PELAYANAN KEDOKTERAN NUKLIR
RAWAT JALAN UMUM
No Jenis Pemeriksaan / Tindakan Jasa Sarana Jasa Pelayanan Jumlah
(Rp.) (Rp.) (Rp.)
A DIAGNOSIS IN-VIVO
1 Sidik Tulang 1,100,000 300,000 1,400,000
2 Sidik Kelenjar Gondok (SKG)/Uptake 350,000 250,000 600,000
3 SST MIBI 925,000 725,000 1,650,000
4 GFR 425,000 350,000 775,000
5 Renografi 425,000 350,000 775,000
6 Studi Lintas Pertama 425,000 350,000 775,000
7 Sidik Hati 950,000 350,000 1,300,000
8 Ventrikulografi (MUGA) 825,000 400,000 1,225,000
9 Skintimamografi 1,100,000 600,000 1,700,000
10 Sidik Ventilasi/Inhalasi paru 2,100,000 1,000,000 3,100,000
11 Sidik Perfusi Paru 1,000,000 400,000 1,400,000
12 Dakriosistografi (DSG) 350,000 250,000 600,000
13 Sidik Limpa 700,000 525,000 1,225,000
14 Sidik Kelenjar saliva/ Sidik Kelenjar parotis 700,000 300,000 1,000,000
15 Sidik Sistem Hepatobilaris 950,000 550,000 1,500,000
16 Sidik Divertikulum Meckels 450,000 350,000 800,000
17 Sidik Pooling darah Hati 650,000 350,000 1,000,000
18 Sidik Plebiografi/Venografi 850,000 650,000 1,500,000
19 Sistografi 500,000 450,000 950,000
20 Deteksi refluks esofagus 550,000 350,000 900,000
21 Lokasi Pendarahan Interstinal (LPI) 900,000 400,000 1,300,000
22 Waktu Pengosongan Lambung 575,000 475,000 1,050,000
23 Waktu Transit Esofagus 550,000 350,000 900,000
24 Sidik infeksi/Etambutol 970,000 580,000 1,550,000
25 Sidik Perfusi Miokard 2,250,000 1,000,000 3,250,000
26 Sidik Otak HMPAO 2,650,000 1,000,000 3,650,000
27 SST-131 600,000 450,000 1,050,000
28 Sentinel node, gamma probe detection 2,700,000 1,000,000 3,700,000
29 Sidik testis 500,000 450,000 950,000
30 PET Ga-68 5,500,000 1,500,000 7,000,000
31 Laju Filtrasi Glomerulus 365,000 250,000 615,000
B DIAGNOSIS IN-VITRO
1 T3 97,000 45,000 142,000
2 FT4 97,000 45,000 142,000
3 TSHs 105,000 65,000 170,000
4 Anti Tiroglobulin 267,500 142,500 410,000
5 Tiroglobulin 267,500 142,500 410,000
6 Skrining hipotiroid kongenital 41,000 14,000 55,000
C TERAPI
1 Hemangioma kulit 600,000 500,000 1,100,000
2 Terapi Keloid denga P-32 600,000 800,000 1,400,000
3 Terapi Kecil Iodium 131<10 mCi 1,200,000 500,000 1,700,000
4 Terapi Kecil Iodium 131 10-20 mCi 2,250,000 500,000 2,750,000
5 Terapi Paliatif Samarium 50 mCi 4,960,000 800,000 5,760,000
RAWAT JALAN SPESIALIS
No Jenis Pemeriksaan / Tindakan Jasa Sarana Jasa Pelayanan Jumlah
(Rp.) (Rp.) (Rp.)
