Tarif Penunjang Diagnostik Radiologi
| No. | Jenis Tindakan | Tarif | |
|---|---|---|---|
| 1. | Scheidell AP | Rp. | 130.000,- |
| 2. | Scheidell Lat | Rp. | 130.000,- |
| 3. | Scheidell AP LAT | Rp. | 260.000,- |
| 4. | Basis Cranium | Rp. | 130.000,- |
| 5. | MandibulaEisler DX | Rp. | 130.000,- |
| 6. | MandibulaEisler SIN | Rp. | 130.000,- |
| 7 | MandibulaEisler DX dan SIN | Rp. | 260.000,- |
| 8. | Orbita | Rp. | 130.000,- |
| 9. | TMJDX/SIN | Rp. | 260.000,- |
| 10. | TMJDX dan SIN | Rp. | 400.000,- |
| 11. | MaxillaAP | Rp. | 130.000,- |
| 12. | MaxillaLat | Rp. | 130.000,- |
| 13. | MaxillaAP Lat | Rp. | 260.000,- |
| 14. | Water’s/Sinusparanasal | Rp. | 130.000,- |
| 15. | SinusParanasal Caldwell | Rp. | 130.000,- |
| 16 | SinusParanasal Water’s Caldwell | Rp. | 260.000,- |
| 17 | MastoidStenver dan Schuller (DX/SIN) | Rp. | 260.000,- |
| 18 | MastoidStenver dan Schuller (DX/SIN) | Rp. | 400.000,- |
| 19. | SoftTissue Nasal AP | Rp. | 130.000,- |
| 20. | SoftTissue Nasal Lat | Rp. | 130.000,- |
| 21. | SoftTissue Nasal AP Lat | Rp. | 260.000,- |
| 22. | SoftTissue Leher AP | Rp. | 130.000,- |
| 23. | SoftTissue Leher Lat | Rp. | 130.000,- |
| 24. | SoftTissue Leher AP Lat | Rp. | 260.000,- |
| 25. | ThoraxAP | Rp. | 130.000,- |
| 26. | ThoraxLat | Rp. | 130.000,- |
| 27. | ThoraxOblique | Rp. | 130.000,- |
| 28 | ThoraxAP/PA dan Lateral dan Oblique | Rp. | 400.000,- |
| 29 | Abdomen Polos | Rp. | 130.000,- |
| 30 | AbodomenTegak/ Setengah Duduk | Rp. | 130.000,- |
| 31 | Abdomen2 Posisi | Rp. | 260.000,- |
| 32 | Abdomen3 Posisi | Rp. | 400.000,- |
| 33 | PelvisAP | Rp. | 130.000,- |
| 34 | PelvisLateral | Rp. | 130.000,- |
| 35 | PelvisOblique | Rp. | 130.000,- |
| 36 | PelvisAP/Lateral | Rp. | 260.000,- |
| 37 | VertebraCervical AP | Rp. | 130.000,- |
| 38 | VertebraCervical Lat | Rp. | 130.000,- |
| 39 | VertebraCervical AP Lat | Rp. | 260.000,- |
| 40 | VertebraCervical AP dan Lateral dan Oblique | Rp. | 400.000,- |
| 41 | VertebraCervical AP dan Lateral (Hyper dan Hypo Fleksi) | Rp. | 400.000,- |
| 42 | VertebraCervicothoracal AP | Rp. | 130.000,- |
| 43 | VertebraCervicothoracal Lat` | Rp. | 130.000,- |
| 44. | VertebraCervicothoracal | Rp. | 260.000,- |
| APLat | |||
| 45. | Vertebra | Rp. | 400.000,- |
| Cervicothoracalis AP dan | |||
| Lateraldan Oblique | |||
| 46. | VertebraThoracal AP | Rp. | 130.000,- |
| 47. | VertebraThoracal Lat | Rp. | 130.000,- |
| 48. | VertebraThoracal AP Lat | Rp. | 260.000,- |
| 49. | VertebraThoracal AP Lat | Rp. | 400.000,- |
| Oblique | |||
| 50. | VertebraThoracolumbal | Rp. | 130.000,- |
| AP | |||
| 51. | VertebraThoracolumbal | Rp. | 130.000,- |
| Lat | |||
| 52. | VertebraThoracolumbal | Rp. | 260.000,- |
| APLat | |||
| 53. | VertebraThoracolumbal | Rp. | 400.000,- |
| APLat Oblique | |||
| 54. | VertebraThoracolumbal | Rp. | 400.000,- |
