PMK No 64 Tahun 2016 PDF

PERATURAN MENTERl KESEHATAN REPUBLIK INDONESIA
NOMOR 64 TAHUN 2016

TENTANG
PERUBAHAN ATAS PERATURAN MENTERI KESEHATAN
NOMOR 52 TAHUN 2016 TENTANG STANDAR TARIF PELAYANAN
KESEHATAN DALAM PENYELENGGARAAN PROGRAM JAMINAN KESEHATAN
DENGAN RAHMAT TUHAN YANG MAHA ESA

MENTERI KESEHATAN REPUBLIK INDONESIA,
Menimbang
: a.
bahwa
standar
tarif
pelayanan
kesehatan
dalam
penyelenggaraan program jaminan kesehatan disusun

bersama antara Menteri Kesehatan, Badan Penyelenggara
Jaminan Sosial (BPJS) Kesehatan, Dewan Jaminan Sosial
Nasional (DJSN), dan menteri yang menyelenggarakan
urusan
pemerintahan di bidang keuangan, dengan
memperhatikan kecukupan anggaran;

b.
bahwa
standar
penyelenggaraan
tarif
pelayanan
program
jaminan
kesehatan
kesehatan
dalam
telah
ditetapkan melalui Peraturan Menteri Kesehatan Nomor

52
Tahun
2016
Tentang
Standar
Tarif
Pelayanan
Kesehatan dalam Penyelenggaraan Program Jaminan

Kesehatan,
namun
belum
memenuhi
ketentuan
sebagaimana dimaksud dalam huruf a;

c.
bahwa
berdasarkan
pertimbangan
sebagaimana
dimaksud dalam huruf a dan huruf b, perlu menetapkan

Peraturan Menteri Kesehatan tentang Perubahan atas
Peraturan Menteri Kesehatan Nomor 52 Tahun 2016
-2-
tentang
Standar
Tarif
Pelayanan
Kesehatan
Dalam
Penyelenggaraan Program Jaminan Kesehatan;

Mengingat
: 1. Undang-Undang Nomor 40 Tahun 2004 tentang Sistem

Jaminan Sosial Nasional (Lembaran Negara Republik
Indonesia Nomor 2004 Tahun 150, Tambahan Lembaran
Negara Republik Indonesia Nomor 4456);
2. Undang-Undang
Nomor
36
Tahun
2009
tentang
Kesehatan (Lembaran Negara Republik Indonesia 2009

Nomor
144,
Tambahan
Lembaran
Negara
Republik
Indonesi Nomor 5063);

3. Undang-UndangNomor 24 Tahun 2011 tentang Badan
Penyelenggara Jaminan Sosial (Lembaran Negar Republik
Indonesia Tahun 2011 Nomor 116, Tambahan Lembaran
Negara Republik Indonesia Nomor 5256);
4. Peraturan Presiden Nomor 12 Tahun 2013 tentang
Jaminan
Kesehatan
(Lembaran
Negara
Republik
Indonesia Tahun 2013 Nomor 29) sebagaimana telah

diubah beberapa kali terakhir dengan Peraturan Presiden
Nomor 19 Tahun 2016 (Lembaran Negara Republik
Indonesia Tahun 2016 Nomor 42);
5. Peraturan Menteri Kesehatan Nomor 9 Tahun 2014
tentang Klinik (Berita Negara Republik Indonesia Tahun
2014 Nomor 232);
6.
Peraturan Menteri Kesehatan Nomor 52 Tahun 2016

tentang
Standar
Tarif
Pelayanan
Kesehatan
Dalam
Penyelenggaraan Program Jaminan Kesehatan (Berita

Negara Republik Indonesia Tahun 2016 Nomor 1601);
MEMUTUSKAN:
Menetapkan
: PERATURAN MENTERI KESEHATAN TENTANG PERUBAHAN

ATAS PERATURAN MENTERI KESEHATAN NOMOR 52 TAHUN
2016 TENTANG STANDAR TARIF PELAYANAN KESEHATAN
DALAM
PENYELENGGARAAN
KESEHATAN.
PROGRAM
JAMINAN
-3-
Pasal I
Beberapa Ketentuan dalam Peraturan Menteri Kesehatan
Nomor 52 Tahun 2016 tentang Standar Tarif Pelayanan
Kesehatan
Dalam
Penyelenggaraan
Program
Jaminan
Kesehatan (Berita Negara Republik Indonesia Tahun 2016

Nomor 1601), diubah sebagai berikut:
1.
Ketentuan Pasal 25 diubah, sehingga berbunyi sebagai

berikut:
Pasal 25
(1)
Besaran tambahan pembayaran pelayanan rawat

jalan eksekutif paling banyak sebesar Rp 250.000
untuk setiap episode rawat jalan.
(2)
Peserta yang menginginkan kelas pelayanan rawat

inap yang lebih tinggi dari haknya, harus membayar
tambahan biaya dengan ketentuan:
a.
untuk kenaikan kelas pelayanan rawat inap ke

kelas 2 atau kelas 1, tambahan pembayaran
adalah sebesar selisih antara tarif INA-CBG
pada
kelas
rawat
inap
yang
lebih
tinggi
terhadap tarif INA CBG pada kelas rawat inap

yang sesuai hak peserta; dan
b.
untuk kenaikan kelas pelayanan rawat inap ke

kelas
VIP,
tambahan
pembayaran
adalah
sebesar selisih antara tarif kamar rawat inap

kelas VIP terhadap tarif kamar rawat inap pada
kelas yang menjadi hak peserta, sesuai lama
waktu rawat.
(3)
Pembayaran besaran selisih biaya sebagaimana

dimaksud pada ayat (2) dapat dilakukan oleh:
a.
peserta;
b.
pemberi kerja; dan/atau
c.
asuransi kesehatan tambahan.
-4-
2.
Diantara Pasal 26 dan Pasal 27 disisipkan satu pasal,

yakni Pasal 26A, sehingga berbunyi sebagai berikut:
Pasal 26A
Pada saat Peraturan Menteri ini mulai berlaku:
a.
Pembayaran atas pasien yang mendapat pelayanan

rawat
jalan
mulai
menggunakan
tanggal
tarif
dalam
26
Oktober
ketentuan
2016
Peraturan
Menteri ini;
b.

rawat inap yang masuk mulai tanggal 26 Oktober
2016 menggunakan tarif dalam ketentuan Peraturan
Menteri ini;
c.

rawat inap yang masuk sebelum tanggal 26 Oktober
2016 dan pulang setelah tanggal 26 Oktober 2016
menggunakan tarif Peraturan Menteri Kesehatan
Nomor
59
Tahun
Pelayanan
2014
Kesehatan
tentang
Dalam
Standar
Tarif
Penyelenggaraan
Program Jaminan Kesehatan;

d.
Pembayaran atas selisih tarif pelayanan rawat inap

akibat naik kelas bagi pasien yang dirawat sebelum
tanggal 26 Oktober 2016 sampai dengan Peraturan
Menteri
ini
ketentuan
Nomor
59
Pelayanan
berlaku, menggunakan tarif

dalam
Peraturan
Tahun
2014
Kesehatan
Menteri
tentang
Dalam
sesuai
Kesehatan
Standar
Tarif
Penyelenggaraan
Program Jaminan Kesehatan.

3.
Ketentuan dalam Lampiran diubah, sehingga berbunyi

sebagaimana
tercantum
dalam
Lampiran
yang
merupakan bagian tidak terpisahkan dari Peraturan

Menteri ini.
Pasal II
Peraturan
Menteri
diundangkan.
ini
mulai
berlaku
pada
tanggal
-5-
Agar
setiap
orang
mengetahuinya,
memerintahkan
pengundangan Peraturan Menteri ini dengan penempatannya

dalam Berita Negara Republik Indonesia.
Ditetapkan di Jakarta
pada tanggal 23 November 2016
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NILA FARID MOELOEK
Diundangkan di Jakarta
pada tanggal 24 November 2016
DIREKTUR JENDERAL
PERATURAN PERUNDANG-UNDANGAN
KEMENTERIAN HUKUM DAN HAK ASASI MANUSIA
REPUBLIK INDONESIA,
ttd
WIDODO EKATJAHJANA
BERITA NEGARA REPUBLIK INDONESIA TAHUN 2016 NOMOR 1790
Telah diperiksa dan disetujui:

Kepala Biro Hukum
dan Organisasi
Kepala Pusat Jaminan

Kesehatan
Sekretaris Jenderal
Kementerian Kesehatan
Tanggal
Tanggal
Tanggal
Paraf
Paraf
Paraf
-6-
-6-
LAMPIRAN
PERATURAN MENTERI KESEHATAN
NOMOR 64 TAHUN 2016
TENTANG
PERUBAHAN ATAS PERATURAN MENTERI KESEHATAN
NOMOR 52 TAHUN 2016
TENTANG
STANDAR TARIF PELAYANAN KESEHATAN DALAM
PENYELENGGARAAN PROGRAM JAMINAN
STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN
TINGKAT LANJUTAN (INA-CBG)
TARIF INA-CBG TAHUN 2016
REGIONAL 1
RUMAH SAKIT KELAS A PEMERINTAH
RAWAT INAP
NO
KODE
INA-CBG
DESKRIPSI KODE INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1
2
A-4-10-I
A-4-10-II
SEPTIKEMIA (RINGAN)
SEPTIKEMIA (SEDANG)
3,516,500
6,007,600
4,219,800
7,209,200
4,923,100
8,410,700
A-4-10-III
SEPTIKEMIA (BERAT)
8,100,200
9,720,200
11,340,300
4
5
A-4-11-I
A-4-11-II
INFEKSI SESUDAH OPERASI & TRAUMA (RINGAN)

INFEKSI SESUDAH OPERASI & TRAUMA (SEDANG)
4,263,700
6,068,500
5,116,500
7,282,200
5,969,200
8,495,900
6
7
A-4-11-III
A-4-12-I
INFEKSI SESUDAH OPERASI & TRAUMA (BERAT)

DEMAM YANG TIDAK DITENTUKAN (RINGAN)
8,399,400
2,780,700
10,079,200
3,336,800
11,759,100
3,893,000
A-4-12-II
DEMAM YANG TIDAK DITENTUKAN (SEDANG)
4,800,000
5,760,000
6,719,900
9 A-4-12-III
10 A-4-13-I
DEMAM YANG TIDAK DITENTUKAN (BERAT)

INFEKSI VIRAL & NON-BAKTERIAL LAIN (RINGAN)
6,915,900
2,069,600
8,299,000
2,483,500
9,682,200
2,897,500
11 A-4-13-II
12 A-4-13-III
3,657,500
4,389,000
4,389,000
5,266,900
5,120,600
6,144,700
2,318,600
2,782,300
3,246,000
3,901,100
4,681,300
5,461,500
4,681,300
5,617,600
6,553,800
16 A-4-15-I
INFEKSI VIRAL & NON-BAKTERIAL LAIN (SEDANG)

INFEKSI VIRAL & NON-BAKTERIAL LAIN (BERAT)
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
INFEKSI HIV (RINGAN)
18,100,900
21,721,100
25,341,300
17
18
19
20
21
22
23
24
25
26
27
INFEKSI HIV (SEDANG)

INFEKSI HIV (BERAT)
PENCANGKOKAN HATI (RINGAN)
PENCANGKOKAN HATI (SEDANG)
PENCANGKOKAN HATI (BERAT)
PROSEDUR HATI DAN PANKREAS (RINGAN)
PROSEDUR HATI DAN PANKREAS (SEDANG)
PROSEDUR HATI DAN PANKREAS (BERAT)
PROSEDUR SALURAN EMPEDU KOMPLEK (RINGAN)
PROSEDUR SALURAN EMPEDU KOMPLEK (SEDANG)
PROSEDUR SALURAN EMPEDU KOMPLEK (BERAT)
22,541,700
25,465,800
49,908,000
55,061,700
121,370,800
8,067,400
17,906,000
35,348,800
32,192,200
38,358,700
59,275,000
27,050,000
30,558,900
59,889,600
66,074,000
145,644,900
9,680,800
21,487,200
42,418,600
38,630,700
46,030,500
71,130,000
31,558,300
35,652,100
69,871,200
77,086,400
169,919,100
11,294,300
25,068,400
49,488,400
45,069,100
53,702,200
82,985,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
A-4-15-II
A-4-15-III
B-1-01-I
B-1-01-II
B-1-01-III
B-1-10-I
B-1-10-II
B-1-10-III
B-1-11-I
B-1-11-II
B-1-11-III
28 B-1-12-I
CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN)
9,473,000
11,367,600
13,262,200
29 B-1-12-II
CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG)
10,535,700
12,642,800
14,750,000
30 B-1-12-III
CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT)
16,481,900
19,778,300
23,074,700
7,545,400
9,054,500
10,563,500
12,415,000
14,898,000
17,381,000
16,063,900
19,276,700
22,489,500
19,768,800
23,722,600
27,676,300
20,762,800
24,915,400
29,067,900
36,753,800
3,207,700
5,120,500
7,063,900
44,104,500
3,849,300
6,144,600
8,476,700
51,455,300
4,490,800
7,168,700
9,889,400
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAINLAIN (RINGAN)

PROSEDUR PANKREAS DAN HEPATOBILLIARI LAINLAIN (SEDANG)
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAINLAIN (BERAT)
CHOLESISTEKTOMI DENGAN LAPAROSKOPIK
(RINGAN)
(SEDANG)
CHOLESISTEKTOMI DENGAN LAPAROSKOPIK (BERAT)
SIROSIS HATI DAN HEPATITIS ALKOHOLIK (RINGAN)
SIROSIS HATI DAN HEPATITIS ALKOHOLIK (SEDANG)
SIROSIS HATI DAN HEPATITIS ALKOHOLIK (BERAT)
-7-

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
43 B-4-12-I
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS

(RINGAN)
(SEDANG)
(BERAT)
GANGGUAN PANKREAS SELAIN TUMOR (RINGAN)
44 B-4-12-II
45 B-4-12-III
GANGGUAN PANKREAS SELAIN TUMOR (SEDANG)

GANGGUAN PANKREAS SELAIN TUMOR (BERAT)
46 B-4-13-I
47 B-4-13-II
48 B-4-13-III
40
B-4-11-I
41 B-4-11-II
42 B-4-11-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,763,200
8,115,800
9,468,400
9,468,500
11,362,200
13,255,900
11,470,900
13,765,100
16,059,300
6,114,600
7,337,600
8,560,500
8,707,000
12,954,100
10,448,400
15,544,900
12,189,800
18,135,800
GANGGUAN HATI LAIN-LAIN (RINGAN)
5,832,900
6,999,400
8,166,000
GANGGUAN HATI LAIN-LAIN (SEDANG)

GANGGUAN HATI LAIN-LAIN (BERAT)
6,795,000
9,360,800
8,154,000
11,232,900
9,513,100
13,105,100
49 B-4-14-I
GANGGUAN SALURAN EMPEDU LAIN-LAIN (RINGAN)
5,826,600
6,992,000
8,157,300
50 B-4-14-II
GANGGUAN SALURAN EMPEDU LAIN-LAIN (SEDANG)
6,797,500
8,157,000
9,516,500
51 B-4-14-III
GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT)
9,105,400
10,926,500
12,747,600
52 C-4-10-I
53 C-4-10-II
LEUKEMIA AKUT (RINGAN)

LEUKEMIA AKUT (SEDANG)
11,801,200
18,979,600
14,161,500
22,775,600
16,521,700
26,571,500
54 C-4-10-III
LEUKEMIA AKUT (BERAT)
35,561,700
42,674,000
49,786,300
55 C-4-11-I
56 C-4-11-II
LIMFOMA & LEUKEMIA NON AKUT (RINGAN)

LIMFOMA & LEUKEMIA NON AKUT (SEDANG)
6,142,900
8,220,100
7,371,500
9,864,100
8,600,100
11,508,200
57 C-4-11-III
58 C-4-12-I
LIMFOMA & LEUKEMIA NON AKUT (BERAT)

RADIOTERAPI (RINGAN)
12,638,500
4,090,100
15,166,200
4,908,200
17,694,000
5,726,200
59 C-4-12-II
RADIOTERAPI (SEDANG)
8,056,000
9,667,200
11,278,400
60 C-4-12-III
61 C-4-13-I
RADIOTERAPI (BERAT)
KEMOTERAPI (RINGAN)
20,690,100
3,075,000
24,828,100
3,690,000
28,966,100
4,304,900
62 C-4-13-II
63 C-4-13-III
KEMOTERAPI (SEDANG)
KEMOTERAPI (BERAT)
5,787,100
7,833,800
6,944,500
9,400,500
8,101,900
10,967,300
64 C-4-14-I
TUMOR MYELOPROLIFERATIF LAIN-LAIN (RINGAN)
5,109,200
6,131,000
7,152,900
65
66
67
68
69
70
71
72
TUMOR MYELOPROLIFERATIF LAIN-LAIN (SEDANG)

TUMOR MYELOPROLIFERATIF LAIN-LAIN (BERAT)
PENCANGKOKAN SUMSUM TULANG (RINGAN)
PENCANGKOKAN SUMSUM TULANG (SEDANG)
PENCANGKOKAN SUMSUM TULANG (BERAT)
PROSEDUR LIMPA (RINGAN)
PROSEDUR LIMPA (SEDANG)
PROSEDUR LIMPA (BERAT)
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK
DARAH LAIN-LAIN (RINGAN)
DARAH LAIN-LAIN (SEDANG)
DARAH LAIN-LAIN (BERAT)
AGRANULOSITOSIS (RINGAN)
AGRANULOSITOSIS (SEDANG)
AGRANULOSITOSIS (BERAT)
GANGGUAN PEMBEKUAN DARAH (RINGAN)
GANGGUAN PEMBEKUAN DARAH (SEDANG)
GANGGUAN PEMBEKUAN DARAH (BERAT)
KRISIS ANEMIA SEL SICKLE (RINGAN)
KRISIS ANEMIA SEL SICKLE (SEDANG)
KRISIS ANEMIA SEL SICKLE (BERAT)
GANGGUAN SEL DARAH MERAH SELAIN KRISIS
ANEMIA SEL SICKLE (RINGAN)
ANEMIA SEL SICKLE (SEDANG)
ANEMIA SEL SICKLE (BERAT)
GANGGUAN PADA DARAH & ORGAN PEMBENTUK
7,167,100
10,678,900
30,868,200
47,014,500
67,376,800
8,264,700
21,103,600
27,424,900
8,600,600
12,814,700
37,041,900
56,417,300
80,852,200
9,917,600
25,324,300
32,909,900
10,034,000
14,950,500
43,215,500
65,820,200
94,327,500
11,570,500
29,545,000
38,394,900
7,164,500
8,597,400
10,030,300
19,744,300
23,693,200
27,642,100
31,320,300
37,584,400
43,848,400
2,831,200
4,646,300
7,309,700
5,608,800
10,078,900
13,845,900
4,835,600
6,707,100
10,299,000
3,397,400
5,575,600
8,771,700
6,730,600
12,094,600
16,615,000
5,802,700
8,048,500
12,358,800
3,963,700
6,504,800
10,233,600
7,852,400
14,110,400
19,384,200
6,769,800
9,389,900
14,418,600
4,144,000
4,972,800
5,801,600
5,865,100
7,038,200
8,211,200
7,501,700
9,002,000
10,502,400
4,444,600
5,333,500
6,222,400
7,276,900
8,732,300
10,187,700
8,900,400
10,680,500
12,460,600
C-4-14-II
C-4-14-III
D-1-10-I
D-1-10-II
D-1-10-III
D-1-11-I
D-1-11-II
D-1-11-III
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
-8-

REGIONAL 1
RAWAT INAP
NO
91
KODE
INA-CBG
E-1-01-I
92 E-1-01-II

PROSEDUR KELENJAR PITUITARI DAN PINEAL
(RINGAN)
(SEDANG)
93 E-1-01-III
PROSEDUR KELENJAR PITUITARI DAN PINEAL (BERAT)
94 E-1-10-I
PROSEDUR KELENJAR ADRENAL (RINGAN)
95 E-1-10-II
96 E-1-10-III
103 E-4-11-I
PROSEDUR KELENJAR ADRENAL (SEDANG)

PROSEDUR KELENJAR ADRENAL (BERAT)
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN
TIROGLOSAL (RINGAN)
TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
HIPOVOLEMIA & GANGGUAN ELEKROLIT (RINGAN)
104 E-4-11-II
HIPOVOLEMIA & GANGGUAN ELEKROLIT (SEDANG)
105 E-4-11-III
106 E-4-12-I
107 E-4-12-II
108 E-4-12-III
97 E-1-20-I
98 E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,859,800
10,631,800
12,403,700
12,094,900
14,513,900
16,932,900
29,162,200
34,994,600
40,827,000
9,211,300
11,053,600
12,895,800
12,786,400
24,157,700
15,343,700
28,989,300
17,901,000
33,820,800
10,427,900
12,513,500
14,599,100
14,035,700
16,842,900
19,650,000
19,344,100
23,212,900
27,081,700
3,690,400
4,428,500
5,166,600
7,147,700
8,577,200
10,006,800
11,976,800
14,372,200
16,767,500
4,099,400
4,919,300
5,739,200
6,249,900
7,499,900
8,749,900
HIPOVOLEMIA & GANGGUAN ELEKROLIT (BERAT)

GANGGUAN METABOLIK BAWAAN (RINGAN)
8,469,100
4,710,200
10,162,900
5,652,200
11,856,700
6,594,200
GANGGUAN
GANGGUAN
GANGGUAN
(RINGAN)
GANGGUAN
(SEDANG)
8,156,900
9,668,900
9,788,300
11,602,700
11,419,600
13,536,400
5,129,200
6,155,000
7,180,900
7,513,400
9,016,100
10,518,700
METABOLIK BAWAAN (SEDANG)

METABOLIK BAWAAN (BERAT)
KELENJAR ENDOKRIN LAIN-LAIN
KELENJAR ENDOKRIN LAIN-LAIN
111 E-4-13-III
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN (BERAT)
9,821,500
11,785,800
13,750,100
112
113
114
115
116
117
SCHIZOFRENIA (RINGAN)
SCHIZOFRENIA (SEDANG)
SCHIZOFRENIA (BERAT)
DEPRESI MAYOR (RINGAN)
DEPRESI MAYOR (SEDANG)
DEPRESI MAYOR (BERAT)
GANGGUAN PERSONALITI & KONTROL IMPULSE
(RINGAN)
(SEDANG)
(BERAT)
GANGGUAN BIPOLAR (RINGAN)
GANGGUAN BIPOLAR (SEDANG)
GANGGUAN BIPOLAR (BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,460,700
6,276,000
7,531,100
5,281,400
6,153,300
7,890,800
6,552,800
7,531,100
9,037,400
6,337,600
7,384,000
9,469,000
7,645,000
8,786,300
10,543,600
7,393,900
8,614,700
11,047,200
2,895,000
3,474,000
4,053,100
4,115,800
4,939,000
5,762,200
8,941,400
10,729,700
12,518,000
4,254,300
5,613,600
7,267,500
2,427,300
3,113,300
4,189,200
5,105,100
6,736,300
8,721,000
2,912,700
3,736,000
5,027,000
5,956,000
7,859,000
10,174,500
3,398,200
4,358,600
5,864,900
127 F-4-15-I
FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (RINGAN)
3,865,600
4,638,700
5,411,800
128 F-4-15-II
FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (SEDANG)
5,760,200
6,912,200
8,064,300
129 F-4-15-III
7,605,300
9,126,300
10,647,400
7,605,700
9,126,800
10,648,000
8,842,900
10,611,500
12,380,000
11,803,700
14,164,500
16,525,200
133 F-4-17-I
FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (BERAT)

GANGGUAN ORGANIK LAIN-LAIN TERMASUK
KETERBELAKANGAN MENTAL (RINGAN)
KETERBELAKANGAN MENTAL (SEDANG)
KETERBELAKANGAN MENTAL (BERAT)
GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN)
1,796,200
2,155,400
2,514,600
134 F-4-17-II
GANGGUAN MENTAL PADA KANAK-KANAK (SEDANG)
5,264,400
6,317,200
7,370,100
F-4-10-I
F-4-10-II
F-4-10-III
F-4-11-I
F-4-11-II
F-4-11-III
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
-9-

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
135 F-4-17-III
GANGGUAN MENTAL PADA KANAK-KANAK (BERAT)
5,616,600
6,739,900
7,863,200
136 F-4-18-I
137 F-4-18-II
GANGGUAN NUTRISI KOMPULSIF (RINGAN)

GANGGUAN NUTRISI KOMPULSIF (SEDANG)
6,608,800
7,271,600
7,930,600
8,725,900
9,252,300
10,180,200
138 F-4-18-III
139 F-4-19-I
GANGGUAN NUTRISI KOMPULSIF (BERAT)

GANGGUAN MENTAL LAIN-LAIN (RINGAN)
11,209,600
5,050,700
13,451,600
6,060,800
15,693,500
7,070,900
140 F-4-19-II
GANGGUAN MENTAL LAIN-LAIN (SEDANG)
6,467,600
7,761,100
9,054,700
141 F-4-19-III
8,052,100
9,662,500
11,273,000
21,425,500
25,710,500
29,995,600
30,729,300
36,875,100
43,021,000
50,275,600
60,330,800
70,385,900
145 G-1-10-I
GANGGUAN MENTAL LAIN-LAIN (BERAT)

PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL
(RINGAN)
(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
33,312,800
39,975,400
46,637,900
146 G-1-10-II
KRANIOTOMI (SEDANG)
40,799,900
48,959,900
57,119,800
147 G-1-10-III
148 G-1-11-I
KRANIOTOMI (BERAT)
PROSEDUR VENTRICULAR SHUNT (RINGAN)
50,137,500
16,396,900
60,165,000
19,676,300
70,192,500
22,955,700
149 G-1-11-II
150 G-1-11-III
29,977,400
48,172,300
35,972,800
57,806,800
41,968,300
67,441,300
6,846,300
8,215,500
9,584,800
12,833,700
15,400,400
17,967,100
17,489,800
20,987,800
24,485,700
154 G-1-13-I
PROSEDUR
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
2,065,300
2,478,400
2,891,400
155 G-1-13-II
156 G-1-13-III
PROSEDUR CARPAL TUNNEL RELEASE (SEDANG)

PROSEDUR CARPAL TUNNEL RELEASE (BERAT)
5,546,400
12,515,200
6,655,700
15,018,200
7,765,000
17,521,300
157 G-1-20-I
PROSEDUR SARAF KRANIAL DAN PERIFER (RINGAN)
11,594,600
13,913,500
16,232,400
158 G-1-20-II
PROSEDUR SARAF KRANIAL DAN PERIFER (SEDANG)
17,544,400
21,053,300
24,562,200
159
160
161
162
PROSEDUR SARAF KRANIAL DAN PERIFER (BERAT)

PROSEDUR TULANG BELAKANG (RINGAN)
PROSEDUR TULANG BELAKANG (SEDANG)
PROSEDUR TULANG BELAKANG (BERAT)
KECEDERAAN & GANGGUAN TULANG BELAKANG
(RINGAN)
(SEDANG)
(BERAT)
TUMOR SISTEM PERSARAFAN & GANGGUAN
DEGENERATIF (RINGAN)
DEGENERATIF (SEDANG)
DEGENERATIF (BERAT)
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR
(RINGAN)
(SEDANG)
29,916,400
28,885,100
38,944,200
58,481,500
35,899,700
34,662,100
46,733,000
70,177,800
41,883,000
40,439,200
54,521,900
81,874,100
5,876,800
7,052,100
8,227,500
7,183,400
8,620,100
10,056,800
9,856,900
11,828,300
13,799,600
6,152,100
7,382,500
8,612,900
8,172,300
9,806,700
11,441,200
12,007,800
14,409,400
16,811,000
6,825,000
8,190,000
9,555,000
8,620,500
10,344,600
12,068,700
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR (BERAT)
12,520,200
15,024,200
17,528,200
4,099,900
4,919,900
5,739,800
7,149,400
8,579,300
10,009,100
8,479,300
10,175,200
11,871,100
6,955,000
8,346,000
9,737,000
9,298,300
11,157,900
13,017,600
11,670,400
14,004,500
16,338,600
142 G-1-01-I
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
G-1-20-III
G-1-30-I
G-1-30-II
G-1-30-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
VENTRICULAR SHUNT (SEDANG)

VENTRICULAR SHUNT (BERAT)
PEMBULUH DARAH EXTRA KRANIAL
CARPAL TUNNEL RELEASE (RINGAN)
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK

(RINGAN)
(SEDANG)
(BERAT)
KECEDERAAN PEMBULUH DARAH OTAK DENGAN
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 10 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I
182 G-4-16-II
183 G-4-16-III
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
187 G-4-18-I
188 G-4-18-II
189 G-4-18-III

KECEDERAAN PEMBULUH DARAH OTAK NON
SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
ISKEMIK TRANSIENT (RINGAN)
ISKEMIK TRANSIENT (SEDANG)
ISKEMIK TRANSIENT (BERAT)
GANGUAN PERSARAFAN KRANIAL DAN PERIFER
(RINGAN)
(SEDANG)
(BERAT)
INFEKSI BAKTERI SISTEM PERSARAFAN (RINGAN)
INFEKSI BAKTERI SISTEM PERSARAFAN (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,682,800
6,819,400
7,956,000
6,782,200
8,138,600
9,495,000
9,572,400
11,486,900
13,401,400
4,684,700
6,219,600
5,621,700
7,463,500
6,558,600
8,707,400
8,857,200
10,628,700
12,400,100
6,239,700
7,487,700
8,735,600
8,181,700
9,818,000
11,454,300
10,280,600
12,336,700
14,392,900
6,145,200
8,214,200
7,374,200
9,857,100
8,603,200
11,499,900
9,191,100
11,029,300
12,867,500
5,127,000
6,152,500
7,177,900
8,665,900
10,399,100
12,132,300
11,378,000
13,653,600
15,929,200
3,586,600
5,070,400
4,304,000
6,084,500
5,021,300
7,098,500
193 G-4-20-I
194 G-4-20-II
INFEKSI BAKTERI SISTEM PERSARAFAN (BERAT)

INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK
TERMASUK MENINGITIS VIRUS) (RINGAN)
TERMASUK MENINGITIS VIRUS) (SEDANG)
TERMASUK MENINGITIS VIRUS) (BERAT)
MENINGITIS VIRUS (RINGAN)
MENINGITIS VIRUS (SEDANG)
195 G-4-20-III
MENINGITIS VIRUS (BERAT)
8,375,100
10,050,100
11,725,100
196 G-4-21-I
197 G-4-21-II
KOMA & STUPOR NON TRAUMA (RINGAN)

KOMA & STUPOR NON TRAUMA (SEDANG)
3,734,900
6,321,400
4,481,900
7,585,700
5,228,900
8,849,900
198
199
200
201
202
203
204
205
206
207
208
209
210
KOMA & STUPOR NON TRAUMA (BERAT)

SERANGAN KEJANG (RINGAN)
SERANGAN KEJANG (SEDANG)
SERANGAN KEJANG (BERAT)
MIGREN DAN SAKIT KEPALA LAIN (RINGAN)
MIGREN DAN SAKIT KEPALA LAIN ((SEDANG)
MIGREN DAN SAKIT KEPALA LAIN (BERAT)
TRAUMA KEPALA (RINGAN)
TRAUMA KEPALA (SEDANG)
TRAUMA KEPALA (BERAT)
GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
GANGGUAN - PENYAKIT SISTEM PERSARAFAN LAINLAIN (RINGAN)
GANGGUAN - PENYAKIT SISTEM PERSARAFAN LAINLAIN (SEDANG)
GANGGUAN - PENYAKIT SISTEM PERSARAFAN LAINLAIN (BERAT)
PROSEDUR EKSTRAOKULER DAN ORBITA (RINGAN)
PROSEDUR EKSTRAOKULER DAN ORBITA (SEDANG)
PROSEDUR EKSTRAOKULER DAN ORBITA (BERAT)
PROSEDUR LENSA DAN INTRA OKULER (RINGAN)
PROSEDUR LENSA DAN INTRA OKULER (SEDANG)
PROSEDUR LENSA DAN INTRA OKULER (BERAT)
INFEKSI MATA AKUT MAYOR (RINGAN)
INFEKSI MATA AKUT MAYOR (SEDANG)
INFEKSI MATA AKUT MAYOR (BERAT)
GANGGUAN PERSARAFAN MATA (RINGAN)
GANGGUAN PERSARAFAN MATA (SEDANG)
GANGGUAN PERSARAFAN MATA (BERAT)
GANGGUAN MATA LAIN-LAIN (RINGAN)
GANGGUAN MATA LAIN-LAIN (SEDANG)
7,429,100
2,798,200
4,955,600
7,817,000
3,676,700
4,612,900
6,567,700
4,095,200
5,116,400
8,523,800
3,499,300
4,425,300
5,864,300
8,914,900
3,357,800
5,946,700
9,380,400
4,412,000
5,535,500
7,881,200
4,914,300
6,139,700
10,228,500
4,199,200
5,310,300
7,037,200
10,400,700
3,917,400
6,937,800
10,943,800
5,147,300
6,458,100
9,194,800
5,733,300
7,163,000
11,933,300
4,899,000
6,195,400
8,210,100
3,989,500
4,787,400
5,585,300
4,641,000
5,569,200
6,497,400
6,939,700
8,327,700
9,715,600
11,801,000
13,041,900
17,736,300
8,041,400
9,990,600
13,993,300
4,263,700
5,784,900
11,370,600
4,088,500
4,663,700
6,678,100
4,820,300
5,759,400
14,161,200
15,650,300
21,283,500
9,649,600
11,988,700
16,791,900
5,116,400
6,941,900
13,644,700
4,906,100
5,596,400
8,013,700
5,784,400
6,911,300
16,521,400
18,258,700
24,830,800
11,257,900
13,986,800
19,590,600
5,969,100
8,098,900
15,918,800
5,723,800
6,529,100
9,349,300
6,748,500
8,063,100
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-21-III
G-4-22-I
G-4-22-II
G-4-22-III
G-4-23-I
G-4-23-II
G-4-23-III
G-4-24-I
G-4-24-II
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
- 11 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
228 H-4-12-III
GANGGUAN MATA LAIN-LAIN (BERAT)
229 I-1-01-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,651,700
11,582,100
13,512,400
TRANPLANTASI PARU ATAU/DAN JANTUNG (RINGAN)
64,745,400
77,694,500
90,643,600
230 I-1-01-II
TRANPLANTASI PARU ATAU/DAN JANTUNG (SEDANG)
66,169,800
79,403,800
92,637,700
231 I-1-01-III
TRANPLANTASI PARU ATAU/DAN JANTUNG (BERAT)

PROSEDUR KATUP JANTUNG DENGAN KATETERISASI
(RINGAN)
(SEDANG)
(BERAT)
OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
PROSEDUR KATUP JANTUNG TANPA KATETERISASI
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
PEMBEDAHAN BYPASS PEMBULUH KORONER
DENGAN KATETERISASI JANTUNG (RINGAN)
DENGAN KATETERISASI JANTUNG (SEDANG)
DENGAN KATETERISASI JANTUNG (BERAT)
PROSEDUR KARDIOTORASIK LAIN (RINGAN)
104,448,100
125,337,800
146,227,400
35,920,500
43,104,600
50,288,700
46,337,000
55,604,400
64,871,800
57,113,200
68,535,900
79,958,500
33,876,900
40,652,300
47,427,600
46,960,400
56,352,500
65,744,500
59,596,300
71,515,600
83,434,900
51,050,600
61,260,700
71,470,900
80,571,700
96,686,000
112,800,300
128,712,700
154,455,200
180,197,800
84,564,000
101,476,800
118,389,600
103,356,000
124,027,200
144,698,400
140,940,000
169,128,000
197,316,000
48,292,200
57,950,600
67,609,100
69,955,200
83,469,500
83,946,200
100,163,400
97,937,300
116,857,300
75,168,000
90,201,600
105,235,200
93,960,000
112,752,000
131,544,000
140,940,000
169,128,000
197,316,000
5,628,900
6,754,600
7,880,400
6,258,700
7,510,500
8,762,200
8,328,500
9,994,100
11,659,800
16,202,500
19,443,000
22,683,600
26,462,000
31,754,400
37,046,800
34,814,800
41,777,700
48,740,700
15,716,200
18,859,500
22,002,700
20,929,400
25,115,300
29,301,100
25,811,700
30,974,100
36,136,400
32,167,300
38,600,700
45,034,200
39,979,200
47,975,000
55,970,900
52,386,500
62,863,800
73,341,200
6,110,900
8,533,700
16,432,500
7,333,000
10,240,400
19,719,000
8,555,200
11,947,200
23,005,500
15,841,600
19,009,900
22,178,200
232 I-1-02-I
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
244 I-1-06-I
245 I-1-06-II
246 I-1-06-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
PROSEDUR KARDIOTORASIK LAIN (SEDANG)

PROSEDUR KARDIOTORASIK LAIN (BERAT)
PROSEDUR BYPASS KORONER TANPA KATETERISASI
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM
BANTUAN JANTUNG (RINGAN)
BANTUAN JANTUNG (SEDANG)
BANTUAN JANTUNG (BERAT)
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PEMBULUH DARAH ABDOMINAL
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
PEMASANGAN PACEMAKER JANTUNG PERMANEN
(RINGAN)
(SEDANG)
(BERAT)
KATETERISASI JANTUNG (RINGAN)
KATETERISASI JANTUNG (SEDANG)
KATETERISASI JANTUNG (BERAT)
REVISI DEFIBRILATOR & PACEMAKER JANTUNG
TIDAK TERMASUK PENGGANTIAN ALAT (RINGAN)
- 12 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

TIDAK TERMASUK PENGGANTIAN ALAT (SEDANG)
TIDAK TERMASUK PENGGANTIAN ALAT (BERAT)
LIGASI DAN STRIPPING PEMBULUH DARAH VENA
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
PROSEDUR KARDIOVASKULAR PERKUTAN (RINGAN)
278 I-1-40-II
PROSEDUR KARDIOVASKULAR PERKUTAN (SEDANG)
35,683,500
42,820,200
49,956,900
279 I-1-40-III
280 I-4-10-I
PROSEDUR KARDIOVASKULAR PERKUTAN (BERAT)

INFARK MYOKARD AKUT (RINGAN)
47,661,100
5,440,800
57,193,300
6,528,900
66,725,500
7,617,100
281 I-4-10-II
INFARK MYOKARD AKUT (SEDANG)
9,715,200
11,658,200
13,601,200
282 I-4-10-III
283 I-4-11-I
INFARK MYOKARD AKUT (BERAT)

ENDOKARDITIS AKUT DAN SUBAKUT (RINGAN)
13,998,200
8,370,600
16,797,800
10,044,800
19,597,500
11,718,900
284 I-4-11-II
285 I-4-11-III
ENDOKARDITIS AKUT DAN SUBAKUT (SEDANG)

ENDOKARDITIS AKUT DAN SUBAKUT (BERAT)
10,358,700
19,162,500
12,430,500
22,995,000
14,502,200
26,827,500
286 I-4-12-I
287 I-4-12-II
288 I-4-12-III
KEGAGALAN JANTUNG (RINGAN)

KEGAGALAN JANTUNG (SEDANG)
KEGAGALAN JANTUNG (BERAT)
THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA
(RINGAN)
(SEDANG)
(BERAT)
CARDIAC ARREST DAN LAIN-LAIN (RINGAN)
CARDIAC ARREST DAN LAIN-LAIN (SEDANG)
CARDIAC ARREST DAN LAIN-LAIN (BERAT)
PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN
(RINGAN)
(SEDANG)
4,811,900
5,577,700
6,693,200
5,774,300
6,693,200
8,031,900
6,736,700
7,808,800
9,370,500
4,896,700
5,876,100
6,855,400
8,743,700
10,492,400
12,241,100
12,598,400
15,118,100
17,637,700
4,624,100
4,783,200
8,385,000
5,548,900
5,739,900
10,062,000
6,473,700
6,696,500
11,739,000
4,722,500
5,667,000
6,611,500
8,905,200
10,686,300
12,467,300
297 I-4-15-III
PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN (BERAT)
10,686,300
12,823,500
14,960,800
298
299
300
301
302
303
ATHEROSKLEROSIS (RINGAN)
ATHEROSKLEROSIS (SEDANG)
ATHEROSKLEROSIS (BERAT)
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
PENYAKIT JANTUNG KONGENITAL DAN KATUP
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,918,500
4,686,400
5,623,700
1,948,600
3,144,400
4,402,200
3,502,200
5,623,700
6,748,400
2,338,300
3,773,300
5,282,600
4,085,900
6,560,900
7,873,100
2,728,000
4,402,200
6,163,000
5,629,400
6,755,300
7,881,200
8,571,100
10,285,300
11,999,500
11,636,600
13,964,000
16,291,300
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
35,843,100
43,011,700
50,180,300
41,344,400
49,613,300
57,882,200
18,343,000
22,011,600
25,680,200
22,967,200
27,560,600
32,154,100
28,410,100
34,092,100
39,774,100
20,675,700
24,810,900
28,946,000
25,829,700
30,995,600
36,161,600
27,152,300
32,582,800
38,013,300
15,640,000
18,768,000
21,896,000
32,534,700
39,041,700
45,548,600
50,417,100
60,500,600
70,584,000
14,434,100
17,320,900
20,207,700
307 I-4-19-I
GANGGUAN KONDUKSI & ARITMIA JANTUNG (RINGAN)
5,431,300
6,517,500
7,603,800
308 I-4-19-II
GANGGUAN KONDUKSI & ARITMIA JANTUNG

(SEDANG)
8,478,500
10,174,200
11,870,000
- 13 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
309 I-4-19-III
GANGGUAN KONDUKSI & ARITMIA JANTUNG (BERAT)
310 I-4-20-I
311 I-4-20-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,121,800
12,146,100
14,170,500
ANGINA PEKTORIS DAN NYERI DADA (RINGAN)

ANGINA PEKTORIS DAN NYERI DADA (SEDANG)
5,655,600
6,532,200
6,786,700
7,838,600
7,917,800
9,145,100
312 I-4-20-III
313 I-4-21-I
ANGINA PEKTORIS DAN NYERI DADA (BERAT)

SYNCOPE & COLLAPSE (RINGAN)
9,767,000
3,808,800
11,720,400
4,570,600
13,673,800
5,332,400
314 I-4-21-II
SYNCOPE & COLLAPSE (SEDANG)
4,825,800
5,791,000
6,756,200
315 I-4-21-III
316 I-4-22-I
SYNCOPE & COLLAPSE (BERAT)

KARDIOMIOPATHI (RINGAN)
6,965,600
3,422,100
8,358,700
4,106,500
9,751,800
4,791,000
317 I-4-22-II
318 I-4-22-III
KARDIOMIOPATHI (SEDANG)
KARDIOMIOPATHI (BERAT)
MALFUNGSI, REAKSI DAN KOMPLIKASI DARI ALAT
ATAU PROSEDUR KARDIOVASKULER (RINGAN)
ATAU PROSEDUR KARDIOVASKULER (SEDANG)
ATAU PROSEDUR KARDIOVASKULER (BERAT)
GANGGUAN SISTEM PEMBULUH DARAH LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
VENTILASI MEKANIKAL LONG TERM DENGAN
TRAKEOSTOMI (RINGAN)
TRAKEOSTOMI (SEDANG)
TRAKEOSTOMI (BERAT)
VENTILASI MEKANIKAL LONG TERM TANPA
TRAKEOSTOMI (BERAT)
PROSEDUR SISTEM PERNAFASAN SANGAT KOMPLEKS
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR SISTEM PERNAFASAN NON-KOMPLEKS
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR SISTEM PERNAFASAN KOMPLEKS
(RINGAN)
(SEDANG)
4,260,000
6,226,800
5,112,000
7,472,200
5,964,000
8,717,500
4,642,400
5,570,900
6,499,400
5,699,600
6,839,500
7,979,400
11,136,600
13,363,900
15,591,300
3,016,000
3,619,200
4,222,400
6,945,100
8,334,100
9,723,100
8,780,800
10,537,000
12,293,200
95,561,100
114,673,400
133,785,600
108,145,200
129,774,200
151,403,300
148,339,800
178,007,700
207,675,700
62,342,100
74,810,500
87,278,900
78,663,600
94,396,300
110,129,000
92,025,200
110,430,300
128,835,300
12,153,800
14,584,600
17,015,400
24,593,400
29,512,000
34,430,700
25,558,600
30,670,300
35,782,000
33,481,700
40,178,000
46,874,300
35,059,800
42,071,800
49,083,700
39,455,200
47,346,300
55,237,300
10,142,700
12,171,200
14,199,800
18,373,400
22,048,000
25,722,700
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
PROSEDUR SISTEM PERNAFASAN KOMPLEKS (BERAT)
53,034,100
63,640,900
74,247,700
340
341
342
343
344
345
346
347
348
349
350
351
352
KISTA FIBROSIS (RINGAN)

KISTA FIBROSIS (SEDANG)
KISTA FIBROSIS (BERAT)
KEGAGALAN PERNAFASAN (RINGAN)
KEGAGALAN PERNAFASAN (SEDANG)
KEGAGALAN PERNAFASAN (BERAT)
EMBOLI PARU (RINGAN)
EMBOLI PARU (SEDANG)
EMBOLI PARU (BERAT)
TRAUMA DADA (RINGAN)
TRAUMA DADA (SEDANG)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
2,989,800
6,174,800
9,341,500
3,699,000
5,152,000
6,905,800
6,282,800
7,152,100
9,986,300
5,555,100
7,732,500
14,426,300
6,124,600
3,587,800
7,409,700
11,209,800
4,438,900
6,182,500
8,287,000
7,539,400
8,582,500
11,983,500
6,666,100
9,279,000
17,311,600
7,349,500
4,185,700
8,644,700
13,078,100
5,178,700
7,212,900
9,668,100
8,795,900
10,012,900
13,980,800
7,777,100
10,825,500
20,196,800
8,574,400
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
- 14 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
353 J-4-14-II
TUMOR PARU (SEDANG)
9,966,500
11,959,800
13,953,100
354 J-4-14-III
355 J-4-15-I
TUMOR PARU (BERAT)

PERADANGAN DAN INFEKSI PERNAFASAN (RINGAN)
11,791,400
4,431,800
14,149,600
5,318,100
16,507,900
6,204,500
356 J-4-15-II
357 J-4-15-III
PERADANGAN DAN INFEKSI PERNAFASAN (SEDANG)

PERADANGAN DAN INFEKSI PERNAFASAN (BERAT)
7,339,100
13,329,900
8,806,900
15,995,900
10,274,700
18,661,900
358 J-4-16-I
SIMPLE PNEUMONIA & WHOOPING COUGH (RINGAN)
3,692,600
4,431,100
5,169,700
359 J-4-16-II
SIMPLE PNEUMONIA & WHOOPING COUGH (SEDANG)
7,192,600
8,631,100
10,069,600
360 J-4-16-III
SIMPLE PNEUMONIA & WHOOPING COUGH (BERAT)
12,276,800
14,732,200
17,187,500
361 J-4-17-I
PENYAKIT PARU OBSTRUKTIF KRONIS (RINGAN)
5,117,700
6,141,200
7,164,700
362 J-4-17-II
363 J-4-17-III
PENYAKIT PARU OBSTRUKTIF KRONIS (SEDANG)

PENYAKIT PARU OBSTRUKTIF KRONIS (BERAT)
6,128,500
8,042,500
7,354,300
9,651,000
8,580,000
11,259,500
364 J-4-18-I
365 J-4-18-II
ASTHMA & BRONKIOLITIS (RINGAN)

ASTHMA & BRONKIOLITIS (SEDANG)
2,274,800
4,336,800
2,729,800
5,204,200
3,184,700
6,071,500
366 J-4-18-III
ASTHMA & BRONKIOLITIS (BERAT)
6,162,800
7,395,400
8,628,000
367 J-4-19-I
368 J-4-19-II
PENYAKIT PARU INTERSTITIAL (RINGAN)

PENYAKIT PARU INTERSTITIAL (SEDANG)
6,487,500
7,357,300
7,785,000
8,828,700
9,082,600
10,300,200
369 J-4-19-III
370 J-4-20-I
PENYAKIT PARU INTERSTITIAL (BERAT)

PLEURAL EFUSI DAN PNEUMOTORAK (RINGAN)
8,125,200
5,160,800
9,750,300
6,192,900
11,375,300
7,225,100
371 J-4-20-II
PLEURAL EFUSI DAN PNEUMOTORAK (SEDANG)
7,150,800
8,580,900
10,011,100
372 J-4-20-III
PLEURAL EFUSI DAN PNEUMOTORAK (BERAT)

GEJALA, TANDA DAN DIAGNOSIS SISTEM
PERNAFASAN LAIN-LAIN (RINGAN)
PERNAFASAN LAIN-LAIN (SEDANG)
PERNAFASAN LAIN-LAIN (BERAT)
PROSEDUR NON KOMPLEKS USUS HALUS & USUS
BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
ADHESIOLISIS PERITONEAL (RINGAN)
ADHESIOLISIS PERITONEAL (SEDANG)
ADHESIOLISIS PERITONEAL (BERAT)
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL &
FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
PROSEDUR APPENDIK (RINGAN)
PROSEDUR APPENDIK (SEDANG)
PROSEDUR APPENDIK (BERAT)
PROSEDUR HERNIA INGUINAL DAN FEMORAL
(RINGAN)
(SEDANG)
8,382,900
10,059,500
11,736,100
2,948,500
3,538,200
4,127,800
6,583,800
7,900,600
9,217,400
12,402,800
14,883,300
17,363,900
11,018,200
13,221,800
15,425,500
13,846,700
16,616,100
19,385,400
16,228,800
19,474,600
22,720,400
10,347,500
13,584,900
26,851,900
12,416,900
16,301,900
32,222,200
14,486,400
19,018,900
37,592,600
4,623,100
5,547,700
6,472,300
6,012,800
7,215,400
8,418,000
11,912,400
14,294,800
16,677,300
5,213,900
5,735,300
9,166,200
6,256,700
6,882,400
10,999,500
7,299,500
8,029,400
12,832,700
7,615,100
9,138,100
10,661,200
8,924,700
10,709,700
12,494,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
PROSEDUR HERNIA INGUINAL DAN FEMORAL (BERAT)
15,580,000
18,696,000
21,812,000
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III
PROSEDUR INTESTINAL KOMPLEKS (RINGAN)

PROSEDUR INTESTINAL KOMPLEKS (SEDANG)
PROSEDUR INTESTINAL KOMPLEKS (BERAT)
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG
NON KOMPLEKS (RINGAN)
NON KOMPLEKS (SEDANG)
NON KOMPLEKS (BERAT)
16,383,700
22,884,300
33,413,500
19,660,400
27,461,200
40,096,200
22,937,100
32,038,000
46,778,900
9,689,200
11,627,000
13,564,900
17,207,800
20,649,300
24,090,900
23,678,100
28,413,800
33,149,400
397 K-1-40-I
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (RINGAN)
10,810,900
12,973,100
15,135,200
398 K-1-40-II
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN

(SEDANG)
11,919,400
14,303,300
16,687,100
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
- 15 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
399 K-1-40-III
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (BERAT)
400 K-1-50-I
PROSEDUR ANAL (RINGAN)
401 K-1-50-II
402 K-1-50-III
PROSEDUR ANAL (SEDANG)

PROSEDUR ANAL (BERAT)
403 K-4-10-I
404 K-4-10-II
TUMOR PENCERNAAN (RINGAN)

TUMOR PENCERNAAN (SEDANG)
405 K-4-10-III
TUMOR PENCERNAAN (BERAT)
406 K-4-11-I
407 K-4-11-II
GASTRITIS & ULKUS PEPTIKUM (RINGAN)

GASTRITIS & ULKUS PEPTIKUM (SEDANG)
408 K-4-11-III
409 K-4-12-I
TARIF
KELAS 3
TARIF
KELAS 1
24,238,900
28,278,700
8,260,600
9,912,700
11,564,800
10,727,400
15,159,800
12,872,900
18,191,800
15,018,400
21,223,700
6,819,600
9,798,700
8,183,500
11,758,400
9,547,400
13,718,200
14,937,600
17,925,100
20,912,600
2,370,600
4,669,500
2,844,800
5,603,400
3,318,900
6,537,300
GASTRITIS & ULKUS PEPTIKUM (BERAT)

GANGGUAN ESOFAGUS (RINGAN)
5,603,400
4,099,400
6,724,100
4,919,300
7,844,700
5,739,200
410 K-4-12-II
GANGGUAN ESOFAGUS (SEDANG)
5,516,600
6,619,900
7,723,200
411 K-4-12-III
GANGGUAN ESOFAGUS (BERAT)

DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT
PERADANGAN USUS BESAR (RINGAN)
PERADANGAN USUS BESAR (SEDANG)
PERADANGAN USUS BESAR (BERAT)
GANGGUAN PEMBULUH DARAH GASTROINTERTINAL
(RINGAN)
(SEDANG)
(BERAT)
9,126,200
10,951,400
12,776,700
5,526,300
6,631,500
7,736,800
7,148,600
8,578,300
10,008,100
11,011,100
13,213,400
15,415,600
3,153,300
3,784,000
4,414,700
4,232,800
5,079,400
5,925,900
6,792,000
8,150,400
9,508,800
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
20,199,100
TARIF
KELAS 2
418 K-4-15-I
OBSTRUKSI SALURAN GASTROINTESTINAL (RINGAN)
4,494,700
5,393,600
6,292,600
419 K-4-15-II
OBSTRUKSI SALURAN GASTROINTESTINAL (SEDANG)
6,922,300
8,306,800
9,691,200
420 K-4-15-III
OBSTRUKSI SALURAN GASTROINTESTINAL (BERAT)
9,853,000
11,823,600
13,794,200
421 K-4-16-I
422 K-4-16-II
423 K-4-16-III
INFEKSI-INFEKSI GASTROINTESTINAL (RINGAN)

INFEKSI-INFEKSI GASTROINTESTINAL (SEDANG)
INFEKSI-INFEKSI GASTROINTESTINAL (BERAT)
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
GANGGUAN SISTEM PENCERNAAN LAIN-LAIN
(RINGAN)
(SEDANG)
4,070,500
4,881,700
5,696,200
4,884,600
5,858,000
6,835,400
5,698,700
6,834,400
7,974,700
1,996,600
2,396,000
2,795,300
2,458,900
2,950,600
3,442,400
2,950,600
3,540,800
4,130,900
1,759,500
2,111,400
2,463,300
2,969,200
3,563,000
4,156,900
429 K-4-18-III
GANGGUAN SISTEM PENCERNAAN LAIN-LAIN (BERAT)
3,563,000
4,275,600
4,988,200
430
431
432
433
434
435
PEMINDAHAN KULIT PADA LUKA BAKAR (RINGAN)

PEMINDAHAN KULIT PADA LUKA BAKAR (SEDANG)
PEMINDAHAN KULIT PADA LUKA BAKAR (BERAT)
PEMINDAHAN KULIT TANPA LUKA BAKAR (RINGAN)
PEMINDAHAN KULIT TANPA LUKA BAKAR (SEDANG)
PEMINDAHAN KULIT TANPA LUKA BAKAR (BERAT)
PROSEDUR PADA KULIT, JARINGAN) BAWAH KULIT
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PADA PAYUDARA (RINGAN)
PROSEDUR PADA PAYUDARA (SEDANG)
PROSEDUR PADA PAYUDARA (BERAT)
PENYAKIT KULIT MAYOR (RINGAN)
PENYAKIT KULIT MAYOR (SEDANG)
PENYAKIT KULIT MAYOR (BERAT)
TUMOR PAYUDARA (RINGAN)
26,121,700
39,430,100
52,685,000
12,324,500
21,148,000
26,255,600
31,346,100
47,316,100
63,222,000
14,789,400
25,377,600
31,506,700
36,570,400
55,202,100
73,759,000
17,254,300
29,607,200
36,757,800
6,906,900
8,288,300
9,669,700
13,853,700
16,624,500
19,395,200
23,318,900
27,982,700
32,646,500
9,067,400
14,593,000
20,873,900
2,371,600
2,752,800
3,195,300
4,966,500
10,880,900
17,511,600
25,048,600
2,845,900
3,303,400
3,834,300
5,959,800
12,694,400
20,430,200
29,223,400
3,320,300
3,853,900
4,473,400
6,953,200
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
- 16 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
446 L-4-11-II
TUMOR PAYUDARA (SEDANG)
6,826,100
8,191,300
9,556,500
447 L-4-11-III
448 L-4-12-I
TUMOR PAYUDARA (BERAT)

PERADANGAN KULIT/CELLULITIS (RINGAN)
15,511,000
2,358,700
18,613,200
2,830,400
21,715,400
3,302,100
449 L-4-12-II
450 L-4-12-III
PERADANGAN KULIT/CELLULITIS (SEDANG)

PERADANGAN KULIT/CELLULITIS (BERAT)
TRAUMA PADA KULIT, JA(RINGAN) BAWAH KULIT DAN
PAYUDARA (RINGAN)
PAYUDARA (SEDANG)
PAYUDARA (BERAT)
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR BILATERAL DAN MULTIPLE PADA SENDI
TUNGKAI BAWAH (RINGAN)
TUNGKAI BAWAH (SEDANG)
TUNGKAI BAWAH (BERAT)
AMPUTASI (RINGAN)
AMPUTASI (SEDANG)
3,119,600
10,315,400
3,743,600
12,378,500
4,367,500
14,441,600
2,511,500
3,013,800
3,516,100
4,091,400
4,909,700
5,727,900
8,127,700
9,753,300
11,378,800
4,084,400
4,901,300
5,718,100
6,134,900
7,361,900
8,588,800
8,647,900
10,377,400
12,107,000
14,437,900
17,325,500
20,213,000
20,521,400
24,625,700
28,730,000
28,826,500
34,591,800
40,357,100
12,796,500
20,992,200
15,355,800
25,190,600
17,915,100
29,389,000
35,665,200
42,798,200
49,931,200
51,152,200
61,382,600
71,613,100
59,830,000
71,795,900
83,761,900
74,049,500
88,859,500
103,669,400
466 M-1-04-I
AMPUTASI (BERAT)
PROSEDUR FUSI TULANG BELAKANG PADA
LENGKUNGAN TULANG BELAKANG (RINGAN)
LENGKUNGAN TULANG BELAKANG (SEDANG)
LENGKUNGAN TULANG BELAKANG (BERAT)
PROSEDUR PADA SENDI TUNGKAI BAWAH (RINGAN)
26,197,900
31,437,500
36,677,100
467 M-1-04-II
PROSEDUR PADA SENDI TUNGKAI BAWAH (SEDANG)
33,656,700
40,388,100
47,119,400
468
469
470
471
PROSEDUR PADA SENDI TUNGKAI BAWAH (BERAT)

PROSEDUR PADA SENDI TUNGKAI ATAS (RINGAN)
PROSEDUR PADA SENDI TUNGKAI ATAS (SEDANG)
PROSEDUR PADA SENDI TUNGKAI ATAS (BERAT)
PROSEDUR FUSI TULANG BELAKANG SELAIN
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG
WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
PROSEDUR PADA PAHA DAN SENDI PANGGUL
(RINGAN)
(SEDANG)
40,271,100
10,186,700
16,477,400
21,047,800
48,325,300
12,224,100
19,772,900
25,257,400
56,379,500
14,261,400
23,068,400
29,466,900
18,618,600
22,342,300
26,066,000
24,942,400
29,930,900
34,919,400
50,810,100
60,972,100
71,134,100
22,002,200
26,402,600
30,803,100
52,606,300
63,127,600
73,648,800
113,466,900
136,160,300
158,853,700
17,145,100
20,574,100
24,003,100
21,904,600
26,285,500
30,666,400
451 L-4-13-I
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
M-1-04-III
M-1-05-I
M-1-05-II
M-1-05-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
PROSEDUR PADA PAHA DAN SENDI PANGGUL (BERAT)
54,535,700
65,442,800
76,350,000
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III
PROSEDUR KAKI (RINGAN)

PROSEDUR KAKI (SEDANG)
PROSEDUR KAKI (BERAT)
EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI
INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
PROSEDUR JARINGAN LUNAK (RINGAN)
PROSEDUR JARINGAN LUNAK (SEDANG)
11,762,000
19,059,200
27,252,900
14,114,300
22,871,000
32,703,500
16,466,700
26,682,800
38,154,100
7,184,700
8,621,700
10,058,600
10,618,200
12,741,800
14,865,500
15,160,700
18,192,900
21,225,000
7,174,800
11,906,600
8,609,800
14,287,900
10,044,800
16,669,200
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
- 17 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
489 M-1-50-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
19,555,800
23,466,900
27,378,100
11,081,000
13,297,100
15,513,300
13,931,300
16,717,600
19,503,800
21,044,900
25,253,900
29,462,900
20,529,500
24,635,400
28,741,300
22,582,400
27,098,900
31,615,400
25,853,900
31,024,700
36,195,400
496 M-1-80-I
PROSEDUR JARINGAN LUNAK (BERAT)

PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN
PENGHUBUNG LAIN-LAIN (RINGAN)
PENGHUBUNG LAIN-LAIN (SEDANG)
PENGHUBUNG LAIN-LAIN (BERAT)
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN
KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
PROSEDUR ANGGOTA TUBUH ATAS (RINGAN)
11,670,100
14,004,200
16,338,200
497 M-1-80-II
498 M-1-80-III
PROSEDUR ANGGOTA TUBUH ATAS (SEDANG)

PROSEDUR ANGGOTA TUBUH ATAS (BERAT)
13,859,400
31,194,500
16,631,300
37,433,400
19,403,100
43,672,300
499 M-4-10-I
500 M-4-10-II
FRAKTUR FEMUR (RINGAN)

FRAKTUR FEMUR (SEDANG)
4,111,000
6,130,800
4,933,200
7,357,000
5,755,300
8,583,100
501 M-4-10-III
FRAKTUR FEMUR (BERAT)

FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL
(RINGAN)
(SEDANG)
(BERAT)
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS
(RINGAN)
(SEDANG)
(BERAT)
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN
FRAKTUR PATOLOGIS (RINGAN)
FRAKTUR PATOLOGIS (SEDANG)
FRAKTUR PATOLOGIS (BERAT)
OSTEOMIELITIS (RINGAN)
OSTEOMIELITIS (SEDANG)
OSTEOMIELITIS (BERAT)
ARTRITIS SEPSIS (RINGAN)
ARTRITIS SEPSIS (SEDANG)
ARTRITIS SEPSIS (BERAT)
GANGGUAN JARINGAN KONEKTIF (RINGAN)
GANGGUAN JARINGAN KONEKTIF (SEDANG)
GANGGUAN JARINGAN KONEKTIF (BERAT)
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG
(RINGAN)
(SEDANG)
(BERAT)
PENYAKIT TULANG DAN SENDI LAIN-LAIN (RINGAN)
PENYAKIT TULANG DAN SENDI LAIN-LAIN (SEDANG)
PENYAKIT TULANG DAN SENDI LAIN-LAIN (BERAT)
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI
PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK
(RINGAN)
(SEDANG)
(BERAT)
TANDA, GEJALA & PERADANGAN MUSKULOSKELETAL
(RINGAN)
11,599,500
13,919,400
16,239,400
5,122,600
6,147,200
7,171,700
11,231,200
13,477,400
15,723,600
16,238,300
19,486,000
22,733,700
4,089,000
4,906,800
5,724,600
6,801,200
8,161,400
9,521,600
9,097,300
10,916,700
12,736,200
6,808,600
8,170,300
9,532,100
10,229,700
12,275,600
14,321,500
19,957,800
23,949,400
27,941,000
7,765,000
9,577,000
14,391,400
4,604,400
6,137,400
13,927,500
3,942,100
6,312,800
10,605,000
9,318,000
11,492,400
17,269,700
5,525,300
7,364,800
16,713,000
4,730,500
7,575,300
12,726,100
10,871,000
13,407,800
20,148,000
6,446,200
8,592,300
19,498,500
5,518,900
8,837,900
14,847,100
4,604,700
5,525,600
6,446,500
6,440,200
7,728,200
9,016,200
8,993,200
10,791,900
12,590,500
3,867,100
5,827,900
7,017,100
4,640,500
6,993,500
8,420,500
5,414,000
8,159,100
9,823,900
4,032,800
4,839,400
5,645,900
6,792,800
8,151,300
9,509,900
13,266,700
15,920,100
18,573,400
3,661,200
4,393,400
5,125,700
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
511
512
513
514
515
516
517
518
519
M-4-14-I
M-4-14-II
M-4-14-III
M-4-15-I
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
- 18 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
535 N-1-01-I

(SEDANG)
(BERAT)
GANGGUAN SISTEM MUSKULOSKELETAL &
JA(RINGAN) PENYAMBUNG LAIN-LAIN (RINGAN)
JA(RINGAN) PENYAMBUNG LAIN-LAIN (SEDANG)
JA(RINGAN) PENYAMBUNG LAIN-LAIN (BERAT)
TRANSPLANTASI GINJAL (RINGAN)
536 N-1-01-II
537 N-1-01-III
TRANSPLANTASI GINJAL (SEDANG)

TRANSPLANTASI GINJAL (BERAT)
538 N-1-11-I
539 N-1-11-II
540 N-1-11-III
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,361,200
6,433,400
7,505,600
5,991,800
7,190,100
8,388,500
3,686,500
4,423,800
5,161,100
4,610,800
5,532,900
6,455,100
10,337,300
12,404,700
14,472,200
283,523,900
340,228,700
396,933,400
283,523,900
283,523,900
340,228,700
340,228,700
396,933,400
396,933,400
PROSEDUR KANDUNG KEMIH KOMPLEK (RINGAN)

PROSEDUR KANDUNG KEMIH KOMPLEK (SEDANG)
11,815,200
18,682,800
14,178,300
22,419,300
16,541,300
26,155,900
PROSEDUR KANDUNG KEMIH KOMPLEK (BERAT)

MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN
ALAT DIALISIS (RINGAN)
ALAT DIALISIS (SEDANG)
ALAT DIALISIS (BERAT)
PROSEDUR SALURAN URIN ATAS (RINGAN)
PROSEDUR SALURAN URIN ATAS (SEDANG)
29,126,400
34,951,700
40,777,000
6,021,800
7,226,200
8,430,600
11,988,800
14,386,600
16,784,400
26,016,200
31,219,400
36,422,700
13,166,000
18,425,100
15,799,200
22,110,100
18,432,400
25,795,200
PROSEDUR SALURAN URIN ATAS (BERAT)

PROSEDUR KANDUNG KEMIH DAN SALURAN URIN
BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
PROSEDUR PADA URETRA DAN TRANSURETRA
(RINGAN)
(SEDANG)
(BERAT)
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL
(RINGAN)
(SEDANG)
(BERAT)
PERADANGAN GINJAL (RINGAN)
PERADANGAN GINJAL (SEDANG)
PERADANGAN GINJAL (BERAT)
INFEKSI GINJAL DAN SALURAN URIN (RINGAN)
INFEKSI GINJAL DAN SALURAN URIN (SEDANG)
INFEKSI GINJAL DAN SALURAN URIN (BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN
KULIT ATAU PENCAKOKAN (RINGAN)
KULIT ATAU PENCAKOKAN (SEDANG)
KULIT ATAU PENCAKOKAN (BERAT)
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
25,783,700
30,940,500
36,097,200
12,049,200
14,459,100
16,868,900
18,228,100
21,873,700
25,519,300
20,978,800
25,174,600
29,370,300
10,821,100
12,985,300
15,149,500
14,694,700
17,633,700
20,572,600
17,102,800
20,523,300
23,943,900
4,597,400
5,516,900
6,436,400
5,560,700
6,672,800
7,785,000
8,179,000
9,814,800
11,450,500
3,529,300
6,166,100
7,671,900
2,661,000
5,528,100
8,982,800
3,600,700
6,019,700
12,453,400
4,235,100
7,399,300
9,206,300
3,193,100
6,633,700
10,779,400
4,320,900
7,223,600
14,944,100
4,941,000
8,632,500
10,740,700
3,725,300
7,739,400
12,576,000
5,041,000
8,427,500
17,434,800
3,544,600
4,253,500
4,962,400
5,029,600
6,035,500
7,041,400
8,062,300
9,674,800
11,287,300
4,187,400
5,024,900
5,862,400
5,195,900
6,235,000
7,274,200
5,929,400
7,115,200
8,301,100
- 19 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
576 O-6-10-III

PENYAKIT GINJAL DAN SALURAN URIN LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
OPERASI PEMBEDAHAN CAESAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,127,500
6,153,000
7,178,500
7,318,600
8,782,300
10,246,000
9,741,600
11,689,900
13,638,200
5,253,900
6,304,700
7,355,500
6,762,600
10,660,100
8,115,100
12,792,100
9,467,600
14,924,100
4,766,300
5,719,500
6,672,800
5,297,200
6,356,600
7,416,000
6,589,700
7,907,700
9,225,600
3,376,800
4,052,200
4,727,600
4,055,500
4,866,600
5,677,800
5,095,900
6,115,100
7,134,300
583 O-6-13-I
OPERASI PEMBEDAHAN CAESAR (SEDANG)

OPERASI PEMBEDAHAN CAESAR (BERAT)
PERSALINAN VAGINAL DENGAN STERILISASI &/
DILATASI & KURET (RINGAN)
DILATASI & KURET (SEDANG)
DILATASI & KURET (BERAT)
PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN
STERILISASI &/ DILATASI &KURET (RINGAN)
STERILISASI &/ DILATASI & KURET (SEDANG)
STERILISASI &/ DILATASI & KURET (BERAT)
PERSALINAN VAGINAL (RINGAN)
1,711,800
2,054,100
2,396,500
584 O-6-13-II
PERSALINAN VAGINAL (SEDANG)
2,808,200
3,369,900
3,931,500
585 O-6-13-III
PERSALINAN VAGINAL (BERAT)

NEONATAL DENGAN PENCANGKOKAN ORGAN ATAU
OKSIGENASI SELAPUT EKSTRAKORPORAL (RINGAN)
OKSIGENASI SELAPUT EKSTRAKORPORAL (SEDANG)
OKSIGENASI SELAPUT EKSTRAKORPORAL (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 DENGAN
PROSEDUR MAYOR (RINGAN)
PROSEDUR MAYOR (SEDANG)
PROSEDUR MAYOR (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 TANPA
SINDROMA DISTRES PERNAFASAN (RINGAN)
3,369,900
4,043,900
4,717,800
75,405,000
90,486,000
105,567,000
93,302,400
111,962,900
130,623,400
109,510,800
131,412,900
153,315,100
102,924,300
123,509,200
144,094,000
118,064,500
141,677,400
165,290,300
134,897,100
161,876,500
188,855,900
15,438,500
18,526,200
21,613,900
20,435,000
24,522,000
28,609,000
28,732,600
34,479,100
40,225,600
49,751,400
59,701,600
69,651,900
64,566,500
77,479,800
90,393,100
92,572,200
111,086,600
129,601,000
27,053,200
32,463,800
37,874,500
41,734,300
50,081,100
58,428,000
56,495,000
67,794,000
79,093,000
7,303,500
8,764,200
10,224,900
20,477,300
24,572,800
28,668,300
27,127,400
32,552,900
37,978,400
8,646,200
10,375,500
12,104,700
24,242,000
29,090,400
33,938,800
32,114,700
38,537,700
44,960,600
5,002,800
6,003,400
7,003,900
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
- 20 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II

SINDROMA DISTRES PERNAFASAN (SEDANG)
SINDROMA DISTRES PERNAFASAN (BERAT)
NEONATAL, BBL 1000 - 1499 GR TANPA PROSEDUR
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
NEONATAL, BBL > 2499 GR DENGAN ANOMALI MAYOR
ATAU KONDISI HEREDITER (RINGAN)
ATAU KONDISI HEREDITER (SEDANG)
ATAU KONDISI HEREDITER (BERAT)
NEONATAL, BBL > 2499 GR DENGAN SINDROMA
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
NEONATAL, BBL > 2499 GR DENGAN
KONGENITAL/INFEKSI PERINATAL (RINGAN)
KONGENITAL/INFEKSI PERINATAL (SEDANG)
KONGENITAL/INFEKSI PERINATAL (BERAT)
NEONATAL, BBL > 2499 GR TANPA PROSEDUR MAYOR
(RINGAN)
(SEDANG)
(BERAT)
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK
ATAU BANYAK TEMPAT (RINGAN)
ATAU BANYAK TEMPAT (SEDANG)
ATAU BANYAK TEMPAT (BERAT)
REAKSI ALLERGI (RINGAN)
REAKSI ALLERGI (SEDANG)
REAKSI ALLERGI (BERAT)
EFEK TOKSIK DAN KERACUNAN OBAT (RINGAN)
EFEK TOKSIK DAN KERACUNAN OBAT (SEDANG)
EFEK TOKSIK DAN KERACUNAN OBAT (BERAT)
KOMPLIKASI DARI PENATALAKSANAAN PASIEN
(RINGAN)
(SEDANG)
(BERAT)
SINDROMA MALTREATMENT PADA DEWASA ATAU
KANAK-KANAK (RINGAN)
KANAK-KANAK (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,098,700
8,518,500
9,938,200
13,809,800
16,571,800
19,333,800
12,865,400
15,438,500
18,011,600
17,029,200
20,435,000
23,840,800
23,943,800
28,732,600
33,521,300
11,695,900
14,035,000
16,374,200
14,191,000
17,029,200
19,867,400
20,820,700
24,984,800
29,149,000
6,497,700
7,797,200
9,096,800
10,136,400
12,163,700
14,191,000
16,015,900
19,219,100
22,422,300
4,918,300
5,901,900
6,885,600
10,011,600
12,013,900
14,016,300
39,146,200
46,975,400
54,804,700
3,688,800
4,426,500
5,164,300
7,386,900
8,864,300
10,341,700
8,667,200
10,400,600
12,134,100
3,338,400
4,006,000
4,673,700
6,415,200
7,698,300
8,981,300
15,044,700
18,053,700
21,062,600
4,331,800
5,198,200
6,064,500
7,797,200
9,356,700
10,916,100
13,346,600
16,015,900
18,685,200
3,764,000
4,516,800
5,269,600
4,637,800
5,565,300
6,492,900
6,348,600
7,618,400
8,888,100
1,729,700
3,515,800
8,112,200
2,767,300
3,683,200
6,384,800
2,075,700
4,219,000
9,734,600
3,320,700
4,419,800
7,661,700
2,421,600
4,922,200
11,357,000
3,874,200
5,156,400
8,938,700
4,086,500
4,903,800
5,721,100
7,249,800
8,699,800
10,149,800
11,767,400
14,120,800
16,474,300
2,068,100
2,481,700
2,895,300
4,392,700
5,271,300
6,149,800
- 21 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I
650 S-4-16-II
651 S-4-16-III
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I

KANAK-KANAK (BERAT)
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN
AKUT YANG LAIN (RINGAN)
AKUT YANG LAIN (SEDANG)
AKUT YANG LAIN (BERAT)
LUKA BAKAR (RINGAN)
LUKA BAKAR (SEDANG)
LUKA BAKAR (BERAT)
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK
TOKSIK LAIN-LAIN (RINGAN)
TOKSIK LAIN-LAIN (SEDANG)
TOKSIK LAIN-LAIN (BERAT)
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL &
OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT DAN
ALKOHOL, MENOLAK NASEHAT DOKTER (RINGAN)
ALKOHOL, MENOLAK NASEHAT DOKTER (SEDANG)
ALKOHOL, MENOLAK NASEHAT DOKTER (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN
ALKOHOL,OPIUM DAN KOKAIN (RINGAN)
ALKOHOL,OPIUM DAN KOKAIN (SEDANG)
ALKOHOL,OPIUM DAN KOKAIN (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAINLAIN (RINGAN)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAINLAIN (SEDANG)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAINLAIN (BERAT)
PROSEDUR KOMPLEKS LARING (RINGAN)
PROSEDUR KOMPLEKS LARING (SEDANG)
PROSEDUR KOMPLEKS LARING (BERAT)
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR MASTOID DAN SINUS (RINGAN)
PROSEDUR MASTOID DAN SINUS (SEDANG)
PROSEDUR MASTOID DAN SINUS (BERAT)
PROSEDUR KELENJAR LUDAH (RINGAN)
PROSEDUR KELENJAR LUDAH (SEDANG)
PROSEDUR KELENJAR LUDAH (BERAT)
OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR TONSIL & ADENOID (RINGAN)
PROSEDUR TONSIL & ADENOID (SEDANG)
PROSEDUR TONSIL & ADENOID (BERAT)
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN
TELINGA LAIN-LAIN (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,330,200
9,996,200
11,662,300
1,383,100
1,659,800
1,936,400
2,610,200
3,132,300
3,654,300
3,380,700
4,056,800
4,733,000
7,162,200
9,108,600
8,594,600
10,930,300
10,027,000
12,752,100
13,041,700
15,650,000
18,258,300
3,452,000
4,142,400
4,832,900
5,123,200
6,147,800
7,172,500
6,161,800
7,394,200
8,626,500
2,309,700
2,771,600
3,233,600
3,102,200
3,722,600
4,343,100
5,643,400
6,772,100
7,900,700
1,264,700
1,517,600
1,770,600
2,409,800
2,891,800
3,373,800
3,502,800
4,203,400
4,903,900
1,221,400
1,465,700
1,709,900
1,922,100
2,306,600
2,691,000
3,096,000
3,715,200
4,334,400
2,861,800
3,434,200
4,006,500
4,320,200
5,184,200
6,048,300
6,687,000
8,024,400
9,361,800
7,547,800
11,717,200
30,948,100
9,057,400
14,060,600
37,137,700
10,566,900
16,404,000
43,327,400
11,911,500
14,293,800
16,676,100
17,966,300
21,559,600
25,152,800
21,297,800
25,557,400
29,817,000
9,124,100
13,991,300
20,550,400
9,130,400
10,638,300
17,635,100
10,948,900
16,789,600
24,660,500
10,956,500
12,766,000
21,162,100
12,773,800
19,587,900
28,770,500
12,782,600
14,893,700
24,689,100
5,486,700
6,584,000
7,681,400
6,733,500
8,080,200
9,426,900
7,979,200
9,575,000
11,170,900
4,294,600
6,105,700
9,300,900
5,153,600
7,326,900
11,161,100
6,012,500
8,548,000
13,021,300
8,329,700
9,995,600
11,661,600
- 22 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III

TELINGA LAIN-LAIN (SEDANG)
TELINGA LAIN-LAIN (BERAT)
PROSEDUR MULUT (RINGAN)
PROSEDUR MULUT (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
12,396,900
14,876,300
17,355,700
31,825,200
38,190,200
44,555,300
7,143,600
9,686,400
8,572,300
11,623,700
10,001,100
13,561,000
18,942,200
22,730,700
26,519,100
5,140,800
6,169,000
7,197,200
11,769,000
14,122,800
16,476,500
18,069,000
21,682,800
25,296,600
1,625,100
2,363,400
1,950,100
2,836,100
2,275,100
3,308,800
694 U-4-11-I
695 U-4-11-II
PROSEDUR MULUT (BERAT)

NEOPLASMA TELIGA, HIDUNG, MULUT DAN
TENGGOROKAN (RINGAN)
TENGGOROKAN (SEDANG)
TENGGOROKAN (BERAT)
DYSEQUILIBRIUM (RINGAN)
DYSEQUILIBRIUM (SEDANG)
696 U-4-11-III
DYSEQUILIBRIUM (BERAT)
2,486,300
2,983,600
3,480,900
697 U-4-12-I
698 U-4-12-II
EPISTAKSIS/PERDARAHAN HIDUNG (RINGAN)

EPISTAKSIS/PERDARAHAN HIDUNG (SEDANG)
2,670,200
4,305,300
3,204,300
5,166,300
3,738,300
6,027,400
699 U-4-12-III
EPISTAKSIS/PERDARAHAN HIDUNG (BERAT)

PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA
DAN LARINGOTRAKEITIS (RINGAN)
DAN LARINGOTRAKEITIS (SEDANG)
DAN LARINGOTRAKEITIS (BERAT)
PENYAKIT MULUT DAN GIGI (RINGAN)
PENYAKIT MULUT DAN GIGI (SEDANG)
7,539,900
9,047,900
10,555,800
2,023,700
2,428,400
2,833,100
3,306,800
3,968,200
4,629,500
5,339,400
6,407,300
7,475,200
5,116,900
6,127,300
6,140,200
7,352,800
7,163,600
8,578,200
PENYAKIT MULUT DAN GIGI (BERAT)

PENYAKIT TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN LAIN-LAIN (RINGAN)
TENGGOROKAN LAIN-LAIN (SEDANG)
TENGGOROKAN LAIN-LAIN (BERAT)
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PADA PENIS (RINGAN)
PROSEDUR PADA PENIS (SEDANG)
PROSEDUR PADA PENIS (BERAT)
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEKMODERAT (RINGAN)
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEKMODERAT (SEDANG)
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEKMODERAT (BERAT)
PROSEDUR PADA SKROTUM DAN PROSTAT NON
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
PENGANGKATAN PROSTAT MELALUI URETRA
(RINGAN)
(SEDANG)
10,289,600
12,347,500
14,405,500
4,108,700
4,930,400
5,752,200
5,118,900
6,142,700
7,166,500
7,164,000
8,596,800
10,029,600
6,701,600
8,042,000
9,382,300
13,805,100
16,566,100
19,327,100
16,930,000
20,316,000
23,702,000
12,749,500
14,558,500
22,799,200
15,299,400
17,470,100
27,359,000
17,849,400
20,381,800
31,918,800
11,987,000
14,384,400
16,781,800
16,369,200
19,643,100
22,916,900
20,748,200
24,897,800
29,047,500
6,252,600
7,503,100
8,753,600
11,946,600
14,336,000
16,725,300
18,742,800
22,491,400
26,239,900
12,261,300
14,713,500
17,165,800
17,815,300
21,378,300
24,941,400
723 V-1-14-III
PENGANGKATAN PROSTAT MELALUI URETRA (BERAT)
22,245,600
26,694,700
31,143,800
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI
(RINGAN)
1,974,700
2,179,100
2,410,500
2,369,600
2,614,900
2,892,600
2,764,600
3,050,700
3,374,700
5,336,400
6,403,700
7,471,000
691 U-4-10-I
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
- 23 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

(SEDANG)
(BERAT)
PENYAKIT SISTEM REPRODUKSI LAKI-LAKI SELAIN
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
OPERASI PENGANGKATAN RAHIM DAN VULVA
RADIKAL & EVISCERASI (RINGAN)
RADIKAL & EVISCERASI (SEDANG)
RADIKAL & EVISCERASI (BERAT)
PROSEDUR ABORSI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,864,100
10,636,900
12,409,700
14,613,700
17,536,500
20,459,200
5,123,300
6,148,000
7,172,600
6,874,200
8,249,000
9,623,800
9,208,000
11,049,600
12,891,200
13,964,300
16,757,200
19,550,100
16,737,200
20,084,700
23,432,100
23,883,600
28,660,300
33,437,000
2,962,000
3,554,400
4,146,800
3,268,600
3,615,700
3,922,300
4,338,900
4,576,000
5,062,000
3,096,000
3,715,200
4,334,400
3,416,400
4,099,700
4,783,000
3,779,200
4,535,100
5,290,900
742 W-1-12-I
PROSEDUR ABORSI (SEDANG)

PROSEDUR ABORSI (BERAT)
PROSEDUR DILATASI, KURET, INTRAUTERIN &
SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
PROSEDUR PADAA TUBA FALOPII (RINGAN)
3,330,600
3,996,800
4,662,900
743 W-1-12-II
744 W-1-12-III
PROSEDUR PADAA TUBA FALOPII (SEDANG)

PROSEDUR PADAA TUBA FALOPII (BERAT)
4,157,200
7,361,500
4,988,700
8,833,800
5,820,100
10,306,100
745 W-1-13-I
INTERUPSI TUBA DENGAN ENDOSKOP (RINGAN)
3,423,600
4,108,300
4,793,100
746 W-1-13-II
747 W-1-13-III
INTERUPSI TUBA DENGAN ENDOSKOP (SEDANG)

INTERUPSI TUBA DENGAN ENDOSKOP (BERAT)
3,716,900
4,992,800
4,460,300
5,991,300
5,203,700
6,989,900
748 W-1-20-I
749 W-1-20-II
750 W-1-20-III
PROSEDUR PADA RAHIM & ADNEKSA (RINGAN)

PROSEDUR PADA RAHIM & ADNEKSA (SEDANG)
PROSEDUR PADA RAHIM & ADNEKSA (BERAT)
11,465,400
14,326,100
16,607,700
13,758,500
17,191,400
19,929,200
16,051,600
20,056,600
23,250,700
751 W-1-30-I
PROSEDUR PADA VAGINA, SERVIK & VULVA (RINGAN)
6,472,400
7,766,800
9,061,300
752 W-1-30-II
PROSEDUR PADA VAGINA, SERVIK & VULVA (SEDANG)
10,323,400
12,388,100
14,452,800
753 W-1-30-III
PROSEDUR PADA VAGINA, SERVIK & VULVA (BERAT)
25,329,100
30,394,900
35,460,700
754
755
756
757
758
759
TUMOR SISTEM REPRODUKSI WANITA (RINGAN)

TUMOR SISTEM REPRODUKSI WANITA (SEDANG)
TUMOR SISTEM REPRODUKSI WANITA (BERAT)
INFEKSI SISTEM REPRODUKSI WANITA (RINGAN)
INFEKSI SISTEM REPRODUKSI WANITA (SEDANG)
INFEKSI SISTEM REPRODUKSI WANITA (BERAT)
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI
WANITA LAIN-LAIN (RINGAN)
WANITA LAIN-LAIN (SEDANG)
WANITA LAIN-LAIN (BERAT)
ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
ABORTUS MENGANCAM (RINGAN)
ABORTUS MENGANCAM (SEDANG)
ABORTUS MENGANCAM (BERAT)
PERSALINAN FALSE LABOR (RINGAN)
PERSALINAN FALSE LABOR (SEDANG)
PERSALINAN FALSE LABOR (BERAT)
GANGGUAN ANTEPARTUM (RINGAN)
GANGGUAN ANTEPARTUM (SEDANG)
GANGGUAN ANTEPARTUM (BERAT)
GANGGUAN POSTPARTUM (RINGAN)
4,822,600
7,149,300
14,128,400
3,947,200
5,992,500
7,294,000
5,787,100
8,579,100
16,954,100
4,736,700
7,191,000
8,752,800
6,751,600
10,009,000
19,779,800
5,526,100
8,389,500
10,211,600
2,959,900
3,551,900
4,143,800
5,632,700
6,759,300
7,885,800
8,289,000
9,946,800
11,604,500
1,725,600
2,357,200
2,931,300
2,306,000
2,744,800
3,511,600
1,665,400
2,563,800
4,792,000
2,215,900
4,107,300
7,515,200
1,635,100
2,070,700
2,828,600
3,517,500
2,767,200
3,293,700
4,213,900
1,998,500
3,076,500
5,750,400
2,659,100
4,928,800
9,018,200
1,962,100
2,415,800
3,300,000
4,103,800
3,228,400
3,842,700
4,916,200
2,331,600
3,589,300
6,708,800
3,102,300
5,750,300
10,521,200
2,289,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-I
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
- 24 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
776 W-4-17-II
GANGGUAN POSTPARTUM (SEDANG)
4,092,100
4,910,500
5,728,900
777 W-4-17-III
778 Z-4-10-I
GANGGUAN POSTPARTUM (BERAT)

REHABILITASI (RINGAN)
8,167,600
4,863,200
9,801,100
5,835,800
11,434,600
6,808,500
779 Z-4-10-II
780 Z-4-10-III
REHABILITASI (SEDANG)
REHABILITASI (BERAT)
6,454,800
9,170,200
7,745,800
11,004,300
9,036,700
12,838,300
781 Z-4-11-I
GEJALA-GEJALA DAN TANDA-TANDA (RINGAN)
3,165,900
3,799,100
4,432,300
782 Z-4-11-II
783 Z-4-11-III
GEJALA-GEJALA DAN TANDA-TANDA (SEDANG)

GEJALA-GEJALA DAN TANDA-TANDA (BERAT)
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS
KESEHATAN LAIN-LAIN (RINGAN)
KESEHATAN LAIN-LAIN (SEDANG)
KESEHATAN LAIN-LAIN (BERAT)
3,802,500
5,226,700
4,562,900
6,272,000
5,323,400
7,317,400
2,092,500
2,511,000
2,929,500
4,201,500
5,041,800
5,882,100
8,864,100
10,636,900
12,409,700
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III
- 25 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS A PEMERINTAH
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR PADA HATI DAN PANKREAS
PROSEDUR BESAR PADA SALURAN EMPEDU
PROSEDUR KOLESISTEKTOMI TANPA LAPAROSKOPI
PROSEDUR LAIN-LAIN PADA HEPATOBILIARI & PANKREAS
PROSEDUR KOLESISTEKTOMI DENGAN LAPAROSKOPI
PROSEDUR PERKUTAN PADA HATI DAN SALURAN EMPEDU
PROSEDUR ENDOSKOPI SALURAN EMPEDU
PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN PANKREAS
PROSEDUR RADIOTERAPI
KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH
KEMOTERAPI PADA TUMOR KOLON
KEMOTERAPI PADA TUMOR PAYUDARA ATAU OVARIUM
KEMOTERAPI PADA TUMOR GASTROINTESTINAL
KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU PROSTAT
KEMOTERAPI PADA TUMOR OTAK
KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER
KEMOTERAPI PADA LEUKEMIA AKUT
KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS
KEMOTERAPI PADA TUMOR KULIT
KEMOTERAPI PADA TUMOR GINEKOLOGI
KEMOTERAPI PADA TUMOR METASTASE
KEMOTERAPI PADA TUMOR LAIN-LAIN
PROSEDUR PENCANGKOKAN SUMSUM TULANG
PROSEDUR LIMPA
PROSEDUR BESAR PADA NODUL LIMPA DAN TYMUS
PROSEDUR KECIL PADA NODUL LIMPA DAN TYMUS
PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG
PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH
PROSEDUR PADA KELENJAR ADRENAL
PROSEDUR BESAR PADA KELENJAR TIROID DAN PARATIROID
31 E-2-22-0
PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
PROSEDUR DIAGNOSTIK PADA KELENJAR ENDOKRIN

TERAPI SHOCK
PELAYANAN KESEHATAN MENTAL EKSTENSIF
TERAPI KELOMPOK
PROSEDUR TES DIAGNOSTIK KESEHATAN JIWA
PSIKOTERAPI INDIVIDU DEWASA AKUT
PSIKOTHERAPI INDIVIDU DEWASA BUKAN AKUT
PENGOBATAN INDIVIDU KETERBELAKANGAN MENTAL
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN MENTAL
PROSEDUR KRANIOTOMI
PROSEDUR SHUNT VENTRIKEL
PROSEDUR PADA PEMBULUH DARAH EKSTRAKRANIAL
PROSEDUR CARPAL TUNNEL RELEASE
PROSEDUR BESAR PADA SARAF PERIFER
PROSEDUR KECIL PADA SARAF PERIFER
PROSEDUR BESAR PADA TULANG BELAKANG
PROSEDUR KECIL PADA TULANG BELAKANG
PROSEDUR TAP & INJEKSI PADA SPINAL
PROSEDUR INJEKSI PADA SARAF PERIFER
PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN
PROSEDUR ELEKROENSEFALOGRAFI (EEG)
PENYAKIT SARAF KRANIAL DAN SARAF PERIFER LAIN-LAIN
PROSEDUR BESAR PADA MATA EKSTERNAL
PROSEDUR SEDANG PADA MATA EKSTERNAL
PROSEDUR KECIL PADA MATA EKSTERNAL
PROSEDUR BESAR PADA SEGMEN ANTERIOR MATA
PROSEDUR SEDANG PADA SEGMEN ANTERIOR MATA
PROSEDUR KECIL PADA SEGMEN ANTERIOR MATA
PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA
PROSEDUR KECIL PADA SEGMEN POSTERIOR MATA
PROSEDUR OPERASI KATARAK
PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA
PROSEDUR LASER SEDANG PADA MATA
PROSEDUR KECIL PADA EKTRAOKULER
PROSEDUR LAIN-LAIN PADA MATA
PROSEDUR DIAGNOSTIK & IMAGING PADA MATA
PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTUNG
PROSEDUR BESAR PADA PEMBULUH DARAH TORASIK
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,390,000
1,803,000
3,352,900
2,770,800
3,600,800
662,300
1,471,600
517,900
1,144,400
981,300
1,114,000
1,674,900
2,284,500
2,093,800
678,300
1,565,600
567,900
975,000
2,969,800
1,063,600
2,511,700
612,800
1,787,000
2,237,600
1,876,700
460,300
1,394,900
775,600
498,500
431,200
380,600
455,100
633,700
466,700
512,600
394,800
683,500
354,400
351,700
358,500
8,183,600
3,270,600
3,281,600
844,100
1,727,800
1,081,800
2,198,800
1,127,100
645,500
487,400
786,100
557,800
371,500
3,623,600
1,449,400
966,300
3,772,100
2,514,700
391,800
4,086,400
2,829,100
4,410,000
1,469,700
904,000
389,000
384,800
365,300
5,570,300
2,711,500
- 26 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
70 I-2-13-0 PROSEDUR BESAR PADA PEMBULUH DARAH ABDOMEN
71 I-2-14-0 PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUNG
72 I-2-15-0 PROSEDUR KATETERISASI JANTUNG
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK
73 I-2-16-0
PENGGANTIAN ALAT
74 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA
75 I-2-21-0 ANGIOGRAFI ARTERI BUKAN JANTUNG
76 I-2-22-0 PROSEDUR SEDANG PADA PEMBULUH DARAH
77 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH
78 I-2-31-0 PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR JANTUNG
79 I-2-32-0 PEMASANGAN ATAU PENGGANTIAN ALAT PACU JANTUNG
80 I-2-41-0 PROSEDUR ELEKTROFISIOLOGIK
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR
81 I-2-42-0
PERKUTAN LAIN
82 I-3-10-0 PROSEDUR RESUSITASI
83 I-3-11-0 PROSEDUR KARDIOVERSI
84 I-3-12-0 PROSEDUR KECIL LAIN-LAIN PADA JANTUNG
85 I-3-13-0 PROSEDUR EKOKARDIOGRAFI
86 I-3-14-0 PROSEDUR STRESS TESTING
87 I-3-15-0 PROSEDUR PENGAWASAN FUNGSI KARDIOVASKULAR
88 J-2-10-0 PROSEDUR BESAR PADA SISTEM SALURAN PERNAFASAN
89 J-2-21-0 PROSEDUR VENTILASI MEKANIKAL JANGKA PENDEK
90 J-2-22-0 PROSEDUR PADA LARING DAN TRAKEA
91 J-2-31-0 PROSEDUR THORAKOSKOPI/MEDIASTINOSKOPI
92 J-2-32-0 PROSEDUR DADA INTERMEDIATE
93 J-3-10-0 PROSEDUR PADA DINDING DADA
94 J-3-11-0 PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA
95 J-3-12-0 PROSEDUR THORACENTESIS
96 J-3-13-0 PROSEDUR TERAPI SALURAN PERNAFASAN
97 J-3-14-0 PROSEDUR BIOPSI PERKUTAN DAN ASPIRASI
98 J-3-15-0 PROSEDUR BRONKOSKOPI
99 J-3-16-0 PROSEDUR UJI FUNGSI PARU
100 J-3-17-0 PROSEDUR LAIN-LAIN PADA SISTEM SALURAN PERNAFASAN
101 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL
102 K-2-11-0 PROSEDUR ADHESIOLYSIS PADA PERITONEUM
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS
104 K-2-13-0 PROSEDUR PADA USUS BUNTU
105 K-2-14-0 PROSEDUR PADA HERNIA INGUINALIS DAN FEMORALIS
106 K-2-21-0 PROSEDUR BESAR PADA USUS HALUS DAN USUS BESAR
107 K-2-22-0 PROSEDUR BESAR PADA GASTROINTESTINAL ATAS
108 K-2-31-0 PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS
109 K-2-32-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL ATAS
110 K-2-41-0 PROSEDUR LAPAROSKOPI
111 K-2-42-0 PROSEDUR LAPAROTOMI & GASTROINTESTINAL LAINNYA
112 K-2-51-0 PROSEDUR UNTUK WASIR
113 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM
114 K-2-53-0 PROSEDUR KECIL PADA ANUS & REKTUM
115 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL
116 K-3-11-0 PROSEDUR LAIN-LAIN PADA ANUS & REKTUM
117 K-3-12-0 PROSEDUR SIGMOIDOSKOPI DAN ANOSKOPI
118 K-3-13-0 PROSEDUR KOLONOSKOPI
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS
120 K-3-15-0 PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS
121 K-3-16-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL
122 K-5-18-0 PENYAKIT SISTEM PENCERNAAN LAIN-LAIN
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR
124 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR
125 L-2-31-0 PROSEDUR BESAR PEMINDAHAN KULIT TANPA LUKA BAKAR
126 L-2-32-0 PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR
127 L-2-41-0 PROSEDUR BEDAH PLASTIK
128 L-2-42-0 PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH KULIT
129 L-2-51-0 PROSEDUR PENGANGKATAN PAYUDARA
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA
131 L-2-53-0 PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA
132 L-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA PAYUDARA
133 L-3-11-0 PROSEDUR BESAR PADA KULIT
134 L-3-12-0 PROSEDUR KECIL PADA KULIT
135 M-2-10-0 PROSEDUR REKONTRUKSI TULANG KRANIAL DAN WAJAH
136 M-2-21-0 PROSEDUR BESAR PADA SENDI PANGGUL DAN PAHA
137 M-2-22-0 PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA
NO
TARIF
INA-CBG
3,446,100
6,098,800
5,056,600
3,852,100
1,269,900
4,287,500
2,799,500
688,200
6,437,000
5,827,300
3,907,200
3,701,600
457,500
439,600
1,768,900
483,400
430,700
476,000
2,042,400
2,231,800
1,949,400
2,152,000
1,303,300
433,200
763,700
524,200
473,300
461,200
585,500
667,700
391,400
1,123,400
2,047,400
1,571,600
3,694,800
481,100
481,100
4,267,700
1,985,300
380,800
1,761,800
4,576,800
1,050,800
827,700
405,500
273,600
549,000
765,600
1,833,100
1,615,700
1,131,000
675,000
371,500
1,963,900
1,258,900
672,400
613,800
2,011,400
528,100
2,568,700
1,965,200
479,400
531,500
519,100
373,100
2,141,200
2,353,500
466,400
- 27 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR LAIN-LAIN PADA KAKI
PROSEDUR EKSISI, INSISI DAN ARTHROTOMI TULANG
PROSEDUR PEMINDAHAN ALAT IMPLAN
PROSEDUR BESAR PADA JARINGAN LUNAK
PROSEDUR KECIL PADA JARINGAN LUNAK
PROSEDUR ARTROSKOPI
PROSEDUR LAIN-LAIN PADA SENDI & TULANG
PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG
PROSEDUR BESAR PADA TULANG KEPALA & WAJAH
PROSEDUR KECIL PADA TULANG KEPALA & WAJAH
PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH
PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH
PROSEDUR BESAR PADA LENGAN, SIKU & BAHU
PROSEDUR KECIL PADA LENGAN, SIKU & BAHU
PROSEDUR BESAR PADA TANGAN & PERGELANGAN TANGAN
PROSEDUR KECIL PADA TANGAN & PERGELANGAN TANGAN
PROSEDUR MANIPULATIVE OSTEOPATHIC
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK MUSKULOSKELETAL
PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL
PROSEDUR REDUKSI FRAKTUR TERTUTUP
PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP
PROSEDUR APLIKASI CASTS DAN SPLINTS
PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL
PROSEDUR PEMASANGAN ALAT PROSTETIK
PROSEDUR BESAR PADA KANDUNG KEMIH
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN KEMIH
PROSEDUR BESAR PADA GINJAL DAN URETER
PROSEDUR SEDANG PADA GINJAL DAN URETER
PROSEDUR KECIL PADA GINJAL DAN URETER
PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA
PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA
PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA
PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA
PROSEDUR PADA GINJAL DAN URETER
PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN KEMIH
PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH
PROSEDUR KECIL ENDOSKOPI PADA SALURAN KEMIH
PROSEDUR DIALISIS
PROSEDUR PERSALINAN DENGAN BEDAH CAESAR
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN KURETASE
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU
PELEBARAN DAN KURETASE
PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR
NEONATAL, BBL GROUP-2
NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDITER
NEONATAL, BBL GROUP-5 DENGAN SINDROM ASPIRASI
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL
PENYALAHGUNAAN ZAT KIMIA AKUT
PENYALAHGUNAAN ZAT KIMIA BUKAN AKUT
GIGI
MEDICAL CHECK-UP
RONGENT (PLAIN FILM)
ELEKTROKARDIOGRAM (ECG)
VAKSINASI
PROSEDUR CAIRAN INTRA VENA
KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN
KONTAK PELAYANAN KESEHATAN LAIN-LAIN
ABORSI MENGANCAM
ABORSI
PERSALINAN YANG SUKAR (FALSE LABOR)
PEMERIKSAAN ANTEPARTUM
PEMERIKSAAN POSTPARTUM
GASTROINTESTINAL AKUT
BRONKIAL AKUT
TARIF
INA-CBG
1,429,500
533,600
576,900
534,200
847,500
651,900
1,632,700
481,700
1,340,300
2,238,700
392,200
2,387,300
1,293,700
2,795,700
1,411,300
623,300
479,400
79,000
621,400
1,404,100
547,200
739,100
422,700
201,000
426,800
6,356,400
3,613,100
6,030,300
1,851,700
827,700
564,000
1,275,500
674,600
1,357,700
786,100
468,000
783,300
440,800
672,800
515,800
982,400
2,460,700
1,979,800
1,745,600
1,232,000
453,200
453,200
453,200
370,200
234,800
369,200
451,300
488,100
359,500
317,100
110,700
121,700
90,000
105,600
100,700
153,800
163,800
252,000
276,800
122,400
148,600
101,600
158,500
224,900
- 28 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

SISTEM PERSARAFAN PUSAT AKUT
KECEDERAAN SISTEM PERSARAFAN PUSAT
GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN
INFARK MIOKARD AKUT DAN ARITMIA
FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
KEKACAUAN METABOLIK AKUT
CARDIAC ARREST, RESPIRATORY ARREST & SHOCK
PARU AKUT
KECEDERAAN BESAR PADA JARINGAN LUNAK
INFEKSI SALURAN KEMIH AKUT
PENYAKIT AKUT BESAR LAIN-LAIN
PENYAKIT AKUT KECIL LAIN-LAIN
PENYAKIT KRONIS BESAR LAIN-LAIN
PENYAKIT KRONIS KECIL LAIN-LAIN
PEMULIHAN ALKOHOL, OBAT DAN ATAU TERAPI DETOKSIKASI
PROSEDUR BESAR PADA LARING
PROSEDUR BESAR LAIN-LAIN PADA KEPALA & LEHER
PROSEDUR PADA SINUS & MASTOID
PROSEDUR KELENJAR LUDAH
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT
PROSEDUR OPERASI TONSIL & AMANDEL
PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
RHINOPLASTY
PROSEDUR KECIL PADA HIDUNG
PROSEDUR PADA TELINGA TENGAH
PROSEDUR BESAR PADA MULUT DAN LIDAH
PROSEDUR KECIL PADA MULUT DAN LIDAH
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR KAUTERISASI & PACKING PADA RONGGA HIDUNG
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR BESAR PADA PENGANGKATAN PROSTAT
PROSEDUR PADA PENIS
PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM
PROSEDUR KECIL PADA PROSTAT DAN SKROTUM
PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL
SIRKUMSISI/SUNAT
PROSEDUR STERILISASI PADA LAKI-LAKI
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI
PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI
PROSEDUR ABORSI
PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM
PROSEDUR TERBUKA PADA TUBA FALOPII
PROSEDUR ENDOSKOPI PADA TUBA FALOPII
PROSEDUR BESAR TERBUKA PADA PANGGUL
PROSEDUR KECIL TERBUKA PADA PANGGUL
PROSEDUR LAPAROSKOPI GINEKOLOGI
PROSEDUR PEMBUANGAN RAHIM MELALUI JALAN LAHIR
PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL INTERMEDIATE
PROSEDUR KECIL VULVOVAGINAL
PROSEDUR GINEKOLOGI LAIN-LAIN
PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI
PROSEDUR SEDANG GINEKOLOGI
PROSEDUR KECIL GINEKOLOGI
PROSEDUR RADIOSURGICAL
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN
EMPEDU
PROSEDUR REHABILITASI
PROSEDUR KECIL PELAYANAN PENUNJANG LAIN-LAIN
DIAGNOSTIK TIDUR
IMAGING NUKLIR JANTUNG
TARIF
INA-CBG
160,100
282,900
799,600
927,000
151,400
384,800
184,300
263,100
647,300
554,100
398,300
377,200
150,600
147,900
444,100
332,900
477,500
377,100
217,800
3,492,100
2,873,600
456,600
472,900
904,300
888,000
1,157,600
598,000
1,863,500
314,900
486,000
487,600
390,400
493,100
466,700
218,600
480,300
425,800
385,100
435,500
3,605,600
585,200
1,297,600
465,400
827,700
543,500
433,500
1,126,800
1,154,000
1,230,400
1,076,300
1,586,700
320,600
2,782,800
422,700
1,410,600
3,205,800
2,965,400
1,295,500
469,500
915,600
912,000
422,700
3,313,100
2,606,000
241,200
180,100
234,000
503,900
- 29 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

PROSEDUR MAGNETIC RESONANCE IMAGING (MRI)
PELAYANAN KEDOKTERAN NUKLIR
CT-SCAN KEPALA
CT SCAN LAIN-LAIN
IMAGING KONTRAS SALURAN URINARI
IMAGING KONTRAS PEMBULUH DARAH
IMAGING KONTRAS LAIN-LAIN
PROSEDUR ULTRASOUND LAIN-LAIN
PROSEDUR ULTRASOUND PEMBULUH DARAH
PROSEDUR ULTRASOUND GINEKOLOGIK
PROSEDUR BESAR RADIOGRAFI
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,243,900
1,487,500
1,373,100
1,656,600
793,800
1,104,300
763,300
642,100
785,600
454,900
1,075,400
215,000
796,400
1,339,200
87,300
- 30 -

REGIONAL 1
RUMAH SAKIT KELAS A SWASTA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,622,000
4,346,400
A-4-10-II
SEPTIKEMIA (SEDANG)
6,187,900
7,425,500
8,663,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,343,200
4,391,600
10,011,900
5,270,000
11,680,500
6,148,300
5
6
A-4-11-II
A-4-11-III

6,250,600
8,651,300
7,500,700
10,381,600
8,750,800
12,111,900
A-4-12-I
2,864,100
3,436,900
4,009,800
8
9
A-4-12-II
A-4-12-III

4,944,000
7,123,300
5,932,800
8,548,000
6,921,500
9,972,700
10 A-4-13-I
11 A-4-13-II

2,131,700
3,767,300
2,558,000
4,520,700
2,984,400
5,274,200
12 A-4-13-III
4,520,700
5,424,900
6,329,000
2,388,100
2,865,700
3,343,400
4,018,100
4,821,700
5,625,400
4,821,700
5,786,100
6,750,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,644,000
23,217,900
22,372,700
27,861,500
26,101,500
32,505,100
18 A-4-15-III
INFEKSI HIV (BERAT)
26,229,700
31,475,700
36,721,600
19 B-1-01-I
20 B-1-01-II

51,405,300
56,713,500
61,686,300
68,056,200
71,967,400
79,399,000
21 B-1-01-III
22 B-1-10-I

125,011,900
8,309,400
150,014,300
9,971,300
175,016,700
11,633,100
23 B-1-10-II
18,443,200
22,131,800
25,820,400
24 B-1-10-III
25 B-1-11-I

36,409,300
33,158,000
43,691,200
39,789,600
50,973,000
46,421,200
26 B-1-11-II
27 B-1-11-III

39,509,500
61,053,200
47,411,400
73,263,900
55,313,300
85,474,500
28 B-1-12-I
9,757,200
11,708,700
13,660,100
29 B-1-12-II
10,851,800
13,022,100
15,192,500
30 B-1-12-III
16,976,400
20,371,600
23,766,900
7,771,700
9,326,100
10,880,400
12,787,400
15,344,900
17,902,400
16,545,800
19,855,000
23,164,100
20,361,900
24,434,200
28,506,600
21,385,700
25,662,800
29,940,000
37,856,400
3,304,000
5,274,100
7,275,800
45,427,600
3,964,800
6,328,900
8,731,000
52,998,900
4,625,600
7,383,700
10,186,100
6,966,000
8,359,300
9,752,500
9,752,500
11,703,100
13,653,600
11,815,100
14,178,100
16,541,100
6,298,100
8,968,200
13,342,700
6,007,900
7,557,700
10,761,900
16,011,300
7,209,400
8,817,300
12,555,500
18,679,800
8,411,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,070,800
- 31 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,998,900
8,398,700
9,798,400
48 B-4-13-III
49 B-4-14-I

9,641,600
6,001,400
11,569,900
7,201,700
13,498,200
8,402,000
50 B-4-14-II
7,001,400
8,401,700
9,802,000
51 B-4-14-III
52 C-4-10-I

9,378,600
12,155,300
11,254,300
14,586,300
13,130,000
17,017,400
53 C-4-10-II
54 C-4-10-III

19,549,000
36,628,500
23,458,800
43,954,200
27,368,600
51,279,900
55 C-4-11-I
6,327,200
7,592,600
8,858,100
56 C-4-11-II
57 C-4-11-III

8,466,700
13,017,700
10,160,100
15,621,200
11,853,400
18,224,800
58 C-4-12-I
59 C-4-12-II
4,212,900
8,297,700
5,055,400
9,957,200
5,898,000
11,616,800
60 C-4-12-III
RADIOTERAPI (BERAT)
21,310,800
25,572,900
29,835,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,167,200
5,960,700
3,800,700
7,152,900
4,434,100
8,345,000
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,068,800
5,262,500
9,682,600
6,314,900
11,296,300
7,367,400
65 C-4-14-II
7,382,200
8,858,600
10,335,000
66 C-4-14-III
67 D-1-10-I

10,999,300
31,794,300
13,199,100
38,153,100
15,399,000
44,512,000
68 D-1-10-II
69 D-1-10-III

48,424,900
69,398,100
58,109,900
83,277,700
67,794,800
97,157,300
70 D-1-11-I
8,512,600
10,215,100
11,917,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,736,700
28,247,700
26,084,000
33,897,200
30,431,300
39,546,700
7,379,400
8,855,300
10,331,200
20,336,700
24,404,000
28,471,300
32,259,900
38,711,900
45,163,900
2,916,100
4,785,700
7,529,000
5,777,100
10,381,200
14,261,200
4,980,700
6,908,300
10,608,000
3,499,400
5,742,800
9,034,800
6,932,500
12,457,500
17,113,500
5,976,800
8,289,900
12,729,600
4,082,600
6,700,000
10,540,700
8,087,900
14,533,700
19,965,700
6,972,900
9,671,600
14,851,200
4,268,300
5,122,000
5,975,600
6,041,100
7,249,300
8,457,500
7,726,700
9,272,100
10,817,400
4,577,900
5,493,500
6,409,100
7,495,200
8,994,300
10,493,300
9,167,400
11,000,900
12,834,400
9,125,600
10,950,700
12,775,800
12,457,800
14,949,300
17,440,900
93 E-1-01-III
30,037,000
36,044,400
42,051,800
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,487,700
13,170,000
24,882,500
11,385,200
15,804,000
29,859,000
13,282,700
18,438,000
34,835,400
10,740,800
12,888,900
15,037,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 32 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,222,400
5,066,900
5,911,400
104 E-4-11-II
105 E-4-11-III

6,437,400
8,723,200
7,724,900
10,467,800
9,012,400
12,212,400
106 E-4-12-I
107 E-4-12-II

GANGGUAN METABOLIK BAWAAN (SEDANG)
4,851,500
8,401,600
5,821,800
10,081,900
6,792,100
11,762,200
108 E-4-12-III
GANGGUAN METABOLIK BAWAAN (BERAT)

GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN
(RINGAN)
(SEDANG)
9,958,900
11,950,700
13,942,500
5,283,100
6,339,700
7,396,300
7,738,800
9,286,500
10,834,300
10,116,100
12,139,300
14,162,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
14,456,800
17,348,100
20,239,500
19,924,400
23,909,300
27,894,200
3,801,100
4,561,300
5,321,600
7,362,100
8,834,500
10,307,000
12,336,100
14,803,300
17,270,500
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,624,500
6,464,200
6,749,400
7,757,100
7,874,300
9,049,900
114 F-4-10-III
115 F-4-11-I
7,757,100
5,439,800
9,308,500
6,527,800
10,859,900
7,615,700
116 F-4-11-II
6,337,900
7,605,500
8,873,100
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,127,600
9,753,100
11,378,600
2,981,900
3,578,300
4,174,600
4,239,300
5,087,200
5,935,000
9,209,700
11,051,600
12,893,500
4,381,900
5,782,000
7,485,500
2,500,100
3,206,700
4,314,900
5,258,300
6,938,400
8,982,700
3,000,100
3,848,000
5,177,800
6,134,600
8,094,800
10,479,800
3,500,100
4,489,400
6,040,800
127 F-4-15-I
3,981,500
4,777,900
5,574,200
128 F-4-15-II
5,933,000
7,119,600
8,306,200
129 F-4-15-III
7,833,400
9,400,100
10,966,800
7,833,900
9,400,600
10,967,400
9,108,200
10,929,800
12,751,400
12,157,800
14,589,400
17,021,000
133 F-4-17-I

1,850,100
2,220,100
2,590,100
134 F-4-17-II
5,422,300
6,506,700
7,591,200
135
136
137
138
139
140
141

(RINGAN)
5,785,100
6,807,100
7,489,700
11,545,900
5,202,200
6,661,600
8,293,700
6,942,100
8,168,500
8,987,600
13,855,100
6,242,600
7,994,000
9,952,400
8,099,100
9,529,900
10,485,600
16,164,300
7,283,100
9,326,300
11,611,200
22,068,200
26,481,900
30,895,500
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 33 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
51,641,600
61,969,900
72,298,200
148 G-1-11-I
149 G-1-11-II

PROSEDUR VENTRICULAR SHUNT (SEDANG)
16,888,800
30,876,700
20,266,600
37,052,000
23,644,300
43,227,400
150 G-1-11-III
49,617,500
59,541,000
69,464,500
7,051,700
8,462,000
9,872,300
13,218,700
15,862,400
18,506,200
18,014,500
21,617,400
25,220,300
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,127,300
5,712,800
2,552,700
6,855,400
2,978,200
7,997,900
156 G-1-13-III
157 G-1-20-I

12,890,600
11,942,400
15,468,800
14,330,900
18,046,900
16,719,400
158 G-1-20-II
18,070,800
21,684,900
25,299,100
159 G-1-20-III
30,813,900
36,976,700
43,139,500
160 G-1-30-I
29,751,700
35,702,000
41,652,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
40,112,500
60,236,000
48,135,000
72,283,200
56,157,500
84,330,400
6,053,100
7,263,700
8,474,300
7,398,900
8,878,700
10,358,500
10,152,600
12,183,100
14,213,600
6,336,600
7,604,000
8,871,300
8,417,400
10,100,900
11,784,400
12,368,100
14,841,700
17,315,300
7,029,800
8,435,700
9,841,700
8,879,100
10,654,900
12,430,700
12,895,800
15,474,900
18,054,100
4,222,900
5,067,400
5,912,000
7,363,900
8,836,600
10,309,400
8,733,700
10,480,500
12,227,200
7,163,600
8,596,300
10,029,100
9,577,200
11,492,700
13,408,100
12,020,600
14,424,700
16,828,800
5,853,300
7,024,000
8,194,600
6,985,600
8,382,700
9,779,900
9,859,600
11,831,500
13,803,500
4,825,300
5,790,300
6,755,400
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I

CARPAL TUNNEL RELEASE (SEDANG)

(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
31,651,200
37,981,400
44,311,600
51,783,900
62,140,700
72,497,500
34,312,200
42,023,900
41,174,600
50,428,600
48,037,100
58,833,400
- 34 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,406,200
7,687,400
8,968,700
183 G-4-16-III
9,122,900
10,947,500
12,772,100
6,426,900
7,712,300
8,997,700
8,427,100
10,112,500
11,797,900
10,589,000
12,706,800
14,824,700
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,329,500
7,595,400
8,861,300
188 G-4-18-II
8,460,700
10,152,800
11,844,900
189 G-4-18-III
9,466,800
11,360,200
13,253,500
5,280,900
6,337,000
7,393,200
8,925,900
10,711,100
12,496,300
11,719,300
14,063,200
16,407,100
193 G-4-20-I

3,694,200
4,433,100
5,171,900
194 G-4-20-II
5,222,500
6,267,000
7,311,500
195 G-4-20-III
196 G-4-21-I

8,626,300
3,846,900
10,351,600
4,616,300
12,076,800
5,385,700
197 G-4-21-II
198 G-4-21-III

6,511,000
7,652,000
7,813,200
9,182,400
9,115,400
10,712,700
199 G-4-22-I
2,882,100
3,458,500
4,034,900
200 G-4-22-II
201 G-4-22-III

5,104,300
8,051,500
6,125,100
9,661,800
7,146,000
11,272,100
202 G-4-23-I
203 G-4-23-II

3,787,000
4,751,300
4,544,300
5,701,600
5,301,700
6,651,800
204 G-4-23-III
6,764,700
8,117,700
9,470,600
205 G-4-24-I
206 G-4-24-II

4,218,100
5,269,900
5,061,700
6,323,900
5,905,300
7,377,900
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,779,500
3,604,300
4,558,000
6,040,300
10,535,400
4,325,200
5,469,600
7,248,300
12,291,300
5,046,000
6,381,200
8,456,400
4,109,200
4,931,000
5,752,800
4,780,200
5,736,300
6,692,300
7,147,900
8,577,500
10,007,100
12,155,000
13,433,200
18,268,400
8,282,600
10,290,300
14,413,100
4,391,600
5,958,500
11,711,700
4,211,100
4,803,600
6,878,400
4,964,900
5,932,200
9,941,300
14,586,000
16,119,800
21,922,000
9,939,100
12,348,400
17,295,700
5,269,900
7,150,200
14,054,000
5,053,300
5,764,300
8,254,100
5,957,900
7,118,600
11,929,500
17,017,000
18,806,500
25,575,700
11,595,700
14,406,400
20,178,300
6,148,200
8,341,900
16,396,300
5,895,500
6,725,000
9,629,800
6,950,900
8,305,000
13,917,800
229 I-1-01-I
66,687,800
80,025,300
93,362,900
230 I-1-01-II
68,154,900
81,785,900
95,416,800
231 I-1-01-III

(RINGAN)
107,581,600
129,097,900
150,614,200
36,998,100
44,397,700
51,797,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 35 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
49,741,000
59,689,200
69,637,400
245 I-1-06-II
72,053,900
86,464,600
100,875,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
85,973,600
103,168,300
120,363,000
77,423,000
92,907,600
108,392,300
96,778,800
116,134,600
135,490,300
145,168,200
174,201,800
203,235,500
5,797,700
6,957,300
8,116,800
6,446,500
7,735,800
9,025,100
8,578,300
10,294,000
12,009,600
16,688,600
20,026,300
23,364,100
27,255,900
32,707,000
38,158,200
35,859,200
43,031,000
50,202,900
16,187,700
19,425,300
22,662,800
21,557,300
25,868,700
30,180,200
26,586,100
31,903,300
37,220,500
33,132,300
39,758,800
46,385,200
41,178,600
49,414,300
57,650,000
53,958,100
64,749,800
75,541,400
6,294,200
8,789,700
16,925,500
7,553,000
10,547,600
20,310,600
8,811,900
12,305,600
23,695,700
16,316,800
19,580,200
22,843,500
36,918,400
44,302,000
51,685,700
42,584,800
51,101,700
59,618,700
18,893,300
22,672,000
26,450,600
23,656,200
28,387,400
33,118,700
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
47,727,100
57,272,500
66,817,900
58,826,600
70,592,000
82,357,300
34,893,200
41,871,800
48,850,500
48,369,200
58,043,000
67,716,900
61,384,200
73,661,100
85,937,900
52,582,100
63,098,600
73,615,000
82,988,800
99,586,600
116,184,300
132,574,100
159,088,900
185,603,700
87,100,900
104,521,100
121,941,300
106,456,700
127,748,000
149,039,400
145,168,200
174,201,800
203,235,500
- 36 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,754,000
44,104,800
51,455,600
279 I-1-40-III
49,090,900
58,909,100
68,727,200
280 I-4-10-I
281 I-4-10-II

5,604,000
10,006,600
6,724,800
12,008,000
7,845,600
14,009,300
282 I-4-10-III
14,418,100
17,301,800
20,185,400
283 I-4-11-I
284 I-4-11-II

8,621,800
10,669,500
10,346,100
12,803,400
12,070,500
14,937,300
285 I-4-11-III
286 I-4-12-I

19,737,400
4,956,300
23,684,900
5,947,500
27,632,400
6,938,800
287 I-4-12-II
5,745,000
6,894,000
8,043,000
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,894,000
8,272,800
9,651,600
5,043,600
6,052,300
7,061,100
9,006,000
10,807,200
12,608,400
12,976,300
15,571,600
18,166,900
4,762,800
4,926,700
8,636,600
5,715,400
5,912,100
10,363,900
6,667,900
6,897,400
12,091,200
4,864,200
5,837,000
6,809,800
9,172,400
11,006,900
12,841,300
11,006,900
13,208,200
15,409,600
3,006,000
4,827,000
5,792,400
2,007,000
3,238,700
4,534,200
3,607,300
5,792,400
6,950,800
2,408,400
3,886,500
5,441,100
4,208,500
6,757,800
8,109,300
2,809,900
4,534,200
6,347,900
5,798,300
6,958,000
8,117,700
8,828,200
10,593,800
12,359,500
11,985,700
14,382,900
16,780,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
29,262,400
35,114,800
40,967,300
21,296,000
25,555,200
29,814,400
26,604,600
31,925,500
37,246,400
27,966,900
33,560,300
39,153,700
16,109,200
19,331,100
22,552,900
33,510,800
40,212,900
46,915,100
51,929,600
62,315,600
72,701,500
14,867,100
17,840,500
20,813,900
307 I-4-19-I
5,594,200
6,713,100
7,831,900
308 I-4-19-II

(SEDANG)
8,732,900
10,479,500
12,226,100
309 I-4-19-III
10,425,400
12,510,500
14,595,600
310
311
312
313
314

5,825,200
6,728,200
10,060,000
3,923,100
4,970,600
6,990,300
8,073,800
12,072,000
4,707,700
5,964,700
8,155,300
9,419,400
14,084,000
5,492,300
6,958,800
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 37 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,174,500
8,609,400
10,044,300
316 I-4-22-I
317 I-4-22-II
3,524,800
4,387,800
4,229,700
5,265,400
4,934,700
6,143,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,413,600
7,696,300
8,979,100
4,781,700
5,738,000
6,694,400
5,870,500
7,044,700
8,218,800
11,470,700
13,764,900
16,059,000
3,106,500
3,727,800
4,349,100
7,153,400
8,584,100
10,014,800
9,044,300
10,853,100
12,662,000
98,428,000
118,113,600
137,799,200
111,389,600
133,667,500
155,945,400
152,790,000
183,348,000
213,906,000
64,212,300
77,054,800
89,897,300
81,023,500
97,228,200
113,432,900
94,786,000
113,743,200
132,700,400
12,518,500
15,022,100
17,525,800
25,331,200
30,397,400
35,463,600
26,325,300
31,590,400
36,855,500
34,486,100
41,383,300
48,280,600
36,111,600
43,333,900
50,556,200
40,638,900
48,766,700
56,894,400
10,447,000
12,536,400
14,625,800
18,924,600
22,709,500
26,494,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
54,625,100
65,550,100
76,475,100
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,079,500
6,360,000
9,621,700
3,810,000
5,306,600
7,113,000
6,471,300
7,366,600
10,285,900
5,721,700
7,964,500
14,859,100
6,308,300
10,265,500
12,145,100
4,564,700
7,559,200
13,729,800
3,695,400
7,632,000
11,546,100
4,572,000
6,367,900
8,535,600
7,765,600
8,840,000
12,343,000
6,866,100
9,557,400
17,830,900
7,570,000
12,318,600
14,574,100
5,477,700
9,071,100
16,475,700
4,311,300
8,904,000
13,470,400
5,334,000
7,429,200
9,958,200
9,059,800
10,313,300
14,400,200
8,010,400
11,150,300
20,802,700
8,831,700
14,371,700
17,003,100
6,390,600
10,582,900
19,221,700
3,803,400
4,564,100
5,324,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 38 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,408,400
8,890,000
10,371,700
12,645,100
15,174,200
17,703,200
5,271,200
6,312,400
6,325,400
7,574,900
7,379,700
8,837,400

