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
VIII. PEMERIKSAAN RADIOLOGI (RADIO DIAGNOSTIK)
A. KECIL
1. Scheedel AP / L 58,500 31,500 90,000
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
9. TMJ (Temporo Mandibular Joint ) Kanan 65,000 35,000 100,000
10. TMJ ( Dua Sisi) Kiri dan Kanan 97,500 52,500 150,000
11. Scheedel Basis 65,000 35,000 100,000
12. Thorax Anak Ap. 52,000 28,000 80,000
13. Thorax Dewasa PA 52,000 28,000 80,000
14. Manus Kiri AP / Oblique 52,000 28,000 80,000
15. Manus Kanan AP / Oblique 52,000 28,000 80,000
16. Manus Kiri dan Kanan AP / Oblique 78,000 42,000 120,000
17. Wrist Joint Kiri AP / Lateral 52,000 28,000 80,000
18. Wrist Joint Kanan AP / Lateral 52,000 28,000 80,000
19. Wrist Joint Kiri dan Kanan AP / Lateral 78,000 42,000 120,000
20. Ante Brachii Kiri AP / Lateral 52,000 28,000 80,000
21. Ante Brachii Kanan AP / Lateral 52,000 28,000 80,000
22. Ante Brachii Kiri dan Kanan AP / Lateral 78,000 42,000 120,000
23. Elbow Joint Kiri AP / L 52,000 28,000 80,000
24. Elbow Joint Kanan AP / L 52,000 28,000 80,000
25. Humerus Kiri AP / L 52,000 28,000 80,000
26. Humerus Kanan AP / L 52,000 28,000 80,000
27. Articulatio Humerus / Shoulder Joint Kiri 52,000 28,000 80,000
28. Articulatio Humerus / Shoulder Joint Kanan 52,000 28,000 80,000
29. Clavicula Kiri 58,500 31,500 90,000
30. Clavicula Kanan 58,500 31,500 90,000
31. Scapula Kiri 58,500 31,500 90,000
32. Scapula Kanan 58,500 31,500 90,000
33. Sternum 58,500 31,500 90,000
34. Pedis Kiri AP / Oblique 58,500 31,500 90,000
35. Pedis Kanan AP / Oblique 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
50. BNO / Abdomen 58,500 31,500 90,000
B. SEDANG
1. Thorax PA / L (2 Posisi) 81,250 43,750 125,000
2. Cervical PA / L (2 Posisi) 81,250 43,750 125,000
3. Thoracal PA / L 2 Posisi 81,250 43,750 125,000
4. Lumbal PA / L (2 Posisi) 81,250 43,750 125,000
5. Sacrum PA / L (2 Posisi) 81,250 43,750 125,000
6. Coccygis PA / L (2 Posisi) 81,250 43,750 125,000
7. Pelvimetri 81,250 43,750 125,000
8. Cervical PA / L (4 Posisi) / Oblique ki-ka (4 posisi ) 162,500 87,500 250,000
9. Thoracal PA / L (4Posisi) / 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
11. Sacrum AP / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
12. Thorax PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 162,500 87,500 250,000
13. Abdomen 3 Posisi 130,000 70,000 200,000
C. KHUSUS
1. Mammografi 162,500 87,500 250,000
2. Cor Analisa 164,450 88,550 253,000
3. Panoramic 48,750 26,250 75,000
4. Chepalografi 48,750 26,250 75,000
5. Panoramic + Chepalografi 97,500 52,500 150,000
6. AnteBrachii ka/ki, Femur ka/ki, Cruris ka/ki) 354,900 191,100 546,000
7. BNO-IVP (Dengan Kontras Intravena) 260,000 140,000 400,000
8. Larynx / Oesophagus (Non Kontras) 64,350 34,650 99,000
9. Dacryografi 162,500 87,500 250,000
D. FLUOROSCOPI
1. Fluoroscopi C - Arm tanpa kontras 162,500 87,500 250,000
2. Fluoroscopi C - Arm dengan kontras 276,250 148,750 425,000
3. Apendix dengan BaSO4 162,500 87,500 250,000
4. Cholecistografi Oral dengan kontras 195,000 105,000 300,000
5. Cholangiografigrafi T. Tube dengan kontras 260,000 140,000 400,000
6. Urethrografi dengan kontras 260,000 140,000 400,000
7. MDF dengan BaSO4 227,500 122,500 350,000
8. Usus Halus / Follow Through (kontras BaSO4) 260,000 140,000 400,000