| APLat (Hyper dan Hypo | |||
| Fleksi) | |||
| 55. | VertebraLumbal AP | Rp. | 130.000,- |
| 56. | VertebraLumbal Lat | Rp. | 130.000,- |
| 57. | VertebraLumbal AP Lat | Rp. | 260.000,- |
| 58. | VertebraLumbal AP Lat | Rp. | 400.000,- |
| Oblique | |||
| 59. | VertebraLumbosacral AP | Rp. | 130.000,- |
| 60. | VertebraLumbosacral | Rp. | 130.000,- |
| Lat | |||
| 61. | Vertebra Lumbosacral AP | Rp. | 260.000,- |
| Lat | |||
| 62. | Vertebra Lumbosacral AP | Rp. | 400.000,- |
| LatOblique | |||
| 63. | Vertebra Lumbosacral AP | Rp. | 400.000,- |
| danLat (Hyper dan Hypo | |||
| Flexsi) | |||
| 64. | VertebraSacral AP | Rp. | 130.000,- |
| 65. | VertebraSacral Lat | Rp. | 130.000,- |
| 66. | VertebraSacral AP Lat | Rp. | 260.000,- |
| 67. | VertebraThoracolumbal | Rp. | 260.000,- |
| AP(Bending DX dan SIN) | |||
| 68. | VertebraSacrococycxgeus | Rp. | 130.000,- |
| AP | |||
| 69. | VertebraSacrococycxgeus | Rp. | 130.000,- |
| LAT | |||
| 70. | Vertebra Sacrococycxgeus | Rp. | 260.000,- |
| AP LAT | |||
| 71. | Coxcae AP danLat | Rp. | 260.000,- |
| 72. | CoxcaeAP | Rp. | 130.000,- |
| 73. | CoxcaeLat | Rp. | 130.000,- |
| 74. | ClaviculaDX | Rp. | 130.000,- |
| 75. | ClaviculaSIN | Rp. | 130.000,- |
| 76. | ClaviculaDX/SIN | Rp. | 260.000,- |
| 77. | Scapula Lateral View | Rp. | 130.000,- |
| DX/SIN | |||
| 78. | Scapula Y ViewDX/SIN | Rp. | 130.000,- |
| 79. | ScapulaDX dan SIN | Rp. | 260.000,- |
| 80. | ScapulaAP | Rp. | 130.000,- |
| 81. | Sternum | Rp. | 130.000,- |
| 82. | HumerusDX/SIN | Rp. | 130.000,- |
| 83. | HumerusDX dan SIN | Rp. | 260.000,- |
| 84. | ElbowJoint DX/SIN | Rp. | 130.000,- |
| 85. | ElbowJoint DX dan SIN | Rp. | 260.000,- |
| 86. | AntebrachiDX/SIN | Rp. | 130.000,- |
| 87. | AntebrachiDX dan SIN | Rp. | 260.000,- |
| 88. | WristJoint DX/SIN | Rp. | 130.000,- |
| 89. | WristJoint DX dan SIN | Rp. | 260.000,- |
| 90. | ManusDX/SIN | Rp. | 130.000,- |
| 91. | ManusDX dan SIN | Rp. | 260.000,- |
| 92. | HipJoint | Rp. | 130.000,- |
| 93. | FemurDX/SIN | Rp. | 130.000,- |
| 94. | FemurDX dan SIN | Rp. | 260.000,- |
| 95. | SendiBahu AP | Rp. | 130.000,- |
| 96. | SendiBahu DX/SIN | Rp. | 260.000,- |
| (Eksodan Endorotasi) | |||
| 97. | SendiBahu DX dan SIN AP | Rp. | 260.000,- |
| 98. | Sendi Bahu DX dan SIN | Rp. | 400.000,- |
| (Ekso dan Endorotasi) | |||
| 99. | Baby Gram | Rp. | 130.000,- |
| 100. | CrurisDX/SIN | Rp. | 130.000,- |
| 101. | CrurisDX dan SIN | Rp. | 260.000,- |
| 102. | AnkleJoint DX/SIN | Rp. | 130.000,- |
| 103. | AnkleJoint DX dan SIN | Rp. | 260.000,- |
| 104. | PedisDX/SIN | Rp. | 130.000,- |
| 105. | PedisDX dan SIN | Rp. | 260.000,- |
| 106. | CalcaneusDX/SIN | Rp. | 130.000,- |
| 107. | CalcaneusDX dan SIN | Rp. | 260.000,- |
| 108. | GenuDX dan SIN | Rp. | 260.000,- |
| 109. | GenuSky Line SIN | Rp. | 260.000,- |
| 110. | BOFSonde | Rp. | 260.000,- |
