GENERAL ROOM

No ITEM NAME TARIF

In Patient Room :
1 3rd Class 275,000
2 2nd Class 550,000
3 1st Class 750,000
4 Premium 1St Class 1,000,000
5 Deluxe 1,300,000
6 VIP 1,500,000
7 Junior Suite 2,000,000
8 Governor Suite 3,500,000
9 President Suite 4,800,000
10 Mandaya Royal Suite 5,800,000
SPECIAL ROOM
No ITEM NAME 3rd CLASS 1st CLASS VIP JUNIOR ROYAL SUITE
SUITE
1 Nursery 520,000 600,000 640,000 720,000 880,000
2 Sick Baby Ward (SBW) 650,000 750,000 800,000 900,000 1,100,000
3 HCU 1,300,000 1,500,000 1,600,000 1,800,000 2,200,000
4 NICU 1,560,000 1,800,000 1,920,000 2,160,000 2,640,000
5 PICU 2,080,000 2,400,000 2,560,000 2,880,000 3,520,000
6 CICU 2,080,000 2,400,000 2,560,000 2,880,000 3,520,000
7 ICU 2,080,000 2,400,000 2,560,000 2,880,000 3,520,000
8 Isolation Room 1,560,000 1,800,000 1,920,000 2,160,000 2,640,000
9 Sterilized Isolation Room 2,340,000 2,700,000 2,880,000 3,240,000 3,960,000
OTHER
No ITEM NAME TARIF
1 A&E - Isolation Room (Covid-19) 800,000
2 Covid-19 Room 1st Class 1,500,000
3 Covid-19 Room VIP 2,500,000
4 Covid-19 NICU/ PICU/ ICU/ CICU 3,000,000
INPATIENT VISITE
No ITEM NAME 3rd CLASS 1st CLASS VIP JUNIOR ROYAL SUITE
SUITE
1 RMO Visite 40,000 45,000 50,000 55,000 70,000
2 Visite Specialist 250,000 270,000 290,000 325,000 400,000
3 Visite Sub - Specialist 300,000 330,000 355,000 400,000 500,000
4 Visite Specialist Critical Care 300,000 330,000 355,000 400,000 500,000
COVID-19 IN PATIENT VISITE
No ITEM NAME 3rd CLASS 1st CLASS VIP JUNIOR ROYAL SUITE
SUITE
5 Covid-19 RMO Visite 65,000 75,000 80,000 90,000 110,000
6 Covid-19 Visite Specialist 390,000 450,000 480,000 540,000 660,000
7 Covid-19 Visite Sub - Specialist 455,000 525,000 560,000 630,000 770,000
8 Covid-19 Visite Specialist Critical Care 455,000 525,000 560,000 630,000 770,000
Catatan:
* Semua visite hanya dihitung satu kali dalam satu hari, kecuali ada permintaan khusus.
WXCODE No WXCODE WXNAME WANABLE TOTAL ROOM

MS 1 MS MANDAYA ROYAL SUITE MS-0901 1

PS 2 PS PRESIDENT SUITE PS-0933 1
GS GS-0902
JS GS-0905
VIP 3 GS GOVERN0R SUITE GS-0907 5
DX GS-0908
P1 GS-0909
1C JS-0910
2C JS-0911
3C 4 JS JUNIOR SUITE JS-0912 5
ICIR JS-0915
ISO JS-0935
NUR VIP-0906
ICU VIP-0916
HCU VIP-0917
CICU VIP-0918
PICU VIP-0919
NICU VIP-0921
PERI VIP-0922
DL VIP-0923
ODC VIP-0925
NMISO VIP-0926
5 VIP VIP 20
VIP-0927
VIP-0928
VIP-0929
VIP-0930
VIP-0931
VIP-1005
VIP-1006
VIP-1007
VIP-1020
VIP-1021
DX-1001
DX-1002
DX-1003
DX-1012
DX-1033
6 DX DELUXE DX-1101 11
DX-1102
DX-1103
DX-1112
DX-1117
DX-1135
P1-0903
P1-0920
WXCODE No WXCODE WXNAME WANABLE TOTAL ROOM

P1-1008
P1-1015
P1-1016
7 P1 PREMIUM 1ST CLASS 10
P1-1022
P1-1108
P1-1115
P1-1116
P1-1123
1C-1009
1C-1018
1C-1019
1C-1023
1C-1025
1C-1026
1C-1027
1C-1028
1C-1031
1C-1032
1C-1105
1C-1106
1C-1107
8 1C 1ST CLASS 26
1C-1109
1C-1119
1C-1120
1C-1121
1C-1122
1C-1125
1C-1126
1C-1127
1C-1128
1C-1129
1C-1132
1C-1133
1C-1137
9 2C 2ND CLASS 2C-1011 1
3C-1010
3C-1017
3C-1029
3C-1030
10 3C 3RD CLASS 3C-1110 9
3C-1111
3C-1118
3C-1130
3C-1131
ICIR-1035
11 ICIR ICIR 2
WXCODE No WXCODE WXNAME WANABLE TOTAL ROOM
11 ICIR ICIR 2
ICIR-1036
ISO-0932
12 ISO ISOLATION BED 2
ISO-1136
13 NUR NURSERY NUR 1
ICU-0807
ICU-0808
ICU-0809
14 ICU ICU ICU-0810 7
ICU-0811
ICU-0812
ICU-0815
HCU-0801
HCU-0802
15 HCU HCU HCU-0803 5
HCU-0805
HCU-0806
CICU-0816
CICU-0817
CICU-0818
16 CICU CICU 6
CICU-0819
CICU-0820
CICU-0821
PICU-0822
PICU-0823
17 PICU PICU 4
PICU-0825
PICU-0826
18 NICU NICU NICU-0827 1
19 PERI PERINATOLOGY - 1
DL-0001
DL-0002
20 DL DELIVERY BED 4
DL-0003
DL-0004
ODC-0001
21 ODC ONE DAY CARE BED ODC-0002 3
ODC-0003
NMISO-0001
NUCLEAR MEDICINE
22 NMISO NMISO-0002 3
ISOLATION BED
NMISO-0003
Total Of Room 128
 VALET PARKING

Mandaya Royal Hospital Puri menyediakan valet service khusus untuk pelanggan kami.
Disini kami menyediakan :

Valet Parkir Standard Rp. 40.000,-

Valet Parkir VIP Rp. 100.000,-

Silahkan hubungi staff doorman kami untuk bantuan Valet parkir.

Pastikan tidak ada barang-barang berharga anda tertinggal di mobil sebelum
meninggalkan mobil anda.
PARKING
SCRIPT HOSPITAL TOUR ( KUNJUNGAN )
MANDAYA ROYAL HOSPITAL PURI
NO. LANTAI RUANGAN

1 GF - LOBBY UTAMA LOBBY DEPAN

GF - LOBBY AE ( WAITING
2 LOBBY AE
UGD )

GF - LOBBY AE ( WAITING
3 RUANG KONSUL DOKTER AE
UGD )

4 GF - AE LOBBY AE LOBBY
 RUANG RAWAT AE ( G22 / MOCK
5 GF - AE
UP )

6 GF - RADIOLOGY AREA MRI

7 GF - RADIOLOGY AREA CT-SCAN

8 GF - RADIOLOGY AREA RADIOLOGY KORIDOR

9 GF - KOMERSIAL AREA KOMERSIAL AREA

10 GF - LOBBY EVENT LOBBY EVENT

11 GF - RECEPTION RECEPTION DESK

12 GF - DOCTOR'S LIST DOCTOR'S LIST

13 GF - WELCOME CENTER WELCOME CENTER

14 GF - RADIOLOGY CENTER LOBBY RADIOLOGY

LANTAI 9

15 LANTAI 9 - VIP FLOOR VIP MOCK UP - # 927

16 LANTAI 9 - VIP FLOOR VIP MOCK UP - # 901

 LANTAI 8

17 LANTAI 8 - ICU ICU MOCK UP - # IC 807

LANTAI 7

18 LANTAI 7 - OT OT ROOM - OT # 2

19 LANTAI 7 - DELIVERY SUITES DELIVERY SUITES MOCK UP - # 3

LANTAI 6
20 LANTAI 6 - POLI JANTUNG POLI JANTUNG MOCK UP - # 2

21 LANTAI 6 - CATH LAB CATH LAB ROOM

LANTAI 2

22 LANTAI 2 LANTAI 2 - POLI

LANTAI 1

23 LANTAI 1 LANTAI 1 - POLI

 SCRIPT

Bapak/Ibu untuk Lobby utama kami memiliki cukup area drop off dan pick up yang cukup luas dengan 2
jalur mobil seperti di mall, yang kami khusus sediakan agar para pasien dan keluarga pasien kami lebih
nyaman dan leluasa pada saat tiba di lobby ini dapat turun atau naik mobil dengan mudah tanpa tergesa-
gesa. Dan dengan bantuan concierge kami yang siap melayani pasien dan keluarga pasien.

Bapak/Ibu kami mari kami tunjukkan salah satu tempat yang terbaik adalah Ruang Tunggu di UGD kami
sangat nyaman, berkonsep seperti lobby hotel yang disediakan Wifi, Sofa, Meja dan kami memiliki coffee
shop yang selalu buka 24 jam setiap harinya. Kami menyediakan tempat yang paling nyaman bagi keluarga
pasien yang sedang menunggu pasien selama observasi di dalam UGD.

Ruangan ini kami sediakan untuk keperluan dokter UGD memberikan konsultasi tindakan dalam
penanganan pasien yang sedang di rawat di AE, ruangan konsultasi akan dilengkapi Screen dan beberapa
alat peraga untuk memberikan penjelasan bagi keluarga pasien.

Bapak/Ibu kami memiliki pintu khusus untuk pasien emergency yang bisa dilalui saat butuh pertolongan
pertama. Untuk Ruangan AE sendiri kami memiliki 20 beds private termasuk Emergency covig-19.
Silahkan Bapak/Ibu kami tunjukkan untuk ruang perawatan di UGD kami memiliki design khusus untuk
kenyamanan pasien dan keluarga pasie. Kami memiliki kamar UGD yang masing-masing pasien akan
mendapatkan satu ruangan khusus untuk pasien. Kami memiliki 20 ruang private, dengan bertujuan untuk
meminimalisir cross-infection, dikamar ini dilengkapi Patient Entertainment System yang bisa dinikmati
untuk pasien menonton hiburan di tv seperti Netflix,Youtube dan juga bisa melihat Vital sense pasien yang
terintergrasi dengan Digital Early Warning System yang dapat memberikan warning sign keadaan pasien
otomatis kepada tim UGD sebelum terlambat. Kamar ini juga dilengkapi oleh Switchable Smart Glass yaitu
kaca yang dapat diubah tembus pandang saat diperlukan.

Selanjutnya kami tunjukkan ke Radiologi area, Mari Bapak/Ibu kami memiliki Mesin MRI yaitu Ingenia
Ambition X ( 1.5 Tesla ) pertama di Indonesia. Keunggulannya dari MRI ini adalah memiliki Gradient
magnet tertinggi, digital technology untuk menghasilkan gambar yang lebih tajam, akurat dan waktu
pemeriksaan lebih cepat 50%, selain itu MRI kami dilengkapi dengan digital wall video projection dan
warna cahaya lampu yang dapat dipilih oleh pasien sesuai keinginannya agar dapat membantu pasien
merasa nyaman dan relax saat pemeriksaan.

MRI kami lanjutkan untuk CT-Scan kami yaitu Iqon Spectral CT yang pertama di Indonesia. CT-Scan ini
dilenkapi detector based Spectral Technology yang menghasilkan gambar konvensional dan spectral,
untuk hasil spectral dapat mengidentifikasi abnormalitas yang tidak dapat dengan jelas terlihat di scan
konvensional.
Selanjutnya mari kami tunjukkan beberapa ruangan untuk pemeriksaan X-ray, Fluoroscopy, Ultrasound
dan Mammography. Untuk Mammography yang kami miliki adalah Fuji Amulet Innovality series terbaru
dari Fuji dengan gambaran pixel yang terecil sehingga menghasilkan image yang jelas dan juga dilengkapi
sweet pad agar bisa menyesuaikan dengan bentuk payudara pasien sehingga pasien merasa lebih nyaman
saat pemeriksaan.

Bapak/Ibu kami juga memiliki komersial area yang akan menyediakan Coffee shop, restaurant, florist, ATM
center dan area untuk berbagai event di outdoor.

Bapak/Ibu rumah sakit ini memiliki khusus ballroom yang di design megah seperti hotel berbintan lima
dengan luar area 500 M² yang dilengkapi dengan big screen LED 28 M², sound system dan stage yang luas
yang dapat digunakan untuk menyelenggarakan even-event besar seperti seminar, private wedding,
maupun special celebration.

Untuk bagian di depan lobby area kami memiliki reception desk yang dapat membantu pasien saat
pertama tiba jika membutuhkan bantuan kursi roda, stroller baby dan pelayanan informasi.

Bapak/Ibu dilobby kami dilengkapi layar besar untuk informasi jadwal dokter, pelayanan kami, dan juga
sebagai pusat informasi yang terupdate untuk pasien bisa lebih banyak mendapatkan informasi tentang
rumah sakit ini dan fasilitas rumah sakit.
Bapak/Ibu selanjutnya kami memiliki Welcome center yang khusus bagi pasien atau keluarga pasien yang
non emergency ingin melakukan registrasi rawat inap, kami memfasilitasi dokter welcome center yang
dapat membantu setiap calon pasien menbutuhkan edukasi medis secara lisan yang sesuai dengan
kebutuhan pasien tersebut. Dan disini juga akan ada beberapa Tim Asuransi yang akan stand by untuk
membantu para pasien menerima perawatan di rumah sakit ini.

Selanjutnya kami juga memiliki lobby khusus Radiology center yang menangani registrasi, pembayaran
dan kami juga mempunyai ruangan konsultasi khusus.

LANTAI 9

Bapak/Ibu kami tunjukkan pertama dilantai 9 kami memiliki beberapa type VIP room yaitu VIP, Governor
suite, President suite dan Mandaya Royal Suite. Mari kita lihat VIP room yang paling terendah dilantai ini
yang kami miliki. Kamar ini difasilitasi dengan TV cabel, Safety box, Kulkas besar, microwave, water sink
beserta kitchen set lengkap, sofa yang bisa dijadikan bed tambahan dan Tablet pribadi untuk pasien agar
pasien dapat melihat Vital sense-nya, nama dokter yang merawatnya dan nama perawat yang
merawatnya. Dan juga dilengkapi patient entertainment system untuk setiap service di rumah sakit
seperti room service dan permintaan lainnya.

Selanjutnya silahkan kita melihat satu lagi ruangan VIP terbesar yaitu Mandaya Royal Suite, kami hanya
memiliki 1 unit saja untuk type ini. Kamar ini dilengkapi 2 bedroom yang khusus untuk pasien dan
keluarga pasien. Kami mengutamakan kenyamanan pasien dalam masa perawatan dan juga kelurga
pasien yang sedang menunggu keluarganya yang dirawat akan lebih nyaman dengan fasilitas kama ini,
dan juga kamar ini memiliki best view yang menghadap Danau dan Green lake city view.
 LANTAI 8

{ Jalur koridor dari kiri lift } Mari Bapak/Ibu selanjutnya kami tunjukkan ruang ICU yang kami miliki ada 26
beds terdiri dari ICU/CICU/PICU/NICU. Untuk ICU kami tetap mengutamakan kenyamanan pasien dan
keluarga pasien yang menerapkan 1 pasien 1 ruang private untuk mengurangi penularan infeksi ( cross
infection ) yang sering terjadi terhadap pasien ICU, dan juga kamar ini dlengkapi swichable smart glass
untuk keluarga pasien ingin melihat kondisi pasien tanpa masuk ke dalam ruang ICU.

{ Jika keluarga ingin masuk ke ruang ICU } Jika terpaksa keluarga pasien mau masuk ICU wajib masuk
melalui pintu sebelah kanan dari lift maka nanti akan dibantu oleh petugas kami untuk mensterilkan
seluruh tubuh keluarga pasien dengan alat Air Chamber kami ini yang tahap pertama akan dihembuskan
angin untuk melepaskan bakteri dan debu dibaju dan setelah itu akan distreilkan dengan desinfektan yang
aman bagi tubuh.

LANTAI 7

Selanjutnya boleh kami tunjukan dilantai 7 kami memiliki ruangan operasi yang memiliki peralatan
modern, dan disisi kanan kiri bisa dilihat kami menyediakan ruangan pre-op dan post operasi.

Dilantai ini tersedia kami juga memiliki Delivery Suites bagi Pasien maternity yang ingin melahirkan normal
tersedia ruangan private 1 pasien 1 ruang demi kenyamanan sang Ibu dan suami jika ingin melahirkan
secara normal disini.

LANTAI 6
Bapak/Ibu selanjutnya kami di lantai 6 khusus memiliki pelayanan poli jantung disebelah kiri kita dan
disebelah kanan adalah poli syaraf, pelayanan disini dilengkapi mulai dari bedah, EEG, EMG, EKG. Ini
adalah ruangan poli jantung yang dilengkapi display screen didepan poli untuk informasi digital nomor
antrian, nama dokter yang bertugas.

Mari Bapak/Ibu izinkan kami membawa Bapak/Ibu untuk melihat cath lab yang kami miliki yaitu alat cath
lab series paling terbaru yang ada di indonesia yaitu Azurion 7 M12 dari Phillips yang mampu memberikan
resolusi yang tinggi sehingga gambar sangat jelas jika ada penyempitan/penyumbatan di pembuluh darah

LANTAI 2

Bapak/Ibu selanjutnya kami mempunyai beberapa Poli yang tersedia sesuai kebutuhan pasien. Ada
disebelah kanan kami ada Poli Bedah, Poli THT, Poli Mata, Poli Paru, dan Poli Ginjal & Urologi. Dan yang
ada didepan ini ada jogging track yang difasilitaskan untuk fisioterapi, didepannya kami memiliki Poli
Diabetik & Geriatri dan disebelah kanannya kami memiliki Rehab Medik ( Hydrotheraphy/terapi dengan
gelombang air ) untuk pasien.

