UMUM & ASURANSI BPJS

EKSISTING EKSISTING
NO JENIS PELAYANAN
VIP / KLS 1 RJ/KLS II/KLS Ranap Rajal
III
1 Darah Lengkap 136,950 128,150 75,000 75,000
2 Darah Rutin 114,400 106,700 60,000 60,000
3 H2TL 114,400 106,700 60,000 60,000
4 Golongan Darah + Resus 57,200 53,350 35,000 35,000
5 D-Rutin + G-Darah 171,050 160,050 100,000 100,000
6 Hemoglobin 61,050 56,650 36,000 36,000
7 Trombosit 61,050 56,650 36,000 36,000
8 Lekosit 61,050 56,650 30,000 30,000
9 Eritrosit 61,050 566,500 30,000 30,000
10 IT Ratio 188,650 176,000 126,000 126,000
11 LED 53,350 49,500 30,000 30,000
12 Eosinofil 132,000 123,750 42,000 42,000
13 Retikulosit 172,150 160,600 66,000 66,000
14 Ms Perdarahan (BT) 45,650 42,900 20,000 20,000
15 Ms Pembekuan (CT) 45,650 42,900 20,000 20,000
16 Widal 129,250 121,000 80,000 80,000
17 PT 370,150 345,950 280,000 280,000
18 APTT 370,150 345,950 275,000 275,000
19 Trombin Time 370,150 345,950 252,000 252,000
20 INR 370,150 345,950 300,000 300,000
21 Fibrinogen 403,700 376,750 388,000 388,000
22 Agregrasi Trombosit 572,550 535,150 280,000 280,000
23 Trombo Test Owren (TTO) 377,300 352,000 157,000 157,000
24 Viskositas Plasma 231,550 216,150 216,000 216,000
25 Viskositas Darah 317,350 296,450 270,000 270,000
26 Reaksi LE 397,100 370,700 165,000 165,000
27 Sel LE 208,450 194,700 225,000 225,000
28 Serum Iron (FE) 330,550 309,100 225,000 225,000
29 TIBC 330,550 309,100 225,000 225,000
30 UIBC 330,550 309,100 - -
31 Ferritin 463,100 432,300 - -
32 Transferin 618,750 578,050 - -
33 G6PD 453,200 422,950 - -
34 Electroforesa HB 945,450 883,300 - -
35 COMBs Test 1,038,400 969,650 - -
36 CD-4 496,100 463,100 - -
37 CD-8 529,100 493,900 360,000 360,000
38 Viral Load 2,844,050 2,655,950 990,000 990,000
39 Malaria 158,950 148,500 108,000 108,000
40 Hapusan Darah (GDT) 323,950 302,500 220,000 220,000
FUNGSI LEMAK
1 CHOLESTROL TOTAL 65,450 60,500 40,000 40,000
2 TRIGLICERIDE 64,900 60,500 40,000 40,000
3 HDL CHOLESTEROL 83,600 78,100 40,000 40,000
4 LDL CHOLESTEROL 115,500 115,500 105,000 105,000
5 APO A 476,300 444,840 - -
6 APO B 476,300 444,840 - -
7 LIPO PROTEIN (A) 589,050 561,000 - -
8 SMAL DENSE LDL 508,200 484,000 - -
FUNGSI GINJAL
1 UREUM 64,900 60,500 40,000 40,000
2 UREUM URINE 185,350 172,700 120,000 120,000
3 UREA CLEARENCE 226,050 211,200 150,000 150,000
4 CREATININE 64,900 60,500 40,000 40,000
5 CREATININE URIN 185,350 172,700 125,000 125,000
6 CREATININE CLEARANCE 226,050 211,200 150,000 150,000
7 ASAM URAT 64,900 60,500 40,000 40,000
8 ASAM URAT URINE 185,350 172,700 125,000 125,000
