NO NAMA TARIF BHP MEREK JUMLAH

1 Abdomen / BNO Polos Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 2
Fixer Agfa 1
Labelling RSIA BJ 2

2 Abdomen 2 posisi Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

3 Abdomen 3 posisi Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 4
Fixer Agfa 1
Labelling RSIA BJ 2

4 Ankle Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

5 Antebrachii Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

6 Appendicogram Amplop 30x40 RSIA BJ 1

Barium Eskay 32
Developer Agfa 1
Film 30x40 Agfa 10
Fixer Agfa 1
Labelling RSIA BJ 7

7 B.N.O. I.V.P Alkohol swab PD 2

Amplop Coklat 30x40 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 2
Film 30x40 Agfa 10
 Fixer Agfa 1
Kontras Iopamiro Iopamiro 1
Labelling RSIA BJ 12
Micropore 3M 1
Spuit 1 cc Terumo 1
Spuit 10 cc Terumo 1
Spuit 20cc Terumo 3
Venvlon no 18 Heur 1

8 Calvicula Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

9 Cocygis Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

10 Costae Amplop 35x35 RSIA BJ 1

Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
11 Cruris Amplop 30x40 RSIA BJ 1
Developer Agfa 1
Film 30x40 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

12 Elbow Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

13 Femur Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 4
Fixer Agfa 1
Labelling RSIA BJ 2
14 H S G Alkohol swab PD 1
Amplop 30x40 RSIA BJ 1
Bethadine MBF 10
Catheter HSG Angiotech 1
Developer Agfa 1
Film 24x30 Agfa 5
Film 30x40 Agfa 6
Fixer Agfa 1
Handscoen No 6,5 PD 1
Handscoen Uk S Sensigloves 4
Kasa DRC 15
Kontras Iopamiro Iopamiro 1
Micropore 3M 1
Needle No 18 Terumo 1
Profenid supp Sanofi Aventis 1
Spuit 1 cc Terumo 1
Spuit 5 cc Terumo 1
Spuit 10 cc Terumo 1
Xylocain 2% 10 gr gel AstraZeneca 1

15 H S G Tanpa Catheter Alkohol swab PD 1

Amplop 30x40 RSIA BJ 1
Bethadine MBF 10
Developer Agfa 1
Film 24x30 Agfa 5
Film 30x40 Agfa 6
Fixer Agfa 1
Handscoen No 6,5 PD 1
Handscoen Uk S Sensigloves 4
Kasa DRC 15
Kontras Iopamiro Iopamiro 1
Micropore 3M 1
Needle No 18 Terumo 1
Profenid supp Sanofi Aventis 1
Spuit 1 cc Terumo 1
Spuit 5 cc Terumo 1
Spuit 10 cc Terumo 1
Xylocain 2% 10 gr gel AstraZeneca 1

16 Hip Amplop 35x35 RSIA BJ 1

Developer Agfa 1
 Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3

17 Humerus Amplop 30x40 RSIA BJ 1

Developer Agfa 1
Film 30x40 Agfa 4
Fixer Agfa 1
Labelling RSIA BJ 2

18 Jari kaki Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2

19 Jari Tangan Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 2
Fixer Agfa 1
Labelling RSIA BJ 2
20 Knee Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3