LANTAI 1

Bapak/Ibu selain dilantai 2 kami memiliki lantai 1 yang memiliki Poli Pediatric, Poli Obgyn, Poli Kecantikan,
MCU dan Poli Gigi disebelah kiri lift. Dan juga dilantai ini dilengkapi Playground khusus pasien pediatric.
DENAH HOSPITAL TOUR
LANTAI GF
LANTAI 9
LANTAI 8
LANTAI 7
LANTAI 6
LANTAI 2
 JUMLAH SENIN
NO SPESIALISASI LANTAI RUANGAN POLI
TAHAP 1 PAGI

ANAK 1 3 (3/5) A,B,C

1 dr. Andi Sugoro, SpA C 08 - 11
2 dr. Datu B.I Tambing, SpA A,B
3 dr. Diana Chandra, SpA A 08 - 12
4 dr. Fransisca Handy Agung, SpA A
5 dr. Hildegardis Febriana Elanda Liando, Sp.A C
6 dr. Karel Albert Lodewijk Staa, SpA B 08 - 12
7 dr. Suryadi Susanto, SpA B
8 dr. Tiurma Lisapine, SpA C
9 dr. Yose Muliawan Pangestu, SpA B,C

BEDAH ANAK
1 dr. Leo Rendy, Sp.BA B,C 13 - 16
2 dr. Yessi Eldiyani,Sp.BA B,C

BEDAH 2 6 (6/10) A-J

BEDAH UMUM 2 A,B
1 dr. Erwin Suryanegara,Msi.Med,SpB B 08 - 12
2 dr. Ledia, SpB B
3 dr. Tjhin Sun Fu,M.Biomed, Sp.B A 08 - 12

BEDAH DIGESTIF 1 C
1 dr. Eko Priatno, SpB-KBD B,C
2 dr. Handy Wing,SpB,FBMS,FICS C 08 - 12
3 dr. Heber Bombang Sapan SpB-KBD C

BEDAH VASKULAR 1 D
1 dr. Ismon Kusasi, SpB(K)V D
2 dr. Nyityasmono Tri Nugroho,SpB(K)V D

ORTOPEDI & TRAUMATOLOGI 1(1/2) E,F

1 dr. Ardi Setiawan, SpOT(K) E
2 dr. Jecky Chandra, Sp.OT E
3 dr. Muhammad Bahtera Tri Abadi, SpOT (K) E
4 dr. Paulus Ronald Hibono, SpOT E 08 - 12
5 dr. Troydimas Panjaitan, SpOT(K) E
6 dr. Venansius Herry Perdana Suryanta, SpOT E
AKUPUNTUR 2 2 A,B
1 dr. Febyana Anggraeni Tjahjar, Sp.Ak A 08 - 12
2 dr. Cherry Tanudjaja, SpAk A
3 dr. Alvin Hardi Hardjawinata, SpAk A

OBSGYN 1 4 (4/5) A-D

OBSTETRI & GINEKOLOGI 3
1 Dr. Andre Viscountie Saputra, Sp.OG, FMAS C,D
2 dr. Angelina Vitria, SpOG A,C
3 dr. Dasep Suwanda, SpOG B
4 dr. Doddy FP Gultom,SpOG(K),Mkes B,C
5 dr. Elita Gustiana Ardi, Sp.OG A,B
6 dr. Johan, Sp.OG B
7 dr. Noviyanti, SpOG C 08 - 12
dr. Rahmadsyah,M.kes,MARS,SpOG(K)FER, MARS,
B,C
8 M.KES
9 dr. Sigit Pradoro Diptoadi, SpOG B,C 08 - 12
10 dr. Sukardi Gozali, SpOG VISITING

OBSGIN-ONKO 1 D
1 dr. Iwan Kurni Effendi, SpOG (K) Onk D

ANDROLOGI
1 dr. Androniko Setiawan, SpAnd
PENYAKIT DALAM 2 6 (6/9) A-F
PENYAKIT DALAM 3 A-C
1 dr. Martin Winardi, SpPD B
2 dr. Nancy Indah Lestari, SpPD A 08 - 12
3 dr. Natalia Budisantoso, SpPD, FINASIM B,C
4 dr. Sandy Perkasa, SpPD C
5 dr. Tryono,M,Ked(PD),SpPD A
GINJAL - HIPERTENSI 1 D
1 dr. Dina Nilasari, SpPD-KGH D 09 - 12
2 dr. Ratna J Soewardi, SpPD-KGH D

GASTRO-ENTERO-HEPATOLOGI 1 E
1 dr. Hendra Nurjadin, SpPD-KGEH E 08 - 12
2 dr. Epistel Pangujian Simatupang, Sp.PD-KGEH
ENDOKRIN 1 F(DM)
1 dr. Johannes Poerwoto, SpPD-KEMD F 09 - 14

WOUND PHYSICIAN 1 F(DM)

1 dr. Adisaputra Ramadhinara F
 NEUROSCIENCE 6 4 (4/7) A-G
NEUROLOGI
1 dr. Andreas Andy Atmadja, SpS A 08 - 12
2 dr. Djung Lilya Wati, SpN A,B,C 08 - 12
3 dr. Fran Efendy, SpN A
4 dr. Hartono Alam, SpS C
5 dr. Pukovisa Prawiroharjo, SpS (K) B
6 dr. Vania Listiani Hidajat, Sp.N B
BEDAH SARAF
1 dr. Christian Ariono SpBS 08 - 12
2 dr. Djoko Riadi,SpBS 08 - 12
3 dr. Nia Yuliatri, SpBS
JANTUNG & PEMBULUH DARAH 6 5(5/6) A-F
JANTUNG DEWASA
1 dr. A. Sunarya Soerianata, SpJP, FIHA A
2 dr. Abhirama Nofandra Putra, SpJP * B 08 - 12
3 dr. Amir Alkathiri, SpJP C
4 dr. Arwin S. Mangkuanom, SpJP B
5 Dr. dr.Amiliana , SpJP, FIHA A
6 dr. Ellen, SpJP C
7 dr. Estu Rudiktyo,SpJP, FIHA A
8 dr. Stefanus Andy Wiyoyono, SpJP(K) B,C
9 dr. Suci Indriani, SpJP

JANTUNG ANAK 6 3 D
1 dr. Anna Ulfah, SpJP (K) D
2 dr. Oktavia Lilyasari, SpJP (K) D
3 dr. Sisca Natalia Siagian, SpJP (K) D

BEDAH THORAKS & KARDIO VASKULAR 6 1

1 dr. Bagus Herlambang, SpBTKV
2 dr. Budi Rahmat, SpBTKV
KEDOKTERAN JIWA 1
1 dr. Elly Tania, SpKJ
2 dr. Kresno Mulyadi, SpKJ
GIZI 2
1 dr. Sanny Ngatidjan, SpGK 08 - 12
2 Dr. dr. Samuel Oetoro, MS,SpGK(K)
THT 1 1
1 Dr. dr. Cita Herawati, Sp.THT-KL (K) 09 - 11
2 Dr. dr. Imam Prabowo, SpTHT-KL (K) FICS
3 dr. Handoko Nugroho Y, Sp.THT-KL, MKes
4 dr. Zuki Saputra, SpTHT-KL
5 dr. Abdillah Hasbi, SpTHT-KL
MATA 2 1 (1/2) A,B
1 dr. Melissa Yulita, SpM A
2 dr. Naomi Patioran, SpM A
3 dr. Yessica Wilanda, SpM A

KULIT & KELAMIN 1 (1/2) A,B

1 dr. Hans Utama Sutanto, SpKK A
2 dr. Melyawati Hermawan, SpKK A
3 dr. Wiwi Widjaya Chandra, SpKK A 08 - 12

KEDOKTERAN FISIK & REHABILITASI

1 dr. Christine Nyoto, Sp.KFR
2 dr. Kevin Triangto, SpKFR

DOKTER GIGI SPESIALIS

1 Dr.drg.Andi Setiawan Budihardja, SpBM(K)
2 drg. Antonius Surya Putra, SpBM
3 drg. Bramadita Satya, SpBM 08 - 12
4 drg. Devi Irawan, SpKG
5 drg. Edwin, SpKG
6 drg. Esther Esti, SpKG
7 drg. Gisela Petrina, SpKG
8 drg. Leslie Odelia, SpProst
9 drg. Priscilla Daniego, SpKG 08 - 12
10 drg. Priscilla Lavine, SpKGA
11 drg. Ratih, Sp Prost
12 drg. Stevany Gyanti SpPerio
DOKTER GIGI UMUM
1 drg.Claudia Ang
2 drg. Jelita, SpOrt
3 drg.Selvi Mulyawan

FORENSIK & MEDIKOLEGAL

1 dr. Yudy, SpFM
EMERGENCY (AE)
1 dr. Andy Wijaya, SpEM
 FARMAKOLOGI KLINIK
1 Dr. dr. Linawati Hananta, SpPK
2 dr. Lonah, SpFK
PATOLOGI KLINIK
1 dr. Budiarijanto (Bing) Widjaja, SpPK(K)
MIKROBIOLOGI
1 dr. Ardath Herland D, SpMK
PATOLOGI ANATOMI
1 dr. Agnes Stephanie Harahap, Sp.PA(K)
2 dr. Rizky Ifandriani Putri, SpPA
RADIOLOGI
1 dr. Christopher Silman, SpRad
2 dr. Rina Safrina, SpRad
3 dr. Sugianto Santosa, SpRad
4 dr. Vera Sutedjo, SpRad
RADIASI ONKOLOGI
1 dr. Arry Setyawan, Sp.Onk-Rad
KEDOKTERAN NUKLIR
1 dr. Eko Purnomo, Sp-KN
ANESTESI
1 dr. Alexander Samuel Partogi, SpAn-KNA
2 dr. Bona Akhmad Fitrah, SpAn-KNA
3 dr. Primartanto Wibowo, SpAn-KIC
4 dr. Ronal Yosua Limen, SpAn-KIC
5 dr. Wihandra Gunadi, SpAn
6 dr. Yudi Hananta, SpKAKV
7 dr. Frans Pangalila, SpPD-KIC
DOKTER GIGI SPESIALIS
1 drg. Andi Budirahardja SpBM
GENERAL PRACTITIONER
1 dr. Aris Gunawan
2 dr. Edo Aditya Dwi Susanto
3 dr. Grace Miko Lukito
4 dr. Henry Andri Theodorus
5 dr. Kelli Julianti
6 dr. Martin Sutanto
7 dr. Steven Alviano Yuwono
8 dr. Victor Anderson Christopher Nguru, AIFM
 9 dr. Welly Surya
10 dr. Yessy Cristina Tanujaya

NOTE

PENUNJANG
SENIN SELASA RABU KAMIS

SIANG SORE PAGI SIANG SORE PAGI SIANG SORE PAGI

08 - 11 08 - 11 08 - 11
17 - 20
13 - 16 08 - 12 13 - 16 08 - 12 13 - 16 08 - 12
17 - 20 16 - 19
17 - 20
08 - 12
17 - 20 17 - 20 18 - 20 08 - 10
17 - 20 17 - 20
12 - 16 14 - 17 14 - 17

13 - 16
13 - 16 08 - 12

13 - 16
13 - 16 17 - 20 08 - 12 13 - 16 17 - 20 08 - 12 13 - 16 17 - 20 08 - 12

17 - 20 17 - 20
08 - 12 08 - 12
17 - 20 17 - 20 17 - 20 08 - 12

16 - 18 16 - 18
17 - 20 13 - 16

17 - 20 08 - 12 08 - 12
13 - 16
13 - 16 08 - 12
13 - 16
17 - 20
17 - 20

08 - 12
 16 - 20
15.30 - 17.30 15.30 - 17.30

09 - 12
17 - 20 17 - 20 17 - 20
13 - 16
17 - 20
17 - 20
17 - 20 08 - 12 17 - 20 08 - 12
08 - 12 08 - 12

13 - 16 13 - 16 13 - 16

17 - 20 08 - 12

13 - 16 17 - 20 13 - 16 17 - 20

17 - 20 08 - 12 13 - 16 08 - 12
13 - 16 08 - 12 13 - 16 08 - 12 13 - 16 08 - 12
17 - 20
12 - 15 13 - 16 10 - 13
17 - 20 17 - 20

08 - 10 17 - 20
15 - 20 18 - 20 13 - 15

08 - 12
18 - 20 08 - 12

09 - 14 09 - 14 09 - 14

17-19 17-19 17-19

 17 - 20 08 - 12
08 - 12

17 - 20
17 - 20 17 - 20 17 - 20
08 - 12 13 - 16

13 - 16 08 - 12 08 - 12 13 - 16 17 - 20 08 - 12
08 - 12 14 - 18 08 - 12 08 - 12
17 - 20

08 - 12 13 - 16 17 - 20 08 - 12
13 - 16 08 - 12 13 - 16 08 - 12 13 - 16 08 - 12
17 - 20
17 - 20

13 - 16
16.30 - 20 16.30 - 20
13 - 16 17 - 20 17 - 20
17 - 20

08 - 12 08 - 12
17 - 20
17 - 20

17 - 20 17 - 20 17 - 20
16 - 18

17 - 20
08 - 12 08 - 12

13 - 16 08 - 12 13 - 16 08 - 12 13 - 16 08 - 12
14 - 16
 16 - 18
16 - 18
16 - 18 18 - 20 18 - 20
08 - 12 08 -10

08 - 12
08 - 12 13 - 17 13 - 17
13 - 17 08 - 12

18 - 20 18 - 20
13 - 17 12 - 15 10 - 12
08 - 12

08 - 12
16.30 - 20.30 16.30 - 20.30 16.30 - 20.30

08 - 12 12 - 16 08 - 12
12 - 16

08 - 12
08 - 12 12 - 16
16 - 20
12 - 16

16 - 20
16 - 20
12 - 16

08 - 12 08 - 12
08 - 12 08 -12
12 - 16 16 - 20
KAMIS JUMAT SABTU MINGGU

SIANG SORE PAGI SIANG SORE PAGI SIANG SORE PAGI

08 - 11 08 - 11
13 - 16 17 - 20 17 - 20
13 - 16 08 - 12 13 - 16 13 - 16
08 - 11
17 - 20 13 - 16 17 - 20
08 - 12 08 - 12
18 - 20 18 - 20 18 - 20
13 - 16
17 - 20

13 - 16
13 - 16 13 - 16

08 - 12
17 - 20
13 - 16 17 - 20 08 - 12 13 - 16 17 - 20 08 - 12 13 - 16 17 - 20

17 - 20 17 - 20
13 - 16 08 - 12 13 - 16
17 - 20 08 - 12

08 - 10
17 - 20 13 - 16 13 - 16 17 - 20

08 - 12 13 - 16
17 - 20

13 - 16 08 - 12 13 - 16
17 - 20
17 - 20

08 - 12
 16 - 20 16 - 20 15 - 18

14 - 18 09 - 12
17 - 20 13 - 16 13 - 16
13 - 16
13 - 16 08 - 12
17 - 20 17 - 20
17 - 20
08 - 12

13 - 16 08 - 12 17 - 20

17 - 20 17 - 20

17 - 20 13 - 16

14 - 16 13 - 15

17 - 20
13 - 16 08 - 12 13 - 16 08 - 12 13 - 16
17 - 20 17 - 20
10 - 13
17 - 20

17 - 20
15 - 20 15 - 18 11 - 13

09 - 14

17-19 17-19 17-19

 17 - 20 08 - 12 08 - 12
13 - 16 13 - 16
17 - 20 17 - 20
17 - 20 17 - 20
17 - 20 17 - 20 08 - 12 13 - 16
08 - 12 08 - 12

13 - 16 08 - 12 13 - 16 08 - 12 13 - 16 17 - 20
13 - 16 08 - 12 13 - 16
17 - 20

13 - 16
13 - 16 08 - 12 13 - 16 08 - 12
09 - 12
17 - 20
17 - 20
17 - 20

17 - 20

13 - 16 08 - 12

17 - 20

17 - 20
16 - 18

17 - 20 13 - 16
08 - 12

13 - 16 08 - 12 13 - 16 08 - 12 13 - 16
14 - 16
 16 - 19 16 - 18
18 - 20 08 - 12

12 -16
08 - 12 13 - 17
13 - 17

18 - 20 15 - 17
12 - 15 10 - 12 08 - 12

14 - 18 08 - 12
16.30 - 20.30 16.30 - 20.30 08 - 14

16 - 20
12 - 16

12 - 16
08 - 12 12 -16
16 - 20 08 - 12
08 - 12
08 - 12 12 - 16
16 - 20 12 - 16 16 - 20
16 - 20
12 - 16

