RUMAH SAKIT MEDINA

0262-2448808 / 08560255592

DATA TARIF RADIOLOGI

J000040 SCHEIDELL AP 0 0 0 0 52,000 0 78,000 130,000

J000041 SCHEIDELL LAT 0 0 0 0 52,000 0 78,000 130,000
J000042 SCHEIDELL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000043 BASIS CRANIUM 0 0 0 0 52,000 0 78,000 130,000
J000044 MANDIBULA EISLER DX 0 0 0 0 52,000 0 78,000 130,000
J000045 MANDIBULA EISLER SIN 0 0 0 0 52,000 0 78,000 130,000
J000046 MANDIBULA EISLER DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000047 ORBITA 0 0 0 0 52,000 0 78,000 130,000
J000048 TMJ DX/SIN 0 0 0 0 104,000 0 156,000 260,000
J000049 TMJ DX dan SIN 0 0 0 0 160,000 0 240,000 400,000
J000050 MAXILLA AP 0 0 0 0 52,000 0 78,000 130,000
J000051 MAXILLA LAT 0 0 0 0 52,000 0 78,000 130,000
J000052 MAXILLA AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000053 WATERS / SINUS PARANASAL 0 0 0 0 52,000 0 78,000 130,000
J000054 SINUS PARANASAL CALDWELL 0 0 0 0 52,000 0 78,000 130,000
J000055 SINUS PARANASAL WATERS CALDWELL 0 0 0 0 104,000 0 156,000 260,000
J000056 MASTOID STENVER dan SCHULLER (DX/SIN) 0 0 0 0 104,000 0 156,000 260,000
J000057 MASTOID STENVER dan SCHULLER (DX/SIN) 0 0 0 0 160,000 0 240,000 400,000
J000058 SOFT TISSUE NASAL AP 0 0 0 0 52,000 0 78,000 130,000
J000059 SOFT TISSUE NASAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000060 SOFT TISSUE NASAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000061 SOFT TISSUE LEHER AP 0 0 0 0 52,000 0 78,000 130,000
J000062 SOFT TISSUE LEHER LAT 0 0 0 0 52,000 0 78,000 130,000
J000063 SOFT TISSUE LEHER AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000064 THORAX AP 0 0 0 0 52,000 0 78,000 130,000
J000065 THORAX LAT 0 0 0 0 52,000 0 78,000 130,000
J000066 THORAX OBLIQUE 0 0 0 0 52,000 0 78,000 130,000
J000067 THORAX AP/PA dan LATERAL dan OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000068 ABDOMEN POLOS 0 0 0 0 52,000 0 78,000 130,000
J000069 ABDOMEN TEGAK / SETENGAH DUDUK 0 0 0 0 52,000 0 78,000 130,000
J000070 ABDOMEN 2 POSISI 0 0 0 0 104,000 0 156,000 260,000
J000071 ABDOMEN 3 POSISI 0 0 0 0 160,000 0 240,000 400,000
J000072 PELVIS AP 0 0 0 0 52,000 0 78,000 130,000
J000073 PELVIS LATERAL 0 0 0 0 52,000 0 78,000 130,000
J000074 PELVIS OBLIQUE 0 0 0 0 52,000 0 78,000 130,000
J000075 PELVIS AP / LATERAL 0 0 0 0 104,000 0 156,000 260,000
J000076 VERTEBRA CERVICAL AP 0 0 0 0 52,000 0 78,000 130,000
J000077 VERTEBRA CERVICAL LAT 0 0 0 0 52,000 0 78,000 130,000