A DIAGNOSIS IN-VIVO
1 Sidik Tulang 1,350,000 350,000 1,700,000
2 Sidik Kelenjar Gondok (SKG)/Uptake 450,000 300,000 750,000
3 SST MIBI 1,150,000 850,000 2,000,000
4 GFR 525,000 425,000 950,000
5 Renografi 525,000 425,000 950,000
6 Studi Lintas Pertama 525,000 425,000 950,000
7 Sidik Hati 1,150,000 425,000 1,575,000
8 Ventrikulografi (MUGA) 1,000,000 475,000 1,475,000
9 Skintimamografi 1,325,000 725,000 2,050,000
10 Sidik Ventilasi/Inhalasi paru 2,525,000 1,200,000 3,725,000
11 Sidik Perfusi Paru 1,225,000 475,000 1,700,000
12 Dakriosistografi (DSG) 425,000 300,000 725,000
13 Sidik Limpa 850,000 625,000 1,475,000
14 Sidik Kelenjar saliva/ Sidik Kelenjar parotis 850,000 350,000 1,200,000
15 Sidik Sistem Hepatobilaris 1,150,000 650,000 1,800,000
16 Sidik Divertikulum Meckels 550,000 425,000 975,000
17 Sidik Pooling darah Hati 775,000 425,000 1,200,000
18 Sidik Plebiografi/Venografi 1,025,000 775,000 1,800,000
19 Sistografi 600,000 550,000 1,150,000
20 Deteksi refluks esofagus 675,000 425,000 1,100,000
21 Lokasi Pendarahan Interstinal (LPI) 1,100,000 475,000 1,575,000
22 Waktu Pengosongan Lambung 700,000 575,000 1,275,000
23 Waktu Transit Esofagus 675,000 425,000 1,100,000
24 Sidik infeksi/Etambutol 1,175,000 700,000 1,875,000
25 Sidik Perfusi Miokard 2,700,000 1,200,000 3,900,000
26 Sidik Otak HMPAO 3,200,000 1,200,000 4,400,000
27 SST-131 725,000 550,000 1,275,000
28 Sentinel node, gamma probe detection 3,250,000 1,200,000 4,450,000
29 Sidik testis 600,000 550,000 1,150,000
30 PET Ga-68 5,500,000 1,500,000 7,000,000
31 Laju Filtrasi Glomerulus 475,000 275,000 750,000
B DIAGNOSIS IN-VITRO
1 T3 115,000 55,000 170,000
2 FT4 115,000 55,000 170,000
3 TSHs 135,000 75,000 210,000
4 Anti Tiroglobulin 325,000 175,000 500,000
5 Tiroglobulin 325,000 175,000 500,000
6 Skrining hipotiroid kongenital 41,000 14,000 55,000
C TERAPI
1 Hemangioma kulit 725,000 600,000 1,325,000
2 Terapi Keloid denga P-32 750,000 1,000,000 1,750,000
3 Terapi Kecil Iodium 131<10 mCi 1,450,000 600,000 2,050,000
4 Terapi Kecil Iodium 131 10-20 mCi 2,700,000 600,000 3,300,000
5 Terapi Paliatif Samarium 50 mCi 5,925,000 1,000,000 6,925,000
RAWAT INAP
No Jenis Pemeriksaan / Tindakan Jasa Sarana Jasa Pelayanan Jumlah
(Rp.) (Rp.) (Rp.)
1 Terapi iodium 131 (21-29.9)mCi
Kelas III  3,350,000  500,000  3,850,000
Kelas II  3,350,000  500,000  3,850,000
Kelas I  4,025,000  600,000  4,625,000
VIP B/A  4,025,000  600,000  4,625,000
2 Terapi iodium 30-80 mCi
Kelas III 10,400,000 1,000,000 11,400,000
Kelas II 10,400,000 1,000,000 11,400,000
Kelas I 12,500,000 1,200,000 13,700,000
VIP B/A 12,500,000 1,200,000 13,700,000
3 Terapi iodium 131 100 mCi
Kelas III 12,550,000 1,000,000 13,550,000
Kelas II 12,550,000 1,000,000 13,550,000
Kelas I 15,075,000 1,200,000 16,275,000
VIP B/A 15,075,000 1,200,000 16,275,000
4 Terapi Iodium 131 150 mCi
Kelas III 18,100,000 1,000,000 19,100,000
Kelas II 18,100,000 1,000,000 19,100,000
Kelas I 21,725,000 1,200,000 22,925,000
VIP B/A 21,725,000 1,200,000 22,925,000
5 Terapi Iodium 131 >150 mCi
Kelas III 18,100,000 1,000,000 19,100,000
Kelas II 18,100,000 1,000,000 19,100,000
Kelas I 21,725,000 1,200,000 22,925,000
VIP B/A 21,725,000 1,200,000 22,925,000

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