8,283,800
2,343,000
9,940,500
2,811,700
11,597,300
3,280,300
365 J-4-18-II
4,466,900
5,360,300
6,253,700
366 J-4-18-III
367 J-4-19-I

6,347,700
6,682,200
7,617,300
8,018,600
8,886,800
9,355,000
368 J-4-19-II
369 J-4-19-III

7,578,000
8,369,000
9,093,600
10,042,800
10,609,200
11,716,600
370 J-4-20-I
5,315,600
6,378,700
7,441,800
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,365,300
8,634,400
8,838,400
10,361,300
10,311,400
12,088,200
3,036,900
3,644,300
4,251,700
6,781,400
8,137,600
9,493,900
12,774,900
15,329,800
17,884,800
11,348,700
13,618,500
15,888,200
14,262,100
17,114,500
19,967,000
16,715,700
20,058,800
23,402,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,657,900
12,789,500
14,921,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
13,992,500
27,657,400
16,791,000
33,188,900
19,589,500
38,720,400
4,761,800
5,714,100
6,666,500
6,193,200
7,431,900
8,670,500
12,269,700
14,723,700
17,177,600
5,370,300
5,907,400
9,441,200
6,444,400
7,088,800
11,329,400
7,518,500
8,270,300
13,217,700
7,843,600
9,412,300
10,981,000
9,192,500
11,031,000
12,869,500
390 K-1-14-III
16,047,400
19,256,900
22,466,300
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

16,875,200
23,570,800
34,415,900
20,250,200
28,285,000
41,299,100
23,625,200
32,999,200
48,182,300
9,979,900
11,975,800
13,971,800
17,724,000
21,268,800
24,813,600
24,388,500
29,266,200
34,143,900
397 K-1-40-I
11,135,200
13,362,300
15,589,300
398 K-1-40-II

(SEDANG)
12,277,000
14,732,400
17,187,700
399 K-1-40-III
20,805,000
24,966,000
29,127,000
400
401
402
403
404

8,508,400
11,049,200
15,614,600
7,024,100
10,092,700
10,210,100
13,259,100
18,737,500
8,429,000
12,111,200
11,911,800
15,468,900
21,860,400
9,833,800
14,129,700
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 39 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,385,700
18,462,900
21,540,000
406 K-4-11-I
407 K-4-11-II

2,441,800
4,809,600
2,930,100
5,771,500
3,418,500
6,733,400
408 K-4-11-III
409 K-4-12-I

5,771,500
4,222,400
6,925,800
5,066,900
8,080,100
5,911,400
410 K-4-12-II
5,682,100
6,818,500
7,954,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,400,000
11,280,000
13,160,000
5,692,100
6,830,500
7,968,900
7,363,100
8,835,700
10,308,300
11,341,500
13,609,800
15,878,100
3,247,900
3,897,500
4,547,100
4,359,800
5,231,700
6,103,700
6,995,700
8,394,900
9,794,000
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,629,500
5,555,400
6,481,400
419 K-4-15-II
7,130,000
8,556,000
9,982,000
420 K-4-15-III
10,148,600
12,178,300
14,208,000
421 K-4-16-I
4,192,600
5,031,200
5,869,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,028,100
5,867,100
6,033,800
7,040,500
7,039,400
8,213,900
2,056,500
2,467,800
2,879,200
2,532,600
3,039,200
3,545,700
3,039,200
3,647,000
4,254,800
1,812,300
2,174,800
2,537,200
3,058,300
3,669,900
4,281,600
429 K-4-18-III
3,669,900
4,403,900
5,137,900
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
26,905,400
40,613,000
54,265,600
12,694,200
21,782,500
27,043,300
32,286,500
48,735,500
65,118,700
15,233,100
26,139,000
32,451,900
37,667,600
56,858,100
75,971,800
17,771,900
30,495,500
37,860,600
7,114,100
8,536,900
9,959,800
14,269,300
17,123,200
19,977,100
24,018,500
28,822,200
33,625,900
9,339,400
15,030,800
21,500,100
2,442,800
2,835,400
3,291,100
5,115,500
7,030,900
15,976,300
2,429,400
3,213,200
10,624,900
11,207,300
18,037,000
25,800,100
2,931,300
3,402,500
3,949,400
6,138,600
8,437,000
19,171,600
2,915,300
3,855,900
12,749,800
13,075,200
21,043,100
30,100,100
3,419,900
3,969,600
4,607,600
7,161,700
9,843,200
22,366,800
3,401,200
4,498,500
14,874,800
2,586,900
3,104,200
3,621,600
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 40 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,214,100
5,057,000
5,899,800
8,371,600
10,045,900
11,720,200
4,206,900
5,048,300
5,889,700
6,318,900
7,582,700
8,846,500
8,907,300
10,688,700
12,470,200
14,871,000
17,845,200
20,819,400
21,137,100
25,364,500
29,591,900
29,691,300
35,629,500
41,567,800
13,180,400
15,816,400
18,452,500
21,621,900
36,735,100
25,946,300
44,082,200
30,270,700
51,429,200
52,686,800
63,224,100
73,761,500
61,624,900
73,949,800
86,274,800
76,271,000
91,525,200
106,779,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,983,900
32,380,700
37,777,400
467 M-1-04-II
34,666,500
41,599,700
48,533,000
468 M-1-04-III
41,479,200
49,775,100
58,070,900
469 M-1-05-I
470 M-1-05-II

10,492,300
16,971,700
12,590,800
20,366,100
14,689,300
23,760,400
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,679,200
26,015,100
30,350,900
19,177,100
23,012,500
26,848,000
25,690,700
30,828,900
35,967,000
52,334,400
62,801,200
73,268,100
22,662,300
27,194,700
31,727,200
54,184,500
65,021,400
75,858,300
116,870,900
140,245,100
163,619,300
17,659,400
21,191,300
24,723,200
22,561,700
27,074,000
31,586,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
56,171,800
67,406,100
78,640,500
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,114,800
19,631,000
28,070,500
14,537,800
23,557,100
33,684,600
16,960,700
27,483,300
39,298,700
7,400,300
8,880,300
10,360,400
10,936,700
13,124,100
15,311,400
15,615,600
18,738,700
21,861,800
7,390,100
12,263,800
20,142,400
8,868,100
14,716,500
24,170,900
10,346,100
17,169,300
28,199,400
11,413,400
13,696,100
15,978,700
14,349,300
17,219,100
20,089,000
21,676,300
26,011,500
30,346,800
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 41 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,997,900
9,597,500
11,197,100
512 M-4-14-II
9,864,300
11,837,100
13,810,000
513 M-4-14-III
514 M-4-15-I
14,823,200
4,742,500
17,787,800
5,691,100
20,752,400
6,639,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,321,500
14,345,300
4,060,400
6,502,200
10,923,200
7,585,800
17,214,400
4,872,400
7,802,600
13,107,800
8,850,100
20,083,400
5,684,500
9,103,000
15,292,500
4,742,800
5,691,400
6,639,900
6,633,400
7,960,000
9,286,700
9,263,000
11,115,700
12,968,300
3,983,100
6,002,800
7,227,600
4,779,800
7,203,300
8,673,100
5,576,400
8,403,900
10,118,600
4,153,800
4,984,500
5,815,300
6,996,600
8,395,900
9,795,200
13,664,700
16,397,700
19,130,600
3,771,000
4,525,200
5,279,400
5,522,000
6,626,400
7,730,800
6,171,500
7,405,800
8,640,100
3,797,100
4,556,500
5,316,000
4,749,100
5,698,900
6,648,700
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,145,400
25,374,400
29,603,500
23,259,900
27,911,900
32,563,900
26,629,500
31,955,400
37,281,300
12,020,200
14,424,300
16,828,300
14,275,200
32,130,300
17,130,200
38,556,400
19,985,200
44,982,400
4,234,300
5,081,100
5,928,000
6,314,700
11,947,500
7,577,700
14,337,000
8,840,600
16,726,500
5,276,300
6,331,600
7,386,800
11,568,100
13,881,700
16,195,300
16,725,500
20,070,600
23,415,700
4,211,700
5,054,000
5,896,400
7,005,200
8,406,200
9,807,300
9,370,200
11,244,200
13,118,200
7,012,900
8,415,500
9,818,000
10,536,600
12,643,900
14,751,200
20,556,600
24,667,900
28,779,200
- 42 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,647,400
12,776,900
14,906,400
535 N-1-01-I

292,029,600
350,435,500
408,841,400
536 N-1-01-II
292,029,600
350,435,500
408,841,400
537 N-1-01-III
538 N-1-11-I

292,029,600
12,169,700
350,435,500
14,603,600
408,841,400
17,037,600
539 N-1-11-II
540 N-1-11-III

19,243,200
30,000,200
23,091,900
36,000,300
26,940,500
42,000,300
6,202,500
7,443,000
8,683,500
12,348,500
14,818,200
17,287,900
26,796,700
32,156,000
37,515,300
13,561,000
16,273,200
18,985,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
18,977,900
26,557,300
22,773,400
31,868,700
26,569,000
37,180,200
12,410,700
14,892,800
17,375,000
18,774,900
22,529,900
26,284,900
21,608,200
25,929,800
30,251,400
11,145,700
13,374,800
15,604,000
15,135,600
18,162,700
21,189,800
17,615,800
21,139,000
24,662,200
4,735,400
5,682,400
6,629,500
5,727,500
6,873,000
8,018,500
8,424,300
10,109,200
11,794,100
3,635,200
6,351,100
7,902,100
2,740,800
5,694,000
9,252,300
3,708,700
6,200,300
12,827,000
4,362,200
7,621,300
9,482,500
3,288,900
6,832,700
11,102,800
4,450,500
7,440,300
15,392,400
5,089,200
8,891,500
11,062,900
3,837,100
7,971,500
12,953,300
5,192,200
8,680,400
17,957,800
3,650,900
4,381,100
5,111,200
5,180,400
6,216,500
7,252,600
8,304,200
9,965,100
11,625,900
4,313,100
5,175,700
6,038,300
5,351,700
6,422,100
7,492,400
6,107,300
7,328,700
8,550,200
5,281,300
6,337,600
7,393,900
7,538,100
9,045,800
10,553,400
10,033,800
12,040,600
14,047,300
5,411,600
6,965,500
6,493,900
8,358,600
7,576,200
9,751,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 43 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,979,900
13,175,900
15,371,900
4,909,200
5,891,100
6,872,900
5,456,100
6,547,300
7,638,500
6,787,400
8,144,900
9,502,400
3,478,100
4,173,800
4,869,400
4,177,200
5,012,600
5,848,100
5,248,800
6,298,600
7,348,400
1,763,100
2,115,700
2,468,400
2,892,500
3,471,000
3,471,000
4,165,200
4,049,500
4,859,400
77,667,200
93,200,600
108,734,000
96,101,500
115,321,800
134,542,100
112,796,100
135,355,300
157,914,600
106,012,000
127,214,400
148,416,800
121,606,400
145,927,700
170,249,000
138,944,000
166,732,800
194,521,600
15,901,700
19,082,000
22,262,400
21,048,100
25,257,700
29,467,300
29,594,500
35,513,400
41,432,400
51,243,900
61,492,700
71,741,400
66,503,500
79,804,200
93,104,900
95,349,300
114,419,200
133,489,000
27,864,800
33,437,700
39,010,700
42,986,300
51,583,500
60,180,800
58,189,900
69,827,800
81,465,800
7,522,600
9,027,100
10,531,600
21,091,700
25,310,000
29,528,300
27,941,300
33,529,500
39,117,800
8,905,600
10,686,700
12,467,800
24,969,300
29,963,100
34,957,000
33,078,200
39,693,800
46,309,400
5,152,900
6,183,500
7,214,000
7,311,700
8,774,000
10,236,400
14,224,100
17,069,000
19,913,800
13,251,400
15,901,700
18,552,000
17,540,000
21,048,100
24,556,100
- 44 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,662,100
29,594,500
34,527,000
12,046,700
14,456,100
16,865,400
14,616,700
17,540,000
20,463,400
21,445,300
25,734,400
30,023,400
6,692,600
8,031,200
9,369,700
10,440,500
12,528,600
14,616,700
16,496,400
19,795,700
23,095,000
5,065,800
6,079,000
7,092,100
10,312,000
12,374,400
14,436,700
40,320,600
48,384,700
56,448,800
3,799,400
4,559,300
5,319,200
7,608,500
9,130,200
10,651,900
8,927,200
10,712,600
12,498,100
3,438,500
4,126,200
4,813,900
6,607,700
7,929,200
9,250,700
15,496,100
18,595,300
21,694,500
4,461,800
5,354,100
6,246,500
8,031,200
9,637,400
11,243,600
13,747,000
16,496,400
19,245,800
3,876,900
4,652,300
5,427,600
4,776,900
5,732,300
6,687,700
6,539,100
7,846,900
9,154,700
1,781,600
3,621,300
8,355,500
2,850,300
3,793,700
6,576,300
2,138,000
4,345,600
10,026,600
3,420,300
4,552,400
7,891,600
2,494,300
5,069,800
11,697,700
3,990,400
5,311,100
9,206,900
4,209,100
5,051,000
5,892,800
7,467,300
8,960,800
10,454,200
12,120,400
14,544,500
16,968,500
2,130,100
2,556,100
2,982,200
4,524,500
5,429,400
6,334,300
8,580,100
10,296,100
12,012,100
1,424,600
1,709,600
1,994,500
2,688,500
3,226,200
3,763,900
3,482,100
4,178,500
4,874,900
7,377,000
8,852,400
10,327,900
- 45 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,381,900
11,258,300
13,134,600
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,432,900
16,119,500
18,806,100
3,555,600
4,266,700
4,977,800
5,276,900
6,332,300
7,387,700
6,346,600
7,616,000
8,885,300
2,379,000
2,854,800
3,330,600
3,195,300
3,834,300
4,473,400
5,812,700
6,975,200
8,137,800
1,302,600
1,563,100
1,823,700
2,482,100
2,978,600
3,475,000
3,607,900
4,329,500
5,051,000
1,258,000
1,509,600
1,761,200
1,979,800
2,375,800
2,771,700
3,188,900
3,826,700
4,464,400
2,947,700
3,537,200
4,126,700
4,449,800
5,339,700
6,229,700
6,887,600
8,265,100
9,642,700
7,774,200
9,329,100
10,883,900

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,068,700
31,876,600
14,482,400
38,251,900
16,896,200
44,627,200
12,268,800
14,722,600
17,176,400
18,505,300
22,206,300
25,907,400
21,936,800
26,324,100
30,711,500
9,397,800
14,411,100
21,166,900
9,404,300
10,957,500
18,164,100
11,277,400
17,293,300
25,400,300
11,285,200
13,149,000
21,796,900
13,157,000
20,175,500
29,633,700
13,166,000
15,340,500
25,429,700
5,651,300
6,781,600
7,911,800
6,935,500
8,322,600
9,709,700
8,218,600
9,862,300
11,506,000
4,423,500
6,288,900
9,580,000
5,308,200
7,546,700
11,496,000
6,192,900
8,804,500
13,411,900
8,579,600
10,295,500
12,011,400
12,768,800
15,322,600
17,876,300
32,780,000
39,335,900
45,891,900
7,357,900
9,977,000
19,510,500
8,829,500
11,972,500
23,412,600
10,301,100
13,967,900
27,314,700
5,295,100
6,354,100
7,413,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 46 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,560,900
3,073,100
3,585,300
697 U-4-12-I
698 U-4-12-II

2,750,300
4,434,400
3,300,400
5,321,300
3,850,500
6,208,200
699 U-4-12-III

7,766,100
9,319,300
10,872,500
2,084,400
2,501,200
2,918,100
3,406,000
4,087,200
4,768,400
5,499,600
6,599,500
7,699,400
5,270,400
6,311,100
6,324,500
7,573,300
7,378,500
8,835,600

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,598,300
12,718,000
14,837,600
4,232,000
5,078,300
5,924,700
5,272,500
6,327,000
7,381,500
7,378,900
8,854,700
10,330,500
6,902,700
8,283,200
9,663,700
14,219,300
17,063,100
19,907,000
17,437,900
20,925,500
24,413,100
13,132,000
14,995,200
23,483,100
15,758,400
17,994,300
28,179,700
18,384,800
20,993,300
32,876,400
12,346,600
14,816,000
17,285,300
16,860,300
20,232,400
23,604,400
21,370,600
25,644,800
29,918,900
6,440,200
7,728,200
9,016,200
12,305,000
14,766,000
17,227,000
19,305,100
23,166,100
27,027,100
12,629,100
15,154,900
17,680,800
18,349,700
22,019,700
25,689,600
723 V-1-14-III
22,913,000
27,495,600
32,078,200
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,033,900
2,244,400
2,482,800
2,440,700
2,693,300
2,979,300
2,847,500
3,142,200
3,475,900
5,496,500
6,595,800
7,695,100
9,130,000
10,956,000
12,782,000
15,052,100
18,062,600
21,073,000
5,277,000
6,332,400
7,387,800
7,080,400
8,496,500
9,912,500
9,484,300
11,381,100
13,278,000
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,122,000
14,546,400
16,970,800
18,611,000
22,333,200
26,055,500
1,673,800
2,434,300
2,008,600
2,921,200
2,343,400
3,408,100
- 47 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,383,300
17,259,900
20,136,600
17,239,300
20,687,200
24,135,100
24,600,100
29,520,100
34,440,100
3,050,900
3,661,100
4,271,300
3,366,600
3,724,200
4,040,000
4,469,000
4,713,300
5,213,900
3,188,900
3,826,600
4,464,400
3,518,900
4,222,700
4,926,500
3,892,600
4,671,100
5,449,600
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,430,600
4,116,700
4,802,800
743 W-1-12-II
744 W-1-12-III

4,281,900
7,582,400
5,138,300
9,098,800
5,994,700
10,615,300
745 W-1-13-I
3,526,300
4,231,600
4,936,900
746 W-1-13-II
747 W-1-13-III

3,828,400
5,142,500
4,594,100
6,171,000
5,359,800
7,199,600
748 W-1-20-I
749 W-1-20-II

11,809,400
14,755,900
14,171,200
17,707,100
16,533,100
20,658,300
750 W-1-20-III
17,105,900
20,527,100
23,948,300
751 W-1-30-I
6,666,500
7,999,900
9,333,200
752 W-1-30-II
10,633,100
12,759,800
14,886,400
753 W-1-30-III
26,089,000
31,306,700
36,524,500
754 W-4-10-I
4,967,300
5,960,700
6,954,200
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,363,800
14,552,200
4,065,600
6,172,300
7,512,800
8,836,500
17,462,700
4,878,800
7,406,700
9,015,300
10,309,300
20,373,100
5,691,900
8,641,200
10,517,900
3,048,700
3,658,400
4,268,200
5,801,700
6,962,000
8,122,400
8,537,600
10,245,200
11,952,700
1,777,300
2,427,900
3,019,200
2,375,200
2,827,100
3,616,900
1,715,400
2,640,700
4,935,800
2,282,400
4,230,600
7,740,600
1,684,100
4,214,800
8,412,600
5,009,100
6,648,500
9,445,300
3,260,900
3,916,500
5,383,500
2,132,800
2,913,500
3,623,100
2,850,200
3,392,500
4,340,300
2,058,500
3,168,800
5,922,900
2,738,800
5,076,700
9,288,700
2,021,000
5,057,800
10,095,100
6,010,900
7,978,200
11,334,400
3,913,100
4,699,800
6,460,200
2,488,300
3,399,100
4,226,900
3,325,300
3,957,900
5,063,700
2,401,600
3,696,900
6,910,100
3,195,300
5,922,800
10,836,900
2,357,800
5,900,800
11,777,700
7,012,700
9,307,800
13,223,500
4,565,300
5,483,100
7,536,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 48 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,155,300
2,586,300
3,017,400
4,327,500
5,193,100
6,058,600
9,130,000
10,956,000
12,782,000
- 49 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS A SWASTA
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,459,500
1,893,200
3,520,500
2,909,300
3,780,800
695,500
1,545,200
543,800
1,201,600
1,030,300
1,169,700
1,758,600
2,398,700
2,198,500
712,200
1,643,800
596,300
1,023,700
3,118,300
1,116,700
2,637,300
643,400
1,876,300
2,349,500
1,970,500
483,300
1,464,700
814,300
523,400
452,700
399,600
477,900
665,400
490,100
538,200
414,500
717,600
372,200
369,300
376,400
8,592,800
3,434,200
3,445,600
886,300
1,814,200
1,135,900
2,308,800
1,183,500
677,700
511,800
825,400
585,700
390,100
3,804,800
1,521,900
1,014,600
3,960,700
2,640,400
411,400
4,290,700
2,970,500
4,630,500
1,543,200
949,200
408,400
404,100
383,600
5,848,800
2,847,000
- 50 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,618,400
6,403,700
5,309,400
4,044,700
1,333,400
4,501,800
2,939,500
722,600
6,758,800
6,118,700
4,102,600
3,886,700
480,400
461,600
1,857,300
507,600
452,300
499,800
2,144,500
2,343,400
2,046,900
2,259,600
1,368,500
454,900
801,800
550,400
497,000
484,200
614,800
701,100
411,000
1,179,600
2,149,800
1,650,200
3,879,500
505,200
505,200
4,481,100
2,084,500
399,900
1,849,900
4,805,600
1,103,300
869,000
425,700
287,300
576,400
803,800
1,924,800
1,696,500
1,187,600
708,700
390,100
2,062,100
1,321,900
706,000
644,500
2,111,900
554,500
2,697,100
2,063,400
503,400
558,000
545,100
391,700
2,248,300
2,471,200
489,800
- 51 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,501,000
560,300
605,800
560,900
889,900
684,500
1,714,300
505,800
1,407,300
2,350,600
411,800
2,506,700
1,358,400
2,935,500
1,481,800
654,400
503,400
82,900
652,400
1,474,300
574,500
776,100
443,800
211,000
448,200
6,674,300
3,793,800
6,331,800
1,944,300
869,000
592,200
1,339,300
708,400
1,425,600
825,400
491,400
822,500
462,900
706,500
541,600
1,031,500
2,583,800
2,078,800
1,832,900
1,293,600
475,900
475,900
475,900
388,700
246,500
387,600
473,800
512,500
377,500
333,000
116,200
127,800
94,500
110,900
105,800
161,500
172,000
264,600
290,600
128,600
156,100
106,700
166,500
236,200
- 52 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
168,200
297,000
839,600
973,300
159,000
404,000
193,500
276,200
679,600
581,900
418,300
396,000
158,100
155,300
466,400
349,500
501,300
395,900
228,700
3,666,700
3,017,300
479,400
496,500
949,600
932,400
1,215,500
627,900
1,956,700
330,700
510,300
512,000
409,900
517,800
490,000
229,600
504,400
447,100
404,400
457,300
3,785,800
614,400
1,362,500
488,700
869,000
570,600
455,200
1,183,200
1,211,700
1,291,900
1,130,100
1,666,100
336,700
2,921,900
443,800
1,481,100
3,366,000
3,113,700
1,360,200
493,000
961,400
957,600
443,800
3,478,800
2,736,300
253,200
189,100
245,700
529,100
- 53 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,306,100
1,561,800
1,441,800
1,739,400
833,500
1,159,600
801,500
674,200
824,900
477,600
1,129,100
225,700
836,200
1,406,200
91,700
- 54 -

REGIONAL 1
RUMAH SAKIT KELAS B PEMERINTAH
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,460,900
2,953,000
3,445,200
A-4-10-II
SEPTIKEMIA (SEDANG)
4,204,200
5,045,000
5,885,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,668,600
3,197,800
6,802,300
3,837,300
7,936,000
4,476,900
5
6
A-4-11-II
A-4-11-III

4,551,400
6,299,500
5,461,700
7,559,400
6,371,900
8,819,300
A-4-12-I
2,562,400
3,074,900
3,587,400
8
9
A-4-12-II
A-4-12-III

3,191,100
3,511,100
3,829,300
4,213,300
4,467,500
4,915,500
10 A-4-13-I
11 A-4-13-II

2,029,100
2,589,700
2,434,900
3,107,700
2,840,700
3,625,600
12 A-4-13-III
3,107,700
3,729,200
4,350,800
2,202,600
2,643,200
3,083,700
2,673,700
3,208,500
3,743,200
3,208,500
3,850,200
4,491,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,046,300
17,492,300
16,855,600
20,990,800
19,664,800
24,489,300
18 A-4-15-III
INFEKSI HIV (BERAT)
19,761,400
23,713,700
27,666,000
19 B-1-01-I
20 B-1-01-II

38,418,400
42,385,600
46,102,100
50,862,700
53,785,800
59,339,900
21 B-1-01-III
22 B-1-10-I

93,429,300
6,210,100
112,115,100
7,452,200
130,801,000
8,694,200
23 B-1-10-II
13,783,700
16,540,500
19,297,200
24 B-1-10-III
25 B-1-11-I

27,211,000
6,789,200
32,653,200
8,147,000
38,095,400
9,504,800
26 B-1-11-II
27 B-1-11-III

9,070,400
11,718,800
10,884,500
14,062,500
12,698,500
16,406,300
28 B-1-12-I
6,834,300
8,201,100
9,568,000
29 B-1-12-II
7,600,900
9,121,100
10,641,300
30 B-1-12-III
11,890,800
14,269,000
16,647,100
5,443,600
6,532,300
7,621,000
8,956,800
10,748,100
12,539,500
11,589,300
13,907,100
16,225,000
7,479,700
8,975,700
10,471,600
8,318,800
9,982,500
11,646,300
13,013,800
2,244,800
3,583,300
4,943,300
15,616,500
2,693,700
4,300,000
5,932,000
18,219,300
3,142,700
5,016,700
6,920,700
4,732,900
5,679,500
6,626,000
6,626,100
7,951,300
9,276,500
8,027,400
9,632,900
11,238,400
4,279,000
6,281,600
9,345,700
4,081,900
5,134,900
7,538,000
11,214,800
4,898,200
5,990,700
8,794,300
13,084,000
5,714,600
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 55 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,755,200
5,706,200
6,657,300
48 B-4-13-III
49 B-4-14-I

6,550,700
4,077,500
7,860,800
4,893,000
9,171,000
5,708,500
50 B-4-14-II
4,756,900
5,708,300
6,659,700
51 B-4-14-III
52 C-4-10-I

6,372,000
3,889,100
7,646,400
4,666,900
8,920,800
5,444,700
53 C-4-10-II
54 C-4-10-III

7,462,200
12,776,300
8,954,600
15,331,500
10,447,100
17,886,800
55 C-4-11-I
4,298,800
5,158,600
6,018,400
56 C-4-11-II
57 C-4-11-III

5,752,500
9,118,000
6,903,000
10,941,600
8,053,400
12,765,300
58 C-4-12-I
59 C-4-12-II
2,862,300
5,812,000
3,434,800
6,974,400
4,007,200
8,136,800
60 C-4-12-III
RADIOTERAPI (BERAT)
14,926,800
17,912,100
20,897,500
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,151,900
4,049,800
2,582,200
4,859,800
3,012,600
5,669,800
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,482,100
3,575,400
6,578,500
4,290,500
7,675,000
5,005,600
65 C-4-14-II
5,015,600
6,018,700
7,021,800
66 C-4-14-III
67 D-1-10-I

7,704,300
21,385,700
9,245,100
25,662,800
10,786,000
29,939,900
68 D-1-10-II
69 D-1-10-III

32,571,900
51,865,600
39,086,300
62,238,700
45,600,600
72,611,800
70 D-1-11-I
5,783,600
6,940,400
8,097,100
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
14,768,300
19,785,600
17,722,000
23,742,700
20,675,700
27,699,900
5,013,800
6,016,500
7,019,300
13,817,200
16,580,600
19,344,000
21,918,100
26,301,700
30,685,300
2,471,600
4,056,200
6,381,400
3,925,100
7,053,200
9,989,100
3,384,000
4,693,600
7,207,300
2,966,000
4,867,500
7,657,700
4,710,100
8,463,900
11,986,900
4,060,800
5,632,300
8,648,700
3,460,300
5,678,700
8,934,000
5,495,100
9,874,500
13,984,700
4,737,500
6,571,100
10,090,200
2,900,000
3,480,000
4,060,000
4,104,400
4,925,300
5,746,200
5,249,700
6,299,700
7,349,600
3,110,300
3,732,400
4,354,500
5,092,400
6,110,900
7,129,400
6,228,600
7,474,300
8,720,000
6,820,100
8,184,200
9,548,200
9,310,500
11,172,600
13,034,700
93 E-1-01-III
22,448,600
26,938,300
31,428,000
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,090,700
9,842,800
18,596,200
8,508,900
11,811,300
22,315,500
9,927,000
13,779,900
26,034,700
7,297,500
8,757,000
10,216,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 56 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,868,800
3,442,500
4,016,300
104 E-4-11-II
105 E-4-11-III

4,373,700
6,110,000
5,248,400
7,332,000
6,123,200
8,554,000
106 E-4-12-I
107 E-4-12-II

3,296,200
5,708,200
3,955,400
6,849,900
4,614,700
7,991,500
108 E-4-12-III

(RINGAN)
(SEDANG)
6,766,300
8,119,600
9,472,800
3,589,400
4,307,300
5,025,200
5,257,900
6,309,500
7,361,000
111 E-4-13-III
7,085,700
8,502,800
9,919,900
112 F-4-10-I
113 F-4-10-II
3,939,600
4,527,700
4,727,500
5,433,300
5,515,400
6,338,800
114 F-4-10-III
115 F-4-11-I
5,433,300
3,810,200
6,520,000
4,572,300
7,606,600
5,334,300
116 F-4-11-II
4,439,300
5,327,200
6,215,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,692,800
6,831,400
7,970,000
2,026,000
2,431,100
2,836,300
2,880,300
3,456,300
4,032,400
6,257,200
7,508,700
8,760,100
3,069,200
4,049,900
5,243,100
1,751,100
2,246,100
3,022,300
3,683,100
4,859,900
6,291,800
2,101,400
2,695,300
3,626,700
4,296,900
5,669,900
7,340,400
2,451,600
3,144,500
4,231,200
127 F-4-15-I
2,705,100
3,246,200
3,787,200
128 F-4-15-II
4,031,000
4,837,200
5,643,400
129 F-4-15-III
5,322,200
6,386,600
7,451,100
5,487,100
6,584,500
7,682,000
6,379,700
7,655,600
8,931,500
8,515,800
10,218,900
11,922,100
133 F-4-17-I

1,257,000
1,508,400
1,759,800
134 F-4-17-II
3,684,000
4,420,800
5,157,600
135
136
137
138
139
140
141

(RINGAN)
3,930,500
4,767,900
5,246,000
8,087,200
3,643,800
4,666,000
5,809,200
4,716,600
5,721,500
6,295,300
9,704,600
4,372,500
5,599,200
6,971,000
5,502,700
6,675,100
7,344,500
11,322,000
5,101,300
6,532,500
8,132,800
16,493,000
19,791,600
23,090,200
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
9,822,200
11,786,700
13,751,100
13,955,700
16,746,900
19,538,000
3,400,700
4,080,900
4,761,000
4,751,900
5,702,300
6,652,600
6,080,400
7,296,500
8,512,600
- 57 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
21,906,500
26,287,800
30,669,100
148 G-1-11-I
149 G-1-11-II

11,474,600
20,978,300
13,769,500
25,173,900
16,064,500
29,369,600
150 G-1-11-III
34,804,500
41,765,400
48,726,300
4,791,100
5,749,300
6,707,500
9,258,800
11,110,600
12,962,300
12,618,000
15,141,600
17,665,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,445,300
3,881,400
1,734,400
4,657,700
2,023,400
5,434,000
156 G-1-13-III
157 G-1-20-I

8,758,200
8,552,700
10,509,800
10,263,200
12,261,400
11,973,700
158 G-1-20-II
13,923,100
16,707,800
19,492,400
159 G-1-20-III
21,367,300
25,640,700
29,914,200
160 G-1-30-I
10,882,300
13,058,800
15,235,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
22,722,600
30,955,900
27,267,100
37,147,100
31,811,600
43,338,300
4,112,600
4,935,100
5,757,600
5,027,000
6,032,400
7,037,800
7,111,200
8,533,500
9,955,700
4,438,400
5,326,100
6,213,800
5,895,900
7,075,000
8,254,200
8,663,000
10,395,600
12,128,200
4,923,900
5,908,700
6,893,400
6,032,600
7,239,200
8,445,700
8,761,700
10,514,000
12,266,300
2,869,100
3,442,900
4,016,800
5,003,200
6,003,800
7,004,400
5,933,900
7,120,600
8,307,400
4,867,100
5,840,500
6,814,000
6,708,200
8,049,900
9,391,500
8,419,600
10,103,500
11,787,500
3,976,900
4,772,200
5,567,600
4,746,200
5,695,400
6,644,600
6,698,800
8,038,600
9,378,400
3,278,400
3,934,100
4,589,700
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
23,654,900
28,385,900
33,116,900
35,908,500
43,090,200
50,271,900
16,887,000
19,882,700
20,264,400
23,859,200
23,641,700
27,835,700
- 58 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,352,500
5,223,000
6,093,500
183 G-4-16-III
6,198,300
7,438,000
8,677,600
4,366,600
5,239,900
6,113,200
5,725,600
6,870,700
8,015,800
7,416,900
8,900,300
10,383,700
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,300,400
5,160,500
6,020,600
188 G-4-18-II
5,748,300
6,898,000
8,047,700
189 G-4-18-III
6,431,900
7,718,300
9,004,700
3,587,900
4,305,500
5,023,100
6,064,500
7,277,400
8,490,200
7,962,400
9,554,800
11,147,300
193 G-4-20-I

2,509,900
3,011,900
3,513,900
194 G-4-20-II
3,548,300
4,257,900
4,967,600
195 G-4-20-III
196 G-4-21-I

5,860,900
2,613,700
7,033,100
3,136,400
8,205,300
3,659,200
197 G-4-21-II
198 G-4-21-III

4,423,700
5,359,700
5,308,500
6,431,600
6,193,200
7,503,600
199 G-4-22-I
2,578,500
3,094,200
3,609,900
200 G-4-22-II
201 G-4-22-III

3,294,500
3,849,500
3,953,500
4,619,400
4,612,400
5,389,300
202 G-4-23-I
203 G-4-23-II

2,572,900
3,228,100
3,087,500
3,873,800
3,602,100
4,519,400
204 G-4-23-III
4,596,100
5,515,300
6,434,500
205 G-4-24-I
206 G-4-24-II

2,954,500
3,691,200
3,545,400
4,429,500
4,136,300
5,167,700
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,149,500
2,448,800
3,096,800
4,103,900
7,379,300
2,938,600
3,716,200
4,924,700
8,609,200
3,428,400
4,335,500
5,745,400
3,482,800
4,179,400
4,876,000
4,176,900
5,012,300
5,847,700
6,058,400
7,270,100
8,481,700
9,885,600
10,925,200
14,857,500
7,237,200
8,991,500
12,593,900
3,315,300
4,498,100
8,841,300
2,861,100
3,263,700
4,673,400
3,373,300
4,155,100
6,963,200
11,862,800
13,110,300
17,829,000
8,684,600
10,789,800
15,112,700
3,978,300
5,397,800
10,609,500
3,433,300
3,916,400
5,608,000
4,047,900
4,986,100
8,355,900
13,839,900
15,295,300
20,800,500
10,132,100
12,588,100
17,631,500
4,641,400
6,297,400
12,377,800
4,005,600
4,569,100
6,542,700
4,722,600
5,817,100
9,748,500
229 I-1-01-I
45,309,100
54,370,900
63,432,700
230 I-1-01-II
46,305,900
55,567,000
64,828,200
231 I-1-01-III

(RINGAN)
73,093,200
87,711,800
102,330,500
25,137,300
30,164,800
35,192,200
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 59 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
21,337,800
25,605,400
29,872,900
245 I-1-06-II
30,909,500
37,091,400
43,273,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
36,880,800
44,256,900
51,633,100
47,150,400
56,580,500
66,010,500
58,938,000
70,725,600
82,513,200
88,407,000
106,088,400
123,769,700
4,060,900
4,873,100
5,685,300
4,515,300
5,418,400
6,321,500
6,008,500
7,210,200
8,412,000
11,689,300
14,027,100
16,365,000
18,518,200
22,221,900
25,925,500
24,363,500
29,236,200
34,108,900
11,338,400
13,606,100
15,873,800
15,099,400
18,119,300
21,139,200
18,621,800
22,346,100
26,070,500
23,207,000
27,848,400
32,489,800
28,842,900
34,611,400
40,380,000
37,794,100
45,352,900
52,911,800
4,408,700
6,156,600
11,855,200
5,290,400
7,387,900
14,226,200
6,172,100
8,619,200
16,597,300
11,086,000
13,303,200
15,520,400
25,858,900
31,030,700
36,202,400
29,827,800
35,793,400
41,758,900
13,233,500
15,880,200
18,526,900
16,569,600
19,883,500
23,197,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
32,426,800
38,912,100
45,397,500
39,968,000
47,961,700
55,955,300
14,519,400
17,423,200
20,327,100
20,126,800
24,152,200
28,177,600
26,332,500
31,599,000
36,865,500
22,556,600
27,067,900
31,579,200
35,600,400
42,720,500
49,840,600
56,871,400
68,245,700
79,620,000
53,044,200
63,653,000
74,261,800
64,831,800
77,798,100
90,764,500
88,407,000
106,088,400
123,769,700
- 60 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
24,971,400
29,965,700
34,960,000
279 I-1-40-III
33,353,400
40,024,100
46,694,700
280 I-4-10-I
281 I-4-10-II

3,925,200
7,009,000
4,710,300
8,410,800
5,495,300
9,812,600
282 I-4-10-III
10,099,000
12,118,800
14,138,500
283 I-4-11-I
284 I-4-11-II

5,857,800
7,249,100
7,029,400
8,698,900
8,200,900
10,148,700
285 I-4-11-III
286 I-4-12-I

13,410,000
3,471,500
16,092,000
4,165,800
18,774,000
4,860,100
287 I-4-12-II
4,024,000
4,828,800
5,633,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,828,800
5,794,500
6,760,300
3,532,700
4,239,300
4,945,800
6,308,100
7,569,700
8,831,300
9,089,100
10,906,900
12,724,700
3,236,000
3,450,800
5,867,900
3,883,100
4,141,000
7,041,400
4,530,300
4,831,200
8,215,000
4,351,800
5,222,100
6,092,500
5,920,300
7,104,400
8,288,400
297 I-4-15-III
7,104,400
8,525,200
9,946,100
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,105,500
3,381,000
4,057,200
1,851,200
2,155,100
2,586,100
2,526,600
4,057,200
4,868,600
2,221,400
2,586,100
3,103,300
2,947,700
4,733,400
5,680,000
2,591,600
3,017,100
3,620,600
3,939,500
4,727,400
5,515,300
6,183,600
7,420,300
8,657,000
8,143,400
9,772,000
11,400,700
307 I-4-19-I
3,800,800
4,561,000
5,321,200
308 I-4-19-II

(SEDANG)
5,933,300
7,120,000
8,306,600
309 I-4-19-III
7,083,300
8,499,900
9,916,600
310
311
312
313
314

4,080,200
4,712,600
6,835,000
3,053,200
3,868,400
4,896,200
5,655,200
8,202,000
3,663,800
4,642,100
5,712,300
6,597,700
9,569,000
4,274,500
5,415,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
20,496,400
24,595,600
28,694,900
14,916,500
17,899,700
20,883,000
18,634,700
22,361,700
26,088,600
19,589,000
23,506,800
27,424,600
11,283,500
13,540,100
15,796,800
23,472,100
28,166,500
32,860,900
36,373,300
43,648,000
50,922,600
10,413,400
12,496,100
14,578,800
- 61 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,583,600
6,700,400
7,817,100
316 I-4-22-I
317 I-4-22-II
3,079,900
3,834,000
3,695,900
4,600,800
4,311,900
5,367,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,604,100
6,725,000
7,845,800
3,248,800
3,898,500
4,548,300
3,988,600
4,786,300
5,584,000
7,793,400
9,352,100
10,910,800
2,714,400
3,257,300
3,800,200
6,250,600
7,500,700
8,750,800
7,902,800
9,483,300
11,063,900
52,779,300
63,335,200
73,891,000
59,729,600
71,675,500
83,621,500
67,573,000
81,087,600
94,602,200
28,008,100
33,609,700
39,211,300
38,998,300
46,798,000
54,597,700
64,399,600
77,279,500
90,159,400
8,505,300
10,206,400
11,907,400
17,210,500
20,652,600
24,094,700
18,439,200
22,127,000
25,814,800
14,544,200
17,453,000
20,361,900
18,318,800
21,982,600
25,646,300
28,287,200
33,944,600
39,602,100
7,097,900
8,517,500
9,937,100
12,857,800
15,429,300
18,000,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
37,113,400
44,536,100
51,958,800
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,690,800
5,390,600
8,155,100
2,668,700
3,605,400
4,982,200
4,396,700
5,005,100
6,988,400
4,007,700
5,578,600
10,407,800
4,286,000
7,190,300
8,506,800
4,210,200
5,030,000
6,767,400
3,229,000
6,468,700
9,786,100
3,202,400
4,326,500
5,978,600
5,276,100
6,006,100
8,386,100
4,809,200
6,694,300
12,489,400
5,143,200
8,628,300
10,208,200
5,052,200
6,036,000
8,120,900
3,767,200
7,546,800
11,417,200
3,736,100
5,047,600
6,975,000
6,155,400
7,007,100
9,783,800
5,610,800
7,810,000
14,570,900
6,000,400
10,066,400
11,909,600
5,894,300
7,042,000
9,474,300
3,508,000
4,209,600
4,911,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 62 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,929,600
5,915,500
6,901,500
360 J-4-16-III
6,232,800
7,479,300
8,725,900
361 J-4-17-I
362 J-4-17-II

3,581,400
4,288,800
4,297,600
5,146,500
5,013,900
6,004,300
363 J-4-17-III
364 J-4-18-I

5,628,200
2,161,100
6,753,800
2,593,300
7,879,400
3,025,500
365 J-4-18-II
2,883,200
3,459,800
4,036,400
366 J-4-18-III
367 J-4-19-I

3,034,900
5,044,400
3,641,900
6,053,300
4,248,900
7,062,200
368 J-4-19-II
369 J-4-19-III

5,720,700
6,317,800
6,864,900
7,581,400
8,009,000
8,845,000
370 J-4-20-I
4,505,300
5,406,400
6,307,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,242,600
7,544,600
7,491,100
9,053,600
8,739,700
10,562,500
2,717,000
3,260,400
3,803,800
4,377,000
5,252,400
6,127,800
6,107,800
7,329,400
8,550,900
7,710,600
9,252,700
10,794,800
9,989,700
11,987,600
13,985,500
11,708,200
14,049,900
16,391,500
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,029,600
9,635,600
11,241,500

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,541,900
18,796,300
12,650,300
22,555,600
14,758,700
26,314,800
3,335,300
4,002,400
4,669,400
4,338,000
5,205,500
6,073,100
8,594,100
10,313,000
12,031,800
3,761,600
4,137,700
4,175,300
4,513,900
4,965,300
5,010,400
5,266,200
5,792,800
5,845,500
5,329,100
6,394,900
7,460,700
6,245,600
7,494,700
8,743,800
390 K-1-14-III
11,240,100
13,488,200
15,736,200
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

11,819,900
16,509,800
24,106,100
14,183,900
19,811,800
28,927,300
16,547,900
23,113,700
33,748,500
6,990,200
8,388,300
9,786,300
12,042,100
14,450,500
16,858,900
17,082,500
20,499,000
23,915,500
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,565,500
9,078,600
10,591,700
398 K-1-40-II

(SEDANG)
8,599,200
10,319,000
12,038,900
399 K-1-40-III
14,572,500
17,487,100
20,401,600
400
401
402
403
404

5,780,800
7,739,300
10,608,900
4,772,300
6,857,200
6,937,000
9,287,100
12,730,700
5,726,800
8,228,600
8,093,100
10,835,000
14,852,400
6,681,300
9,600,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 63 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
10,776,700
12,932,000
15,087,400
406 K-4-11-I
407 K-4-11-II

2,252,100
3,200,400
2,702,500
3,840,500
3,152,900
4,480,600
408 K-4-11-III
409 K-4-12-I

3,840,500
2,868,800
4,608,600
3,442,500
5,376,700
4,016,300
410 K-4-12-II
3,979,900
4,775,900
5,571,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,584,100
7,900,900
9,217,700
3,867,300
4,640,800
5,414,200
5,002,600
6,003,100
7,003,700
7,705,600
9,246,800
10,787,900
2,527,700
3,033,300
3,538,800
3,393,000
4,071,600
4,750,300
5,444,500
6,533,400
7,622,300
418 K-4-15-I
2,569,500
3,083,400
3,597,300
419 K-4-15-II
3,960,700
4,752,800
5,545,000
420 K-4-15-III
5,558,700
6,670,400
7,782,200
421 K-4-16-I
3,579,700
4,295,600
5,011,600
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,293,100
5,009,300
5,151,700
6,011,200
6,010,300
7,013,100
1,667,900
2,001,500
2,335,100
2,054,000
2,464,800
2,875,600
2,464,800
2,957,800
3,450,700
1,410,500
1,692,600
1,974,700
2,380,100
2,856,200
3,332,200
429 K-4-18-III
2,856,200
3,427,400
3,998,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
18,845,500
28,446,700
38,009,400
8,624,700
15,257,200
18,942,000
22,614,500
34,136,000
45,611,300
10,349,700
18,308,600
22,730,400
26,383,600
39,825,400
53,213,200
12,074,600
21,360,100
26,518,800
4,833,500
5,800,200
6,766,900
9,694,900
11,633,900
13,572,800
16,318,700
19,582,400
22,846,100
6,345,400
10,212,200
14,607,600
1,711,000
1,986,000
2,305,200
3,475,600
4,776,900
11,190,300
1,701,600
2,250,700
7,442,000
7,614,500
12,254,700
17,529,100
2,053,200
2,383,200
2,766,300
4,170,700
5,732,300
13,428,400
2,042,000
2,700,800
8,930,400
8,883,600
14,297,100
20,450,600
2,395,400
2,780,400
3,227,300
4,865,800
6,687,700
15,666,500
2,382,300
3,150,900
10,418,800
2,314,400
2,777,200
3,240,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 64 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,720,000
3,264,000
3,808,000
4,002,500
4,803,000
5,603,500
2,858,300
3,429,900
4,001,600
4,293,200
5,151,900
6,010,500
6,051,800
7,262,200
8,472,500
10,103,700
12,124,400
14,145,200
14,361,000
17,233,200
20,105,400
20,172,900
24,207,400
28,242,000
9,232,000
11,078,400
12,924,800
15,144,700
24,958,600
18,173,700
29,950,300
21,202,600
34,942,100
22,601,500
27,121,800
31,642,100
26,435,700
31,722,900
37,010,000
32,718,600
39,262,300
45,806,100
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,228,200
13,473,900
15,719,500
467 M-1-04-II
14,425,000
17,310,000
20,195,000
468 M-1-04-III
17,793,700
21,352,400
24,911,200
469 M-1-05-I
470 M-1-05-II

7,349,200
11,531,000
8,819,000
13,837,100
10,288,900
16,143,300
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,184,900
18,221,800
21,258,800
7,979,800
9,575,700
11,171,700
10,690,100
12,828,200
14,966,200
21,776,800
26,132,200
30,487,500
18,431,100
22,117,300
25,803,500
44,068,100
52,881,700
61,695,300
95,050,800
114,061,000
133,071,100
11,998,200
14,397,800
16,797,400
15,803,000
18,963,600
22,124,200
480 M-1-20-III
39,402,000
47,282,400
55,162,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,485,600
13,750,200
19,661,500
10,182,800
16,500,200
23,593,800
11,879,900
19,250,300
27,526,100
4,189,900
5,027,900
5,865,900
7,430,700
8,916,800
10,402,900
10,609,500
12,731,400
14,853,300
5,176,300
8,590,000
14,108,500
6,211,500
10,307,900
16,930,100
7,246,800
12,025,900
19,751,800
7,754,500
9,305,400
10,856,300
9,749,200
11,699,000
13,648,900
15,182,800
18,219,400
21,255,900
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 65 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,876,900
3,452,200
4,027,600
500 M-4-10-II
501 M-4-10-III
4,290,400
8,117,400
5,148,400
9,740,900
6,006,500
11,364,400
3,584,800
4,301,800
5,018,800
7,859,600
9,431,500
11,003,500
11,715,100
14,058,100
16,401,100
2,861,500
3,433,800
4,006,100
4,759,500
5,711,400
6,663,300
6,563,200
7,875,800
9,188,500
4,764,700
5,717,600
6,670,600
7,158,800
8,590,500
10,022,300
13,966,600
16,759,900
19,553,200
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,434,000
6,520,800
7,607,600
512 M-4-14-II
6,702,000
8,042,400
9,382,800
513 M-4-14-III
514 M-4-15-I
10,071,200
3,321,800
12,085,400
3,986,200
14,099,600
4,650,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,295,000
9,746,500
2,758,700
4,554,300
7,651,000
5,153,900
11,695,800
3,310,400
5,465,200
9,181,200
6,012,900
13,645,100
3,862,200
6,376,100
10,711,400
3,580,400
4,296,500
5,012,600
5,007,600
6,009,100
7,010,600
6,992,800
8,391,300
9,789,900
2,706,200
4,078,400
4,910,600
3,247,500
4,894,100
5,892,700
3,788,700
5,709,800
6,874,800
2,909,500
3,491,300
4,073,200
4,753,600
5,704,300
6,655,100
9,284,100
11,140,900
12,997,800
2,846,800
3,416,100
3,985,500
4,168,600
5,002,400
5,836,100
4,659,000
5,590,700
6,522,500
2,866,500
3,439,800
4,013,100
3,585,200
4,302,200
5,019,200
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
14,810,900
17,773,100
20,735,300
16,292,000
19,550,400
22,808,800
18,652,200
22,382,700
26,113,100
8,419,400
10,103,300
11,787,100
9,998,800
22,505,200
11,998,600
27,006,200
13,998,300
31,507,200
- 66 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,037,900
9,645,400
11,253,000
535 N-1-01-I

170,114,300
204,137,200
238,160,100
536 N-1-01-II
170,114,300
204,137,200
238,160,100
537 N-1-01-III
538 N-1-11-I

170,114,300
8,268,300
204,137,200
9,922,000
238,160,100
11,575,700
539 N-1-11-II
540 N-1-11-III

13,074,300
20,382,800
15,689,100
24,459,300
18,304,000
28,535,900
4,214,100
5,056,900
5,899,700
8,649,300
10,379,200
12,109,000
18,769,300
22,523,200
26,277,000
9,498,600
11,398,300
13,298,000

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,292,700
18,043,600
15,951,300
21,652,300
18,609,800
25,261,000
8,432,100
10,118,500
11,804,900
12,756,100
15,307,300
17,858,500
14,681,000
17,617,300
20,553,500
7,806,800
9,368,200
10,929,600
10,601,500
12,721,800
14,842,100
12,338,700
14,806,500
17,274,200
3,217,300
3,860,800
4,504,200
4,011,700
4,814,100
5,616,400
5,900,700
7,080,800
8,261,000
2,546,200
4,315,100
5,368,800
2,323,000
4,083,500
4,915,200
3,318,100
4,002,000
6,322,400
3,055,400
5,178,100
6,442,600
2,787,600
4,900,200
5,898,200
3,981,700
4,802,400
7,586,900
3,564,700
6,041,100
7,516,400
3,252,200
5,716,900
6,881,200
4,645,300
5,602,700
8,851,400
2,480,500
2,976,600
3,472,700
3,519,700
4,223,600
4,927,600
5,642,100
6,770,500
7,898,900
2,930,400
3,516,500
4,102,500
3,748,500
4,498,300
5,248,000
4,277,700
5,133,300
5,988,800
3,588,200
4,305,900
5,023,500
5,121,600
6,145,900
7,170,200
7,028,000
8,433,600
9,839,200
4,841,500
5,247,800
5,809,800
6,297,300
6,778,100
7,346,900
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 67 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

8,789,300
10,547,100
12,305,000
3,335,400
4,002,500
4,669,600
3,707,000
4,448,400
5,189,800
4,754,100
5,705,000
6,655,800
2,436,200
2,923,400
3,410,700
2,925,900
3,511,000
4,096,200
3,676,500
4,411,700
5,147,000
1,626,200
1,951,400
2,276,600

MAYOR (RINGAN)
MAYOR (SEDANG)
1,924,700
2,309,700
2,309,700
2,771,600
2,694,600
3,233,500
52,768,700
63,322,500
73,876,200
65,293,400
78,352,000
91,410,700
76,636,000
91,963,300
107,290,500
82,448,400
98,938,000
115,427,700
94,576,700
113,492,100
132,407,400
108,060,700
129,672,900
151,285,000
11,928,200
14,313,800
16,699,400
16,842,900
20,211,500
23,580,100
23,575,000
28,290,100
33,005,100
34,404,100
41,285,000
48,165,800
44,475,300
53,370,400
62,265,500
63,766,500
76,519,800
89,273,100
18,681,600
22,417,900
26,154,200
29,205,800
35,046,900
40,888,100
38,868,400
46,642,000
54,415,700
5,111,000
6,133,200
7,155,400
14,330,100
17,196,100
20,062,200
18,983,900
22,780,700
26,577,400
4,950,500
5,940,600
6,930,800
13,880,200
16,656,200
19,432,200
18,387,800
22,065,400
25,742,900
4,099,000
4,918,800
5,738,600
5,816,200
6,979,500
8,142,700
9,417,800
11,301,300
13,184,900
9,940,100
11,928,200
13,916,200
14,035,800
16,842,900
19,650,100
- 68 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
19,645,900
23,575,000
27,504,200
9,390,800
11,269,000
13,147,100
10,796,800
12,956,100
15,115,500
15,112,200
18,134,600
21,157,100
5,323,800
6,388,600
7,453,400
8,305,200
9,966,200
11,627,300
12,902,400
15,482,900
18,063,400
3,548,300
4,257,900
4,967,600
7,222,800
8,667,400
10,112,000
12,999,100
15,598,900
18,198,700
2,661,200
3,193,500
3,725,700
5,329,300
6,395,100
7,461,000
6,252,900
7,503,500
8,754,100
2,408,500
2,890,200
3,371,800
4,628,200
5,553,900
6,479,500
11,325,900
13,591,100
15,856,200
3,549,200
4,259,100
4,968,900
6,388,600
7,666,300
8,944,100
8,989,900
10,787,900
12,585,900
2,634,000
3,160,800
3,687,700
3,245,500
3,894,600
4,543,700
4,442,800
5,331,400
6,219,900
1,594,000
2,337,400
3,994,900
1,936,500
2,577,500
4,468,100
1,912,800
2,804,800
4,793,800
2,323,800
3,093,000
5,361,700
2,231,500
3,272,300
5,592,800
2,711,200
3,608,500
6,255,300
2,859,800
3,431,700
4,003,700
5,073,500
6,088,100
7,102,800
8,234,800
9,881,800
11,528,800
1,447,200
1,736,700
2,026,100
3,074,100
3,688,900
4,303,700
5,829,500
6,995,400
8,161,300
967,900
1,161,500
1,355,100
1,826,600
2,192,000
2,557,300
2,365,800
2,839,000
3,312,100
5,012,100
6,014,500
7,017,000
- 69 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,571,400
7,885,700
9,199,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,408,900
11,290,600
13,172,400
2,415,700
2,898,900
3,382,000
3,585,200
4,302,300
5,019,300
4,312,000
5,174,500
6,036,900
1,666,300
1,999,600
2,332,800
2,238,100
2,685,700
3,133,300
4,071,400
4,885,700
5,700,000
722,800
867,300
1,011,900
1,377,500
1,653,000
1,928,600
2,002,600
2,403,100
2,803,600
986,500
1,183,800
1,381,100
1,552,400
1,862,900
2,173,400
2,500,500
3,000,600
3,500,700
1,625,200
1,950,300
2,275,300
2,421,600
2,906,000
3,390,300
3,715,400
4,458,500
5,201,500
5,282,000
6,338,400
7,394,800

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,199,700
21,657,600
9,839,700
25,989,100
11,479,600
30,320,600
8,171,500
9,805,800
11,440,000
10,358,600
12,430,300
14,502,000
15,365,300
18,438,300
21,511,400
6,385,100
9,791,200
14,381,200
6,389,500
7,444,800
12,341,100
7,662,100
11,749,400
17,257,500
7,667,400
8,933,700
14,809,300
8,939,100
13,707,700
20,133,700
8,945,300
10,422,700
17,277,500
3,958,400
4,750,000
5,541,700
4,857,900
5,829,500
6,801,000
5,756,600
6,907,900
8,059,200
3,787,100
5,384,200
6,939,900
4,544,500
6,461,000
8,327,900
5,301,900
7,537,800
9,715,900
6,009,400
7,211,300
8,413,200
8,943,700
10,732,400
12,521,200
22,271,400
26,725,700
31,179,900
5,153,700
6,988,300
13,255,800
6,184,500
8,385,900
15,907,000
7,215,200
9,783,600
18,558,200
3,708,800
4,450,600
5,192,400
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 70 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,254,200
2,705,000
3,155,800
697 U-4-12-I
698 U-4-12-II

2,460,600
2,862,200
2,952,700
3,434,600
3,444,800
4,007,100
699 U-4-12-III

3,827,900
4,593,500
5,359,000
1,922,500
2,307,000
2,691,500
2,266,400
2,719,700
3,173,000
2,710,700
3,252,900
3,795,000
3,580,800
4,287,900
4,297,000
5,145,500
5,013,100
6,003,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,200,700
8,640,800
10,081,000
2,875,300
3,450,300
4,025,400
3,582,200
4,298,700
5,015,100
5,013,400
6,016,100
7,018,700
4,834,900
5,801,800
6,768,800
9,660,900
11,593,000
13,525,200
11,847,700
14,217,200
16,586,800
8,922,200
10,188,100
15,954,900
10,706,600
12,225,700
19,145,900
12,491,000
14,263,300
22,336,900
8,388,600
10,066,300
11,744,000
11,809,500
14,171,400
16,533,400
14,519,700
17,423,600
20,327,500
4,510,900
5,413,100
6,315,300
8,618,900
10,342,600
12,066,400
13,116,300
15,739,500
18,362,800
8,580,500
10,296,600
12,012,700
12,467,200
14,960,600
17,454,100
15,567,600
18,681,100
21,794,600
1,424,600
1,572,100
1,739,000
1,709,600
1,886,500
2,086,800
1,994,500
2,200,900
2,434,600
4,277,700
5,133,300
5,988,800
7,105,500
8,526,600
9,947,700
11,714,500
14,057,400
16,400,300
3,585,300
4,302,400
5,019,400
4,810,600
5,772,700
6,734,800
6,643,100
7,971,700
9,300,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,236,000
9,883,200
11,530,300
12,644,700
15,173,700
17,702,600
1,473,300
2,142,700
1,768,000
2,571,300
2,062,700
2,999,800
- 71 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,074,500
12,089,400
14,104,300
11,712,800
14,055,300
16,397,900
17,230,700
20,676,900
24,123,000
2,136,900
2,564,300
2,991,700
2,358,100
2,608,500
2,829,700
3,130,300
3,301,400
3,652,000
2,233,600
2,680,300
3,127,000
2,464,800
2,957,700
3,450,700
2,726,500
3,271,800
3,817,100
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,402,900
2,883,500
3,364,000
743 W-1-12-II
744 W-1-12-III

2,999,200
5,151,600
3,599,100
6,181,900
4,198,900
7,212,300
745 W-1-13-I
2,395,900
2,875,000
3,354,200
746 W-1-13-II
747 W-1-13-III