5/25/21, 9:33 AM Page 1 of 5

J000078 VERTEBRA CERVICAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000079 VERTEBRA CERVICAL AP dan LATERAL dan OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000080 VERTEBRA CERVICAL AP dan LATERAL (Hyper dan Hypo 0 0 0 0 160,000 0 240,000 400,000
J000081 Fleksi)
VERTEBRA CERVICOTHORACAL AP 0 0 0 0 52,000 0 78,000 130,000
J000082 VERTEBRA CERVICOTHORACAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000083 VERTEBRA CERVICOTHORACAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000084 VERTEBRA CERVICOTHORACALIS AP dan LATERAL dan 0 0 0 0 160,000 0 240,000 400,000
OBLIQUE
J000085 VERTEBRA THORACAL AP 0 0 0 0 52,000 0 78,000 130,000
J000086 VERTEBRA THORACAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000087 VERTEBRA THORACAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000088 VERTEBRA THORACAL AP LAT OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000089 VERTEBRA THORACOLUMBAL AP 0 0 0 0 52,000 0 78,000 130,000
J000090 VERTEBRA THORACOLUMBAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000091 VERTEBRA THORACOLUMBAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000092 VERTEBRA THORACOLUMBAL AP LAT OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000093 VERTEBRA THORACOLUMBAL AP LAT (Hyper dan Hypo 0 0 0 0 160,000 0 240,000 400,000
J000094 Fleksi)
VERTEBRA LUMBAL AP 0 0 0 0 52,000 0 78,000 130,000
J000095 VERTEBRA LUMBAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000096 VERTEBRA LUMBAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000097 VERTEBRA LUMBAL AP LAT OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000098 VERTEBRA LUMBOSACRAL AP 0 0 0 0 52,000 0 78,000 130,000
J000099 VERTEBRA LUMBOSACRAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000100 VERTEBRA LUMBOSACRAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000101 VERTEBRA LUMBOSACRAL AP LAT OBLIQUE 0 0 0 0 160,000 0 240,000 400,000
J000102 VERTEBRA LUMBOSACRAL AP dan LAT (Hyper dan Hypo 0 0 0 0 160,000 0 240,000 400,000
J000103 Flexsi)
VERTEBRA SACRAL AP 0 0 0 0 52,000 0 78,000 130,000
J000104 VERTEBRA SACRAL LAT 0 0 0 0 52,000 0 78,000 130,000
J000105 VERTEBRA SACRAL AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000106 VERTEBRA THORACOLUMBAL AP (BENDING DX dan SIN) 0 0 0 0 104,000 0 156,000 260,000
J000107 VERTEBRA SACROCOCYCXGEUS AP 0 0 0 0 52,000 0 78,000 130,000
J000108 VERTEBRA SACROCOCYCXGEUS LAT 0 0 0 0 52,000 0 78,000 130,000
J000109 VERTEBRA SACROCOCYCXGEUS AP LAT 0 0 0 0 104,000 0 156,000 260,000
J000110 COXCAE AP dan LAT 0 0 0 0 104,000 0 156,000 260,000
J000111 COXCAE AP 0 0 0 0 52,000 0 78,000 130,000
J000112 COXCAE LAT 0 0 0 0 52,000 0 78,000 130,000
J000113 CLAVICULA DX 0 0 0 0 52,000 0 78,000 130,000
J000114 CLAVICULA SIN 0 0 0 0 52,000 0 78,000 130,000
J000115 CLAVICULA DX/SIN 0 0 0 0 104,000 0 156,000 260,000
J000116 SCAPULA LATERAL VIEW DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000117 SCAPULA Y VIEW DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000118 SCAPULA DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000119 SCAPULA AP 0 0 0 0 52,000 0 78,000 130,000
J000120 STERNUM 0 0 0 0 52,000 0 78,000 130,000
J000121 HUMERUS DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000122 HUMERUS DX dan SIN 0 0 0 0 104,000 0 156,000 260,000