08 - 12
MINGGU

SIANG SORE
N ITEM NAME OPD 3rd CLASS 1st CLASS VIP JUNIOR
o SUITE
Hematologi Umum
1 Hematologi Dasar (Hb,Ht,Eri,Leu,Trom) 117,000 152,000 164,000 176,000 187,000
2 Hematologi Rutin (H-Dasar,Ner,Rdw,Hj Leu, LED) 130,000 169,000 182,000 195,000 208,000
3 Hematologi Lengkap (H-Rutin,Ret,Ret-He,Trom Imatur (IPF) 150,000 195,000 210,000 225,000 240,000
4 Mikrohematokrit 72,000 94,000 101,000 108,000 115,000
5 MCV / MCH / MCHC 99,000 129,000 139,000 149,000 158,000
6 Retikulosit 99,000 129,000 139,000 149,000 158,000
7 Hitung Eosinofil 99,000 129,000 139,000 149,000 158,000
8 Laju Endap Darah (LED) 54,000 70,000 76,000 81,000 86,000
9 Limfosit Plasma Biru * 243,000 316,000 340,000 365,000 389,000
10 Morfologi Darah Tepi 288,000 374,000 403,000 432,000 461,000
11 Morfologi Darah Tepi + Consult * 873,000 1,135,000 1,222,000 1,310,000 1,397,000
12 Morfologi Sumsum Tulang A + Consult* 1,138,500 1,480,000 1,594,000 1,708,000 1,822,000
13 Morfologi Sumsum Tulang B* 711,000 924,000 995,000 1,067,000 1,138,000
14 Rasio I/T 112,500 146,000 158,000 169,000 180,000
15 Golongan Darah ABO/Rh* 67,500 88,000 95,000 101,000 108,000
16 Lymphocyte Subset 666,000 866,000 932,000 999,000 1,066,000
17 Malaria 153,000 199,000 214,000 230,000 245,000
18 Mikrofilaria 288,000 374,000 403,000 432,000 461,000
19 Platelet-rich Plasma (PRP)* 63,000 82,000 88,000 95,000 101,000
20 Hematologi CKD-HD (H-Dasar, Ret-He) 112,500 146,000 158,000 169,000 180,000
Hemostasis - Koagulasi
21 Hemostasis Rutin (Trom, BT, PT, APTT) 567,000 737,000 794,000 851,000 907,000
22 Hemostasis Lengkap (Hemostasis Rutin, TT, Fibrinogen, D-Di 1,966,500 2,556,000 2,753,000 2,950,000 3,146,000
23 Hemostasis Lengkap Plus (Hemostasis Lengkap, AT III, Protei 4,932,000 6,412,000 6,905,000 7,398,000 7,891,000
24 Uji Bendungan (RL) 54,000 70,000 76,000 81,000 86,000
25 Masa Perdarahan (BT) 54,000 70,000 76,000 81,000 86,000
26 Masa Pembekuan (CT) 54,000 70,000 76,000 81,000 86,000
27 Masa Protrombin (PT) 243,000 316,000 340,000 365,000 389,000
28 Masa Tromboplastin(APTT) 243,000 316,000 340,000 365,000 389,000
29 Masa Trombin (TT) * 522,000 679,000 731,000 783,000 835,000
30 Serial Trombine Time 1,377,000 1,790,000 1,928,000 2,066,000 2,203,000
31 Fibrinogen 301,500 392,000 422,000 452,000 482,000
32 INR 288,000 374,000 403,000 432,000 461,000
33 Trombotest Owren * 355,500 462,000 498,000 533,000 569,000
34 Agregasi Trombosit 375,000 488,000 525,000 563,000 600,000
35 Viskositas Darah * 391,500 509,000 548,000 587,000 626,000
36 Viskositas Plasma * 391,500 509,000 548,000 587,000 626,000
37 ACT (Activated Clotting Time) 1,147,500 1,492,000 1,607,000 1,721,000 1,836,000
Fibrinolisis - Trombosis
38 D-Dimer 751,500 977,000 1,052,000 1,127,000 1,202,000
39 Faktor VIII * 720,000 936,000 1,008,000 1,080,000 1,152,000
40 Faktor IX * 720,000 936,000 1,008,000 1,080,000 1,152,000
41 Faktor Von Willebrand * 2,515,500 3,270,000 3,522,000 3,773,000 4,025,000
42 Protein C & Protein S * 2,182,500 2,837,000 3,056,000 3,274,000 3,492,000
43 Protein C * 1,125,000 1,463,000 1,575,000 1,688,000 1,800,000
44 Protein S * 1,255,500 1,632,000 1,758,000 1,883,000 2,009,000
45 Anti Trombin III (ATIII) * 720,000 936,000 1,008,000 1,080,000 1,152,000
46 Anti Cardiolipin (ACA) IgG & IgM * 2,052,000 2,668,000 2,873,000 3,078,000 3,283,000
47 ACA IgM * 1,120,500 1,457,000 1,569,000 1,681,000 1,793,000
48 ACA IgG * 1,089,000 1,416,000 1,525,000 1,634,000 1,742,000
49 Anti-β2 Gp 1 IgG & IgM * 1,579,500 2,053,000 2,211,000 2,369,000 2,527,000
50 Antikoagulan Lupus * 1,444,500 1,878,000 2,022,000 2,167,000 2,311,000
Anemia
51 G6PD (Aktifitas) * 499,500 649,000 699,000 749,000 799,000
52 Resistensi Osmotik Eritrosit * 171,000 222,000 239,000 257,000 274,000
53 Uji Coombs Direk / Indirek * 675,000 878,000 945,000 1,013,000 1,080,000
54 Elektroforesis Hb * 792,000 1,030,000 1,109,000 1,188,000 1,267,000
55 Hb F * 261,000 339,000 365,000 392,000 418,000
56 Besi Serum (SI) & Daya Ikat Besi Serum (TIBC), Saturasi Trans 913,500 1,188,000 1,279,000 1,370,000 1,462,000
57 Besi (Iron) 202,500 263,000 284,000 304,000 324,000
58 TIBC 202,500 263,000 284,000 304,000 324,000
59 Ferritin * 432,000 562,000 605,000 648,000 691,000
60 Transferin * 504,000 655,000 706,000 756,000 806,000
61 Vitamin B12 * 1,246,500 1,620,000 1,745,000 1,870,000 1,994,000
62 Asam Folat * 1,404,000 1,825,000 1,966,000 2,106,000 2,246,000
63 Sel Le * 184,500 240,000 258,000 277,000 295,000
64 Le Reaksi * 198,000 257,000 277,000 297,000 317,000
Kimia
Uji Fungsi Hati
65 Protein Total / Albumin / Globulin 279,000 363,000 391,000 419,000 446,000
66 Albumin 85,500 111,000 120,000 128,000 137,000
67 Elektroforesis Protein * 360,000 468,000 504,000 540,000 576,000
68 Serum Protein Immunoelektroforesis* 297,000 386,000 416,000 446,000 475,000
69 Cholinesterase(ChE) * 202,500 263,000 284,000 304,000 324,000
70 Bilirubin Total / Direk / Indirek 216,000 281,000 302,000 324,000 346,000
71 Bilirubin Total Neonatus 144,000 187,000 202,000 216,000 230,000
72 ALT (SGPT) & AST (SGOT) 126,000 164,000 176,000 189,000 202,000
73 SGOT 72,000 94,000 101,000 108,000 115,000
74 SGPT 72,000 94,000 101,000 108,000 115,000
75 Gamma GT 103,500 135,000 145,000 155,000 166,000
76 Fosfatase Alkali 94,500 123,000 132,000 142,000 151,000
77 Glutamat DH (GLDH) * 886,500 1,152,000 1,241,000 1,330,000 1,418,000
78 Asam Empedu (Bile Acid) * 1,107,000 1,439,000 1,550,000 1,661,000 1,771,000
79 Serum Bile Acid-2 Hr Pp * 819,000 1,065,000 1,147,000 1,229,000 1,310,000
80 Amoniak * 837,000 1,088,000 1,172,000 1,256,000 1,339,000
81 Pivka * 3,802,500 4,943,000 5,324,000 5,704,000 6,084,000
Jantung
79 Hstroponin 463,500 603,000 649,000 695,000 742,000
80 CK-MB 342,000 445,000 479,000 513,000 547,000
81 CK Total 216,000 281,000 302,000 324,000 346,000
82 Mioglobin * 661,500 860,000 926,000 992,000 1,058,000
83 NT-Pro BNP 846,000 1,100,000 1,184,000 1,269,000 1,354,000
84 LDH 166,500 216,000 233,000 250,000 266,000
85 Troponin T Kualitatif * 693,000 901,000 970,000 1,040,000 1,109,000
 86 Troponin I 657,000 854,000 920,000 986,000 1,051,000
Fungsi Ginjal
87 Ureum 72,000 94,000 101,000 108,000 115,000
88 Kreatinin 76,500 99,000 107,000 115,000 122,000
89 EGFR 76,500 99,000 107,000 115,000 122,000
90 Cystatin C * 612,000 796,000 857,000 918,000 979,000
91 Asam Urat 72,000 94,000 101,000 108,000 115,000
92 Uji Bersihan Ureum 171,000 222,000 239,000 257,000 274,000
93 Uji Bersihan Kreatinin 171,000 222,000 239,000 257,000 274,000
94 β2-Mikroglobulin * 1,111,500 1,445,000 1,556,000 1,667,000 1,778,000
95 NGAL * 724,500 942,000 1,014,000 1,087,000 1,159,000
Elektrolit
96 Electrolyte Serum (Na, K, Cl) 288,000 374,000 403,000 432,000 461,000
97 Kalsium Total 103,500 135,000 145,000 155,000 166,000
98 Kalsium Ion 400,500 521,000 561,000 601,000 641,000
99 Fosfat Anorganik 103,500 135,000 145,000 155,000 166,000
100 Magnesium 148,500 193,000 208,000 223,000 238,000
101 Analisa Gas Darah 450,000 585,000 630,000 675,000 720,000
102 Asam Laktat 814,500 1,059,000 1,140,000 1,222,000 1,303,000
103 Asam Laktat POCT 94,500 123,000 132,000 142,000 151,000
104 Analisa Gas Darah Plus (AGD+Na,K,iCa, GDS) 850,500 1,106,000 1,191,000 1,276,000 1,361,000
Diabetes Melitus
105 Glukosa Darah Sewaktu 54,000 70,000 76,000 81,000 86,000
106 Glukosa Darah Puasa 50,000 65,000 70,000 75,000 80,000
107 Glukosa Darah 2 Jam PP 50,000 65,000 70,000 75,000 80,000
108 Uji Toleransi Glukosa Oral 75 g 256,500 333,000 359,000 385,000 410,000
109 Kurva Harian 157,500 205,000 221,000 236,000 252,000
110 Hb Glikat (HbA1C) 225,000 293,000 315,000 338,000 360,000
111 Insulin Puasa * 639,000 831,000 895,000 959,000 1,022,000
112 Insulin 2 Jam pp * 639,000 831,000 895,000 959,000 1,022,000
113 C-Peptide Puasa * 666,000 866,000 932,000 999,000 1,066,000
114 C-Peptide 2 Jam PP * 666,000 866,000 932,000 999,000 1,066,000
115 Benda Keton (β-OH Butirat) 355,500 462,000 498,000 533,000 569,000
116 Keton Darah 346,500 450,000 485,000 520,000 554,000
117 Fruktosamine* 2,101,500 2,732,000 2,942,000 3,152,000 3,362,000
Pankreas
118 Amilase Total * 441,000 573,000 617,000 662,000 706,000
119 Amilase Pankreas 414,000 538,000 580,000 621,000 662,000
120 Lipase 324,000 421,000 454,000 486,000 518,000
Profil Lipid
121 Kolesterol Total 70,000 91,000 98,000 105,000 112,000
122 Kolesterol LDL 125,000 163,000 175,000 188,000 200,000
123 Kolesterol HDL 85,500 111,000 120,000 128,000 137,000
124 Trigliserida 72,000 94,000 101,000 108,000 115,000
125 Small, Dense-LDL Kualitatif * 432,000 562,000 605,000 648,000 691,000
126 Small, Dense-LDL Kuantitatif * 432,000 562,000 605,000 648,000 691,000
127 APO B * 297,000 386,000 416,000 446,000 475,000
128 APO A1 * 508,500 661,000 712,000 763,000 814,000
129 Lipoprotein (A) * 625,500 813,000 876,000 938,000 1,001,000
130 Adiponektin * 828,000 1,076,000 1,159,000 1,242,000 1,325,000
131 LDL Cholestrol Direk 162,000 211,000 227,000 243,000 259,000
132 Ratio Cholesterol/HDL 130,500 170,000 183,000 196,000 209,000
Faktor Resiko Pkv
133 HS-CRP 333,000 433,000 466,000 500,000 533,000
134 Homosistein * 1,048,500 1,363,000 1,468,000 1,573,000 1,678,000
135 Status Antioksidan Status (TAS) * 1,134,000 1,474,000 1,588,000 1,701,000 1,814,000
136 Super Oksid Dismutase (SOD) * 1,134,000 1,474,000 1,588,000 1,701,000 1,814,000
137 Glutathion (GPX) * 814,500 1,059,000 1,140,000 1,222,000 1,303,000
138 β-Cross Lap (CTX) * 841,500 1,094,000 1,178,000 1,262,000 1,346,000
139 N-Mid-Osteocalcin * 801,000 1,041,000 1,121,000 1,202,000 1,282,000
Imunoserologi
Virus Hepatitis
140 Anti HAV Total * 841,500 1,094,000 1,178,000 1,262,000 1,346,000
141 Anti HAV IgM * 724,500 942,000 1,014,000 1,087,000 1,159,000
142 HBsAg Kualitatif (Elisa) 171,000 222,000 239,000 257,000 274,000
143 HBsAg Rapid Kualitatif 144,000 187,000 202,000 216,000 230,000
144 HBsAg Kuantitatif (HBsAg Konfirmasi Test) * 1,575,000 2,048,000 2,205,000 2,363,000 2,520,000
145 Anti-HBs Kuantitatif 202,500 263,000 284,000 304,000 324,000
146 Anti HBC Total * 594,000 772,000 832,000 891,000 950,000
147 Anti HBC IgM * 868,500 1,129,000 1,216,000 1,303,000 1,390,000
148 HBeAg * 774,000 1,006,000 1,084,000 1,161,000 1,238,000
149 Anti HBe * 1,012,500 1,316,000 1,418,000 1,519,000 1,620,000
150 Anti HCV Rapid 369,000 480,000 517,000 554,000 590,000
151 Anti-HCV 441,000 573,000 617,000 662,000 706,000
152 Anti HCV IgM * 990,000 1,287,000 1,386,000 1,485,000 1,584,000
153 Anti HEV IgG * 3,321,000 4,317,000 4,649,000 4,982,000 5,314,000
154 Anti HEV IgM * 3,406,500 4,428,000 4,769,000 5,110,000 5,450,000
Sexual Transmitted Disease
155 VDRL 130,500 170,000 183,000 196,000 209,000
156 TPHA 166,500 216,000 233,000 250,000 266,000
157 Anti-HIV (HIV1 / HIV2)(Rapid Test)(3 Metode) 639,000 831,000 895,000 959,000 1,022,000
158 Anti-HIV Kualitatif/Elisa 405,000 527,000 567,000 608,000 648,000
159 HIV Duo Test (Ag+Ab) 472,500 614,000 662,000 709,000 756,000
160 Anti-HIV Western Blot * 1,089,000 1,416,000 1,525,000 1,634,000 1,742,000
161 HIV RNA Viral Load * 1,917,000 2,492,000 2,684,000 2,876,000 3,067,000
162 Anti Chlamydia IgG * 1,152,000 1,498,000 1,613,000 1,728,000 1,843,000
163 Anti Chlamydia IgM * 1,152,000 1,498,000 1,613,000 1,728,000 1,843,000
Petanda Tumor
164 AFP (Hati) 499,500 649,000 699,000 749,000 799,000
165 CEA 333,000 433,000 466,000 500,000 533,000
166 Ca 125 864,000 1,123,000 1,210,000 1,296,000 1,382,000
167 PAP (Prostat) * 589,500 766,000 825,000 884,000 943,000
168 PSA Total (Prostat) 463,500 603,000 649,000 695,000 742,000
169 PSA Bebas * 1,273,500 1,656,000 1,783,000 1,910,000 2,038,000
170 Ca 15-3 * 841,500 1,094,000 1,178,000 1,262,000 1,346,000
171 He 4 * 801,000 1,041,000 1,121,000 1,202,000 1,282,000
172 Ca 72-4 * 1,354,500 1,761,000 1,896,000 2,032,000 2,167,000
173 Ca 19-9 * 909,000 1,182,000 1,273,000 1,364,000 1,454,000
174 SCC (Serviks) * 1,012,500 1,316,000 1,418,000 1,519,000 1,620,000
175 NSE * 1,156,500 1,503,000 1,619,000 1,735,000 1,850,000
176 Cyfra 21-1 * 949,500 1,234,000 1,329,000 1,424,000 1,519,000
177 β-HCG * 733,500 954,000 1,027,000 1,100,000 1,174,000
178 Anti EBV VCA – IGA * 1,998,000 2,597,000 2,797,000 2,997,000 3,197,000
179 Anti-EBV-EA IGA &* 1,197,000 1,556,000 1,676,000 1,796,000 1,915,000
180 Anti-EBV-NA IGA * 769,500 1,000,000 1,077,000 1,154,000 1,231,000
181 Anti EBV VCA – IgG * 1,327,500 1,726,000 1,859,000 1,991,000 2,124,000
182 Anti EBV EA – IgG * 1,138,500 1,480,000 1,594,000 1,708,000 1,822,000
183 Anti EBV VCA – IgM * 1,530,000 1,989,000 2,142,000 2,295,000 2,448,000
184 Anti EBV EA – IgM * 1,912,500 2,486,000 2,678,000 2,869,000 3,060,000
Alergi
185 IGE Total * 486,000 632,000 680,000 729,000 778,000
186 IGE Spesifik (Rast) * 1,980,000 2,574,000 2,772,000 2,970,000 3,168,000
187 Panel Alergi Atopi 44* 2,353,500 3,060,000 3,295,000 3,530,000 3,766,000
188 Panel Alergi Atopi 54* 2,353,500 3,060,000 3,295,000 3,530,000 3,766,000
189 Panel Alergi Inhalasi * 2,124,000 2,761,000 2,974,000 3,186,000 3,398,000
190 Panel Alergi Makanan Asia * 2,124,000 2,761,000 2,974,000 3,186,000 3,398,000
191 LgE Atopi Ingestant * 2,097,000 2,726,000 2,936,000 3,146,000 3,355,000
192 Rast Debu Rumah * 724,500 942,000 1,014,000 1,087,000 1,159,000
193 Rast Tungau Debu Rumah * 738,000 959,000 1,033,000 1,107,000 1,181,000
194 Rast Aspergilus * 688,500 895,000 964,000 1,033,000 1,102,000
195 Rast Penicilin * 796,500 1,035,000 1,115,000 1,195,000 1,274,000
196 Rast Penicilium N * 702,000 913,000 983,000 1,053,000 1,123,000
197 Rast Kuning Telur * 724,500 942,000 1,014,000 1,087,000 1,159,000
198 Rast Susu * 724,500 942,000 1,014,000 1,087,000 1,159,000
199 Rast Udang * 724,500 942,000 1,014,000 1,087,000 1,159,000
200 Rast Soy-Bean/Kedelai * 751,500 977,000 1,052,000 1,127,000 1,202,000
Serologi Umum
201 Asto Semikuantitatif 225,000 293,000 315,000 338,000 360,000
202 Asto 207,000 269,000 290,000 311,000 331,000
203 Asto Kuantitatif 292,500 380,000 410,000 439,000 468,000
204 CRP Kuantitatif = HS CRP 342,000 445,000 479,000 513,000 547,000
205 Procalcitonin 1,282,500 1,667,000 1,796,000 1,924,000 2,052,000
206 Ra Factor Kualitatif 247,500 322,000 347,000 371,000 396,000
207 Anti-CCP * 1,156,500 1,503,000 1,619,000 1,735,000 1,850,000
208 HLA-B27 * 3,285,000 4,271,000 4,599,000 4,928,000 5,256,000
209 ANA Elisa * 1,116,000 1,451,000 1,562,000 1,674,000 1,786,000
210 ANA Imunofluoresen* 1,854,000 2,410,000 2,596,000 2,781,000 2,966,000
211 ANA Profile * 1,552,500 2,018,000 2,174,000 2,329,000 2,484,000
212 ANA Panel (ANA IF + ANA Profile) * 2,254,500 2,931,000 3,156,000 3,382,000 3,607,000
213 Anti DS DNA * 859,500 1,117,000 1,203,000 1,289,000 1,375,000
214 ANCA * 945,000 1,229,000 1,323,000 1,418,000 1,512,000
215 Ant. Microsomal-Ab (AMA) * 288,000 374,000 403,000 432,000 461,000
216 Ant. Striated Ms * 175,500 228,000 246,000 263,000 281,000
217 Komplemen C3 & C4 * 1,647,000 2,141,000 2,306,000 2,471,000 2,635,000
218 C3 Complemen * 756,000 983,000 1,058,000 1,134,000 1,210,000
219 C4 Complemen * 756,000 983,000 1,058,000 1,134,000 1,210,000
220 IgG Kuantitatif * 760,500 989,000 1,065,000 1,141,000 1,217,000
221 IgA Kuantitatif * 693,000 901,000 970,000 1,040,000 1,109,000
222 IgM Kuantitatif * 760,500 989,000 1,065,000 1,141,000 1,217,000
223 Elektroforesis Imunofiksasi * 999,000 1,299,000 1,399,000 1,499,000 1,598,000
224 CD 4 * 409,500 532,000 573,000 614,000 655,000
225 CD 8 * 409,500 532,000 573,000 614,000 655,000
226 CD 34 760,500 989,000 1,065,000 1,141,000 1,217,000
Pemantauan Obat / Tdm
227 Teofilin/Aminofilin* 1,890,000 2,457,000 2,646,000 2,835,000 3,024,000
228 Digoxin * 1,431,000 1,860,000 2,003,000 2,147,000 2,290,000
229 Fenobarbital * 2,565,000 3,335,000 3,591,000 3,848,000 4,104,000
230 Karbamazepin* 1,557,000 2,024,000 2,180,000 2,336,000 2,491,000
231 Asam Valproat (Valproic Acid) * 2,137,500 2,779,000 2,993,000 3,206,000 3,420,000
232 Tacrolimus * 1,120,500 1,457,000 1,569,000 1,681,000 1,793,000
233 Siklosporin (Cyclosporin)* 1,678,500 2,182,000 2,350,000 2,518,000 2,686,000
234 Gentamisin * 949,500 1,234,000 1,329,000 1,424,000 1,519,000
235 Phenytoin / Dilatin * 1,210,500 1,574,000 1,695,000 1,816,000 1,937,000
Infeksi Lain
236 Widal Uji Slide 112,500 146,000 158,000 169,000 180,000
237 Anti-Salmonella Typhi IgM (Tubex) 247,500 322,000 347,000 371,000 396,000
238 Anti-Salmonella Typhi IgM Rapid 445,500 579,000 624,000 668,000 713,000
239 Salmonella IgG * 450,000 585,000 630,000 675,000 720,000
240 Dengue Ns1 Ag (Rapid) 441,000 573,000 617,000 662,000 706,000
241 Anti Dengue IgG Dan IgM 945,000 1,229,000 1,323,000 1,418,000 1,512,000
242 Malaria Antigen 324,000 421,000 454,000 486,000 518,000
243 Anti-H. Pylori IgG & IgM (Rapid) * 1,840,500 2,393,000 2,577,000 2,761,000 2,945,000
244 Helicobacter Pylory IgG * 913,500 1,188,000 1,279,000 1,370,000 1,462,000
245 Helicobacter Pylory IgM * 900,000 1,170,000 1,260,000 1,350,000 1,440,000
246 Leptospira IgM Elisa * 976,500 1,269,000 1,367,000 1,465,000 1,562,000
247 Anti-Leptospira IgM (Rapid) * 513,000 667,000 718,000 770,000 821,000
248 Measles IgG * 1,876,500 2,439,000 2,627,000 2,815,000 3,002,000
249 Measles IgM * 2,173,500 2,826,000 3,043,000 3,260,000 3,478,000
250 Anti Amuba * 589,500 766,000 825,000 884,000 943,000
251 Monotest Rapid * 409,500 532,000 573,000 614,000 655,000
252 Anti-Chikungunya IgM * 598,500 778,000 838,000 898,000 958,000
253 Anti-Mycoplasma IgG & IgM * 3,676,500 4,779,000 5,147,000 5,515,000 5,882,000
254 Anti Micoplasma IgG * 1,795,500 2,334,000 2,514,000 2,693,000 2,873,000
255 Anti Micoplasma IgM * 1,795,500 2,334,000 2,514,000 2,693,000 2,873,000
256 Serologi Jamur (Candida) * 418,500 544,000 586,000 628,000 670,000
257 Serologi Jamur * 1,836,000 2,387,000 2,570,000 2,754,000 2,938,000
258 Serologi Jamur (Histoplasma) * 427,500 556,000 599,000 641,000 684,000
259 Serologi Jamur (Aspergillus) * 436,500 567,000 611,000 655,000 698,000
260 Serologi Jamur (Cryptococcus) * 648,000 842,000 907,000 972,000 1,037,000
261 Paket Serologi Jamur * 2,727,000 3,545,000 3,818,000 4,091,000 4,363,000
262 Anti TB IgG * 369,000 480,000 517,000 554,000 590,000
TORCH
263 Anti-Toxoplasma IgG & IgM * 945,000 1,229,000 1,323,000 1,418,000 1,512,000
264 Toxoplasma IgG 427,500 556,000 599,000 641,000 684,000
265 Toxoplasma IgM * 477,000 620,000 668,000 716,000 763,000
266 Anti-Rubella IgG * 481,500 626,000 674,000 722,000 770,000
267 Anti-Rubella IgM * 598,500 778,000 838,000 898,000 958,000
268 Anti-CMV IgG & IgM * 1,147,500 1,492,000 1,607,000 1,721,000 1,836,000
269 CMV IgM 598,500 778,000 838,000 898,000 958,000
270 CMV IgG * 423,000 550,000 592,000 635,000 677,000
271 Anti-HSV 2 IgG & IgM * 931,500 1,211,000 1,304,000 1,397,000 1,490,000
272 Anti-HSV 1 IgG & IgM * 1,030,500 1,340,000 1,443,000 1,546,000 1,649,000
273 Anti HSV 1 IgG * 580,500 755,000 813,000 871,000 929,000
274 Anti HSV 1 IgM * 598,500 778,000 838,000 898,000 958,000
275 Anti HSV 2 IgG * 526,500 684,000 737,000 790,000 842,000
276 Anti HSV 2 IgM * 540,000 702,000 756,000 810,000 864,000
277 Aviditas Anti-Toxo IgG * 1,449,000 1,884,000 2,029,000 2,174,000 2,318,000
278 Aviditas Anti-CMV IgG * 1,629,000 2,118,000 2,281,000 2,444,000 2,606,000
279 TORCH 4,693,500 6,102,000 6,571,000 7,040,000 7,510,000
Hipofisis-Adrenal-Lainnya
280 Growth Hormon * 715,500 930,000 1,002,000 1,073,000 1,145,000
281 Somatomedin (IGF - I) * 1,206,000 1,568,000 1,688,000 1,809,000 1,930,000