2,601,100
3,493,900
3,121,300
4,192,700
3,641,500
4,891,500
748 W-1-20-I
749 W-1-20-II

8,023,500
10,025,500
9,628,200
12,030,600
11,232,900
14,035,700
750 W-1-20-III
11,622,100
13,946,500
16,270,900
751 W-1-30-I
4,529,400
5,435,300
6,341,100
752 W-1-30-II
7,224,400
8,669,200
10,114,100
753 W-1-30-III
17,725,400
21,270,500
24,815,500
754 W-4-10-I
3,374,900
4,049,800
4,724,800
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,003,100
9,887,100
3,069,200
4,659,500
5,671,500
6,003,700
11,864,500
3,683,000
5,591,400
6,805,800
7,004,300
13,841,900
4,296,900
6,523,300
7,940,100
2,727,500
3,273,000
3,818,500
3,744,700
4,493,600
5,242,600
4,081,900
4,898,300
5,714,700
1,207,600
1,649,600
2,051,300
1,613,800
1,980,200
2,457,400
1,534,700
1,704,400
2,359,900
2,105,100
2,815,100
3,815,300
1,506,700
2,720,500
4,022,200
2,780,000
3,690,100
5,242,100
2,532,700
3,042,000
4,181,300
1,449,100
1,979,500
2,461,600
1,936,500
2,376,200
2,948,900
1,841,700
2,045,300
2,831,800
2,526,100
3,378,100
4,578,400
1,808,100
3,264,600
4,826,600
3,336,000
4,428,100
6,290,500
3,039,300
3,650,400
5,017,600
1,690,600
2,309,400
2,871,900
2,259,300
2,772,300
3,440,400
2,148,600
2,386,200
3,303,800
2,947,100
3,941,100
5,341,500
2,109,400
3,808,600
5,631,000
3,892,000
5,166,100
7,339,000
3,545,800
4,258,800
5,853,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 72 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,822,000
2,186,400
2,550,800
3,823,300
4,588,000
5,352,600
5,885,400
7,062,500
8,239,600
- 73 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS B PEMERINTAH
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
915,400
1,187,400
2,208,000
1,824,700
2,371,300
436,200
1,066,100
341,100
915,500
680,200
772,200
1,161,000
1,583,600
1,451,400
470,200
1,085,300
393,700
675,900
2,058,700
737,300
1,741,100
424,800
1,294,500
1,473,600
1,235,900
303,100
967,000
510,700
361,100
283,900
250,600
299,700
417,300
358,600
337,600
303,300
450,100
196,500
231,600
265,600
5,389,300
2,153,900
2,161,100
555,900
1,251,600
783,700
1,592,800
742,300
425,100
321,000
517,700
343,800
257,500
2,624,900
1,225,000
700,000
2,732,500
1,821,700
258,000
2,960,200
2,049,400
3,780,000
1,064,600
654,900
256,100
213,400
240,600
3,668,300
1,785,600
- 74 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,269,400
4,016,300
3,505,300
2,536,800
836,300
2,823,500
1,843,600
453,200
4,239,100
3,837,600
2,573,100
2,437,700
317,100
289,500
1,164,900
335,100
283,600
313,500
1,479,500
1,469,800
1,283,800
1,558,900
944,100
285,300
502,900
345,200
311,700
303,700
385,600
439,700
257,800
739,800
1,348,300
1,035,000
2,433,200
316,800
316,800
3,091,600
1,307,400
250,800
1,160,300
3,172,700
692,000
545,100
267,000
253,100
397,700
554,600
1,327,900
1,170,400
819,300
444,500
257,500
1,422,700
829,100
487,100
404,200
1,324,600
292,800
1,860,800
1,423,600
315,700
350,000
341,900
206,900
1,551,100
1,549,900
307,200
- 75 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
941,400
351,400
379,900
351,800
558,100
429,300
1,075,200
317,200
882,600
1,621,700
258,300
1,572,200
851,900
1,841,100
929,400
410,400
315,700
73,100
409,200
924,700
360,300
486,700
278,300
113,100
281,100
4,186,000
2,379,400
3,971,200
1,341,400
545,100
371,400
840,000
444,300
894,100
517,700
308,200
515,900
319,300
487,400
339,700
879,100
1,705,800
1,372,400
1,210,100
854,000
298,400
298,400
298,400
243,800
154,600
243,100
297,200
321,500
236,800
208,800
102,400
112,600
83,300
97,700
93,200
142,200
127,600
165,900
182,300
107,600
137,500
94,000
146,700
208,100
- 76 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
148,100
186,300
526,600
610,500
140,100
253,400
170,500
243,300
426,300
364,900
262,300
248,400
139,300
130,000
292,500
184,600
264,800
183,300
143,500
2,529,700
1,892,400
300,700
311,400
595,600
780,400
762,300
393,800
1,227,200
291,300
320,000
321,100
257,100
324,700
307,300
144,000
316,300
280,400
253,600
286,800
2,374,400
423,900
854,500
306,500
599,600
477,600
401,000
742,100
759,900
810,300
708,800
1,356,600
211,200
2,015,900
278,300
1,021,800
2,322,300
1,952,900
853,100
309,200
603,000
600,600
278,300
2,181,800
1,716,200
153,700
166,600
216,500
384,200
- 77 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,119,500
603,300
951,900
1,091,000
550,300
727,300
529,100
564,300
707,000
315,300
708,200
198,900
699,800
1,205,200
80,800
- 78 -

REGIONAL 1
RUMAH SAKIT KELAS B SWASTA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,534,700
3,041,600
3,548,600
A-4-10-II
SEPTIKEMIA (SEDANG)
4,330,300
5,196,400
6,062,400
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,838,600
3,293,700
7,006,300
3,952,500
8,174,100
4,611,200
5
6
A-4-11-II
A-4-11-III

4,687,900
6,488,500
5,625,500
7,786,200
6,563,100
9,083,900
A-4-12-I
2,639,300
3,167,100
3,695,000
8
9
A-4-12-II
A-4-12-III

3,286,800
3,616,400
3,944,200
4,339,700
4,601,500
5,063,000
10 A-4-13-I
11 A-4-13-II

2,090,000
2,667,400
2,507,900
3,200,900
2,925,900
3,734,400
12 A-4-13-III
3,200,900
3,841,100
4,481,300
2,268,700
2,722,500
3,176,200
2,753,900
3,304,700
3,855,500
3,304,700
3,965,700
4,626,600
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,467,700
18,017,100
17,361,200
21,620,500
20,254,800
25,224,000
18 A-4-15-III
INFEKSI HIV (BERAT)
20,354,300
24,425,100
28,496,000
19 B-1-01-I
20 B-1-01-II

39,571,000
43,657,200
47,485,200
52,388,600
55,399,300
61,120,000
21 B-1-01-III
22 B-1-10-I

96,232,200
6,396,400
115,478,600
7,675,700
134,725,000
8,955,000
23 B-1-10-II
14,197,300
17,036,700
19,876,200
24 B-1-10-III
25 B-1-11-I

28,027,300
6,992,800
33,632,800
8,391,400
39,238,200
9,790,000
26 B-1-11-II
27 B-1-11-III

9,342,500
12,070,300
11,211,000
14,484,400
13,079,500
16,898,500
28 B-1-12-I
7,039,300
8,447,200
9,855,000
29 B-1-12-II
7,829,000
9,394,800
10,960,600
30 B-1-12-III
12,247,500
14,697,100
17,146,600
5,606,900
6,728,300
7,849,700
9,225,500
11,070,600
12,915,600
11,936,900
14,324,300
16,711,700
7,704,100
9,244,900
10,785,700
8,568,300
10,282,000
11,995,700
13,404,200
2,312,100
3,690,800
5,091,600
16,085,000
2,774,600
4,429,000
6,110,000
18,765,900
3,237,000
5,167,200
7,128,300
4,874,900
5,849,800
6,824,800
6,824,900
8,189,800
9,554,800
8,268,200
9,921,900
11,575,500
4,407,400
6,470,100
9,626,100
4,204,300
5,288,900
7,764,100
11,551,300
5,045,200
6,170,400
9,058,100
13,476,500
5,886,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 79 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,897,800
5,877,400
6,857,000
48 B-4-13-III
49 B-4-14-I

6,747,200
4,199,800
8,096,600
5,039,800
9,446,100
5,879,800
50 B-4-14-II
4,899,600
5,879,600
6,859,500
51 B-4-14-III
52 C-4-10-I

6,563,200
4,005,800
7,875,800
4,806,900
9,188,400
5,608,100
53 C-4-10-II
54 C-4-10-III

7,686,100
13,159,600
9,223,300
15,791,500
10,760,500
18,423,400
55 C-4-11-I
4,427,800
5,313,400
6,198,900
56 C-4-11-II
57 C-4-11-III

5,925,000
9,391,600
7,110,000
11,269,900
8,295,000
13,148,200
58 C-4-12-I
59 C-4-12-II
2,948,200
5,986,300
3,537,800
7,183,600
4,127,400
8,380,900
60 C-4-12-III
RADIOTERAPI (BERAT)
15,374,600
18,449,500
21,524,400
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,216,400
4,171,300
2,659,700
5,005,600
3,103,000
5,839,900
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,646,600
3,682,700
6,775,900
4,419,200
7,905,200
5,155,800
65 C-4-14-II
5,166,100
6,199,300
7,232,500
66 C-4-14-III
67 D-1-10-I

7,935,400
22,027,200
9,522,500
26,432,700
11,109,500
30,838,100
68 D-1-10-II
69 D-1-10-III

33,549,000
53,421,500
40,258,800
64,105,900
46,968,600
74,790,200
70 D-1-11-I
5,957,200
7,148,600
8,340,000
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,211,400
20,379,200
18,253,700
24,455,000
21,296,000
28,530,900
5,164,200
6,197,000
7,229,800
14,231,700
17,078,000
19,924,300
22,575,600
27,090,700
31,605,800
2,545,800
4,177,900
6,572,900
4,042,800
7,264,800
10,288,700
3,485,500
4,834,400
7,423,500
3,055,000
5,013,500
7,887,400
4,851,400
8,717,800
12,346,500
4,182,600
5,801,300
8,908,200
3,564,100
5,849,100
9,202,000
5,660,000
10,170,700
14,404,200
4,879,700
6,768,200
10,392,900
2,987,000
3,584,400
4,181,800
4,227,600
5,073,100
5,918,600
5,407,200
6,488,600
7,570,100
3,203,700
3,844,400
4,485,100
5,245,200
6,294,200
7,343,300
6,415,400
7,698,500
8,981,600
7,024,700
8,429,700
9,834,600
9,589,800
11,507,800
13,425,700
93 E-1-01-III
23,122,000
27,746,400
32,370,800
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,303,400
10,138,100
19,154,100
8,764,100
12,165,700
22,984,900
10,224,800
14,193,300
26,815,800
7,516,400
9,019,700
10,523,000
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 80 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,954,900
3,545,800
4,136,800
104 E-4-11-II
105 E-4-11-III

4,504,900
6,293,300
5,405,900
7,552,000
6,306,900
8,810,600
106 E-4-12-I
107 E-4-12-II

3,395,100
5,879,500
4,074,100
7,055,400
4,753,100
8,231,300
108 E-4-12-III

(RINGAN)
(SEDANG)
6,969,300
8,363,200
9,757,000
3,697,100
4,436,500
5,176,000
5,415,600
6,498,800
7,581,900
111 E-4-13-III
7,298,200
8,757,900
10,217,500
112 F-4-10-I
113 F-4-10-II
4,057,800
4,663,600
4,869,300
5,596,300
5,680,900
6,529,000
114 F-4-10-III
115 F-4-11-I
5,596,300
3,924,500
6,715,600
4,709,400
7,834,800
5,494,300
116 F-4-11-II
4,572,500
5,487,000
6,401,500
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,863,600
7,036,300
8,209,000
2,086,700
2,504,100
2,921,400
2,966,700
3,560,000
4,153,400
6,445,000
7,734,000
9,023,000
3,161,300
4,171,400
5,400,400
1,803,700
2,313,500
3,113,000
3,793,600
5,005,700
6,480,500
2,164,400
2,776,200
3,735,500
4,425,800
5,840,000
7,560,600
2,525,100
3,238,800
4,358,100
127 F-4-15-I
2,786,300
3,343,600
3,900,800
128 F-4-15-II
4,151,900
4,982,300
5,812,700
129 F-4-15-III
5,481,900
6,578,200
7,674,600
5,651,700
6,782,100
7,912,400
6,571,100
7,885,300
9,199,500
8,771,200
10,525,500
12,279,700
133 F-4-17-I

1,294,700
1,553,600
1,812,600
134 F-4-17-II
3,794,500
4,553,400
5,312,300
135
136
137
138
139
140
141

(RINGAN)
4,048,400
4,910,900
5,403,400
8,329,800
3,753,100
4,806,000
5,983,500
4,858,100
5,893,100
6,484,100
9,995,700
4,503,700
5,767,200
7,180,100
5,667,800
6,875,300
7,564,800
11,661,700
5,254,300
6,728,400
8,376,800
16,987,800
20,385,300
23,782,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,116,900
12,140,300
14,163,700
14,374,400
17,249,300
20,124,200
3,502,700
4,203,300
4,903,800
4,894,400
5,873,300
6,852,200
6,262,900
7,515,400
8,768,000
- 81 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,563,700
27,076,400
31,589,200
148 G-1-11-I
149 G-1-11-II

11,818,800
21,607,600
14,182,600
25,929,100
16,546,400
30,250,700
150 G-1-11-III
35,848,700
43,018,400
50,188,100
4,934,800
5,921,700
6,908,700
9,536,600
11,443,900
13,351,200
12,996,500
15,595,800
18,195,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,488,700
3,997,800
1,786,400
4,797,400
2,084,100
5,597,000
156 G-1-13-III
157 G-1-20-I

9,020,900
8,809,200
10,825,100
10,571,100
12,629,300
12,332,900
158 G-1-20-II
14,340,800
17,209,000
20,077,200
159 G-1-20-III
22,008,300
26,410,000
30,811,600
160 G-1-30-I
11,208,800
13,450,500
15,692,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
23,404,300
31,884,600
28,085,100
38,261,500
32,766,000
44,638,400
4,236,000
5,083,200
5,930,400
5,177,800
6,213,400
7,248,900
7,324,600
8,789,500
10,254,400
4,571,500
5,485,900
6,400,200
6,072,700
7,287,300
8,501,800
8,922,900
10,707,500
12,492,100
5,071,600
6,085,900
7,100,200
6,213,600
7,456,300
8,699,100
9,024,500
10,829,400
12,634,300
2,955,200
3,546,200
4,137,300
5,153,300
6,183,900
7,214,600
6,111,900
7,334,300
8,556,600
5,013,100
6,015,800
7,018,400
6,909,500
8,291,400
9,673,300
8,672,200
10,406,600
12,141,100
4,096,200
4,915,400
5,734,600
4,888,600
5,866,300
6,844,000
6,899,800
8,279,800
9,659,700
3,376,700
4,052,100
4,727,400
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
24,364,600
29,237,500
34,110,400
36,985,800
44,382,900
51,780,100
17,393,600
20,479,100
20,872,300
24,575,000
24,351,000
28,670,800
- 82 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,483,100
5,379,700
6,276,300
183 G-4-16-III
6,384,300
7,661,100
8,938,000
4,497,600
5,397,100
6,296,600
5,897,300
7,076,800
8,256,200
7,639,400
9,167,300
10,695,200
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,429,400
5,315,300
6,201,200
188 G-4-18-II
5,920,800
7,105,000
8,289,100
189 G-4-18-III
6,624,900
7,949,900
9,274,900
3,695,600
4,434,700
5,173,800
6,246,400
7,495,700
8,745,000
8,201,200
9,841,500
11,481,700
193 G-4-20-I

2,585,200
3,102,300
3,619,300
194 G-4-20-II
3,654,700
4,385,700
5,116,600
195 G-4-20-III
196 G-4-21-I

6,036,700
2,692,100
7,244,100
3,230,500
8,451,400
3,769,000
197 G-4-21-II
198 G-4-21-III

4,556,400
5,520,500
5,467,700
6,624,600
6,379,000
7,728,700
199 G-4-22-I
2,655,900
3,187,000
3,718,200
200 G-4-22-II
201 G-4-22-III

3,393,400
3,965,000
4,072,100
4,758,000
4,750,700
5,551,000
202 G-4-23-I
203 G-4-23-II

2,650,100
3,325,000
3,180,100
3,990,000
3,710,200
4,655,000
204 G-4-23-III
4,734,000
5,680,800
6,627,600
205 G-4-24-I
206 G-4-24-II

3,043,100
3,802,000
3,651,800
4,562,400
4,260,400
5,322,700
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,333,900
2,522,300
3,189,700
4,227,000
7,600,700
3,026,800
3,827,700
5,072,400
8,867,500
3,531,200
4,465,600
5,917,800
3,587,300
4,304,800
5,022,200
4,302,200
5,162,700
6,023,100
6,240,100
7,488,200
8,736,200
10,182,200
11,253,000
15,303,200
7,454,300
9,261,200
12,971,800
3,414,700
4,633,100
9,106,500
2,946,900
3,361,600
4,813,600
3,474,500
4,279,700
7,172,100
12,218,600
13,503,600
18,363,900
8,945,200
11,113,500
15,566,100
4,097,700
5,559,700
10,927,800
3,536,300
4,033,900
5,776,300
4,169,400
5,135,700
8,606,500
14,255,100
15,754,200
21,424,500
10,436,100
12,965,700
18,160,500
4,780,600
6,486,300
12,749,100
4,125,700
4,706,200
6,739,000
4,864,300
5,991,600
10,040,900
229 I-1-01-I
46,668,400
56,002,000
65,335,700
230 I-1-01-II
47,695,000
57,234,000
66,773,100
231 I-1-01-III

(RINGAN)
75,286,000
90,343,200
105,400,400
25,891,400
31,069,700
36,248,000
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 83 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
21,977,900
26,373,500
30,769,100
245 I-1-06-II
31,836,800
38,204,200
44,571,600
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
37,987,200
45,584,600
53,182,100
48,564,900
58,277,900
67,990,800
60,706,100
72,847,300
84,988,600
91,059,200
109,271,000
127,482,800
4,182,800
5,019,300
5,855,900
4,650,800
5,581,000
6,511,100
6,188,800
7,426,600
8,664,300
12,040,000
14,447,900
16,855,900
19,073,800
22,888,500
26,703,300
25,094,400
30,113,300
35,132,200
11,678,600
14,014,300
16,350,000
15,552,400
18,662,900
21,773,400
19,180,400
23,016,500
26,852,600
23,903,200
28,683,800
33,464,500
29,708,200
35,649,800
41,591,400
38,927,900
46,713,500
54,499,100
4,540,900
6,341,300
12,210,800
5,449,100
7,609,600
14,653,000
6,357,300
8,877,800
17,095,200
11,418,600
13,702,300
15,986,000
26,634,600
31,961,600
37,288,500
30,722,700
36,867,200
43,011,700
13,630,500
16,356,600
19,082,700
17,066,700
20,480,000
23,893,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
33,399,600
40,079,500
46,759,400
41,167,100
49,400,500
57,633,900
14,954,900
17,945,900
20,936,900
20,730,700
24,876,800
29,022,900
27,122,500
32,547,000
37,971,500
23,233,300
27,879,900
32,526,600
36,668,400
44,002,100
51,335,800
58,577,500
70,293,000
82,008,600
54,635,500
65,562,600
76,489,700
66,776,700
80,132,100
93,487,400
91,059,200
109,271,000
127,482,800
- 84 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
25,720,600
30,864,700
36,008,800
279 I-1-40-III
34,354,000
41,224,800
48,095,600
280 I-4-10-I
281 I-4-10-II

4,043,000
7,219,300
4,851,600
8,663,100
5,660,200
10,107,000
282 I-4-10-III
10,401,900
12,482,300
14,562,700
283 I-4-11-I
284 I-4-11-II

6,033,500
7,466,500
7,240,200
8,959,800
8,447,000
10,453,200
285 I-4-11-III
286 I-4-12-I

13,812,300
3,575,600
16,574,800
4,290,800
19,337,200
5,005,900
287 I-4-12-II
4,144,700
4,973,600
5,802,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,973,600
5,968,400
6,963,100
3,638,700
4,366,400
5,094,200
6,497,300
7,796,800
9,096,300
9,361,700
11,234,100
13,106,400
3,333,000
3,554,400
6,043,900
3,999,600
4,265,200
7,252,700
4,666,300
4,976,100
8,461,500
4,482,300
5,378,800
6,275,300
6,097,900
7,317,500
8,537,100
297 I-4-15-III
7,317,500
8,781,000
10,244,500
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,168,700
3,482,400
4,178,900
1,906,700
2,219,700
2,663,700
2,602,400
4,178,900
5,014,700
2,288,000
2,663,700
3,196,400
3,036,200
4,875,400
5,850,400
2,669,400
3,107,600
3,729,200
4,057,700
4,869,200
5,680,800
6,369,100
7,642,900
8,916,700
8,387,700
10,065,200
11,742,700
307 I-4-19-I
3,914,900
4,697,800
5,480,800
308 I-4-19-II

(SEDANG)
6,111,300
7,333,600
8,555,800
309 I-4-19-III
7,295,800
8,754,900
10,214,100
310
311
312
313
314

4,202,600
4,854,000
7,040,000
3,144,800
3,984,500
5,043,100
5,824,800
8,448,000
3,773,700
4,781,400
5,883,600
6,795,600
9,856,000
4,402,700
5,578,300
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,111,200
25,333,500
29,555,700
15,363,900
18,436,700
21,509,500
19,193,800
23,032,500
26,871,300
20,176,600
24,212,000
28,247,300
11,622,000
13,946,400
16,270,700
24,176,300
29,011,500
33,846,800
37,464,500
44,957,400
52,450,300
10,725,800
12,871,000
15,016,100
- 85 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,751,200
6,901,400
8,051,600
316 I-4-22-I
317 I-4-22-II
3,172,300
3,949,000
3,806,800
4,738,900
4,441,200
5,528,700
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,772,300
6,926,700
8,081,200
3,346,200
4,015,500
4,684,700
4,108,200
4,929,900
5,751,500
8,027,200
9,632,700
11,238,100
2,795,900
3,355,000
3,914,200
6,438,100
7,725,700
9,013,300
8,139,800
9,767,800
11,395,800
54,362,700
65,235,200
76,107,800
61,521,500
73,825,800
86,130,100
69,600,200
83,520,200
97,440,200
28,848,300
34,618,000
40,387,600
40,168,300
48,201,900
56,235,600
66,331,600
79,597,900
92,864,200
8,760,500
10,512,600
12,264,600
17,726,800
21,272,200
24,817,600
18,992,300
22,790,800
26,589,300
14,980,500
17,976,600
20,972,700
18,868,400
22,642,000
26,415,700
29,135,800
34,963,000
40,790,100
7,310,800
8,773,000
10,235,200
13,243,500
15,892,200
18,540,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
38,226,800
45,872,200
53,517,600
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,771,600
5,552,300
8,399,800
2,748,700
3,713,600
5,131,600
4,528,600
5,155,200
7,198,100
4,127,900
5,745,900
10,720,000
4,414,600
7,406,000
8,762,000
4,336,500
5,180,900
6,970,400
3,325,900
6,662,700
10,079,700
3,298,500
4,456,300
6,158,000
5,434,400
6,186,200
8,637,700
4,953,500
6,895,100
12,864,100
5,297,500
8,887,200
10,514,500
5,203,800
6,217,100
8,364,500
3,880,200
7,773,200
11,759,700
3,848,200
5,199,000
7,184,300
6,340,100
7,217,300
10,077,300
5,779,100
8,044,300
15,008,100
6,180,400
10,368,400
12,266,900
6,071,100
7,253,300
9,758,600
3,613,200
4,335,900
5,058,500
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 86 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,077,500
6,093,000
7,108,500
360 J-4-16-III
6,419,700
7,703,700
8,987,600
361 J-4-17-I
362 J-4-17-II

3,688,800
4,417,400
4,426,600
5,300,900
5,164,300
6,184,400
363 J-4-17-III
364 J-4-18-I

5,797,000
2,225,900
6,956,400
2,671,100
8,115,800
3,116,300
365 J-4-18-II
2,969,700
3,563,600
4,157,500
366 J-4-18-III
367 J-4-19-I

3,126,000
5,195,800
3,751,100
6,234,900
4,376,300
7,274,100
368 J-4-19-II
369 J-4-19-III

5,892,300
6,507,400
7,070,800
7,808,800
8,249,300
9,110,300
370 J-4-20-I
4,640,500
5,568,600
6,496,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,429,900
7,771,000
7,715,900
9,325,200
9,001,900
10,879,400
2,798,500
3,358,200
3,917,900
4,508,300
5,410,000
6,311,700
6,291,000
7,549,300
8,807,500
7,941,900
9,530,300
11,118,700
10,289,400
12,347,200
14,405,100
12,059,500
14,471,400
16,883,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,270,500
9,924,600
11,578,700

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,858,200
19,360,200
13,029,800
23,232,200
15,201,400
27,104,300
3,435,400
4,122,400
4,809,500
4,468,100
5,361,700
6,255,300
8,852,000
10,622,400
12,392,800
3,874,400
4,261,800
4,300,600
4,649,300
5,114,200
5,160,700
5,424,200
5,966,600
6,020,800
5,489,000
6,586,700
7,684,500
6,432,900
7,719,500
9,006,100
390 K-1-14-III
11,577,300
13,892,800
16,208,300
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,174,500
17,005,100
24,829,300
14,609,500
20,406,100
29,795,100
17,044,400
23,807,200
34,761,000
7,199,900
8,639,900
10,079,900
12,403,300
14,884,000
17,364,600
17,595,000
21,114,000
24,633,000
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,792,500
9,351,000
10,909,500
398 K-1-40-II

(SEDANG)
8,857,200
10,628,600
12,400,100
399 K-1-40-III
15,009,700
18,011,700
21,013,600
400
401
402
403
404

5,954,200
7,971,400
10,927,200
4,915,500
7,062,900
7,145,100
9,565,700
13,112,600
5,898,600
8,475,400
8,335,900
11,160,000
15,298,000
6,881,700
9,888,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 87 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,100,000
13,320,000
15,540,000
406 K-4-11-I
407 K-4-11-II

2,319,600
3,296,400
2,783,600
3,955,700
3,247,500
4,615,000
408 K-4-11-III
409 K-4-12-I

3,955,700
2,954,900
4,746,800
3,545,800
5,538,000
4,136,800
410 K-4-12-II
4,099,300
4,919,200
5,739,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,781,600
8,137,900
9,494,200
3,983,300
4,780,000
5,576,700
5,152,700
6,183,200
7,213,800
7,936,800
9,524,200
11,111,500
2,603,600
3,124,300
3,645,000
3,494,800
4,193,800
4,892,800
5,607,800
6,729,400
7,851,000
418 K-4-15-I
2,646,600
3,175,900
3,705,200
419 K-4-15-II
4,079,500
4,895,400
5,711,300
420 K-4-15-III
5,725,500
6,870,600
8,015,600
421 K-4-16-I
3,687,100
4,424,500
5,161,900
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,421,800
5,159,600
5,306,200
6,191,500
6,190,600
7,223,500
1,718,000
2,061,500
2,405,100
2,115,600
2,538,800
2,961,900
2,538,800
3,046,500
3,554,300
1,452,800
1,743,400
2,033,900
2,451,500
2,941,900
3,432,200
429 K-4-18-III
2,941,900
3,530,200
4,118,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,410,800
29,300,100
39,149,700
8,883,500
15,714,900
19,510,300
23,293,000
35,160,100
46,979,700
10,660,100
18,857,900
23,412,300
27,175,100
41,020,100
54,809,600
12,436,800
22,000,900
27,314,400
4,978,500
5,974,200
6,969,900
9,985,700
11,982,900
13,980,000
16,808,200
20,169,900
23,531,500
6,535,800
10,518,600
15,045,800
1,762,300
2,045,600
2,374,400
3,579,900
4,920,200
11,526,100
1,752,700
2,318,200
7,665,300
7,842,900
12,622,300
18,055,000
2,114,800
2,454,700
2,849,200
4,295,800
5,904,300
13,831,300
2,103,200
2,781,800
9,198,300
9,150,100
14,726,100
21,064,200
2,467,300
2,863,800
3,324,100
5,011,800
6,888,300
16,136,500
2,453,800
3,245,500
10,731,400
2,383,800
2,860,500
3,337,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 88 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,801,600
3,361,900
3,922,300
4,122,600
4,947,100
5,771,700
2,944,000
3,532,800
4,121,600
4,422,000
5,306,400
6,190,800
6,233,400
7,480,000
8,726,700
10,406,800
12,488,200
14,569,500
14,791,800
17,750,200
20,708,500
20,778,100
24,933,700
29,089,300
9,508,900
11,410,700
13,312,500
15,599,100
25,707,400
18,718,900
30,848,800
21,838,700
35,990,300
23,279,500
27,935,400
32,591,300
27,228,800
32,674,600
38,120,300
33,700,200
40,440,200
47,180,200
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,565,100
13,878,100
16,191,100
467 M-1-04-II
14,857,800
17,829,300
20,800,900
468 M-1-04-III
18,327,500
21,993,000
25,658,500
469 M-1-05-I
470 M-1-05-II

7,569,700
11,876,900
9,083,600
14,252,300
10,597,500
16,627,600
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,640,400
18,768,500
21,896,600
8,219,200
9,863,000
11,506,800
11,010,800
13,213,000
15,415,200
22,430,100
26,916,100
31,402,100
18,984,000
22,780,800
26,577,600
45,390,100
54,468,200
63,546,200
97,902,300
117,482,800
137,063,300
12,358,100
14,829,700
17,301,400
16,277,100
19,532,500
22,787,900
480 M-1-20-III
40,584,100
48,700,900
56,817,700
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,740,200
14,162,700
20,251,400
10,488,200
16,995,200
24,301,700
12,236,300
19,827,800
28,351,900
4,315,600
5,178,700
6,041,900
7,653,600
9,184,300
10,715,000
10,927,800
13,113,400
15,298,900
5,331,600
8,847,700
14,531,700
6,397,900
10,617,200
17,438,000
7,464,200
12,386,700
20,344,400
7,987,100
9,584,600
11,182,000
10,041,700
12,050,000
14,058,300
15,638,300
18,765,900
21,893,600
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 89 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,255,300
18,306,300
21,357,400
16,780,800
20,136,900
23,493,100
19,211,800
23,054,100
26,896,500
8,672,000
10,406,400
12,140,800
10,298,800
23,180,300
12,358,500
27,816,400
14,418,300
32,452,500
2,963,200
3,555,800
4,148,400
4,419,100
8,360,900
5,302,900
10,033,100
6,186,700
11,705,300
3,692,400
4,430,900
5,169,300
8,095,400
9,714,500
11,333,600
12,066,500
14,479,900
16,893,200
2,947,400
3,536,800
4,126,300
4,902,300
5,882,700
6,863,200
6,760,100
8,112,100
9,464,100
4,907,600
5,889,200
6,870,700
7,373,500
8,848,200
10,322,900
14,385,600
17,262,700
20,139,800
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,597,000
6,716,400
7,835,800
512 M-4-14-II
6,903,100
8,283,700
9,664,300
513 M-4-14-III
514 M-4-15-I
10,373,300
3,421,500
12,448,000
4,105,800
14,522,600
4,790,100
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,423,800
10,038,900
2,841,500
4,691,000
7,880,500
5,308,600
12,046,700
3,409,700
5,629,200
9,456,600
6,193,300
14,054,500
3,978,000
6,567,400
11,032,700
3,687,800
4,425,400
5,162,900
5,157,800
6,189,400
7,221,000
7,202,600
8,643,100
10,083,600
2,787,400
4,200,800
5,057,900
3,344,900
5,040,900
6,069,500
3,902,400
5,881,100
7,081,000
2,996,700
3,596,100
4,195,400
4,896,200
5,875,500
6,854,700
9,562,600
11,475,200
13,387,700
2,932,200
3,518,600
4,105,100
4,293,700
5,152,400
6,011,200
4,798,700
5,758,500
6,718,200
2,952,500
3,543,000
4,133,500
3,692,700
4,431,300
5,169,800
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 90 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,279,000
9,934,800
11,590,600
535 N-1-01-I

175,217,800
210,261,300
245,304,900
536 N-1-01-II
175,217,800
210,261,300
245,304,900
537 N-1-01-III
538 N-1-11-I

175,217,800
8,516,400
210,261,300
10,219,700
245,304,900
11,923,000
539 N-1-11-II
540 N-1-11-III

13,466,500
20,994,300
16,159,800
25,193,100
18,853,100
29,392,000
4,340,500
5,208,600
6,076,700
8,908,800
10,690,500
12,472,300
19,332,400
23,198,900
27,065,300
9,783,500
11,740,200
13,696,900

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,691,500
18,584,900
16,429,800
22,301,800
19,168,100
26,018,800
8,685,100
10,422,100
12,159,100
13,138,800
15,766,500
18,394,300
15,121,500
18,145,800
21,170,100
8,041,000
9,649,200
11,257,400
10,919,500
13,103,400
15,287,300
12,708,900
15,250,700
17,792,500
3,313,800
3,976,600
4,639,400
4,132,100
4,958,500
5,784,900
6,077,700
7,293,200
8,508,800
2,622,600
4,444,500
5,529,900
2,392,700
4,206,000
5,062,600
3,417,600
4,122,000
6,512,100
3,147,100
5,333,400
6,635,900
2,871,200
5,047,200
6,075,100
4,101,100
4,946,400
7,814,500
3,671,600
6,222,300
7,741,900
3,349,800
5,888,400
7,087,700
4,784,600
5,770,800
9,116,900
2,554,900
3,065,900
3,576,900
3,625,300
4,350,400
5,075,400
5,811,300
6,973,600
8,135,800
3,018,300
3,622,000
4,225,600
3,861,000
4,633,200
5,405,400
4,406,100
5,287,300
6,168,500
3,695,900
4,435,100
5,174,200
5,275,200
6,330,300
7,385,300
7,238,900
8,686,600
10,134,400
4,986,800
5,405,200
5,984,100
6,486,300
6,981,500
7,567,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 91 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,052,900
10,863,500
12,674,100
3,435,500
4,122,600
4,809,700
3,818,200
4,581,800
5,345,400
4,896,800
5,876,100
6,855,500
2,509,300
3,011,100
3,513,000
3,013,600
3,616,400
4,219,100
3,786,700
4,544,100
5,301,400
1,674,900
2,009,900
2,344,900

MAYOR (RINGAN)
MAYOR (SEDANG)
1,982,500
2,379,000
2,379,000
2,854,700
2,775,400
3,330,500
54,351,800
65,222,100
76,092,500
67,252,200
80,702,600
94,153,000
78,935,100
94,722,200
110,509,200
84,921,800
101,906,200
118,890,600
97,414,000
116,896,900
136,379,700
111,302,600
133,563,100
155,823,600
12,286,000
14,743,200
17,200,400
17,348,200
20,817,900
24,287,500
24,282,300
29,138,800
33,995,200
35,436,300
42,523,500
49,610,800
45,809,600
54,971,500
64,133,400
65,679,500
78,815,400
91,951,300
19,242,000
23,090,400
26,938,800
30,082,000
36,098,300
42,114,700
40,034,400
48,041,300
56,048,200
5,264,300
6,317,200
7,370,100
14,760,000
17,712,000
20,664,000
19,553,400
23,464,100
27,374,800
5,099,100
6,118,900
7,138,700
14,296,600
17,155,900
20,015,200
18,939,500
22,727,300
26,515,200
4,222,000
5,066,300
5,910,700
5,990,700
7,188,800
8,387,000
9,700,300
11,640,400
13,580,400
10,238,400
12,286,000
14,333,700
14,456,900
17,348,200
20,239,600
- 92 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,235,200
24,282,300
28,329,300
9,672,500
11,607,000
13,541,500
11,120,700
13,344,800
15,568,900
15,565,600
18,678,700
21,791,800
5,483,600
6,580,300
7,677,000
8,554,400
10,265,200
11,976,100
13,289,500
15,947,400
18,605,300
3,654,700
4,385,700
5,116,600
7,439,500
8,927,400
10,415,300
13,389,100
16,066,900
18,744,700
2,741,100
3,289,300
3,837,500
5,489,100
6,587,000
7,684,800
6,440,500
7,728,600
9,016,700
2,480,700
2,976,900
3,473,000
4,767,100
5,720,500
6,673,900
11,665,700
13,998,800
16,331,900
3,655,700
4,386,800
5,118,000
6,580,300
7,896,300
9,212,400
9,259,600
11,111,500
12,963,400
2,713,100
3,255,700
3,798,300
3,342,900
4,011,500
4,680,100
4,576,100
5,491,300
6,406,500
1,641,800
2,407,500
4,114,700
1,994,600
2,654,800
4,602,100
1,970,100
2,889,000
4,937,700
2,393,600
3,185,800
5,522,600
2,298,500
3,370,500
5,760,600
2,792,500
3,716,700
6,443,000
2,945,600
3,534,700
4,123,800
5,225,700
6,270,800
7,315,900
8,481,900
10,178,300
11,874,600
1,490,700
1,788,800
2,086,900
3,166,300
3,799,500
4,432,800
6,004,400
7,205,300
8,406,100
997,000
1,196,400
1,395,800
1,881,400
2,257,700
2,634,000
2,436,800
2,924,100
3,411,500
5,162,500
6,195,000
7,227,500
- 93 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,768,500
8,122,200
9,475,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,691,100
11,629,400
13,567,600
2,488,200
2,985,900
3,483,500
3,692,800
4,431,400
5,169,900
4,441,400
5,329,700
6,218,000
1,716,300
2,059,600
2,402,800
2,305,200
2,766,300
3,227,300
4,193,500
5,032,300
5,871,000
744,500
893,400
1,042,300
1,418,900
1,702,600
1,986,400
2,062,700
2,475,200
2,887,700
1,016,100
1,219,300
1,422,500
1,599,000
1,918,800
2,238,600
2,575,500
3,090,600
3,605,700
1,674,000
2,008,800
2,343,600
2,494,300
2,993,100
3,492,000
3,826,800
4,592,200
5,357,600
5,440,400
6,528,500
7,616,600

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,445,700
22,307,300
10,134,900
26,768,800
11,824,000
31,230,300
8,416,600
10,099,900
11,783,200
10,669,300
12,803,200
14,937,000
15,826,200
18,991,500
22,156,700
6,576,600
10,084,900
14,812,700
6,581,200
7,668,100
12,711,300
7,892,000
12,101,900
17,775,200
7,897,400
9,201,700
15,253,600
9,207,300
14,118,900
20,737,700
9,213,600
10,735,300
17,795,800
4,077,100
4,892,500
5,708,000
5,003,600
6,004,300
7,005,100
5,929,300
7,115,100
8,301,000
3,900,700
5,545,700
7,148,100
4,680,900
6,654,800
8,577,800
5,461,000
7,764,000
10,007,400
6,189,700
7,427,700
8,665,600
9,212,000
11,054,400
12,896,800
22,939,500
27,527,400
32,115,300
5,308,400
7,197,900
13,653,500
6,370,000
8,637,500
16,384,200
7,431,700
10,077,100
19,114,900
3,820,100
4,584,100
5,348,200
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 94 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,321,800
2,786,100
3,250,500
697 U-4-12-I
698 U-4-12-II

2,534,400
2,948,100
3,041,300
3,537,700
3,548,200
4,127,300
699 U-4-12-III

3,942,700
4,731,300
5,519,800
1,980,100
2,376,200
2,772,200
2,334,400
2,801,300
3,268,200
2,792,100
3,350,500
3,908,900
3,688,200
4,416,500
4,425,900
5,299,900
5,163,500
6,183,200

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,416,700
8,900,100
10,383,400
2,961,500
3,553,800
4,146,200
3,689,700
4,427,600
5,165,600
5,163,800
6,196,500
7,229,300
4,979,900
5,975,900
6,971,900
9,950,700
11,940,800
13,931,000
12,203,100
14,643,700
17,084,400
9,189,800
10,493,700
16,433,600
11,027,800
12,592,400
19,720,300
12,865,800
14,691,200
23,007,000
8,640,200
10,368,300
12,096,300
12,163,800
14,596,600
17,029,400
14,955,300
17,946,300
20,937,400
4,646,200
5,575,500
6,504,700
8,877,400
10,652,900
12,428,400
13,509,800
16,211,700
18,913,700
8,837,900
10,605,500
12,373,100
12,841,200
15,409,500
17,977,700
16,034,600
19,241,500
22,448,400
1,467,400
1,619,200
1,791,200
1,760,800
1,943,100
2,149,400
2,054,300
2,266,900
2,507,700
4,406,000
5,287,200
6,168,500
7,318,700
8,782,400
10,246,100
12,065,900
14,479,100
16,892,300
3,692,900
4,431,500
5,170,000
4,954,900
5,945,900
6,936,800
6,842,400
8,210,900
9,579,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,483,000
10,179,600
11,876,300
13,024,100
15,628,900
18,233,700
1,517,500
2,207,000
1,821,000
2,648,400
2,124,500
3,089,800
- 95 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,376,800
12,452,100
14,527,500
12,064,100
14,477,000
16,889,800
17,747,700
21,297,200
24,846,700
2,201,100
2,641,300
3,081,500
2,428,900
2,686,800
2,914,600
3,224,200
3,400,400
3,761,500
2,300,600
2,760,700
3,220,800
2,538,700
3,046,400
3,554,200
2,808,300
3,370,000
3,931,600
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,475,000
2,970,000
3,465,000
743 W-1-12-II
744 W-1-12-III

3,089,200
5,306,200
3,707,000
6,367,400
4,324,900
7,428,600
745 W-1-13-I
2,467,700
2,961,300
3,454,800
746 W-1-13-II
747 W-1-13-III

2,679,100
3,598,800
3,215,000
4,318,500
3,750,800
5,038,300
748 W-1-20-I
749 W-1-20-II

8,264,200
10,326,200
9,917,100
12,391,500
11,569,900
14,456,700
750 W-1-20-III
11,970,800
14,364,900
16,759,100
751 W-1-30-I
4,665,300
5,598,300
6,531,400
752 W-1-30-II
7,441,100
8,929,300
10,417,500
753 W-1-30-III
18,257,100
21,908,600
25,560,000
754 W-4-10-I
3,476,100
4,171,300
4,866,600
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,153,200
10,183,700
3,161,300
4,799,300
5,841,600
6,183,800
12,220,500
3,793,500
5,759,200
7,010,000
7,214,500
14,257,200
4,425,800
6,719,000
8,178,300
2,809,400
3,371,200
3,933,100
3,857,000
4,628,500
5,399,900
4,204,400
5,045,300
5,886,200
1,243,800
1,699,000
2,112,900
1,662,200
2,039,600
2,531,100
1,580,800
1,755,500
2,430,600
2,168,300
2,899,500
3,929,800
1,551,900
2,802,100
4,142,800
2,863,400
3,800,800
5,399,400
2,608,700
3,133,200
4,306,800
1,492,500
2,038,900
2,535,400
1,994,600
2,447,500
3,037,400
1,896,900
2,106,700
2,916,800
2,601,900
3,479,400
4,715,700
1,862,300
3,362,500
4,971,400
3,436,100
4,561,000
6,479,300
3,130,500
3,759,900
5,168,100
1,741,300
2,378,700
2,958,000
2,327,000
2,855,500
3,543,600
2,213,100
2,457,800
3,402,900
3,035,600
4,059,300
5,501,700
2,172,700
3,922,900
5,800,000
4,008,800
5,321,100
7,559,100
3,652,200
4,386,500
6,029,500
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 96 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,876,700
2,252,000
2,627,300
3,938,000
4,725,600
5,513,200
6,062,000
7,274,400
8,486,700
- 97 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS B SWASTA
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
961,100
1,246,700
2,318,400
1,915,900
2,489,800
458,000
1,119,400
358,100
961,300
714,200
810,900
1,219,100
1,662,800
1,524,000
493,700
1,139,500
413,300
709,600
2,161,600
774,100
1,828,200
446,000
1,359,200
1,547,200
1,297,700
318,300
1,015,300
536,300
379,100
298,100
263,200
314,700
438,200
376,500
354,400
318,500
472,600
206,400
243,200
278,800
5,658,800
2,261,600
2,269,100
583,700
1,314,200
822,800
1,672,500
779,400
446,300
337,000
543,600
360,900
270,400
2,756,200
1,286,200
735,000
2,869,100
1,912,700
270,900
3,108,200
2,151,800
3,969,000
1,117,900
687,600
269,000
224,100
252,600
3,851,700
1,874,900
- 98 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,382,900
4,217,200
3,680,600
2,663,700
878,100
2,964,700
1,935,800
475,800
4,451,000
4,029,500
2,701,800
2,559,600
333,000
304,000
1,223,100
351,900
297,800
329,200
1,553,500
1,543,200
1,348,000
1,636,900
991,300
299,600
528,100
362,500
327,300
318,900
404,900
461,700
270,700
776,800
1,415,700
1,086,700
2,554,800
332,700
332,700
3,246,100
1,372,800
263,300
1,218,300
3,331,300
726,600
572,300
280,400
265,700
417,600
582,300
1,394,300
1,228,900
860,300
466,700
270,400
1,493,800
870,500
511,400
424,400
1,390,800
307,500
1,953,800
1,494,800
331,500
367,500
359,000
217,200
1,628,600
1,627,400
322,500
- 99 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
988,500
369,000
398,900
369,400
586,000
450,800
1,129,000
333,100
926,800
1,702,800
271,200
1,650,800
894,500
1,933,200
975,900
431,000
331,500
76,700
429,700
970,900
378,400
511,100
292,300
118,700
295,100
4,395,300
2,498,400
4,169,800
1,408,500
572,300
390,000
882,000
466,500
938,800
543,600
323,600
541,700
335,300
511,800
356,700
923,100
1,791,100
1,441,000
1,270,600
896,700
313,400
313,400
313,400
256,000
162,400
255,300
312,000
337,500
248,600
219,300
107,500
118,200
87,400
102,600
97,900
149,300
134,000
174,200
191,400
113,000
144,400
98,700
154,000
218,500
- 100 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
155,500
195,600
552,900
641,000
147,100
266,100
179,000
255,500
447,600
383,200
275,400
260,800
146,200
136,500
307,100
193,800
278,000
192,400
150,600
2,656,200
1,987,000
315,700
327,000
625,300
819,400
800,400
413,500
1,288,600
305,900
336,100
337,100
270,000
341,000
322,700
151,200
332,100
294,400
266,300
301,200
2,493,200
445,100
897,300
321,800
629,500
501,500
421,100
779,200
797,900
850,800
744,200
1,424,500
221,700
2,116,600
292,300
1,072,900
2,438,400
2,050,500
895,800
324,600
633,100
630,700
292,300
2,290,900
1,802,000
161,400
174,900
227,300
403,400
- 101 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,175,500
633,400
999,500
1,145,500
577,800
763,600
555,600
592,500
742,400
331,100
743,600
208,800
734,800
1,265,500
84,800
- 102 -

REGIONAL 1
RUMAH SAKIT KELAS C PEMERINTAH
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,882,200
2,258,700
2,635,100
A-4-10-II
SEPTIKEMIA (SEDANG)
3,215,600
3,858,700
4,501,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,335,600
2,771,400
5,202,800
3,325,700
6,069,900
3,880,000
5
6
A-4-11-II
A-4-11-III

3,944,500
5,459,600
4,733,400
6,551,500
5,522,300
7,643,400
A-4-12-I
2,509,600
3,011,500
3,513,400
8
9
A-4-12-II
A-4-12-III

3,125,300
3,335,500
3,750,300
4,002,600
4,375,400
4,669,700
10 A-4-13-I
11 A-4-13-II

1,509,200
2,273,500
1,811,000
2,728,200
2,112,800
3,182,900
12 A-4-13-III
2,728,200
3,273,800
3,819,500
2,092,500
2,511,000
2,929,500
2,540,000
3,048,000
3,556,000
3,048,000
3,657,600
4,267,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,285,300
4,917,700
3,942,300
5,901,200
4,599,400
6,884,700
18 A-4-15-III
INFEKSI HIV (BERAT)
6,171,300
7,405,500
8,639,800
19 B-1-01-I
20 B-1-01-II

22,492,100
24,814,800
26,990,500
29,777,800
31,489,000
34,740,800
21 B-1-01-III
22 B-1-10-I

43,530,400
3,886,300
52,236,400
4,663,500
60,942,500
5,440,800
23 B-1-10-II
8,625,800
10,350,900
12,076,100
24 B-1-10-III
25 B-1-11-I

17,028,500
5,192,800
20,434,200
6,231,300
23,839,900
7,269,900
26 B-1-11-II
27 B-1-11-III

6,729,400
8,694,300
8,075,300
10,433,200
9,421,200
12,172,100
28 B-1-12-I
5,070,500
6,084,500
7,098,600
29 B-1-12-II
5,639,200
6,767,100
7,894,900
30 B-1-12-III
8,822,000
10,586,400
12,350,800
4,038,700
4,846,400
5,654,100
6,645,100
7,974,200
9,303,200
8,598,200
10,317,900
12,037,500
5,549,300
6,659,200
7,769,000
6,171,800
7,406,200
8,640,500
9,655,100
1,716,900
2,740,800
3,781,000
11,586,100
2,060,300
3,288,900
4,537,100
13,517,100
2,403,700
3,837,100
5,293,300
3,620,000
4,344,000
5,068,000
5,068,000
6,081,600
7,095,200
6,139,800
7,367,800
8,595,800
3,272,900
4,660,400
6,933,700
3,122,100
3,927,400
5,592,500
8,320,400
3,746,500
4,582,000
6,524,600
9,707,200
4,370,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 103 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,637,100
4,364,500
5,091,900
48 B-4-13-III
49 B-4-14-I

5,010,400
3,118,700
6,012,400
3,742,500
7,014,500
4,366,200
50 B-4-14-II
3,638,400
4,366,100
5,093,700
51 B-4-14-III
52 C-4-10-I

4,873,700
2,885,400
5,848,400
3,462,400
6,823,200
4,039,500
53 C-4-10-II
54 C-4-10-III

5,536,300
9,772,100
6,643,600
11,726,500
7,750,800
13,680,900
55 C-4-11-I
3,288,000
3,945,600
4,603,200
56 C-4-11-II
57 C-4-11-III

4,399,800
6,764,800
5,279,800
8,117,800
6,159,800
9,470,700
58 C-4-12-I
59 C-4-12-II
2,189,300
4,312,000
2,627,100
5,174,400
3,065,000
6,036,800
60 C-4-12-III
RADIOTERAPI (BERAT)
11,074,400
13,289,300
15,504,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,645,900
3,097,600
1,975,100
3,717,100
2,304,200
4,336,600
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,193,000
2,734,700
5,031,700
3,281,600
5,870,300
3,828,600
65 C-4-14-II
3,836,200
4,603,500
5,370,700
66 C-4-14-III
67 D-1-10-I

5,715,900
13,383,000
6,859,100
16,059,600
8,002,300
18,736,200
68 D-1-10-II
69 D-1-10-III

20,383,300
32,457,200
24,460,000
38,948,600
28,536,600
45,440,100
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,423,700
5,308,400
6,193,100
11,295,700
14,679,200
13,554,900
17,615,100
15,814,000
20,550,900
3,834,800
4,601,800
5,368,700
10,568,200
12,681,800
14,795,500
16,764,200
20,117,100
23,469,900
2,293,300
3,447,200
5,423,200
3,002,100
5,394,700
7,411,000
2,588,300
3,590,000
5,512,600
2,751,900
4,136,600
6,507,800
3,602,600
6,473,700
8,893,200
3,105,900
4,308,000
6,615,100
3,210,600
4,826,000
7,592,500
4,203,000
7,552,600
10,375,400
3,623,600
5,025,900
7,717,600
2,218,100
2,661,700
3,105,300
3,139,300
3,767,200
4,395,100
4,015,300
4,818,400
5,621,400
2,379,000
2,854,800
3,330,600
3,895,000
4,674,000
5,453,000
4,764,000
5,716,800
6,669,600
4,234,900
5,081,900
5,928,900
5,547,300
6,656,800
7,766,200
93 E-1-01-III
9,632,900
11,559,500
13,486,100
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,303,600
4,009,700
8,451,400
3,964,300
4,811,700
10,141,600
4,625,000
5,613,600
11,831,900
5,581,600
6,697,900
7,814,200
97 E-1-20-I
- 104 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,194,200
2,633,100
3,071,900
104 E-4-11-II
105 E-4-11-III

3,345,300
4,533,100
4,014,300
5,439,700
4,683,400
6,346,300
106 E-4-12-I
107 E-4-12-II

2,521,100
4,366,000
3,025,300
5,239,200
3,529,600
6,112,400
108 E-4-12-III

(RINGAN)
(SEDANG)
5,175,300
6,210,300
7,245,400
2,745,400
3,294,500
3,843,600
4,021,500
4,825,900
5,630,200
111 E-4-13-III
5,257,000
6,308,300
7,359,700
112 F-4-10-I
113 F-4-10-II
2,922,900
3,359,200
3,507,400
4,031,100
4,092,000
4,702,900
114 F-4-10-III
115 F-4-11-I
4,031,100
2,826,900
4,837,300
3,392,200
5,643,500
3,957,600
116 F-4-11-II
3,293,600
3,952,300
4,611,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,223,600
5,068,300
5,913,000
1,549,600
1,859,500
2,169,400
2,203,000
2,643,600
3,084,200
4,785,900
5,743,100
6,700,300
2,277,100
3,004,700
3,890,000
1,299,200
1,666,400
2,242,300
2,732,500
3,605,600
4,667,900
1,559,000
1,999,700
2,690,700
3,187,900
4,206,600
5,445,900
1,818,900
2,333,000
3,139,200
127 F-4-15-I
2,069,100
2,482,900
2,896,700
128 F-4-15-II
3,083,200
3,699,800
4,316,400
129 F-4-15-III
4,070,700
4,884,900
5,699,000
4,071,000
4,885,200
5,699,400
4,733,200
5,679,800
6,626,400
6,318,000
7,581,600
8,845,100
133 F-4-17-I

961,400
1,153,700
1,346,000
134 F-4-17-II
2,817,800
3,381,300
3,944,900
135
136
137
138
139
140
141

(RINGAN)
3,006,300
3,537,400
3,892,100
6,000,000
2,703,400
3,461,800
4,309,900
3,607,500
4,244,800
4,670,500
7,200,000
3,244,000
4,154,200
5,171,900
4,208,800
4,952,300
5,449,000
8,400,000
3,784,700
4,846,500
6,033,900
10,309,700
12,371,600
14,433,500
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,512,600
9,015,200
10,517,700
10,354,000
12,424,700
14,495,500
3,330,600
3,996,700
4,662,800
4,653,900
5,584,700
6,515,500
5,776,400
6,931,700
8,087,000
- 105 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
13,709,000
16,450,800
19,192,600
148 G-1-11-I
149 G-1-11-II

8,776,500
16,045,400
10,531,800
19,254,500
12,287,100
22,463,600
150 G-1-11-III
29,583,800
35,500,600
41,417,400
3,664,500
4,397,400
5,130,300
6,869,200
8,243,100
9,616,900
9,361,400
11,233,700
13,106,000
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,105,500
2,968,700
1,326,600
3,562,500
1,547,700
4,156,200
156 G-1-13-III
157 G-1-20-I

6,698,800
4,642,400
8,038,500
5,570,900
9,378,300
6,499,400
158 G-1-20-II
5,520,700
6,624,800
7,728,900
159 G-1-20-III
12,884,700
15,461,600
18,038,600
160 G-1-30-I
6,810,100
8,172,100
9,534,100
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
13,793,100
19,372,000
16,551,700
23,246,400
19,310,300
27,120,800
3,145,600
3,774,700
4,403,800
3,844,900
4,613,900
5,382,900
5,275,900
6,331,100
7,386,300
3,292,900
3,951,500
4,610,100
4,374,200
5,249,100
6,123,900
6,427,200
7,712,700
8,998,100
3,653,100
4,383,700
5,114,300
4,614,100
5,537,000
6,459,800
6,701,400
8,041,700
9,382,000
2,194,500
2,633,400
3,072,300
3,826,700
4,592,100
5,357,400
4,538,600
5,446,300
6,354,000
3,722,700
4,467,200
5,211,700
4,976,900
5,972,300
6,967,700
6,246,600
7,496,000
8,745,300
3,041,700
3,650,100
4,258,400
3,630,200
4,356,200
5,082,200
5,123,700
6,148,400
7,173,100
2,507,500
3,009,000
3,510,500
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,054,400
19,265,200
22,476,100
30,875,500
37,050,600
43,225,700
10,567,800
12,442,500
12,681,300
14,930,900
14,794,900
17,419,400
- 106 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,329,000
3,994,900
4,660,700
183 G-4-16-III
4,740,800
5,689,000
6,637,200
3,339,800
4,007,800
4,675,800
4,379,200
5,255,100
6,130,900
5,502,700
6,603,300
7,703,800
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,289,200
3,947,100
4,604,900
188 G-4-18-II
4,396,700
5,276,000
6,155,300
189 G-4-18-III
4,919,500
5,903,400
6,887,400
2,744,300
3,293,100
3,842,000
4,638,500
5,566,200
6,493,800
6,090,100
7,308,100
8,526,100
193 G-4-20-I

1,919,700
2,303,700
2,687,600
194 G-4-20-II
2,713,900
3,256,700
3,799,500
195 G-4-20-III
196 G-4-21-I

4,482,800
1,999,100
5,379,300
2,398,900
6,275,900
2,798,800
197 G-4-21-II
198 G-4-21-III

3,383,500
3,976,400
4,060,200
4,771,700
4,736,900
5,567,000
199 G-4-22-I
2,525,300
3,030,400
3,535,500
200 G-4-22-II
201 G-4-22-III

3,226,600
3,770,200
3,871,900
4,524,200
4,517,300
5,278,200
202 G-4-23-I
203 G-4-23-II

1,967,900
2,469,100
2,361,500
2,962,900
2,755,100
3,456,700
204 G-4-23-III
3,515,400
4,218,400
4,921,500
205 G-4-24-I
206 G-4-24-II

2,192,000
2,738,600
2,630,400
3,286,300
3,068,800
3,834,000
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,562,400
1,873,000
2,368,600
3,138,900
5,474,800
2,247,600
2,842,400
3,766,700
6,387,300
2,622,200
3,316,100
4,394,500
2,959,900
3,551,800
4,143,800
3,443,200
4,131,900
4,820,500
5,148,700
6,178,400
7,208,200
4,227,800
5,389,400
7,329,100
6,433,000
7,992,400
11,194,600
2,535,700
3,440,400
6,762,300
2,188,400
2,496,200
3,574,500
2,580,100
3,082,700
5,166,100
5,073,400
6,467,200
8,794,900
7,719,600
9,590,900
13,433,500
3,042,900
4,128,500
8,114,800
2,626,000
2,995,500
4,289,400
3,096,100
3,699,300
6,199,300
5,918,900
7,545,100
10,260,800
9,006,300
11,189,400
15,672,400
3,550,000
4,816,600
9,467,300
3,063,700
3,494,700
5,004,300
3,612,100
4,315,800
7,232,500
229 I-1-01-I
34,655,100
41,586,100
48,517,100
230 I-1-01-II
35,417,500
42,501,000
49,584,500
231 I-1-01-III

(RINGAN)
55,906,000
67,087,200
78,268,400
19,226,500
23,071,800
26,917,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 107 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
15,830,800
18,997,000
22,163,100
245 I-1-06-II
22,932,200
27,518,700
32,105,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
27,362,400
32,834,800
38,307,300
18,844,600
22,613,600
26,382,500
23,248,700
27,898,400
32,548,200
25,364,200
30,437,100
35,509,900
3,012,900
3,615,400
4,218,000
3,350,000
4,020,000
4,690,000
4,457,800
5,349,400
6,240,900
8,672,400
10,406,900
12,141,400
14,163,800
16,996,600
19,829,400
18,634,700
22,361,600
26,088,500
8,412,100
10,094,600
11,777,000
11,202,500
13,443,000
15,683,500
13,815,800
16,578,900
19,342,100
17,217,600
20,661,100
24,104,600
21,398,900
25,678,700
29,958,500
28,040,000
33,648,000
39,256,000
3,270,800
4,567,700
8,795,500
3,925,000
5,481,200
10,554,600
4,579,200
6,394,700
12,313,700
8,479,200
10,175,100
11,870,900
19,185,100
23,022,100
26,859,100
22,129,700
26,555,600
30,981,500
9,818,100
11,781,800
13,745,400
12,293,200
14,751,900
17,210,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
24,801,900
29,762,300
34,722,700
30,570,000
36,683,900
42,797,900
11,105,300
13,326,300
15,547,400
15,394,200
18,473,100
21,551,900
19,536,400
23,443,700
27,351,000
16,735,000
20,082,100
23,429,100
26,412,400
31,694,900
36,977,400
42,193,700
50,632,400
59,071,200
21,472,600
25,767,100
30,061,700
25,767,200
30,920,700
36,074,100
35,455,500
42,546,600
49,637,700
- 108 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,099,700
22,919,600
26,739,500
279 I-1-40-III
25,510,700
30,612,800
35,714,900
280 I-4-10-I
281 I-4-10-II

2,912,200
5,200,100
3,494,600
6,240,100
4,077,100
7,280,100
282 I-4-10-III
7,492,600
8,991,100
10,489,600
283 I-4-11-I
284 I-4-11-II

4,480,400
5,544,500
5,376,500
6,653,400
6,272,600
7,762,300
285 I-4-11-III
286 I-4-12-I

10,256,800
2,575,600
12,308,100
3,090,800
14,359,500
3,605,900
287 I-4-12-II
2,985,500
3,582,600
4,179,700
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,582,600
4,299,100
5,015,600
2,621,000
3,145,200
3,669,400
4,680,100
5,616,100
6,552,100
6,743,300
8,092,000
9,440,600
2,475,100
2,560,200
4,488,100
2,970,100
3,072,300
5,385,700
3,465,100
3,584,300
6,283,300
4,262,100
5,114,500
5,966,900
5,798,200
6,957,900
8,117,500
297 I-4-15-III
6,957,900
8,349,500
9,741,000
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,562,100
2,508,400
3,010,100
1,758,600
2,047,300
2,456,800
1,874,600
3,010,100
3,612,100
2,110,300
2,456,800
2,948,200
2,187,000
3,511,700
4,214,100
2,462,000
2,866,300
3,439,500
3,013,200
3,615,800
4,218,400
4,587,700
5,505,200
6,422,700
6,228,500
7,474,200
8,719,900
307 I-4-19-I
2,907,100
3,488,500
4,069,900
308 I-4-19-II