5/25/21, 9:33 AM Page 2 of 5

J000123 ELBOW JOINT DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000124 ELBOW JOINT DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000125 ANTEBRACHI DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000126 ANTEBRACHI DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000127 WRIST JOINT DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000128 WRIST JOINT DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000129 MANUS DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000130 MANUS DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000131 HIP JOINT 0 0 0 0 52,000 0 78,000 130,000
J000132 FEMUR DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000133 FEMUR DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000134 SENDI BAHU AP 0 0 0 0 52,000 0 78,000 130,000
J000135 SENDI BAHU DX/SIN (Ekso dan Endorotasi) 0 0 0 0 104,000 0 156,000 260,000
J000136 SENDI BAHU DX dan SIN AP 0 0 0 0 104,000 0 156,000 260,000
J000137 SENDI BAHU DX dan SIN (Ekso dan Endorotasi) 0 0 0 0 160,000 0 240,000 400,000
J000138 BABY GRAM 0 0 0 0 52,000 0 78,000 130,000
J000139 CRURIS DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000140 CRURIS DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000141 ANKLE JOINT DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000142 ANKLE JOINT DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000143 PEDIS DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000144 PEDIS DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000145 CALCANEUS DX/SIN 0 0 0 0 52,000 0 78,000 130,000
J000146 CALCANEUS DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000147 GENU DX dan SIN 0 0 0 0 104,000 0 156,000 260,000
J000148 GENU SKY LINE DX/SIN 0 0 0 0 104,000 0 156,000 260,000
J000149 BOF SONDE 0 0 0 0 104,000 0 156,000 260,000
J000150 WONGENSTAIN/PRONE CROSS TABLE 0 0 0 0 160,000 0 240,000 400,000
J000151 BNO IVP 0 0 0 0 340,000 0 510,000 850,000
J000152 OMD/MDG 0 0 0 0 340,000 0 510,000 850,000
J000153 APPEDICORAFI 0 0 0 0 340,000 0 510,000 850,000
J000154 COLON IN LOOP 0 0 0 0 340,000 0 510,000 850,000
J000155 URETROCYSTOGRAPI 0 0 0 0 340,000 0 510,000 850,000
J000156 OESOPHAGOGRAFI 0 0 0 0 340,000 0 510,000 850,000
J000157 MAAG DUODENOGRAFI 0 0 0 0 340,000 0 510,000 850,000
J000158 HSG 0 0 0 0 340,000 0 510,000 850,000
J000159 FISTULOGRAFI 0 0 0 0 340,000 0 510,000 850,000
J000160 SIALOGRAFI 0 0 0 0 340,000 0 510,000 850,000
J000161 URETROGRAFI 0 0 0 0 340,000 0 510,000 850,000
J000162 USG UPPER ABDOMEN 0 0 0 0 60,000 0 90,000 150,000
J000163 USG LOWER ABDOMEN 0 0 0 0 60,000 0 90,000 150,000
J000164 USG WHOLE ABDOMEN 0 0 0 0 100,000 0 200,000 300,000
J000165 USG KEPALA 0 0 0 0 100,000 0 200,000 300,000
J000166 USG THORAX 0 0 0 0 100,000 0 150,000 250,000
J000167 USG THORAX GAIDING 0 0 0 0 160,000 0 240,000 400,000
J000168 USG PROSTAT 0 0 0 0 100,000 0 150,000 250,000