9. Usus Besar / Colon in Loop (kontras BaSO4) 260,000 140,000 400,000
10. Cystografi dengan kontras 260,000 140,000 400,000
11. Barium Oesphagus dengan kontras 227,500 122,500 350,000
12. Myelografi dengan kontras 260,000 140,000 400,000
13. Fistulografi dengan kontras 260,000 140,000 400,000
14. APG / RPG dengan kontras 276,250 148,750 425,000
15. ERCP Fluoroscopy (Tanpa Kontras) 164,450 88,550 253,000
16. ERCP Fluoroscopy (Dengan Kontras) 260,000 140,000 400,000
17. Sialografi dengan kontras 260,000 140,000 400,000
18. HSG / Histero Salphingografi (T. Kontras) 164,450 88,550 253,000
19. Discografi 1,235,000 665,000 1,900,000
20. Ductulografi 260,000 140,000 400,000
21. Fluoroskopi / Spot Fluoroskopi 121,875 65,625 187,500
22. Foto OMD (Osesophagus Maag Duodenum) 260,000 140,000 400,000
23. Lopografi 260,000 140,000 400,000
24. Phlebografi dengan pesawat fluoroskopi (1 ekst) 520,000 280,000 800,000
25. Phlebografi dengan pesawat fluoroskopi (2 ekst) 1,040,000 560,000 1,600,000
26. Sacroiliac joint injection 1,235,000 665,000 1,900,000
E. USG
1. USG Liver 104,000 56,000 160,000
2. USG Spleen 104,000 56,000 160,000
3. USG GB / Billary 104,000 56,000 160,000
4. USG Upper Abdomen 227,500 122,500 350,000
5. USG Lower Abdomen / Pelvic 162,500 87,500 250,000
6. USG Upper - Lower Abdomen 325,000 175,000 500,000
7. USG Ginjal/Tract Urinarius 175,500 94,500 270,000
8. USG Thorax 156,000 84,000 240,000
9. USG Small Organ (Breast, Thyroid, Testis) 156,000 84,000 240,000
10. USG Peripheral Vascular 156,000 84,000 240,000
11. USG Organ Superfisial 156,000 84,000 240,000
12. USG Vaskuler Access Dopler 260,000 140,000 400,000
13. Tuntunan USG pada Biopsi 156,000 84,000 240,000
14. USG Kepala Bayi 156,000 84,000 240,000
15. USG Transvaginal / Transrectal 227,500 122,500 350,000
16. Appendix 156,000 84,000 240,000
F. CT SCAN SINGLE SLICE
1. CT Scan Head / Brain 325,000 175,000 500,000
2. CT Scan Head dengan I.V Contrast 552,500 297,500 850,000
3. CT Scan Sinus Paranasal 325,000 175,000 500,000
4. CT Scan Sinus Paranasal dengan I.V Contrast 552,500 297,500 850,000
5. CT Scan Mastoid 325,000 175,000 500,000
6. CT Scan Mastoid dengan I.V Contrast 487,500 262,500 750,000
7. CT Scan Thyroid 325,000 175,000 500,000
8. CT Scan Thyroid dengan I.V Contrast 487,500 262,500 750,000
9. CT Scan Neck/Larynx 325,000 175,000 500,000
10. CT Scan Neck/Larynx dengan I.V Contrast 552,500 297,500 850,000

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
11. CT Scan Nasoparing 325,000 175,000 500,000
12. CT Scan Nasoparing dengan I.V Contrast 552,500 297,500 850,000
13. CT Scan Upper Abdomen 455,000 245,000 700,000
14. CT Scan Upper Abdomen dengan I.V Contrast 650,000 350,000 1,000,000
15. CT Scan Lower Abdomen 455,000 245,000 700,000
16. CT Scan Lower Abdomen dengan I.V Contrast 650,000 350,000 1,000,000
17. CT Scan Whole Abdomen 585,000 315,000 900,000
18. CT Scan Whole Abdomen dengan I.V Contrast 975,000 525,000 1,500,000
19. CT Scan Thorax 455,000 245,000 700,000
20. CT Scan Thorax dengan I.V Contrast 650,000 350,000 1,000,000
21. CT Extermitas 293,150 157,850 451,000
22. CT Extermitas dengan I.V Contrast 464,750 250,250 715,000
23. CT Scan Spine/Vertebra ( 3-4 corpus ) 455,000 245,000 700,000
24. CT Scan Spine/Vertebra dengan I.V Contrast 585,000 315,000 900,000
25. CT Biopsi 1,218,750 656,250 1,875,000