(SEDANG)
4,538,200
5,445,800
6,353,400
309 I-4-19-III
5,417,700
6,501,200
7,584,800
310
311
312
313
314

3,027,200
3,496,400
5,227,800
2,265,200
2,870,000
3,632,600
4,195,600
6,273,300
2,718,200
3,444,000
4,238,000
4,894,900
7,318,900
3,171,300
4,018,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,206,500
18,247,800
21,289,100
11,066,700
13,280,100
15,493,400
13,825,400
16,590,500
19,355,500
14,533,300
17,440,000
20,346,700
8,371,400
10,045,600
11,719,900
17,414,300
20,897,100
24,380,000
26,985,900
32,383,000
37,780,200
7,725,900
9,271,000
10,816,200
- 109 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,142,600
4,971,100
5,799,600
316 I-4-22-I
317 I-4-22-II
2,538,900
3,160,600
3,046,700
3,792,700
3,554,500
4,424,800
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,619,800
5,543,700
6,467,700
2,484,900
2,981,800
3,478,800
3,050,700
3,660,800
4,271,000
5,960,900
7,153,100
8,345,300
2,237,600
2,685,200
3,132,700
5,152,700
6,183,200
7,213,700
6,514,600
7,817,500
9,120,500
40,368,800
48,442,500
56,516,300
45,684,800
54,821,700
63,958,700
51,683,800
62,020,600
72,357,400
21,422,200
25,706,700
29,991,100
29,828,300
35,793,900
41,759,600
49,256,700
59,108,000
68,959,300
6,505,400
7,806,400
9,107,500
13,163,600
15,796,400
18,429,100
13,680,300
16,416,300
19,152,400
9,217,400
11,060,900
12,904,400
12,179,400
14,615,200
17,051,100
18,651,400
22,381,600
26,111,900
5,428,900
6,514,700
7,600,500
9,834,400
11,801,300
13,768,100
28,386,600
34,063,900
39,741,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,218,200
4,581,100
6,930,600
1,979,900
2,757,600
3,696,300
3,362,900
3,828,200
5,345,200
2,973,400
4,138,800
7,721,700
3,278,200
5,334,600
6,311,300
3,999,700
4,778,500
6,429,000
2,661,800
5,497,400
8,316,700
2,375,900
3,309,200
4,435,600
4,035,500
4,593,800
6,414,200
3,568,000
4,966,600
9,266,000
3,933,800
6,401,500
7,573,600
4,799,600
5,734,200
7,714,800
3,105,500
6,413,600
9,702,800
2,771,900
3,860,700
5,174,900
4,708,000
5,359,400
7,483,200
4,162,700
5,794,400
10,810,400
4,589,500
7,468,400
8,835,900
5,599,600
6,689,900
9,000,600
3,332,600
3,999,100
4,665,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 110 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,683,100
5,619,800
6,556,400
360 J-4-16-III
5,921,100
7,105,300
8,289,600
361 J-4-17-I
362 J-4-17-II

2,739,200
3,280,300
3,287,100
3,936,400
3,834,900
4,592,400
363 J-4-17-III
364 J-4-18-I

4,304,800
2,053,000
5,165,700
2,463,600
6,026,700
2,874,200
365 J-4-18-II
2,823,700
3,388,500
3,953,200
366 J-4-18-III
367 J-4-19-I

2,972,300
3,858,300
3,566,800
4,630,000
4,161,300
5,401,600
368 J-4-19-II
369 J-4-19-III

4,375,600
4,832,300
5,250,700
5,798,700
6,125,800
6,765,200
370 J-4-20-I
3,828,800
4,594,600
5,360,400
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,305,300
6,219,400
6,366,300
7,463,300
7,427,400
8,707,200
2,661,000
3,193,200
3,725,400
4,286,800
5,144,100
6,001,500
5,981,900
7,178,200
8,374,600
5,897,500
7,077,000
8,256,500
7,411,500
8,893,800
10,376,100
8,686,500
10,423,800
12,161,100
6,622,400
7,946,800
9,271,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
8,694,400
13,157,400
10,433,200
15,788,900
12,172,100
18,420,400
2,474,500
2,969,400
3,464,300
3,218,400
3,862,100
4,505,700
6,376,100
7,651,300
8,926,600
2,790,800
3,069,800
3,097,700
3,348,900
3,683,800
3,717,300
3,907,100
4,297,800
4,336,800
4,528,900
5,434,700
6,340,400
5,307,800
6,369,300
7,430,900
8,339,200
10,007,100
11,674,900
8,769,400
12,248,900
17,884,600
10,523,300
14,698,600
21,461,600
12,277,100
17,148,400
25,038,500
5,186,200
6,223,400
7,260,600
9,210,500
11,052,600
12,894,700
12,673,800
15,208,500
17,743,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,786,500
6,943,900
8,101,200
398 K-1-40-II

(SEDANG)
6,379,900
7,655,800
8,931,800
399 K-1-40-III
10,811,600
12,973,900
15,136,200
400
401
402
403
404

4,421,500
5,741,900
8,114,300
3,650,200
5,244,800
5,305,800
6,890,200
9,737,200
4,380,200
6,293,700
6,190,100
8,038,600
11,360,000
5,110,200
7,342,700
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 111 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,995,400
9,594,500
11,193,500
406 K-4-11-I
407 K-4-11-II

2,139,500
3,040,400
2,567,400
3,648,500
2,995,300
4,256,500
408 K-4-11-III
409 K-4-12-I

3,648,500
2,194,200
4,378,200
2,633,100
5,107,800
3,071,900
410 K-4-12-II
2,952,800
3,543,300
4,133,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,884,800
5,861,800
6,838,700
2,958,000
3,549,500
4,141,100
3,826,300
4,591,600
5,356,800
5,893,700
7,072,500
8,251,200
1,875,400
2,250,400
2,625,500
2,517,300
3,020,800
3,524,300
4,039,300
4,847,200
5,655,100
418 K-4-15-I
1,937,700
2,325,200
2,712,800
419 K-4-15-II
2,873,100
3,447,700
4,022,300
420 K-4-15-III
4,032,300
4,838,800
5,645,200
421 K-4-16-I
2,738,000
3,285,600
3,833,200
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,283,600
3,831,400
3,940,300
4,597,700
4,597,000
5,364,000
1,406,200
1,687,500
1,968,700
1,923,400
2,308,000
2,692,700
2,308,000
2,769,600
3,231,200
1,242,600
1,491,100
1,739,600
1,765,800
2,119,000
2,472,100
429 K-4-18-III
2,119,000
2,542,800
2,966,500
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
13,981,700
21,105,000
28,199,700
6,596,700
11,319,500
14,053,400
16,778,000
25,326,000
33,839,700
7,916,000
13,583,400
16,864,000
19,574,400
29,547,000
39,479,600
9,235,400
15,847,300
19,674,700
3,696,900
4,436,300
5,175,700
7,415,200
8,898,300
10,381,300
12,481,500
14,977,800
17,474,100
4,853,300
7,810,900
11,172,800
1,269,400
1,473,400
1,710,300
2,658,300
3,653,700
8,302,300
1,262,500
1,669,800
4,417,100
5,824,000
9,373,100
13,407,300
1,523,300
1,768,100
2,052,300
3,190,000
4,384,400
9,962,700
1,515,000
2,003,800
5,300,500
6,794,700
10,935,300
15,641,900
1,777,200
2,062,800
2,394,400
3,721,700
5,115,100
11,623,200
1,767,500
2,337,700
6,183,900
2,266,600
2,720,000
3,173,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 112 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,663,900
3,196,700
3,729,500
3,920,000
4,704,000
5,488,000
2,186,200
2,623,400
3,060,600
3,283,700
3,940,400
4,597,200
4,628,800
5,554,500
6,480,300
7,727,900
9,273,500
10,819,100
10,984,100
13,181,000
15,377,800
15,429,400
18,515,300
21,601,200
6,849,300
8,219,200
9,589,100
11,236,100
19,089,800
13,483,300
22,907,800
15,730,500
26,725,800
18,596,400
22,315,700
26,035,000
21,751,200
26,101,400
30,451,700
26,920,700
32,304,900
37,689,000
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,588,000
10,305,600
12,023,200
467 M-1-04-II
11,033,100
13,239,700
15,446,400
468 M-1-04-III
13,201,400
15,841,700
18,481,900
469 M-1-05-I
470 M-1-05-II

5,452,500
8,819,600
6,543,000
10,583,500
7,633,400
12,347,400
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,265,900
13,519,000
15,772,200
6,103,400
7,324,100
8,544,800
8,176,500
9,811,700
11,447,000
16,656,200
19,987,400
23,318,700
10,047,200
12,056,700
14,066,100
22,047,400
26,456,900
30,866,400
47,554,200
57,065,100
66,575,900
9,176,900
11,012,300
12,847,700
11,724,500
14,069,300
16,414,200
480 M-1-20-III
29,190,300
35,028,400
40,866,400
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,295,600
10,201,500
14,587,200
7,554,700
12,241,700
17,504,600
8,813,800
14,282,000
20,422,000
3,204,700
3,845,600
4,486,600
5,683,400
6,820,100
7,956,800
8,114,800
9,737,800
11,360,700
3,840,300
6,373,000
10,467,300
4,608,400
7,647,600
12,560,700
5,376,500
8,922,200
14,654,200
5,931,100
7,117,300
8,303,500
7,456,800
8,948,100
10,439,500
11,264,300
13,517,200
15,770,100
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 113 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,200,400
2,640,500
3,080,600
500 M-4-10-II
501 M-4-10-III
3,281,500
6,208,700
3,937,800
7,450,400
4,594,100
8,692,100
2,741,900
3,290,300
3,838,700
6,011,500
7,213,800
8,416,100
8,691,600
10,429,900
12,168,200
2,188,700
2,626,400
3,064,100
3,640,300
4,368,400
5,096,500
4,869,300
5,843,200
6,817,000
3,644,300
4,373,200
5,102,100
5,475,400
6,570,500
7,665,600
10,682,500
12,819,000
14,955,500
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,156,200
4,987,500
5,818,700
512 M-4-14-II
5,126,100
6,151,300
7,176,500
513 M-4-14-III
514 M-4-15-I
7,703,000
2,464,500
9,243,600
2,957,400
10,784,200
3,450,300
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,285,000
7,454,700
2,110,000
3,378,900
5,676,400
3,942,000
8,945,700
2,532,000
4,054,700
6,811,600
4,599,100
10,436,600
2,954,000
4,730,500
7,946,900
2,738,500
3,286,200
3,833,900
3,830,100
4,596,100
5,362,200
5,348,500
6,418,200
7,487,900
2,069,900
3,119,400
3,755,900
2,483,900
3,743,300
4,507,100
2,897,800
4,367,200
5,258,300
2,158,600
2,590,300
3,022,000
3,635,800
4,363,000
5,090,200
7,101,000
8,521,300
9,941,500
2,177,400
2,612,900
3,048,400
3,188,400
3,826,100
4,463,800
3,563,400
4,276,100
4,988,800
2,192,500
2,631,000
3,069,500
2,742,100
3,290,600
3,839,000
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
10,988,400
13,186,100
15,383,800
12,087,300
14,504,700
16,922,200
13,838,300
16,606,000
19,373,700
6,246,500
7,495,800
8,745,100
7,418,300
16,696,900
8,901,900
20,036,300
10,385,600
23,375,700
- 114 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,147,800
7,377,400
8,607,000
535 N-1-01-I

102,068,600
122,482,300
142,896,000
536 N-1-01-II
102,068,600
122,482,300
142,896,000
537 N-1-01-III
538 N-1-11-I

102,068,600
6,324,100
122,482,300
7,589,000
142,896,000
8,853,800
539 N-1-11-II
540 N-1-11-III

10,000,000
15,590,000
12,000,000
18,708,000
14,000,000
21,826,000
3,223,200
3,867,800
4,512,500
6,417,000
7,700,400
8,983,900
13,925,200
16,710,200
19,495,300
7,047,100
8,456,600
9,866,000

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,862,100
13,800,800
11,834,500
16,561,000
13,806,900
19,321,100
6,449,400
7,739,200
9,029,100
9,756,600
11,707,900
13,659,300
11,228,900
13,474,700
15,720,500
5,792,000
6,950,400
8,108,800
7,865,400
9,438,500
11,011,500
9,154,300
10,985,100
12,816,000
2,460,800
2,952,900
3,445,100
2,976,400
3,571,600
4,166,900
4,377,800
5,253,400
6,128,900
1,889,100
3,300,400
4,106,400
2,155,400
3,999,300
4,813,800
3,249,600
3,919,400
6,006,300
2,266,900
3,960,500
4,927,700
2,586,500
4,799,200
5,776,600
3,899,600
4,703,300
7,207,600
2,644,700
4,620,600
5,749,000
3,017,500
5,599,000
6,739,300
4,549,500
5,487,200
8,408,800
1,897,200
2,276,700
2,656,100
2,692,100
3,230,500
3,768,900
4,315,400
5,178,500
6,041,500
2,241,300
2,689,600
3,137,900
2,781,100
3,337,300
3,893,500
3,173,700
3,808,400
4,443,200
2,744,500
3,293,400
3,842,300
3,917,300
4,700,700
5,484,200
5,214,200
6,257,000
7,299,900
4,830,200
5,102,000
5,796,300
6,122,400
6,762,300
7,142,800
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 115 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,396,100
7,675,300
8,954,500
2,551,100
3,061,400
3,571,600
2,835,300
3,402,400
3,969,400
3,527,200
4,232,600
4,938,000
1,807,500
2,168,900
2,530,400
2,170,700
2,604,900
3,039,000
2,727,600
3,273,100
3,818,700
1,544,900
1,853,900
2,162,800

MAYOR (RINGAN)
MAYOR (SEDANG)
1,828,500
2,194,200
2,194,200
2,633,000
2,559,900
3,071,800
40,360,700
48,432,800
56,504,900
49,940,300
59,928,300
69,916,400
58,615,800
70,339,000
82,062,200
67,998,700
81,598,400
95,198,200
78,001,400
93,601,700
109,202,000
89,122,200
106,946,700
124,771,100
7,348,100
8,817,700
10,287,300
10,902,100
13,082,600
15,263,000
12,339,000
14,806,800
17,274,700
21,787,800
26,145,300
30,502,900
36,680,700
44,016,900
51,353,000
52,590,900
63,109,100
73,627,200
15,407,500
18,489,000
21,570,500
22,338,300
26,806,000
31,273,700
32,056,400
38,467,700
44,879,000
3,909,200
4,691,100
5,472,900
10,960,500
13,152,600
15,344,700
14,520,000
17,424,000
20,328,000
3,786,500
4,543,800
5,301,100
10,616,400
12,739,700
14,862,900
14,064,100
16,876,900
19,689,700
3,841,500
4,609,800
5,378,100
5,451,100
6,541,300
7,631,500
8,826,400
10,591,700
12,357,000
6,680,100
8,016,100
9,352,100
9,911,000
11,893,200
13,875,400
- 116 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,217,300
13,460,800
15,704,200
5,808,700
6,970,500
8,132,200
8,259,200
9,911,000
11,562,900
9,347,800
11,217,300
13,086,900
4,989,600
5,987,500
6,985,400
7,783,800
9,340,500
10,897,300
10,624,500
12,749,400
14,874,300
2,632,500
3,159,000
3,685,500
5,358,700
6,430,500
7,502,200
9,942,500
11,931,000
13,919,500
1,974,400
2,369,300
2,764,200
3,953,900
4,744,600
5,535,400
4,639,100
5,567,000
6,494,800
1,786,900
2,144,200
2,501,600
3,433,800
4,120,500
4,807,300
7,002,400
8,402,800
9,803,300
3,326,400
3,991,700
4,657,000
5,987,500
7,185,000
8,382,500
8,172,700
9,807,200
11,441,800
2,014,700
2,417,600
2,820,500
2,482,400
2,978,900
3,475,300
3,398,100
4,077,700
4,757,400
1,561,100
2,289,200
3,912,500
1,481,200
1,971,400
3,417,500
1,873,300
2,747,000
4,695,000
1,777,400
2,365,700
4,101,000
2,185,500
3,204,800
5,477,500
2,073,700
2,760,000
4,784,500
2,187,300
2,624,800
3,062,300
3,880,500
4,656,600
5,432,700
6,298,500
7,558,200
8,817,900
1,106,900
1,328,300
1,549,700
2,351,200
2,821,500
3,291,700
4,458,700
5,350,500
6,242,200
740,300
888,400
1,036,500
1,397,100
1,676,500
1,956,000
1,809,500
2,171,400
2,533,300
3,833,600
4,600,300
5,367,000
- 117 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,875,400
5,850,500
6,825,600
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,980,600
8,376,700
9,772,800
1,847,700
2,217,300
2,586,800
2,742,200
3,290,600
3,839,100
3,298,100
3,957,700
4,617,400
1,236,300
1,483,500
1,730,800
1,660,500
1,992,600
2,324,600
3,020,600
3,624,800
4,228,900
589,500
707,400
825,300
1,123,600
1,348,300
1,573,000
1,633,300
1,960,000
2,286,600
789,200
947,100
1,104,900
1,241,900
1,490,300
1,738,700
2,000,400
2,400,500
2,800,600
1,226,300
1,471,600
1,716,900
1,853,600
2,224,300
2,595,000
2,869,500
3,443,400
4,017,300
4,040,000
4,848,000
5,656,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,271,600
16,565,000
7,526,000
19,878,000
8,780,300
23,191,000
6,250,000
7,500,000
8,750,000
7,922,800
9,507,400
11,092,000
11,399,700
13,679,600
15,959,600
4,883,700
7,488,900
10,999,600
4,887,100
5,694,200
9,439,200
5,860,400
8,986,700
13,199,600
5,864,500
6,833,000
11,327,000
6,837,200
10,484,400
15,399,500
6,841,900
7,971,900
13,214,900
2,936,800
3,524,100
4,111,500
3,604,100
4,325,000
5,045,800
4,270,900
5,125,100
5,979,200
3,549,300
5,046,100
6,504,100
4,259,200
6,055,300
7,805,000
4,969,000
7,064,500
9,105,800
4,458,500
5,350,200
6,241,900
6,635,500
7,962,500
9,289,600
17,034,500
20,441,400
23,848,300
3,823,600
5,184,700
10,138,900
4,588,400
6,221,600
12,166,600
5,353,100
7,258,600
14,194,400
2,751,600
3,302,000
3,852,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 118 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,672,400
2,006,900
2,341,400
697 U-4-12-I
698 U-4-12-II

2,409,900
2,803,200
2,891,800
3,363,800
3,373,800
3,924,500
699 U-4-12-III

3,636,500
4,363,800
5,091,100
1,826,300
2,191,600
2,556,900
2,153,100
2,583,700
3,014,300
2,575,200
3,090,200
3,605,300
2,738,800
3,279,700
3,286,600
3,935,600
3,834,300
4,591,500

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,507,500
6,609,000
7,710,500
2,199,200
2,639,000
3,078,900
2,739,900
3,287,900
3,835,900
3,834,500
4,601,400
5,368,300
3,587,100
4,304,500
5,021,900
7,389,200
8,867,000
10,344,900
9,061,800
10,874,200
12,686,600
6,824,200
7,792,400
12,203,300
8,189,100
9,350,900
14,643,900
9,553,900
10,909,400
17,084,600
6,416,100
7,699,300
8,982,500
8,761,700
10,514,000
12,266,300
11,105,500
13,326,600
15,547,700
3,346,700
4,016,000
4,685,400
6,394,500
7,673,300
8,952,200
10,032,100
12,038,500
14,045,000
6,562,900
7,875,400
9,188,000
9,535,700
11,442,800
13,349,900
11,907,000
14,288,400
16,669,800
1,057,000
1,166,300
1,290,200
1,268,300
1,399,600
1,548,300
1,479,700
1,632,900
1,806,300
3,173,700
3,808,400
4,443,200
5,271,700
6,326,000
7,380,300
8,691,100
10,429,400
12,167,600
2,742,300
3,290,700
3,839,200
3,679,400
4,415,300
5,151,200
4,928,600
5,914,300
6,900,100
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,299,400
7,559,200
8,819,100
9,671,400
11,605,700
13,540,000
1,311,700
1,589,700
1,574,000
1,907,700
1,836,400
2,225,600
- 119 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,474,400
8,969,300
10,464,200
8,958,600
10,750,300
12,542,100
12,783,700
15,340,500
17,897,200
1,585,400
1,902,500
2,219,600
1,749,500
1,935,300
2,099,400
2,322,400
2,449,300
2,709,400
1,657,100
1,988,600
2,320,000
1,828,600
2,194,400
2,560,100
2,022,800
2,427,400
2,832,000
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,782,700
2,139,300
2,495,800
743 W-1-12-II
744 W-1-12-III

2,225,200
3,940,300
2,670,200
4,728,300
3,115,200
5,516,400
745 W-1-13-I
1,832,500
2,199,000
2,565,500
746 W-1-13-II
747 W-1-13-III

1,989,500
2,672,400
2,387,400
3,206,900
2,785,300
3,741,300
748 W-1-20-I
749 W-1-20-II

6,136,900
7,668,100
7,364,200
9,201,700
8,591,600
10,735,300
750 W-1-20-III
8,889,300
10,667,100
12,445,000
751 W-1-30-I
3,464,300
4,157,200
4,850,100
752 W-1-30-II
5,525,600
6,630,800
7,735,900
753 W-1-30-III
13,557,400
16,268,900
18,980,400
754 W-4-10-I
2,581,300
3,097,600
3,613,800
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,826,700
7,562,200
2,347,500
3,563,900
4,337,900
4,592,000
9,074,700
2,817,000
4,276,600
5,205,500
5,357,300
10,587,100
3,286,500
4,989,400
6,073,100
2,671,300
3,205,600
3,739,800
3,667,500
4,401,000
5,134,500
3,997,800
4,797,300
5,596,900
923,600
1,261,700
1,569,000
1,234,300
1,469,100
1,879,600
1,503,100
1,669,300
2,311,200
1,999,800
2,674,300
3,624,600
1,475,700
2,664,400
3,939,200
2,267,400
3,009,700
4,275,500
2,026,200
2,433,600
3,345,100
1,108,300
1,514,000
1,882,800
1,481,200
1,763,000
2,255,500
1,803,700
2,003,100
2,773,400
2,399,800
3,209,200
4,349,500
1,770,800
3,197,200
4,727,100
2,720,900
3,611,600
5,130,600
2,431,400
2,920,300
4,014,100
1,293,100
1,766,400
2,196,600
1,728,000
2,056,800
2,631,400
2,104,300
2,337,000
3,235,700
2,799,800
3,744,000
5,074,400
2,065,900
3,730,100
5,514,900
3,174,300
4,213,600
5,985,700
2,836,700
3,407,000
4,683,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 120 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,166,200
1,399,400
1,632,700
2,860,900
3,433,100
4,005,300
4,092,700
4,911,200
5,729,800
- 121 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS C PEMERINTAH
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
905,800
1,175,000
2,185,000
1,805,600
2,346,500
431,600
767,200
337,500
732,400
639,500
726,000
1,091,500
1,488,700
1,364,500
442,000
1,020,200
370,100
635,400
1,935,300
693,100
1,636,800
399,300
931,600
1,458,200
1,223,000
299,900
909,000
505,400
259,900
281,000
248,000
296,600
413,000
354,800
334,000
300,200
445,400
194,500
229,200
262,800
5,333,000
2,131,400
2,138,500
550,100
900,800
564,000
1,146,300
734,500
420,600
317,600
512,300
282,700
242,100
1,889,100
881,600
503,800
1,966,500
1,311,000
255,300
2,130,400
1,474,900
3,465,000
766,200
471,300
253,500
211,200
238,100
3,630,000
1,767,000
- 122 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,245,700
3,974,400
3,295,200
2,510,300
827,600
2,794,000
1,824,400
448,500
4,194,800
3,797,500
2,546,200
2,412,200
298,100
286,500
1,152,700
315,000
280,700
310,200
1,064,800
1,454,400
1,270,400
1,121,900
679,500
282,300
497,700
341,600
308,500
300,500
381,600
435,100
255,100
732,100
1,334,200
1,024,200
2,407,800
313,500
313,500
2,224,900
1,293,700
248,200
1,148,100
2,982,600
684,800
539,400
264,200
234,100
286,200
399,100
955,700
842,300
589,600
439,900
242,100
1,023,900
820,400
350,500
400,000
1,310,700
289,800
1,339,200
1,024,500
312,400
346,300
338,300
204,700
1,116,300
1,533,700
304,000
- 123 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
931,600
347,700
376,000
348,100
552,300
424,800
1,064,000
313,900
873,400
1,167,100
255,600
1,555,700
843,000
1,821,900
919,700
406,200
312,400
67,600
404,900
915,000
356,600
481,700
275,400
107,400
278,200
4,142,300
2,354,500
3,929,800
965,400
539,400
367,500
831,200
439,600
884,800
512,300
305,000
510,500
229,800
350,800
336,100
786,200
1,603,600
1,290,200
1,137,600
802,800
295,300
295,300
295,300
241,200
153,000
240,600
294,100
318,100
234,300
206,700
94,700
104,100
77,000
90,400
86,200
131,600
118,000
164,200
180,400
104,800
127,200
86,900
135,700
192,500
- 124 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
137,000
184,300
521,100
604,100
129,600
250,700
157,700
225,100
421,800
361,100
259,600
245,800
128,800
126,600
289,400
182,600
262,000
181,400
142,000
1,820,500
1,872,600
297,500
308,200
589,300
759,800
754,400
389,700
1,214,400
269,500
316,700
317,700
254,400
321,300
304,100
142,500
313,000
277,500
251,000
283,800
2,349,600
305,100
845,600
303,300
431,500
465,000
371,000
734,300
752,000
801,800
701,400
1,285,200
209,000
1,450,800
275,400
735,400
1,671,300
1,932,500
844,200
305,900
596,700
594,300
275,400
2,159,100
1,698,200
138,400
154,100
200,200
262,700
- 125 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
995,100
434,100
894,800
1,079,600
517,300
719,700
497,400
549,400
628,500
296,400
700,800
183,900
681,400
1,071,300
74,700
- 126 -

REGIONAL 1
RUMAH SAKIT KELAS C SWASTA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,938,700
2,326,400
2,714,200
A-4-10-II
SEPTIKEMIA (SEDANG)
3,312,100
3,974,500
4,636,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,465,700
2,854,600
5,358,900
3,425,500
6,252,000
3,996,400
5
6
A-4-11-II
A-4-11-III

4,062,900
5,623,400
4,875,400
6,748,000
5,688,000
7,872,700
A-4-12-I
2,584,900
3,101,800
3,618,800
8
9
A-4-12-II
A-4-12-III

3,219,000
3,435,600
3,862,900
4,122,700
4,506,700
4,809,800
10 A-4-13-I
11 A-4-13-II

1,554,400
2,341,700
1,865,300
2,810,100
2,176,200
3,278,400
12 A-4-13-III
2,810,100
3,372,100
3,934,100
2,155,300
2,586,400
3,017,400
2,616,200
3,139,400
3,662,700
3,139,400
3,767,300
4,395,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,383,800
5,065,200
4,060,600
6,078,200
4,737,400
7,091,300
18 A-4-15-III
INFEKSI HIV (BERAT)
6,356,400
7,627,700
8,899,000
19 B-1-01-I
20 B-1-01-II

23,166,900
25,559,300
27,800,200
30,671,100
32,433,600
35,783,000
21 B-1-01-III
22 B-1-10-I

44,836,300
4,002,800
53,803,500
4,803,400
62,770,800
5,604,000
23 B-1-10-II
8,884,600
10,661,500
12,438,400
24 B-1-10-III
25 B-1-11-I

17,539,300
5,348,500
21,047,200
6,418,300
24,555,100
7,488,000
26 B-1-11-II
27 B-1-11-III

6,931,300
8,955,200
8,317,600
10,746,200
9,703,900
12,537,200
28 B-1-12-I
5,222,600
6,267,100
7,311,600
29 B-1-12-II
5,808,400
6,970,100
8,131,800
30 B-1-12-III
9,086,600
10,903,900
12,721,300
4,159,800
4,991,800
5,823,800
6,844,500
8,213,400
9,582,300
8,856,200
10,627,400
12,398,600
5,715,800
6,858,900
8,002,100
6,357,000
7,628,300
8,899,700
9,944,800
1,768,500
2,823,000
3,894,400
11,933,700
2,122,100
3,387,600
4,673,300
13,922,700
2,475,800
3,952,200
5,452,100
3,728,600
4,474,300
5,220,000
5,220,100
6,264,100
7,308,100
6,324,000
7,588,800
8,853,600
3,371,100
4,800,300
7,141,700
3,215,700
4,045,300
5,760,300
8,570,100
3,858,900
4,719,500
6,720,400
9,998,400
4,502,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 127 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,746,200
4,495,400
5,244,600
48 B-4-13-III
49 B-4-14-I

5,160,700
3,212,300
6,192,800
3,854,700
7,224,900
4,497,200
50 B-4-14-II
3,747,500
4,497,000
5,246,500
51 B-4-14-III
52 C-4-10-I

5,019,900
2,971,900
6,023,900
3,566,300
7,027,900
4,160,700
53 C-4-10-II
54 C-4-10-III

5,702,400
10,065,200
6,842,900
12,078,300
7,983,400
14,091,300
55 C-4-11-I
3,386,600
4,064,000
4,741,300
56 C-4-11-II
57 C-4-11-III

4,531,800
6,967,700
5,438,200
8,361,300
6,344,500
9,754,800
58 C-4-12-I
59 C-4-12-II
2,254,900
4,441,300
2,705,900
5,329,600
3,156,900
6,217,900
60 C-4-12-III
RADIOTERAPI (BERAT)
11,406,600
13,687,900
15,969,300
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,695,300
3,190,500
2,034,300
3,828,600
2,373,400
4,466,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,318,800
2,816,700
5,182,600
3,380,100
6,046,400
3,943,400
65 C-4-14-II
3,951,300
4,741,600
5,531,800
66 C-4-14-III
67 D-1-10-I

5,887,400
13,784,500
7,064,900
16,541,400
8,242,300
19,298,300
68 D-1-10-II
69 D-1-10-III

20,994,800
33,430,900
25,193,800
40,117,100
29,392,700
46,803,300
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,556,400
5,467,700
6,378,900
11,634,600
15,119,600
13,961,500
18,143,500
16,288,400
21,167,400
3,949,900
4,739,800
5,529,800
10,885,200
13,062,300
15,239,300
17,267,200
20,720,600
24,174,000
2,362,100
3,550,600
5,585,900
3,092,200
5,556,600
7,633,400
2,665,900
3,697,700
5,677,900
2,834,500
4,260,700
6,703,100
3,710,600
6,667,900
9,160,000
3,199,100
4,437,200
6,813,500
3,306,900
4,970,800
7,820,300
4,329,100
7,779,200
10,686,700
3,732,300
5,176,700
7,949,100
2,284,600
2,741,500
3,198,500
3,233,500
3,880,200
4,526,900
4,135,800
4,962,900
5,790,100
2,450,400
2,940,400
3,430,500
4,011,800
4,814,200
5,616,600
4,906,900
5,888,300
6,869,600
4,361,900
5,234,300
6,106,700
5,713,700
6,856,500
7,999,200
93 E-1-01-III
9,921,900
11,906,300
13,890,600
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,402,700
4,130,000
8,704,900
4,083,200
4,956,000
10,445,900
4,763,700
5,782,000
12,186,900
5,749,000
6,898,800
8,048,600
97 E-1-20-I
- 128 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,260,000
2,712,100
3,164,100
104 E-4-11-II
105 E-4-11-III

3,445,600
4,669,100
4,134,800
5,602,900
4,823,900
6,536,700
106 E-4-12-I
107 E-4-12-II

2,596,800
4,497,000
3,116,100
5,396,400
3,635,500
6,295,800
108 E-4-12-III

(RINGAN)
(SEDANG)
5,330,500
6,396,700
7,462,800
2,827,800
3,393,300
3,958,900
4,142,200
4,970,600
5,799,100
111 E-4-13-III
5,414,700
6,497,600
7,580,500
112 F-4-10-I
113 F-4-10-II
3,010,500
3,460,000
3,612,600
4,152,000
4,214,800
4,844,000
114 F-4-10-III
115 F-4-11-I
4,152,000
2,911,700
4,982,400
3,494,000
5,812,800
4,076,300
116 F-4-11-II
3,392,400
4,070,900
4,749,400
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,350,300
5,220,300
6,090,400
1,596,100
1,915,300
2,234,500
2,269,100
2,722,900
3,176,700
4,929,500
5,915,400
6,901,300
2,345,400
3,094,800
4,006,600
1,338,200
1,716,400
2,309,500
2,814,500
3,713,800
4,808,000
1,605,800
2,059,700
2,771,500
3,283,600
4,332,800
5,609,300
1,873,400
2,402,900
3,233,400
127 F-4-15-I
2,131,100
2,557,400
2,983,600
128 F-4-15-II
3,175,700
3,810,800
4,445,900
129 F-4-15-III
4,192,900
5,031,400
5,870,000
4,193,100
5,031,700
5,870,300
4,875,200
5,850,200
6,825,200
6,507,500
7,809,000
9,110,500
133 F-4-17-I

990,200
1,188,300
1,386,300
134 F-4-17-II
2,902,300
3,482,700
4,063,200
135
136
137
138
139
140
141

(RINGAN)
3,096,500
3,643,500
4,008,900
6,180,000
2,784,500
3,565,700
4,439,200
3,715,800
4,372,200
4,810,700
7,416,000
3,341,400
4,278,800
5,327,000
4,335,100
5,100,900
5,612,400
8,652,000
3,898,300
4,991,900
6,214,900
10,619,000
12,742,800
14,866,500
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,738,000
9,285,600
10,833,200
10,664,600
12,797,500
14,930,400
3,430,500
4,116,600
4,802,700
4,793,500
5,752,200
6,710,900
5,949,700
7,139,700
8,329,600
- 129 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,120,200
16,944,300
19,768,300
148 G-1-11-I
149 G-1-11-II

9,039,800
16,526,800
10,847,700
19,832,200
12,655,700
23,137,500
150 G-1-11-III
30,471,300
36,565,600
42,659,900
3,774,400
4,529,300
5,284,200
7,075,300
8,490,400
9,905,500
9,642,300
11,570,700
13,499,200
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,138,600
3,057,800
1,366,400
3,669,400
1,594,100
4,280,900
156 G-1-13-III
157 G-1-20-I

6,899,700
4,781,700
8,279,700
5,738,000
9,659,600
6,694,400
158 G-1-20-II
5,686,300
6,823,600
7,960,800
159 G-1-20-III
13,271,200
15,925,500
18,579,700
160 G-1-30-I
7,014,400
8,417,300
9,820,100
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,206,900
19,953,200
17,048,200
23,943,800
19,889,600
27,934,500
3,239,900
3,887,900
4,535,900
3,960,300
4,752,400
5,544,400
5,434,200
6,521,000
7,607,900
3,391,700
4,070,000
4,748,400
4,505,400
5,406,500
6,307,600
6,620,000
7,944,000
9,268,000
3,762,700
4,515,200
5,267,800
4,752,600
5,703,100
6,653,600
6,902,500
8,283,000
9,663,500
2,260,300
2,712,400
3,164,400
3,941,500
4,729,800
5,518,100
4,674,700
5,609,700
6,544,600
3,834,300
4,601,200
5,368,100
5,126,200
6,151,500
7,176,700
6,434,000
7,720,800
9,007,600
3,133,000
3,759,600
4,386,200
3,739,100
4,486,900
5,234,700
5,277,400
6,332,900
7,388,300
2,582,700
3,099,300
3,615,800
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,536,000
19,843,200
23,150,400
31,801,800
38,162,100
44,522,500
10,884,800
12,815,700
13,061,800
15,378,900
15,238,700
17,942,000
- 130 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,428,900
4,114,700
4,800,500
183 G-4-16-III
4,883,100
5,859,700
6,836,300
3,440,000
4,128,000
4,816,000
4,510,600
5,412,700
6,314,900
5,667,800
6,801,400
7,934,900
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,387,900
4,065,500
4,743,000
188 G-4-18-II
4,528,600
5,434,300
6,340,000
189 G-4-18-III
5,067,100
6,080,500
7,094,000
2,826,600
3,391,900
3,957,200
4,777,600
5,733,100
6,688,700
6,272,800
7,527,400
8,781,900
193 G-4-20-I

1,977,300
2,372,800
2,768,300
194 G-4-20-II
2,795,400
3,354,400
3,913,500
195 G-4-20-III
196 G-4-21-I

4,617,200
2,059,100
5,540,700
2,470,900
6,464,100
2,882,700
197 G-4-21-II
198 G-4-21-III

3,485,000
4,095,700
4,182,000
4,914,900
4,879,100
5,734,000
199 G-4-22-I
2,601,100
3,121,300
3,641,500
200 G-4-22-II
201 G-4-22-III

3,323,400
3,883,300
3,988,100
4,659,900
4,652,800
5,436,600
202 G-4-23-I
203 G-4-23-II

2,027,000
2,543,100
2,432,400
3,051,800
2,837,800
3,560,400
204 G-4-23-III
3,620,800
4,345,000
5,069,200
205 G-4-24-I
206 G-4-24-II

2,257,700
2,820,700
2,709,300
3,384,900
3,160,800
3,949,000
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,699,200
1,929,200
2,439,700
3,233,100
5,639,100
2,315,000
2,927,600
3,879,700
6,578,900
2,700,900
3,415,600
4,526,300
3,048,700
3,658,400
4,268,100
3,546,500
4,255,800
4,965,100
5,303,100
6,363,800
7,424,400
4,354,600
5,551,100
7,549,000
6,626,000
8,232,200
11,530,400
2,611,800
3,543,600
6,965,200
2,254,000
2,571,100
3,681,700
2,657,500
3,175,200
5,321,100
5,225,600
6,661,300
9,058,800
7,951,200
9,878,600
13,836,500
3,134,100
4,252,400
8,358,300
2,704,800
3,085,400
4,418,000
3,189,000
3,810,200
6,385,300
6,096,500
7,771,500
10,568,600
9,276,400
11,525,100
16,142,600
3,656,500
4,961,100
9,751,300
3,155,600
3,599,600
5,154,400
3,720,500
4,445,300
7,449,500
229 I-1-01-I
35,694,700
42,833,700
49,972,600
230 I-1-01-II
36,480,000
43,776,000
51,072,000
231 I-1-01-III

(RINGAN)
57,583,200
69,099,900
80,616,500
19,803,300
23,764,000
27,724,600
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 131 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,305,700
19,566,900
22,828,000
245 I-1-06-II
23,620,200
28,344,200
33,068,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
28,183,200
33,819,900
39,456,500
19,410,000
23,292,000
27,174,000
23,946,200
28,735,400
33,524,600
26,125,200
31,350,200
36,575,200
3,103,200
3,723,900
4,344,500
3,450,500
4,140,600
4,830,700
4,591,600
5,509,900
6,428,200
8,932,600
10,719,100
12,505,700
14,588,700
17,506,500
20,424,200
19,193,700
23,032,400
26,871,200
8,664,500
10,397,400
12,130,300
11,538,600
13,846,300
16,154,000
14,230,200
17,076,300
19,922,300
17,734,100
21,280,900
24,827,800
22,040,900
26,449,100
30,857,300
28,881,200
34,657,400
40,433,700
3,369,000
4,704,700
9,059,400
4,042,800
5,645,600
10,871,300
4,716,600
6,586,600
12,683,100
8,733,600
10,480,300
12,227,000
19,760,600
23,712,700
27,664,900
22,793,600
27,352,300
31,911,000
10,112,700
12,135,200
14,157,800
12,662,000
15,194,400
17,726,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,546,000
30,655,200
35,764,400
31,487,000
37,784,500
44,081,900
11,438,400
13,726,100
16,013,800
15,856,000
19,027,300
22,198,500
20,122,500
24,147,000
28,171,600
17,237,100
20,684,500
24,131,900
27,204,800
32,645,800
38,086,700
43,459,500
52,151,400
60,843,300
22,116,800
26,540,200
30,963,500
26,540,200
31,848,300
37,156,300
36,519,200
43,823,000
51,126,800
- 132 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,672,600
23,607,200
27,541,700
279 I-1-40-III
26,276,000
31,531,200
36,786,400
280 I-4-10-I
281 I-4-10-II

2,999,600
5,356,100
3,599,500
6,427,300
4,199,400
7,498,500
282 I-4-10-III
7,717,300
9,260,800
10,804,300
283 I-4-11-I
284 I-4-11-II

4,614,800
5,710,900
5,537,800
6,853,000
6,460,700
7,995,200
285 I-4-11-III
286 I-4-12-I

10,564,500
2,652,900
12,677,400
3,183,500
14,790,300
3,714,100
287 I-4-12-II
3,075,000
3,690,100
4,305,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,690,100
4,428,100
5,166,100
2,699,600
3,239,500
3,779,400
4,820,500
5,784,600
6,748,600
6,945,600
8,334,700
9,723,800
2,549,300
2,637,000
4,622,700
3,059,200
3,164,400
5,547,300
3,569,000
3,691,900
6,471,800
4,389,900
5,267,900
6,145,900
5,972,200
7,166,600
8,361,100
297 I-4-15-III
7,166,600
8,600,000
10,033,300
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,609,000
2,583,600
3,100,400
1,811,400
2,108,800
2,530,500
1,930,800
3,100,400
3,720,400
2,173,600
2,530,500
3,036,600
2,252,600
3,617,100
4,340,500
2,535,900
2,952,300
3,542,700
3,103,600
3,724,300
4,345,000
4,725,300
5,670,400
6,615,400
6,415,400
7,698,500
8,981,500
307 I-4-19-I
2,994,300
3,593,200
4,192,000
308 I-4-19-II

(SEDANG)
4,674,300
5,609,200
6,544,000
309 I-4-19-III
5,580,200
6,696,300
7,812,300
310
311
312
313
314

3,118,000
3,601,300
5,384,600
2,333,200
2,956,100
3,741,600
4,321,500
6,461,500
2,799,800
3,547,400
4,365,200
5,041,800
7,538,500
3,266,400
4,138,600
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,662,700
18,795,300
21,927,800
11,398,700
13,678,500
15,958,200
14,240,100
17,088,200
19,936,200
14,969,300
17,963,200
20,957,100
8,622,500
10,347,000
12,071,500
17,936,700
21,524,000
25,111,400
27,795,400
33,354,500
38,913,600
7,957,600
9,549,200
11,140,700
- 133 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,266,900
5,120,200
5,973,600
316 I-4-22-I
317 I-4-22-II
2,615,100
3,255,400
3,138,100
3,906,500
3,661,100
4,557,500
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,758,300
5,710,000
6,661,700
2,559,400
3,071,300
3,583,200
3,142,200
3,770,700
4,399,100
6,139,700
7,367,700
8,595,600
2,304,800
2,765,700
3,226,700
5,307,200
6,368,700
7,430,100
6,710,100
8,052,100
9,394,100
41,579,800
49,895,800
58,211,800
47,055,300
56,466,400
65,877,500
53,234,400
63,881,200
74,528,100
22,064,900
26,477,900
30,890,900
30,723,100
36,867,700
43,012,300
50,734,400
60,881,200
71,028,100
6,700,500
8,040,600
9,380,700
13,558,500
16,270,300
18,982,000
14,090,700
16,908,800
19,726,900
9,494,000
11,392,800
13,291,500
12,544,700
15,053,700
17,562,600
19,210,900
23,053,100
26,895,300
5,591,800
6,710,100
7,828,500
10,129,400
12,155,300
14,181,200
29,238,200
35,085,800
40,933,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,284,700
4,718,600
7,138,500
2,039,300
2,840,400
3,807,200
3,463,800
3,943,000
5,505,500
3,062,600
4,263,000
7,953,400
3,376,500
5,494,600
6,500,700
4,119,700
4,921,900
6,621,900
2,741,700
5,662,300
8,566,200
2,447,200
3,408,400
4,568,700
4,156,500
4,731,600
6,606,600
3,675,100
5,115,600
9,544,000
4,051,900
6,593,500
7,800,800
4,943,600
5,906,200
7,946,300
3,198,600
6,606,000
9,993,900
2,855,000
3,976,500
5,330,100
4,849,300
5,520,200
7,707,700
4,287,600
5,968,200
11,134,700
4,727,200
7,692,500
9,101,000
5,767,500
6,890,600
9,270,600
3,432,600
4,119,100
4,805,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 134 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,823,600
5,788,400
6,753,100
360 J-4-16-III
6,098,800
7,318,500
8,538,300
361 J-4-17-I
362 J-4-17-II

2,821,400
3,378,700
3,385,700
4,054,500
3,950,000
4,730,200
363 J-4-17-III
364 J-4-18-I

4,433,900
2,114,600
5,320,700
2,537,500
6,207,500
2,960,400
365 J-4-18-II
2,908,400
3,490,100
4,071,800
366 J-4-18-III
367 J-4-19-I

3,061,500
3,974,000
3,673,800
4,768,900
4,286,100
5,563,700
368 J-4-19-II
369 J-4-19-III

4,506,800
4,977,200
5,408,200
5,972,700
6,309,500
6,968,100
370 J-4-20-I
3,943,700
4,732,400
5,521,200
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,464,400
6,406,000
6,557,300
7,687,200
7,650,200
8,968,400
2,740,800
3,289,000
3,837,100
4,415,400
5,298,500
6,181,500
6,161,300
7,393,600
8,625,900
6,074,400
7,289,300
8,504,200
7,633,800
9,160,600
10,687,400
8,947,100
10,736,500
12,525,900
6,821,000
8,185,300
9,549,500

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
8,955,200
13,552,100
10,746,200
16,262,600
12,537,300
18,973,000
2,548,700
3,058,500
3,568,200
3,314,900
3,977,900
4,640,900
6,567,400
7,880,900
9,194,400
2,874,500
3,161,900
3,190,700
3,449,400
3,794,300
3,828,800
4,024,300
4,426,700
4,466,900
4,664,800
5,597,700
6,530,700
5,467,000
6,560,400
7,653,800
8,589,400
10,307,300
12,025,100
9,032,500
12,616,300
18,421,200
10,839,000
15,139,600
22,105,400
12,645,500
17,662,900
25,789,700
5,341,700
6,410,100
7,478,400
9,486,800
11,384,200
13,281,500
13,054,000
15,664,800
18,275,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,960,100
7,152,200
8,344,200
398 K-1-40-II

(SEDANG)
6,571,300
7,885,500
9,199,800
399 K-1-40-III
11,135,900
13,363,100
15,590,300
400
401
402
403
404

4,554,100
5,914,100
8,357,700
3,759,700
5,402,100
5,465,000
7,097,000
10,029,300
4,511,600
6,482,500
6,375,800
8,279,800
11,700,800
5,263,600
7,563,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 135 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,235,200
9,882,300
11,529,300
406 K-4-11-I
407 K-4-11-II

2,203,700
3,131,600
2,644,400
3,757,900
3,085,200
4,384,200
408 K-4-11-III
409 K-4-12-I

3,757,900
2,260,000
4,509,500
2,712,100
5,261,100
3,164,100
410 K-4-12-II
3,041,300
3,649,600
4,257,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,031,400
6,037,600
7,043,900
3,046,700
3,656,000
4,265,400
3,941,100
4,729,300
5,517,500
6,070,500
7,284,600
8,498,800
1,931,600
2,317,900
2,704,300
2,592,900
3,111,400
3,630,000
4,160,500
4,992,600
5,824,700
418 K-4-15-I
1,995,800
2,395,000
2,794,200
419 K-4-15-II
2,959,300
3,551,200
4,143,000
420 K-4-15-III
4,153,300
4,983,900
5,814,600
421 K-4-16-I
2,820,100
3,384,100
3,948,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,382,100
3,946,400
4,058,500
4,735,700
4,734,900
5,524,900
1,448,400
1,738,100
2,027,800
1,981,100
2,377,300
2,773,500
2,377,300
2,852,700
3,328,200
1,279,900
1,535,900
1,791,800
1,818,800
2,182,500
2,546,300
429 K-4-18-III
2,182,500
2,619,000
3,055,500
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,401,200
21,738,200
29,045,700
6,794,600
11,659,100
14,475,000
17,281,400
26,085,800
34,854,900
8,153,500
13,990,900
17,369,900
20,161,600
30,433,400
40,664,000
9,512,400
16,322,700
20,264,900
3,807,800
4,569,400
5,331,000
7,637,700
9,165,200
10,692,800
12,855,900
15,427,100
17,998,300
4,998,900
8,045,300
11,508,000
1,307,500
1,517,600
1,761,600
2,738,100
3,763,300
8,551,300
1,300,300
1,719,900
4,549,600
5,998,700
9,654,300
13,809,500
1,569,000
1,821,200
2,113,900
3,285,700
4,515,900
10,261,600
1,560,400
2,063,900
5,459,500
6,998,500
11,263,400
16,111,100
1,830,500
2,124,700
2,466,200
3,833,300
5,268,600
11,971,900
1,820,500
2,407,800
6,369,400
2,334,600
2,801,600
3,268,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 136 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,743,800
3,292,600
3,841,400
4,037,600
4,845,100
5,652,700
2,251,800
2,702,100
3,152,500
3,382,200
4,058,700
4,735,100
4,767,600
5,721,200
6,674,700
7,959,700
9,551,700
11,143,600
11,313,700
13,576,400
15,839,100
15,892,300
19,070,800
22,249,200
7,054,800
8,465,800
9,876,700
11,573,200
19,662,500
13,887,800
23,595,000
16,202,400
27,527,600
19,154,300
22,985,200
26,816,100
22,403,700
26,884,500
31,365,200
27,728,400
33,274,000
38,819,700
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,845,700
10,614,800
12,383,900
467 M-1-04-II
11,364,100
13,636,900
15,909,800
468 M-1-04-III
13,597,400
16,316,900
19,036,400
469 M-1-05-I
470 M-1-05-II

5,616,000
9,084,100
6,739,200
10,901,000
7,862,500
12,717,800
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,603,800
13,924,600
16,245,400
6,286,500
7,543,800
8,801,100
8,421,700
10,106,100
11,790,400
17,155,900
20,587,100
24,018,200
10,348,600
12,418,400
14,488,100
22,708,800
27,250,600
31,792,400
48,980,800
58,777,000
68,573,200
9,452,200
11,342,700
13,233,100
12,076,200
14,491,400
16,906,700
480 M-1-20-III
30,066,000
36,079,200
42,092,400
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,484,500
10,507,500
15,024,800
7,781,400
12,609,000
18,029,700
9,078,300
14,710,500
21,034,700
3,300,800
3,961,000
4,621,200
5,853,900
7,024,700
8,195,500
8,358,300
10,029,900
11,701,600
3,955,600
6,564,200
10,781,300
4,746,700
7,877,000
12,937,500
5,537,800
9,189,900
15,093,800
6,109,000
7,330,800
8,552,600
7,680,500
9,216,600
10,752,600
11,602,300
13,922,700
16,243,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 137 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,266,400
2,719,700
3,173,000
500 M-4-10-II
501 M-4-10-III
3,380,000
6,394,900
4,056,000
7,673,900
4,732,000
8,952,900
2,824,200
3,389,000
3,953,800
6,191,800
7,430,200
8,668,600
8,952,300
10,742,800
12,533,300
2,254,300
2,705,200
3,156,000
3,749,500
4,499,400
5,249,400
5,015,400
6,018,500
7,021,600
3,753,700
4,504,400
5,255,100
5,639,700
6,767,700
7,895,600
11,002,900
13,203,500
15,404,100
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,280,900
5,137,100
5,993,300
512 M-4-14-II
5,279,900
6,335,800
7,391,800
513 M-4-14-III
514 M-4-15-I
7,934,100
2,538,500
9,520,900
3,046,100
11,107,800
3,553,800
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,383,600
7,678,400
2,173,300
3,480,300
5,846,700
4,060,300
9,214,000
2,608,000
4,176,400
7,016,000
4,737,000
10,749,700
3,042,600
4,872,400
8,185,300
2,820,700
3,384,800
3,948,900
3,945,000
4,734,000
5,523,000
5,509,000
6,610,700
7,712,500
2,132,000
3,213,000
3,868,600
2,558,400
3,855,600
4,642,300
2,984,800
4,498,200
5,416,000
2,223,300
2,668,000
3,112,700
3,744,900
4,493,900
5,242,900
7,314,100
8,776,900
10,239,700
2,242,700
2,691,300
3,139,800
3,284,100
3,940,900
4,597,700
3,670,400
4,404,400
5,138,500
2,258,200
2,709,900
3,161,500
2,824,400
3,389,300
3,954,200
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,318,100
13,581,700
15,845,300
12,449,900
14,939,900
17,429,900
14,253,500
17,104,200
19,954,900
6,433,900
7,720,600
9,007,400
7,640,800
17,197,800
9,169,000
20,637,400
10,697,100
24,076,900
- 138 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,332,300
7,598,700
8,865,200
535 N-1-01-I

105,130,700
126,156,800
147,182,900
536 N-1-01-II
105,130,700
126,156,800
147,182,900
537 N-1-01-III
538 N-1-11-I

105,130,700
6,513,900
126,156,800
7,816,600
147,182,900
9,119,400
539 N-1-11-II
540 N-1-11-III

10,300,000
16,057,700
12,360,000
19,269,200
14,420,000
22,480,700
3,319,900
3,983,900
4,647,900
6,609,600
7,931,500
9,253,400
14,343,000
17,211,600
20,080,100
7,258,500
8,710,200
10,162,000

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,157,900
14,214,800
12,189,500
17,057,800
14,221,100
19,900,700
6,642,800
7,971,400
9,300,000
10,049,300
12,059,200
14,069,000
11,565,800
13,879,000
16,192,100
5,965,800
7,158,900
8,352,100
8,101,300
9,721,600
11,341,900
9,428,900
11,314,700
13,200,500
2,534,600
3,041,500
3,548,500
3,065,700
3,678,800
4,291,900
4,509,100
5,411,000
6,312,800
1,945,700
3,399,400
4,229,600
2,220,000
4,119,300
4,958,200
3,347,100
4,037,000
6,186,500
2,334,900
4,079,300
5,075,500
2,664,000
4,943,200
5,949,900
4,016,600
4,844,400
7,423,800
2,724,000
4,759,200
5,921,400
3,108,100
5,767,000
6,941,500
4,686,000
5,651,800
8,661,100
1,954,100
2,345,000
2,735,800
2,772,800
3,327,400
3,882,000
4,444,800
5,333,800
6,222,800
2,308,600
2,770,300
3,232,000
2,864,500
3,437,400
4,010,300
3,268,900
3,922,700
4,576,500
2,826,800
3,392,200
3,957,600
4,034,800
4,841,800
5,648,700
5,370,600
6,444,700
7,518,900
4,975,200
5,255,100
5,970,200
6,306,100
6,965,200
7,357,100
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 139 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,587,900
7,905,500
9,223,100
2,627,700
3,153,200
3,678,800
2,920,400
3,504,400
4,088,500
3,633,000
4,359,600
5,086,200
1,861,700
2,234,000
2,606,300
2,235,900
2,683,000
3,130,200
2,809,400
3,371,300
3,933,200
1,591,200
1,909,500
2,227,700

MAYOR (RINGAN)
MAYOR (SEDANG)
1,883,300
2,260,000
2,260,000
2,712,000
2,636,700
3,164,000
41,571,500
49,885,800
58,200,100
51,438,500
61,726,200
72,013,900
60,374,300
72,449,200
84,524,000
70,038,700
84,046,400
98,054,100
80,341,500
96,409,800
112,478,100
91,795,900
110,155,100
128,514,200
7,568,500
9,082,200
10,595,900
11,229,200
13,475,000
15,720,900
12,709,200
15,251,100
17,792,900
22,441,400
26,929,700
31,418,000
37,781,100
45,337,400
52,893,600
54,168,600
65,002,300
75,836,100
15,869,700
19,043,600
22,217,600
23,008,500
27,610,200
32,211,900
33,018,100
39,621,700
46,225,400
4,026,500
4,831,800
5,637,100
11,289,300
13,547,200
15,805,100
14,955,600
17,946,700
20,937,900
3,900,100
4,680,100
5,460,100
10,934,900
13,121,900
15,308,800
14,486,000
17,383,200
20,280,400
3,956,800
4,748,100
5,539,500
5,614,600
6,737,500
7,860,400
9,091,200
10,909,400
12,727,700
6,880,500
8,256,500
9,632,600
10,208,400
12,250,000
14,291,700
- 140 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,553,800
13,864,600
16,175,400
5,983,000
7,179,600
8,376,200
8,507,000
10,208,400
11,909,800
9,628,200
11,553,800
13,479,500
5,139,300
6,167,100
7,195,000
8,017,300
9,620,700
11,224,200
10,943,200
13,131,900
15,320,500
2,711,500
3,253,800
3,796,100
5,519,500
6,623,400
7,727,300
10,240,700
12,288,900
14,337,000
2,033,600
2,440,400
2,847,100
4,072,500
4,887,000
5,701,500
4,778,300
5,734,000
6,689,600
1,840,500
2,208,600
2,576,700
3,536,800
4,244,100
4,951,500
7,212,400
8,654,900
10,097,400
3,426,200
4,111,400
4,796,700
6,167,100
7,400,600
8,634,000
8,417,900
10,101,500
11,785,000
2,075,100
2,490,100
2,905,200
2,556,800
3,068,200
3,579,600
3,500,100
4,200,100
4,900,100
1,607,900
2,357,900
4,029,900
1,525,600
2,030,600
3,520,000
1,929,500
2,829,400
4,835,800
1,830,700
2,436,700
4,224,000
2,251,100
3,301,000
5,641,800
2,135,900
2,842,800
4,928,000
2,252,900
2,703,500
3,154,100
3,996,900
4,796,300
5,595,700
6,487,500
7,784,900
9,082,400
1,140,100
1,368,200
1,596,200
2,421,800
2,906,100
3,390,500
4,592,500
5,511,000
6,429,500
762,500
915,000
1,067,600
1,439,000
1,726,800
2,014,700
1,863,800
2,236,600
2,609,300
3,948,600
4,738,300
5,528,000
- 141 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,021,700
6,026,000
7,030,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,190,000
8,628,000
10,066,000
1,903,100
2,283,800
2,664,400
2,824,500
3,389,400
3,954,300
3,397,100
4,076,500
4,755,900
1,273,400
1,528,000
1,782,700
1,710,300
2,052,300
2,394,400
3,111,300
3,733,500
4,355,800
607,200
728,600
850,100
1,157,300
1,388,700
1,620,200
1,682,300
2,018,800
2,355,200
812,900
975,500
1,138,000
1,279,200
1,535,000
1,790,800
2,060,400
2,472,500
2,884,600
1,263,100
1,515,800
1,768,400
1,909,200
2,291,000
2,672,800
2,955,600
3,546,700
4,137,800
4,161,200
4,993,400
5,825,600

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,459,800
17,062,000
7,751,700
20,474,400
9,043,700
23,886,800
6,437,500
7,725,000
9,012,500
8,160,500
9,792,600
11,424,700
11,741,700
14,090,000
16,438,400
5,030,200
7,713,600
11,329,600
5,033,700
5,865,000
9,722,400
6,036,300
9,256,300
13,595,500
6,040,400
7,038,000
11,666,800
7,042,300
10,799,000
15,861,500
7,047,100
8,211,000
13,611,300
3,024,900
3,629,800
4,234,800
3,712,300
4,454,700
5,197,200
4,399,000
5,278,800
6,158,600
3,655,800
5,197,500
6,699,300
4,386,900
6,236,900
8,039,100
5,118,100
7,276,400
9,379,000
4,592,200
5,510,700
6,429,100
6,834,500
8,201,400
9,568,300
17,545,500
21,054,600
24,563,700
3,938,300
5,340,200
10,443,000
4,726,000
6,408,300
12,531,600
5,513,700
7,476,300
14,620,200
2,834,200
3,401,000
3,967,900
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 142 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,722,600
2,067,100
2,411,600
697 U-4-12-I
698 U-4-12-II

2,482,200
2,887,300
2,978,600
3,464,700
3,475,000
4,042,200
699 U-4-12-III

3,745,600
4,494,700
5,243,800
1,881,100
2,257,400
2,633,600
2,217,700
2,661,200
3,104,800
2,652,400
3,182,900
3,713,400
2,821,000
3,378,000
3,385,200
4,053,600
3,949,400
4,729,300

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,672,800
6,807,300
7,941,900
2,265,200
2,718,200
3,171,200
2,822,100
3,386,500
3,950,900
3,949,600
4,739,500
5,529,400
3,694,700
4,433,600
5,172,500
7,610,900
9,133,100
10,655,200
9,333,700
11,200,400
13,067,200
7,028,900
8,026,200
12,569,400
8,434,700
9,631,500
15,083,300
9,840,500
11,236,700
17,597,100
6,608,600
7,930,300
9,252,000
9,024,500
10,829,400
12,634,300
11,438,700
13,726,400
16,014,100
3,447,100
4,136,500
4,826,000
6,586,300
7,903,500
9,220,800
10,333,100
12,399,700
14,466,300
6,759,800
8,111,700
9,463,700
9,821,700
11,786,100
13,750,400
12,264,200
14,717,000
17,169,900
1,088,700
1,201,300
1,328,900
1,306,400
1,441,600
1,594,700
1,524,100
1,681,900
1,860,500
3,268,900
3,922,700
4,576,500
5,429,800
6,515,800
7,601,700
8,951,900
10,742,200
12,532,600
2,824,500
3,389,400
3,954,300
3,789,800
4,547,700
5,305,700
5,076,500
6,091,800
7,107,100
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,488,300
7,786,000
9,083,700
9,961,600
11,953,900
13,946,200
1,351,100
1,637,400
1,621,300
1,964,900
1,891,500
2,292,400
- 143 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,698,700
9,238,400
10,778,100
9,227,400
11,072,900
12,918,300
13,167,200
15,800,700
18,434,100
1,633,000
1,959,600
2,286,200
1,802,000
1,993,400
2,162,400
2,392,000
2,522,800
2,790,700
1,706,800
2,048,200
2,389,600
1,883,500
2,260,200
2,636,900
2,083,500
2,500,200
2,916,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,836,200
2,203,500
2,570,700
743 W-1-12-II
744 W-1-12-III

2,291,900
4,058,500
2,750,300
4,870,200
3,208,700
5,681,900
745 W-1-13-I
1,887,500
2,265,000
2,642,500
746 W-1-13-II
747 W-1-13-III