21 Manus Amplop 24x30 RSIA BJ 1

Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
22 Os. Nasale Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
23 Pedis Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
24 Pelvis Amplop 35x35 RSIA BJ 1
 Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
25 Schedel AP + Lat Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
26 Sella Tursica Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
27 Shoulder / Bahu Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
28 Sinus Paranasal ( SPN ) Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
29 Thorax AP / PA Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
30 Thorax AP / PA + Lateral (Anak) Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
31 Thorax PA+Lateral (Dewasa) Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 3
32 Top Lordotic Amplop 35x35 RSIA BJ 1
Developer Agfa 1
Film 35x35 Agfa 3
Fixer Agfa 1
 Labelling RSIA BJ 3
33 V. Carvical 2 posisi Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
34 V. Carvical 4 posisi Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 5
Fixer Agfa 1
Labelling RSIA BJ 2
35 V. Lumbal Amplop 30x40 RSIA BJ 1
Developer Agfa 1
Film 30x40 Agfa 4
Fixer Agfa 1
Labelling RSIA BJ 2
36 V. Lumbo Sarcal Amplop 30x40 RSIA BJ 1
Developer Agfa 1
Film 30x40 Agfa 4
Fixer Agfa 1
Labelling RSIA BJ 2
37 V. Thoracal Amplop 30x40 RSIA BJ 1
Developer Agfa 1
Film 30x40 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
38 V. Thoracalumbal Amplop 30x40 RSIA BJ 1
Developer Agfa 1
Film 30x40 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
39 Wrist Amplop 24x30 RSIA BJ 1
Developer Agfa 1
Film 24x30 Agfa 3
Fixer Agfa 1
Labelling RSIA BJ 2
40 Densitometri Amplop 24x30 Densito RSIA BJ 1
Kertas HVS RSIA BJ 8
41 USG Mammae Amplop USG Besar RSIA BJ 1
Jelly 20
Kertas USG 10
Tissue USG RSIA BJ 5
42 USG Thyroid Amplop USG Besar RSIA BJ 1
 Jelly 20
Kertas USG 10
Tissue USG RSIA BJ 5
43 USG Kepala Bayi Amplop USG Kecil RSIA BJ 1
Jelly 20
Kertas USG 10
Tissue USG RSIA BJ 5
44 USG Abdomen Amplop USG Besar RSIA BJ 1
Jelly 20
Kertas USG 12
Tissue USG RSIA BJ 5
45 USG Testis Amplop USG Besar RSIA BJ 1
Jelly 20
Kertas USG 10
Tissue USG RSIA BJ 5
SATUAN HNA + PPN jumlah total
lembar 4,500 4,500 125,260
32,300 32,300
lembar 18,975 37,950
50,400 50,400
lembar 55 110

lembar 4,500 4,500 144,235

32,300 32,300
lembar 18,975 56,925
50,400 50,400
lembar 55 110

lembar 4,500 4,500 163,210

32,300 32,300
lembar 18,975 75,900
50,400 50,400
lembar 55 110

lembar 3,500 3,500 122,415

32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110

lembar 4,500 4,500 144,235

32,300 32,300
lembar 18,975 56,925
50,400 50,400
lembar 55 110

Pcs 4,500 4,500 282,935

gram 175 5,600
32,300 32,300
Lembar 18,975 189,750
50,400 50,400
Lembar 55 385

pcs 275 550 735,235

lembar 4,500 4,500
32,300 32,300
lembar 12,035 24,070
lembar 18,975 189,750
 50,400 50,400
vial 358,600 358,600
pcs 55 660
30 cm 12,788 12,788
pcs 3,254 3,254
pcs 4,086 4,086
pcs 10,759 32,277
pcs 22,000 22,000
-
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110

lembar 3,500 3,500 122,415

32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
-
lembar 4,000 4,000 145,845
32,300 32,300
lembar 19,660 58,980
50,400 50,400
lembar 55 165
lembar 4,500 4,500 144,235
32,300 32,300
lembar 18,975 56,925
50,400 50,400
lembar 55 110
-
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110

lembar 32,300 32,300 191,010

32,300 32,300
lembar 18,975 75,900
50,400 50,400
lembar 55 110
 pcs 275 275 2,202,325
pcs 4,500 4,500
cc 19,250 192,500
pcs 1,258,400 1,258,400
32,300 32,300
pcs 12,035 60,175
pcs 18,975 113,850
50,400 50,400
pcs 11,000 11,000
pcs 644 2,576
pcs 1,000 15,000
vial 358,600 358,600
30 cm 12,788 12,788
pcs 990 990
pcs 13,368 13,368
pcs 3,254 3,254
pcs 3,364 3,364
pcs 4,086 4,086
Tube 79,899 79,899