| 111. | Wongenstain/ProneCross Table | Rp. | 400.000,- |
| No. | Jenis Tindakan | Tarif | |
|---|---|---|---|
| 1. | BNO IVP | Rp. | 850.000, |
| 2. | OMD/MDG | Rp. | 850.000, |
| 3. | Appedicorafi | Rp. | 850.000, |
| 4. | Colon in Loop | Rp. | 850.000, |
| 5. | Uretrocystograpi | Rp. | 850.000, |
| 6. | Oesophagografi | Rp. | 850.000, |
| 7 | Maag Duodenografi | Rp. | 850.000, |
| 8. | HSG | Rp. | 850.000, |
| 9. | Fistulografi | Rp. | 850.000, |
| 10. | Sialografi | Rp. | 850.000, |
| 11. | Uretrografi | Rp. | 850.000, |
| 12. | Cystografi | Rp. | 850.000, |
|
No. |
Jenis Tindakan |
Tarif |
|
|
1. |
USG Upper Abdomen |
Rp. |
150.000,- |
|
2. |
USG Lower Abdomen |
Rp. |
150.000,- |
|
3. |
USG Whole Abdomen |
Rp. |
300.000,- |
|
4. |
USG Kepala |
Rp. |
300.000,- |
|
5. |
USG Thorax |
Rp. |
250.000,- |
|
6. |
USG Thorax Gaiding |
Rp. |
400.000,- |
|
7. |
USG Prostat |
Rp. |
250.000,- |
|
8. |
USG Doppler Colour |
Rp. |
400.000,- |
|
|
Upper Abdomen |
|
|
|
9. |
USG Doppler Colour |
Rp. |
400.000,- |
|
|
Lower Abdomen |
|
|
|
10 |
USG Doppler Whole |
Rp. |
400.000,- |
|
|
Abdomen |
|
|
|
11. |
USG Doppler Thyroid |
Rp. |
400.000,- |
|
12. |
USG Doppler Colour |
Rp. |
400.000,- |
|
|
Ginjal |
|
|
|
13. |
USG Doppler Colour |
Rp. |
400.000,- |
|
|
Prostat |
|
|
|
14. |
USG Doppler Testis |
Rp. |
400.000,- |
|
15. |
USG FAST (focused |
Rp. |
200.000,- |
|
|
assesment with |
|
|
|
|
sonography for |
|
|
|
|
trauma |
|
|
|
16. |
USG 4 Dimensi |
Rp. |
400.000,- |
|
17. |
USG 2 Dimensi |
Rp. |
300.000,- |
|
18. |
USG Transvaginal |
Rp. |
150.000,- |
| No. | Jenis Tindakan | Tarif | |
|---|---|---|---|
| 1. | Foto Dental | Rp. | 40.000,- |
| 2. | Foto Dental Panoramic | Rp. | 150.000,- |
| 3. | Foto Cephalometri | Rp. | 200.000,- |
| 4. | Foto Dental (diluar jam | Rp. | 50.000,- |
| kerja) | |||
| 5. | Foto Dental Panoramic | Rp. | 187.500,- |
| (diluar jam kerja) | |||
| 6. | Foto Cephalometri (diluar | Rp. | 250.000,- |
| jam kerja) | |||
| No. | Jenis Tindakan | Tarif | |
|---|---|---|---|
| 1. | ECG (Electro Cardiografi) | Rp. | 100.000,- |
| 2. | Electro Enchepalo | Rp. | 450.000,- |
| Graphy (EEG) | |||
| 3. | Nerve Conduction Study | Rp. | 450.000,- |
| (NCS) | |||
| 4. | Electro Myography | Rp. | 650.000,- |
| 5. | Treadmill | Rp. | 750.000,- |
| 6. | Echocardiography Basic | Rp. | 500.000,- |
| 7. | DC Shock | Rp. | 320.000,- |
| 8. | Puntur Great Arteri/ Vein | Rp. | 375.000,- |
| + Introducer Sheat | |||
| 9. | Audiometri | Rp. | 130.000,- |
| 10 | Timpanometri | Rp. | 100.000,- |
| 11. | Oto Kustik Emition (OAE) | Rp. | 130.000,- |
| 12. | Brain Evolved Response | Rp. | 1.000.000,- |
| Audiometry | |||
| 13. | CTG | Rp. | 100.000,- |
| No. | Jenis Tindakan | Tarif | |
|---|---|---|---|
| 1. | USG 2D | Rp. | 100.000,- |
| 2. | USG 4D | Rp. | 400.000,- |
| 3. | USG Transvaginal | Rp. | 200.000,- |