2,049,200
2,752,600
2,459,000
3,303,100
2,868,800
3,853,600
748 W-1-20-I
749 W-1-20-II

6,321,000
7,898,100
7,585,200
9,477,800
8,849,400
11,057,400
750 W-1-20-III
9,156,000
10,987,200
12,818,300
751 W-1-30-I
3,568,300
4,281,900
4,995,600
752 W-1-30-II
5,691,400
6,829,700
7,968,000
753 W-1-30-III
13,964,200
16,757,000
19,549,800
754 W-4-10-I
2,658,700
3,190,500
3,722,200
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,941,500
7,789,100
2,417,900
3,670,800
4,468,000
4,729,800
9,346,900
2,901,500
4,404,900
5,361,600
5,518,000
10,904,800
3,385,100
5,139,100
6,255,200
2,751,400
3,301,700
3,852,000
3,777,500
4,533,000
5,288,500
4,117,700
4,941,200
5,764,800
951,300
1,299,500
1,616,000
1,271,300
1,513,200
1,936,000
1,548,200
1,719,400
2,380,500
2,059,800
2,754,500
3,733,300
1,519,900
2,744,300
4,057,400
2,335,400
3,100,000
4,403,800
2,087,000
2,506,600
3,445,400
1,141,600
1,559,400
1,939,300
1,525,600
1,815,900
2,323,200
1,857,800
2,063,200
2,856,600
2,471,800
3,305,500
4,480,000
1,823,900
3,293,200
4,868,900
2,802,500
3,720,000
5,284,500
2,504,400
3,007,900
4,134,500
1,331,800
1,819,300
2,262,500
1,779,900
2,118,500
2,710,400
2,167,400
2,407,100
3,332,700
2,883,800
3,856,400
5,226,600
2,127,900
3,842,000
5,680,400
3,269,600
4,340,000
6,165,300
2,921,800
3,509,200
4,823,600
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 144 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,201,200
1,441,400
1,681,700
2,946,700
3,536,100
4,125,400
4,215,500
5,058,600
5,901,700
- 145 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS C SWASTA
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
951,100
1,233,700
2,294,200
1,895,900
2,463,800
453,200
805,600
354,400
769,000
671,400
762,300
1,146,000
1,563,200
1,432,700
464,100
1,071,200
388,600
667,100
2,032,100
727,700
1,718,600
419,300
978,200
1,531,100
1,284,100
314,900
954,500
530,700
272,900
295,000
260,400
311,400
433,600
372,600
350,700
315,200
467,700
204,200
240,700
275,900
5,599,700
2,237,900
2,245,400
577,600
945,800
592,200
1,203,600
771,200
441,700
333,500
537,900
296,900
254,200
1,983,600
925,700
529,000
2,064,800
1,376,600
268,100
2,236,900
1,548,600
3,638,300
804,500
494,900
266,100
221,800
250,000
3,811,500
1,855,300
- 146 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,358,000
4,173,100
3,460,000
2,635,800
869,000
2,933,700
1,915,600
470,900
4,404,500
3,987,400
2,673,500
2,532,900
313,100
300,800
1,210,400
330,800
294,700
325,700
1,118,000
1,527,100
1,333,900
1,178,000
713,400
296,500
522,500
358,700
323,900
315,600
400,600
456,900
267,800
768,700
1,400,900
1,075,400
2,528,100
329,200
329,200
2,336,200
1,358,400
260,600
1,205,500
3,131,700
719,000
566,300
277,400
245,800
300,500
419,100
1,003,400
884,400
619,100
461,900
254,200
1,075,100
861,400
368,100
420,000
1,376,300
304,300
1,406,100
1,075,700
328,100
363,700
355,200
215,000
1,172,100
1,610,400
319,200
- 147 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
978,200
365,100
394,800
365,500
579,900
446,100
1,117,200
329,600
917,100
1,225,500
268,400
1,633,500
885,200
1,913,000
965,700
426,500
328,100
71,000
425,200
960,800
374,400
505,700
289,200
112,800
292,100
4,349,400
2,472,300
4,126,200
1,013,600
566,300
385,900
872,800
461,600
929,000
537,900
320,200
536,000
241,300
368,300
352,900
825,500
1,683,800
1,354,700
1,194,500
843,000
310,100
310,100
310,100
253,300
160,700
252,600
308,800
334,000
246,000
217,000
99,500
109,300
80,900
94,900
90,500
138,100
123,900
172,400
189,400
110,000
133,500
91,300
142,400
202,100
- 148 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
143,900
193,500
547,100
634,300
136,000
263,300
165,600
236,300
442,900
379,200
272,600
258,100
135,300
132,900
303,900
191,800
275,100
190,400
149,100
1,911,600
1,966,300
312,400
323,600
618,800
797,800
792,100
409,200
1,275,100
282,900
332,500
333,600
267,100
337,400
319,300
149,600
328,700
291,300
263,500
298,000
2,467,100
320,300
887,900
318,500
453,100
488,300
389,500
771,000
789,600
841,900
736,400
1,349,500
219,400
1,523,300
289,200
772,200
1,754,800
2,029,100
886,400
321,200
626,500
624,100
289,200
2,267,000
1,783,100
145,300
161,800
210,300
275,800
- 149 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,044,900
455,900
939,600
1,133,500
543,200
755,700
522,300
576,900
659,900
311,300
735,800
193,100
715,500
1,124,900
78,400
- 150 -

REGIONAL 1
RUMAH SAKIT KELAS D PEMERINTAH
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,642,100
1,970,500
2,298,900
A-4-10-II
SEPTIKEMIA (SEDANG)
2,805,300
3,366,400
3,927,400
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,782,400
2,131,900
4,538,900
2,558,200
5,295,400
2,984,600
5
6
A-4-11-II
A-4-11-III

3,034,300
4,199,700
3,641,100
5,039,600
4,248,000
5,879,500
A-4-12-I
2,384,100
2,860,900
3,337,700
8
9
A-4-12-II
A-4-12-III

2,969,000
3,168,800
3,562,800
3,802,500
4,156,600
4,436,300
10 A-4-13-I
11 A-4-13-II

1,047,100
1,408,300
1,256,500
1,690,000
1,465,900
1,971,700
12 A-4-13-III
1,690,000
2,028,000
2,366,000
2,092,500
2,511,000
2,929,500
2,540,000
3,048,000
3,556,000
3,048,000
3,657,600
4,267,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,866,100
4,290,200
3,439,300
5,148,200
4,012,500
6,006,300
18 A-4-15-III
INFEKSI HIV (BERAT)
5,383,800
6,460,600
7,537,400
19 B-1-01-I
20 B-1-01-II

18,766,600
20,704,500
22,519,900
24,845,400
26,273,200
28,986,300
21 B-1-01-III
22 B-1-10-I

36,320,100
3,390,400
43,584,100
4,068,500
50,848,100
4,746,500
23 B-1-10-II
7,525,200
9,030,200
10,535,200
24 B-1-10-III
25 B-1-11-I

14,855,700
4,530,200
17,826,800
5,436,200
20,798,000
6,342,300
26 B-1-11-II
27 B-1-11-III

5,870,800
7,585,000
7,044,900
9,102,000
8,219,100
10,618,900
28 B-1-12-I
4,423,500
5,308,200
6,192,900
29 B-1-12-II
4,919,700
5,903,600
6,887,600
30 B-1-12-III
7,696,300
9,235,600
10,774,800
3,523,400
4,228,000
4,932,700
5,797,200
6,956,700
8,116,100
7,501,100
9,001,400
10,501,600
4,841,200
5,809,500
6,777,700
5,384,300
6,461,200
7,538,000
8,423,100
1,497,900
2,391,000
3,298,500
10,107,800
1,797,400
2,869,200
3,958,200
11,792,400
2,097,000
3,347,500
4,617,900
3,158,100
3,789,700
4,421,300
4,421,400
5,305,600
6,189,900
5,356,400
6,427,700
7,499,000
2,855,300
4,065,800
6,049,000
2,723,700
3,426,300
4,878,900
7,258,800
3,268,400
3,997,400
5,692,100
8,468,600
3,813,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 151 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,173,000
3,807,600
4,442,200
48 B-4-13-III
49 B-4-14-I

4,371,100
2,720,800
5,245,300
3,264,900
6,119,500
3,809,100
50 B-4-14-II
3,174,100
3,809,000
4,443,800
51 B-4-14-III
52 C-4-10-I

4,251,800
2,517,200
5,102,200
3,020,700
5,952,600
3,524,100
53 C-4-10-II
54 C-4-10-III

4,829,900
8,525,200
5,795,900
10,230,200
6,761,900
11,935,300
55 C-4-11-I
2,868,500
3,442,200
4,015,900
56 C-4-11-II
57 C-4-11-III

3,838,400
5,901,600
4,606,100
7,082,000
5,373,800
8,262,300
58 C-4-12-I
59 C-4-12-II
1,909,900
3,761,800
2,291,900
4,514,200
2,673,900
5,266,500
60 C-4-12-III
RADIOTERAPI (BERAT)
9,661,300
11,593,600
13,525,900
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,435,900
2,702,300
1,723,000
3,242,800
2,010,200
3,783,200
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,658,000
2,385,800
4,389,600
2,862,900
5,121,200
3,340,100
65 C-4-14-II
3,346,700
4,016,100
4,685,400
66 C-4-14-III
67 D-1-10-I

4,986,600
11,675,400
5,983,900
14,010,500
6,981,200
16,345,600
68 D-1-10-II
69 D-1-10-III

17,782,500
28,315,800
21,339,000
33,978,900
24,895,400
39,642,100
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
3,859,200
4,631,100
5,402,900
9,854,400
12,806,200
11,825,300
15,367,400
13,796,200
17,928,700
3,345,500
4,014,600
4,683,700
9,219,700
11,063,700
12,907,600
14,625,200
17,550,200
20,475,300
2,063,900
3,007,300
4,731,200
2,619,100
4,706,400
6,465,400
2,258,000
3,131,900
4,809,200
2,476,700
3,608,800
5,677,500
3,142,900
5,647,700
7,758,500
2,709,600
3,758,300
5,771,000
2,889,500
4,210,200
6,623,700
3,666,700
6,588,900
9,051,600
3,161,200
4,384,700
6,732,800
1,935,100
2,322,100
2,709,100
2,738,800
3,286,500
3,834,300
3,503,000
4,203,500
4,904,100
2,075,400
2,490,500
2,905,600
3,398,000
4,077,600
4,757,200
4,156,100
4,987,300
5,818,600
3,236,700
3,884,000
4,531,300
4,239,700
5,087,600
5,935,600
93 E-1-01-III
8,403,800
10,084,500
11,765,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,756,300
3,345,600
7,051,400
3,307,600
4,014,700
8,461,700
3,858,900
4,683,800
9,872,000
4,869,400
5,843,300
6,817,100
97 E-1-20-I
- 152 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,914,200
2,297,100
2,679,900
104 E-4-11-II
105 E-4-11-III

2,918,400
3,954,700
3,502,100
4,745,600
4,085,800
5,536,600
106 E-4-12-I
107 E-4-12-II

2,199,400
3,808,900
2,639,300
4,570,700
3,079,200
5,332,500
108 E-4-12-III

(RINGAN)
(SEDANG)
4,514,900
5,417,900
6,320,900
2,395,100
2,874,100
3,353,100
3,508,400
4,210,100
4,911,800
111 E-4-13-III
4,586,200
5,503,400
6,420,700
112 F-4-10-I
113 F-4-10-II
2,549,900
2,930,600
3,059,800
3,516,700
3,569,800
4,102,800
114 F-4-10-III
115 F-4-11-I
3,516,700
2,466,200
4,220,000
2,959,400
4,923,400
3,452,600
116 F-4-11-II
2,873,300
3,448,000
4,022,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,684,700
4,421,600
5,158,500
1,351,900
1,622,200
1,892,600
1,921,900
2,306,300
2,690,700
4,175,300
5,010,300
5,845,400
1,986,600
2,621,300
3,393,600
1,133,400
1,453,800
1,956,200
2,383,900
3,145,600
4,072,300
1,360,100
1,744,500
2,347,400
2,781,200
3,669,800
4,751,100
1,586,800
2,035,300
2,738,600
127 F-4-15-I
1,805,100
2,166,100
2,527,100
128 F-4-15-II
2,689,800
3,227,700
3,765,700
129 F-4-15-III
3,551,300
4,261,600
4,971,900
3,551,500
4,261,800
4,972,100
4,129,200
4,955,100
5,780,900
5,511,800
6,614,200
7,716,500
133 F-4-17-I

838,700
1,006,500
1,174,200
134 F-4-17-II
2,458,200
2,949,900
3,441,500
135
136
137
138
139
140
141

(RINGAN)
2,622,700
3,086,000
3,395,500
5,234,400
2,358,400
3,020,100
3,760,000
3,147,200
3,703,200
4,074,600
6,281,300
2,830,100
3,624,100
4,512,000
3,671,800
4,320,400
4,753,700
7,328,200
3,301,800
4,228,100
5,264,000
5,233,700
6,280,400
7,327,100
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,554,100
7,864,900
9,175,700
9,032,800
10,839,400
12,646,000
3,164,100
3,796,900
4,429,700
4,421,200
5,305,500
6,189,700
5,487,600
6,585,100
7,682,600
- 153 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,241,100
6,289,400
7,337,600
148 G-1-11-I
149 G-1-11-II

7,656,600
13,998,100
9,187,900
16,797,700
10,719,300
19,597,300
150 G-1-11-III
22,494,300
26,993,200
31,492,100
3,196,900
3,836,300
4,475,700
5,992,800
7,191,300
8,389,900
8,167,000
9,800,300
11,433,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
964,400
2,589,900
1,157,300
3,107,900
1,350,200
3,625,900
156 G-1-13-III
157 G-1-20-I

5,844,000
2,886,600
7,012,800
3,463,900
8,181,700
4,041,200
158 G-1-20-II
4,767,700
5,721,200
6,674,800
159 G-1-20-III
9,559,300
11,471,200
13,383,000
160 G-1-30-I
4,511,700
5,414,100
6,316,400
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
11,781,500
15,134,600
14,137,700
18,161,500
16,494,000
21,188,400
2,744,200
3,293,000
3,841,900
3,354,300
4,025,200
4,696,100
4,602,700
5,523,300
6,443,800
2,872,700
3,447,300
4,021,800
3,816,100
4,579,300
5,342,500
5,607,100
6,728,500
7,850,000
3,187,000
3,824,400
4,461,800
4,025,400
4,830,500
5,635,500
5,846,400
7,015,600
8,184,900
1,914,500
2,297,400
2,680,200
3,338,400
4,006,100
4,673,800
3,959,500
4,751,400
5,543,300
3,247,700
3,897,200
4,546,700
4,341,900
5,210,300
6,078,600
5,449,600
6,539,500
7,629,400
2,653,600
3,184,300
3,715,100
3,167,000
3,800,400
4,433,700
4,469,900
5,363,900
6,257,900
2,187,600
2,625,100
3,062,600
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,211,600
8,653,900
10,096,200
14,019,400
16,823,200
19,627,100
3,130,300
4,419,600
3,756,300
5,303,500
4,382,400
6,187,400
- 154 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
2,904,300
3,485,100
4,066,000
183 G-4-16-III
4,135,900
4,963,100
5,790,300
2,913,700
3,496,400
4,079,100
3,820,500
4,584,600
5,348,700
4,800,600
5,760,700
6,720,800
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,869,500
3,443,400
4,017,300
188 G-4-18-II
3,835,700
4,602,800
5,369,900
189 G-4-18-III
4,291,800
5,150,200
6,008,500
2,394,100
2,872,900
3,351,700
4,046,600
4,855,900
5,665,300
5,313,000
6,375,600
7,438,200
193 G-4-20-I

1,674,800
2,009,800
2,344,700
194 G-4-20-II
2,367,600
2,841,200
3,314,700
195 G-4-20-III
196 G-4-21-I

3,910,800
1,744,000
4,692,900
2,092,800
5,475,100
2,441,600
197 G-4-21-II
198 G-4-21-III

2,951,800
3,469,100
3,542,200
4,162,900
4,132,500
4,856,700
199 G-4-22-I
2,399,100
2,878,900
3,358,700
200 G-4-22-II
201 G-4-22-III

3,065,300
3,581,600
3,678,300
4,298,000
4,291,400
5,014,300
202 G-4-23-I
203 G-4-23-II

1,716,800
2,154,000
2,060,200
2,584,800
2,403,600
3,015,600
204 G-4-23-III
3,066,800
3,680,200
4,293,500
205 G-4-24-I
206 G-4-24-II

1,912,300
2,389,100
2,294,800
2,867,000
2,677,200
3,344,800
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
3,980,200
1,634,000
2,066,400
2,738,400
4,776,300
1,960,800
2,479,700
3,286,100
5,572,300
2,287,600
2,893,000
3,833,700
2,582,200
3,098,600
3,615,100
3,003,900
3,604,700
4,205,400
4,491,700
5,390,100
6,288,400
1,844,000
4,142,900
5,634,200
5,629,000
6,993,400
9,795,300
2,212,200
3,001,400
5,899,500
1,909,100
2,177,700
3,118,400
2,250,900
2,689,400
4,506,900
2,212,700
4,971,500
6,761,000
6,754,800
8,392,100
11,754,300
2,654,600
3,601,700
7,079,400
2,290,900
2,613,300
3,742,100
2,701,100
3,227,300
5,408,300
2,581,500
5,800,100
7,887,800
7,880,600
9,790,800
13,713,400
3,097,000
4,202,000
8,259,300
2,672,800
3,048,800
4,365,700
3,151,200
3,765,100
6,309,700
229 I-1-01-I
30,233,200
36,279,900
42,326,500
230 I-1-01-II
30,898,300
37,078,000
43,257,700
231 I-1-01-III

(RINGAN)
48,772,600
58,527,100
68,281,700
16,773,300
20,127,900
23,482,600
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 155 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
13,810,900
16,573,000
19,335,200
245 I-1-06-II
20,006,100
24,007,400
28,008,600
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
23,871,000
28,645,200
33,419,400
16,440,100
19,728,200
23,016,200
20,282,200
24,338,700
28,395,100
22,127,900
26,553,400
30,979,000
2,628,400
3,154,100
3,679,800
2,922,500
3,507,100
4,091,600
3,889,000
4,666,800
5,444,600
7,565,900
9,079,000
10,592,200
12,356,600
14,827,900
17,299,200
16,256,900
19,508,300
22,759,700
7,338,800
8,806,500
10,274,300
9,773,100
11,727,700
13,682,300
12,052,900
14,463,500
16,874,100
15,020,700
18,024,800
21,029,000
18,668,500
22,402,200
26,135,900
24,462,200
29,354,600
34,247,100
2,853,500
3,984,800
7,673,200
3,424,200
4,781,800
9,207,900
3,994,900
5,578,800
10,742,500
7,397,300
8,876,800
10,356,200
16,737,100
20,084,500
23,432,000
19,306,000
23,167,200
27,028,400
8,565,400
10,278,500
11,991,500
10,724,700
12,869,600
15,014,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
21,637,300
25,964,800
30,292,200
26,669,300
32,003,200
37,337,100
9,688,300
11,625,900
13,563,600
13,430,000
16,116,000
18,802,000
17,043,700
20,452,400
23,861,100
14,599,700
17,519,700
20,439,600
23,042,300
27,650,800
32,259,200
36,809,900
44,171,900
51,533,900
18,732,800
22,479,300
26,225,900
22,479,400
26,975,300
31,471,200
30,931,500
37,117,800
43,304,100
- 156 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
16,662,600
19,995,100
23,327,600
279 I-1-40-III
22,255,600
26,706,700
31,157,800
280 I-4-10-I
281 I-4-10-II

2,540,600
4,536,600
3,048,700
5,443,900
3,556,800
6,351,200
282 I-4-10-III
6,536,500
7,843,800
9,151,200
283 I-4-11-I
284 I-4-11-II

3,908,700
4,837,100
4,690,500
5,804,500
5,472,200
6,771,900
285 I-4-11-III
286 I-4-12-I

8,948,000
2,247,000
10,737,700
2,696,400
12,527,300
3,145,800
287 I-4-12-II
2,604,500
3,125,400
3,646,300
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,125,400
3,750,500
4,375,600
2,286,500
2,743,900
3,201,200
4,082,900
4,899,500
5,716,100
5,882,900
7,059,500
8,236,000
2,159,200
2,233,600
3,915,400
2,591,100
2,680,300
4,698,500
3,022,900
3,127,000
5,481,600
4,048,900
4,858,700
5,668,500
5,508,300
6,610,000
7,711,700
297 I-4-15-III
6,610,000
7,932,000
9,254,000
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,362,800
2,188,300
2,626,000
1,670,700
1,945,000
2,334,000
1,635,400
2,626,000
3,151,200
2,004,800
2,334,000
2,800,800
1,907,900
3,063,700
3,676,400
2,338,900
2,723,000
3,267,600
2,628,700
3,154,400
3,680,200
4,002,300
4,802,800
5,603,200
5,433,800
6,520,500
7,607,300
307 I-4-19-I
2,536,200
3,043,400
3,550,600
308 I-4-19-II

(SEDANG)
3,959,100
4,750,900
5,542,700
309 I-4-19-III
4,726,400
5,671,700
6,617,000
310
311
312
313
314

2,640,900
3,050,200
4,560,700
1,976,200
2,503,800
3,169,100
3,660,300
5,472,900
2,371,400
3,004,600
3,697,300
4,270,300
6,385,000
2,766,600
3,505,400
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,266,200
15,919,500
18,572,700
9,654,700
11,585,600
13,516,500
12,061,300
14,473,600
16,885,800
12,678,900
15,214,700
17,750,500
7,303,200
8,763,800
10,224,500
15,192,300
18,230,700
21,269,200
23,542,600
28,251,100
32,959,600
6,740,100
8,088,100
9,436,100
- 157 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,614,000
4,336,800
5,059,600
316 I-4-22-I
317 I-4-22-II
2,215,000
2,757,300
2,658,000
3,308,800
3,100,900
3,860,200
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,030,300
4,836,400
5,642,400
2,167,800
2,601,400
3,034,900
2,661,400
3,193,700
3,726,000
5,200,300
6,240,400
7,280,400
1,952,100
2,342,500
2,733,000
4,495,200
5,394,200
6,293,300
5,683,400
6,820,100
7,956,700
35,217,900
42,261,400
49,305,000
39,855,600
47,826,700
55,797,800
45,089,200
54,107,000
63,124,800
18,688,800
22,426,600
26,164,400
26,022,300
31,226,700
36,431,200
42,971,700
51,566,000
60,160,400
5,675,300
6,810,400
7,945,400
11,484,000
13,780,800
16,077,600
11,934,700
14,321,700
16,708,600
6,669,100
8,002,900
9,336,700
7,895,400
9,474,500
11,053,600
12,191,800
14,630,200
17,068,600
4,736,200
5,683,400
6,630,700
8,579,500
10,295,500
12,011,400
24,764,600
29,717,500
34,670,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
1,935,100
3,996,600
6,046,300
1,727,300
2,405,800
3,224,700
2,933,800
3,339,700
4,663,100
2,594,000
3,610,700
6,736,400
2,859,900
4,653,900
5,506,000
3,799,700
4,539,600
6,107,600
2,322,200
4,795,900
7,255,500
2,072,700
2,886,900
3,869,600
3,520,600
4,007,600
5,595,800
3,112,800
4,332,900
8,083,700
3,431,900
5,584,700
6,607,200
4,559,600
5,447,500
7,329,100
2,709,200
5,595,200
8,464,800
2,418,200
3,368,100
4,514,600
4,107,300
4,675,600
6,528,400
3,631,600
5,055,000
9,431,000
4,003,900
6,515,500
7,708,500
5,319,600
6,355,400
8,550,600
3,166,000
3,799,100
4,432,300
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 158 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,449,000
5,338,800
6,228,600
360 J-4-16-III
5,625,100
6,750,100
7,875,100
361 J-4-17-I
362 J-4-17-II

2,389,700
2,861,800
2,867,700
3,434,100
3,345,600
4,006,500
363 J-4-17-III
364 J-4-18-I

3,755,500
1,950,400
4,506,600
2,340,400
5,257,700
2,730,500
365 J-4-18-II
2,682,500
3,219,100
3,755,600
366 J-4-18-III
367 J-4-19-I

2,823,700
3,366,000
3,388,500
4,039,200
3,953,200
4,712,400
368 J-4-19-II
369 J-4-19-III

3,817,200
4,215,700
4,580,700
5,058,800
5,344,100
5,902,000
370 J-4-20-I
3,340,300
4,008,400
4,676,400
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,628,300
5,425,800
5,554,000
6,511,000
6,479,700
7,596,200
2,527,900
3,033,500
3,539,100
4,072,400
4,886,900
5,701,400
5,682,800
6,819,300
7,955,900
5,145,000
6,174,000
7,203,000
6,465,800
7,759,000
9,052,100
7,578,100
9,093,800
10,609,400
5,297,900
6,357,500
7,417,100

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
6,955,500
9,210,200
8,346,600
11,052,200
9,737,700
12,894,300
2,158,800
2,590,500
3,022,300
2,807,700
3,369,300
3,930,800
5,562,500
6,675,100
7,787,600
2,434,700
2,678,100
2,702,500
2,921,600
3,213,800
3,243,000
3,408,500
3,749,400
3,783,500
3,951,000
4,741,200
5,531,400
4,630,500
5,556,600
6,482,700
390 K-1-14-III
7,275,200
8,730,200
10,185,200
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,650,400
10,686,000
15,602,600
9,180,500
12,823,100
18,723,200
10,710,600
14,960,300
21,843,700
4,524,400
5,429,300
6,334,200
8,035,300
9,642,300
11,249,400
11,056,600
13,268,000
15,479,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,048,200
6,057,800
7,067,500
398 K-1-40-II

(SEDANG)
5,565,800
6,679,000
7,792,100
399 K-1-40-III
9,432,100
11,318,500
13,204,900
400
401
402
403
404

3,857,300
5,009,200
7,079,000
3,184,400
4,575,600
4,628,800
6,011,100
8,494,700
3,821,300
5,490,700
5,400,300
7,012,900
9,910,500
4,458,200
6,405,800
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 159 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
6,975,200
8,370,200
9,765,300
406 K-4-11-I
407 K-4-11-II

2,032,600
2,888,400
2,439,100
3,466,000
2,845,600
4,043,700
408 K-4-11-III
409 K-4-12-I

3,466,000
1,914,200
4,159,200
2,297,100
4,852,500
2,679,900
410 K-4-12-II
2,576,000
3,091,200
3,606,400
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,261,500
5,113,800
5,966,100
2,580,500
3,096,600
3,612,700
3,338,100
4,005,700
4,673,300
5,141,700
6,170,100
7,198,400
1,636,100
1,963,300
2,290,500
2,196,100
2,635,400
3,074,600
3,523,900
4,228,700
4,933,500
418 K-4-15-I
1,624,300
1,949,200
2,274,000
419 K-4-15-II
2,421,600
2,905,900
3,390,200
420 K-4-15-III
3,398,600
4,078,300
4,758,000
421 K-4-16-I
2,388,600
2,866,300
3,344,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,864,600
3,342,600
3,437,500
4,011,100
4,010,500
4,679,600
1,079,600
1,295,500
1,511,400
1,618,800
1,942,600
2,266,400
1,942,600
2,331,100
2,719,600
1,084,000
1,300,900
1,517,700
1,540,500
1,848,600
2,156,700
429 K-4-18-III
1,848,600
2,218,400
2,588,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,197,700
18,412,100
24,601,600
5,755,000
9,875,200
12,260,200
14,637,200
22,094,500
29,521,900
6,906,000
11,850,200
14,712,200
17,076,800
25,776,900
34,442,200
8,057,000
13,825,300
17,164,300
3,225,200
3,870,300
4,515,300
6,469,100
7,762,900
9,056,700
10,888,900
13,066,700
15,244,500
4,234,100
6,814,300
9,747,200
1,107,400
1,285,400
1,492,000
2,319,200
3,187,500
7,242,900
1,101,400
1,456,700
3,853,500
5,080,900
8,177,100
11,696,600
1,328,900
1,542,500
1,790,500
2,783,000
3,825,000
8,691,500
1,321,700
1,748,100
4,624,200
5,927,700
9,540,000
13,646,000
1,550,400
1,799,600
2,088,900
3,246,800
4,462,500
10,140,100
1,541,900
2,039,400
5,394,800
2,153,300
2,584,000
3,014,600
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 160 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,530,700
3,036,900
3,543,000
3,724,000
4,468,800
5,213,600
1,907,200
2,288,700
2,670,100
2,864,700
3,437,700
4,010,600
4,038,200
4,845,800
5,653,400
6,741,800
8,090,200
9,438,600
9,582,600
11,499,100
13,415,600
13,460,700
16,152,800
18,845,000
5,975,400
7,170,500
8,365,500
9,802,400
16,654,000
11,762,900
19,984,900
13,723,400
23,315,700
14,628,800
17,554,500
20,480,300
17,110,500
20,532,600
23,954,700
21,177,100
25,412,500
29,647,900
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,492,200
8,990,700
10,489,100
467 M-1-04-II
9,625,300
11,550,400
13,475,500
468 M-1-04-III
11,516,900
13,820,300
16,123,700
469 M-1-05-I
470 M-1-05-II

4,756,700
7,694,200
5,708,100
9,233,100
6,659,400
10,771,900
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
9,828,400
11,794,100
13,759,700
5,324,600
6,389,600
7,454,500
7,133,200
8,559,800
9,986,400
14,530,900
17,437,100
20,343,300
8,765,200
10,518,300
12,271,300
19,234,200
23,081,100
26,927,900
41,486,500
49,783,800
58,081,000
8,006,000
9,607,200
11,208,400
10,228,500
12,274,100
14,319,800
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
25,465,700
30,558,900
35,652,000
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,492,300
8,899,800
12,725,900
6,590,800
10,679,700
15,271,100
7,689,200
12,459,700
17,816,300
2,795,800
3,355,000
3,914,100
4,958,200
5,949,900
6,941,500
7,079,400
8,495,300
9,911,100
3,350,300
5,559,800
9,131,700
4,020,400
6,671,800
10,958,000
4,690,500
7,783,800
12,784,300
5,174,300
6,209,200
7,244,000
6,505,300
7,806,400
9,107,400
9,827,000
11,792,500
13,757,900
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 161 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,919,600
2,303,600
2,687,500
500 M-4-10-II
501 M-4-10-III
2,862,800
5,416,500
3,435,400
6,499,800
4,007,900
7,583,100
2,392,000
2,870,500
3,348,900
5,244,500
6,293,300
7,342,200
7,582,600
9,099,100
10,615,600
1,909,400
2,291,300
2,673,100
3,175,800
3,811,000
4,446,200
4,248,000
5,097,600
5,947,200
3,179,300
3,815,200
4,451,100
4,776,800
5,732,200
6,687,500
9,319,400
11,183,300
13,047,200
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,625,900
4,351,100
5,076,300
512 M-4-14-II
4,472,000
5,366,400
6,260,800
513 M-4-14-III
514 M-4-15-I
6,720,100
2,150,100
8,064,200
2,580,100
9,408,200
3,010,100
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,865,900
6,503,500
1,840,800
2,947,800
4,952,100
3,439,100
7,804,200
2,208,900
3,537,300
5,942,500
4,012,200
9,104,900
2,577,100
4,126,900
6,932,900
2,389,100
2,866,900
3,344,700
3,341,400
4,009,700
4,678,000
4,666,100
5,599,300
6,532,500
1,805,800
2,721,400
3,276,700
2,166,900
3,265,700
3,932,000
2,528,100
3,809,900
4,587,300
1,883,100
2,259,800
2,636,400
3,171,900
3,806,300
4,440,700
6,195,000
7,434,000
8,673,000
1,899,600
2,279,500
2,659,400
2,781,600
3,337,900
3,894,200
3,108,800
3,730,500
4,352,300
1,912,700
2,295,300
2,677,800
2,392,300
2,870,700
3,349,200
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,586,400
11,503,600
13,420,900
10,545,000
12,654,000
14,763,000
12,072,600
14,487,100
16,901,700
5,449,400
6,539,300
7,629,200
6,471,700
14,566,400
7,766,100
17,479,700
9,060,400
20,393,000
- 162 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,363,400
6,436,100
7,508,700
535 N-1-01-I

61,241,200
73,489,400
85,737,600
536 N-1-01-II
61,241,200
73,489,400
85,737,600
537 N-1-01-III
538 N-1-11-I

61,241,200
5,517,200
73,489,400
6,620,600
85,737,600
7,724,100
539 N-1-11-II
540 N-1-11-III

8,724,000
13,600,700
10,468,800
16,320,900
12,213,600
19,041,000
2,811,900
3,374,300
3,936,700
5,598,200
6,717,900
7,837,500
12,148,400
14,578,100
17,007,800
6,147,900
7,377,500
8,607,100

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,603,700
12,039,900
10,324,500
14,447,800
12,045,200
16,855,800
5,626,400
6,751,700
7,877,000
8,511,700
10,214,100
11,916,400
9,796,200
11,755,400
13,714,600
5,053,000
6,063,500
7,074,100
6,861,800
8,234,100
9,606,500
7,986,200
9,583,500
11,180,700
2,146,800
2,576,200
3,005,500
2,596,600
3,115,900
3,635,200
3,819,200
4,583,100
5,346,900
1,648,000
2,879,300
3,582,400
1,939,800
3,799,400
4,573,100
3,087,200
3,723,500
5,706,000
1,977,600
3,455,200
4,298,900
2,327,800
4,559,200
5,487,800
3,704,600
4,468,200
6,847,200
2,307,200
4,031,000
5,015,400
2,715,800
5,319,100
6,402,400
4,322,000
5,212,900
7,988,400
1,655,100
1,986,200
2,317,200
2,348,600
2,818,300
3,288,000
3,764,800
4,517,700
5,270,700
1,955,300
2,346,400
2,737,500
2,426,200
2,911,500
3,396,700
2,768,800
3,322,500
3,876,300
2,394,300
2,873,200
3,352,000
3,417,500
4,100,900
4,784,400
4,548,900
5,458,700
6,368,400
4,293,500
4,542,200
5,152,300
5,450,700
6,011,000
6,359,100
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 163 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,330,100
6,396,100
7,462,100
2,225,600
2,670,800
3,115,900
2,473,500
2,968,200
3,462,900
3,077,100
3,692,500
4,308,000
1,576,800
1,892,200
2,207,600
1,893,800
2,272,500
2,651,300
2,379,600
2,855,500
3,331,400
1,467,600
1,761,100
2,054,600

MAYOR (RINGAN)
MAYOR (SEDANG)
1,737,000
2,084,400
2,084,400
2,501,300
2,431,900
2,918,200
35,210,800
42,252,900
49,295,100
43,568,100
52,281,700
60,995,300
51,136,700
61,364,000
71,591,300
48,061,100
57,673,300
67,285,500
55,130,900
66,157,000
77,183,200
62,990,900
75,589,100
88,187,300
5,857,400
7,028,900
8,200,400
8,317,500
9,981,000
11,644,500
9,398,800
11,278,500
13,158,300
19,007,700
22,809,300
26,610,800
24,667,900
29,601,500
34,535,100
35,367,600
42,441,100
49,514,600
10,335,800
12,402,900
14,470,100
19,488,000
23,385,600
27,283,200
23,782,000
28,538,400
33,294,800
3,410,400
4,092,500
4,774,600
9,562,000
11,474,400
13,386,800
12,667,300
15,200,800
17,734,200
3,303,300
3,964,000
4,624,700
9,261,800
11,114,100
12,966,500
12,269,600
14,723,500
17,177,400
3,492,300
4,190,700
4,889,200
4,955,500
5,946,600
6,937,700
8,024,000
9,628,700
11,233,500
5,533,700
6,640,400
7,747,200
7,857,800
9,429,400
11,001,000
- 164 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,879,400
10,655,200
12,431,100
5,227,900
6,273,400
7,319,000
7,433,300
8,919,900
10,406,600
8,413,000
10,095,600
11,778,200
4,536,000
5,443,200
6,350,400
5,987,500
7,185,000
8,382,500
8,915,600
10,698,800
12,481,900
2,296,600
2,755,900
3,215,300
4,675,000
5,610,000
6,545,000
8,673,800
10,408,600
12,143,400
1,722,500
2,067,000
2,411,500
3,449,400
4,139,200
4,829,100
4,047,200
4,856,600
5,666,100
1,558,900
1,870,600
2,182,400
2,995,600
3,594,700
4,193,900
6,108,900
7,330,700
8,552,400
3,024,000
3,628,800
4,233,600
5,443,200
6,531,800
7,620,500
7,429,700
8,915,600
10,401,600
1,757,600
2,109,100
2,460,600
2,165,600
2,598,800
3,031,900
2,964,500
3,557,400
4,150,300
1,483,000
2,174,700
3,716,900
1,292,200
1,719,900
2,981,400
1,779,600
2,609,700
4,460,200
1,550,600
2,063,900
3,577,700
2,076,300
3,044,600
5,203,600
1,809,100
2,407,800
4,174,000
1,908,200
2,289,900
2,671,500
3,385,300
4,062,400
4,739,500
5,494,800
6,593,800
7,692,800
965,700
1,158,800
1,352,000
2,051,200
2,461,500
2,871,700
3,889,800
4,667,800
5,445,800
645,900
775,000
904,200
1,218,900
1,462,600
1,706,400
1,578,600
1,894,400
2,210,100
3,344,400
4,013,300
4,682,200
- 165 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,253,300
5,104,000
5,954,600
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,089,900
7,307,800
8,525,800
1,611,900
1,934,300
2,256,700
2,392,300
2,870,800
3,349,200
2,877,300
3,452,700
4,028,200
1,078,500
1,294,200
1,509,900
1,448,600
1,738,300
2,028,000
2,635,200
3,162,300
3,689,300
491,900
590,200
688,600
937,400
1,124,900
1,312,400
1,362,800
1,635,300
1,907,900
582,500
699,000
815,500
916,700
1,100,000
1,283,300
1,476,400
1,771,600
2,066,900
1,018,700
1,222,500
1,426,200
1,540,100
1,848,100
2,156,100
2,403,600
2,884,400
3,365,100
3,524,500
4,229,400
4,934,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,471,400
14,451,400
6,565,700
17,341,700
7,660,000
20,231,900
5,452,500
6,543,100
7,633,600
6,911,900
8,294,300
9,676,700
9,945,100
11,934,200
13,923,200
4,260,600
6,533,300
9,596,100
4,039,100
4,706,200
7,801,400
5,112,700
7,840,000
11,515,300
4,846,900
5,647,400
9,361,700
5,964,800
9,146,700
13,434,600
5,654,700
6,588,600
10,921,900
2,562,000
3,074,500
3,586,900
3,144,300
3,773,100
4,402,000
3,725,900
4,471,100
5,216,300
2,839,400
4,036,900
5,203,300
3,407,300
4,844,200
6,244,000
3,975,200
5,651,600
7,284,600
3,889,600
4,667,500
5,445,400
5,788,800
6,946,600
8,104,300
14,861,000
17,833,100
20,805,300
3,335,800
4,523,100
8,845,200
4,002,900
5,427,800
10,614,200
4,670,100
6,332,400
12,383,200
2,400,500
2,880,700
3,360,800
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 166 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,459,000
1,750,800
2,042,600
697 U-4-12-I
698 U-4-12-II

2,289,400
2,663,000
2,747,300
3,195,600
3,205,100
3,728,200
699 U-4-12-III

3,454,700
4,145,600
4,836,500
1,735,000
2,082,000
2,429,000
2,045,400
2,454,500
2,863,600
2,446,400
2,935,700
3,425,000
2,389,400
2,861,200
2,867,200
3,433,400
3,345,100
4,005,700

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,804,800
5,765,700
6,726,700
1,918,600
2,302,300
2,686,000
2,390,300
2,868,400
3,346,400
3,345,300
4,014,300
4,683,400
3,129,400
3,755,200
4,381,100
6,446,400
7,735,600
9,024,900
7,905,600
9,486,700
11,067,800
5,953,500
6,798,200
10,646,200
7,144,200
8,157,800
12,775,400
8,334,900
9,517,400
14,904,700
5,597,400
6,716,900
7,836,400
7,643,700
9,172,400
10,701,200
9,688,500
11,626,200
13,563,900
2,919,700
3,503,600
4,087,600
5,578,500
6,694,300
7,810,000
8,752,000
10,502,500
12,252,900
5,725,500
6,870,600
8,015,700
8,318,900
9,982,700
11,646,500
10,387,700
12,465,200
14,542,800
922,100
1,017,500
1,125,600
1,106,500
1,221,000
1,350,700
1,290,900
1,424,500
1,575,800
2,768,700
3,322,500
3,876,200
4,599,000
5,518,800
6,438,600
7,582,200
9,098,600
10,615,000
2,392,400
2,870,800
3,349,300
3,209,900
3,851,900
4,493,900
4,299,700
5,159,700
6,019,600
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,495,600
6,594,700
7,693,800
8,437,400
10,124,900
11,812,400
1,144,300
1,386,900
1,373,200
1,664,300
1,602,100
1,941,600
- 167 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,520,700
7,824,900
9,129,000
7,815,500
9,378,600
10,941,700
11,152,600
13,383,100
15,613,600
1,383,100
1,659,800
1,936,400
1,526,300
1,688,400
1,831,500
2,026,000
2,136,800
2,363,700
1,445,700
1,734,800
2,024,000
1,595,300
1,914,400
2,233,400
1,764,700
2,117,700
2,470,600
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,555,300
1,866,300
2,177,400
743 W-1-12-II
744 W-1-12-III

1,941,200
3,437,500
2,329,500
4,125,000
2,717,700
4,812,500
745 W-1-13-I
1,598,700
1,918,400
2,238,200
746 W-1-13-II
747 W-1-13-III

1,735,600
2,331,400
2,082,800
2,797,700
2,429,900
3,264,000
748 W-1-20-I
749 W-1-20-II

5,353,800
6,689,700
6,424,600
8,027,600
7,495,400
9,365,500
750 W-1-20-III
7,755,000
9,306,000
10,857,100
751 W-1-30-I
3,022,300
3,626,800
4,231,200
752 W-1-30-II
4,820,600
5,784,700
6,748,800
753 W-1-30-III
11,827,600
14,193,100
16,558,600
754 W-4-10-I
2,251,900
2,702,300
3,152,700
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,338,400
6,597,300
2,048,000
3,109,100
3,784,400
4,006,100
7,916,800
2,457,600
3,731,000
4,541,300
4,673,800
9,236,300
2,867,200
4,352,800
5,298,200
2,537,700
3,045,300
3,552,800
3,484,100
4,180,900
4,877,800
3,797,900
4,557,500
5,317,000
805,800
1,100,700
1,368,800
1,076,800
1,281,700
1,639,800
1,427,900
1,585,800
2,195,600
1,899,900
2,540,600
3,443,300
1,401,900
2,531,200
3,742,300
1,891,800
2,511,200
3,567,300
1,621,000
1,946,900
2,676,100
966,900
1,320,800
1,642,500
1,292,200
1,538,000
1,967,700
1,713,500
1,903,000
2,634,800
2,279,800
3,048,700
4,132,000
1,682,300
3,037,400
4,490,700
2,270,200
3,013,400
4,280,700
1,945,100
2,336,200
3,211,300
1,128,100
1,541,000
1,916,300
1,507,500
1,794,400
2,295,700
1,999,100
2,220,100
3,073,900
2,659,800
3,556,800
4,820,700
1,962,600
3,543,600
5,239,200
2,648,600
3,515,600
4,994,200
2,269,300
2,725,600
3,746,500
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 168 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
753,800
904,600
1,055,300
1,836,700
2,204,000
2,571,400
2,329,300
2,795,200
3,261,000
- 169 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS D PEMERINTAH
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
860,100
1,115,600
2,074,600
1,714,500
2,228,000
409,800
728,500
320,500
585,900
607,200
689,300
1,036,300
1,413,600
1,295,600
419,700
968,700
351,400
603,300
1,837,600
658,100
1,554,100
379,200
884,600
1,384,500
1,161,200
284,800
863,100
479,900
246,700
266,800
235,500
281,600
392,100
336,900
317,200
285,000
422,900
184,700
217,600
249,600
5,063,700
2,023,700
2,030,500
522,300
855,300
535,500
1,088,400
697,400
399,400
301,600
486,400
268,500
229,900
1,793,700
837,100
478,300
1,867,200
1,244,800
242,400
2,022,800
1,400,400
3,150,000
727,500
447,500
240,700
200,600
226,000
3,446,700
1,677,700
- 170 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,132,300
3,773,700
3,128,800
2,383,500
785,800
2,652,900
1,732,200
425,800
3,982,900
3,605,700
2,417,600
2,290,400
283,100
272,000
1,094,500
299,100
266,500
294,600
1,011,000
1,381,000
1,206,200
1,065,300
645,100
268,100
472,500
324,400
292,900
285,400
362,300
413,200
242,200
695,100
1,266,800
972,500
2,286,200
297,700
297,700
2,112,600
1,228,400
235,600
1,090,200
2,831,900
650,200
512,100
250,900
216,500
271,800
379,000
907,400
799,800
559,900
417,700
229,900
972,200
779,000
332,800
379,800
1,244,600
275,200
1,271,500
972,800
296,700
328,800
321,200
194,400
1,059,900
1,456,300
288,600
- 171 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
884,500
330,200
357,000
330,600
524,400
403,400
1,010,300
298,100
829,300
1,108,200
242,700
1,477,200
800,500
1,729,900
873,200
385,600
296,700
62,500
384,500
868,800
338,600
457,300
261,500
101,800
264,100
3,933,100
2,235,600
3,731,300
916,600
512,100
349,000
789,200
417,400
840,100
486,400
289,600
484,700
218,200
333,100
319,200
702,600
1,522,600
1,225,000
1,080,100
762,300
280,400
280,400
280,400
229,000
145,300
228,400
279,200
302,000
222,500
196,200
87,600
96,300
71,200
83,600
79,700
121,700
109,100
155,900
171,300
96,900
117,600
80,400
125,500
178,000
- 172 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
126,800
175,000
494,800
573,600
119,900
238,100
145,800
208,200
400,500
342,900
246,500
233,400
119,200
117,100
274,800
173,400
248,800
176,200
134,800
1,728,600
1,778,100
282,500
292,600
559,600
702,800
716,300
370,000
1,153,100
249,300
300,700
301,700
241,600
305,100
288,700
135,300
297,200
263,500
238,300
269,500
2,231,000
289,700
802,900
288,000
409,700
430,100
343,100
697,200
714,000
761,300
665,900
1,156,700
198,400
1,377,500
261,500
698,200
1,586,900
1,834,900
801,600
290,500
566,600
564,300
261,500
2,050,000
1,612,500
130,200
142,600
185,200
249,400
- 173 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
870,800
412,200
849,600
1,025,000
491,200
683,300
472,300
508,200
549,900
281,500
665,400
170,200
630,300
937,400
69,100
- 174 -

REGIONAL 1
RUMAH SAKIT KELAS D SWASTA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,691,300
2,029,600
2,367,800
A-4-10-II
SEPTIKEMIA (SEDANG)
2,889,500
3,467,400
4,045,200
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,895,900
2,195,800
4,675,100
2,635,000
5,454,300
3,074,100
5
6
A-4-11-II
A-4-11-III

3,125,300
4,325,700
3,750,300
5,190,800
4,375,400
6,055,900
A-4-12-I
2,455,600
2,946,700
3,437,900
8
9
A-4-12-II
A-4-12-III

3,058,100
3,263,800
3,669,700
3,916,600
4,281,300
4,569,300
10 A-4-13-I
11 A-4-13-II

1,078,500
1,450,600
1,294,200
1,740,700
1,509,900
2,030,800
12 A-4-13-III
1,740,700
2,088,800
2,437,000
2,155,300
2,586,400
3,017,400
2,616,200
3,139,400
3,662,700
3,139,400
3,767,300
4,395,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,952,100
4,418,900
3,542,500
5,302,700
4,132,900
6,186,400
18 A-4-15-III
INFEKSI HIV (BERAT)
5,545,300
6,654,400
7,763,500
19 B-1-01-I
20 B-1-01-II

19,329,600
21,325,700
23,195,500
25,590,800
27,061,400
29,855,900
21 B-1-01-III
22 B-1-10-I

37,409,700
3,492,100
44,891,600
4,190,500
52,373,500
4,888,900
23 B-1-10-II
7,750,900
9,301,100
10,851,300
24 B-1-10-III
25 B-1-11-I

15,301,400
4,666,100
18,361,600
5,599,300
21,421,900
6,532,500
26 B-1-11-II
27 B-1-11-III

6,046,900
7,812,500
7,256,300
9,375,000
8,465,700
10,937,500
28 B-1-12-I
4,556,200
5,467,400
6,378,700
29 B-1-12-II
5,067,300
6,080,700
7,094,200
30 B-1-12-III
7,927,200
9,512,600
11,098,100
3,629,100
4,354,900
5,080,700
5,971,200
7,165,400
8,359,600
7,726,200
9,271,400
10,816,600
4,986,500
5,983,800
6,981,100
5,545,800
6,655,000
7,764,200
8,675,800
1,542,800
2,462,800
3,397,500
10,411,000
1,851,400
2,955,300
4,077,000
12,146,200
2,159,900
3,447,900
4,756,500
3,252,800
3,903,400
4,554,000
4,554,000
5,464,800
6,375,600
5,517,100
6,620,500
7,724,000
2,940,900
4,187,800
6,230,500
2,805,400
3,529,100
5,025,300
7,476,600
3,366,500
4,117,300
5,862,900
8,722,600
3,927,600
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 175 -

REGIONAL 1
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,268,200
3,921,800
4,575,400
48 B-4-13-III
49 B-4-14-I

4,502,200
2,802,400
5,402,600
3,362,900
6,303,100
3,923,400
50 B-4-14-II
3,269,400
3,923,200
4,577,100
51 B-4-14-III
52 C-4-10-I

4,379,400
2,592,700
5,255,300
3,111,300
6,131,100
3,629,800
53 C-4-10-II
54 C-4-10-III

4,974,800
8,780,900
5,969,800
10,537,100
6,964,700
12,293,300
55 C-4-11-I
2,954,500
3,545,400
4,136,300
56 C-4-11-II
57 C-4-11-III

3,953,600
6,078,700
4,744,300
7,294,400
5,535,000
8,510,200
58 C-4-12-I
59 C-4-12-II
1,967,200
3,874,600
2,360,700
4,649,600
2,754,100
5,424,500
60 C-4-12-III
RADIOTERAPI (BERAT)
9,951,200
11,941,400
13,931,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,478,900
2,783,400
1,774,700
3,340,100
2,070,500
3,896,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,767,800
2,457,300
4,521,300
2,948,800
5,274,900
3,440,300
65 C-4-14-II
3,447,100
4,136,600
4,826,000
66 C-4-14-III
67 D-1-10-I

5,136,200
12,025,700
6,163,400
14,430,800
7,190,600
16,835,900
68 D-1-10-II
69 D-1-10-III

18,315,900
29,165,200
21,979,100
34,998,300
25,642,300
40,831,300
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
3,975,000
4,770,000
5,565,000
10,150,100
13,190,400
12,180,100
15,828,500
14,210,100
18,466,600
3,445,900
4,135,000
4,824,200
9,496,300
11,395,600
13,294,800
15,063,900
18,076,700
21,089,500
2,125,900
3,097,500
4,873,200
2,697,600
4,847,600
6,659,400
2,325,700
3,225,900
4,953,400
2,551,000
3,717,000
5,847,800
3,237,200
5,817,100
7,991,200
2,790,900
3,871,000
5,944,100
2,976,200
4,336,500
6,822,400
3,776,700
6,786,600
9,323,100
3,256,000
4,516,200
6,934,800
1,993,100
2,391,700
2,790,400
2,820,900
3,385,100
3,949,300
3,608,000
4,329,700
5,051,300
2,137,700
2,565,200
2,992,800
3,499,900
4,199,900
4,899,900
4,280,800
5,136,900
5,993,100
3,333,800
4,000,500
4,667,300
4,366,900
5,240,200
6,113,600
93 E-1-01-III
8,655,900
10,387,100
12,118,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,839,000
3,446,000
7,263,000
3,406,800
4,135,100
8,715,600
3,974,600
4,824,300
10,168,200
5,015,500
6,018,600
7,021,600
97 E-1-20-I
- 176 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,971,700
2,366,000
2,760,300
104 E-4-11-II
105 E-4-11-III

3,006,000
4,073,300
3,607,200
4,888,000
4,208,400
5,702,700
106 E-4-12-I
107 E-4-12-II

2,265,400
3,923,200
2,718,500
4,707,800
3,171,600
5,492,400
108 E-4-12-III

(RINGAN)
(SEDANG)
4,650,400
5,580,500
6,510,500
2,467,000
2,960,400
3,453,700
3,613,700
4,336,400
5,059,100
111 E-4-13-III
4,723,800
5,668,500
6,613,300
112 F-4-10-I
113 F-4-10-II
2,626,400
3,018,500
3,151,600
3,622,200
3,676,900
4,225,900
114 F-4-10-III
115 F-4-11-I
3,622,200
2,540,100
4,346,600
3,048,200
5,071,100
3,556,200
116 F-4-11-II
2,959,500
3,551,400
4,143,400
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,795,200
4,554,300
5,313,300
1,392,400
1,670,900
1,949,400
1,979,600
2,375,500
2,771,400
4,300,500
5,160,600
6,020,700
2,046,100
2,699,900
3,495,400
1,167,400
1,497,400
2,014,900
2,455,400
3,239,900
4,194,500
1,400,900
1,796,900
2,417,800
2,864,600
3,779,900
4,893,600
1,634,400
2,096,300
2,820,800
127 F-4-15-I
1,859,200
2,231,000
2,602,900
128 F-4-15-II
2,770,400
3,324,500
3,878,600
129 F-4-15-III
3,657,900
4,389,400
5,121,000
3,658,100
4,389,700
5,121,300
4,253,100
5,103,700
5,954,400
5,677,200
6,812,600
7,948,000
133 F-4-17-I

863,900
1,036,700
1,209,500
134 F-4-17-II
2,532,000
3,038,400
3,544,700
135
136
137
138
139
140
141

(RINGAN)
2,701,400
3,178,600
3,497,400
5,391,400
2,429,200
3,110,700
3,872,800
3,241,600
3,814,300
4,196,800
6,469,700
2,915,000
3,732,800
4,647,300
3,781,900
4,450,000
4,896,300
7,548,000
3,400,900
4,355,000
5,421,900
5,390,700
6,468,800
7,546,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,750,700
8,100,800
9,450,900
9,303,800
11,164,600
13,025,300
3,259,000
3,910,800
4,562,600
4,553,800
5,464,600
6,375,400
5,652,200
6,782,700
7,913,100
- 177 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,398,400
6,478,100
7,557,700
148 G-1-11-I
149 G-1-11-II

7,886,300
14,418,000
9,463,600
17,301,600
11,040,800
20,185,300
150 G-1-11-III
23,169,200
27,803,000
32,436,800
3,292,800
3,951,400
4,609,900
6,172,500
7,407,000
8,641,600
8,412,000
10,094,400
11,776,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
993,300
2,667,600
1,192,000
3,201,200
1,390,700
3,734,700
156 G-1-13-III
157 G-1-20-I

6,019,400
2,973,200
7,223,200
3,567,800
8,427,100
4,162,400
158 G-1-20-II
4,910,700
5,892,900
6,875,000
159 G-1-20-III
9,846,100
11,815,300
13,784,500
160 G-1-30-I
4,647,100
5,576,500
6,505,900
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,134,900
15,588,600
14,561,900
18,706,400
16,988,900
21,824,100
2,826,500
3,391,800
3,957,100
3,455,000
4,146,000
4,837,000
4,740,800
5,689,000
6,637,100
2,958,900
3,550,700
4,142,500
3,930,600
4,716,700
5,502,800
5,775,300
6,930,400
8,085,500
3,282,600
3,939,100
4,595,600
4,146,100
4,975,400
5,804,600
6,021,800
7,226,100
8,430,500
1,971,900
2,366,300
2,760,600
3,438,600
4,126,300
4,814,000
4,078,300
4,893,900
5,709,600
3,345,100
4,014,100
4,683,100
4,472,100
5,366,600
6,261,000
5,613,100
6,735,700
7,858,300
2,733,200
3,279,900
3,826,500
3,262,000
3,914,400
4,566,800
4,604,000
5,524,800
6,445,600
2,253,200
2,703,800
3,154,500
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,428,000
8,913,500
10,399,100
14,439,900
17,327,900
20,215,900
3,224,200
4,552,200
3,869,000
5,462,600
4,513,800
6,373,100
- 178 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
2,991,400
3,589,700
4,188,000
183 G-4-16-III
4,260,000
5,112,000
5,964,000
3,001,100
3,601,300
4,201,500
3,935,100
4,722,100
5,509,100
4,944,600
5,933,500
6,922,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,955,600
3,546,700
4,137,900
188 G-4-18-II
3,950,700
4,740,900
5,531,000
189 G-4-18-III
4,420,600
5,304,700
6,188,800
2,465,900
2,959,100
3,452,300
4,168,000
5,001,600
5,835,200
5,472,400
6,566,900
7,661,400
193 G-4-20-I

1,725,000
2,070,000
2,415,100
194 G-4-20-II
2,438,700
2,926,400
3,414,100
195 G-4-20-III
196 G-4-21-I

4,028,100
1,796,400
4,833,700
2,155,600
5,639,300
2,514,900
197 G-4-21-II
198 G-4-21-III

3,040,400
3,573,100
3,648,400
4,287,700
4,256,500
5,002,400
199 G-4-22-I
2,471,000
2,965,300
3,459,500
200 G-4-22-II
201 G-4-22-III

3,157,200
3,689,100
3,788,700
4,426,900
4,420,100
5,164,700
202 G-4-23-I
203 G-4-23-II

1,768,300
2,218,600
2,122,000
2,662,400
2,475,700
3,106,100
204 G-4-23-III
3,158,800
3,790,600
4,422,400
205 G-4-24-I
206 G-4-24-II

1,969,700
2,460,800
2,363,600
2,953,000
2,757,500
3,445,100
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,099,600
1,683,000
2,128,400
2,820,500
4,919,600
2,019,700
2,554,100
3,384,600
5,739,500
2,356,300
2,979,800
3,948,800
2,659,700
3,191,600
3,723,500
3,094,000
3,712,800
4,331,600
4,626,500
5,551,800
6,477,100
1,899,300
4,267,200
5,803,200
5,797,800
7,203,200
10,089,100
2,278,500
3,091,500
6,076,500
1,966,400
2,243,100
3,211,900
2,318,400
2,770,100
4,642,100
2,279,100
5,120,700
6,963,800
6,957,400
8,643,900
12,106,900
2,734,200
3,709,800
7,291,800
2,359,700
2,691,700
3,854,300
2,782,100
3,324,100
5,570,600
2,659,000
5,974,100
8,124,500
8,117,000
10,084,500
14,124,800
3,189,900
4,328,100
8,507,100
2,753,000
3,140,300
4,496,700
3,245,800
3,878,100
6,499,000
229 I-1-01-I
31,140,200
37,368,300
43,596,300
230 I-1-01-II
31,825,300
38,190,400
44,555,400
231 I-1-01-III

(RINGAN)
50,235,800
60,283,000
70,330,100
17,276,500
20,731,800
24,187,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 179 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,225,200
17,070,200
19,915,200
245 I-1-06-II
20,606,300
24,727,600
28,848,900
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,587,200
29,504,600
34,422,000
16,933,300
20,320,000
23,706,700
20,890,700
25,068,900
29,247,000
22,791,700
27,350,000
31,908,400
2,707,300
3,248,700
3,790,200
3,010,200
3,612,300
4,214,300
4,005,700
4,806,800
5,608,000
7,792,800
9,351,400
10,910,000
12,727,300
15,272,700
17,818,200
16,744,600
20,093,600
23,442,500
7,558,900
9,070,700
10,582,500
10,066,300
12,079,500
14,092,800
12,414,500
14,897,400
17,380,300
15,471,300
18,565,600
21,659,800
19,228,600
23,074,300
26,920,000
25,196,000
30,235,300
35,274,500
2,939,100
4,104,400
7,903,400
3,526,900
4,925,300
9,484,100
4,114,700
5,746,200
11,064,800
7,619,200
9,143,100
10,666,900
17,239,200
20,687,100
24,134,900
19,885,200
23,862,200
27,839,300
8,822,300
10,586,800
12,351,300
11,046,400
13,255,700
15,465,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,286,400
26,743,700
31,201,000
27,469,400
32,963,300
38,457,200
9,978,900
11,974,700
13,970,500
13,832,900
16,599,400
19,366,000
17,555,000
21,066,000
24,577,000
15,037,700
18,045,300
21,052,800
23,733,600
28,480,300
33,227,000
37,914,200
45,497,100
53,079,900
19,294,800
23,153,700
27,012,700
23,153,800
27,784,600
32,415,300
31,859,500
38,231,300
44,603,200
- 180 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,162,500
20,595,000
24,027,500
279 I-1-40-III
22,923,300
27,507,900
32,092,600
280 I-4-10-I
281 I-4-10-II

2,616,800
4,672,700
3,140,200
5,607,200
3,663,600
6,541,700
282 I-4-10-III
6,732,600
8,079,200
9,425,700
283 I-4-11-I
284 I-4-11-II

4,026,000
4,982,200
4,831,200
5,978,600
5,636,400
6,975,000
285 I-4-11-III
286 I-4-12-I

9,216,500
2,314,400
11,059,800
2,777,300
12,903,100
3,240,100
287 I-4-12-II
2,682,600
3,219,200
3,755,700
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,219,200
3,863,000
4,506,800
2,355,100
2,826,200
3,297,200
4,205,400
5,046,500
5,887,500
6,059,400
7,271,200
8,483,100
2,224,000
2,300,600
4,032,900
2,668,800
2,760,700
4,839,500
3,113,600
3,220,800
5,646,000
4,170,400
5,004,500
5,838,600
5,673,600
6,808,300
7,943,000
297 I-4-15-III
6,808,300
8,170,000
9,531,600
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,403,700
2,254,000
2,704,800
1,720,800
2,003,300
2,404,000
1,684,400
2,704,800
3,245,700
2,064,900
2,404,000
2,884,800
1,965,200
3,155,600
3,786,700
2,409,100
2,804,700
3,365,600
2,707,600
3,249,100
3,790,600
4,122,400
4,946,800
5,771,300
5,596,800
6,716,200
7,835,500
307 I-4-19-I
2,612,300
3,134,700
3,657,200
308 I-4-19-II

