TARIF PELAYANAN / TINDAKAN KELAS III RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014 NO
1
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp ) 3 4 5
PELAYANAN 2
VIII. PEMERIKSAAN RADIOLOGI (RADIO DIAGNOSTIK) A. KECIL 1. Scheedel AP / L 2. Sinus Paranasal 3. Mastoid Kiri 4. Mastoid Kanan 5. Mastoid Kiri dan Kanan (Duplex) 6. Mandibula (satu sisi) PA + Eisler 7. Mandibula (dua sisi) PA + Eisler Kiri + Kanan 8. TMJ (Temporo Mandibular Joint ) Kiri 9. TMJ (Temporo Mandibular Joint ) Kanan 10. TMJ ( Dua Sisi) Kiri dan Kanan 11. Scheedel Basis 12. Thorax Anak Ap. 13. Thorax Dewasa PA 14. Manus Kiri AP / Oblique 15. Manus Kanan AP / Oblique 16. Manus Kiri dan Kanan AP / Oblique 17. Wrist Joint Kiri AP / Lateral 18. Wrist Joint Kanan AP / Lateral 19. Wrist Joint Kiri dan Kanan AP / Lateral 20. Ante Brachii Kiri AP / Lateral 21. Ante Brachii Kanan AP / Lateral 22. Ante Brachii Kiri dan Kanan AP / Lateral 23. Elbow Joint Kiri AP / L 24. Elbow Joint Kanan AP / L 25. Humerus Kiri AP / L 26. Humerus Kanan AP / L 27. Articulatio Humerus / Shoulder Joint Kiri 28. Articulatio Humerus / Shoulder Joint Kanan 29. Clavicula Kiri 30. Clavicula Kanan 31. Scapula Kiri 32. Scapula Kanan 33. Sternum 34. Pedis Kiri AP / Oblique 35. Pedis Kanan AP / Oblique 36. Pedis Kiri dan Kanan AP / Oblique 37. Ankle Joint Kiri AP / Lateral 38. Ankle Joint Kanan AP / Lateral 39. Cruris Kiri AP / Lateral 40. Cruris Kanan AP / Lateral 41. Genu (Sendi Lutut) Kiri AP / Lateral 42. Genu (Sendi Lutut) Kanan AP / Lateral 43. Patella Kiri 44. Patella Kanan 45. Femur Kiri AP/Lateral 46. Femur Kanan AP/Lateral 47. Articulatio Coxae / Hip Joint Kiri 48. Articulatio Coxae / Hip Joint Kanan 49. Pelvis 50. BNO / Abdomen B. SEDANG 1. Thorax PA / L (2 Posisi) 2. Cervical PA / L (2 Posisi) 3. Thoracal PA / L 2 Posisi 4. Lumbal PA / L (2 Posisi) 5. Sacrum PA / L (2 Posisi) 6. Coccygis PA / L (2 Posisi) 7. Pelvimetri 8. Cervical PA / L (4 Posisi) / Oblique ki-ka (4 posisi ) 9. Thoracal PA / L (4Posisi) / Oblique ki-ka ( 4 posisi ) 10. Lumbal PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 11. Sacrum AP / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 1
58,500 58,500 58,500 58,500 97,500 65,000 97,500 65,000 65,000 97,500 65,000 52,000 52,000 52,000 52,000 78,000 52,000 52,000 78,000 52,000 52,000 78,000 52,000 52,000 52,000 52,000 52,000 52,000 58,500 58,500 58,500 58,500 58,500 58,500 58,500 78,000 52,000 52,000 65,000 65,000 65,000 65,000 65,000 65,000 65,000 65,000 52,000 52,000 58,500 58,500
31,500 31,500 31,500 31,500 52,500 35,000 52,500 35,000 35,000 52,500 35,000 28,000 28,000 28,000 28,000 42,000 28,000 28,000 42,000 28,000 28,000 42,000 28,000 28,000 28,000 28,000 28,000 28,000 31,500 31,500 31,500 31,500 31,500 31,500 31,500 42,000 28,000 28,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 28,000 28,000 31,500 31,500
90,000 90,000 90,000 90,000 150,000 100,000 150,000 100,000 100,000 150,000 100,000 80,000 80,000 80,000 80,000 120,000 80,000 80,000 120,000 80,000 80,000 120,000 80,000 80,000 80,000 80,000 80,000 80,000 90,000 90,000 90,000 90,000 90,000 90,000 90,000 120,000 80,000 80,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 80,000 80,000 90,000 90,000
81,250 81,250 81,250 81,250 81,250 81,250 81,250 162,500 162,500 162,500 162,500
43,750 43,750 43,750 43,750 43,750 43,750 43,750 87,500 87,500 87,500 87,500
125,000 125,000 125,000 125,000 125,000 125,000 125,000 250,000 250,000 250,000 250,000
JENIS
NO
C.