pcs 275 275 958,925

pcs 4,500 4,500
cc 19,250 192,500
32,300 32,300
pcs 12,035 60,175
pcs 18,975 113,850
50,400 50,400
pcs 11,000 11,000
pcs 644 2,576
pcs 1,000 15,000
vial 358,600 358,600
30 cm 12,788 12,788
pcs 990 990
pcs 13,368 13,368
pcs 3,254 3,254
pcs 3,364 3,364
pcs 4,086 4,086
Tube 79,899 79,899

lembar 4,000 4,000 145,845

32,300 32,300
lembar 19,660 58,980
50,400 50,400
lembar 55 165

lembar 4,500 4,500 163,210

32,300 32,300
lembar 18,975 75,900
50,400 50,400
lembar 55 110

lembar 3,500 3,500 122,415

32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110

lembar 3,500 3,500 110,380

32,300 32,300
lembar 12,035 24,070
50,400 50,400
lembar 55 110
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
-
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 4,000 4,000 171,125
 19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 4,000 4,000 171,125
19,660 19,660
lembar 32,300 96,900
50,400 50,400
lembar 55 165
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
lembar 3,500 3,500 146,485
32,300 32,300
lembar 12,035 60,175
50,400 50,400
lembar 55 110
lembar 4,500 4,500 163,210
32,300 32,300
lembar 18,975 75,900
50,400 50,400
lembar 55 110
lembar 4,500 4,500 163,210
32,300 32,300
lembar 18,975 75,900
50,400 50,400
lembar 55 110
lembar 4,500 4,500 144,235
32,300 32,300
lembar 18,975 56,925
50,400 50,400
lembar 55 110
lembar 4,500 4,500 144,235
32,300 32,300
lembar 18,975 56,925
50,400 50,400
lembar 55 110
lembar 3,500 3,500 122,415
32,300 32,300
lembar 12,035 36,105
50,400 50,400
lembar 55 110
3,000 3,000 3,440
55 440
lembar 3,500 3,500 132,700
cc 55 1,100
lembar 12,800 128,000
100 100
lembar 3,500 3,500 132,700
 cc 55 1,100
lembar 12,800 128,000
100 100
lembar 3,500 3,500 132,700 3,500 3,500
cc 55 1,100 1,100 1,100
lembar 12,800 128,000 102,400
100 100 100 100
lembar 3,500 3,500 158,300 107,100 4,700
cc 55 1,100 10,000
lembar 12,800 153,600 117,100
100 100
lembar 3,500 3,500 132,700
cc 55 1,100
lembar 12,800 128,000
100 100
-
 BARIUM SULPHATE SUSPENSI 150 ML
BARIUM SULPHATE POWDER 175 GR