(SEDANG)
4,077,900
4,893,400
5,709,000
309 I-4-19-III
4,868,200
5,841,900
6,815,500
310
311
312
313
314

2,720,100
3,141,800
4,697,600
2,035,500
2,578,900
3,264,100
3,770,100
5,637,100
2,442,500
3,094,700
3,808,200
4,398,500
6,576,600
2,849,600
3,610,500
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,664,200
16,397,100
19,129,900
9,944,300
11,933,100
13,922,000
12,423,200
14,907,800
17,392,400
13,059,300
15,671,200
18,283,000
7,522,300
9,026,800
10,531,200
15,648,000
18,777,700
21,907,300
24,248,800
29,098,600
33,948,400
6,942,300
8,330,700
9,719,200
- 181 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,722,400
4,466,900
5,211,400
316 I-4-22-I
317 I-4-22-II
2,281,400
2,840,000
2,737,700
3,408,000
3,194,000
3,976,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,151,200
4,981,400
5,811,700
2,232,800
2,679,400
3,126,000
2,741,300
3,289,500
3,837,800
5,356,300
6,427,600
7,498,800
2,010,700
2,412,800
2,814,900
4,630,100
5,556,100
6,482,100
5,853,900
7,024,700
8,195,400
36,274,400
43,529,300
50,784,200
41,051,200
49,261,500
57,471,700
46,441,800
55,730,200
65,018,600
19,249,500
23,099,400
26,949,300
26,802,900
32,163,500
37,524,100
44,260,800
53,113,000
61,965,200
5,845,600
7,014,700
8,183,800
11,828,500
14,194,200
16,559,900
12,292,800
14,751,300
17,209,900
6,869,200
8,243,000
9,616,800
8,132,300
9,758,700
11,385,200
12,557,600
15,069,100
17,580,600
4,878,300
5,853,900
6,829,600
8,836,900
10,604,300
12,371,700
25,507,500
30,609,000
35,710,500
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
1,993,200
4,116,500
6,227,600
1,779,100
2,477,900
3,321,400
3,021,800
3,439,900
4,803,000
2,671,800
3,719,100
6,938,500
2,945,700
4,793,500
5,671,200
3,913,700
4,675,800
6,290,800
2,391,800
4,939,800
7,473,200
2,134,900
2,973,500
3,985,700
3,626,200
4,127,900
5,763,600
3,206,100
4,462,900
8,326,200
3,534,900
5,752,200
6,805,500
4,696,400
5,610,900
7,549,000
2,790,500
5,763,100
8,718,700
2,490,800
3,469,100
4,650,000
4,230,500
4,815,900
6,724,300
3,740,500
5,206,700
9,713,900
4,124,000
6,710,900
7,939,700
5,479,200
6,546,100
8,807,100
3,260,900
3,913,100
4,565,300
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 182 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,582,500
5,498,900
6,415,400
360 J-4-16-III
5,793,800
6,952,600
8,111,300
361 J-4-17-I
362 J-4-17-II

2,461,400
2,947,600
2,953,700
3,537,100
3,446,000
4,126,700
363 J-4-17-III
364 J-4-18-I

3,868,200
2,008,900
4,641,800
2,410,600
5,415,400
2,812,400
365 J-4-18-II
2,763,000
3,315,600
3,868,200
366 J-4-18-III
367 J-4-19-I

2,908,400
3,467,000
3,490,100
4,160,400
4,071,800
4,853,800
368 J-4-19-II
369 J-4-19-III

3,931,800
4,342,200
4,718,100
5,210,600
5,504,500
6,079,000
370 J-4-20-I
3,440,500
4,128,600
4,816,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,767,200
5,588,600
5,720,600
6,706,300
6,674,000
7,824,000
2,603,800
3,124,500
3,645,300
4,194,600
5,033,500
5,872,500
5,853,300
7,023,900
8,194,600
5,299,400
6,359,200
7,419,100
6,659,800
7,991,700
9,323,700
7,805,500
9,366,600
10,927,700
5,456,800
6,548,200
7,639,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,164,200
9,486,500
8,597,000
11,383,800
10,029,800
13,281,100
2,223,500
2,668,200
3,112,900
2,892,000
3,470,400
4,048,700
5,729,400
6,875,300
8,021,200
2,507,700
2,758,500
2,783,600
3,009,200
3,310,200
3,340,300
3,510,800
3,861,900
3,897,000
4,069,600
4,883,500
5,697,400
4,769,400
5,723,300
6,677,200
390 K-1-14-III
7,493,400
8,992,100
10,490,800
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,880,000
11,006,500
16,070,700
9,455,900
13,207,800
19,284,800
11,031,900
15,409,100
22,499,000
4,660,200
5,592,200
6,524,200
8,276,300
9,931,600
11,586,800
11,388,300
13,666,000
15,943,700
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,199,600
6,239,600
7,279,500
398 K-1-40-II

(SEDANG)
5,732,800
6,879,400
8,025,900
399 K-1-40-III
9,715,000
11,658,000
13,601,000
400
401
402
403
404

3,973,100
5,159,500
7,291,300
3,280,000
4,712,800
4,767,700
6,191,400
8,749,600
3,936,000
5,655,400
5,562,300
7,223,300
10,207,900
4,591,900
6,597,900
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 183 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,184,500
8,621,300
10,058,200
406 K-4-11-I
407 K-4-11-II

2,093,500
2,975,000
2,512,200
3,570,000
2,931,000
4,165,000
408 K-4-11-III
409 K-4-12-I

3,570,000
1,971,700
4,284,000
2,366,000
4,998,000
2,760,300
410 K-4-12-II
2,653,300
3,183,900
3,714,600
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,389,400
5,267,200
6,145,100
2,657,900
3,189,500
3,721,100
3,438,200
4,125,900
4,813,500
5,296,000
6,355,200
7,414,300
1,685,200
2,022,200
2,359,200
2,262,000
2,714,400
3,166,800
3,629,700
4,355,600
5,081,500
418 K-4-15-I
1,673,000
2,007,600
2,342,200
419 K-4-15-II
2,494,200
2,993,100
3,491,900
420 K-4-15-III
3,500,600
4,200,700
4,900,800
421 K-4-16-I
2,460,300
2,952,300
3,444,400
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,950,500
3,442,800
3,540,700
4,131,400
4,130,800
4,820,000
1,112,000
1,334,400
1,556,800
1,667,400
2,000,900
2,334,400
2,000,900
2,401,100
2,801,200
1,116,600
1,339,900
1,563,200
1,586,700
1,904,100
2,221,400
429 K-4-18-III
1,904,100
2,284,900
2,665,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,563,600
18,964,400
25,339,600
5,927,600
10,171,400
12,628,000
15,076,300
22,757,300
30,407,500
7,113,200
12,205,700
15,153,600
17,589,100
26,550,200
35,475,400
8,298,700
14,240,000
17,679,200
3,322,000
3,986,400
4,650,800
6,663,100
7,995,800
9,328,400
11,215,600
13,458,700
15,701,800
4,361,100
7,018,700
10,039,600
1,140,700
1,324,000
1,536,800
2,388,700
3,283,100
7,460,200
1,134,400
1,500,400
3,969,100
5,233,300
8,422,500
12,047,500
1,368,800
1,588,800
1,844,200
2,866,500
3,939,700
8,952,300
1,361,300
1,800,500
4,762,900
6,105,500
9,826,200
14,055,400
1,596,900
1,853,600
2,151,500
3,344,200
4,596,300
10,444,300
1,588,200
2,100,600
5,556,700
2,217,900
2,661,500
3,105,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 184 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,606,700
3,128,000
3,649,300
3,835,700
4,602,900
5,370,000
1,964,400
2,357,300
2,750,200
2,950,700
3,540,800
4,130,900
4,159,300
4,991,200
5,823,000
6,944,100
8,332,900
9,721,700
9,870,100
11,844,100
13,818,100
13,864,500
16,637,400
19,410,300
6,154,600
7,385,600
8,616,500
10,096,500
17,153,700
12,115,800
20,584,400
14,135,100
24,015,100
15,067,600
18,081,200
21,094,700
17,623,800
21,148,600
24,673,300
21,812,400
26,174,900
30,537,300
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,717,000
9,260,400
10,803,800
467 M-1-04-II
9,914,100
11,896,900
13,879,700
468 M-1-04-III
11,862,400
14,234,900
16,607,400
469 M-1-05-I
470 M-1-05-II

4,899,500
7,925,000
5,879,300
9,510,100
6,859,200
11,095,100
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,123,200
12,147,900
14,172,500
5,484,400
6,581,200
7,678,100
7,347,200
8,816,600
10,286,000
14,966,900
17,960,200
20,953,600
9,028,200
10,833,800
12,639,500
19,811,300
23,773,500
27,735,800
42,731,100
51,277,300
59,823,500
8,246,200
9,895,400
11,544,600
10,535,300
12,642,400
14,749,400
480 M-1-20-III
26,229,700
31,475,700
36,721,600
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,657,100
9,166,800
13,107,700
6,788,500
11,000,100
15,729,200
7,919,900
12,833,500
18,350,700
2,879,700
3,455,600
4,031,500
5,107,000
6,128,400
7,149,800
7,291,800
8,750,100
10,208,500
3,450,800
5,726,600
9,405,600
4,141,000
6,872,000
11,286,700
4,831,200
8,017,300
13,167,900
5,329,500
6,395,500
7,461,400
6,700,500
8,040,600
9,380,600
10,121,900
12,146,200
14,170,600
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 185 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,977,200
2,372,700
2,768,100
500 M-4-10-II
501 M-4-10-III
2,948,700
5,579,000
3,538,400
6,694,800
4,128,200
7,810,500
2,463,800
2,956,600
3,449,300
5,401,800
6,482,100
7,562,500
7,810,100
9,372,100
10,934,100
1,966,700
2,360,000
2,753,300
3,271,100
3,925,300
4,579,600
4,375,500
5,250,500
6,125,600
3,274,700
3,929,600
4,584,600
4,920,100
5,904,100
6,888,100
9,599,000
11,518,800
13,438,600
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,734,700
4,481,600
5,228,600
512 M-4-14-II
4,606,200
5,527,400
6,448,600
513 M-4-14-III
514 M-4-15-I
6,921,800
2,214,600
8,306,100
2,657,500
9,690,500
3,100,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,951,900
6,698,600
1,896,000
3,036,200
5,100,600
3,542,200
8,038,400
2,275,200
3,643,500
6,120,800
4,132,600
9,378,100
2,654,400
4,250,700
7,140,900
2,460,800
2,952,900
3,445,100
3,441,600
4,130,000
4,818,300
4,806,000
5,767,200
6,728,400
1,859,900
2,803,000
3,375,000
2,231,900
3,363,600
4,049,900
2,603,900
3,924,200
4,724,900
1,939,600
2,327,600
2,715,500
3,267,100
3,920,500
4,573,900
6,380,800
7,657,000
8,933,200
1,956,600
2,347,900
2,739,200
2,865,000
3,438,000
4,011,100
3,202,000
3,842,400
4,482,800
1,970,100
2,364,100
2,758,100
2,464,000
2,956,800
3,449,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,873,900
11,848,700
13,823,500
10,861,300
13,033,600
15,205,900
12,434,800
14,921,800
17,408,700
5,612,900
6,735,500
7,858,100
6,665,900
15,003,400
7,999,000
18,004,100
9,332,200
21,004,800
- 186 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,524,300
6,629,100
7,734,000
535 N-1-01-I

63,078,400
75,694,100
88,309,700
536 N-1-01-II
63,078,400
75,694,100
88,309,700
537 N-1-01-III
538 N-1-11-I

63,078,400
5,682,700
75,694,100
6,819,200
88,309,700
7,955,800
539 N-1-11-II
540 N-1-11-III

8,985,700
14,008,800
10,782,900
16,810,500
12,580,000
19,612,300
2,896,300
3,475,500
4,054,800
5,766,200
6,919,400
8,072,700
12,512,900
15,015,400
17,518,000
6,332,400
7,598,900
8,865,300

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,861,800
12,401,100
10,634,200
14,881,300
12,406,600
17,361,500
5,795,200
6,954,300
8,113,300
8,767,100
10,520,500
12,273,900
10,090,100
12,108,100
14,126,100
5,204,500
6,245,500
7,286,400
7,067,600
8,481,200
9,894,700
8,225,800
9,871,000
11,516,100
2,211,200
2,653,400
3,095,700
2,674,500
3,209,400
3,744,300
3,933,800
4,720,500
5,507,300
1,697,500
2,965,700
3,689,900
1,998,000
3,913,300
4,710,300
3,179,800
3,835,200
5,877,200
2,037,000
3,558,800
4,427,900
2,397,600
4,696,000
5,652,400
3,815,700
4,602,200
7,052,600
2,376,400
4,151,900
5,165,900
2,797,200
5,478,700
6,594,400
4,451,700
5,369,300
8,228,000
1,704,800
2,045,800
2,386,700
2,419,000
2,902,800
3,386,700
3,877,700
4,653,200
5,428,800
2,014,000
2,416,800
2,819,600
2,499,000
2,998,800
3,498,600
2,851,800
3,422,200
3,992,500
2,466,100
2,959,400
3,452,600
3,520,000
4,224,000
4,928,000
4,685,300
5,622,400
6,559,500
4,422,400
4,678,500
5,306,800
5,614,200
6,191,300
6,549,900
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 187 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,490,000
6,587,900
7,685,900
2,292,400
2,750,900
3,209,400
2,547,700
3,057,300
3,566,800
3,169,400
3,803,300
4,437,200
1,624,100
1,949,000
2,273,800
1,950,600
2,340,700
2,730,800
2,451,000
2,941,200
3,431,400
1,511,600
1,814,000
2,116,300

MAYOR (RINGAN)
MAYOR (SEDANG)
1,789,200
2,147,000
2,147,000
2,576,400
2,504,800
3,005,800
36,267,100
43,520,500
50,774,000
44,875,100
53,850,100
62,825,100
52,670,800
63,204,900
73,739,100
49,502,900
59,403,500
69,304,000
56,784,800
68,141,700
79,498,700
64,880,600
77,856,800
90,832,900
6,033,100
7,239,800
8,446,400
8,567,000
10,280,400
11,993,900
9,680,800
11,616,900
13,553,100
19,578,000
23,493,500
27,409,100
25,407,900
30,489,500
35,571,100
36,428,600
43,714,400
51,000,100
10,645,900
12,775,000
14,904,200
20,072,700
24,087,200
28,101,700
24,495,500
29,394,600
34,293,600
3,512,700
4,215,300
4,917,800
9,848,900
11,818,600
13,788,400
13,047,300
15,656,800
18,266,300
3,402,400
4,082,900
4,763,400
9,539,600
11,447,500
13,355,500
12,637,700
15,165,200
17,692,700
3,597,000
4,316,500
5,035,900
5,104,200
6,125,000
7,145,800
8,264,700
9,917,600
11,570,500
5,699,700
6,839,600
7,979,600
8,093,600
9,712,300
11,331,000
- 188 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,145,700
10,974,900
12,804,000
5,384,700
6,461,600
7,538,600
7,656,300
9,187,500
10,718,800
8,665,400
10,398,400
12,131,500
4,672,100
5,606,500
6,540,900
6,167,100
7,400,600
8,634,000
9,183,100
11,019,700
12,856,400
2,365,500
2,838,600
3,311,700
4,815,200
5,778,300
6,741,300
8,934,100
10,720,900
12,507,700
1,774,200
2,129,000
2,483,800
3,552,800
4,263,400
4,974,000
4,168,600
5,002,300
5,836,100
1,605,600
1,926,800
2,247,900
3,085,500
3,702,600
4,319,700
6,292,200
7,550,600
8,809,000
3,114,700
3,737,700
4,360,600
5,606,500
6,727,800
7,849,100
7,652,600
9,183,100
10,713,600
1,810,300
2,172,400
2,534,500
2,230,600
2,676,700
3,122,800
3,053,500
3,664,200
4,274,900
1,527,500
2,240,000
3,828,400
1,331,000
1,771,500
3,070,900
1,833,000
2,688,000
4,594,100
1,597,100
2,125,800
3,685,000
2,138,500
3,135,900
5,359,700
1,863,300
2,480,100
4,299,200
1,965,500
2,358,600
2,751,700
3,486,900
4,184,300
4,881,700
5,659,700
6,791,600
7,923,500
994,700
1,193,600
1,392,500
2,112,800
2,535,300
2,957,900
4,006,500
4,807,800
5,609,100
665,200
798,300
931,300
1,255,400
1,506,500
1,757,600
1,626,000
1,951,200
2,276,400
3,444,700
4,133,700
4,822,600
- 189 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,380,900
5,257,100
6,133,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,272,600
7,527,100
8,781,600
1,660,300
1,992,400
2,324,400
2,464,100
2,956,900
3,449,700
2,963,600
3,556,300
4,149,000
1,110,900
1,333,100
1,555,200
1,492,000
1,790,500
2,088,900
2,714,300
3,257,100
3,800,000
506,600
607,900
709,200
965,600
1,158,700
1,351,800
1,403,700
1,684,400
1,965,100
600,000
719,900
839,900
944,100
1,133,000
1,321,800
1,520,700
1,824,800
2,128,900
1,049,300
1,259,100
1,469,000
1,586,300
1,903,500
2,220,800
2,475,700
2,970,900
3,466,000
3,630,200
4,356,300
5,082,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,635,500
14,884,900
6,762,600
17,861,900
7,889,800
20,838,900
5,616,100
6,739,300
7,862,600
7,119,300
8,543,100
9,967,000
10,243,500
12,292,200
14,340,900
4,388,400
6,729,300
9,884,000
4,160,300
4,847,400
8,035,400
5,266,000
8,075,200
11,860,800
4,992,300
5,816,800
9,642,500
6,143,700
9,421,100
13,837,600
5,824,400
6,786,300
11,249,600
2,638,900
3,166,700
3,694,500
3,238,600
3,886,300
4,534,000
3,837,700
4,605,300
5,372,800
2,924,600
4,158,000
5,359,400
3,509,500
4,989,600
6,431,300
4,094,500
5,821,100
7,503,200
4,006,300
4,807,500
5,608,800
5,962,500
7,155,000
8,347,400
15,306,800
18,368,100
21,429,500
3,435,800
4,658,800
9,110,500
4,123,000
5,590,600
10,932,600
4,810,200
6,522,400
12,754,700
2,472,600
2,967,100
3,461,600
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 190 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,502,800
1,803,300
2,103,900
697 U-4-12-I
698 U-4-12-II

2,358,100
2,742,900
2,829,700
3,291,500
3,301,300
3,840,100
699 U-4-12-III

3,558,300
4,270,000
4,981,600
1,787,100
2,144,500
2,501,900
2,106,800
2,528,200
2,949,500
2,519,800
3,023,800
3,527,800
2,461,000
2,947,000
2,953,200
3,536,400
3,445,400
4,125,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,948,900
5,938,700
6,928,500
1,976,100
2,371,400
2,766,600
2,462,000
2,954,400
3,446,800
3,445,600
4,134,700
4,823,900
3,223,200
3,867,900
4,512,500
6,639,800
7,967,700
9,295,700
8,142,700
9,771,300
11,399,800
6,132,100
7,002,100
10,965,600
7,358,500
8,402,500
13,158,700
8,584,900
9,802,900
15,351,800
5,765,300
6,918,400
8,071,500
7,873,000
9,447,600
11,022,200
9,979,100
11,975,000
13,970,800
3,007,300
3,608,700
4,210,200
5,745,900
6,895,100
8,044,300
9,014,600
10,817,500
12,620,500
5,897,200
7,076,700
8,256,100
8,568,500
10,282,200
11,995,900
10,699,300
12,839,200
14,979,100
949,800
1,048,000
1,159,400
1,139,700
1,257,700
1,391,200
1,329,700
1,467,300
1,623,100
2,851,800
3,422,200
3,992,500
4,737,000
5,684,400
6,631,800
7,809,600
9,371,600
10,933,500
2,464,100
2,957,000
3,449,800
3,306,200
3,967,500
4,628,700
4,428,700
5,314,500
6,200,200
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,660,400
6,792,500
7,924,600
8,690,500
10,428,600
12,166,700
1,178,700
1,428,500
1,414,400
1,714,200
1,650,100
1,999,900
- 191 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,716,300
8,059,600
9,402,900
8,050,000
9,660,000
11,270,000
11,487,100
13,784,600
16,082,000
1,424,600
1,709,600
1,994,500
1,572,100
1,739,000
1,886,500
2,086,800
2,200,900
2,434,600
1,489,100
1,786,900
2,084,700
1,643,200
1,971,800
2,300,400
1,817,700
2,181,200
2,544,700
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,601,900
1,922,300
2,242,700
743 W-1-12-II
744 W-1-12-III

1,999,500
3,540,600
2,399,400
4,248,700
2,799,300
4,956,900
745 W-1-13-I
1,646,600
1,976,000
2,305,300
746 W-1-13-II
747 W-1-13-III

1,787,700
2,401,300
2,145,200
2,881,600
2,502,800
3,361,900
748 W-1-20-I
749 W-1-20-II

5,514,400
6,890,400
6,617,300
8,268,400
7,720,200
9,646,500
750 W-1-20-III
7,987,700
9,585,200
11,182,800
751 W-1-30-I
3,113,000
3,735,600
4,358,200
752 W-1-30-II
4,965,200
5,958,200
6,951,300
753 W-1-30-III
12,182,400
14,618,900
17,055,300
754 W-4-10-I
2,319,500
2,783,400
3,247,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,438,500
6,795,300
2,109,400
3,202,400
3,897,900
4,126,300
8,154,300
2,531,300
3,842,900
4,677,500
4,814,000
9,513,400
2,953,200
4,483,400
5,457,100
2,613,900
3,136,600
3,659,400
3,588,600
4,306,400
5,024,100
3,911,800
4,694,200
5,476,500
829,900
1,133,700
1,409,800
1,109,100
1,320,100
1,688,900
1,470,800
1,633,400
2,261,500
1,956,800
2,616,800
3,546,600
1,443,900
2,607,100
3,854,500
1,948,600
2,586,500
3,674,300
1,669,600
2,005,300
2,756,300
995,900
1,360,500
1,691,800
1,330,900
1,584,200
2,026,700
1,764,900
1,960,100
2,713,800
2,348,200
3,140,200
4,256,000
1,732,700
3,128,500
4,625,500
2,338,300
3,103,800
4,409,200
2,003,500
2,406,300
3,307,600
1,161,900
1,587,200
1,973,800
1,552,800
1,848,200
2,364,500
2,059,100
2,286,700
3,166,100
2,739,600
3,663,500
4,965,300
2,021,500
3,649,900
5,396,400
2,728,000
3,621,100
5,144,000
2,337,400
2,807,400
3,858,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 192 -

REGIONAL 1
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
776,400
931,700
1,087,000
1,891,800
2,270,200
2,648,500
2,399,200
2,879,000
3,358,900
- 193 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS D SWASTA
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
903,100
1,171,400
2,178,400
1,800,200
2,339,400
430,300
764,900
336,500
615,200
637,500
723,800
1,088,200
1,484,200
1,360,300
440,700
1,017,100
369,000
633,400
1,929,400
691,000
1,631,800
398,100
928,800
1,453,700
1,219,300
299,000
906,300
503,900
259,100
280,100
247,300
295,700
411,700
353,800
333,000
299,300
444,000
194,000
228,500
262,000
5,316,900
2,124,900
2,132,000
548,400
898,100
562,300
1,142,900
732,300
419,400
316,700
510,700
281,900
241,400
1,883,400
878,900
502,200
1,960,600
1,307,000
254,500
2,123,900
1,470,400
3,307,500
763,900
469,900
252,700
210,600
237,300
3,619,000
1,761,600
- 194 -

REGIONAL 1
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,238,900
3,962,400
3,285,300
2,502,700
825,100
2,785,500
1,818,800
447,100
4,182,100
3,786,000
2,538,500
2,404,900
297,200
285,600
1,149,200
314,100
279,800
309,300
1,061,500
1,450,000
1,266,500
1,118,500
677,400
281,500
496,100
340,600
307,500
299,600
380,400
433,800
254,300
729,900
1,330,200
1,021,100
2,400,500
312,600
312,600
2,218,200
1,289,800
247,400
1,144,700
2,973,500
682,700
537,700
263,400
227,400
285,300
397,900
952,800
839,800
587,800
438,500
241,400
1,020,800
817,900
349,500
398,800
1,306,800
289,000
1,335,100
1,021,400
311,500
345,300
337,300
204,100
1,112,900
1,529,100
303,000
- 195 -

REGIONAL 1
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
928,800
346,700
374,800
347,100
550,600
423,600
1,060,800
313,000
870,800
1,163,600
254,800
1,551,000
840,500
1,816,400
916,900
404,900
311,500
65,600
403,700
912,300
355,500
480,200
274,600
106,800
277,300
4,129,800
2,347,400
3,917,900
962,400
537,700
366,400
828,700
438,300
882,100
510,700
304,100
508,900
229,100
349,700
335,100
737,700
1,598,700
1,286,300
1,134,100
800,400
294,400
294,400
294,400
240,500
152,500
239,800
293,200
317,100
233,600
206,000
92,000
101,100
74,800
87,800
83,700
127,800
114,600
163,700
179,800
101,700
123,500
84,400
131,800
186,900
- 196 -

REGIONAL 1
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
133,100
183,800
519,500
602,200
125,800
250,000
153,100
218,600
420,500
360,000
258,800
245,100
125,100
122,900
288,600
182,100
261,200
185,000
141,500
1,815,000
1,867,000
296,600
307,200
587,600
738,000
752,100
388,500
1,210,700
261,700
315,700
316,800
253,700
320,400
303,200
142,000
312,100
276,600
250,200
283,000
2,342,500
304,200
843,000
302,400
430,200
451,600
360,300
732,100
749,700
799,400
699,200
1,214,600
208,300
1,446,400
274,600
733,200
1,666,200
1,926,600
841,700
305,000
594,900
592,500
274,600
2,152,500
1,693,100
136,700
149,700
194,500
261,900
- 197 -

REGIONAL 1
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
914,300
432,800
892,100
1,076,300
515,800
717,500
495,900
533,600
577,400
295,500
698,700
178,700
661,800
984,300
72,600
- 198 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,548,200
4,257,800
A-4-10-II
SEPTIKEMIA (SEDANG)
6,061,700
7,274,100
8,486,400
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,173,100
4,302,100
9,807,700
5,162,500
11,442,400
6,022,900
5
6
A-4-11-II
A-4-11-III

6,123,100
8,474,900
7,347,800
10,169,900
8,572,400
11,864,900
A-4-12-I
2,805,700
3,366,900
3,928,000
8
9
A-4-12-II
A-4-12-III

4,843,200
6,978,100
5,811,800
8,373,700
6,780,400
9,769,400
10 A-4-13-I
11 A-4-13-II

2,088,200
3,690,500
2,505,900
4,428,500
2,923,500
5,166,600
12 A-4-13-III
4,428,500
5,314,300
6,200,000
2,339,400
2,807,300
3,275,200
3,936,200
4,723,400
5,510,700
4,723,400
5,668,100
6,612,800
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,263,800
22,744,500
21,916,600
27,293,500
25,569,400
31,842,400
18 A-4-15-III
INFEKSI HIV (BERAT)
25,694,900
30,833,900
35,972,900
19 B-1-01-I
20 B-1-01-II

50,357,200
55,557,200
60,428,600
66,668,700
70,500,100
77,780,100
21 B-1-01-III
22 B-1-10-I

122,463,100
8,140,000
146,955,700
9,768,000
171,448,400
11,396,000
23 B-1-10-II
18,067,100
21,680,600
25,294,000
24 B-1-10-III
25 B-1-11-I

35,667,000
32,481,900
42,800,400
38,978,300
49,933,800
45,474,700
26 B-1-11-II
27 B-1-11-III

38,704,000
59,808,500
46,444,700
71,770,200
54,185,500
83,731,800
28 B-1-12-I
9,558,300
11,469,900
13,381,600
29 B-1-12-II
10,630,500
12,756,600
14,882,700
30 B-1-12-III
16,630,200
19,956,300
23,282,300
7,613,300
9,135,900
10,658,600
12,526,700
15,032,100
17,537,400
16,208,500
19,450,200
22,691,900
19,946,700
23,936,100
27,925,400
20,949,700
25,139,600
29,329,500
37,084,500
3,236,600
5,166,600
7,127,500
44,501,400
3,883,900
6,199,900
8,553,000
51,918,300
4,531,300
7,233,200
9,978,400
6,824,000
8,188,800
9,553,600
9,553,700
11,464,400
13,375,200
11,574,200
13,889,000
16,203,900
6,169,700
8,785,400
13,070,700
5,885,400
7,403,600
10,542,400
15,684,800
7,062,400
8,637,500
12,299,500
18,299,000
8,239,500
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
4,967,400
- 199 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,856,200
8,227,400
9,598,700
48 B-4-13-III
49 B-4-14-I

9,445,000
5,879,100
11,334,000
7,054,900
13,223,000
8,230,700
50 B-4-14-II
6,858,700
8,230,400
9,602,200
51 B-4-14-III
52 C-4-10-I

9,187,400
11,907,400
11,024,900
14,288,900
12,862,300
16,670,400
53 C-4-10-II
54 C-4-10-III

19,150,500
35,881,700
22,980,500
43,058,100
26,810,600
50,234,400
55 C-4-11-I
6,198,200
7,437,800
8,677,500
56 C-4-11-II
57 C-4-11-III

8,294,100
12,752,300
9,952,900
15,302,700
11,611,700
17,853,200
58 C-4-12-I
59 C-4-12-II
4,127,000
8,128,500
4,952,400
9,754,200
5,777,700
11,379,900
60 C-4-12-III
RADIOTERAPI (BERAT)
20,876,300
25,051,500
29,226,800
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,102,600
5,839,200
3,723,200
7,007,000
4,343,700
8,174,900
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
7,904,300
5,155,200
9,485,100
6,186,200
11,066,000
7,217,200
65 C-4-14-II
7,231,700
8,678,000
10,124,300
66 C-4-14-III
67 D-1-10-I

10,775,000
31,146,000
12,930,000
37,375,200
15,085,000
43,604,400
68 D-1-10-II
69 D-1-10-III

47,437,600
67,983,200
56,925,100
81,579,800
66,412,600
95,176,500
70 D-1-11-I
8,339,100
10,006,900
11,674,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,293,500
27,671,700
25,552,200
33,206,100
29,810,900
38,740,400
7,229,000
8,674,800
10,120,600
19,922,000
23,906,400
27,890,800
31,602,200
37,922,600
44,243,100
2,856,700
4,688,100
7,375,500
5,659,300
10,169,600
13,970,500
4,879,100
6,767,400
10,391,700
3,428,000
5,625,700
8,850,600
6,791,200
12,203,500
16,764,600
5,854,900
8,120,900
12,470,000
3,999,400
6,563,400
10,325,700
7,923,000
14,237,400
19,558,700
6,830,800
9,474,400
14,548,400
4,181,300
5,017,500
5,853,800
5,917,900
7,101,500
8,285,100
7,569,200
9,083,100
10,596,900
4,484,600
5,381,500
6,278,400
7,342,400
8,810,900
10,279,400
8,980,500
10,776,600
12,572,800
8,939,500
10,727,400
12,515,400
12,203,800
14,644,600
17,085,300
93 E-1-01-III
29,424,600
35,309,500
41,194,500
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,294,200
12,901,500
24,375,100
11,153,100
15,481,800
29,250,200
13,011,900
18,062,100
34,125,200
10,521,800
12,626,100
14,730,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 200 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,136,300
4,963,600
5,790,800
104 E-4-11-II
105 E-4-11-III

6,306,200
8,545,300
7,567,400
10,254,400
8,828,600
11,963,400
106 E-4-12-I
107 E-4-12-II

4,752,600
8,230,300
5,703,100
9,876,400
6,653,600
11,522,400
108 E-4-12-III

(RINGAN)
(SEDANG)
9,755,900
11,707,100
13,658,300
5,175,400
6,210,400
7,245,500
7,581,000
9,097,200
10,613,400
111 E-4-13-III
9,909,900
11,891,800
13,873,800
112 F-4-10-I
113 F-4-10-II
5,509,800
6,332,400
6,611,800
7,598,900
7,713,800
8,865,400
114 F-4-10-III
115 F-4-11-I
7,598,900
5,328,900
9,118,700
6,394,700
10,638,500
7,460,400
116 F-4-11-II
6,208,700
7,450,500
8,692,200
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,961,900
9,554,200
11,146,600
2,921,100
3,505,300
4,089,500
4,152,900
4,983,500
5,814,000
9,021,900
10,826,300
12,630,700
4,292,500
5,664,100
7,332,900
2,449,100
3,141,300
4,226,900
5,151,100
6,796,900
8,799,500
2,938,900
3,769,600
5,072,300
6,009,600
7,929,800
10,266,100
3,428,700
4,397,800
5,917,700
127 F-4-15-I
3,900,400
4,680,400
5,460,500
128 F-4-15-II
5,812,000
6,974,400
8,136,900
129 F-4-15-III
7,673,700
9,208,500
10,743,200
7,674,200
9,209,000
10,743,800
8,922,500
10,707,000
12,491,500
11,910,000
14,291,900
16,673,900
133 F-4-17-I

1,812,300
2,174,800
2,537,300
134 F-4-17-II
5,311,700
6,374,100
7,436,400
135
136
137
138
139
140
141

(RINGAN)
5,667,100
6,668,300
7,337,000
11,310,500
5,096,100
6,525,800
8,124,600
6,800,500
8,001,900
8,804,400
13,572,600
6,115,300
7,831,000
9,749,500
7,934,000
9,335,600
10,271,800
15,834,700
7,134,600
9,136,100
11,374,400
21,618,300
25,941,900
30,265,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,162,000
16,994,400
19,826,800
19,518,200
23,421,800
27,325,500
3,723,600
4,468,300
5,213,100
7,212,000
8,654,400
10,096,800
12,084,600
14,501,500
16,918,400
- 201 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,588,700
60,706,500
70,824,200
148 G-1-11-I
149 G-1-11-II

16,544,500
30,247,200
19,853,400
36,296,600
23,162,300
42,346,000
150 G-1-11-III
48,605,900
58,327,100
68,048,200
6,907,900
8,289,500
9,671,100
12,949,200
15,539,000
18,128,900
17,647,200
21,176,600
24,706,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,083,900
5,596,300
2,500,700
6,715,600
2,917,500
7,834,900
156 G-1-13-III
157 G-1-20-I

12,627,800
11,698,900
15,153,400
14,038,700
17,679,000
16,378,500
158 G-1-20-II
17,702,300
21,242,800
24,783,300
159 G-1-20-III
30,185,700
36,222,800
42,259,900
160 G-1-30-I
29,145,100
34,974,100
40,803,100
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
39,294,700
59,007,900
47,153,600
70,809,400
55,012,600
82,611,000
5,929,700
7,115,600
8,301,600
7,248,100
8,697,700
10,147,300
9,945,600
11,934,700
13,923,800
6,207,400
7,448,900
8,690,400
8,245,800
9,895,000
11,544,100
12,115,900
14,539,100
16,962,300
6,886,400
8,263,700
9,641,000
8,698,100
10,437,700
12,177,300
12,632,900
15,159,400
17,686,000
4,136,800
4,964,100
5,791,500
7,213,700
8,656,500
10,099,200
8,555,600
10,266,800
11,977,900
7,017,600
8,421,100
9,824,600
9,382,000
11,258,400
13,134,800
11,775,500
14,130,600
16,485,700
5,734,000
6,880,800
8,027,600
6,843,200
8,211,800
9,580,500
9,658,600
11,590,300
13,522,000
4,726,900
5,672,300
6,617,600
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
31,005,800
37,207,000
43,408,200
50,728,100
60,873,800
71,019,400
33,612,600
41,167,100
40,335,100
49,400,500
47,057,700
57,633,900
- 202 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,275,600
7,530,700
8,785,800
183 G-4-16-III
8,936,900
10,724,300
12,511,700
6,295,900
7,555,100
8,814,200
8,255,300
9,906,300
11,557,400
10,373,100
12,447,800
14,522,400
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,200,500
7,440,600
8,680,700
188 G-4-18-II
8,288,200
9,945,800
11,603,400
189 G-4-18-III
9,273,800
11,128,500
12,983,300
5,173,200
6,207,800
7,242,500
8,743,900
10,492,700
12,241,500
11,480,400
13,776,500
16,072,600
193 G-4-20-I

3,618,900
4,342,700
5,066,500
194 G-4-20-II
5,116,000
6,139,200
7,162,400
195 G-4-20-III
196 G-4-21-I

8,450,400
3,768,500
10,140,500
4,522,200
11,830,600
5,275,900
197 G-4-21-II
198 G-4-21-III

6,378,300
7,495,900
7,653,900
8,995,100
8,929,600
10,494,300
199 G-4-22-I
2,823,300
3,388,000
3,952,700
200 G-4-22-II
201 G-4-22-III

5,000,200
7,887,400
6,000,200
9,464,800
7,000,300
11,042,300
202 G-4-23-I
203 G-4-23-II

3,709,700
4,654,400
4,451,700
5,585,300
5,193,600
6,516,200
204 G-4-23-III
6,626,800
7,952,200
9,277,500
205 G-4-24-I
206 G-4-24-II

4,132,100
5,162,500
4,958,500
6,195,000
5,784,900
7,227,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,600,500
3,530,800
4,465,100
5,917,100
10,320,600
4,237,000
5,358,100
7,100,600
12,040,700
4,943,100
6,251,100
8,284,000
4,025,400
4,830,500
5,635,600
4,682,800
5,619,300
6,555,900
7,002,200
8,402,600
9,803,100
11,907,200
13,159,300
17,895,900
8,113,700
10,080,500
14,119,200
4,302,100
5,837,000
11,472,900
4,125,200
4,705,700
6,738,200
4,863,700
5,811,200
9,738,600
14,288,600
15,791,200
21,475,100
9,736,500
12,096,600
16,943,100
5,162,500
7,004,400
13,767,500
4,950,300
5,646,800
8,085,800
5,836,400
6,973,500
11,686,300
16,670,100
18,423,000
25,054,300
11,359,200
14,112,700
19,766,900
6,022,900
8,171,800
16,062,000
5,775,300
6,587,900
9,433,500
6,809,200
8,135,700
13,634,000
229 I-1-01-I
65,328,100
78,393,800
91,459,400
230 I-1-01-II
66,765,300
80,118,400
93,471,500
231 I-1-01-III

(RINGAN)
105,388,200
126,465,800
147,543,400
36,243,800
43,492,500
50,741,300
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 203 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,726,800
58,472,200
245 I-1-06-II
70,584,800
84,701,800
98,818,700
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
84,220,700
101,064,800
117,909,000
75,844,500
91,013,400
106,182,300
94,805,600
113,766,800
132,727,900
142,208,500
170,650,200
199,091,800
5,679,500
6,815,400
7,951,300
6,315,100
7,578,100
8,841,100
8,403,400
10,084,100
11,764,800
16,348,400
19,618,000
22,887,700
26,700,200
32,040,200
37,380,200
35,128,100
42,153,700
49,179,300
15,857,700
19,029,200
22,200,800
21,117,700
25,341,300
29,564,800
26,044,000
31,252,800
36,461,600
32,456,800
38,948,100
45,439,500
40,339,000
48,406,800
56,474,600
52,858,000
63,429,600
74,001,200
6,165,900
8,610,500
16,580,400
7,399,000
10,332,600
19,896,500
8,632,200
12,054,700
23,212,600
15,984,100
19,181,000
22,377,800
36,165,700
43,398,800
50,631,900
41,716,500
50,059,800
58,403,200
18,508,100
22,209,700
25,911,400
23,173,900
27,808,700
32,443,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
46,754,000
56,104,800
65,455,600
57,627,300
69,152,700
80,678,200
34,181,800
41,018,100
47,854,500
47,383,000
56,859,600
66,336,200
60,132,700
72,159,200
84,185,800
51,510,100
61,812,100
72,114,100
81,296,800
97,556,200
113,815,500
129,871,100
155,845,300
181,819,600
85,325,100
102,390,100
119,455,100
104,286,200
125,143,400
146,000,700
142,208,500
170,650,200
199,091,800
68,217,600
- 204 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,004,700
43,205,600
50,406,500
279 I-1-40-III
48,090,000
57,708,000
67,326,000
280 I-4-10-I
281 I-4-10-II

5,489,800
9,802,600
6,587,700
11,763,100
7,685,700
13,723,700
282 I-4-10-III
14,124,200
16,949,000
19,773,900
283 I-4-11-I
284 I-4-11-II

8,446,000
10,451,900
10,135,200
12,542,300
11,824,400
14,632,700
285 I-4-11-III
286 I-4-12-I

19,335,000
4,855,200
23,202,000
5,826,300
27,069,000
6,797,300
287 I-4-12-II
5,627,900
6,753,500
7,879,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,753,500
8,104,200
9,454,900
4,940,800
5,928,900
6,917,100
8,822,400
10,586,800
12,351,300
12,711,800
15,254,100
17,796,500
4,665,700
4,826,300
8,460,500
5,598,900
5,791,500
10,152,600
6,532,000
6,756,800
11,844,700
4,765,000
5,718,000
6,671,000
8,985,400
10,782,400
12,579,500
10,782,400
12,938,900
15,095,400
2,944,800
4,728,600
5,674,300
1,966,100
3,172,700
4,441,800
3,533,700
5,674,300
6,809,100
2,359,300
3,807,200
5,330,100
4,122,700
6,620,000
7,944,000
2,752,600
4,441,800
6,218,500
5,680,100
6,816,100
7,952,100
8,648,200
10,377,800
12,107,500
11,741,400
14,089,600
16,437,900
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
28,665,700
34,398,900
40,132,000
20,861,800
25,034,200
29,206,600
26,062,100
31,274,600
36,487,000
27,396,700
32,876,000
38,355,400
15,780,800
18,937,000
22,093,100
32,827,600
39,393,100
45,958,600
50,870,900
61,045,100
71,219,200
14,564,000
17,476,800
20,389,500
307 I-4-19-I
5,480,200
6,576,200
7,672,200
308 I-4-19-II

(SEDANG)
8,554,800
10,265,800
11,976,800
309 I-4-19-III
10,212,900
12,255,400
14,298,000
310
311
312
313
314

5,706,500
6,591,000
9,854,900
3,843,100
4,869,300
6,847,800
7,909,200
11,825,900
4,611,700
5,843,100
7,989,100
9,227,400
13,796,800
5,380,300
6,817,000
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 205 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,028,200
8,433,900
9,839,500
316 I-4-22-I
317 I-4-22-II
3,452,900
4,298,400
4,143,500
5,158,000
4,834,100
6,017,700
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,282,900
7,539,400
8,796,000
4,684,200
5,621,000
6,557,900
5,750,900
6,901,000
8,051,200
11,236,800
13,484,200
15,731,600
3,043,200
3,651,800
4,260,400
7,007,600
8,409,100
9,810,600
8,859,900
10,631,800
12,403,800
96,421,200
115,705,400
134,989,700
109,118,500
130,942,200
152,765,900
149,674,800
179,609,800
209,544,800
62,903,200
75,483,800
88,064,400
79,371,600
95,245,900
111,120,200
92,853,500
111,424,200
129,994,900
12,263,200
14,715,900
17,168,500
24,814,700
29,777,600
34,740,600
25,788,600
30,946,300
36,104,000
33,783,000
40,539,600
47,296,200
35,375,300
42,450,400
49,525,500
39,810,300
47,772,400
55,734,500
10,234,000
12,280,800
14,327,600
18,538,700
22,246,500
25,954,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
53,511,400
64,213,700
74,915,900
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,016,700
6,230,300
9,425,600
3,732,300
5,198,400
6,967,900
6,339,400
7,216,400
10,076,200
5,605,100
7,802,100
14,556,100
6,179,700
10,056,200
11,897,500
4,471,700
7,405,100
13,449,900
3,620,100
7,476,400
11,310,700
4,478,800
6,238,100
8,361,500
7,607,200
8,659,700
12,091,400
6,726,100
9,362,500
17,467,400
7,415,700
12,067,400
14,277,000
5,366,000
8,886,100
16,139,800
4,223,400
8,722,500
13,195,800
5,225,300
7,277,800
9,755,100
8,875,100
10,103,000
14,106,600
7,847,100
10,922,900
20,378,600
8,651,600
14,078,700
16,656,500
6,260,300
10,367,200
18,829,800
3,725,800
4,471,000
5,216,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 206 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,257,300
8,708,800
10,160,300
12,387,300
14,864,800
17,342,200
5,163,700
6,183,700
6,196,500
7,420,400
7,229,200
8,657,200

8,114,900
2,295,300
9,737,900
2,754,300
11,360,800
3,213,400
365 J-4-18-II
4,375,900
5,251,000
6,126,200
366 J-4-18-III
367 J-4-19-I

6,218,300
6,545,900
7,461,900
7,855,100
8,705,600
9,164,300
368 J-4-19-II
369 J-4-19-III

7,423,500
8,198,300
8,908,200
9,838,000
10,392,900
11,477,700
370 J-4-20-I
5,207,200
6,248,700
7,290,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,215,100
8,458,400
8,658,200
10,150,000
10,101,200
11,841,700
2,975,000
3,570,000
4,165,000
6,643,100
7,971,700
9,300,300
12,514,400
15,017,300
17,520,200
11,117,400
13,340,800
15,564,300
13,971,300
16,765,600
19,559,900
16,374,900
19,649,900
22,924,800
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,440,600
12,528,700
14,616,800

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
13,707,200
27,093,500
16,448,700
32,512,200
19,190,100
37,931,000
4,664,700
5,597,600
6,530,600
6,067,000
7,280,400
8,493,700
12,019,600
14,423,500
16,827,400
5,260,800
5,786,900
9,248,700
6,313,000
6,944,300
11,098,500
7,365,200
8,101,700
12,948,200
7,683,600
9,220,400
10,757,100
9,005,100
10,806,100
12,607,100
390 K-1-14-III
15,720,200
18,864,200
22,008,300
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

16,531,100
23,090,300
33,714,200
19,837,300
27,708,300
40,457,100
23,143,600
32,326,400
47,199,900
9,776,400
11,731,700
13,686,900
17,362,600
20,835,200
24,307,700
23,891,200
28,669,500
33,447,700
397 K-1-40-I
10,908,200
13,089,800
15,271,500
398 K-1-40-II

(SEDANG)
12,026,700
14,432,000
16,837,300
399 K-1-40-III
20,380,800
24,457,000
28,533,200
400
401
402
403
404

8,334,900
10,824,000
15,296,200
6,880,900
9,886,900
10,001,900
12,988,800
18,355,500
8,257,100
11,864,300
11,668,900
15,153,600
21,414,700
9,633,300
13,841,600
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 207 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,072,000
18,086,500
21,100,900
406 K-4-11-I
407 K-4-11-II

2,392,000
4,711,500
2,870,400
5,653,800
3,348,800
6,596,100
408 K-4-11-III
409 K-4-12-I

5,653,800
4,136,300
6,784,600
4,963,600
7,915,300
5,790,800
410 K-4-12-II
5,566,200
6,679,500
7,792,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,208,300
11,050,000
12,891,700
5,576,000
6,691,200
7,806,400
7,212,900
8,655,500
10,098,100
11,110,200
13,332,300
15,554,300
3,181,700
3,818,000
4,454,400
4,270,900
5,125,100
5,979,200
6,853,100
8,223,700
9,594,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,535,200
5,442,200
6,349,200
419 K-4-15-II
6,984,600
8,381,500
9,778,400
420 K-4-15-III
9,941,700
11,930,000
13,918,300
421 K-4-16-I
4,107,200
4,928,600
5,750,000
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,925,600
5,747,500
5,910,800
6,896,900
6,895,900
8,046,400
2,014,600
2,417,500
2,820,500
2,481,000
2,977,200
3,473,400
2,977,200
3,572,600
4,168,100
1,775,400
2,130,400
2,485,500
2,995,900
3,595,100
4,194,300
429 K-4-18-III
3,595,100
4,314,100
5,033,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
26,356,800
39,784,900
53,159,200
12,435,400
21,338,400
26,491,900
31,628,200
47,741,900
63,791,000
14,922,500
25,606,000
31,790,300
36,899,600
55,698,900
74,422,800
17,409,600
29,873,700
37,088,700
6,969,100
8,362,900
9,756,700
13,978,400
16,774,100
19,569,800
23,528,800
28,234,500
32,940,300
9,149,000
14,724,400
21,061,700
2,393,000
2,777,600
3,224,000
5,011,200
6,887,500
15,650,600
2,379,900
3,147,700
10,408,200
10,978,800
17,669,200
25,274,100
2,871,600
3,333,100
3,868,800
6,013,500
8,265,000
18,780,700
2,855,900
3,777,300
12,489,900
12,808,600
20,614,100
29,486,400
3,350,200
3,888,600
4,513,600
7,015,700
9,642,500
21,910,800
3,331,800
4,406,800
14,571,500
2,534,100
3,040,900
3,547,800
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 208 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,128,200
4,953,900
5,779,500
8,200,900
9,841,100
11,481,200
4,121,100
4,945,400
5,769,600
6,190,100
7,428,100
8,666,100
8,725,700
10,470,800
12,216,000
14,567,800
17,481,400
20,395,000
20,706,100
24,847,300
28,988,600
29,085,900
34,903,100
40,720,300
12,911,600
15,494,000
18,076,300
21,181,100
35,986,200
25,417,300
43,183,400
29,653,500
50,380,600
51,612,600
61,935,100
72,257,600
60,368,400
72,442,100
84,515,800
74,716,000
89,659,200
104,602,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,433,700
31,720,500
37,007,200
467 M-1-04-II
33,959,700
40,751,600
47,543,500
468 M-1-04-III
40,633,500
48,760,300
56,887,000
469 M-1-05-I
470 M-1-05-II

10,278,400
16,625,700
12,334,100
19,950,800
14,389,800
23,276,000
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,237,200
25,484,700
29,732,100
18,786,100
22,543,300
26,300,600
25,166,900
30,200,300
35,233,700
51,267,400
61,520,800
71,774,300
22,200,200
26,640,300
31,080,300
53,079,800
63,695,700
74,311,700
114,488,100
137,385,700
160,283,300
17,299,400
20,759,200
24,219,100
22,101,700
26,522,000
30,942,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
55,026,500
66,031,800
77,037,100
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
11,867,800
19,230,700
27,498,200
14,241,400
23,076,900
32,997,800
16,614,900
26,923,000
38,497,500
7,249,400
8,699,300
10,149,200
10,713,800
12,856,500
14,999,300
15,297,200
18,356,600
21,416,000
7,239,400
12,013,700
19,731,800
8,687,300
14,416,500
23,678,100
10,135,200
16,819,200
27,624,500
11,180,700
13,416,800
15,653,000
14,056,700
16,868,000
19,679,400
21,234,300
25,481,200
29,728,100
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 209 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,834,900
9,401,900
10,968,800
512 M-4-14-II
9,663,200
11,595,800
13,528,400
513 M-4-14-III
514 M-4-15-I
14,520,900
4,645,900
17,425,100
5,575,000
20,329,300
6,504,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,192,600
14,052,800
3,977,600
6,369,600
10,700,500
7,431,100
16,863,400
4,773,100
7,643,500
12,840,600
8,669,700
19,674,000
5,568,600
8,917,400
14,980,700
4,646,100
5,575,300
6,504,600
6,498,100
7,797,700
9,097,400
9,074,200
10,889,000
12,703,900
3,901,900
5,880,400
7,080,200
4,682,300
7,056,500
8,496,300
5,462,700
8,232,500
9,912,300
4,069,100
4,882,900
5,696,700
6,853,900
8,224,700
9,595,500
13,386,100
16,063,400
18,740,600
3,694,100
4,433,000
5,171,800
5,409,400
6,491,300
7,573,200
6,045,700
7,254,800
8,464,000
3,719,700
4,463,600
5,207,600
4,652,300
5,582,700
6,513,200
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
20,714,200
24,857,100
28,999,900
22,785,700
27,342,800
31,899,900
26,086,600
31,303,900
36,521,200
11,775,200
14,130,200
16,485,200
13,984,100
31,475,200
16,780,900
37,770,300
19,577,800
44,065,300
4,148,000
4,977,500
5,807,100
6,186,000
11,703,900
7,423,200
14,044,700
8,660,400
16,385,500
5,168,700
6,202,500
7,236,200
11,332,200
13,598,700
15,865,100
16,384,500
19,661,400
22,938,300
4,125,800
4,951,000
5,776,100
6,862,400
8,234,800
9,607,300
9,179,100
11,015,000
12,850,800
6,869,900
8,243,900
9,617,900
10,321,700
12,386,100
14,450,400
20,137,500
24,165,000
28,192,500
- 210 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,430,300
12,516,400
14,602,400
535 N-1-01-I

286,075,600
343,290,700
400,505,800
536 N-1-01-II
286,075,600
343,290,700
400,505,800
537 N-1-01-III
538 N-1-11-I

286,075,600
11,921,600
343,290,700
14,305,900
400,505,800
16,690,200
539 N-1-11-II
540 N-1-11-III

18,850,900
29,388,600
22,621,100
35,266,300
26,391,300
41,144,000
6,076,000
7,291,200
8,506,400
12,096,700
14,516,100
16,935,400
26,250,300
31,500,400
36,750,500
13,284,500
15,941,400
18,598,300

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
18,590,900
26,015,800
22,309,100
31,219,000
26,027,300
36,422,100
12,157,700
14,589,200
17,020,700
18,392,200
22,070,600
25,749,000
21,167,600
25,401,100
29,634,700
10,918,500
13,102,100
15,285,800
14,827,000
17,792,400
20,757,800
17,256,700
20,708,000
24,159,400
4,638,800
5,566,600
6,494,400
5,610,700
6,732,900
7,855,000
8,252,600
9,903,100
11,553,600
3,561,000
6,221,600
7,741,000
2,684,900
5,577,900
9,063,700
3,633,100
6,073,900
12,565,500
4,273,300
7,465,900
9,289,200
3,221,900
6,693,400
10,876,400
4,359,700
7,288,600
15,078,600
4,985,500
8,710,200
10,837,300
3,758,900
7,809,000
12,689,200
5,086,400
8,503,400
17,591,700
3,576,500
4,291,700
5,007,000
5,074,800
6,089,800
7,104,800
8,134,900
9,761,900
11,388,900
4,225,100
5,070,100
5,915,200
5,242,600
6,291,200
7,339,700
5,982,700
7,179,300
8,375,800
5,173,600
6,208,400
7,243,100
7,384,400
8,861,300
10,338,200
9,829,200
11,795,100
13,760,900
5,301,200
6,823,500
6,361,500
8,188,200
7,421,700
9,552,800
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 211 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,756,000
12,907,300
15,058,500
4,809,200
5,771,000
6,732,800
5,344,800
6,413,800
7,482,800
6,649,000
7,978,800
9,308,600
3,407,200
4,088,700
4,770,100
4,092,000
4,910,400
5,728,900
5,141,800
6,170,200
7,198,500
1,727,200
2,072,600
2,418,000
2,833,500
3,400,200
3,400,200
4,080,300
3,966,900
4,760,300
76,083,700
91,300,400
106,517,100
94,142,100
112,970,500
131,799,000
110,496,400
132,595,700
154,694,900
103,850,600
124,620,700
145,390,900
119,127,100
142,952,500
166,777,900
136,111,100
163,333,400
190,555,600
15,577,500
18,693,000
21,808,500
20,618,900
24,742,700
28,866,500
28,991,200
34,789,400
40,587,600
50,199,100
60,238,900
70,278,800
65,147,600
78,177,100
91,206,600
93,405,300
112,086,400
130,767,400
27,296,700
32,756,000
38,215,300
42,109,900
50,531,800
58,953,800
57,003,500
68,404,200
79,804,900
7,369,200
8,843,100
10,316,900
20,661,600
24,794,000
28,926,300
27,371,600
32,845,900
38,320,200
8,724,000
10,468,800
12,213,700
24,460,200
29,352,200
34,244,300
32,403,800
38,884,500
45,365,300
5,047,800
6,057,400
7,067,000
7,162,600
8,595,200
10,027,700
13,934,100
16,721,000
19,507,800
12,981,200
15,577,500
18,173,700
17,182,400
20,618,900
24,055,400
- 212 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,159,300
28,991,200
33,823,000
11,801,100
14,161,300
16,521,600
14,318,700
17,182,400
20,046,200
21,008,100
25,209,700
29,411,300
6,556,200
7,867,400
9,178,700
10,227,600
12,273,200
14,318,700
16,160,100
19,392,100
22,624,100
4,962,500
5,955,000
6,947,500
10,101,700
12,122,100
14,142,400
39,498,500
47,398,200
55,297,900
3,722,000
4,466,300
5,210,700
7,453,400
8,944,100
10,434,700
8,745,200
10,494,200
12,243,300
3,368,400
4,042,100
4,715,800
6,472,900
7,767,500
9,062,100
15,180,100
18,216,200
21,252,200
4,370,800
5,244,900
6,119,100
7,867,400
9,440,900
11,014,400
13,466,700
16,160,100
18,853,400
3,797,800
4,557,400
5,317,000
4,679,500
5,615,400
6,551,300
6,405,800
7,686,900
8,968,100
1,745,300
3,547,500
8,185,200
2,792,200
3,716,300
6,442,300
2,094,400
4,257,000
9,822,200
3,350,600
4,459,600
7,730,700
2,443,400
4,966,500
11,459,200
3,909,000
5,202,800
9,019,200
4,123,300
4,948,000
5,772,600
7,315,100
8,778,100
10,241,100
11,873,300
14,247,900
16,622,600
2,086,700
2,504,000
2,921,400
4,432,300
5,318,700
6,205,200
8,405,200
10,086,200
11,767,200
1,395,600
1,674,700
1,953,800
2,633,700
3,160,500
3,687,200
3,411,100
4,093,300
4,775,600
7,226,600
8,672,000
10,117,300
- 213 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,190,600
11,028,700
12,866,800
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,159,000
15,790,800
18,422,600
3,483,100
4,179,700
4,876,300
5,169,300
6,203,200
7,237,000
6,217,200
7,460,700
8,704,100
2,330,500
2,796,600
3,262,700
3,130,100
3,756,100
4,382,200
5,694,200
6,833,000
7,971,800
1,276,100
1,531,300
1,786,500
2,431,500
2,917,800
3,404,100
3,534,300
4,241,200
4,948,100
1,232,400
1,478,900
1,725,300
1,939,400
2,327,300
2,715,200
3,123,900
3,748,600
4,373,400
2,887,600
3,465,100
4,042,600
4,359,100
5,230,900
6,102,700
6,747,200
8,096,600
9,446,100
7,615,700
9,138,900
10,662,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
11,822,600
31,226,700
14,187,200
37,472,000
16,551,700
43,717,300
12,018,700
14,422,400
16,826,200
18,128,000
21,753,600
25,379,200
21,489,500
25,787,400
30,085,300
9,206,200
14,117,300
20,735,300
9,212,600
10,734,100
17,793,800
11,047,500
16,940,700
24,882,400
11,055,100
12,880,900
21,352,500
12,888,700
19,764,200
29,029,500
12,897,600
15,027,700
24,911,300
5,536,100
6,643,300
7,750,500
6,794,100
8,152,900
9,511,800
8,051,000
9,661,200
11,271,400
4,333,300
6,160,700
9,384,600
5,200,000
7,392,800
11,261,600
6,066,600
8,625,000
13,138,500
8,404,700
10,085,600
11,766,500
12,508,500
15,010,200
17,511,900
32,111,600
38,534,000
44,956,300
7,207,900
9,773,600
19,112,700
8,649,500
11,728,400
22,935,200
10,091,100
13,683,100
26,757,800
5,187,100
6,224,500
7,262,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 214 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,508,700
3,010,500
3,512,200
697 U-4-12-I
698 U-4-12-II

2,694,200
4,344,000
3,233,100
5,212,800
3,771,900
6,081,600
699 U-4-12-III

7,607,700
9,129,300
10,650,800
2,041,900
2,450,200
2,858,600
3,336,600
4,003,900
4,671,200
5,387,400
6,464,900
7,542,400
5,162,900
6,182,500
6,195,500
7,418,900
7,228,100
8,655,400

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,382,200
12,458,700
14,535,100
4,145,700
4,974,800
5,803,900
5,165,000
6,198,000
7,231,000
7,228,500
8,674,100
10,119,800
6,761,900
8,114,300
9,466,700
13,929,300
16,715,200
19,501,100
17,082,400
20,498,900
23,915,400
12,864,300
14,689,500
23,004,300
15,437,100
17,627,400
27,605,200
18,010,000
20,565,300
32,206,100
12,094,900
14,513,900
16,932,900
16,516,600
19,819,900
23,123,200
20,934,900
25,121,900
29,308,900
6,308,900
7,570,600
8,832,400
12,054,200
14,465,000
16,875,800
18,911,500
22,693,800
26,476,100
12,371,600
14,846,000
17,320,300
17,975,600
21,570,700
25,165,900
723 V-1-14-III
22,445,800
26,935,000
31,424,100
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
1,992,500
2,198,700
2,432,200
2,391,000
2,638,400
2,918,600
2,789,400
3,078,100
3,405,000
5,384,400
6,461,300
7,538,200
8,943,800
10,732,600
12,521,400
14,745,200
17,694,300
20,643,300
5,169,400
6,203,300
7,237,200
6,936,000
8,323,200
9,710,400
9,290,900
11,149,100
13,007,200
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
11,874,900
14,249,900
16,624,800
18,231,600
21,877,900
25,524,200
1,639,700
2,384,700
1,967,700
2,861,700
2,295,600
3,338,600
- 215 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,090,000
16,908,000
19,726,000
16,887,900
20,265,400
23,643,000
24,098,500
28,918,200
33,737,900
2,988,700
3,586,400
4,184,200
3,298,000
3,648,300
3,957,600
4,377,900
4,617,200
5,107,600
3,123,800
3,748,600
4,373,400
3,447,200
4,136,600
4,826,000
3,813,200
4,575,900
5,338,500
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,360,600
4,032,700
4,704,900
743 W-1-12-II
744 W-1-12-III

4,194,600
7,427,800
5,033,600
8,913,300
5,872,500
10,398,900
745 W-1-13-I
3,454,400
4,145,300
4,836,200
746 W-1-13-II
747 W-1-13-III

