EKSEKUTIVE

LABORATORIUM PATOLOGI KLINIS

NO JENIS TINDAKAN SATUAN TARIF(RP)
Hematologi
1 Darah Rutin TINDAKAN 119,000
2 LED TINDAKAN 40,000
3 Darah Lengkap TINDAKAN 159,000
4 Pemeriksaan Malaria (DDR) TINDAKAN 117,000
5 Morfologi Apus Darah Tepi TINDAKAN 141,000
6 IT Ratio TINDAKAN 71,000
7 Waktu perdarahan TINDAKAN 45,000
8 Waktu pembekuan TINDAKAN 45,000
9 Masa Protrombin / Prothombin Time (PT) TINDAKAN 156,000
10 Masa Tromboplastin Partial Teraktivasi (APTT) TINDAKAN 141,000
11 Fibrinogen TINDAKAN 228,000
12 D Dimer TINDAKAN 426,000
13 Agregasi Trombosit TINDAKAN 426,000
14 Paket Hemostasis (PT, aPTT, INR) TINDAKAN 566,000
15 Besi Serum TINDAKAN 93,000
16 Ferritin TINDAKAN 384,000
17 Total iron binding capacity (TIBC) TINDAKAN 171,000
18 Elektroforesis Hb TINDAKAN 498,000
19 Transferrin TINDAKAN 282,000
20 Morfologi sumsum tulang TINDAKAN 711,000
21 Sel LE TINDAKAN 84,000

Kimia Klinik

1 Albumin TINDAKAN 66,000

2 Alkali fosfatase TINDAKAN 57,000
3 Amilase TINDAKAN 84,000
4 Asam urat TINDAKAN 71,000
5 Asam empedu TINDAKAN 77,000
6 Biliirubin Total TINDAKAN 72,000
7 Bilirubin Direk TINDAKAN 72,000
8 Bilirubin Indirek TINDAKAN 48,000
9 Cholinasterase TINDAKAN 69,000
10 Creatinin TINDAKAN 66,000
11 Creatinin Clearance TINDAKAN 99,000
12 Cholesterol Total TINDAKAN 64,000
13 Cholesterol HDL TINDAKAN 123,000
14 Cholesterol LDL TINDAKAN 120,000
15 CK (Creatine Kinase) TINDAKAN 213,000
16 CK – MB TINDAKAN 213,000
17 Elektroforesis protein TINDAKAN 308,000
18 Elektrolit Paket (Na, K, Cl) TINDAKAN 390,000
19 Glutamat dehidrogenase (GLDH) TINDAKAN 77,000
20 Glukosa Darah (Rapid) TINDAKAN 45,000
21 Glukosa Darah Sewaktu (GDS) TINDAKAN 45,000
22 Glukosa Darah Puasa (GDP) TINDAKAN 45,000
23 Glukosa Darah PP TINDAKAN 45,000
24 Gamma GT TINDAKAN 99,000
25 Globulin TINDAKAN 57,000
26 Glikolysis Hb / HbA1c (A1c) TINDAKAN 243,000
27 Glukosa Toleransi Test TINDAKAN 141,000
28 HBDH (Alpha-hydroxybutirate dehidrogenase) TINDAKAN 84,000
29 Kalsium Darah TINDAKAN 48,000
30 Lipase Darah TINDAKAN 141,000
31 Magnesium TINDAKAN 99,000
32 Myoglobin TINDAKAN 308,000
33 Phosphat Darah TINDAKAN 71,000
34 Protein Total TINDAKAN 70,000
35 SGOT TINDAKAN 60,000
36 SGPT TINDAKAN 60,000
37 Trigleserida TINDAKAN 70,000
38 Troponin I TINDAKAN 470,000
39 Troponin T TINDAKAN 470,000
40 Ureum TINDAKAN 66,000
41 Analisa gas darah TINDAKAN 399,000

Cairan Tubuh dan Urinalisa

1 Urine rutin TINDAKAN 70,000

2 Urine sedimen TINDAKAN 57,000
3 Faeces rutin TINDAKAN 96,000
4 Faeces Lengkap (Feses rutin + Darah Samar) TINDAKAN 141,000
5 Analisa Batu TINDAKAN 213,000
6 Analisa Cairan Otak TINDAKAN 716,000
7 Analisa Cairan Pleura / Cairan Asites TINDAKAN 806,000
8 Analisa Cairan Sendi TINDAKAN 357,000