9 MIKRO ALBUMIN URIN 273,900 255,750 200,000 200,000
10 CYSTATIN 661,650 617,650 440,000 440,000
DIABETES
1 GLUKOSA SEWAKTU 57,200 53,350 30,000 30,000
2 GLUKOSA PUASA 57,200 53,350 30,000 30,000
3 GLUKOSA 2 JAM PP 57,200 53,350 30,000 30,000
4 HBA1C 397,100 370,700 150,000 150,000
5 C-PEPTIDE 746,350 710,600 - -
6 INSULIN 687,500 654,500 - -
7 GTT 218,350 203,500 - -
FUNGSI HATI - -
1 SGOT 64,900 60,500 40,000 40,000
2 SGPT 64,900 60,500 40,000 40,000
3 GGT 169,400 158,400 115,000 115,000
4 ALP 141,350 132,000 96,500 96,500
5 BILIRUBIN DIRECT 198,550 185,350 130,000 130,000
6 BILIRUBIN TOTAL 198,550 185,350 130,000 130,000
7 BILIRUBIN BAYI 76,450 70,950 50,000 50,000
8 ALBUMIN 96,800 90,200 65,000 65,000
9 GLOBULIN 198,550 185,350 132,000 132,000
10 AMILASE 310,750 290,400 210,000 210,000
11 LIPASE 376,750 352,000 257,000 257,000
12 TOTAL PROTEIN 108,900 101,750 80,000 80,000
13 PROTEIN ELETROFORESA 434,500 405,900 339,000 339,000
FUNGSI JANTUNG
1 CK 273,900 255,750 186,000 186,000
2 CK-MB 545,050 5,087,500 370,000 370,000
3 LDH 226,050 211,200 153,000 153,000
4 TROPONIN T 741,400 706,200 - -
5 TROPONIN I 1,029,050 960,850 690,000 690,000
6 HOMOCYSTEIN 1,058,200 1,007,600 - -
7 HS CRP 500,500 467,500 335,000 335,000
8 NT Pro BNP 1,699,500 1,587,300 1,150,000 1,150,000
9 ALFA HBDH 297,550 277,750 200,000 200,000
ELECTROLYTE
1 NATRIUM 158,950 148,500 120,000 120,000
2 KALIUM 158,950 148,500 120,000 120,000
3 CHLORIDA 158,950 148,500 120,000 120,000
4 NA, K, CL 397,100 370,700 300,000 300,000
5 KALSIUM 158,950 148,500 115,000 115,000
6 FOSFOR 158,950 148,500 115,000 115,000
7 MAGNESIUM 158,950 148,500 115,000 115,000
8 CA ION 701,250 654,500 470,000 470,000
Imunoserologi
1 HBsAg 212,850 199,100 120,000 120,000
2 HbsAg Kuantitatif 740,850 691,900 500,000 500,000
3 Anti HBs Titer 463,100 432,300 315,000 315,000
4 HBeAg 763,400 712,800 520,000 520,000
5 ANTI HBe 941,600 879,450 635,000 635,000
6 ANTI HBc TOTAL 992,200 926,200 650,000 650,000
7 ANTI HBc IgM 992,200 926,200 650,000 650,000
8 ANTI HCV 763,400 712,800 577,000 577,000
9 ANTI HCV IgM 1,199,550 1,120,350 810,000 810,000
10 ANTI HAV IgM 683,650 638,550 460,000 460,000
11 ANTI HAV TOTAL 763,400 712,800 519,000 519,000
12 HBsAg KONFIRMASI 1,558,700 1,455,850 1,050,000 1,050,000
13 HIV 509,300 475,750 390,000 390,000
14 DENGUE IgG IgM 562,100 525,250 380,000 380,000
15 DENGUE NS1 509,300 475,750 380,000 380,000
16 TUBEX 508,200 474,100 200,000 200,000
17 TB 469,700 438,350 319,000 319,000
18 TOXOPLASMA 1gG 476,300 444,950 324,000 324,000