282 Prolactin * 513,000 667,000 718,000 770,000 821,000
283 LH * 580,500 755,000 813,000 871,000 929,000
284 FSH * 603,000 784,000 844,000 905,000 965,000
285 Parathyroid Hormon (PTH) * 936,000 1,217,000 1,310,000 1,404,000 1,498,000
286 25,OH-Vit D 778,500 1,012,000 1,090,000 1,168,000 1,246,000
287 Cortisol (Darah / Urin 24 Jam) * 1,192,500 1,550,000 1,670,000 1,789,000 1,908,000
288 Cortisol * 850,500 1,106,000 1,191,000 1,276,000 1,361,000
289 Aktivitas Renin * 2,974,500 3,867,000 4,164,000 4,462,000 4,759,000
290 Aldosteron * 2,875,500 3,738,000 4,026,000 4,313,000 4,601,000
291 Dhea-S * 999,000 1,299,000 1,399,000 1,499,000 1,598,000
Tiroid
292 T3 Total * 409,500 532,000 573,000 614,000 655,000
293 FT3 * 657,000 854,000 920,000 986,000 1,051,000
294 T4 Total 400,500 521,000 561,000 601,000 641,000
295 FT4 463,500 603,000 649,000 695,000 742,000
296 FTI * 1,260,000 1,638,000 1,764,000 1,890,000 2,016,000
297 TSH S 373,500 486,000 523,000 560,000 598,000
298 TSH Neonatus * 409,500 532,000 573,000 614,000 655,000
299 T3 Uptake * 850,500 1,106,000 1,191,000 1,276,000 1,361,000
300 Thyroglobulin(hTG) * 810,000 1,053,000 1,134,000 1,215,000 1,296,000
301 Anti-Thyroglobulin (ATg) * 549,000 714,000 769,000 824,000 878,000
302 Ant Tirogl. Ag (ATA) * 526,500 684,000 737,000 790,000 842,000
303 Anti-TPO * 1,102,500 1,433,000 1,544,000 1,654,000 1,764,000
304 TSH Receptor Ab (TRAB) * 2,218,500 2,884,000 3,106,000 3,328,000 3,550,000
305 Calcitonin * 1,737,000 2,258,000 2,432,000 2,606,000 2,779,000
306 Testosteron Total * 666,000 866,000 932,000 999,000 1,066,000
307 Testosteron Bebas (Free Testo) * 2,844,000 3,697,000 3,982,000 4,266,000 4,550,000
308 Dehydrotestosteron(DHT) * 1,836,000 2,387,000 2,570,000 2,754,000 2,938,000
309 Testosteron Bioavailable (Saliva) * 976,500 1,269,000 1,367,000 1,465,000 1,562,000
310 Estradiol * 702,000 913,000 983,000 1,053,000 1,123,000
311 Estradiol Bioavailable (Saliva) * 976,500 1,269,000 1,367,000 1,465,000 1,562,000
312 Progesteron * 738,000 959,000 1,033,000 1,107,000 1,181,000
313 Progesteron Bioavailable (Saliva) * 976,500 1,269,000 1,367,000 1,465,000 1,562,000
314 Hormon Anti-Mullerian (AMH) * 1,161,000 1,509,000 1,625,000 1,742,000 1,858,000
315 Estriol * 1,615,500 2,100,000 2,262,000 2,423,000 2,585,000
PCR Biomolekular
316 PCR Salmonella * 810,000 1,053,000 1,134,000 1,215,000 1,296,000
317 PCR Mycobacterium Tb * 981,000 1,275,000 1,373,000 1,472,000 1,570,000
318 PCR Dengue * 832,500 1,082,000 1,166,000 1,249,000 1,332,000
319 HBV-DNA Kuantitatif * 3,474,000 4,516,000 4,864,000 5,211,000 5,558,000
320 HBV-DNA Genotype * 1,674,000 2,176,000 2,344,000 2,511,000 2,678,000
321 HCV RNA Kuantitatif * 4,257,000 5,534,000 5,960,000 6,386,000 6,811,000
322 HCV Genotip * 6,313,500 8,208,000 8,839,000 9,470,000 10,102,000
323 PCR Malaria * 684,000 889,000 958,000 1,026,000 1,094,000
324 PCR CMV * 850,500 1,106,000 1,191,000 1,276,000 1,361,000
325 PCR HZV * 850,500 1,106,000 1,191,000 1,276,000 1,361,000
326 PCR HSV 1 Dan 2 * 1,021,500 1,328,000 1,430,000 1,532,000 1,634,000
327 HPV DNA Screening * 1,161,000 1,509,000 1,625,000 1,742,000 1,858,000
328 Adenin D-Aminase * 684,000 889,000 958,000 1,026,000 1,094,000
329 HPV DNA High Risk * 1,269,000 1,650,000 1,777,000 1,904,000 2,030,000
330 PCR HIV (Viral Load) * 1,939,500 2,521,000 2,715,000 2,909,000 3,103,000
331 PCR Chlamydia Trachomatis * 2,083,500 2,709,000 2,917,000 3,125,000 3,334,000
332 IFN Y (Gamma Interferon, Elisa) * 1,192,500 1,550,000 1,670,000 1,789,000 1,908,000
333 HPV DNA Genotype * 1,840,500 2,393,000 2,577,000 2,761,000 2,945,000
URINE
Urinalisis
334 Urine Lengkap (Makro, Mikroskopik, Kimia) 80,000 104,000 112,000 120,000 128,000
335 Urin Sedimen (Mikroskopik) 94,500 123,000 132,000 142,000 151,000
336 Protein Bence Jones 180,000 234,000 252,000 270,000 288,000
337 Protein Esbach 148,500 193,000 208,000 223,000 238,000
338 Rasio Albumin / Kreatinin (Urin Pagi) * 315,000 410,000 441,000 473,000 504,000
339 Mikroalbuminuria(Urin 24 Jam) * 216,000 281,000 302,000 324,000 346,000
340 Proteinuria Kuantitatif (Urin 24 Jam) 333,000 433,000 466,000 500,000 533,000
341 Asam Urat (Urin 24 Jam) 157,500 205,000 221,000 236,000 252,000
342 Osmolalitas Urin * 643,500 837,000 901,000 965,000 1,030,000
343 Uji Kehamilan β-HCG (Rapid Test) 135,000 176,000 189,000 203,000 216,000
344 ImmunoelektroforesisProtein Urin * 549,000 714,000 769,000 824,000 878,000
345 BCG Titrasi 499,500 649,000 699,000 749,000 799,000
346 Albumin Urine 67,500 88,000 95,000 101,000 108,000
347 Ureum Urin 157,500 205,000 221,000 236,000 252,000
348 Creatinine Urine 94,500 123,000 132,000 142,000 151,000
349 Asam Urat Urine 157,500 205,000 221,000 236,000 252,000
350 Elektrolit Urine 256,500 333,000 359,000 385,000 410,000
351 Fosfor Anorg 144,000 187,000 202,000 216,000 230,000
352 Amylase Urin 337,500 439,000 473,000 506,000 540,000
353 Estradiol Urin * 486,000 632,000 680,000 729,000 778,000
354 VMA * 171,000 222,000 239,000 257,000 274,000
355 Aldosteron Urine * 2,124,000 2,761,000 2,974,000 3,186,000 3,398,000
356 Cortisol Urine * 472,500 614,000 662,000 709,000 756,000
357 17 Ketosteroid * 414,000 538,000 580,000 621,000 662,000
358 Calsium Urin * 144,000 187,000 202,000 216,000 230,000
359 Magnesium Urin * 171,000 222,000 239,000 257,000 274,000
360 5 - HIAA * 612,000 796,000 857,000 918,000 979,000
361 Electrolyte Urine = Elektrolit Darah Na/K/Cl 256,500 333,000 359,000 385,000 410,000
Drug Abuse
362 Amfetamin (Ectasy, Shabu-Shabu) 193,500 252,000 271,000 290,000 310,000
363 Metamfetamin 193,500 252,000 271,000 290,000 310,000
364 Barbital / Barbiturat * 189,000 246,000 265,000 284,000 302,000
365 Diazepam / Benzodiazepin 193,500 252,000 271,000 290,000 310,000
366 Cannabis (Ganja, Marijuana) 193,500 252,000 271,000 290,000 310,000
367 Cocaine 193,500 252,000 271,000 290,000 310,000
368 Morfin (Opiat, Heroin) 193,500 252,000 271,000 290,000 310,000
369 Phencylidine (PCP) * 198,000 257,000 277,000 297,000 317,000
370 Opiate Urin 193,500 252,000 271,000 290,000 310,000
371 Alkohol * 657,000 854,000 920,000 986,000 1,051,000
Lain-Lain
372 Anti Trombosit * 369,000 480,000 517,000 554,000 590,000
373 Analisis Sperma 427,500 556,000 599,000 641,000 684,000
374 Analisis Sperma (Androlog) 427,500 556,000 599,000 641,000 684,000
375 Antibodi Thdp Sperma * 810,000 1,053,000 1,134,000 1,215,000 1,296,000
376 Analisis Batu Ginjal * 427,500 556,000 599,000 641,000 684,000
377 Analisis Batu Empedu * 261,000 339,000 365,000 392,000 418,000
378 Pewarnaan BTA 261,000 339,000 365,000 392,000 418,000
379 Pewarnaan Neisser * 315,000 410,000 441,000 473,000 504,000
380 Pewarnaan Gram 504,000 655,000 706,000 756,000 806,000
381 Sudan Black B * 625,500 813,000 876,000 938,000 1,001,000
382 Pewarnaan & Hitung NAP * 733,500 954,000 1,027,000 1,100,000 1,174,000
383 A-1 Antitrypsin * 351,000 456,000 491,000 527,000 562,000
384 Chylus * 157,500 205,000 221,000 236,000 252,000
385 Urea Breath Test * 1,885,500 2,451,000 2,640,000 2,828,000 3,017,000
386 Osmolalitas Darah * 576,000 749,000 806,000 864,000 922,000
387 Pb (Plumbum/Timbal)* 216,000 281,000 302,000 324,000 346,000
388 Crossmatching 193,500 252,000 271,000 290,000 310,000
389 Albumin Glikat * 351,000 456,000 491,000 527,000 562,000
390 AVP (Arginin Vasopresin) / ADH * 2,430,000 3,159,000 3,402,000 3,645,000 3,888,000
391 Lithium * 814,500 1,059,000 1,140,000 1,222,000 1,303,000
392 IGRA Test 1,251,000 1,626,000 1,751,000 1,877,000 2,002,000
393 Analisa Batu Ureter * 522,000 679,000 731,000 783,000 835,000
394 Sugar Test * 351,000 456,000 491,000 527,000 562,000
395 Uji Ham Test * 351,000 456,000 491,000 527,000 562,000
396 Imunofiksasi * 706,500 918,000 989,000 1,060,000 1,130,000
397 BCR ABL Qualitative * 2,232,000 2,902,000 3,125,000 3,348,000 3,571,000
398 BCR ABL Kuantitatif * 3,505,500 4,557,000 4,908,000 5,258,000 5,609,000
399 JAK 2 * 2,605,500 3,387,000 3,648,000 3,908,000 4,169,000
400 Analisis Cairan Acites * 387,000 503,000 542,000 581,000 619,000
401 Screening Rectal Swab * 180,000 234,000 252,000 270,000 288,000
402 Imunophenotyping* 1,273,500 1,656,000 1,783,000 1,910,000 2,038,000
403 Nutri Genme 9,900,000 12,870,000 13,860,000 14,850,000 15,840,000
404 Qiastat - DX Respiratory Panel 2,700,000 3,510,000 3,780,000 4,050,000 4,320,000
405 Qiastat - DX GI Panel 2,700,000 3,510,000 3,780,000 4,050,000 4,320,000
406 Screening COVID-19 900,000 1,170,000 1,260,000 1,350,000 1,440,000
Faeces/Tinja
407 Tinja Rutin (Makro, Mikroskopik) 94,500 123,000 132,000 142,000 151,000
408 Tinja Lengkap (TR, Pencernaan, Darah Samar) 360,000 468,000 504,000 540,000 576,000
409 Darah Samar Faeces 171,000 222,000 239,000 257,000 274,000
410 Pencernaan 360,000 468,000 504,000 540,000 576,000
411 Clostridium Difficile Rapid Test * 643,500 837,000 901,000 965,000 1,030,000
412 Faecal Clostridium Dificille Toksin * 657,000 854,000 920,000 986,000 1,051,000
413 Rotavirus Ag Rapid Taest * 481,500 626,000 674,000 722,000 770,000
Cairan Tubuh (Disertai Spesimen Darah)
414 Analisis Cairan Pleura (Disertai Darah) 684,000 889,000 958,000 1,026,000 1,094,000
415 Analisis Cairan Sendi (Disertai Darah) 765,000 995,000 1,071,000 1,148,000 1,224,000
416 Analisis Cairan Otak (Disertai Darah) 765,000 995,000 1,071,000 1,148,000 1,224,000
417 Body Fluid Amylase 337,500 439,000 473,000 506,000 540,000
418 Body Fluid Glucose 54,000 70,000 76,000 81,000 86,000
419 Body Fluid Total Protein 243,000 316,000 340,000 365,000 389,000
420 Body Fluid LDH 121,500 158,000 170,000 182,000 194,000
421 CSF Chloride 94,500 123,000 132,000 142,000 151,000
422 CSF Glucosa 54,000 70,000 76,000 81,000 86,000
423 Nonne 40,500 53,000 57,000 61,000 65,000
424 Pandy 76,500 99,000 107,000 115,000 122,000
425 Transudat Eksudat 535,500 696,000 750,000 803,000 857,000
426 Rivalta 76,500 99,000 107,000 115,000 122,000
427 Analisa Cairan Tubuh Lain-Lain 589,500 766,000 825,000 884,000 943,000
Parasit - Jamur
428 Trichomonas 112,500 146,000 158,000 169,000 180,000
429 Candida 391,500 509,000 548,000 587,000 626,000
430 Amuba 112,500 146,000 158,000 169,000 180,000
431 Cacing 112,500 146,000 158,000 169,000 180,000
432 Kerokan Kulit 112,500 146,000 158,000 169,000 180,000
Mikrobiologi
433 Sediaan Langsung Koh (Jamur) 112,500 146,000 158,000 169,000 180,000
434 Sediaan Langsung Tinta India Crytococcus * 148,500 193,000 208,000 223,000 238,000
435 Test Sensitivitas Antibiotika 562,500 731,000 788,000 844,000 900,000
436 Biakan BTA Dan Sensitivitas Antibiotik * 679,500 883,000 951,000 1,019,000 1,087,000
437 Biakan Kuman Dan Sensitivitas Antibiotik 679,500 883,000 951,000 1,019,000 1,087,000
438 Biakan Anaerob Dan Sensitivitas Antibiotik 679,500 883,000 951,000 1,019,000 1,087,000
439 Sediaan Langsung BTA II 112,500 146,000 158,000 169,000 180,000
440 Sediaan Langsung BTA III 112,500 146,000 158,000 169,000 180,000
441 Sediaan Langsung Trichomonas 112,500 146,000 158,000 169,000 180,000
442 Screening MRSA 562,500 731,000 788,000 844,000 900,000
443 Sediaan Langsung Gram 112,500 146,000 158,000 169,000 180,000
444 Sediaan Langsung BTA 112,500 146,000 158,000 169,000 180,000
445 Sediaan Langsung Diptheri * 112,500 146,000 158,000 169,000 180,000
446 Sediaan Langsung BTA & Gram 220,500 287,000 309,000 331,000 353,000
447 Kultur + Resist 562,500 731,000 788,000 844,000 900,000
448 Sediaan Langsung Tinta India Crytococcus * 148,500 193,000 208,000 223,000 238,000
449 Biakan Jamur 679,500 883,000 951,000 1,019,000 1,087,000
450 Analisa Faeces 427,500 556,000 599,000 641,000 684,000
451 Parasitologi Faeces * 256,500 333,000 359,000 385,000 410,000
452 Gene-Expert TB * 94,500 123,000 132,000 142,000 151,000
Pathology Anatomy
453 PA Small Histology (Jar Kecil < 3Cm) * 715,500 930,000 1,002,000 1,073,000 1,145,000
454 PA Small Histology (Jar Kecil < 3Cm) Cito* 922,500 1,199,000 1,292,000 1,384,000 1,476,000
455 PA Medium Histology (Jar Kecil 3-6Cm) * 1,039,500 1,351,000 1,455,000 1,559,000 1,663,000
456 PA Medium Histology (Jar Kecil 3-6Cm) Cito * 1,296,000 1,685,000 1,814,000 1,944,000 2,074,000
457 PA Large Histology (Jar Besar >6Cm) * 1,426,500 1,854,000 1,997,000 2,140,000 2,282,000
458 PA Large Histology (Jar Besar >6Cm) Cito * 2,043,000 2,656,000 2,860,000 3,065,000 3,269,000
459 Konsul Slide (1-2 Slide) * 247,500 322,000 347,000 371,000 396,000
460 Konsul Slide (1-2 Slide) Cito * 490,500 638,000 687,000 736,000 785,000
461 Konsul Blok (1-2 Blok) * 409,500 532,000 573,000 614,000 655,000
462 Konsul Blok (1-2 Blok) Cito* 814,500 1,059,000 1,140,000 1,222,000 1,303,000
463 Frozen Section * 3,712,500 4,826,000 5,198,000 5,569,000 5,940,000
464 Frozen Section + Batas Sayatan * 4,450,500 5,786,000 6,231,000 6,676,000 7,121,000
465 Biaya Persiapan VC * 1,215,000 1,580,000 1,701,000 1,823,000 1,944,000
466 Biopsi (Hati, Ginjal, Susum Tulang) * 1,138,500 1,480,000 1,594,000 1,708,000 1,822,000
467 Biopsi (Hati, Ginjal, Susum Tulang) Cito* 1,503,000 1,954,000 2,104,000 2,255,000 2,405,000
468 Biopsi (Oesophagus,Gaster,Colon)1-2Botol * 976,500 1,269,000 1,367,000 1,465,000 1,562,000
469 Biopsi (Oesophagus,Gaster,Colon)1-2Botol Cito* 1,273,500 1,656,000 1,783,000 1,910,000 2,038,000
470 Biopsi (Oesophagus,Gaster,Colon)3-4Botol * 1,296,000 1,685,000 1,814,000 1,944,000 2,074,000
471 Biopsi (Oesophagus,Gaster,Colon)3-4Botol Cito* 1,503,000 1,954,000 2,104,000 2,255,000 2,405,000
472 Pap Smear Konvesional * 288,000 374,000 403,000 432,000 461,000
473 Pap Smear Konvesional Cito * 387,000 503,000 542,000 581,000 619,000
474 Pap Smear Dengan Tindakan * 310,500 404,000 435,000 466,000 497,000
475 Pap Smear Dengan Tindakan Cito * 504,000 655,000 706,000 756,000 806,000
476 Pap Smear Thinprep * 571,500 743,000 800,000 857,000 914,000
477 Pap Smear Thinprep Cito* 733,500 954,000 1,027,000 1,100,000 1,174,000
478 Pap Smear Cell Prep * 571,500 743,000 800,000 857,000 914,000
479 Pap Smear Paket Hormonal * 733,500 954,000 1,027,000 1,100,000 1,174,000
480 Pap Smear Paket Hormonal Cito * 940,500 1,223,000 1,317,000 1,411,000 1,505,000
481 Sitopatologi Sputum/Sikatan 1X * 558,000 725,000 781,000 837,000 893,000
482 Sitopatologi Sputum/Sikatan 1X Cito * 549,000 714,000 769,000 824,000 878,000
483 Sitopatologi Sputum/Sikatan 3X * 738,000 959,000 1,033,000 1,107,000 1,181,000
484 Sitopatologi Sputum/Sikatan 3X Cito * 994,500 1,293,000 1,392,000 1,492,000 1,591,000
485 Sitopatologi Cairan Urin 1X * 702,000 913,000 983,000 1,053,000 1,123,000
486 Sitopatologi Cairan Urin 1X Cito * 895,500 1,164,000 1,254,000 1,343,000 1,433,000
487 Sitopatologi Cairan/Bilasan Lain-Lain * 648,000 842,000 907,000 972,000 1,037,000
488 Sitopatologi Cairan/Bilasan Lain-Lain Cito * 882,000 1,147,000 1,235,000 1,323,000 1,411,000
489 FNAB Tanpa Tindakan * 648,000 842,000 907,000 972,000 1,037,000
490 FNAB Tanpa Tindakan Cito* 882,000 1,147,000 1,235,000 1,323,000 1,411,000
491 FNAB Dengan Tindakan * 1,458,000 1,895,000 2,041,000 2,187,000 2,333,000
492 FNAB Dengan Tindakan Cito * 1,620,000 2,106,000 2,268,000 2,430,000 2,592,000
493 Konsul Slide Sitopatologi (1-2 Slide) * 247,500 322,000 347,000 371,000 396,000
494 Konsul Slide Sitopatologi (1-2 Slide) Cito * 490,500 638,000 687,000 736,000 785,000
495 Gomori - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
496 PAS - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
497 PAS - Diastase - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
498 Alcian Blue - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
499 Trichrom - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
500 Mucicarmin - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
501 Retikulin - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
502 Ziehl Nieelsen (BTA) - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
503 Fite Faraco - Histokimia (1 -2 Slaid) * 207,000 269,000 290,000 311,000 331,000
504 Imunohistokimia Er-Pr C-Erb-B2 Ki-67 Topoisomerase 2 Alfa 2,511,000 3,264,000 3,515,000 3,767,000 4,018,000
505 Imunohistokimia 1 Antibody * 1,179,000 1,533,000 1,651,000 1,769,000 1,886,000
506 Imunohistokimia Paket Limfoma Kasus Sukar * 3,712,500 4,826,000 5,198,000 5,569,000 5,940,000
507 Imunohistokimia Paket Gist * 3,712,500 4,826,000 5,198,000 5,569,000 5,940,000
508 Imunohistokimia Paket Fish * 5,967,000 7,757,000 8,354,000 8,951,000 9,547,000
509 Imunohistokima ISH Per Probe * 2,821,500 3,668,000 3,950,000 4,232,000 4,514,000
510 Imunohistokimia Mutasi K-Ras * 4,549,500 5,914,000 6,369,000 6,824,000 7,279,000
511 Imunohistokimia Mutasi N-RAS * 4,153,500 5,400,000 5,815,000 6,230,000 6,646,000
512 Imunohistokimia Mutasi All RAS (K-RAS & N-RAS) * 6,232,500 8,102,000 8,726,000 9,349,000 9,972,000
513 Imunohistokimia Cish * 4,279,500 5,563,000 5,991,000 6,419,000 6,847,000
514 ImunofluoresensiGinjal /Kulit * 702,000 913,000 983,000 1,053,000 1,123,000
515 Mutasi EGFR * 6,534,000 8,494,000 9,148,000 9,801,000 10,454,000
516 HPV Genotyping 33 Type * 1,251,000 1,626,000 1,751,000 1,877,000 2,002,000
517 M2PK * 688,500 895,000 964,000 1,033,000 1,102,000
518 Paket Imunohistokimia KRAS, NRAS, BRAF * 9,270,000 12,051,000 12,978,000 13,905,000 14,832,000
519 Imunohistokimia BRAF Mutation Test * 3,415,500 4,440,000 4,782,000 5,123,000 5,465,000
520 ACTH * 2,772,000 3,604,000 3,881,000 4,158,000 4,435,000
521 IgG Food Detective * 2,794,500 3,633,000 3,912,000 4,192,000 4,471,000
BANK DARAH
Kantong Darah Biasa
522 Packed Red Cell (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
523 Whole Blood (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
524 Fresh Frozen Plasma (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
525 Cryo Presipitate (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
526 Anti Haemophilic Faktor (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
527 Lekodeplatate(Kantong+Screening+Croosmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
528 Washed Eritrosit (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
529 Platelet Concentrate (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
530 Liquid Plasma (Kantong+Screening+Crossmatch)* 981,000 1,275,000 1,373,000 1,472,000 1,570,000
531 Thrombopheresis(Kantong+Screening+Crossmatch)* 5,512,500 7,166,000 7,718,000 8,269,000 8,820,000
Kantong Darah NAT
532 Packed Red Cell NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
533 Whole Blood NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
534 Fresh Frozen Plasma NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
535 Cryo Presipitate NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
536 Anti Haemophilic Faktor NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
537 Lekodeplatate NAT PMI (Kantong+Croosmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
538 Washed Eritrosit NAT PMI(Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
539 Platelet Concentrate NAT PMI (Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
540 Liquid Plasma NAT PMI(Kantong+Crossmatch)* 877,500 1,141,000 1,229,000 1,316,000 1,404,000
541 Thrombopheresis NAT PMI (Kantong+Crossmatch)* 5,926,500 7,704,000 8,297,000 8,890,000 9,482,000
542 TC Pooled (Leukodepleted) 5,598,000 7,277,000 7,837,000 8,397,000 8,957,000
543 PRC Dengan Filter (Leukodepleted) NAT 1,035,000 1,346,000 1,449,000 1,553,000 1,656,000
Catatan :
* Laboratorium Cito tarif Naik 30%
ROYAL CRITICAL
SUITE CARE