D.
E.
F.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
12. Thorax PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 13. Abdomen 3 Posisi KHUSUS 1. Mammografi 2. Cor Analisa 3. Panoramic 4. Chepalografi 5. Panoramic + Chepalografi 6. AnteBrachii ka/ki, Femur ka/ki, Cruris ka/ki) 7. BNO-IVP (Dengan Kontras Intravena) 8. Larynx / Oesophagus (Non Kontras) 9. Dacryografi FLUOROSCOPI 1. Fluoroscopi C - Arm tanpa kontras 2. Fluoroscopi C - Arm dengan kontras 3. Apendix dengan BaSO4 4. Cholecistografi Oral dengan kontras 5. Cholangiografigrafi T. Tube dengan kontras 6. Urethrografi dengan kontras 7. MDF dengan BaSO4 8. Usus Halus / Follow Through (kontras BaSO4) 9. Usus Besar / Colon in Loop (kontras BaSO4) 10. Cystografi dengan kontras 11. Barium Oesphagus dengan kontras 12. Myelografi dengan kontras 13. Fistulografi dengan kontras 14. APG / RPG dengan kontras 15. ERCP Fluoroscopy (Tanpa Kontras) 16. ERCP Fluoroscopy (Dengan Kontras) 17. Sialografi dengan kontras 18. HSG / Histero Salphingografi (T. Kontras) 19. Discografi 20. Ductulografi 21. Fluoroskopi / Spot Fluoroskopi 22. Foto OMD (Osesophagus Maag Duodenum) 23. Lopografi 24. Phlebografi dengan pesawat fluoroskopi (1 ekst) 25. Phlebografi dengan pesawat fluoroskopi (2 ekst) 26. Sacroiliac joint injection USG 1. USG Liver 2. USG Spleen 3. USG GB / Billary 4. USG Upper Abdomen 5. USG Lower Abdomen / Pelvic 6. USG Upper - Lower Abdomen 7. USG Ginjal/Tract Urinarius 8. USG Thorax 9. USG Small Organ (Breast, Thyroid, Testis) 10. USG Peripheral Vascular 11. USG Organ Superfisial 12. USG Vaskuler Access Dopler 13. Tuntunan USG pada Biopsi 14. USG Kepala Bayi 15. USG Transvaginal / Transrectal 16. Appendix CT SCAN SINGLE SLICE 1. CT Scan Head / Brain 2. CT Scan Head dengan I.V Contrast 3. CT Scan Sinus Paranasal 4. CT Scan Sinus Paranasal dengan I.V Contrast 5. CT Scan Mastoid 6. CT Scan Mastoid dengan I.V Contrast 7. CT Scan Thyroid 8. CT Scan Thyroid dengan I.V Contrast 9. CT Scan Neck/Larynx 10. CT Scan Neck/Larynx dengan I.V Contrast 2
162,500 130,000
87,500 70,000
250,000 200,000
162,500 164,450 48,750 48,750 97,500 354,900 260,000 64,350 162,500
87,500 88,550 26,250 26,250 52,500 191,100 140,000 34,650 87,500
250,000 253,000 75,000 75,000 150,000 546,000 400,000 99,000 250,000
162,500 276,250 162,500 195,000 260,000 260,000 227,500 260,000 260,000 260,000 227,500 260,000 260,000 276,250 164,450 260,000 260,000 164,450 1,235,000 260,000 121,875 260,000 260,000 520,000 1,040,000 1,235,000
87,500 148,750 87,500 105,000 140,000 140,000 122,500 140,000 140,000 140,000 122,500 140,000 140,000 148,750 88,550 140,000 140,000 88,550 665,000 140,000 65,625 140,000 140,000 280,000 560,000 665,000
