| II | | MIKROBIOLOGI MEDIK | |
| II.1 | Kultur ( Isolasi & Identifikasi ) | TARIF |
| 1 | Urine | Rp. 150,000 |
| 2 | Sekret | Rp. 150,000 |
| 3 | Darah | Rp. 165,000 |
| 4 | Pus | Rp. 150,000 |
| 5 | Gaal | Rp. 165,000 |
| 6 | LCS | Rp. 165,000 |
| 7 | Faeces | Rp. 143,300 |
| 8 | Jamur ( Kerokan Kulit) | Rp. 123,200 |
| 9 | Rectal Swab Kultur per spesies (salmonella/shigella/vibrio ) | Rp. 170,000 |
| 10 | Corynebacterium diphteri (Swab Tenggorok) | Rp. 165,000 |
| 11 | BTA / M.TBC | Rp. 140,000 |
| 13 | Specimen lainnya | Rp. 150,000 |
| 14 | Identifikasi Per Species | Rp. 100,000 |
| | | |
| II.2 | Uji Sensitivitas | TARIF |
| 1 | DST (Sensitivitas MTBC ) | Rp. 150,000 |
| 2 | Sensitivitas | Rp. 150,000 |
| | | |
| II.3 | MIKROSKOPIS | |
| | PEMERIKSAAN MIKROSKOPIS | TARIF |
| 1 | Faeces Lengkap | Rp. 20,000 |
| 2 | Sekret Vagina/Urethra | Rp. 45,500 |
| 3 | Trichomonas | Rp. 20,000 |
| 4 | Sel Ragi | Rp. 20,000 |
| 5 | Cat Gram | Rp. 20,000 |
| 6 | Mycobaterium leprae (ZN) | Rp. 20,000 |
| 7 | Sputum BTA (ZN) | Rp. 20,000 |
| 8 | Corrynebacterium diphteriae (Neisser) | Rp. 20,000 |
| 9 | Malaria (Giemsa) | Rp. 20,000 |
| 10 | Filaria (Giemsa) | Rp. 20,000 |
| 11 | Benzidine Test | Rp. 20,000 |
| 12 | Specimen lainnya | Rp. 20,000 |
| 13 | Pembacaan Kroscek (program Pemerintah) | Rp. 4,000 |
| | | |
| III | | PEMERIKSAAN IMUNOSEROLOGI | TARIF |
| 1 | Rheumatoid Factor | Rp. 43,000 |
| 2 | C. Reactive Protein | Rp. 40,000 |
| 3 | ASTO | Rp. 37,500 |
| 4 | Widal | Rp. 54,000 |
| 5 | VDRL | Rp. 32,500 |
| 6 | TPHA | Rp. 43,800 |
| 7 | HBs Ag | Rp. 83,300 |
| 8 | Anti HBs Ag | Rp. 93,000 |
| 9 | Anti HBc Total | Rp. 155,000 |
| 10 | Anti Hbe | Rp. 177,500 |
| 11 | Anti HAV Total | Rp. 192,500 |
| 12 | Anti HIV (3 metode) | Rp. 110,000 |
| 13 | VIDAS HIV Duo UTRA | Rp. 127,500 |
| 14 | T-3 | Rp. 127,500 |
| 15 | T-4 | Rp. 127,500 |
| 16 | TSH-s | Rp. 127,500 |
| | | |
| IV | | PEMERIKSAAN BIOLOGI MOLEKULER | TARIF |
| 1 | PCR MTBC | Rp. 595,000 |
| 2 | PCR Salmonella | Rp. 595,000 |
| 3 | PCR Flu Burung / Flu Babi | Rp. 595,000 |
| | | |
| V | | RADIOLOGI | |
| A | TINDAKAN TANPA KONTRAS | TARIF |
| 1 | FOTO THORAX AP/IPA | Rp. 121,000 |
| 2 | FOTO THORAX LATERAL | Rp. 121,000 |
| 3 | FOTO BNO/ABDOMEN AP | Rp. 121,000 |
| 4 | FOTO BNO/ABDOMEN LATERAL | Rp. 121,000 |
| 5 | FOTO WAITER'S | Rp. 131,500 |
| 6 | FOTO SHEDELL LATERAL | Rp. 131,500 |
| 7 | FOTO COLUMA VERTEBRAE AP | Rp. 131,500 |
| 8 | FOTO COLUMA VERTEBRAE LAT | Rp. 131,500 |
| 9 | FOTO AP/LATERAL EXTREMITAS /EXPOSURE | Rp. 104,000 |
| | | |
| B | TINDAKAN DENGAN KONTRAS | TARIF |
| 1 | BNO - IVP | Rp. 570,000 |
| 2 | COLON INLOOP | Rp. 570,000 |
| 3 | OESOPHAGUS MAAG DUODENUM | Rp. 570,000 |
| 4 | HISTEROSALPHINGOGRAPHY | Rp. 570,000 |