199,000 176,000
221,000 195,000
255,000 225,000
122,000 108,000
168,000 149,000
168,000 149,000
168,000 149,000
92,000 81,000
413,000 365,000
490,000 432,000
1,484,000 1,310,000
1,935,000 1,708,000
1,209,000 1,067,000
191,000 169,000
115,000 101,000
1,132,000 999,000
260,000 230,000
490,000 432,000
107,000 95,000
191,000 169,000

964,000 851,000
3,343,000 2,950,000
8,384,000 7,398,000
92,000 81,000
92,000 81,000
92,000 81,000
413,000 365,000
413,000 365,000
887,000 783,000
2,341,000 2,066,000
513,000 452,000
490,000 432,000
604,000 533,000
638,000 563,000
666,000 587,000
666,000 587,000
1,951,000 1,721,000

1,278,000 1,127,000
1,224,000 1,080,000
1,224,000 1,080,000
4,276,000 3,773,000
3,710,000 3,274,000
1,913,000 1,688,000
2,134,000 1,883,000
1,224,000 1,080,000
3,488,000 3,078,000
1,905,000 1,681,000
1,851,000 1,634,000
2,685,000 2,369,000
2,456,000 2,167,000

849,000 749,000
291,000 257,000
1,148,000 1,013,000
1,346,000 1,188,000
444,000 392,000
1,553,000 1,370,000
344,000 304,000
344,000 304,000
734,000 648,000
857,000 756,000
2,119,000 1,870,000
2,387,000 2,106,000
314,000 277,000
337,000 297,000

474,000 419,000
145,000 128,000
612,000 540,000
505,000 446,000
344,000 304,000
367,000 324,000
245,000 216,000
214,000 189,000
122,000 108,000
122,000 108,000
176,000 155,000
161,000 142,000
1,507,000 1,330,000
1,882,000 1,661,000
1,392,000 1,229,000
1,423,000 1,256,000
6,464,000 5,704,000

788,000 695,000
581,000 513,000
367,000 324,000
1,125,000 992,000
1,438,000 1,269,000
283,000 250,000
1,178,000 1,040,000
1,117,000 986,000

122,000 108,000
130,000 115,000
130,000 115,000
1,040,000 918,000
122,000 108,000
291,000 257,000
291,000 257,000
1,890,000 1,667,000
1,232,000 1,087,000

490,000 432,000
176,000 155,000
681,000 601,000
176,000 155,000
252,000 223,000
765,000 675,000
1,385,000 1,222,000
161,000 142,000
1,446,000 1,276,000

92,000 81,000
85,000 75,000
85,000 75,000
436,000 385,000
268,000 236,000
383,000 338,000
1,086,000 959,000
1,086,000 959,000
1,132,000 999,000
1,132,000 999,000
604,000 533,000
589,000 520,000
3,573,000 3,152,000

750,000 662,000
704,000 621,000
551,000 486,000

119,000 105,000
213,000 188,000
145,000 128,000
122,000 108,000
734,000 648,000
734,000 648,000
505,000 446,000
864,000 763,000
1,063,000 938,000
1,408,000 1,242,000
275,000 243,000
222,000 196,000