KASA PEMBALUT HIDROFIL 10 CM

SYRINGE CHATHETER TIP 50CC

SYRINGE WITH NEEDLE 10CC

DEXAMETHASONE 5MG/ML

SYRINGE WITH NEEDLE 1CC

HANDSCOON STERIL 7,0
NO JENIS PEMERIKSAAN

ENEMA DISPOSIBLE KIT

IOPROMIDE-300 50ML
JELLY WITH LIDOCAIN
NaCl 0,9% inf 100 ml

NaCl 0,9% inf 500 ml

FILM CR 11X14 INCH

KASA STERIL 7,5X7,5

FILM DENTAL X-RAY
AIR INSUFFLATOR
AQUADEST 25 ml

CATHETER 2WAY
ALCOHOL SWAB

KASA ALKOHOL
SYRINGE 20CC

WING NEEDLE
NEEDLE
1 Thorax AP/PA 1
2 Thorax Lateral/RLD 1
3 Thorax AP/PA & Lateral 2
4 Top Lordotik 1
5 Thorax AP/PA & Top Lordotik 2
6 Abdomen (BNO) 1
7 Abdomen 2 Posisi 2
8 Abdomen 3 Posisi 3
9 Pelvis AP/Frog Leg/HIP Joint 1
10 Skull AP & Lateral 2
11 SPN 2 Posisi 2
12 SPN 3 Posisi 3
13 Os Nassal 1
14 Temporo Mandibula Joint 4
15 Foramen Opticum 1
16 Orbita 1
17 Maxilla/Mandibula 2
18 Sella Tursica 1
19 Mastoid 2
20 Cervical AP & Lateral 2
21 Cervical AP & Lateral & Obliq 4
22 Cervicothoracal AP & Lateral 2
23 Thoracal AP & Lateral 2
24 Thoracal AP & Lateral & Obliq 4
25 Thoracolumbal AP & Lateral 2
26 Thoracolumbal AP & Lateral & Obliq 4
27 Thoracolumbal Flexi & Extensi 2
28 Lumbosacral AP & Lateral 2
29 Lumbosacral AP & Lateral & Obliq 4
30 Lumbosacral Flexi & Extensi 2
31 Lumbosacral Bending Kiri Kanan 2
32 Coccygeus AP/Lateral 1
33 Coccygeus AP & Lateral 2
34 Scoliosis Program 6
35 Shoulder AP & Lateral R/L 2
36 Shoulder AP & Lateral Bilateral 4
37 Clavicula R/L 2
38 Clavicula Bilateral 4
39 Scapula AP & Lateral R/L 2
40 Scapula AP & Lateral Bilateral 4
41 Humerus AP & Lateral R/L 2
42 Humerus AP & Lateral Bilateral 4
43 Elbow AP & Lateral R/L 2
44 Elbow AP & Lateral Bilateral 4
45 Radius Ulna AP & Lateral R/L 2
46 Radius Ulna AP & Lateral Bilateral 4
47 Wrist Joint AP & Lateral R/L 2
48 Wrist Joint AP & Lateral Bilateral 4
49 Manus AP & ObliqR/L 2
50 Manus AP & Obliq Bilateral 4
51 Digiti…..Manus AP & Lateral R/L 1
52 Digiti…..Manus AP & Lateral Bilateral 2
53 Femur AP & Lateral R/L 2
54 Femur AP & Lateral Bilateral 4
55 Genu AP & Lateral R/L 2
56 Genu AP & Lateral Bilateral 4
57 Genu AP & Lateral & Sky Line (R/L) 3
58 Genu AP & Lateral & Sky Line (Bilateral) 6
59 Genu Stress View 1
60 Cruris AP & Lateral R/L 2
61 Cruris AP & Lateral Bilateral 4
62 Ankle AP & Lateral R/L 2
63 Ankle AP & Lateral Bilateral 4
64 Ankle Mortise View (R/L) 1
65 Ankle Mortise View Bilateral 2
66 Calcaneus R/L 1
67 Calcaneus Bilateral 2
68 Pedis AP & Obliq R/L 2
69 Pedis AP & Obliq Bilateral 4
70 Digiti……Pedis AP & obliq R/L 2
71 Digiti……Pedis AP & Obliq Bilateral 4
72 Bone Age 2
73 Bone Survey I (Skull,Cerv,Thorc,Lum,Pelv) 10
74 Bone Survey II (Bone Survey I + Upper lower Extremitas)
75 Dental X-Ray 3
76 BNO-IVP 1 1 4 6 2 1 1 1 1
77 RPG 1 6 1
78 APG 1 6 1
79 Cystography 1 1 1 1 1 1 4 1 1 1 1
80 Uretrocystography 1 1 4 1 1 1 1 1
81 Retrograde Uretrography 1 1 4 1 1 1 1 1
83 Bipolar Cystography 1 1 1 1 1 4 1 1 1
86 Oesophagography 1 4 1
87 Maag Duodenum 1 4 1
88 Oesophagus Maag Duodenum 1 8 1
89 Apendikogram 1 4 1
90 Follow Through 1 1 1 1 1 5 1
91 Lopography 1 1 1 1 1 5 1
92 Colon Inloop 1 1 1 1 1 1 5 1 1 1
93 HSG 1 1 1 1 5 1 1 1 1 1 1
94 Fistulography 1 1 5 1 1
 PLESTERIN