5/25/21, 9:33 AM Page 3 of 5

J000169 USG DROPPLER COLLOR UPPER ABDOMEN 0 0 0 0 160,000 0 240,000 400,000
J000170 USG DROPPLER COLLOR LOWER ABDOMEN 0 0 0 0 160,000 0 240,000 400,000
J000171 USG DROPPLER COLLOR WHOLE ABDOMEN 0 0 0 0 160,000 0 240,000 400,000
J000172 USG DROPPLER THYROID 0 0 0 0 160,000 0 240,000 400,000
J000173 USG DROPPLER COLLOR GINJAL 0 0 0 0 160,000 0 240,000 400,000
J000174 USG DROPPLER COLLOR PROSTAT 0 0 0 0 160,000 0 240,000 400,000
J000175 USG DROPPLER TESTIS 0 0 0 0 160,000 0 240,000 400,000
J000176 FOTO DENTAL 0 0 0 0 16,000 0 24,000 40,000
J000177 FOTO DENTAL PANORAMIC 0 0 0 0 60,000 0 90,000 150,000
J000178 FOTO CEPHALOMETRI 0 0 0 0 80,000 0 120,000 200,000
J000179 BIOPSI/ ASPIRASI GUIDED CT 0 0 0 0 400,000 0 600,000 1,000,000
J000180 CT SCAN KEPALA TANPA KONTRAS 0 0 0 0 400,000 0 600,000 1,000,000
J000182 CT SCAN KEPALA DENGAN KONTRAS 0 0 0 0 680,000 0 1,020,000 1,700,000
J000183 CT SCAN LEHER 0 0 0 0 400,000 0 600,000 1,000,000
J000184 CT SCAN LEHER DENGAN KONTRAS 0 0 0 0 800,000 0 1,200,000 2,000,000
J000185 CT SCAN ORBITA/MASTOID 0 0 0 0 400,000 0 600,000 1,000,000
J000186 CT MAXILA/MANDIBULA 0 0 0 0 400,000 0 600,000 1,000,000
J000187 CT MAXILA/MANDIBULA DENGAN KOMTRAS 0 0 0 0 800,000 0 1,200,000 2,000,000
J000188 CT SINUS PARANASALIS 0 0 0 0 400,000 0 600,000 1,000,000
J000189 CT SINUS PARANASALIS DENGAN KONTRAS 0 0 0 0 800,000 0 1,200,000 2,000,000
J000190 CT EKTREMITAS PEDIS 0 0 0 0 400,000 0 600,000 1,000,000
J000191 CT EKTREMITAS PEDIS DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000192 CT EKTREMITAS MANUS 0 0 0 0 400,000 0 600,000 1,000,000
J000193 CT EKTREMITAS MANUS DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000194 CT EKTREMITAS ANTEBRACHI 0 0 0 0 500,000 0 750,000 1,250,000
J000195 CT EKTREMITAS ANTEBRACHI DENGAN KONTAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000196 CT SCAN ORBITA/MASTOID DENGAN KONTRAS 0 0 0 0 800,000 0 1,200,000 2,000,000
J000197 CT EKSRENITAS BRACHI 0 0 0 0 500,000 0 750,000 1,250,000
J000198 CT EKREMITAS BRACHI DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000199 CT EXTREMITAS FEMUR 0 0 0 0 500,000 0 750,000 1,250,000
J000200 CT EXTREMITAS FEMUR DENGAN KONTRAS 0 0 0 0 980,000 0 1,470,000 2,450,000
J000201 CT EKREMITAS CRURIS 0 0 0 0 500,000 0 750,000 1,250,000
J000202 CT EKREMITAS CRURIS DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000203 CT WHOLE ABDOMEN 0 0 0 0 600,000 0 900,000 1,500,000
J000204 CT WHOLE ABDOMEN DENGAN KONTRAS 0 0 0 0 1,400,000 0 2,100,000 3,500,000
J000205 CT NASOPHARING DAN LEHER 0 0 0 0 600,000 0 900,000 1,500,000
J000206 CT NASOPHARING DAN LEHER DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000207 CT PARU 0 0 0 0 600,000 0 900,000 1,500,000
J000208 CT PARU DENGAN KONTRAS 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000209 CT PANORAMIK/DENTAL 0 0 0 0 600,000 0 900,000 1,500,000
J000210 CT VERTEBRA CERVICALIS 0 0 0 0 600,000 0 900,000 1,500,000
J000211 CT VERTEBRA CERVICALIS DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000212 CT VERTEBRA THORACALIS 0 0 0 0 600,000 0 900,000 1,500,000
J000213 CT VERTEBRA THORACALIS DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000214 CT LUMBAL 0 0 0 0 600,000 0 900,000 1,500,000
J000215 CT LUMBAL DENGAN KOLNTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000

5/25/21, 9:33 AM Page 4 of 5

J000216 CT CA SCORING 0 0 0 0 400,000 0 600,000 1,000,000
J000217 CT HRCT PARU 0 0 0 0 600,000 0 900,000 1,500,000
J000218 CT LUNG CARE 0 0 0 0 600,000 0 900,000 1,500,000
J000219 CT COLOSCOPY 0 0 0 0 600,000 0 900,000 1,500,000
J000220 CT UROGRAFI DENGAN KONTRAS 0 0 0 0 1,000,000 0 1,500,000 2,500,000
J000221 CT CARDIAC DENGAN KONTRAS 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000222 CT ANGIOGRAPHY PARU/AORTA 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000223 CT ANGIOGRAPHY ABDOMEN 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000224 CT ANGIOGRAPHY EKTREMITAS 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000225 CT ANGIOGRAPHY KEPALA DAN LEHER 0 0 0 0 1,200,000 0 1,800,000 3,000,000
J000226 VERTEBRA CERVICAL AP LATERAL OBLIQUE KIRI 0 0 0 0 220,000 0 330,000 550,000
OBLIQUE KANAN

5/25/21, 9:33 AM Page 5 of 5