566,000 500,000
1,782,000 1,573,000
1,928,000 1,701,000
1,928,000 1,701,000
1,385,000 1,222,000
1,431,000 1,262,000
1,362,000 1,202,000

1,431,000 1,262,000
1,232,000 1,087,000
291,000 257,000
245,000 216,000
2,678,000 2,363,000
344,000 304,000
1,010,000 891,000
1,476,000 1,303,000
1,316,000 1,161,000
1,721,000 1,519,000
627,000 554,000
750,000 662,000
1,683,000 1,485,000
5,646,000 4,982,000
5,791,000 5,110,000

222,000 196,000
283,000 250,000
1,086,000 959,000
689,000 608,000
803,000 709,000
1,851,000 1,634,000
3,259,000 2,876,000
1,958,000 1,728,000
1,958,000 1,728,000

849,000 749,000
566,000 500,000
1,469,000 1,296,000
1,002,000 884,000
788,000 695,000
2,165,000 1,910,000
1,431,000 1,262,000
1,362,000 1,202,000
2,303,000 2,032,000
1,545,000 1,364,000
1,721,000 1,519,000
1,966,000 1,735,000
1,614,000 1,424,000
1,247,000 1,100,000
3,397,000 2,997,000
2,035,000 1,796,000
1,308,000 1,154,000
2,257,000 1,991,000
1,935,000 1,708,000
2,601,000 2,295,000
3,251,000 2,869,000

826,000 729,000
3,366,000 2,970,000
4,001,000 3,530,000
4,001,000 3,530,000
3,611,000 3,186,000
3,611,000 3,186,000
3,565,000 3,146,000
1,232,000 1,087,000
1,255,000 1,107,000
1,170,000 1,033,000
1,354,000 1,195,000
1,193,000 1,053,000
1,232,000 1,087,000
1,232,000 1,087,000
1,232,000 1,087,000
1,278,000 1,127,000

383,000 338,000
352,000 311,000
497,000 439,000
581,000 513,000
2,180,000 1,924,000
421,000 371,000
1,966,000 1,735,000
5,585,000 4,928,000
1,897,000 1,674,000
3,152,000 2,781,000
2,639,000 2,329,000
3,833,000 3,382,000
1,461,000 1,289,000
1,607,000 1,418,000
490,000 432,000
298,000 263,000
2,800,000 2,471,000
1,285,000 1,134,000
1,285,000 1,134,000
1,293,000 1,141,000
1,178,000 1,040,000
1,293,000 1,141,000
1,698,000 1,499,000
696,000 614,000
696,000 614,000
1,293,000 1,141,000

3,213,000 2,835,000
2,433,000 2,147,000
4,361,000 3,848,000
2,647,000 2,336,000
3,634,000 3,206,000
1,905,000 1,681,000
2,853,000 2,518,000
1,614,000 1,424,000
2,058,000 1,816,000

191,000 169,000
421,000 371,000
757,000 668,000
765,000 675,000
750,000 662,000
1,607,000 1,418,000
551,000 486,000
3,129,000 2,761,000
1,553,000 1,370,000
1,530,000 1,350,000
1,660,000 1,465,000
872,000 770,000
3,190,000 2,815,000
3,695,000 3,260,000
1,002,000 884,000
696,000 614,000
1,017,000 898,000
6,250,000 5,515,000
3,052,000 2,693,000
3,052,000 2,693,000
711,000 628,000
3,121,000 2,754,000
727,000 641,000
742,000 655,000
1,102,000 972,000
4,636,000 4,091,000
627,000 554,000
1,607,000 1,418,000
727,000 641,000
811,000 716,000
819,000 722,000
1,017,000 898,000
1,951,000 1,721,000
1,017,000 898,000
719,000 635,000
1,584,000 1,397,000
1,752,000 1,546,000
987,000 871,000
1,017,000 898,000
895,000 790,000
918,000 810,000
2,463,000 2,174,000
2,769,000 2,444,000
7,979,000 7,040,000

1,216,000 1,073,000
2,050,000 1,809,000
872,000 770,000
987,000 871,000
1,025,000 905,000
1,591,000 1,404,000
1,323,000 1,168,000
2,027,000 1,789,000
1,446,000 1,276,000
5,057,000 4,462,000
4,888,000 4,313,000
1,698,000 1,499,000

696,000 614,000
1,117,000 986,000
681,000 601,000
788,000 695,000
2,142,000 1,890,000
635,000 560,000
696,000 614,000
1,446,000 1,276,000
1,377,000 1,215,000
933,000 824,000
895,000 790,000
1,874,000 1,654,000
3,771,000 3,328,000
2,953,000 2,606,000
1,132,000 999,000
4,835,000 4,266,000
3,121,000 2,754,000
 1,660,000 1,465,000
1,193,000 1,053,000
1,660,000 1,465,000
1,255,000 1,107,000
1,660,000 1,465,000
1,974,000 1,742,000
2,746,000 2,423,000

1,377,000 1,215,000
1,668,000 1,472,000
1,415,000 1,249,000
5,906,000 5,211,000
2,846,000 2,511,000
7,237,000 6,386,000
10,733,000 9,470,000
1,163,000 1,026,000
1,446,000 1,276,000
1,446,000 1,276,000
1,737,000 1,532,000
1,974,000 1,742,000
1,163,000 1,026,000
2,157,000 1,904,000
3,297,000 2,909,000
3,542,000 3,125,000
2,027,000 1,789,000
3,129,000 2,761,000

136,000 120,000
161,000 142,000
306,000 270,000
252,000 223,000
536,000 473,000
367,000 324,000
566,000 500,000
268,000 236,000
1,094,000 965,000
230,000 203,000
933,000 824,000
849,000 749,000
115,000 101,000
268,000 236,000
161,000 142,000
268,000 236,000
436,000 385,000
245,000 216,000
574,000 506,000
826,000 729,000
 291,000 257,000
3,611,000 3,186,000
803,000 709,000
704,000 621,000
245,000 216,000
291,000 257,000
1,040,000 918,000
436,000 385,000

329,000 290,000
329,000 290,000
321,000 284,000
329,000 290,000
329,000 290,000
329,000 290,000
329,000 290,000
337,000 297,000
329,000 290,000
1,117,000 986,000

627,000 554,000
727,000 641,000
727,000 641,000
1,377,000 1,215,000
727,000 641,000
444,000 392,000
444,000 392,000
536,000 473,000
857,000 756,000
1,063,000 938,000
1,247,000 1,100,000
597,000 527,000
268,000 236,000
3,205,000 2,828,000
979,000 864,000
367,000 324,000
329,000 290,000
597,000 527,000
4,131,000 3,645,000
1,385,000 1,222,000
2,127,000 1,877,000
887,000 783,000
597,000 527,000
597,000 527,000
1,201,000 1,060,000
3,794,000 3,348,000
5,959,000 5,258,000
4,429,000 3,908,000
 658,000 581,000
306,000 270,000
2,165,000 1,910,000
16,830,000 14,850,000
4,590,000 4,050,000
4,590,000 4,050,000
1,530,000 1,350,000

161,000 142,000
612,000 540,000
291,000 257,000
612,000 540,000
1,094,000 965,000
1,117,000 986,000
819,000 722,000

1,163,000 1,026,000
1,301,000 1,148,000
1,301,000 1,148,000
574,000 506,000
92,000 81,000
413,000 365,000
207,000 182,000
161,000 142,000
92,000 81,000
69,000 61,000
130,000 115,000
910,000 803,000
130,000 115,000
1,002,000 884,000

191,000 169,000
666,000 587,000
191,000 169,000
191,000 169,000
191,000 169,000

191,000 169,000
252,000 223,000
956,000 844,000
1,155,000 1,019,000
1,155,000 1,019,000
1,155,000 1,019,000
191,000 169,000
191,000 169,000
191,000 169,000
956,000 844,000
191,000 169,000
 191,000 169,000
191,000 169,000
375,000 331,000
956,000 844,000
252,000 223,000
1,155,000 1,019,000
727,000 641,000
436,000 385,000
161,000 142,000

1,216,000 1,073,000
1,568,000 1,384,000
1,767,000 1,559,000
2,203,000 1,944,000
2,425,000 2,140,000
3,473,000 3,065,000
421,000 371,000
834,000 736,000
696,000 614,000
1,385,000 1,222,000
6,311,000 5,569,000
7,566,000 6,676,000
2,066,000 1,823,000
1,935,000 1,708,000
2,555,000 2,255,000
1,660,000 1,465,000
2,165,000 1,910,000
2,203,000 1,944,000
2,555,000 2,255,000
490,000 432,000
658,000 581,000
528,000 466,000
857,000 756,000
972,000 857,000
1,247,000 1,100,000
972,000 857,000
1,247,000 1,100,000
1,599,000 1,411,000
949,000 837,000
933,000 824,000
1,255,000 1,107,000
1,691,000 1,492,000
1,193,000 1,053,000
1,522,000 1,343,000
1,102,000 972,000
1,499,000 1,323,000
1,102,000 972,000
1,499,000 1,323,000
 2,479,000 2,187,000
2,754,000 2,430,000
421,000 371,000
834,000 736,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
352,000 311,000
4,269,000 3,767,000
2,004,000 1,769,000
6,311,000 5,569,000
6,311,000 5,569,000
10,144,000 8,951,000
4,797,000 4,232,000
7,734,000 6,824,000
7,061,000 6,230,000
10,595,000 9,349,000
7,275,000 6,419,000
1,193,000 1,053,000
11,108,000 9,801,000
2,127,000 1,877,000
1,170,000 1,033,000
15,759,000 13,905,000
5,806,000 5,123,000
4,712,000 4,158,000
4,751,000 4,192,000

1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
1,668,000 1,472,000
9,371,000 8,269,000

1,492,000 1,316,000
1,492,000 1,316,000
1,492,000 1,316,000
1,492,000 1,316,000
 1,492,000 1,316,000
1,492,000 1,316,000
1,492,000 1,316,000
1,492,000 1,316,000
1,492,000 1,316,000
10,075,000 8,890,000
9,517,000 8,397,000
1,760,000 1,553,000
NO ITEM NAME OPD 3rd CLASS 1st CLASS VIP JUNIOR ROYAL
SUITE SUITE