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HAND WASH SOFTAMAN 500ML Rp 99.000
APRON PLASTIK

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HANDSCOON NON STERIL S Rp 5.500
PLESTER 1 INCH Rp 23.100

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MASKER EAR LOP Rp 47.300

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

AMPLOP EXPERTISE
AMPLOP FILM RAD SMALLL

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

AMPLOP FILM RAD MEDIUM 38X28 CM

AMPLOP FILM RAD LARGE 35X43 CM

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

FORM PERMINTAAN PEMERIKSAAN

FORM PERSETUJUAN TINDAKAN

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

KERTAS A4 70GR

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

LABEL PHOENIX
LISTRIK (VOLT/kV)
JASA RADIOLOG
TINGKAT KESULITAN
 1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
1 1 1 1 1 1 2 1
2 1 1
2 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
1 1 1 1 1 1 1 1 1 3 1
 HAND WASH SOFTAMAN 500ML Rp 99.000

PAPER USG UPP-110HG Rp. 159.500

FORM PERMINTAAN PEMERIKSAAN

HANDSCOON NON STERIL S
MASKER EAR LOP Rp 47.300

USG JELLY 5 L Rp. 316.500

NO JENIS PEMERIKSAAN

TINGKAT KESULITAN
AMPLOP EXPERTISE

LISTRIK (VOLT/kV)
KERTAS A4 70GR

JASA RADIOLOG
TISSUE TOILET
AMPLOP USG
1 USG Fast 1 1 1 1 1 1 1 1 1 3
2 USG Abdomen (Bayi) 1 1 1 1 1 1 1 1 1 3
3 USG Upper Abdomen 1 1 1 1 1 1 1 1 1 3
4 USG Lower Abdomen 1 1 1 1 1 1 1 1 1 3
5 USG Whole Abdomen 1 1 1 1 1 1 1 1 1 3
6 USG Urology 1 1 1 1 1 1 1 1 1 3
7 USG Testis/Scrotum 1 1 1 1 1 1 1 1 1 3
8 USG Breast 1 1 1 1 1 1 1 1 1 3
9 USG Thyroid 1 1 1 1 1 1 1 1 1 3
10 USG Carotis 1 1 1 1 1 1 1 1 1 3
11 USG Colli 1 1 1 1 1 1 1 1 1 3
12 USG Thorax Marker 1 1 1 1 1 1 1 1 1 3
13 USG Ginekologis 1 1 1 1 1 1 1 1 1 3
14 USG Kepala (Bayi) 1 1 1 1 1 1 1 1 1 3
15 USG Arteri/Vena Xtremitas 1 1 1 1 1 1 1 1 1 3
16 USG Arteri & Vena Xtremitas 1 1 1 1 1 1 1 1 1 3
17 USG Shoulder R/L 1 1 1 1 1 1 1 1 1 3
18 USG Shoulder Bilateral 1 1 1 1 1 1 1 1 1 3
19 USG Elbow R/L 1 1 1 1 1 1 1 1 1 3
20 USG Elbow Bilateral 1 1 1 1 1 1 1 1 1 5
21 USG Wrist Joint R/L 1 1 1 1 1 1 1 1 1 3
22 USG Wrist Joint Bilateral 1 1 1 1 1 1 1 1 1 3
23 USG Genu R/L 1 1 1 1 1 1 1 1 1 3
24 USG Genu Bilateral 1 1 1 1 1 1 1 1 1 3
25 USG Ankle R/L 1 1 1 1 1 1 1 1 1 3
26 USG Ankle Bilateral 1 1 1 1 1 1 1 1 1 3
27 USG Doppler Extremitas 1 1 1 1 1 1 1 1 1 3
28 USG Doppler Hepar 1 1 1 1 1 1 1 1 1 3
29 USG Doppler Ginjal 1 1 1 1 1 1 1 1 1 3
30 USG Musculosceletal Tumor 1 1 1 1 1 1 1 1 1 3
31 USG Tanpa Print 1 1 1 1 1 1 1 1