G. CT SCAN MULTI SLICE 64
1. MSCT Scan Head / Brain 474,500 255,500 730,000
2. MSCT Scan Head dengan I.V Contrast 780,000 420,000 1,200,000
3. MSCT Scan Orbita 520,000 280,000 800,000
4. MSCT Scan Orbita dengan I.V Contrast 1,105,000 595,000 1,700,000
5. MSCT Scan Sinus Paranasal 520,000 280,000 800,000
6. MSCT Scan Sinus Paranasal dengan I.V Contrast 1,105,000 595,000 1,700,000
7. MSCT Scan Mastoid / Temporal 520,000 280,000 800,000
8. MSCT Scan Mastoid dengan I.V Contrast 1,105,000 595,000 1,700,000
9. MSCT Scan Thyroid 520,000 280,000 800,000
10. MSCT Scan Thyroid dengan I.V Contrast 1,105,000 595,000 1,700,000
11. MSCT Scan Neck / Larynx 520,000 280,000 800,000
12. MSCT Scan Neck / Larynx dengan I.V Contrast 1,105,000 595,000 1,700,000
13. MSCT Scan Nasoparing 520,000 280,000 800,000
14. MSCT Scan Nasoparing dengan I.V Contrast 1,105,000 595,000 1,700,000
15. MSCT Scan Upper Abdomen 715,000 385,000 1,100,000
16. MSCT Scan Upper Abdomen dengan I.V Contrast 1,072,500 577,500 1,650,000
17. MSCT Scan Lower Abdomen / Pelvic 715,000 385,000 1,100,000
18. MSCT Scan Lower Abdomen dengan I.V Contrast 1,072,500 577,500 1,650,000
19. MSCT Scan Whole Abdomen 845,000 455,000 1,300,000
20. MSCT Scan Whole Abdomen dengan I.V Contrast 1,137,500 612,500 1,750,000
21. MSCT Scan Thorax 715,000 385,000 1,100,000
22. MSCT Scan Thorax dengan I.V Contrast 1,072,500 577,500 1,650,000
23. MSCT Extremitas 520,000 280,000 800,000
24. MSCT Extremitas dengan I.V Contrast 975,000 525,000 1,500,000
25. MSCT Myelografi 1,072,500 577,500 1,650,000
26. MSCT Scan Spine / Vertebra ( 3-4 corpus ) 650,000 350,000 1,000,000
27. MSCT Scan Spine / Vertebra dengan I.V Contrast 1,072,500 577,500 1,650,000
MSCT KHUSUS
28. MSCT Cardiac dengan I.V Contrast 2,080,000 1,120,000 3,200,000
29. MSCT Urologi 1,137,500 612,500 1,750,000
30. MSCT Angiografi dengan I.V Contrast 1,690,000 910,000 2,600,000
31. MSCT Virtual Colonoscopy 1,755,000 945,000 2,700,000
32. MSCT Muskuloskeletal 975,000 525,000 1,500,000
33. Guiding MSCT Biopsi 1,218,750 656,250 1,875,000
34. 3D Kontras (Bahu-Muka-Pelvic-Lumbal) 1,170,000 630,000 1,800,000
35. 3D Kontras Karotis 1,040,000 560,000 1,600,000
36. Whole Body 3 Phase (Thorax-Abdomen) dengan Kontras 1,755,000 945,000 2,700,000
37. CT Perfusion 1,040,000 560,000 1,600,000

H. PEMERIKSAAN GAMMA CAMERA / KEDOKTERAN NUKLIR

H.1. DIAGNOSTIK IN VIVO
PEMERIKSAAN KELENJAR TIROID
1. Thyroid scan dengan Tc-99m 292,500 157,500 450,000
2. Thyroid uptake & scan 325,000 175,000 500,000
3. Whole body scan dengan Nal-131 390,000 210,000 600,000
4. Whole body scan dengan MIBI 1,300,000 700,000 2,000,000
5. Paratiroid scan dengan MIBI 1,300,000 700,000 2,000,000
PEMERIKSAAN FUNGSI JANTUNG
1. First pass study 975,000 525,000 1,500,000
2. Cardioscintigraphy stress exercise 1,300,000 700,000 2,000,000
3. Cardioscintigraphy stress farmakologik 1,950,000 1,050,000 3,000,000

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 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
4. Cardioscintigraphy rest 1,300,000 700,000 2,000,000
5. Cardioscintigraphy stress exercise-rest 2,275,000 1,225,000 3,500,000
6. Cardioscintigraphy stress farmakologik-rest 2,600,000 1,400,000 4,000,000
7. Red blood pool scan dengan Tc-99m stannnous agent 975,000 525,000 1,500,000