250,000 425,000 250,000 300,000 400,000 400,000 350,000 400,000 400,000 400,000 350,000 400,000 400,000 425,000 253,000 400,000 400,000 253,000 1,900,000 400,000 187,500 400,000 400,000 800,000 1,600,000 1,900,000
104,000 104,000 104,000 227,500 162,500 325,000 175,500 156,000 156,000 156,000 156,000 260,000 156,000 156,000 227,500 156,000
56,000 56,000 56,000 122,500 87,500 175,000 94,500 84,000 84,000 84,000 84,000 140,000 84,000 84,000 122,500 84,000
160,000 160,000 160,000 350,000 250,000 500,000 270,000 240,000 240,000 240,000 240,000 400,000 240,000 240,000 350,000 240,000
325,000 552,500 325,000 552,500 325,000 487,500 325,000 487,500 325,000 552,500
175,000 297,500 175,000 297,500 175,000 262,500 175,000 262,500 175,000 297,500
500,000 850,000 500,000 850,000 500,000 750,000 500,000 750,000 500,000 850,000
JENIS
NO
G.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
11. CT Scan Nasoparing 12. CT Scan Nasoparing dengan I.V Contrast 13. CT Scan Upper Abdomen 14. CT Scan Upper Abdomen dengan I.V Contrast 15. CT Scan Lower Abdomen 16. CT Scan Lower Abdomen dengan I.V Contrast 17. CT Scan Whole Abdomen 18. CT Scan Whole Abdomen dengan I.V Contrast 19. CT Scan Thorax 20. CT Scan Thorax dengan I.V Contrast 21. CT Extermitas 22. CT Extermitas dengan I.V Contrast 23. CT Scan Spine/Vertebra ( 3-4 corpus ) 24. CT Scan Spine/Vertebra dengan I.V Contrast 25. CT Biopsi CT SCAN MULTI SLICE 64 1. MSCT Scan Head / Brain 2. MSCT Scan Head dengan I.V Contrast 3. MSCT Scan Orbita 4. MSCT Scan Orbita dengan I.V Contrast 5. MSCT Scan Sinus Paranasal 6. MSCT Scan Sinus Paranasal dengan I.V Contrast 7. MSCT Scan Mastoid / Temporal 8. MSCT Scan Mastoid dengan I.V Contrast 9. MSCT Scan Thyroid 10. MSCT Scan Thyroid dengan I.V Contrast 11. MSCT Scan Neck / Larynx 12. MSCT Scan Neck / Larynx dengan I.V Contrast 13. MSCT Scan Nasoparing 14. MSCT Scan Nasoparing dengan I.V Contrast 15. MSCT Scan Upper Abdomen 16. MSCT Scan Upper Abdomen dengan I.V Contrast 17. MSCT Scan Lower Abdomen / Pelvic 18. MSCT Scan Lower Abdomen dengan I.V Contrast 19. MSCT Scan Whole Abdomen 20. MSCT Scan Whole Abdomen dengan I.V Contrast 21. MSCT Scan Thorax 22. MSCT Scan Thorax dengan I.V Contrast 23. MSCT Extremitas 24. MSCT Extremitas dengan I.V Contrast 25. MSCT Myelografi 26. MSCT Scan Spine / Vertebra ( 3-4 corpus ) 27. MSCT Scan Spine / Vertebra dengan I.V Contrast MSCT KHUSUS 28. MSCT Cardiac dengan I.V Contrast 29. MSCT Urologi 30. MSCT Angiografi dengan I.V Contrast 31. MSCT Virtual Colonoscopy 32. MSCT Muskuloskeletal 33. Guiding MSCT Biopsi 34. 3D Kontras (Bahu-Muka-Pelvic-Lumbal) 35. 3D Kontras Karotis 36. Whole Body 3 Phase (Thorax-Abdomen) dengan Kontras 37. CT Perfusion
