDU B OBGIN
IV. PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK
A. KIMIA DARAH
26 Magnesium 33,000 11,000 44,000
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
28 Natrium Urine 18,000 6,000 24,000
27 Natrium Darah 18,000 6,000 24,000
13 Cholinesterase (Che) 24,750 8,250 33,000
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
1 Glikolysis HB / HbA1c 111,375 37,125 148,500
2 Glukosa Darah ( Rapid) 20,625 6,875 27,500
3 Glukosa Darah PP 15,375 5,125 20,500
14 CK ( Cratine Kinase ) 69,750 23,250 93,000
12 Chlorida Urin 18,000 6,000 24,000
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.
14. Ressusitasi Perinatologi 15,000 10,000 25,000
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
15. Lumbal Fungsi 30,000 20,000 50,000
11 Chlorida Darah 18,000 6,000 24,000
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.
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
B. DIABETES
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
21 Pewarnaan sum-sum tulang 37,500 12,500 50,000
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
22 Serum Iron Binding Capacity (SIBC) 49,500 16,500 66,000
5 Filaria 14,625 4,875 19,500
6 Anti CMV IgM 68,625 22,875 91,500
12 Anti HBs 74,250 24,750 99,000
11 Anti Hbe 165,000 55,000 220,000
10 HBc Total 61,875 20,625 82,500
9 Anti HBc IgM 87,375 29,125 116,500
8 HAV Total 148,500 49,500 198,000
7 Anti HAV IgM 115,500 38,500 154,000
5 Anti CMV IgG 68,625 22,875 91,500
23 Sugar Water Test 19,875 6,625 26,500
4 Anti Chikungunya 219,750 73,250 293,000
3 Anti Amuba 164,625 54,875 219,500
2 ACA IgM 393,375 131,125 524,500
1 ACA IgG 393,375 131,125 524,500
25 Transferin 109,875 36,625 146,500
24 Total Iron Binding Capacity (TIBC) 49,500 16,500 66,000
6 Malaria 18,375 6,125 24,500
4 Golongan Darah ABO + Rhesus Factor 13,875 4,625 18,500
4 Glukosa Darah Puasa 15,375 5,125 20,500
9 SGPT 20,625 6,875 27,500
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
D. FUNGSI GINJAL
3 Retikulosit 14,625 4,875 19,500
4 Trigliceride 28,125 9,375 37,500
2 Hitung Eosinophil 10,875 3,625 14,500
1 Darah Lengkap ( Full Blood Count ) 40,500 13,500 54,000
1 Darah Lengkap ( Full Blood Count ) 40,500 13,500 54,000
F. HEMATOLOGI
6 Apo B 77,625 25,875 103,500
5 Apo A 99,000 33,000 132,000
3 Cholesterol Total 28,125 9,375 37,500
1 Creatinine 19,875 6,625 26,500
2 Cholesterol LDL 18,000 6,000 24,000
1 Cholesterol HDL 23,250 7,750 31,000
E. ANALISA LEMAK
4 Ureum 19,875 6,625 26,500
3 Urea Clearance 27,375 9,125 36,500
2 Creatinine Clearence 36,000 12,000 48,000
G. SEROLOGI
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
13 Resistensi OAT Lini 2 (kana, oflox) 169,500 56,500 226,000
48 Procalcitonin 274,500 91,500 366,000
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
14 Sediaan langsung Pewarnaan BTA 27,375 9,125 36,500
13 Anti HCV 115,500 38,500 154,000
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
1 Estradiol 173,250 57,750 231,000
2 Estrogen 72,750 24,250 97,000
3 Free T3 127,875 42,625 170,500
4 Free T4 103,125 34,375 137,500
5 FSH 148,500 49,500 198,000
6 LH 148,500 49,500 198,000
7 Progesteron 176,625 58,875 235,500
47 Widal 45,750 15,250 61,000
46 Veneral Disease Research Laboratory (VDRL) 39,750 13,250 53,000
45 Treponema Palidium H Antigen (TPHA) 39,750 13,250 53,000
44 PCR Influenza A H1N5 274,500 91,500 366,000
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
43 PCR Influenza A H1N1 274,500 91,500 366,000