8. Infark miokard acute scan 1,300,000 700,000 2,000,000
PEMERIKSAAN FUNGSI GINJAL DAN SALURAN KEMIH
1. Renal scan/renogram dengan Tc-99m cuplikan plasma 520,000 280,000 800,000
2. Renal scan/renogram dengan Tc-99m pemantauan eksternal 520,000 280,000 800,000
3. Renogram dengan Tc-99m pemantauan eksternal :
- Konvensional 650,000 350,000 1,000,000
- Diuresis 975,000 525,000 1,500,000
- Kaptopril 975,000 525,000 1,500,000
4. Renogram/ERPF dengan Tc-99m 650,000 350,000 1,000,000
5. Renal scan (DMSA) dengan hippuran I-131 650,000 350,000 1,000,000
6. Cystography 455,000 245,000 700,000
7. Scrotal Scan 975,000 525,000 1,500,000
PEMERIKSAAN FUNGSI TULANG
1. Bone scanning dengan Tc-99m + kit :
- Statik (1 fase) 1,040,000 560,000 1,600,000
- Dinamik (3 fase) 1,300,000 700,000 2,000,000
- SPECT 1,625,000 875,000 2,500,000
PEMERIKSAAN GASTROINTESTINAL
1. Gastric Emptying Time 1,625,000 875,000 2,500,000
2. Oesopagus motility scan 1,625,000 875,000 2,500,000
3. Oesopagus feflux scan 1,625,000 875,000 2,500,000
4. Divertikulum Meckel scan 975,000 525,000 1,500,000
5. Intestinal bleeding scan 1,950,000 1,050,000 3,000,000
PEMERIKSAAN HEPATOBILIER
1. Liver scanning dengan Tc-99m sulfur colloid 1,625,000 875,000 2,500,000
2. Hepatobiliary scan 1,625,000 875,000 2,500,000
3. Hepatogram 1,625,000 875,000 2,500,000
4. Limpa/spleen scanning dengan Tc-99m sulfur colloid 1,625,000 875,000 2,500,000
PEMERIKSAAN PARU
1. Perfusion lung scan 975,000 525,000 1,500,000
2. Ventilation lung scan Tc-99m 1,300,000 700,000 2,000,000
3. Ventilation perfusion scan (V/Q scan) 1,625,000 875,000 2,500,000
LAIN - LAIN
1. Brain scan dengan Tc-99m + kit (HMPAO) 2,600,000 1,400,000 4,000,000
2. Brain spect 2,925,000 1,575,000 4,500,000
3. Cysternogram dengan Tc-99m + kit 1,300,000 700,000 2,000,000
4. Phlebografi 975,000 525,000 1,500,000
5. Venography 1,105,000 595,000 1,700,000
6. Lymphoskintigrafi 1,300,000 700,000 2,000,000
7. Skintimammografi 2,275,000 1,225,000 3,500,000
8. Infeksi scan dengan infekton 1,300,000 700,000 2,000,000
9. Sentinel node/gamma probe detection 1,300,000 700,000 2,000,000
10. Dakriosistografi 325,000 175,000 500,000
H.2 DIAGNOSTIK IN VITRO
1. T3 RIA 97,500 52,500 150,000
2. T4 RIA 97,500 52,500 150,000
3. TSHS IRMA 113,750 61,250 175,000
4. ANTITIROGLOBULIN 260,000 140,000 400,000
5. TIROGLOBULIN 260,000 140,000 400,000
6. TERAPI :
1) Hipertiroid
- < 5 mCi 357,500 192,500 550,000
- 5-10 mCi 520,000 280,000 800,000
- 11-15 mCi 650,000 350,000 1,000,000
- 16-20 mCi 780,000 420,000 1,200,000
- 21-30 mCi 975,000 525,000 1,500,000
- 40-50 mCi 1,300,000 700,000 2,000,000
2) Ablasi karsinoma tiroid
- 80-100 mCi 2,600,000 1,400,000 4,000,000
- 100-150 mCi 3,250,000 1,750,000 5,000,000
- 150-200 mCi 3,900,000 2,100,000 6,000,000
- 200-300 mCi 4,550,000 2,450,000 7,000,000
3) Paliatif

4
 BESARAN TARIF TA. 2014
NO JENIS PELAYANAN JS JP JLH
( Rp ) ( Rp ) ( Rp )
- Samarium 2,600,000 1,400,000 4,000,000
- Rhenium 2,600,000 1,400,000 4,000,000
4) Terapi hemangioma.keloid 975,000 525,000 1,500,000
5) Permintaan tambahan film
- Copy film thyroid 32,500 17,500 50,000
- Copy film bone scanning 65,000 35,000 100,000
- Copy film renogram/renmal scan 65,000 35,000 100,000
- Copy film cardioscintigraphy 130,000 70,000 200,000
- Copy film pemeriksaan lainnya 97,500 52,500 150,000