19 TOXOPLASMA 1gM 485,650 453,200 330,000 330,000
20 TOXO AVIDITY IgG - 850,850 - -
21 RUBELLA IgG 653,400 610,500 444,000 444,000
22 RUBELLA IgM 653,400 610,500 444,000 444,000
23 ANTI CMV IgG 495,000 462,000 315,000 315,000
24 ANTI CMV IgM 675,950 630,850 451,000 451,000
26 ANTI HSV IgG 535,700 500,500 359,000 359,000
27 ANTI HSV IgM 535,700 500,500 359,000 359,000
28 TORCH 3,996,300 3,731,750 - -
29 CEA 529,100 493,900 360,000 360,000
30 AFP 529,100 493,900 360,000 360,000
31 CA 125 1,076,900 1,005,400 730,000 730,000
32 CA 19-9 1,104,400 1,031,250 751,000 751,000
33 CA 15-3 1,038,400 969,650 706,500 706,500
34 PSA 670,450 626,450 455,500 455,500
35 PAP 783,200 731,500 520,000 520,000
36 FREE PSA 1,510,850 1,410,750 1,025,000 1,025,000
37 SCC 1,302,950 1,216,600 890,000 890,000
0 NSE 1,642,850 1,533,950 1,120,000 1,120,000
39 CYFRA 1,284,250 1,199,550 890,000 890,000
40 CA 72-4 1,699,500 1,587,300 1,182,000 1,182,000
41 T3 TOTAL 405,900 379,500 318,000 318,000
42 T4 TOTAL 405,900 379,500 318,000 318,000
43 T3 UPTAKE 1,246,300 1,163,250 840,000 840,000
44 FREE T3 661,100 617,650 400,000 400,000
45 FREE T4 56,650 529,100 385,000 385,000
46 TSHs 415,250 387,750 324,000 324,000
47 LH 575,300 537,350 391,000 391,000
48 FSH 575,300 537,350 391,000 391,000
49 PROLACTIN 556,600 520,300 375,000 375,000
50 TESTOSTERON 623,150 581,900 - -
51 PROGESTERON 727,650 679,250 - -
52 ESTRADIOL 707,850 660,550 551,000 551,000
53 BETA HCG 825,550 770,550 560,000 560,000
DRUG TEST
1 3 /5Parameter 317,350 296,450 269,500 269,500
FECES
1 FECES RUTIN 99,000 92,400 63,000 63,000
2 FECES LENGKAP 197,450 184,800 117,000 117,000
3 DARAH SAMAR 182,600 170,500 105,000 105,000
URINE
1 URINE LENGKAP 99,000 92,400 50,000 50,000
2 SEDIMENT 37,950 35,750 20,000 20,000
3 PROTEIN 37,950 35,750 50,000 50,000
4 GLUKOSA 37,950 35,750 50,000 50,000
5 UROBILIN 37,950 35,750 50,000 50,000
6 BILIRUBIN 37,950 35,750 50,000 50,000
7 KETON 37,950 35,750 50,000 50,000
8 MITRIT 37,950 35,750 50,000 50,000
9 PH 37,950 35,750 50,000 50,000
10 BERAT JENIS 37,950 35,750 50,000 50,000
11 TES KEHAMILAN 99,000 92,400 60,000 60,000
PATOLOGY ANATOMI
1 PA BESAR 707,850 707,850 585,000 585,000
PA SEDANG 707,000 707,000 550,000 550,000
2 PA KECIL 435,600 435,600 360,000 360,000
3 PAP SMER 130,900 130,900 108,000 108,000
SEDIAAN LANGSUNG - -
1 PREPARAT BTA 152,350 141,900 40,000 40,000
2 PREPARAT GRAM 152,350 141,900 102,000 102,000
 LAIN - LAIN
1 AGD 536,250 487,500 390,000 390,000
2 436,150 396,500 317,200 317,200