42 NS 1 Ag Dengue 183,000 61,000 244,000
42 NS 1 Ag Dengue 183,000 61,000 244,000
41 IgM Salmonella Typhi ( Tubex TF) 219,750 73,250 293,000
40 HBs Ag 91,500 30,500 122,000
39 HBe Ag 183,000 61,000 244,000
38 Hainn Test TB 283,875 94,625 378,500
37 FTA - ABS 55,125 18,375 73,500
36 Faktor Rhematoid 45,750 15,250 61,000
35 Antibodi Dengue Ig G / Ig M 114,375 38,125 152,500
33 C- Reaktif Protein (CRP) 59,625 19,875 79,500 34 hsCRP 91,500 30,500 122,000
32 Clamydia Ig M 205,875 68,625 274,500
31 Clamydia Ig G 205,875 68,625 274,500
H. MIKROBIOLOGI
I. URINE
J. HORMON
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
K. CAIRAN TUBUH
L. FAECES
M. DRUG MONITORING
N. HEMOSTASIS
4 Anti-ds DNA 210,375 70,125 280,500
8 Anti Body Sperma 100,875 33,625 134,500
7 Anti HIV (Elisa) 100,875 33,625 134,500
6 Anti Lamda 64,125 21,375 85,500
5 Anti Kappa 64,125 21,375 85,500
1 Alfa 1 Antitrifsin Kwantitatif 81,375 27,125 108,500
3 ANA Test 146,625 48,875 195,500
2 Alfa 2 Makro Globulin Kwantitatif 57,375 19,125 76,500
10 Complement C4 67,500 22,500 90,000
20 IT Ratio 21,750 7,250 29,000
19 TT(THROMBINE TIME) 57,375 19,125 76,500
18 Thrombotest 91,500 30,500 122,000
9 Complement C3 67,500 22,500 90,000
13 IgE 82,500 27,500 110,000
11 Cryoglobulin 22,875 7,625 30,500
12 IgA / IgG / IgM 87,750 29,250 117,000
8 Prolactin 148,500 49,500 198,000
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
1 AFP 99,000 33,000 132,000
2 CA 125 198,000 66,000 264,000
3 CA 15-3 198,000 66,000 264,000
17 Tromboplastin Generation Time (TGT) 91,500 30,500 122,000
16 PT (Prothorombin Time) + INR 56,625 18,875 75,500
15 PROTEIN C 256,125 85,375 341,500
14 PROTEIN S 256,125 85,375 341,500
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
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
1 Analisa Faeces ( pencernaan ) 18,375 6,125 24,500
2 Benzidine Test / Darah Samar 55,125 18,375 73,500
1 Aminophylin 338,625 112,875 451,500
8 F. Von Wiilebrands 196,875 65,625 262,500
13 Masa Iisis Euglobolin 55,125 18,375 73,500
12 Lupus Anticoagulan 192,375 64,125 256,500
11 Inhibitor VIII 256,125 85,375 341,500
10 D. Dimer 171,750 57,250 229,000
9 FIBRINOGEN 82,500 27,500 110,000
8 F. Von Wiilebrands 196,875 65,625 262,500
1 Aggregasi Trombosit (ADP) 137,250 45,750 183,000
7 Beta 2 Glycoprotein 1 (B2GP-1) 507,750 169,250 677,000
6 Assay Faktor VIII 228,750 76,250 305,000
5 Assay Faktor IX 228,750 76,250 305,000
4 APTT ( Masa Tromboplastin Parsial ) 57,375 19,125 76,500
3 Anti Trombin III 126,000 42,000 168,000
2 Anti Faktor Xa 201,375 67,125 268,500
O. IMUNOLOGI
P. TUMOR MARKER
Biakan Mikro Organisme Aerob Medium Cair dengan Resistensi Biakan Mikro Organisme Anerob Medium Cair dengan Resistensi Biakan Mikro Organisme Jamur Medium Cair dengan Resistensi Biakan Jamur Medium Padat (bahan : kerokan)
16. Sediaan Langsung Pewarnaan BTA - POLI DOTS - - -
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 - - -
Keterangan:
2 CD 8 100,875 33,625 134,500
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
V. PEMERIKSAAN MIKROBIOLOGI KLINIK
1 CD 4 100,875 33,625 134,500
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
3 Amphetamine 40,500 13,500 54,000
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
4 Cocaine 40,500 13,500 54,000
T. IMMUNOPHENOTYPING FLOWCYTOMETRI
b. Kwantitatif 1,262,625 420,875 1,683,500
7 Bakteri Gonorhoae (DNA) 371,625 123,875 495,500
7 Bakteri Gonorhoae (DNA) 371,625 123,875 495,500
6 Chlamydia Trachomatis 977,250 325,750 1,303,000