Imuno-Serologi

1 Anti CMV Ig G TINDAKAN 185,000

2 Anti CMV Ig M TINDAKAN 185,000
3 Anti HAV Ig M TINDAKAN 363,000
4 Anti HAV Total TINDAKAN 426,000
5 Anti HBc Ig M TINDAKAN 242,000
6 Anti HBc Total TINDAKAN 185,000
7 Anti HBs TINDAKAN 255,000
8 Anti HCV TINDAKAN 356,000
9 Anti Helicobacter Pylori Ig G TINDAKAN 185,000
10 Anti Helicobacter Pylori Ig M TINDAKAN 185,000
11 Anti Leptospira TINDAKAN 426,000
12 Anti Malaria TINDAKAN 350,000
13 Anti Rubella Ig G TINDAKAN 285,000
14 Anti Rubella Ig M TINDAKAN 426,000
15 Anti TB TINDAKAN 426,000
16 Anti Toxoplasma Ig G TINDAKAN 426,000
17 Anti Toxoplasma Ig M TINDAKAN 426,000
18 Anti Streptolysin Titer O (ASTO) TINDAKAN 141,000
19 C - reactif Protein (CRP) TINDAKAN 185,000
20 Dengue Blot Ig G TINDAKAN 426,000
21 Dengue Blot Ig M TINDAKAN 426,000
22 Factor Rematoid TINDAKAN 141,000
23 HIV Rapid TINDAKAN 228,000
24 HBs Ag TINDAKAN 210,000
25 Treponema Palidum H Antigen (TPHA) TINDAKAN 99,000
26 Veneral Diseases Reserch Laboratory (VDRL) TINDAKAN 99,000
27 Widal TINDAKAN 141,000
28 Test Kehamilan TINDAKAN 71,000
29 Complement 3 (C3) TINDAKAN 168,000
30 Complement 4 (C4) TINDAKAN 168,000
31 Anti HBe TINDAKAN 570,000
32 Anti HIV TINDAKAN 528,000
33 CD 4 TINDAKAN 909,000
34 CMV Ig G Avidity TINDAKAN 570,000
35 Hbe Ag TINDAKAN 570,000
36 Ig M Salmonella Typhii TINDAKAN 570,000
37 NS1 Ag Dengue TINDAKAN 570,000
38 Paket TORCH TINDAKAN 4403,000
39 Estrogen TINDAKAN 225,000
40 FT3 (Free T3) TINDAKAN 413,000
41 FT4 (Free T4) TINDAKAN 285,000
42 FSH TINDAKAN 456,000
43 LH TINDAKAN 456,000
44 Prolactin TINDAKAN 456,000
45 T3 TINDAKAN 198,000
46 T4 TINDAKAN 198,000
47 Tiroid Stimulating Hormon (TSH) TINDAKAN 255,000
48 ANA Test TINDAKAN 456,000
49 Anti ds DNA TINDAKAN 597,000
50 AFP TINDAKAN 299,000
51 CA 12-5 TINDAKAN 612,000
52 CA 15-3 TINDAKAN 612,000
53 CA 19-9 TINDAKAN 612,000
54 CEA TINDAKAN 356,000
55 PSA (Prostat spesific antigen) TINDAKAN 498,000
56 NSA (Neuron spesific antigen) TINDAKAN 711,000
Paket Tes Narkoba (AMP + Benzo + TCH + Cocain +
57 TINDAKAN
Morphin) 500,000
Mikrobiologi