RADIOLOGI KONVENSIONAL
1 Thorax AP/PA 280,000 364,000 392,000 420,000 448,000 476,000
2 Thorax AP/PA & Lateral 390,000 507,000 546,000 585,000 624,000 663,000
3 Thorax Lateral 300,000 390,000 420,000 450,000 480,000 510,000
4 Thorax Top Lordotik 290,000 377,000 406,000 435,000 464,000 493,000
5 Os Costae R/L 420,000 546,000 588,000 630,000 672,000 714,000
6 Os Costae bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
7 Sternum 350,000 455,000 490,000 525,000 560,000 595,000
8 Mammografi bilateral 540,000 702,000 756,000 810,000 864,000 918,000
9 Mammografi R/L 360,000 468,000 504,000 540,000 576,000 612,000
10 Mammografi Additional View 200,000 260,000 280,000 300,000 320,000 340,000
11 Cranium AP & Lat 420,000 546,000 588,000 630,000 672,000 714,000
12 Os Maxilla 350,000 455,000 490,000 525,000 560,000 595,000
13 Os Mandibula 350,000 455,000 490,000 525,000 560,000 595,000
14 TMJ Open Mouth/ Closed Mouth 810,000 1,053,000 1,134,000 1,215,000 1,296,000 1,377,000
15 Mastoid 420,000 546,000 588,000 630,000 672,000 714,000
16 Sinus Paranasalis 450,000 585,000 630,000 675,000 720,000 765,000
17 Os Nasale 350,000 455,000 490,000 525,000 560,000 595,000
18 Orbita 420,000 546,000 588,000 630,000 672,000 714,000
19 Os Zygomaticum 350,000 455,000 490,000 525,000 560,000 595,000
20 Full Spine 920,000 1,196,000 1,288,000 1,380,000 1,472,000 1,564,000
21 Scoliosis Program (Full Spine Bending) 1,200,000 1,560,000 1,680,000 1,800,000 1,920,000 2,040,000
22 Vertebra Cervical AP & Lateral 350,000 455,000 490,000 525,000 560,000 595,000
23 Vertebra Cervical AP, Lateral, Oblique 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
24 Vertebra Cervico Thoracal AP+Lat 500,000 650,000 700,000 750,000 800,000 850,000
25 Vertebra Cervical Open Mouth 350,000 455,000 490,000 525,000 560,000 595,000
26 Vertebra Thoracal AP & Lateral 450,000 585,000 630,000 675,000 720,000 765,000
27 Vertebra Thoracal AP, Lateral, Oblique 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
28 Vertebra Thoraco-lumbal AP & Lateral 450,000 585,000 630,000 675,000 720,000 765,000
29 Vertebra Thoraco-lumbal AP, Lateral, Oblique 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
30 Sacrum AP & Lateral 450,000 585,000 630,000 675,000 720,000 765,000
31 Coccyx AP & Lateral 420,000 546,000 588,000 630,000 672,000 714,000
32 Sacro Illiaca Joint R/L 290,000 377,000 406,000 435,000 464,000 493,000
33 Pelvis 350,000 455,000 490,000 525,000 560,000 595,000
34 Os Pubis 350,000 455,000 490,000 525,000 560,000 595,000
35 Panoramic 390,000 507,000 546,000 585,000 624,000 663,000
36 Panoramic 3D 1,750,000 2,275,000 2,450,000 2,625,000 2,800,000 2,975,000
37 Cephalometry 390,000 507,000 546,000 585,000 624,000 663,000
38 Abdomen Supine/ Erect 320,000 416,000 448,000 480,000 512,000 544,000
39 Abdomen 3 Posisi 690,000 897,000 966,000 1,035,000 1,104,000 1,173,000
40 Scapula R/L 450,000 585,000 630,000 675,000 720,000 765,000
41 Scapula bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
42 Shoulder R/L 400,000 520,000 560,000 600,000 640,000 680,000
43 Shoulder bilateral 700,000 910,000 980,000 1,050,000 1,120,000 1,190,000
44 Shoulder R/L 4 View 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
45 Shoulder bilateral 4 View 1,400,000 1,820,000 1,960,000 2,100,000 2,240,000 2,380,000
46 Humerus R/L 450,000 585,000 630,000 675,000 720,000 765,000
47 Humerus bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
48 Elbow/ Cubiti R/L 420,000 546,000 588,000 630,000 672,000 714,000
49 Elbow/ Cubiti Bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
50 Antebrachii R/L 450,000 585,000 630,000 675,000 720,000 765,000
51 Antebrachii bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
52 Wrist R/L 350,000 455,000 490,000 525,000 560,000 595,000
53 Wrist bilateral 650,000 845,000 910,000 975,000 1,040,000 1,105,000
54 Manus/ Hand R/L 420,000 546,000 588,000 630,000 672,000 714,000
55 Manus/ Hand Bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
56 Clavicula R/L 420,000 546,000 588,000 630,000 672,000 714,000
57 Clavicula bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
58 Hip Joint/ Coxae R/L 450,000 585,000 630,000 675,000 720,000 765,000
59 Hip Joint/ Coxae Bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
60 Femur R/L 450,000 585,000 630,000 675,000 720,000 765,000
61 Femur bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
62 Genu/ Knee R/L 420,000 546,000 588,000 630,000 672,000 714,000
63 Genu/ Knee Bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
64 Genu/ Knee 3 View R/L 450,000 585,000 630,000 675,000 720,000 765,000
65 Genu/ Knee 3 View Bilateral 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
66 Patela R/L 350,000 455,000 490,000 525,000 560,000 595,000
67 Patela bilateral 640,000 832,000 896,000 960,000 1,024,000 1,088,000
68 Cruris R/L 420,000 546,000 588,000 630,000 672,000 714,000
69 Cruris bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
70 Ankle R/L 420,000 546,000 588,000 630,000 672,000 714,000
71 Ankle bilateral 730,000 949,000 1,022,000 1,095,000 1,168,000 1,241,000
72 Calcaneus R/L 420,000 546,000 588,000 630,000 672,000 714,000
73 Calcaneus bilateral 730,000 949,000 1,022,000 1,095,000 1,168,000 1,241,000
74 Pedis R/L 420,000 546,000 588,000 630,000 672,000 714,000
75 Pedis bilateral 780,000 1,014,000 1,092,000 1,170,000 1,248,000 1,326,000
76 Full Long Leg 840,000 1,092,000 1,176,000 1,260,000 1,344,000 1,428,000
77 Bone Survey A.(Th.Pe.Ce.Th.Lum) 2,200,000 2,860,000 3,080,000 3,300,000 3,520,000 3,740,000
78 Bone Survey B.(Idem.A+Ex At+Bw) 4,200,000 5,460,000 5,880,000 6,300,000 6,720,000 7,140,000
79 Babygram 1,000,000 1,300,000 1,400,000 1,500,000 1,600,000 1,700,000
80 Bone Age 390,000 507,000 546,000 585,000 624,000 663,000
CT SCAN
92 CT Brain non contrast 2,100,000 2,730,000 2,940,000 3,150,000 3,360,000 3,570,000
93 CT Brain contrast 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
94 CT Orbita non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
95 CT Orbita contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
96 Brain Perfussion 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
97 CT Sinus Paranasalis non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
98 CT Sinus Paranasalis contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
99 CT Mastoid non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
100 CT Cervical non contrast 2,500,000 3,250,000 3,500,000 3,750,000 4,000,000 4,250,000
101 CT Cervical contrast 3,700,000 4,810,000 5,180,000 5,550,000 5,920,000 6,290,000
102 CT Nasopharinx non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
103 CT Nasopharinx contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
104 CT Larynx non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
105 CT Larinx contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
106 CT Brain + Facial Bone non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
107 CT Brain + Facial Bone contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
108 CT Inner Ear non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
109 CT Inner Ear contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
110 CT Dental non contrast 1,300,000 1,690,000 1,820,000 1,950,000 2,080,000 2,210,000
111 CT Dental contrast 2,500,000 3,250,000 3,500,000 3,750,000 4,000,000 4,250,000
112 CT TMJ non contrast 1,300,000 1,690,000 1,820,000 1,950,000 2,080,000 2,210,000
113 CT TMJ contrast 2,500,000 3,250,000 3,500,000 3,750,000 4,000,000 4,250,000
114 CT Thorax non contrast 2,730,000 3,549,000 3,822,000 4,095,000 4,368,000 4,641,000
115 CT Thorax contrast 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
116 CT Whole Abdomen non contrast 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
117 CT Whole Abdomen contrast 4,200,000 5,460,000 5,880,000 6,300,000 6,720,000 7,140,000
118 CT Upper Abdomen non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
119 CT Lower Abdomen / Pelvis non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
120 CT Urography non contrast 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
121 CT Whole Body non contrast 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
122 CT Whole Body contrast 7,300,000 9,490,000 10,220,000 10,950,000 11,680,000 12,410,000
123 CTA Cardiac 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
124 CTA Cardiac (a. coroner) 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
125 CT Calcium Score 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
126 CT Whole Spine non contrast 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
127 CT Whole Spine contrast 7,300,000 9,490,000 10,220,000 10,950,000 11,680,000 12,410,000
128 CT Whole arm R/L non contrast 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
129 CT Whole arm bilateral non contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
130 CT Whole arm R/L contrast 2,500,000 3,250,000 3,500,000 3,750,000 4,000,000 4,250,000
131 CT Whole arm bilateral contrast 3,200,000 4,160,000 4,480,000 4,800,000 5,120,000 5,440,000
132 CT Whole Leg R/L non contrast 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
133 CT Whole Leg bilateral non contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
134 CT Whole Leg R/L contrast 4,200,000 5,460,000 5,880,000 6,300,000 6,720,000 7,140,000
135 CT Whole Leg bilateral contrast 4,700,000 6,110,000 6,580,000 7,050,000 7,520,000 7,990,000
136 CTA Cerebral 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
137 CTA Carotis 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
138 CTA Carotis & Cerebral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
139 CTA Aorta Pulmonal 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
140 CTA Renal 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
141 CTA Aorta Thoracal 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
142 CTA Aorta Abdomen 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
143 CTA Aorta Thoraco-Abdominal 6,500,000 8,450,000 9,100,000 9,750,000 10,400,000 11,050,000
144 CTA Upper Extrimity 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
145 CTA Lower Extrimity 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
146 CT Virtual Colon 4,200,000 5,460,000 5,880,000 6,300,000 6,720,000 7,140,000
147 Virtual Broncoscopy 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
148 CT Extremitas Panjang 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
149 CT Extremitas Pendek 1,300,000 1,690,000 1,820,000 1,950,000 2,080,000 2,210,000
150 CT Stent Planning 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
151 CT Mastoid contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
152 CT Upper Abdomen contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
153 CT Lower Abdomen / Pelvis contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
154 CT Urography contrast 3,500,000 4,550,000 4,900,000 5,250,000 5,600,000 5,950,000
FLUOROSCOPY
169 Oesophagography 1,200,000 1,560,000 1,680,000 1,800,000 1,920,000 2,040,000
170 OMD 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
171 Small Bowel Follow Through/ Barium Follow Thr 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
172 Coloninloop (Double Contras) 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
173 Coloninloop (Urograf) 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
174 Hysterosalpingografie / HSG 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
175 BNO-IVP 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
176 Fistulografie 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
177 Lopography 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
178 T-Tube Cholangiography 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
179 Retrograde Uretrografie 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
180 Retrograde Pyelografie/Rpg 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
181 Retrograde Cystografie 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
182 Lumbar puncture 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
183 Appendicography 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
184 Fluoroscopy Endoscopy 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
185 Antegrade Pyelography
ULTRASONOGRAPHY
186 USG Upper Abdomen 600,000 780,000 840,000 900,000 960,000 1,020,000
187 USG Lower Abdomen 600,000 780,000 840,000 900,000 960,000 1,020,000
188 USG Whole Abdomen (Upper & Lower) 800,000 1,040,000 1,120,000 1,200,000 1,280,000 1,360,000
189 USG Mammae 600,000 780,000 840,000 900,000 960,000 1,020,000
190 USG Doppler Carotis 900,000 1,170,000 1,260,000 1,350,000 1,440,000 1,530,000
191 USG Doppler Renal 900,000 1,170,000 1,260,000 1,350,000 1,440,000 1,530,000
192 USG Doppler Upper Extrimity Artery R/L 1,000,000 1,300,000 1,400,000 1,500,000 1,600,000 1,700,000
193 USG Doppler Upper Extrimity Artery bilateral 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
194 USG Doppler Upper Extrimity Vena R/L 1,000,000 1,300,000 1,400,000 1,500,000 1,600,000 1,700,000
195 USG Doppler Upper Extrimity Vena bilateral 1,900,000 2,470,000 2,660,000 2,850,000 3,040,000 3,230,000
196 USG Doppler Lower Extrimity Artery R/L 1,300,000 1,690,000 1,820,000 1,950,000 2,080,000 2,210,000
197 USG Doppler Lower Extrimity Artery bilateral 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
198 USG Doppler Lower Extrimity Vena R/L 1,300,000 1,690,000 1,820,000 1,950,000 2,080,000 2,210,000
199 USG Doppler Lower Extrimity Vena bilateral 2,300,000 2,990,000 3,220,000 3,450,000 3,680,000 3,910,000
200 USG Thyroid 600,000 780,000 840,000 900,000 960,000 1,020,000
201 USG Testis 600,000 780,000 840,000 900,000 960,000 1,020,000
202 USG Rest Urine 450,000 585,000 630,000 675,000 720,000 765,000
203 USG Prostat 600,000 780,000 840,000 900,000 960,000 1,020,000
204 USG Shoulder R/L 600,000 780,000 840,000 900,000 960,000 1,020,000
205 USG Shoulder bilateral 600,000 780,000 840,000 900,000 960,000 1,020,000
206 USG Cranium (Kepala Neonatal) 900,000 1,170,000 1,260,000 1,350,000 1,440,000 1,530,000
207 USG Extremitas Soft Tissue 600,000 780,000 840,000 900,000 960,000 1,020,000
208 USG Renal 600,000 780,000 840,000 900,000 960,000 1,020,000
209 USG Thorax Marker 800,000 1,040,000 1,120,000 1,200,000 1,280,000 1,360,000
MRI
212 MRI Brain Non Contrast 3,600,000 4,680,000 5,040,000 5,400,000 5,760,000 6,120,000
213 MRI, MRA, MRV Brain non contrast 10,000,000 13,000,000 14,000,000 15,000,000 16,000,000 17,000,000
214 MR Brain Spectroscopy non contrast 4,500,000 5,850,000 6,300,000 6,750,000 7,200,000 7,650,000
215 MR Brain + DTI Map 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
216 MRI Brain Perfusi non kontras (3D)ASL 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
217 MRI Brain + Perfusi kontras (PWI) 6,500,000 8,450,000 9,100,000 9,750,000 10,400,000 11,050,000
218 MRI Saraf Cranial 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
219 MRI Brain & Hipocampus non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
220 MRI Brain & Hipocampus contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
221 MRV Brain non contrast 4,000,000 5,200,000 5,600,000 6,000,000 6,400,000 6,800,000
222 MRV Brain contrast 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
223 MRI Orbita non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
224 MRI Sinus Paranasalis non contrast 3,600,000 4,680,000 5,040,000 5,400,000 5,760,000 6,120,000
225 MRI Mastoid non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
226 MRI Naso Pharynx non contrast 3,600,000 4,680,000 5,040,000 5,400,000 5,760,000 6,120,000
227 MRI Larynx non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
228 MRI Cervical Spine non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
229 MRI Cervical Spine contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
230 MRI Cervico - Thoracal Spine non contrast 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
231 MRI Brachial Plexus non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
232 MRI Brachial Plexus contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
233 MRI Thoracal spine non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
234 MRI Thoraco - Lumbal Spine non contrast 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
235 MRI Sacrocoxygeus non contrast 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
236 MRI & MRA Brain 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
237 MRA Carotis 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
238 MRA Carotis & Intra Cerebral 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
239 MRA Intra Cerebral 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
240 MRA Abdomen 5,800,000 7,540,000 8,120,000 8,700,000 9,280,000 9,860,000
241 MRA Renal 5,500,000 7,150,000 7,700,000 8,250,000 8,800,000 9,350,000
242 MRA Aorta Thoracal 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
243 MRA Thoraco Abdomen 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
244 MRA Upper Limb 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
245 MRA Lower Limb 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
246 MRV Upper Limb 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
247 MRV Lower Limb 6,100,000 7,930,000 8,540,000 9,150,000 9,760,000 10,370,000
248 MRI Thorax non contrast 3,000,000 3,900,000 4,200,000 4,500,000 4,800,000 5,100,000
249 MRI Thorax contrast 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
250 MRI Upper Abdomen non contrast 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
251 MRI Upper Abdomen contrast 5,500,000 7,150,000 7,700,000 8,250,000 8,800,000 9,350,000
252 MRI Lower Abdomen / Pelvis non contrast 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
253 MRI Sacral plexus non contrast 4,500,000 5,850,000 6,300,000 6,750,000 7,200,000 7,650,000
254 MRI Whole Abdomen non contrast 5,100,000 6,630,000 7,140,000 7,650,000 8,160,000 8,670,000
255 MRI Whole spine non contrast 6,500,000 8,450,000 9,100,000 9,750,000 10,400,000 11,050,000
256 Abdomen atas + MRCP non contrast 4,500,000 5,850,000 6,300,000 6,750,000 7,200,000 7,650,000
257 MR Urography non contrast 4,500,000 5,850,000 6,300,000 6,750,000 7,200,000 7,650,000
258 MRI Liver With Elastografi non contrast 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
259 MRI Prostate (PIRADS) non contrast 5,500,000 7,150,000 7,700,000 8,250,000 8,800,000 9,350,000
260 MRI Prostate (staging) 6,300,000 8,190,000 8,820,000 9,450,000 10,080,000 10,710,000
261 MRA Cardiac Functional 6,500,000 8,450,000 9,100,000 9,750,000 10,400,000 11,050,000
262 MRI Breast non contrast 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
263 MRI Shoulder R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
264 MRI Shoulder bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
265 MRI Clavicula R/L 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
266 MRI Clavicula bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
267 MRI Cubiti (Elbow Joint) R/L 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
268 MRI Cubiti (Elbow Joint) bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
269 MRI Wrist Joint R/L 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
270 MRI Wrist Joint bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
271 MRI Antebrachi R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
272 MRI Antebrachi bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
273 MRI Manus R/L 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
274 MRI Manus bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
275 MRI HIP R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
276 MRI HIP bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
277 MRI Femur R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
278 MRI Femur bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
279 MRI Genu R/L 4,100,000 5,330,000 5,740,000 6,150,000 6,560,000 6,970,000
280 MRI Genu bilateral 5,200,000 6,760,000 7,280,000 7,800,000 8,320,000 8,840,000
281 MRI Cruris R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
282 MRI Cruris bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
283 MRI Ankle R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
284 MRI Ankle bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
285 MRI Pedis R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
286 MRI Pedis bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
287 MRI Humerus R/L 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
288 MRI Humerus bilateral 5,400,000 7,020,000 7,560,000 8,100,000 8,640,000 9,180,000
289 MRI Hypophysis / Sella Tursica 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
290 MRI Lumbal 3,800,000 4,940,000 5,320,000 5,700,000 6,080,000 6,460,000
291 MRI Fistula Perianal 4,300,000 5,590,000 6,020,000 6,450,000 6,880,000 7,310,000
292 MRI, MRA, MRV Brain contrast 11,200,000 14,560,000 15,680,000 16,800,000 17,920,000 19,040,000
293 MR Brain Spectroscopy contrast 5,700,000 7,410,000 7,980,000 8,550,000 9,120,000 9,690,000
294 MRI Orbita contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
295 MRI Sinus Paranasalis contrast 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
296 MRI Mastoid contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
297 MRI Naso Pharynx contrast 4,800,000 6,240,000 6,720,000 7,200,000 7,680,000 8,160,000
298 MRI Larynx contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
299 MRI Cervico - Thoracal Spine contrast 5,500,000 7,150,000 7,700,000 8,250,000 8,800,000 9,350,000
300 MRI Thoracal spine contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
301 MRI Thoraco - Lumbal Spine contrast 5,500,000 7,150,000 7,700,000 8,250,000 8,800,000 9,350,000
302 MRI Sacrocoxygeus contrast 5,000,000 6,500,000 7,000,000 7,500,000 8,000,000 8,500,000
303 MRI Sacral plexus contrast 5,700,000 7,410,000 7,980,000 8,550,000 9,120,000 9,690,000
304 MR Urography contrast 5,700,000 7,410,000 7,980,000 8,550,000 9,120,000 9,690,000
305 MRI Liver With Elastografi contrast 5,300,000 6,890,000 7,420,000 7,950,000 8,480,000 9,010,000
306 MRI Prostate (PIRADS) contrast 6,700,000 8,710,000 9,380,000 10,050,000 10,720,000 11,390,000
307 MRI Breast contrast 5,300,000 6,890,000 7,420,000 7,950,000 8,480,000 9,010,000
308 Abdomen atas + MRCP contrast 5,700,000 7,410,000 7,980,000 8,550,000 9,120,000 9,690,000
309 MRI Whole spine non contrast contrast 7,700,000 10,010,000 10,780,000 11,550,000 12,320,000 13,090,000
310 MRI Whole Abdomen non contrast contrast 6,300,000 8,190,000 8,820,000 9,450,000 10,080,000 10,710,000
NON CATH-LAB INTERVENTION
315 CT Guided (Tuntunan Biopsi) 2,800,000 3,640,000 3,920,000 4,200,000 4,480,000 4,760,000
316 USG Biopsy Superficial 600,000 780,000 840,000 900,000 960,000 1,020,000
317 Fluoroscopy Tuntunan Biopsi 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
318 USG guided Renal biopsy 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
319 USG guided FNAB Thyroid 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
320 USG tindakan sclerotherapy 1,500,000 1,950,000 2,100,000 2,250,000 2,400,000 2,550,000
OTHER
321 Second opinion hasil radiografi konvensional 150,000 195,000 210,000 225,000 240,000 255,000
322 Second opinion hasil USG atau Fluoroscopy 300,000 390,000 420,000 450,000 480,000 510,000
323 Second opinion hasil CT-scan 600,000 780,000 840,000 900,000 960,000 1,020,000
324 Second opinion hasil MRI 800,000 1,040,000 1,120,000 1,200,000 1,280,000 1,360,000
325 Translate ekspertise INA-ENG/ENG-INA 200,000 260,000 280,000 300,000 320,000 340,000
326 Cetak Foto dengan Film 150,000 195,000 210,000 225,000 240,000 255,000
327 Simpan File ke CD 25,000 32,500 35,000 37,500 40,000 42,500
CRITICAL
CARE

420,000
585,000
450,000
435,000
630,000
1,170,000
525,000
810,000
540,000
300,000
630,000
525,000
525,000
1,215,000
630,000
675,000
525,000
630,000
525,000
1,380,000
1,800,000
525,000
1,260,000
750,000
525,000
675,000
1,260,000
675,000
1,260,000
675,000
630,000
435,000
525,000
525,000
585,000
2,625,000
585,000
480,000
1,035,000
675,000
1,260,000
600,000
1,050,000
1,260,000
2,100,000
675,000
1,260,000
630,000
1,170,000
675,000
1,260,000
525,000
975,000
630,000
1,170,000
630,000
1,170,000
675,000
1,260,000
675,000
1,260,000
630,000
1,170,000
675,000
1,260,000
525,000
960,000
630,000
1,170,000
630,000
1,095,000
630,000
1,095,000
630,000
1,170,000
1,260,000
3,300,000
6,300,000
1,500,000
585,000

3,150,000
4,500,000
3,450,000
5,250,000
4,500,000
3,450,000
5,250,000
 3,450,000
3,750,000
5,550,000
3,450,000
5,250,000
3,450,000
5,250,000
3,450,000
5,250,000
3,450,000
5,250,000
1,950,000
3,750,000
1,950,000
3,750,000
4,095,000
6,150,000
4,500,000
6,300,000
3,450,000
3,450,000
3,450,000
9,150,000
10,950,000
7,200,000
7,200,000
2,250,000
9,150,000
10,950,000
4,500,000
5,250,000
3,750,000
4,800,000
4,500,000
5,250,000
6,300,000
7,050,000
7,200,000
7,200,000
7,800,000
7,200,000
7,200,000
7,200,000
7,200,000
9,750,000
7,200,000
7,800,000
6,300,000
4,500,000
3,450,000
1,950,000
7,200,000
5,250,000
5,250,000
5,250,000
5,250,000

1,800,000
2,850,000
2,850,000
3,450,000
3,450,000
2,850,000
3,450,000
2,850,000
2,850,000
2,850,000
2,850,000
2,850,000
2,850,000
2,850,000
2,250,000
2,250,000

900,000
900,000
1,200,000
900,000
1,350,000
1,350,000
1,500,000
2,850,000
1,500,000
2,850,000
1,950,000
3,450,000
1,950,000
3,450,000
900,000
 900,000
675,000
900,000
900,000
900,000
1,350,000
900,000
900,000
1,200,000

5,400,000
15,000,000
6,750,000
8,100,000
8,100,000
9,750,000
8,100,000
5,700,000
7,500,000
6,000,000
7,800,000
5,700,000
5,400,000
5,700,000
5,400,000
5,700,000
5,700,000
7,500,000
6,450,000
5,700,000
7,500,000
5,700,000
6,450,000
5,700,000
8,100,000
6,150,000
7,200,000
6,450,000
8,700,000
8,250,000
9,150,000
9,150,000
9,150,000
9,150,000
9,150,000
9,150,000
4,500,000
6,450,000
6,150,000
8,250,000
6,450,000
6,750,000
7,650,000
9,750,000
6,750,000
6,750,000
6,150,000
8,250,000
9,450,000
9,750,000
6,150,000
6,450,000
7,800,000
6,150,000
7,800,000
6,150,000
7,800,000
6,150,000
7,800,000
6,450,000
8,100,000
6,150,000
7,800,000
6,450,000
8,100,000
6,450,000
8,100,000
6,150,000
7,800,000
6,450,000
8,100,000
6,450,000
8,100,000
6,450,000
8,100,000
6,450,000
8,100,000
5,700,000
5,700,000
6,450,000
16,800,000
8,550,000
7,500,000
7,200,000
7,500,000
7,200,000
7,500,000
8,250,000
7,500,000
8,250,000
7,500,000
8,550,000
8,550,000
7,950,000
10,050,000
7,950,000
8,550,000
11,550,000
9,450,000