| 5 | RPG | Rp. 570,000 |
| 6 | APG | Rp. 570,000 |
| 7 | FISTULOGRAPHY | Rp. 570,000 |
| 8 | MYESLOGRAPHY | Rp. 570,000 |
| 9 | URETHROCYSTOGRAPHY | Rp. 570,000 |
| | | |
| C | PEMBACAAN HASIL RONTGEN | TARIF |
| 1 | Pembacaan Hasil Rontgen Kolektif | Rp. 32,500 |
| 2 | Pembacaan Hasil Rontgen Personal | Rp. 32,500 |
| | | |
| VI | | PEMERIKSAAN PATOLOGI KLINIK | |
| A | HEMATOLOGI | TARIF |
| 1 | Hemoglobin | Rp. 18,500 |
| 2 | Hitung jumlah Lekosit | Rp. 18,500 |
| 3 | Hitung jenis lekosit | Rp. 18,500 |
| 4 | Laju endap darah | Rp. 18,500 |
| 5 | Hitung jumlah Trombosit | Rp. 18,500 |
| 6 | Hematokrit | Rp. 18,500 |
| 7 | Waktu Perdarahan/ BT | Rp. 14,000 |
| 8 | Waktu Pembekuan / CT | Rp. 19,500 |
| 9 | LE - Sel | Rp. 105,000 |
| 10 | Morfologi darah tepi | Rp. 105,000 |
| 11 | Golongan Darah | Rp. 25,500 |
| 12 | Hitung jumlah Eritrosit | Rp. 23,500 |
| 13 | Hitung jumlah Retikulosit | Rp. 23,500 |
| 14 | Hematologi lengkap (aotumatic hematology Analizer) | Rp. 64,500 |
| 15 | Hitung jumlah Eosinofil | Rp. 23,500 |
| 16 | PTT = Partial Tromboplastin Time | Rp. 93,500 |
| 17 | APTT = Activated Partial Tromboplastin Time | Rp. 77,500 |
| 18 | TIBC = Total Iron Binding Capacity | Rp. 40,000 |
| 19 | LPB = Limposit Plasma Biru | Rp. 125,000 |
| 20 | Sl = Serum Iron | Rp. 78,500 |
| B | URINALISA | TARIF |
| 1 | UL (Dgn Strip) + sed. (Gluk, Prot,bil,urobil,SG,BLD) | Rp. 17,500 |
| 2 | Sedimen Urine | Rp. 12,500 |
| 3 | BD Urine | Rp.12,500 |
| 4 | Darah Samar | Rp. 12,500 |
| 5 | Fisik:Vol, Bau, War, Kekeruhan | Rp. 20,000 |
| 6 | Test Kehamilan | Rp. 25,000 |
| 7 | Protein Esbach | Rp. 30,000 |
| C | KIMIA DARAH | TARIF |
| 1 | Glukosa N | Rp. 26,800 |
| 2 | Glukosa 2 jam PP | Rp. 26,800 |
| 3 | Glukosa sewaktu | Rp. 26,800 |
| 4 | Ureum | Rp. 36,300 |
| 5 | Creatinin | Rp. 33,300 |
| 6 | Asam Urat | Rp. 33,400 |
| 7 | SGOT | Rp. 38,800 |
| 8 | SGPT | Rp. 38,800 |
| 9 | Bilirubin total | Rp. 47,000 |
| 10 | Bilirubin Direct | Rp. 30,000 |
| 11 | Bilirubin Indirect | Rp. 30,000 |
| 12 | Protein total | Rp. 31,500 |
| 13 | Albumin | Rp. 32,700 |
| 14 | Globulin | Rp. 32,700 |
| 15 | Alkali Phospatase | Rp. 40,000 |
| 16 | Cholesterol | Rp. 30,000 |
| 17 | HDL cholesterol | Rp. 40,000 |
| 18 | LDL cholesterol | Rp. 40,000 |
| 19 | Trigliserida | Rp. 40,000 |
| 20 | Gamma GT | Rp. 30,000 |
| 21 | Glukosa metode POCT | Rp. 25,000 |
| 22 | Kalium | Rp. 58,800 |
| 23 | Natrium | Rp. 58,800 |
| 24 | Calsium | Rp. 58,800 |
| 25 | Chlorida | Rp. 58,800 |
| 26 | Magnesium | Rp. 58,800 |
| 27 | HBAIC | Rp. 150,500 |
| D | LAIN LAIN | TARIF |
| 1 | Analisa Batu | Rp. 78,800 |
| 2 | Analisa Sperma | Rp. 70,000 |
| 3 | Analisa LCS | Rp. 52,000 |
| 4 | Analisa Cairan Transudat/ Eksudat | Rp. 52,000 |