1 Pemeriksaan Gen Xpert TINDAKAN 456,000

2 Mikroskopis BTA TINDAKAN 171,000
3 Biakan Jamur TINDAKAN 138,000
4 Biakan dengan Resistensi TB (Medium Padat. OAT lini 1 -2) TINDAKAN 995,000
Biakan dengan Resistensi TB (Medium Padat. OAT lini 1 -
5 TINDAKAN
SIRE) 570,000
6 Biakan Mikroorganisme Medium Cair dgn resistensi TINDAKAN 711,000
7 Biakan mikroorganisme Medium Padat dgn Resistensi TINDAKAN 570,000
8 Biakan Salmonela Shigela (Biakan SS) TINDAKAN 203,000
9 BTA 1 x. Biakan Resistensi Medium Cair. OAT lini 1 TINDAKAN 995,000
10 BTA 1 x. Biakan Resistensi Medium Cair. OAT lini 2 TINDAKAN 1140,000
11 BTA 3 x. Biakan Medium Cair TINDAKAN 855,000
12 BTA 3 x. Biakan Medium Padat TINDAKAN 429,000
13 Resisten OAT Lini 1 (SIRE) TINDAKAN 429,000
14 Resisten OAT Lini 2 (Kana. Oflox) TINDAKAN 428,000
15 Sedian Langsung Perwarnaan Gram TINDAKAN 90,000
16 Sedian Langsung Perwarnaan BTA TINDAKAN 87,000

NO JENIS LAYANAN SATUAN TARIF (RP)

Tindakan Sederhana

1 Foto Abdomen 3 posisi TINDAKAN 684,000

2 Foto Abdomen 2 posisi TINDAKAN 456,000
3 Foto Polos /BNO TINDAKAN 228,000
4 Foto Antebrachi AP /Lat TINDAKAN 456,000
5 Foto Angkle Joint AP / Lat TINDAKAN 456,000
6 Foto Artic Cubiti AP / Lat TINDAKAN 456,000
7 Foto Basis Cranii TINDAKAN 228,000
8 Foto Babygram / Atresiani / Invertogram TINDAKAN 228,000
9 Foto Clavicula AP TINDAKAN 228,000
10 Foto Coxae / Pelvis AP TINDAKAN 228,000
11 Foto Cruris AP / Lat TINDAKAN 456,000
12 Foto Digiti Manus TINDAKAN 456,000
13 Foto Genu AP / Lat TINDAKAN 456,000
14 Foto Humerus AP / Lat TINDAKAN 456,000
15 Foto SPN TINDAKAN 684,000
16 Foto Kepala AP / Lat TINDAKAN 456,000
17 Foto Manus AP / Lat TINDAKAN 456,000
18 Foto Mandibula AP / Lat TINDAKAN 456,000
19 Foto Orbita TINDAKAN 456,000
20 Foto Os Nasal TINDAKAN 228,000
21 Foto Pedis AP/Lat TINDAKAN 456,000
22 Foto Scoliosis program TINDAKAN 365,000
23 Foto shoulder joint AP/Lat TINDAKAN 456,000
24 Foto Thorax PA TINDAKAN 228,000
25 Foto Thorax PA dan lat TINDAKAN 456,000
26 Foto Vert. Cervical AP/Lat TINDAKAN 456,000
27 Foto Vert. Cervikal AP/Lat/Oblik TINDAKAN 684,000
28 Foto vert. Thoracolumbal AP/Lat TINDAKAN 456,000
29 Foto Vet. Lumbosakral AP/Lat TINDAKAN 456,000
30 Foto Femur AP/Lat TINDAKAN 456,000
31 Mastoid TINDAKAN 456,000
32 Wrist Joint TINDAKAN 456,000
33 TMJ TINDAKAN 911,000
34 Top Lordotik TINDAKAN 228,000
TINDAKAN CANGGIH

