TARIF PELAYANAN / TINDAKAN KELAS III

RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014

BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
1 2 3 4 5
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
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
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
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

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
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
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
1 ACA IgG 393,375 131,125 524,500
2 ACA IgM 393,375 131,125 524,500
3 Anti Amuba 164,625 54,875 219,500
4 Anti Chikungunya 219,750 73,250 293,000
5 Anti CMV IgG 68,625 22,875 91,500
6 Anti CMV IgM 68,625 22,875 91,500
7 Anti HAV IgM 115,500 38,500 154,000
8 HAV Total 148,500 49,500 198,000
9 Anti HBc IgM 87,375 29,125 116,500
10 HBc Total 61,875 20,625 82,500
11 Anti Hbe 165,000 55,000 220,000
12 Anti HBs 74,250 24,750 99,000
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

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
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
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
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
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

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
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
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
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
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 :

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
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
T. IMMUNOPHENOTYPING FLOWCYTOMETRI
1 CD 4 100,875 33,625 134,500
2 CD 8 100,875 33,625 134,500