H. PEMERIKSAAN GAMMA CAMERA / KEDOKTERAN NUKLIR H.1. DIAGNOSTIK IN VIVO PEMERIKSAAN KELENJAR TIROID 1. Thyroid scan dengan Tc-99m 2. Thyroid uptake & scan 3. Whole body scan dengan Nal-131 4. Whole body scan dengan MIBI 5. Paratiroid scan dengan MIBI PEMERIKSAAN FUNGSI JANTUNG 1. First pass study 2. Cardioscintigraphy stress exercise 3. Cardioscintigraphy stress farmakologik 3
325,000 552,500 455,000 650,000 455,000 650,000 585,000 975,000 455,000 650,000 293,150 464,750 455,000 585,000 1,218,750
175,000 297,500 245,000 350,000 245,000 350,000 315,000 525,000 245,000 350,000 157,850 250,250 245,000 315,000 656,250
500,000 850,000 700,000 1,000,000 700,000 1,000,000 900,000 1,500,000 700,000 1,000,000 451,000 715,000 700,000 900,000 1,875,000
474,500 780,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 715,000 1,072,500 715,000 1,072,500 845,000 1,137,500 715,000 1,072,500 520,000 975,000 1,072,500 650,000 1,072,500
255,500 420,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 385,000 577,500 385,000 577,500 455,000 612,500 385,000 577,500 280,000 525,000 577,500 350,000 577,500
730,000 1,200,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 1,100,000 1,650,000 1,100,000 1,650,000 1,300,000 1,750,000 1,100,000 1,650,000 800,000 1,500,000 1,650,000 1,000,000 1,650,000
2,080,000 1,137,500 1,690,000 1,755,000 975,000 1,218,750 1,170,000 1,040,000 1,755,000 1,040,000
1,120,000 612,500 910,000 945,000 525,000 656,250 630,000 560,000 945,000 560,000
3,200,000 1,750,000 2,600,000 2,700,000 1,500,000 1,875,000 1,800,000 1,600,000 2,700,000 1,600,000
292,500 325,000 390,000 1,300,000 1,300,000
157,500 175,000 210,000 700,000 700,000
450,000 500,000 600,000 2,000,000 2,000,000
975,000 1,300,000 1,950,000
525,000 700,000 1,050,000
1,500,000 2,000,000 3,000,000
NO
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
4. Cardioscintigraphy rest 5. Cardioscintigraphy stress exercise-rest 6. Cardioscintigraphy stress farmakologik-rest 7. Red blood pool scan dengan Tc-99m stannnous agent 8. Infark miokard acute scan PEMERIKSAAN FUNGSI GINJAL DAN SALURAN KEMIH 1. Renal scan/renogram dengan Tc-99m cuplikan plasma 2. Renal scan/renogram dengan Tc-99m pemantauan eksternal 3. Renogram dengan Tc-99m pemantauan eksternal : - Konvensional - Diuresis - Kaptopril 4. Renogram/ERPF dengan Tc-99m 5. Renal scan (DMSA) dengan hippuran I-131 6. Cystography 7. Scrotal Scan PEMERIKSAAN FUNGSI TULANG 1. Bone scanning dengan Tc-99m + kit : - Statik (1 fase) - Dinamik (3 fase) - SPECT PEMERIKSAAN GASTROINTESTINAL 1. Gastric Emptying Time 2. Oesopagus motility scan 3. Oesopagus feflux scan 4. Divertikulum Meckel scan 5. Intestinal bleeding scan PEMERIKSAAN HEPATOBILIER 1. Liver scanning dengan Tc-99m