1 Bone suvey TINDAKAN 957,000

2 BNO + IVP TINDAKAN 1139,000
3 Colon In Loop TINDAKAN 911,000
4 Fistulografi TINDAKAN 684,000
5 Hysterosalphingografi (HSG) TINDAKAN 839,000
6 OMB TINDAKAN 911,000
7 Oesophagografi TINDAKAN 911,000
8 Uretrografi TINDAKAN 911,000
9 Uretrocystografi TINDAKAN 911,000
10 USG Kepala TINDAKAN 684,000
11 USG Colli TINDAKAN 684,000
12 USG Abdomen TINDAKAN 684,000
13 USG Dopler Abdomen TINDAKAN 759,000
14 USG Obstetri TINDAKAN 445,000
15 USG Ginekologi TINDAKAN 445,000
16 USG Transvaginal TINDAKAN 445,000
17 USG Organ TINDAKAN 395,000
18 USG Thoraks TINDAKAN 395,000
19 USG Thyroid TINDAKAN 684,000
20 USG Testis TINDAKAN 684,000
21 USG Mammae TINDAKAN 684,000
22 USG Musculoskeletal lain TINDAKAN 684,000
23 USG Musculoskeletal lain Bilateral TINDAKAN 759,000
24 USG Cimino TINDAKAN 790,000
25 USG Colour Doppler TINDAKAN 911,000
26 Mammografi TINDAKAN 1215,000
27 Fluoroscopy / Spot Fluoroscopy TINDAKAN 911,000
28 Foto Panoramic TINDAKAN 453,000
29 Phlebografi dengan pesawat Fluoscopy TINDAKAN 2171,000
30 USG Doppler carotis kanan TINDAKAN 990,000
31 USG Doppler carotis kiri TINDAKAN 990,000
32 USG Doppler 1 ekstremitas TINDAKAN 990,000
33 USG Doppler 2 ekstremitas TINDAKAN 1980,000
34 USG orbita TINDAKAN 858,000
35 USG ginjal dan buli2 TINDAKAN 429,000
36 USG soft tissue TINDAKAN 743,000
37 USG FAST TINDAKAN 429,000
CT Scan tanpa Kontras
1 Dual CT Scan Skull

2 Dual CT Scan Sinus TINDAKAN 1,701,000

3 Dual CT Scan Mastoid TINDAKAN 1,701,000
4 Dual CT Scan Thorax TINDAKAN 1,402,000
5 Dual CT Scan Extremitas TINDAKAN 1,701,000
6 Dual CT Scan Abdomen TINDAKAN 1,913,000
7 Dual CT Scan Cervikal TINDAKAN 1,913,000
8 Dual CT Scan Thoracal Lumbal TINDAKAN 1,913,000
9 Dual CT Scan Lumbal TINDAKAN 1,913,000
10 Dual CT Scan Pelvis TINDAKAN 1,913,000
SMCT Scan Dengan kontras

1 Dual CT Scan Skull TINDAKAN 2,733,000

2 Dual CT Scan Sinus TINDAKAN 2,733,000
3 Dual CT Scan thorax TINDAKAN 2,961,000
4 Dual CT Scan Extremitas TINDAKAN
2,733,000
5 Dual CT Scan Abdomen TINDAKAN 3,720,000

6 Dual CT Scan Cervikal TINDAKAN

3,454,000
7 Dual CT Scan Thoracal Lumbal TINDAKAN 3,454,000
8 Dual CT Scan Lumbal TINDAKAN 3,188,000
9 Dual CT Scan Pelvis TINDAKAN 3,188,000
MSCT tanpa Kontras

1 MSCT Scan Skull TINDAKAN 3,553,000

2 MSCT Scan Sinus TINDAKAN 3,553,000
3 MSCT Scan thorax TINDAKAN 3,553,000
4 MSCT Scan Extremitas TINDAKAN 3,553,000
5 MSCT Scan Abdomen TINDAKAN 3,553,000
6 MSCT Scan Cervikal TINDAKAN 3,947,000
7 MSCT Scan Mastoid TINDAKAN 3,947,000
8 MSCT Scan Thoracal Lumbal TINDAKAN 3,947,000
9 MSCT Scan Lumbal TINDAKAN 3,947,000
10 MSCT Scan Pelvis TINDAKAN 3,947,000

MSCT dengan Kontras

1 MSCT Scan Skull TINDAKAN 3,947,000

2 MSCT Scan Sinus TINDAKAN 3,553,000
3 MSCT Scan thorax TINDAKAN 3,553,000
4 MSCT Scan Extremitas TINDAKAN 3,553,000
5 MSCT Scan Abdomen TINDAKAN 6,325,000
6 MSCT Scan Cervikal TINDAKAN 3,947,000
7 MSCT Scan Thoracal Lumbal TINDAKAN 3,947,000
8 MSCT Scan Lumbal TINDAKAN 3,947,000
9 MSCT Scan Pelvis TINDAKAN 3,947,000
10 MSCT Scan Urografi TINDAKAN 3,947,000
11 MSCT Scan Cardiac TINDAKAN 6,325,000
12 MSCT Scan Angiografi TINDAKAN 6,325,000