| 4. | USG Dopler | Rp. | 200.000,- |
| Jenis Tindakan | Tarif | ||
|---|---|---|---|
| 1. | Biopsi/Aspirasi Guided | Rp. | 1.000.000,- |
| CT | |||
| 2. | CT Scan Kepala Tanpa | Rp. | 1.000.000,- |
| Kontras | |||
| 3. | CT Scan Kepala Dengan | Rp. | 1.700.000,- |
| Kontras | |||
| 4. | CT Scan Leher | Rp. | 1.000.000,- |
| 5. | CT Scan Leher Dengan | Rp. | 2.000.000,- |
| Kontras | |||
| 6. | CT Scan Orbita/Mastoid | Rp. | 1.000.000,- |
| 7. | CT Scan Orbita/Mastoid | Rp. | 2.000.000,- |
| Dengan Kontras | |||
| 8. | CT Maxila/ Mandibula | Rp. | 1.000.000,- |
| 9. | CT Maxila/Mandibula | Rp. | 2.000.000,- |
| Dengan Kontras | |||
| 10. | CT Sinus Paranasalis | Rp. | 1.000.000,- |
| 11. | CT Sinus Paranasalis | Rp. | 2.000.000,- |
| Dengan Kontras | |||
| 12. | CT Ektremitas Pedis | Rp. | 1.000.000,- |
| 13 | CT Ektremitas Pedis | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 14. | CT Ektremitas Manus | Rp. | 1.000.000,- |
| 15. | CT Ektremitas Manus | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 16. | CT Ektremitas Antebrachi | Rp. | 1.250.000,- |
| 17. | CT Ektremitas Antebrachi | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 18. | CT Ektremitas Brachi | Rp. | 1.250.000,- |
| 19. | CT Ektremitas Brachi | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 20. | CT Extremitas Femur | Rp. | 1.250.000,- |
| 21. | CT Extremitas Femur | Rp. | 2.450.000,- |
| Dengan Kontras | |||
| 22. | CT Ektremitas Cruris | Rp. | 1.250.000,- |
| 23. | CT Ektremitas Cruris | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 24. | CT Whole Abdomen | Rp. | 1.500.000,- |
| 25. | CT Whole Abdomen | Rp. | 3.500.000,- |
| Dengan Kontras | |||
| 26. | CT Nasopharing dan | Rp. | 1.500.000,- |
| Leher | |||
| 27. | CT Nasopharing dan | Rp. | 2.500.000,- |
| Leher Dengan Kontras | |||
| 28. | CT Paru | Rp. | 1.500.000,- |
| 29. | CT Paru Dengan Kontras | Rp. | 3.000.000,- |
| 30. | CT Panoramik/Dental | Rp. | 1.500.000,- |
| 31. | CT Vertebra Cervicalis | Rp. | 1.500.000,- |
| 32. | CT Vertebra Cervicalis | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 33. | CT Vertebra Thoracalis | Rp. | 1.500.000,- |
| 34. | CT Vertebra Thoracalis | Rp. | 2.500.000,- |
| Dengan Kontras | |||
| 35. | CT Lumbal | Rp. | 1.500.000,- |
| 36. | CT Lumbal Dengan | Rp. | 2.500.000,- |
| Kontras | |||
| 37. | CT Ca Scoring | Rp. | 1.000.000,- |
| 38. | CT HRCT Paru | Rp. | 1.500.000,- |
| 39. | CT Lung Care | Rp. | 1.500.000,- |
| 40. | CT Coloscopy | Rp. | 1.500.000,- |
| 41. | CT Urografi Dengan | Rp. | 2.500.000,- |
| Kontras | |||
| 42. | CT Cardiac Dengan | Rp. | 3.000.000,- |
| Kontras | |||
| 43. | CT Angiography Paru/ | Rp. | 3.000.000,- |
| aorta | |||
| 44. | CT Angiography Abdomen | Rp. | 3.000.000,- |
| 45. | CT Angiography | Rp. | 3.000.000,- |
| Ektremitas | |||
| 46. | CT Angiography Kepala dan Leher | Rp. | 3.000.000,- |