5 CMV DNA Kwantitatif 105,375 35,125 140,500
4 Mycobacterium TBC DNA 442,875 147,625 590,500
3 HBV-DNA Kwantitatif 1,368,000 456,000 1,824,000
a. Kwalitatif 684,000 228,000 912,000
5 Barbiturates 40,500 13,500 54,000
2 HCV RNA :
1 HIV RNA 684,000 228,000 912,000
S. PCR
8 THC + MOP + Met (PAKET) 70,500 23,500 94,000
7 Benzodiazepine 40,500 13,500 54,000
6 THC (Ganja) 40,500 13,500 54,000
- -
VII. PEMERIKSAAN / PELAYANAN DIAGNOSTIK ELEKTROMEDIK
7. Gastroskopy 390,000 260,000 650,000
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
6. Colonoskopy dengan Anestesi Umum 720,000 1,080,000 1,800,000
5. Colonoskopy dengan Clipping 510,000 340,000 850,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
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
12. Biopsi Prostat 600,000 400,000 1,000,000
10. USG Color Dopler Thorax / Paru 300,000 200,000 500,000
11. USG Tuntunan Biopsi 94,500 63,000 157,500
2. EKG 18,000 12,000 30,000
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
A. SEDERHANA
1. Spirometri 90,000 60,000 150,000
B. SEDANG
9. USG Color Dopler P. Dalam, Ginjal 150,000 100,000 250,000
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
15. a. ERCP Tidak Berhasil
- ERCP Diagnostik
- ERCP Spirinterektomy
- ERCP Stenting
- ERCP Basket
b. ERCP Berhasil
1,860,000 1,240,000 3,100,000
750,000 500,000 1,250,000
35. Repair Double Lumen 450,000 300,000 750,000
34. Double Lumen Tunnel (Temporer) 900,000 600,000 1,500,000
33. Double Lumen Tunnel 1,440,000 960,000 2,400,000
32. Treadmill Test 120,000 80,000 200,000
31. Thoracoscopy + Biopsi 1,080,000 1,620,000 2,700,000
30. Pengambilan Benda Asing dengan Bronchoskopy 720,000 1,080,000 1,800,000
29. Bronchoskopy dengan Anestesi Umum 720,000 1,080,000 1,800,000
28. Bronchoskopy + Bilasan 570,000 380,000 950,000
27. Bronchoskopy + Sikatan 570,000 380,000 950,000
26. Bronchoskopy + Biopsi 570,000 380,000 950,000
25. Bronchoskopy 510,000 340,000 850,000
24. ESWL Fase II 940,000 1,410,000 2,350,000
23. ESWL 1,200,000 1,800,000 3,000,000
22. RPG 600,000 400,000 1,000,000
21. Urocystoskopy 150,000 100,000 250,000
20. Fibroscan 300,000 200,000 500,000
(Seluruh tindakan ERCP memakai anasthesi)
1,860,000 1,240,000 3,100,000
1,860,000 1,240,000 3,100,000
VIII. PEMERIKSAAN RADIOLOGI (RADIO DIAGNOSTIK)
A. KECIL
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
50. BNO / Abdomen 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
B. SEDANG
34. Pedis Kiri AP / Oblique 58,500 31,500 90,000
9. Thoracal PA / L (4Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000
1. Mammografi 162,500 87,500 250,000
C. KHUSUS
13. Abdomen 3 Posisi 130,000 70,000 200,000
12. Thorax 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
10. Lumbal PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000
8. Cervical PA / L (4 Posisi) / Oblique ki-ka (4 posisi ) 162,500 87,500 250,000
1. Thorax PA / L (2 Posisi) 81,250 43,750 125,000
7. Pelvimetri 81,250 43,750 125,000
6. Coccygis PA / L (2 Posisi) 81,250 43,750 125,000
5. Sacrum PA / L (2 Posisi) 81,250 43,750 125,000
4. Lumbal PA / L (2 Posisi) 81,250 43,750 125,000
3. Thoracal PA / L 2 Posisi 81,250 43,750 125,000
2. Cervical PA / L (2 Posisi) 81,250 43,750 125,000
35. Pedis Kanan AP / Oblique 58,500 31,500 90,000
33. Sternum 58,500 31,500 90,000
1. Scheedel AP / L 58,500 31,500 90,000
16. Manus Kiri dan Kanan AP / Oblique 78,000 42,000 120,000
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