sulfur colloid 2. Hepatobiliary scan 3. Hepatogram 4. Limpa/spleen scanning dengan Tc-99m sulfur colloid PEMERIKSAAN PARU 1. Perfusion lung scan 2. Ventilation lung scan Tc-99m 3. Ventilation perfusion scan (V/Q scan) LAIN - LAIN 1. Brain scan dengan Tc-99m + kit (HMPAO) 2. Brain spect 3. Cysternogram dengan Tc-99m + kit 4. Phlebografi 5. Venography 6. Lymphoskintigrafi 7. Skintimammografi 8. Infeksi scan dengan infekton 9. Sentinel node/gamma probe detection 10. Dakriosistografi H.2 DIAGNOSTIK IN VITRO 1. T3 RIA 2. T4 RIA 3. TSHS IRMA 4. ANTITIROGLOBULIN 5. TIROGLOBULIN 6. TERAPI : 1) Hipertiroid - < 5 mCi - 5-10 mCi - 11-15 mCi - 16-20 mCi - 21-30 mCi - 40-50 mCi 2) Ablasi karsinoma tiroid - 80-100 mCi - 100-150 mCi - 150-200 mCi - 200-300 mCi 3) Paliatif 4
1,300,000 2,275,000 2,600,000 975,000 1,300,000
700,000 1,225,000 1,400,000 525,000 700,000
2,000,000 3,500,000 4,000,000 1,500,000 2,000,000
520,000 520,000
280,000 280,000
800,000 800,000
650,000 975,000 975,000 650,000 650,000 455,000 975,000
350,000 525,000 525,000 350,000 350,000 245,000 525,000
1,000,000 1,500,000 1,500,000 1,000,000 1,000,000 700,000 1,500,000
1,040,000 1,300,000 1,625,000
560,000 700,000 875,000
1,600,000 2,000,000 2,500,000
1,625,000 1,625,000 1,625,000 975,000 1,950,000
875,000 875,000 875,000 525,000 1,050,000
2,500,000 2,500,000 2,500,000 1,500,000 3,000,000
1,625,000 1,625,000 1,625,000 1,625,000
875,000 875,000 875,000 875,000
2,500,000 2,500,000 2,500,000 2,500,000
975,000 1,300,000 1,625,000
525,000 700,000 875,000
1,500,000 2,000,000 2,500,000
2,600,000 2,925,000 1,300,000 975,000 1,105,000 1,300,000 2,275,000 1,300,000 1,300,000 325,000
1,400,000 1,575,000 700,000 525,000 595,000 700,000 1,225,000 700,000 700,000 175,000
4,000,000 4,500,000 2,000,000 1,500,000 1,700,000 2,000,000 3,500,000 2,000,000 2,000,000 500,000
97,500 97,500 113,750 260,000 260,000
52,500 52,500 61,250 140,000 140,000
150,000 150,000 175,000 400,000 400,000
357,500 520,000 650,000 780,000 975,000 1,300,000
192,500 280,000 350,000 420,000 525,000 700,000
550,000 800,000 1,000,000 1,200,000 1,500,000 2,000,000
2,600,000 3,250,000 3,900,000 4,550,000
1,400,000 1,750,000 2,100,000 2,450,000
4,000,000 5,000,000 6,000,000 7,000,000
JENIS
NO
4) 5)
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
- Samarium - Rhenium Terapi hemangioma.keloid Permintaan tambahan film - Copy film thyroid - Copy film bone scanning - Copy film renogram/renmal scan - Copy film cardioscintigraphy - Copy film pemeriksaan lainnya
5
2,600,000 2,600,000 975,000
1,400,000 1,400,000 525,000
4,000,000 4,000,000 1,500,000
32,500 65,000 65,000 130,000 97,500
17,500 35,000 35,000 70,000 52,500
50,000 100,000 100,000 200,000 150,000