4,200,000
900,000
2,250,000
2,250,000
2,250,000
2,250,000

225,000
450,000
900,000
1,200,000
300,000
225,000
37,500
 No ITEM NAME OPD 3rd CLASS 1st CLASS VIP JUNIOR
SUITE

1 Rehab Medic Consultation 250,000 325,000 350,000 375,000 400,000

PM&R Specialist
2 Exercise Testing - Astrand Leg Cycling 260,000 338,000 364,000 390,000 416,000
3 Exercise Testing - Astrand Arm Cranking 260,000 338,000 364,000 390,000 416,000
4 Radial Shock Wave Therapy 280,000 364,000 392,000 420,000 448,000
5 Dry Needling 1 400,000 520,000 560,000 600,000 640,000
6 Dry Needling 2 500,000 650,000 700,000 750,000 800,000
7 Dry Needling 3 600,000 780,000 840,000 900,000 960,000
8 Gait Plantar Pressure Analysis 300,000 390,000 420,000 450,000 480,000

Physiotherapist
Modalities Room
9 Diathermy - Short Wave (SWD) 110,000 143,000 154,000 165,000 176,000
10 Diathermy - Microwave (MWD) 110,000 143,000 154,000 165,000 176,000
11 Diathermy - Ultrasound (US) 110,000 143,000 154,000 165,000 176,000
12 Electrotherapy - TENS 110,000 143,000 154,000 165,000 176,000
13 Electrotherapy - TENS 8 Electrodes 160,000 208,000 224,000 240,000 256,000
14 Electrotherapy - Electric Stimulation (NMES) 120,000 156,000 168,000 180,000 192,000
15 Electrotherapy - Modified Interferential 130,000 169,000 182,000 195,000 208,000
16 Electrotherapy - Biofeedback 300,000 390,000 420,000 450,000 480,000
17 Thermal - Ice/Hot Pack 50,000 65,000 70,000 75,000 80,000
18 Assessment - Physiotherapist 200,000 260,000 280,000 300,000 320,000
19 Intervention - Physiotherapist 150,000 195,000 210,000 225,000 240,000
20 Respiratory Intervention - Inhalation + Chest Therapy 200,000 260,000 280,000 300,000 320,000
21 Taping 150,000 195,000 210,000 225,000 240,000

Exercise Room
22 Passive Exercise - Range of Motion and Stretching 170,000 221,000 238,000 255,000 272,000
23 Active Exercise - Strengthening 200,000 260,000 280,000 300,000 320,000
24 General Exercise - Overall Recondintioning 220,000 286,000 308,000 330,000 352,000
25 Mobility Exercise - Gait Training 160,000 208,000 224,000 240,000 256,000
26 Manual Therapy - Massage Manipulation 150,000 195,000 210,000 225,000 240,000
Manual Therapy - Manual Lymph Drainage Vodder (MLDV)
27 220,000 286,000 308,000 330,000 352,000

28 Respiratory Intervention - Chest Therapy 150,000 195,000 210,000 225,000 240,000

29 Respiratory Intervention - Postural Drainage 150,000 195,000 210,000 225,000 240,000
30 Mobility Exercise - Stroke Neuromuscular Exercise 250,000 325,000 350,000 375,000 400,000
31 Active Exercise - Finger Ladder 150,000 195,000 210,000 225,000 240,000
32 Exercise Testing - 6 Minute Walk Test 200,000 260,000 280,000 300,000 320,000

Hydrotherapy Room
33 Hydrotherapy - Gait Training 250,000 325,000 350,000 375,000 400,000
34 Hydrotherapy - Pain Management and Flexibility Training 250,000 325,000 350,000 375,000 400,000
35 Hydrotherapy - Strengthening 250,000 325,000 350,000 375,000 400,000
Physiotherapist + Occupational Therapist
Exercise + Motorized Device
36 Respiratory Intervention - Cough Assist 150,000 195,000 210,000 225,000 240,000
37 General Exercise - Tilting Table 150,000 195,000 210,000 225,000 240,000
38 Cardiac Intervention - Leg or Wheelchair Cycle 150,000 195,000 210,000 225,000 240,000
39 Cardiac Intervention - Treadmill 150,000 195,000 210,000 225,000 240,000
40 Cardiac Intervention - Static Cycle 150,000 195,000 210,000 225,000 240,000
41 Balance Exercise - Thera Trainer Balo 180,000 234,000 252,000 270,000 288,000

Occupational Therapist
Balance Room
42 Balance Exercise - Transfer Training 160,000 208,000 224,000 240,000 256,000
43 Balance Exercise - Gym Ball and Trampoline 160,000 208,000 224,000 240,000 256,000
ADL Exercise - Standing Endurance & Energy Conservation
44 180,000 234,000 252,000 270,000 288,000

ADL Exercise - Lower Extremity Activities of Daily Living Training

45 180,000 234,000 252,000 270,000 288,000

46 Assessment - Occupational Therapist 200,000 260,000 280,000 300,000 320,000

47 Intervention - Occupational Therapist 150,000 195,000 210,000 225,000 240,000

Hand Room
48 Dexterity Training - Grip Strengthening 150,000 195,000 210,000 225,000 240,000
49 Dexterity Training - Coordination and Range of Motion 150,000 195,000 210,000 225,000 240,000
ADL Exercise - Upper Extremity Activities of Daily Living Training
50 180,000 234,000 252,000 270,000 288,000

51 Virtual Reality - Basic Movement Therapy 250,000 325,000 350,000 375,000 400,000
52 Virtual Reality - Coordination and Reaction Speed 250,000 325,000 350,000 375,000 400,000
53 Virtual Reality - Immersive ADL Therapy 250,000 325,000 350,000 375,000 400,000
54 Splinting - Functional Splint 130,000 169,000 182,000 195,000 208,000
55 Splinting - Night Splint 130,000 169,000 182,000 195,000 208,000
56 ADL Exercise - Concentration Training for ASD/ADHD 130,000 169,000 182,000 195,000 208,000

Speech Therapist
Speech Therapy Room
57 Assessment - Speech Therapist 200,000 260,000 280,000 300,000 320,000
58 Intervention - Speech Therapist 150,000 195,000 210,000 225,000 240,000
59 Speech - Sensory Stimulation 150,000 195,000 210,000 225,000 240,000
60 Speech - Motoric Stimulation 180,000 234,000 252,000 270,000 288,000
61 Electrotherapy - Oropharyngeal Electric Stimulation 180,000 234,000 252,000 270,000 288,000
62 Electrotherapy - Oropharyngeal Biofeedback 200,000 260,000 280,000 300,000 320,000
63 Electrotherapy - Vocastim 200,000 260,000 280,000 300,000 320,000
64 Active Exercise - Active Stretching Upper Extremities 150,000 195,000 210,000 225,000 240,000
65 Speech - Swallowing Exercise 180,000 234,000 252,000 270,000 288,000
ROYAL SUITE CRITICAL
CARE

425,000 375,000

442,000 390,000
442,000 390,000
476,000 420,000
680,000 600,000
850,000 750,000
1,020,000 900,000
510,000 450,000

187,000 165,000
187,000 165,000
187,000 165,000
187,000 165,000
272,000 240,000
204,000 180,000
221,000 195,000
510,000 450,000
85,000 75,000
340,000 300,000
255,000 225,000
340,000 300,000
255,000 225,000

289,000 255,000
340,000 300,000
374,000 330,000
272,000 240,000
255,000 225,000

374,000 330,000

255,000 225,000
255,000 225,000
425,000 375,000
255,000 225,000
340,000 300,000

425,000 375,000
425,000 375,000
425,000 375,000

255,000 225,000
255,000 225,000
255,000 225,000
255,000 225,000
255,000 225,000
306,000 270,000

272,000 240,000
272,000 240,000

306,000 270,000

306,000 270,000

340,000 300,000
255,000 225,000

255,000 225,000
255,000 225,000

306,000 270,000

425,000 375,000
425,000 375,000
425,000 375,000
221,000 195,000
221,000 195,000
221,000 195,000

340,000 300,000
255,000 225,000
255,000 225,000
306,000 270,000
306,000 270,000
340,000 300,000
340,000 300,000
255,000 225,000
306,000 270,000
FASILITAS HOTEL/POD ICU
HOTEL ICU : 4 KAMAR - RP.
POD ICU : 17 KAMAR - RP.

Hotel POD Type Luas kamar Luas bed Luas toilet

HOTEL 1 9.71 m² 200x160m 1.72 m²

HOTEL 2 9.75 m² 200x160m 2.11 m²

HOTEL 3 11.16 m² 200x160m 1.88 m²

HOTEL 4 9.64 m² 200x160m 1.76 m²

Total Luas Fasilitas
Toilet Pribadi

11.43 m² Meja makan ( 1 pax )

Toilet Pribadi

11.86 m² Meja makan ( 1 pax )

TV

13.04 m² Toilet Pribadi

TV

11.4 m² Toilet Pribadi

FASILITAS HOTEL/POD ICU
HOTEL ICU : 4 KAMAR - RP.
POD ICU : 17 KAMAR - RP.

Hotel POD Type Luas kamar Luas bed Fasilitas Ket

Meja Lipat
BED 1 4.46 m² 200x90m Hook
Toilet diluar

Meja Lipat
BED 2 3.80 m² 200x90m
Toilet diluar

Meja Lipat
BED 3 4.38 m² 200x90m
Toilet diluar

Meja Lipat
BED 4 3.85 m² 200x90m
Toilet diluar

Meja Lipat
BED 5 3.27 m² 200x90m
Toilet diluar

Meja Lipat
BED 6 3.27 m² 200x90m
Toilet diluar

Meja Lipat
BED 7 3.27 m² 200x90m
Toilet diluar

Meja Lipat
BED 8 3.27 m² 200x90m
Toilet diluar

Meja Lipat
BED 9 4.34 m² 200x90m Hook
Toilet diluar

Meja Lipat
BED 10 2.95 m² 200x90m Hook
Toilet diluar

Meja Lipat
BED 11 2.93 m 200x90m
Toilet diluar

Meja Lipat
BED 12 2.93 m² 200x90m
Toilet diluar

Meja Lipat
BED 13 2.93 m² 200x90m
Toilet diluar

Meja Lipat
BED 14 2.93 m² 200x90m
 BED 14 2.93 m² 200x90m
Toilet diluar

Meja Lipat
BED 15 2.93 m² 200x90m
Toilet diluar

Meja Lipat
BED 16 2.93 m² 200x90m
Toilet diluar

Meja Lipat
BED 17 2.95 m² 200x90m Hook
Toilet diluar

Toilet Pria 2 Ruangan Luas 3.14 m²

Toilet Wanita 2 Ruangan Luas 3.58 m²

 LIST INSURANCE

Keterangan

No Nama Pekerjaan Nama Fail TAHAP 1

1 PKS Insurance Nama Insurance Pengiriman Dokumen

Sudah mengirimkan
ADMEDIKA persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
Asuransi Reliance Indonesia. PT
persaratan dokumen
(Payor)
Legalitas MRHP

Sudah mengirimkan
ASIH EKA ABADI, PT
persaratan dokumen
(INTERNATIONAL SOS) Legalitas MRHP

Sudah mengirimkan
Prudentinal persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
AVRIST INSURANCE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI ALLIANZ LIFE INDONESIA
persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
MANULIFE FINANCIAL SOLUTIONpersaratan dokumen
Legalitas MRHP

Sudah mengirimkan
GENERALI LIFE INDONESIA persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI JIWA SINARMAS MSI persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
Provider Sinarmas persaratan dokumen
Legalitas MRHP

FINANSIAL WIRAMITRA Sudah mengirimkan

DANADYAKSA INSURANCE, PT ( persaratan dokumen
FWD ) Legalitas MRHP

Sudah mengirimkan
ASURANSI ASTRA BUANA persaratan dokumen
Legalitas MRHP
 Sudah mengirimkan
ASTRA AVIVA LIFE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
AIA FINANCIAL persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI JIWA CENTRAL ASIA Rpersaratan dokumen
Legalitas MRHP

Sudah mengirimkan
EQUITY LIFE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI JASA INDONESIA (Perspersaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI TAKAFUL KELUARGA persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
PT. AXA FINANCIAL INDONESIA,
persaratan dokumen
PT ( AFI )
Legalitas MRHP

Sudah mengirimkan
PT. AXA MANDIRI FINANCIAL persaratan dokumen
SERVICES, PT
Legalitas MRHP

Sudah mengirimkan
AXA SERVICES INDONESIA ( ASI
persaratan dokumen
) Legalitas MRHP

ASURANSI JIWA SEQUIS LIFE, Sudah mengirimkan

persaratan dokumen
PT
Legalitas MRHP

Sudah mengirimkan
BNI Life persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
INTERNATIONAL SERVICES
persaratan dokumen
PACIFIC CROSS (ISPC )
Legalitas MRHP

Sudah mengirimkan
RELIANCE INSURANCE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
Asuransi Sinarmas (simas Card) persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
WANAARTHA LIFE persaratan dokumen
Legalitas MRHP
 Sudah mengirimkan
ABDA INSURANCE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI CENTRAL ASIA ( ACApersaratan dokumen
Legalitas MRHP

Sudah mengirimkan
PRESTIGE INTERNASIONAL persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI UMUM MEGA persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
TIRTA MEDICAL persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
INOVA CARE persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI KRESNA MITRA, PT persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI RAMAYANA Tbk persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
APLIKANUSA LINTAS ARTA
persaratan dokumen
( OWLEXA HEALTH CARE) Legalitas MRHP

FULLERTON HEALTH Sudah mengirimkan

persaratan dokumen
INDONESIA
Legalitas MRHP

Sudah mengirimkan
ASURANSI ADIRA DINAMIKA persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ZURICH TOPAZ LIFE
persaratan dokumen
ASSURANCE
Legalitas MRHP

Sudah mengirimkan
ASURANSI LIPPO GENERAL persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
ASURANSI JIWA MANDIRI INHEApersaratan dokumen
Legalitas MRHP

Sudah mengirimkan
TOKIO MARINE LIFE
persaratan dokumen
INSURANCE INDONESIA, PT
Legalitas MRHP
 Sudah mengirimkan
ASURANSI BINTANG persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
PJPKSINCAROLUS persaratan dokumen
Legalitas MRHP

Sudah mengirimkan
AAI INSURANCE persaratan dokumen
Legalitas MRHP
erangan

TAHAP II TAHAP III Status

Pembahasan PKS Kontrak Berhasil

MRHP Sudah mengisi dokumen di sistim

PEMBAHASAN PKS Admedika tinggal menunggu konfirmasi dari
Admedika

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
PKS Harus di isi oleh sales

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
PKS Harus di isi oleh sales

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Sales harus Mengisi PKS

PEMBAHASAN PKS
Sales harus Mengisi PKS

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress
Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy
Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS
Sales harus mengisi Dokuman

Insurance Belom
Mengirimkan PKS
On Progress

Insurance Belom
Mengirimkan PKS
On Progress
Insurance Belom
Mengirimkan PKS
On Progress

PEMBAHASAN PKS Kontrak Berhasil

PKS sudah di sepakati

PEMBAHASAN PKS
Dokumen PKS ada di dr. Anna & dr. Esy
 NO TLP

08128456824 ( Ratna)

0818999710 ( Jefri)

08111005520 (dr. Meta)

085211271837 (Dina)

08567737574 ( ria)

081325284242 ( suci)
PERKIRAAN BIAYA MELAHIRKAN
MANDAYA ROYAL HOSPITAL PURI

A. PARTUS NORMAL (3 hari)

No JENIS KAMAR MRHP

1 KELAS 3 / STANDARD B 16,000,000

2 KELAS 2 17,500,000
3 KELAS 1 / KELAS UTAMA 20,000,000
4 VIP 23,500,000
5 SUPERIOR
6 DELUXE
7 EXECUTIVE
8 JUNIOR SUITE 31,500,000
9 SUITE
10 DIAMOND
11 GOVERNOR SUITE 34,500,000
12 PRESIDENT SUITE 38,000,000
13 MANDAYA ROYAL SUITE 42,000,000

B. CAESAR (4 hari)
1 KELAS 3 / STANDARD B 36,500,000
2 KELAS 2 38,500,000
3 KELAS 1 / KELAS UTAMA 41,000,000
4 VIP 46,000,000
5 EXECUTIVE
6 JUNIOR SUITE 56,000,000
7 SUITE
DIAMOND
8 GOVERNOR SUITE 61,500,000
9 PRESIDENT SUITE 67,500,000
10 MANDAYA ROYAL SUITE 74,500,000

Estimation do not include:

> Drugs and consumables
> Laboratory investigation
> Others equipment rent.
> Administration charges

Additional cost Pondok Indah Puri

1 APD Persalinan normal
2 APD C-section ( non infecsius )
3 APD C-section ( Infecsius )
+10% dari kelas sebelumnya
34,650,000
37,950,000
41,800,000

+10% dari kelas sebelumnya

61,600,000
67,650,000
74,415,000
MANDAYA ROYAL HOSPITAL PURI
DESCRIPTION Kelas 3 Kelas 2
Partus normal fee 16,000,000 17,350,000
Delivery C-section fee 36,500,000 38,300,000

Adapula tambahan biaya :

APD Persalinan normal 1,500,000 ( non infecsius/infecsius)
APD C-section ( non infecsius ) 1,800,000
APD C-section ( Infecsius ) 2,800,000

Term and Condition :

DP 75%
Admin fee 7 % ( max 3.250.000 )
Foto bayi dan mandikan
 Kelas 1 VIP Suite Hari

19,600,000 23,325,000 31,425,000 3 hari

40,700,000 46,000,000 56,000,000 4 hari

csius/infecsius)