3,750,400
5,037,700
4,500,400
6,045,200
5,250,500
7,052,800
748 W-1-20-I
749 W-1-20-II

11,568,600
14,455,100
13,882,300
17,346,100
16,196,000
20,237,100
750 W-1-20-III
16,757,100
20,108,600
23,460,000
751 W-1-30-I
6,530,600
7,836,800
9,142,900
752 W-1-30-II
10,416,300
12,499,600
14,582,900
753 W-1-30-III
25,557,000
30,668,500
35,779,900
754 W-4-10-I
4,866,000
5,839,200
6,812,400
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,213,600
14,255,600
3,982,700
6,046,400
7,359,600
8,656,300
17,106,700
4,779,300
7,255,700
8,831,500
10,099,100
19,957,800
5,575,800
8,465,000
10,303,500
2,986,500
3,583,800
4,181,100
5,683,400
6,820,100
7,956,800
8,363,600
10,036,300
11,709,000
1,741,100
2,378,400
2,957,700
2,326,800
2,769,500
3,543,200
1,680,400
2,586,800
4,835,100
2,235,800
4,144,300
7,582,800
1,649,800
4,128,900
8,241,100
4,907,000
6,512,900
9,252,800
3,194,400
3,836,700
5,273,700
2,089,300
2,854,100
3,549,200
2,792,100
3,323,400
4,251,800
2,016,500
3,104,200
5,802,200
2,683,000
4,973,200
9,099,400
1,979,800
4,954,700
9,889,300
5,888,400
7,815,500
11,103,300
3,833,300
4,604,000
6,328,500
2,437,500
3,329,700
4,140,700
3,257,500
3,877,300
4,960,500
2,352,600
3,621,600
6,769,200
3,130,200
5,802,000
10,615,900
2,309,700
5,780,500
11,537,500
6,869,700
9,118,100
12,953,900
4,472,200
5,371,300
7,383,200
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 216 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,111,300
2,533,600
2,955,900
4,239,300
5,087,200
5,935,000
8,943,900
10,732,700
12,521,400
- 217 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,402,500
1,819,200
3,383,100
2,795,700
3,633,200
668,300
1,484,900
522,600
1,154,700
990,100
1,124,000
1,689,900
2,305,100
2,112,600
684,400
1,579,700
573,000
983,700
2,996,500
1,073,100
2,534,300
618,300
1,803,000
2,257,700
1,893,600
464,400
1,407,500
782,500
502,900
435,000
384,000
459,200
639,400
470,900
517,200
398,400
689,600
357,600
354,900
361,700
8,257,300
3,300,100
3,311,100
851,700
1,743,400
1,091,500
2,218,600
1,137,300
651,300
491,800
793,200
562,800
374,800
3,656,200
1,462,500
975,000
3,806,000
2,537,300
395,300
4,123,200
2,854,500
4,449,700
1,482,900
912,100
392,500
388,300
368,600
5,620,400
2,735,900
- 218 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,477,100
6,153,700
5,102,100
3,886,800
1,281,400
4,326,000
2,824,700
694,400
6,494,900
5,879,800
3,942,400
3,734,900
461,600
443,600
1,784,800
487,800
434,600
480,300
2,060,800
2,251,900
1,966,900
2,171,400
1,315,000
437,100
770,500
528,900
477,600
465,300
590,800
673,800
395,000
1,133,500
2,065,800
1,585,800
3,728,000
485,500
485,500
4,306,200
2,003,100
384,300
1,777,700
4,618,000
1,060,200
835,100
409,100
276,100
553,900
772,400
1,849,600
1,630,300
1,141,200
681,100
374,800
1,981,600
1,270,200
678,400
619,300
2,029,500
532,900
2,591,800
1,982,900
483,700
536,200
523,800
376,400
2,160,500
2,374,700
470,600
- 219 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,442,400
538,400
582,100
539,000
855,100
657,800
1,647,400
486,000
1,352,300
2,258,800
395,800
2,408,800
1,305,300
2,820,900
1,424,000
628,900
483,700
79,700
627,000
1,416,800
552,100
745,800
426,500
202,800
430,700
6,413,700
3,645,600
6,084,600
1,868,400
835,100
569,000
1,287,000
680,700
1,369,900
793,200
472,200
790,400
444,800
678,900
520,500
991,200
2,482,900
1,997,600
1,761,300
1,243,100
457,300
457,300
457,300
373,500
236,900
372,500
455,300
492,500
362,800
320,000
111,700
122,800
90,800
106,600
101,700
155,200
165,300
254,300
279,300
123,500
150,000
102,500
160,000
227,000
- 220 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
161,600
285,400
806,800
935,300
152,800
388,200
185,900
265,400
653,100
559,100
401,900
380,600
151,900
149,200
448,100
335,900
481,800
380,500
219,800
3,523,500
2,899,500
460,700
477,100
912,500
896,000
1,168,000
603,300
1,880,300
317,800
490,400
492,000
393,900
497,600
470,900
220,600
484,700
429,600
388,600
439,500
3,638,000
590,400
1,309,300
469,600
835,100
548,400
437,500
1,137,000
1,164,300
1,241,400
1,085,900
1,601,000
323,500
2,807,800
426,500
1,423,300
3,234,600
2,992,100
1,307,100
473,700
923,900
920,200
426,500
3,342,900
2,629,400
243,300
181,700
236,100
508,400
- 221 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,255,100
1,500,800
1,385,500
1,671,500
801,000
1,114,300
770,200
647,900
792,700
459,000
1,085,100
216,900
803,600
1,351,200
88,100
- 222 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,654,600
4,385,500
A-4-10-II
SEPTIKEMIA (SEDANG)
6,243,600
7,492,300
8,741,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,418,300
4,431,200
10,102,000
5,317,400
11,785,600
6,203,600
5
6
A-4-11-II
A-4-11-III

6,306,800
8,729,200
7,568,200
10,475,000
8,829,600
12,220,900
A-4-12-I
2,889,900
3,467,900
4,045,900
8
9
A-4-12-II
A-4-12-III

4,988,500
7,187,500
5,986,200
8,624,900
6,983,800
10,062,400
10 A-4-13-I
11 A-4-13-II

2,150,900
3,801,200
2,581,100
4,561,400
3,011,200
5,321,600
12 A-4-13-III
4,561,400
5,473,700
6,386,000
2,409,600
2,891,500
3,373,500
4,054,300
4,865,100
5,676,000
4,865,100
5,838,200
6,811,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,811,700
23,426,900
22,574,100
28,112,300
26,336,400
32,797,600
18 A-4-15-III
INFEKSI HIV (BERAT)
26,465,800
31,759,000
37,052,100
19 B-1-01-I
20 B-1-01-II

51,867,900
57,224,000
62,241,500
68,668,800
72,615,100
80,113,500
21 B-1-01-III
22 B-1-10-I

126,137,000
8,384,200
151,364,400
10,061,000
176,591,800
11,737,800
23 B-1-10-II
18,609,200
22,331,000
26,052,800
24 B-1-10-III
25 B-1-11-I

36,737,000
33,456,400
44,084,400
40,147,700
51,431,800
46,839,000
26 B-1-11-II
27 B-1-11-III

39,865,100
61,602,700
47,838,100
73,923,300
55,811,100
86,243,800
28 B-1-12-I
9,845,000
11,814,000
13,783,000
29 B-1-12-II
10,949,400
13,139,300
15,329,200
30 B-1-12-III
17,129,100
20,555,000
23,980,800
7,841,700
9,410,000
10,978,400
12,902,500
15,483,000
18,063,500
16,694,700
20,033,700
23,372,600
20,545,100
24,654,100
28,763,200
21,578,200
25,893,800
30,209,400
38,197,100
3,333,700
5,321,600
7,341,300
45,836,500
4,000,500
6,385,900
8,809,500
53,475,900
4,667,200
7,450,200
10,277,800
7,028,700
8,434,500
9,840,200
9,840,300
11,808,400
13,776,400
11,921,400
14,305,700
16,690,000
6,354,800
9,048,900
13,462,800
6,061,900
7,625,700
10,858,700
16,155,400
7,274,300
8,896,700
12,668,500
18,847,900
8,486,700
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,116,400
- 223 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,061,900
8,474,300
9,886,600
48 B-4-13-III
49 B-4-14-I

9,728,300
6,055,400
11,674,000
7,266,500
13,619,700
8,477,600
50 B-4-14-II
7,064,400
8,477,300
9,890,200
51 B-4-14-III
52 C-4-10-I

9,463,000
12,264,700
11,355,600
14,717,600
13,248,200
17,170,500
53 C-4-10-II
54 C-4-10-III

19,725,000
36,958,200
23,670,000
44,349,800
27,614,900
51,741,400
55 C-4-11-I
6,384,100
7,661,000
8,937,800
56 C-4-11-II
57 C-4-11-III

8,542,900
13,134,900
10,251,500
15,761,800
11,960,100
18,388,800
58 C-4-12-I
59 C-4-12-II
4,250,800
8,372,400
5,100,900
10,046,800
5,951,100
11,721,300
60 C-4-12-III
RADIOTERAPI (BERAT)
21,502,600
25,803,100
30,103,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,195,700
6,014,400
3,834,900
7,217,200
4,474,000
8,420,100
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,141,400
5,309,800
9,769,700
6,371,800
11,398,000
7,433,700
65 C-4-14-II
7,448,600
8,938,300
10,428,000
66 C-4-14-III
67 D-1-10-I

11,098,300
32,080,400
13,317,900
38,496,500
15,537,600
44,912,600
68 D-1-10-II
69 D-1-10-III

48,860,700
70,022,700
58,632,900
84,027,200
68,405,000
98,031,800
70 D-1-11-I
8,589,200
10,307,100
12,024,900
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,932,300
28,501,900
26,318,800
34,202,300
30,705,200
39,902,600
7,445,900
8,935,000
10,424,200
20,519,700
24,623,600
28,727,600
32,550,200
39,060,300
45,570,300
2,942,400
4,828,800
7,596,800
5,829,100
10,474,700
14,389,600
5,025,500
6,970,400
10,703,400
3,530,900
5,794,500
9,116,200
6,994,900
12,569,600
17,267,500
6,030,600
8,364,500
12,844,100
4,119,300
6,760,300
10,635,500
8,160,700
14,664,500
20,145,400
7,035,700
9,758,600
14,984,800
4,306,700
5,168,100
6,029,400
6,095,500
7,314,600
8,533,600
7,796,300
9,355,500
10,914,800
4,619,100
5,543,000
6,466,800
7,562,700
9,075,200
10,587,800
9,250,000
11,099,900
12,949,900
9,207,700
11,049,300
12,890,800
12,569,900
15,083,900
17,597,900
93 E-1-01-III
30,307,400
36,368,800
42,430,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,573,000
13,288,500
25,106,400
11,487,700
15,946,200
30,127,700
13,402,300
18,604,000
35,149,000
10,837,400
13,004,900
15,172,400
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 224 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,260,400
5,112,500
5,964,600
104 E-4-11-II
105 E-4-11-III

6,495,300
8,801,700
7,794,400
10,562,000
9,093,500
12,322,300
106 E-4-12-I
107 E-4-12-II

4,895,100
8,477,200
5,874,200
10,172,600
6,853,200
11,868,100
108 E-4-12-III

(RINGAN)
(SEDANG)
10,048,600
12,058,300
14,068,000
5,330,600
6,396,700
7,462,900
7,808,400
9,370,100
10,931,800
111 E-4-13-III
10,207,200
12,248,600
14,290,000
112 F-4-10-I
113 F-4-10-II
5,675,100
6,522,400
6,810,200
7,826,900
7,945,200
9,131,400
114 F-4-10-III
115 F-4-11-I
7,826,900
5,488,800
9,392,300
6,586,500
10,957,600
7,684,300
116 F-4-11-II
6,395,000
7,674,000
8,953,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,200,700
9,840,900
11,481,000
3,008,700
3,610,500
4,212,200
4,277,500
5,133,000
5,988,500
9,292,600
11,151,100
13,009,600
4,421,300
5,834,000
7,552,900
2,522,600
3,235,600
4,353,700
5,305,600
7,000,800
9,063,500
3,027,100
3,882,700
5,224,400
6,189,900
8,167,700
10,574,100
3,531,600
4,529,800
6,095,200
127 F-4-15-I
4,017,400
4,820,900
5,624,300
128 F-4-15-II
5,986,400
7,183,700
8,381,000
129 F-4-15-III
7,903,900
9,484,700
11,065,500
7,904,400
9,485,300
11,066,100
9,190,100
11,028,200
12,866,200
12,267,300
14,720,700
17,174,200
133 F-4-17-I

1,866,700
2,240,100
2,613,400
134 F-4-17-II
5,471,100
6,565,300
7,659,500
135
136
137
138
139
140
141

(RINGAN)
5,837,100
6,868,300
7,557,100
11,649,800
5,249,000
6,721,600
8,368,300
7,004,600
8,242,000
9,068,500
13,979,800
6,298,800
8,065,900
10,042,000
8,172,000
9,615,700
10,580,000
16,309,800
7,348,600
9,410,200
11,715,700
22,266,800
26,720,200
31,173,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,586,900
17,504,300
20,421,600
20,103,700
24,124,500
28,145,200
3,835,300
4,602,400
5,369,500
7,428,400
8,914,100
10,399,700
12,447,100
14,936,600
17,426,000
- 225 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
52,106,400
62,527,700
72,948,900
148 G-1-11-I
149 G-1-11-II

17,040,800
31,154,600
20,449,000
37,385,500
23,857,100
43,616,400
150 G-1-11-III
50,064,100
60,076,900
70,089,700
7,115,100
8,538,200
9,961,200
13,337,700
16,005,200
18,672,700
18,176,600
21,811,900
25,447,300
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,146,400
5,764,200
2,575,700
6,917,100
3,005,000
8,069,900
156 G-1-13-III
157 G-1-20-I

13,006,700
12,049,900
15,608,000
14,459,900
18,209,300
16,869,900
158 G-1-20-II
18,233,400
21,880,100
25,526,800
159 G-1-20-III
31,091,200
37,309,500
43,527,700
160 G-1-30-I
30,019,400
36,023,300
42,027,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
40,473,500
60,778,100
48,568,200
72,933,700
56,662,900
85,089,300
6,107,600
7,329,100
8,550,600
7,465,500
8,958,600
10,451,700
10,244,000
12,292,800
14,341,600
6,393,700
7,672,400
8,951,100
8,493,200
10,191,800
11,890,500
12,479,400
14,975,200
17,471,100
7,093,000
8,511,600
9,930,300
8,959,000
10,750,800
12,542,600
13,011,800
15,614,200
18,216,600
4,260,900
5,113,100
5,965,200
7,430,100
8,916,200
10,402,200
8,812,300
10,574,800
12,337,200
7,228,100
8,673,700
10,119,300
9,663,400
11,596,100
13,528,800
12,128,700
14,554,500
16,980,200
5,906,000
7,087,200
8,268,400
7,048,500
8,458,200
9,867,900
9,948,400
11,938,000
13,927,700
4,868,700
5,842,400
6,816,200
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
31,936,000
38,323,200
44,710,400
52,250,000
62,700,000
73,150,000
34,621,000
42,402,100
41,545,200
50,882,500
48,469,400
59,362,900
- 226 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,463,800
7,756,600
9,049,400
183 G-4-16-III
9,205,000
11,046,000
12,887,100
6,484,800
7,781,700
9,078,700
8,502,900
10,203,500
11,904,100
10,684,300
12,821,200
14,958,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,386,500
7,663,800
8,941,100
188 G-4-18-II
8,536,800
10,244,200
11,951,500
189 G-4-18-III
9,552,000
11,462,400
13,372,800
5,328,400
6,394,100
7,459,700
9,006,300
10,807,500
12,608,800
11,824,800
14,189,800
16,554,700
193 G-4-20-I

3,727,500
4,473,000
5,218,500
194 G-4-20-II
5,269,500
6,323,400
7,377,300
195 G-4-20-III
196 G-4-21-I

8,703,900
3,881,600
10,444,700
4,657,900
12,185,500
5,434,200
197 G-4-21-II
198 G-4-21-III

6,569,600
7,720,800
7,883,600
9,265,000
9,197,500
10,809,200
199 G-4-22-I
2,908,000
3,489,700
4,071,300
200 G-4-22-II
201 G-4-22-III

5,150,200
8,124,000
6,180,200
9,748,800
7,210,300
11,373,600
202 G-4-23-I
203 G-4-23-II

3,821,000
4,794,100
4,585,200
5,752,900
5,349,500
6,711,700
204 G-4-23-III
6,825,600
8,190,700
9,555,900
205 G-4-24-I
206 G-4-24-II

4,256,100
5,317,300
5,107,300
6,380,800
5,958,500
7,444,300
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,858,500
3,636,700
4,599,000
6,094,600
10,630,200
4,364,100
5,518,900
7,313,600
12,401,900
5,091,400
6,438,700
8,532,500
4,146,200
4,975,400
5,804,600
4,823,300
5,787,900
6,752,600
7,212,300
8,654,700
10,097,200
12,264,400
13,554,100
18,432,800
8,357,200
10,382,900
14,542,800
4,431,100
6,012,100
11,817,100
4,249,000
4,846,800
6,940,400
5,009,600
5,985,600
10,030,800
14,717,300
16,264,900
22,119,300
10,028,600
12,459,500
17,451,400
5,317,300
7,214,500
14,180,500
5,098,800
5,816,200
8,328,400
6,011,500
7,182,700
12,036,900
17,170,200
18,975,700
25,805,900
11,700,000
14,536,100
20,359,900
6,203,600
8,416,900
16,543,900
5,948,600
6,785,500
9,716,500
7,013,500
8,379,800
14,043,100
229 I-1-01-I
67,288,000
80,745,600
94,203,200
230 I-1-01-II
68,768,300
82,521,900
96,275,600
231 I-1-01-III

(RINGAN)
108,549,800
130,259,800
151,969,700
37,331,100
44,797,300
52,263,500
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 227 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
50,188,600
60,226,400
70,264,100
245 I-1-06-II
72,702,300
87,242,800
101,783,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
86,747,300
104,096,800
121,446,200
78,119,800
93,743,800
109,367,800
97,649,800
117,179,800
136,709,700
146,474,700
175,769,700
205,064,600
5,849,900
7,019,900
8,189,900
6,504,500
7,805,400
9,106,300
8,655,500
10,386,600
12,117,700
16,838,800
20,206,600
23,574,300
27,501,200
33,001,400
38,501,600
36,181,900
43,418,300
50,654,700
16,333,400
19,600,100
22,866,800
21,751,300
26,101,500
30,451,800
26,825,300
32,190,400
37,555,500
33,430,500
40,116,600
46,802,700
41,549,200
49,859,000
58,168,900
54,443,800
65,332,500
76,221,300
6,350,800
8,868,800
17,077,800
7,621,000
10,642,600
20,493,400
8,891,200
12,416,300
23,908,900
16,463,700
19,756,400
23,049,100
37,250,600
44,700,800
52,150,900
42,968,000
51,561,600
60,155,200
19,063,400
22,876,000
26,688,700
23,869,100
28,642,900
33,416,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
48,156,600
57,788,000
67,419,300
59,356,100
71,227,300
83,098,500
35,207,200
42,248,700
49,290,100
48,804,500
58,565,400
68,326,300
61,936,700
74,324,000
86,711,400
53,055,400
63,666,500
74,277,500
83,735,700
100,482,900
117,230,000
133,767,300
160,520,700
187,274,200
87,884,800
105,461,800
123,038,800
107,414,800
128,897,700
150,380,700
146,474,700
175,769,700
205,064,600
- 228 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
37,084,800
44,501,800
51,918,700
279 I-1-40-III
49,532,700
59,439,200
69,345,800
280 I-4-10-I
281 I-4-10-II

5,654,400
10,096,700
6,785,300
12,116,000
7,916,200
14,135,400
282 I-4-10-III
14,547,900
17,457,500
20,367,100
283 I-4-11-I
284 I-4-11-II

8,699,400
10,765,500
10,439,200
12,918,600
12,179,100
15,071,700
285 I-4-11-III
286 I-4-12-I

19,915,000
5,000,900
23,898,100
6,001,000
27,881,100
7,001,200
287 I-4-12-II
5,796,700
6,956,100
8,115,400
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,956,100
8,347,300
9,738,500
5,089,000
6,106,800
7,124,600
9,087,000
10,904,400
12,721,800
13,093,100
15,711,700
18,330,400
4,805,700
4,971,100
8,714,300
5,766,800
5,965,300
10,457,100
6,728,000
6,959,500
12,200,000
4,907,900
5,889,500
6,871,100
9,254,900
11,105,900
12,956,900
11,105,900
13,327,100
15,548,300
3,033,100
4,870,400
5,844,500
2,025,100
3,267,900
4,575,000
3,639,700
5,844,500
7,013,400
2,430,100
3,921,500
5,490,000
4,246,300
6,818,600
8,182,300
2,835,100
4,575,000
6,405,100
5,850,500
7,020,600
8,190,700
8,907,600
10,689,200
12,470,700
12,093,600
14,512,300
16,931,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
29,525,700
35,430,900
41,336,000
21,487,700
25,785,200
30,082,700
26,844,000
32,212,800
37,581,600
28,218,600
33,862,300
39,506,000
16,254,200
19,505,100
22,755,900
33,812,400
40,574,900
47,337,300
52,397,000
62,876,400
73,355,800
15,000,900
18,001,100
21,001,200
307 I-4-19-I
5,644,600
6,773,500
7,902,400
308 I-4-19-II

(SEDANG)
8,811,500
10,573,800
12,336,100
309 I-4-19-III
10,519,300
12,623,100
14,727,000
310
311
312
313
314

5,877,700
6,788,700
10,150,500
3,958,400
5,015,300
7,053,200
8,146,500
12,180,600
4,750,100
6,018,400
8,228,700
9,504,200
14,210,700
5,541,800
7,021,500
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 229 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,239,100
8,686,900
10,134,700
316 I-4-22-I
317 I-4-22-II
3,556,500
4,427,300
4,267,800
5,312,800
4,979,100
6,198,200
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,471,300
7,765,600
9,059,900
4,824,700
5,789,700
6,754,600
5,923,400
7,108,100
8,292,700
11,574,000
13,888,700
16,203,500
3,134,500
3,761,400
4,388,200
7,217,800
8,661,400
10,105,000
9,125,700
10,950,800
12,775,900
99,313,800
119,176,600
139,039,300
112,392,100
134,870,500
157,348,900
154,165,100
184,998,100
215,831,100
64,790,200
77,748,300
90,706,300
81,752,700
98,103,200
114,453,800
95,639,100
114,766,900
133,894,700
12,631,100
15,157,300
17,683,600
25,559,100
30,671,000
35,782,800
26,562,300
31,874,700
37,187,200
34,796,500
41,755,800
48,715,100
36,436,600
43,723,900
51,011,200
41,004,600
49,205,600
57,406,500
10,541,000
12,649,200
14,757,400
19,094,900
22,913,900
26,732,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
55,116,700
66,140,100
77,163,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,107,200
6,417,200
9,708,300
3,844,300
5,354,400
7,177,000
6,529,500
7,432,900
10,378,400
5,773,200
8,036,100
14,992,800
6,365,100
10,357,900
12,254,400
4,605,800
7,627,300
13,853,400
3,728,700
7,700,700
11,650,000
4,613,200
6,425,200
8,612,400
7,835,500
8,919,500
12,454,100
6,927,900
9,643,400
17,991,400
7,638,100
12,429,400
14,705,300
5,527,000
9,152,700
16,624,000
4,350,100
8,984,100
13,591,600
5,382,000
7,496,100
10,047,800
9,141,400
10,406,100
14,529,800
8,082,500
11,250,600
20,990,000
8,911,100
14,501,000
17,156,200
6,448,200
10,678,200
19,394,700
3,837,600
4,605,100
5,372,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 230 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,475,000
8,970,100
10,465,100
12,758,900
15,310,700
17,862,500
5,318,600
6,369,200
6,382,400
7,643,100
7,446,100
8,916,900

8,358,300
2,364,100
10,030,000
2,837,000
11,701,700
3,309,800
365 J-4-18-II
4,507,100
5,408,600
6,310,000
366 J-4-18-III
367 J-4-19-I

6,404,800
6,742,300
7,685,800
8,090,800
8,966,800
9,439,200
368 J-4-19-II
369 J-4-19-III

7,646,200
8,444,300
9,175,400
10,133,100
10,704,700
11,822,000
370 J-4-20-I
5,363,400
6,436,100
7,508,800
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,431,600
8,712,100
8,917,900
10,454,500
10,404,200
12,197,000
3,064,200
3,677,100
4,289,900
6,842,400
8,210,900
9,579,400
12,889,800
15,467,800
18,045,800
11,450,900
13,741,100
16,031,200
14,390,500
17,268,600
20,146,700
16,866,100
20,239,400
23,612,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,753,800
12,904,600
15,055,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
14,118,400
27,906,300
16,942,100
33,487,600
19,765,800
39,068,900
4,804,600
5,765,500
6,726,500
6,249,000
7,498,800
8,748,600
12,380,200
14,856,200
17,332,200
5,418,700
5,960,500
9,526,200
6,502,400
7,152,600
11,431,400
7,586,100
8,344,700
13,336,600
7,914,200
9,497,000
11,079,800
9,275,200
11,130,300
12,985,300
390 K-1-14-III
16,191,800
19,430,200
22,668,500
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

17,027,100
23,783,000
34,725,700
20,432,500
28,539,600
41,670,800
23,837,900
33,296,200
48,615,900
10,069,700
12,083,600
14,097,600
17,883,500
21,460,200
25,036,900
24,608,000
29,529,600
34,451,200
397 K-1-40-I
11,235,400
13,482,500
15,729,600
398 K-1-40-II

(SEDANG)
12,387,500
14,864,900
17,342,400
399 K-1-40-III
20,992,300
25,190,700
29,389,200
400
401
402
403
404

8,585,000
11,148,700
15,755,100
7,087,400
10,183,500
10,302,000
13,378,400
18,906,200
8,504,800
12,220,200
12,019,000
15,608,200
22,057,200
9,922,300
14,256,900
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 231 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,524,200
18,629,000
21,733,900
406 K-4-11-I
407 K-4-11-II

2,463,700
4,852,900
2,956,500
5,823,400
3,449,200
6,794,000
408 K-4-11-III
409 K-4-12-I

5,823,400
4,260,400
6,988,100
5,112,500
8,152,800
5,964,600
410 K-4-12-II
5,733,200
6,879,800
8,026,500
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,484,600
11,381,500
13,278,400
5,743,300
6,892,000
8,040,600
7,429,300
8,915,200
10,401,100
11,443,500
13,732,200
16,021,000
3,277,200
3,932,600
4,588,000
4,399,000
5,278,800
6,158,600
7,058,700
8,470,400
9,882,200
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,671,200
5,605,400
6,539,700
419 K-4-15-II
7,194,100
8,633,000
10,071,800
420 K-4-15-III
10,239,900
12,287,900
14,335,900
421 K-4-16-I
4,230,400
5,076,400
5,922,500
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,073,400
5,919,900
6,088,100
7,103,900
7,102,800
8,287,800
2,075,000
2,490,100
2,905,100
2,555,400
3,066,500
3,577,600
3,066,500
3,679,800
4,293,100
1,828,600
2,194,300
2,560,100
3,085,800
3,702,900
4,320,100
429 K-4-18-III
3,702,900
4,443,500
5,184,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
27,147,500
40,978,500
54,753,900
12,808,500
21,978,500
27,286,700
32,577,100
49,174,200
65,704,700
15,370,200
26,374,200
32,744,000
38,006,600
57,369,900
76,655,500
17,931,800
30,769,900
38,201,300
7,178,100
8,613,800
10,049,400
14,397,800
17,277,300
20,156,900
24,234,600
29,081,600
33,928,500
9,423,500
15,166,100
21,693,600
2,464,800
2,860,900
3,320,700
5,161,600
7,094,100
16,120,100
2,451,300
3,242,200
10,720,500
11,308,200
18,199,300
26,032,300
2,957,700
3,433,100
3,984,900
6,193,900
8,513,000
19,344,100
2,941,500
3,890,600
12,864,600
13,192,900
21,232,500
30,371,000
3,450,700
4,005,300
4,649,000
7,226,200
9,931,800
22,568,100
3,431,800
4,539,000
15,008,700
2,610,100
3,132,200
3,654,200
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 232 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,252,100
5,102,500
5,952,900
8,446,900
10,136,300
11,825,700
4,244,800
5,093,700
5,942,700
6,375,800
7,651,000
8,926,100
8,987,500
10,784,900
12,582,400
15,004,900
18,005,800
21,006,800
21,327,300
25,592,800
29,858,200
29,958,500
35,950,200
41,941,900
13,299,000
15,958,800
18,618,600
21,816,500
37,065,700
26,179,800
44,478,900
30,543,100
51,892,000
53,160,900
63,793,100
74,425,300
62,179,500
74,615,400
87,051,300
76,957,500
92,349,000
107,740,500
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
27,226,700
32,672,100
38,117,400
467 M-1-04-II
34,978,400
41,974,100
48,969,800
468 M-1-04-III
41,852,600
50,223,100
58,593,600
469 M-1-05-I
470 M-1-05-II

10,586,800
17,124,500
12,704,100
20,549,400
14,821,500
23,974,300
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,874,300
26,249,200
30,624,100
19,349,700
23,219,600
27,089,600
25,921,900
31,106,300
36,290,700
52,805,400
63,366,500
73,927,500
22,866,200
27,439,500
32,012,700
54,672,100
65,606,600
76,541,000
117,922,700
141,507,300
165,091,800
17,818,300
21,382,000
24,945,700
22,764,800
27,317,700
31,870,700
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
56,677,300
68,012,800
79,348,200
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,223,800
19,807,600
28,323,100
14,668,600
23,769,200
33,987,800
17,113,400
27,730,700
39,652,400
7,466,900
8,960,300
10,453,600
11,035,200
13,242,200
15,449,200
15,756,100
18,907,300
22,058,500
7,456,600
12,374,100
20,323,700
8,947,900
14,849,000
24,388,500
10,439,200
17,323,800
28,453,200
11,516,100
13,819,300
16,122,500
14,478,400
17,374,100
20,269,800
21,871,400
26,245,600
30,619,900
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 233 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,069,900
9,683,900
11,297,900
512 M-4-14-II
9,953,100
11,943,700
13,934,300
513 M-4-14-III
514 M-4-15-I
14,956,600
4,785,200
17,947,900
5,742,300
20,939,200
6,699,300
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,378,400
14,474,400
4,096,900
6,560,700
11,021,500
7,654,100
17,369,300
4,916,300
7,872,800
13,225,800
8,929,700
20,264,200
5,735,700
9,185,000
15,430,100
4,785,500
5,742,600
6,699,700
6,693,100
8,031,700
9,370,300
9,346,400
11,215,700
13,085,000
4,019,000
6,056,800
7,292,600
4,822,800
7,268,200
8,751,100
5,626,600
8,479,500
10,209,700
4,191,200
5,029,400
5,867,600
7,059,500
8,471,400
9,883,400
13,787,700
16,545,300
19,302,800
3,805,000
4,565,900
5,326,900
5,571,700
6,686,100
7,800,400
6,227,100
7,472,500
8,717,900
3,831,300
4,597,600
5,363,800
4,791,800
5,750,200
6,708,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,335,700
25,602,800
29,869,900
23,469,200
28,163,100
32,856,900
26,869,200
32,243,000
37,616,800
12,128,400
14,554,100
16,979,800
14,403,600
32,419,500
17,284,400
38,903,400
20,165,100
45,387,300
4,272,400
5,126,900
5,981,400
6,371,600
12,055,000
7,645,900
14,466,100
8,920,200
16,877,100
5,323,800
6,388,600
7,453,300
11,672,200
14,006,700
16,341,100
16,876,000
20,251,200
23,626,400
4,249,600
5,099,500
5,949,400
7,068,200
8,481,900
9,895,500
9,454,500
11,345,400
13,236,300
7,076,000
8,491,200
9,906,400
10,631,400
12,757,700
14,883,900
20,741,600
24,889,900
29,038,200
- 234 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,743,200
12,891,900
15,040,500
535 N-1-01-I

294,657,900
353,589,400
412,521,000
536 N-1-01-II
294,657,900
353,589,400
412,521,000
537 N-1-01-III
538 N-1-11-I

294,657,900
12,279,200
353,589,400
14,735,100
412,521,000
17,190,900
539 N-1-11-II
540 N-1-11-III

19,416,400
30,270,200
23,299,700
36,324,300
27,183,000
42,378,300
6,258,300
7,510,000
8,761,600
12,459,600
14,951,600
17,443,500
27,037,800
32,445,400
37,853,000
13,683,000
16,419,600
19,156,300

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
19,148,700
26,796,300
22,978,400
32,155,500
26,808,100
37,514,800
12,522,400
15,026,900
17,531,400
18,943,900
22,732,700
26,521,500
21,802,600
26,163,200
30,523,700
11,246,000
13,495,200
15,744,400
15,271,800
18,326,200
21,380,500
17,774,400
21,329,300
24,884,100
4,778,000
5,733,600
6,689,200
5,779,100
6,934,900
8,090,700
8,500,100
10,200,200
11,900,200
3,667,900
6,408,200
7,973,200
2,765,500
5,745,200
9,335,600
3,742,100
6,256,100
12,942,500
4,401,500
7,689,900
9,567,800
3,318,500
6,894,200
11,202,700
4,490,500
7,507,300
15,531,000
5,135,000
8,971,500
11,162,500
3,871,600
8,043,300
13,069,800
5,239,000
8,758,500
18,119,500
3,683,700
4,420,500
5,157,200
5,227,100
6,272,500
7,317,900
8,379,000
10,054,700
11,730,500
4,351,900
5,222,300
6,092,600
5,399,900
6,479,900
7,559,900
6,162,200
7,394,700
8,627,100
5,328,900
6,394,600
7,460,400
7,606,000
9,127,200
10,648,400
10,124,100
12,148,900
14,173,800
5,460,300
7,028,200
6,552,300
8,433,800
7,644,400
9,839,400
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 235 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,078,700
13,294,500
15,510,200
4,953,400
5,944,100
6,934,800
5,505,200
6,606,200
7,707,200
6,848,500
8,218,200
9,587,900
3,509,400
4,211,300
4,913,200
4,214,800
5,057,800
5,900,700
5,296,100
6,355,300
7,414,500
1,779,000
2,134,800
2,490,600
2,918,500
3,502,200
3,502,200
4,202,700
4,085,900
4,903,100
78,366,200
94,039,400
109,712,600
96,966,400
116,359,700
135,752,900
113,811,300
136,573,500
159,335,800
106,966,100
128,359,400
149,752,600
122,700,900
147,241,100
171,781,200
140,194,500
168,233,400
196,272,200
16,044,800
19,253,800
22,462,700
21,237,500
25,485,000
29,732,500
29,860,900
35,833,100
41,805,200
51,705,100
62,046,100
72,387,100
67,102,000
80,522,400
93,942,800
96,207,500
115,448,900
134,690,400
28,115,600
33,738,700
39,361,800
43,373,200
52,047,800
60,722,400
58,713,600
70,456,300
82,199,000
7,590,300
9,108,400
10,626,400
21,281,500
25,537,800
29,794,100
28,192,700
33,831,300
39,469,800
8,985,800
10,782,900
12,580,100
25,194,000
30,232,800
35,271,600
33,375,900
40,051,000
46,726,200
5,199,300
6,239,100
7,279,000
7,377,500
8,853,000
10,328,500
14,352,200
17,222,600
20,093,000
13,370,700
16,044,800
18,718,900
17,697,900
21,237,500
24,777,100
- 236 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,884,100
29,860,900
34,837,700
12,155,200
14,586,200
17,017,200
14,748,300
17,697,900
20,647,600
21,638,300
25,966,000
30,293,700
6,752,900
8,103,400
9,454,000
10,534,500
12,641,400
14,748,300
16,644,900
19,973,800
23,302,800
5,111,400
6,133,700
7,156,000
10,404,800
12,485,700
14,566,700
40,683,500
48,820,200
56,956,800
3,833,600
4,600,300
5,367,100
7,677,000
9,212,400
10,747,800
9,007,600
10,809,100
12,610,600
3,469,500
4,163,400
4,857,300
6,667,100
8,000,600
9,334,000
15,635,500
18,762,600
21,889,800
4,501,900
5,402,300
6,302,700
8,103,400
9,724,100
11,344,800
13,870,700
16,644,900
19,419,000
3,911,800
4,694,100
5,476,500
4,819,900
5,783,900
6,747,900
6,598,000
7,917,500
9,237,100
1,797,700
3,653,900
8,430,700
2,875,900
3,827,800
6,635,500
2,157,200
4,384,700
10,116,900
3,451,100
4,593,400
7,962,600
2,516,700
5,115,500
11,803,000
4,026,300
5,358,900
9,289,700
4,247,000
5,096,400
5,945,800
7,534,500
9,041,400
10,548,300
12,229,500
14,675,400
17,121,200
2,149,300
2,579,100
3,009,000
4,565,300
5,478,300
6,391,400
8,657,300
10,388,800
12,120,200
1,437,500
1,725,000
2,012,400
2,712,700
3,255,300
3,797,800
3,513,400
4,216,100
4,918,800
7,443,400
8,932,100
10,420,800
- 237 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,466,300
11,359,600
13,252,800
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,553,800
16,264,600
18,975,300
3,587,600
4,305,100
5,022,600
5,324,400
6,389,300
7,454,100
6,403,800
7,684,500
8,965,300
2,400,400
2,880,500
3,360,500
3,224,000
3,868,800
4,513,600
5,865,000
7,038,000
8,211,000
1,314,300
1,577,200
1,840,100
2,504,500
3,005,400
3,506,300
3,640,400
4,368,400
5,096,500
1,269,400
1,523,200
1,777,100
1,997,600
2,397,100
2,796,700
3,217,600
3,861,100
4,504,600
2,974,200
3,569,000
4,163,900
4,489,800
5,387,800
6,285,800
6,949,600
8,339,500
9,729,400
7,844,200
9,413,000
10,981,900

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,177,300
32,163,500
14,612,800
38,596,100
17,048,200
45,028,800
12,379,300
14,855,100
17,331,000
18,671,800
22,406,200
26,140,600
22,134,200
26,561,000
30,987,900
9,482,400
14,540,800
21,357,400
9,488,900
11,056,100
18,327,600
11,378,900
17,448,900
25,628,900
11,386,700
13,267,300
21,993,100
13,275,400
20,357,100
29,900,400
13,284,500
15,478,600
25,658,600
5,702,200
6,842,600
7,983,000
6,997,900
8,397,500
9,797,100
8,292,500
9,951,100
11,609,600
4,463,300
6,345,500
9,666,200
5,356,000
7,614,600
11,599,400
6,248,600
8,883,700
13,532,700
8,656,800
10,388,200
12,119,500
12,883,700
15,460,500
18,037,200
33,075,000
39,690,000
46,305,000
7,424,200
10,066,800
19,686,100
8,909,000
12,080,200
23,623,300
10,393,800
14,093,600
27,560,500
5,342,700
6,411,300
7,479,800
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 238 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,584,000
3,100,800
3,617,600
697 U-4-12-I
698 U-4-12-II

2,775,100
4,474,300
3,330,100
5,369,200
3,885,100
6,264,100
699 U-4-12-III

7,836,000
9,403,200
10,970,400
2,103,100
2,523,700
2,944,400
3,436,700
4,124,000
4,811,300
5,549,100
6,658,900
7,768,700
5,317,800
6,367,900
6,381,400
7,641,500
7,444,900
8,915,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,693,700
12,832,400
14,971,200
4,270,000
5,124,100
5,978,100
5,319,900
6,383,900
7,447,900
7,445,300
8,934,400
10,423,400
6,964,800
8,357,800
9,750,700
14,347,200
17,216,700
20,086,100
17,594,900
21,113,800
24,632,800
13,250,200
15,130,200
23,694,500
15,900,300
18,156,200
28,433,400
18,550,300
21,182,200
33,172,300
12,457,700
14,949,300
17,440,800
17,012,100
20,414,500
23,816,900
21,563,000
25,875,600
30,188,200
6,498,100
7,797,700
9,097,400
12,415,800
14,898,900
17,382,100
19,478,800
23,374,600
27,270,400
12,742,800
15,291,300
17,839,900
18,514,900
22,217,900
25,920,800
723 V-1-14-III
23,119,200
27,743,000
32,366,900
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,052,200
2,264,600
2,505,100
2,462,700
2,717,600
3,006,200
2,873,100
3,170,500
3,507,200
5,546,000
6,655,200
7,764,400
9,212,100
11,054,600
12,897,000
15,187,600
18,225,100
21,262,600
5,324,500
6,389,400
7,454,300
7,144,100
8,572,900
10,001,800
9,569,600
11,483,500
13,397,500
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,231,100
14,677,400
17,123,600
18,778,500
22,534,200
26,290,000
1,688,900
2,456,300
2,026,700
2,947,500
2,364,500
3,438,800
- 239 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,512,700
17,415,300
20,317,800
17,394,500
20,873,400
24,352,300
24,821,500
29,785,800
34,750,100
3,078,400
3,694,000
4,309,700
3,396,900
3,757,700
4,076,300
4,509,200
4,755,700
5,260,800
3,217,600
3,861,100
4,504,600
3,550,600
4,260,700
4,970,800
3,927,600
4,713,200
5,498,700
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,461,400
4,153,700
4,846,000
743 W-1-12-II
744 W-1-12-III

4,320,500
7,650,600
5,184,600
9,180,700
6,048,700
10,710,800
745 W-1-13-I
3,558,100
4,269,700
4,981,300
746 W-1-13-II
747 W-1-13-III

3,862,900
5,188,800
4,635,400
6,226,600
5,408,000
7,264,400
748 W-1-20-I
749 W-1-20-II

11,915,600
14,888,700
14,298,800
17,866,500
16,681,900
20,844,200
750 W-1-20-III
17,259,800
20,711,800
24,163,800
751 W-1-30-I
6,726,500
8,071,900
9,417,200
752 W-1-30-II
10,728,800
12,874,600
15,020,400
753 W-1-30-III
26,323,800
31,588,500
36,853,300
754 W-4-10-I
5,012,000
6,014,400
7,016,800
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,430,000
14,683,200
4,102,200
6,227,800
7,580,400
8,916,000
17,619,900
4,922,700
7,473,400
9,096,500
10,402,000
20,556,500
5,743,100
8,718,900
10,612,600
3,076,100
3,691,300
4,306,600
5,853,900
7,024,700
8,195,500
8,614,500
10,337,400
12,060,300
1,793,300
2,449,700
3,046,400
2,396,600
2,852,500
3,649,500
1,730,900
2,664,400
4,980,200
2,302,900
4,268,600
7,810,300
1,699,300
4,252,800
8,488,300
5,054,200
6,708,300
9,530,300
3,290,300
3,951,800
5,431,900
2,152,000
2,939,700
3,655,700
2,875,900
3,423,100
4,379,400
2,077,000
3,197,300
5,976,200
2,763,500
5,122,400
9,372,300
2,039,200
5,103,300
10,186,000
6,065,000
8,050,000
11,436,400
3,948,300
4,742,100
6,518,300
2,510,600
3,429,600
4,265,000
3,355,200
3,993,600
5,109,300
2,423,200
3,730,200
6,972,300
3,224,100
5,976,100
10,934,400
2,379,000
5,953,900
11,883,700
7,075,800
9,391,600
13,342,500
4,606,400
5,532,500
7,604,700
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 240 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,174,700
2,609,600
3,044,500
4,366,500
5,239,800
6,113,100
9,212,200
11,054,600
12,897,100
- 241 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,472,600
1,910,200
3,552,200
2,935,500
3,814,800
701,700
1,559,100
548,700
1,212,400
1,039,600
1,180,200
1,774,400
2,420,300
2,218,300
718,600
1,658,600
601,600
1,032,900
3,146,300
1,126,800
2,661,000
649,200
1,893,200
2,370,600
1,988,300
487,600
1,477,800
821,700
528,100
456,800
403,200
482,200
671,400
494,500
543,000
418,300
724,100
375,500
372,700
379,800
8,670,100
3,465,100
3,476,600
894,300
1,830,500
1,146,100
2,329,500
1,194,100
683,800
516,400
832,900
591,000
393,600
3,839,000
1,535,600
1,023,700
3,996,300
2,664,200
415,100
4,329,300
2,997,200
4,672,200
1,557,100
957,800
412,100
407,700
387,000
5,901,400
2,872,600
- 242 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,650,900
6,461,400
5,357,200
4,081,100
1,345,400
4,542,300
2,965,900
729,100
6,819,700
6,173,800
4,139,500
3,921,700
484,700
465,800
1,874,000
512,200
456,300
504,300
2,163,800
2,364,500
2,065,300
2,279,900
1,380,800
459,000
809,100
555,400
501,500
488,600
620,300
707,400
414,700
1,190,200
2,169,100
1,665,100
3,914,400
509,700
509,700
4,521,500
2,103,300
403,500
1,866,600
4,848,900
1,113,300
876,900
429,600
289,900
581,600
811,100
1,942,100
1,711,800
1,198,200
715,100
393,600
2,080,700
1,333,700
712,400
650,300
2,130,900
559,500
2,721,400
2,082,000
507,900
563,100
550,000
395,200
2,268,500
2,493,500
494,200
- 243 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,514,500
565,300
611,200
566,000
897,900
690,700
1,729,800
510,300
1,419,900
2,371,800
415,500
2,529,200
1,370,600
2,961,900
1,495,200
660,300
507,900
83,700
658,300
1,487,600
579,700
783,000
447,800
212,900
452,200
6,734,300
3,827,900
6,388,800
1,961,800
876,900
597,500
1,351,300
714,700
1,438,400
832,900
495,800
829,900
467,000
712,800
546,500
1,040,800
2,607,000
2,097,500
1,849,400
1,305,200
480,100
480,100
480,100
392,200
248,800
391,100
478,100
517,200
380,900
336,000
117,300
128,900
95,400
111,900
106,700
162,900
173,500
267,000
293,200
129,700
157,500
107,600
168,000
238,300
- 244 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
169,700
299,700
847,200
982,100
160,400
407,600
195,200
278,700
685,800
587,100
422,000
399,600
159,500
156,700
470,500
352,700
505,900
399,500
230,800
3,699,700
3,044,400
483,700
501,000
958,100
940,800
1,226,400
633,500
1,974,300
333,700
514,900
516,600
413,600
522,400
494,400
231,600
508,900
451,100
408,000
461,400
3,819,900
620,000
1,374,700
493,100
876,900
575,800
459,300
1,193,800
1,222,600
1,303,500
1,140,200
1,681,000
339,700
2,948,200
447,800
1,494,400
3,396,300
3,141,700
1,372,500
497,400
970,100
966,300
447,800
3,510,100
2,760,900
255,500
190,800
247,900
533,800
- 245 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,317,900
1,575,900
1,454,800
1,755,100
841,000
1,170,000
808,700
680,300
832,300
481,900
1,139,300
227,800
843,800
1,418,800
92,500
- 246 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,483,000
2,979,600
3,476,200
A-4-10-II
SEPTIKEMIA (SEDANG)
4,242,000
5,090,400
5,938,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,719,600
3,226,600
6,863,500
3,871,900
8,007,400
4,517,200
5
6
A-4-11-II
A-4-11-III

4,592,300
6,356,200
5,510,800
7,627,500
6,429,300
8,898,700
A-4-12-I
2,585,500
3,102,600
3,619,700
8
9
A-4-12-II
A-4-12-III

3,219,800
3,542,700
3,863,800
4,251,200
4,507,700
4,959,800
10 A-4-13-I
11 A-4-13-II

2,047,300
2,613,000
2,456,800
3,135,700
2,866,300
3,658,300
12 A-4-13-III
3,135,700
3,762,800
4,389,900
2,222,500
2,667,000
3,111,400
2,697,800
3,237,400
3,776,900
3,237,400
3,884,800
4,532,300
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,172,700
17,649,800
17,007,300
21,179,700
19,841,800
24,709,700
18 A-4-15-III
INFEKSI HIV (BERAT)
19,939,300
23,927,100
27,915,000
19 B-1-01-I
20 B-1-01-II

38,764,200
42,767,100
46,517,000
51,320,500
54,269,800
59,873,900
21 B-1-01-III
22 B-1-10-I

94,270,100
6,266,000
113,124,200
7,519,200
131,978,200
8,772,400
23 B-1-10-II
13,907,800
16,689,400
19,470,900
24 B-1-10-III
25 B-1-11-I

27,455,900
6,850,300
32,947,000
8,220,300
38,438,200
9,590,400
26 B-1-11-II
27 B-1-11-III

9,152,000
11,824,200
10,982,400
14,189,100
12,812,800
16,553,900
28 B-1-12-I
6,895,800
8,275,000
9,654,100
29 B-1-12-II
7,669,300
9,203,200
10,737,100
30 B-1-12-III
11,997,800
14,397,400
16,797,000
5,492,600
6,591,100
7,689,600
9,037,400
10,844,800
12,652,300
11,693,600
14,032,300
16,371,000
7,547,000
9,056,400
10,565,800
8,393,600
10,072,400
11,751,100
13,130,900
2,265,000
3,615,600
4,987,800
15,757,100
2,718,000
4,338,700
5,985,400
18,383,300
3,171,000
5,061,800
6,983,000
4,775,500
5,730,600
6,685,700
6,685,700
8,022,900
9,360,000
8,099,700
9,719,600
11,339,500
4,317,600
6,338,200
9,429,800
4,118,600
5,181,100
7,605,800
11,315,800
4,942,300
6,044,600
8,873,400
13,201,700
5,766,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 247 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,798,000
5,757,600
6,717,200
48 B-4-13-III
49 B-4-14-I

6,609,600
4,114,200
7,931,600
4,937,000
9,253,500
5,759,900
50 B-4-14-II
4,799,700
5,759,700
6,719,600
51 B-4-14-III
52 C-4-10-I

6,429,400
3,924,100
7,715,200
4,708,900
9,001,100
5,493,700
53 C-4-10-II
54 C-4-10-III

7,529,400
12,891,300
9,035,200
15,469,500
10,541,100
18,047,800
55 C-4-11-I
4,337,500
5,205,000
6,072,500
56 C-4-11-II
57 C-4-11-III

5,804,200
9,200,100
6,965,100
11,040,100
8,125,900
12,880,100
58 C-4-12-I
59 C-4-12-II
2,888,100
5,864,300
3,465,700
7,037,100
4,043,300
8,210,000
60 C-4-12-III
RADIOTERAPI (BERAT)
15,061,100
18,073,300
21,085,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,171,200
4,086,300
2,605,500
4,903,500
3,039,700
5,720,800
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,531,400
3,607,600
6,637,700
4,329,100
7,744,000
5,050,600
65 C-4-14-II
5,060,700
6,072,900
7,085,000
66 C-4-14-III
67 D-1-10-I

7,773,600
21,578,100
9,328,300
25,893,800
10,883,000
30,209,400
68 D-1-10-II
69 D-1-10-III

32,865,000
52,332,400
39,438,000
62,798,800
46,011,000
73,265,300
70 D-1-11-I
5,835,700
7,002,800
8,170,000
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
14,901,300
19,963,700
17,881,500
23,956,400
20,861,800
27,949,200
5,058,900
6,070,700
7,082,400
13,941,500
16,729,800
19,518,100
22,115,300
26,538,400
30,961,500
2,493,900
4,092,700
6,438,800
3,960,400
7,116,700
10,079,000
3,414,400
4,735,900
7,272,100
2,992,700
4,911,300
7,726,600
4,752,500
8,540,000
12,094,800
4,097,300
5,683,000
8,726,600
3,491,400
5,729,800
9,014,400
5,544,600
9,963,400
14,110,500
4,780,200
6,630,200
10,181,000
2,926,100
3,511,300
4,096,500
4,141,400
4,969,700
5,797,900
5,297,000
6,356,400
7,415,700
3,138,300
3,766,000
4,393,700
5,138,300
6,165,900
7,193,600
6,284,600
7,541,500
8,798,500
6,881,500
8,257,800
9,634,100
9,394,300
11,273,100
13,152,000
93 E-1-01-III
22,650,600
27,180,700
31,710,800
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,154,500
9,931,400
18,763,600
8,585,400
11,917,600
22,516,300
10,016,400
13,903,900
26,269,000
7,363,200
8,835,800
10,308,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 248 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,894,600
3,473,500
4,052,500
104 E-4-11-II
105 E-4-11-III

4,413,100
6,165,000
5,295,700
7,398,000
6,178,300
8,631,000
106 E-4-12-I
107 E-4-12-II

3,325,900
5,759,600
3,991,000
6,911,500
4,656,200
8,063,400
108 E-4-12-III

(RINGAN)
(SEDANG)
6,827,200
8,192,700
9,558,100
3,621,700
4,346,100
5,070,400
5,305,200
6,366,300
7,427,300
111 E-4-13-III
7,149,400
8,579,300
10,009,200
112 F-4-10-I
113 F-4-10-II
3,975,000
4,568,500
4,770,000
5,482,200
5,565,000
6,395,900
114 F-4-10-III
115 F-4-11-I
5,482,200
3,844,500
6,578,600
4,613,400
7,675,100
5,382,300
116 F-4-11-II
4,479,300
5,375,100
6,271,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,744,100
6,892,900
8,041,700
2,044,200
2,453,000
2,861,900
2,906,200
3,487,400
4,068,700
6,313,600
7,576,300
8,839,000
3,096,800
4,086,400
5,290,300
1,766,900
2,266,300
3,049,500
3,716,200
4,903,600
6,348,400
2,120,300
2,719,600
3,659,400
4,335,600
5,720,900
7,406,400
2,473,700
3,172,800
4,269,300
127 F-4-15-I
2,729,500
3,275,400
3,821,300
128 F-4-15-II
4,067,300
4,880,700
5,694,200
129 F-4-15-III
5,370,100
6,444,100
7,518,100
5,536,500
6,643,800
7,751,100
6,437,100
7,724,500
9,011,900
8,592,400
10,310,900
12,029,400
133 F-4-17-I

1,268,300
1,521,900
1,775,600
134 F-4-17-II
3,717,200
4,460,600
5,204,000
135
136
137
138
139
140
141

(RINGAN)
3,965,900
4,810,800
5,293,300
8,159,900
3,676,600
4,708,000
5,861,500
4,759,000
5,773,000
6,351,900
9,791,900
4,411,900
5,649,600
7,033,700
5,552,200
6,735,100
7,410,600
11,423,900
5,147,200
6,591,200
8,206,000
16,641,400
19,969,700
23,298,000
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
9,910,600
11,892,800
13,874,900
14,081,300
16,897,600
19,713,900
3,431,300
4,117,600
4,803,800
4,794,600
5,753,600
6,712,500
6,135,200
7,362,200
8,589,200
- 249 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,103,700
26,524,400
30,945,100
148 G-1-11-I
149 G-1-11-II

11,577,900
21,167,100
13,893,500
25,400,500
16,209,000
29,633,900
150 G-1-11-III
35,117,800
42,141,300
49,164,900
4,834,200
5,801,000
6,767,800
9,342,100
11,210,600
13,079,000
12,731,500
15,277,800
17,824,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,458,300
3,916,300
1,750,000
4,699,600
2,041,700
5,482,900
156 G-1-13-III
157 G-1-20-I

8,837,000
8,629,600
10,604,400
10,355,600
12,371,800
12,081,500
158 G-1-20-II
14,048,400
16,858,100
19,667,800
159 G-1-20-III
21,559,600
25,871,500
30,183,400
160 G-1-30-I
10,980,200
13,176,300
15,372,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
22,927,100
31,234,500
27,512,500
37,481,400
32,097,900
43,728,300
4,149,600
4,979,500
5,809,500
5,072,200
6,086,700
7,101,100
7,175,200
8,610,300
10,045,300
4,478,300
5,374,000
6,269,700
5,948,900
7,138,700
8,328,500
8,741,000
10,489,200
12,237,400
4,968,200
5,961,800
6,955,500
6,086,900
7,304,300
8,521,700
8,840,500
10,608,600
12,376,700
2,894,900
3,473,900
4,052,900
5,048,200
6,057,800
7,067,500
5,987,300
7,184,700
8,382,200
4,910,900
5,893,100
6,875,300
6,768,600
8,122,300
9,476,000
8,495,400
10,194,500
11,893,500
4,012,700
4,815,200
5,617,700
4,788,900
5,746,700
6,704,400
6,759,100
8,110,900
9,462,800
3,307,900
3,969,500
4,631,000
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
23,867,800
28,641,400
33,414,900
36,231,700
43,478,000
50,724,400
17,038,900
20,061,600
20,446,700
24,073,900
23,854,500
28,086,200
- 250 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,391,700
5,270,000
6,148,300
183 G-4-16-III
6,254,100
7,504,900
8,755,700
4,405,900
5,287,100
6,168,200
5,777,100
6,932,500
8,087,900
7,483,700
8,980,400
10,477,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,339,100
5,206,900
6,074,800
188 G-4-18-II
5,800,100
6,960,100
8,120,100
189 G-4-18-III
6,489,800
7,787,800
9,085,800
3,620,200
4,344,300
5,068,300
6,119,000
7,342,900
8,566,700
8,034,000
9,640,800
11,247,600
193 G-4-20-I

2,532,500
3,039,000
3,545,500
194 G-4-20-II
3,580,200
4,296,300
5,012,300
195 G-4-20-III
196 G-4-21-I

5,913,600
2,637,200
7,096,400
3,164,700
8,279,100
3,692,100
197 G-4-21-II
198 G-4-21-III

4,463,500
5,407,900
5,356,300
6,489,500
6,249,000
7,571,100
199 G-4-22-I
2,601,700
3,122,100
3,642,400
200 G-4-22-II
201 G-4-22-III

3,324,200
3,884,200
3,989,000
4,661,000
4,653,900
5,437,800
202 G-4-23-I
203 G-4-23-II

2,596,100
3,257,200
3,115,300
3,908,600
3,634,500
4,560,100
204 G-4-23-III
4,637,500
5,565,000
6,492,400
205 G-4-24-I
206 G-4-24-II

2,981,100
3,724,400
3,577,300
4,469,300
4,173,500
5,214,200
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,204,800
2,470,900
3,124,700
4,140,800
7,445,800
2,965,000
3,749,600
4,969,000
8,686,700
3,459,200
4,374,600
5,797,200
3,514,200
4,217,000
4,919,800
4,214,500
5,057,400
5,900,300
6,112,900
7,335,500
8,558,100
9,974,600
11,023,500
14,991,200
7,302,300
9,072,400
12,707,300
3,345,100
4,538,600
8,920,900
2,886,900
3,293,000
4,715,400
3,403,600
4,192,500
7,025,900
11,969,500
13,228,300
17,989,500
8,762,800
10,886,900
15,248,700
4,014,100
5,446,300
10,705,000
3,464,200
3,951,600
5,658,500
4,084,400
5,031,000
8,431,100
13,964,400
15,433,000
20,987,700
10,223,300
12,701,400
17,790,200
4,683,100
6,354,100
12,489,200
4,041,600
4,610,200
6,601,600
4,765,100
5,869,500
9,836,200
229 I-1-01-I
45,716,900
54,860,200
64,003,600
230 I-1-01-II
46,722,600
56,067,100
65,411,700
231 I-1-01-III

(RINGAN)
73,751,000
88,501,200
103,251,400
25,363,500
30,436,200
35,508,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 251 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
21,529,800
25,835,800
30,141,800
245 I-1-06-II
31,187,700
37,425,300
43,662,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
37,212,700
44,655,300
52,097,800
47,574,700
57,089,700
66,604,600
59,468,400
71,362,100
83,255,800
89,202,600
107,043,200
124,883,700
4,097,500
4,917,000
5,736,500
4,556,000
5,467,200
6,378,400
6,062,600
7,275,100
8,487,700
11,794,500
14,153,400
16,512,300
18,684,900
22,421,800
26,158,800
24,582,800
29,499,300
34,415,900
11,440,500
13,728,600
16,016,700
15,235,300
18,282,400
21,329,500
18,789,400
22,547,300
26,305,100
23,415,900
28,099,000
32,782,200
29,102,500
34,923,000
40,743,400
38,134,300
45,761,100
53,388,000
4,448,300
6,212,000
11,961,900
5,338,000
7,454,400
14,354,300
6,227,700
8,696,800
16,746,600
11,185,800
13,422,900
15,660,100
26,091,600
31,309,900
36,528,300
30,096,300
36,115,500
42,134,800
13,352,600
16,023,200
18,693,700
16,718,700
20,062,500
23,406,200
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
32,718,600
39,262,400
45,806,100
40,327,800
48,393,300
56,458,900
14,650,000
17,580,100
20,510,100
20,308,000
24,369,600
28,431,200
26,569,500
31,883,400
37,197,300
22,759,600
27,311,500
31,863,400
35,920,800
43,105,000
50,289,100
57,383,200
68,859,900
80,336,500
53,521,600
64,225,900
74,930,200
65,415,300
78,498,300
91,581,400
89,202,600
107,043,200
124,883,700
- 252 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
25,196,200
30,235,400
35,274,700
279 I-1-40-III
33,653,600
40,384,300
47,115,000
280 I-4-10-I
281 I-4-10-II

3,960,600
7,072,100
4,752,700
8,486,500
5,544,800
9,900,900
282 I-4-10-III
10,189,900
12,227,800
14,265,800
283 I-4-11-I
284 I-4-11-II

5,910,500
7,314,300
7,092,600
8,777,200
8,274,700
10,240,000
285 I-4-11-III
286 I-4-12-I

13,530,700
3,502,700
16,236,800
4,203,300
18,943,000
4,903,800
287 I-4-12-II
4,060,200
4,872,200
5,684,300
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,872,200
5,846,700
6,821,100
3,564,500
4,277,400
4,990,300
6,364,900
7,637,800
8,910,800
9,170,900
11,005,000
12,839,200
3,265,100
3,481,900
5,920,700
3,918,100
4,178,300
7,104,800
4,571,100
4,874,700
8,288,900
4,390,900
5,269,100
6,147,300
5,973,600
7,168,300
8,363,000
297 I-4-15-III
7,168,300
8,602,000
10,035,600
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,124,500
3,411,400
4,093,700
1,867,800
2,174,500
2,609,400
2,549,400
4,093,700
4,912,400
2,241,400
2,609,400
3,131,300
2,974,300
4,776,000
5,731,200
2,614,900
3,044,300
3,653,100
3,975,000
4,769,900
5,564,900
6,239,200
7,487,100
8,734,900
8,216,600
9,860,000
11,503,300
307 I-4-19-I
3,835,000
4,602,100
5,369,100
308 I-4-19-II

(SEDANG)
5,986,700
7,184,100
8,381,400
309 I-4-19-III
7,147,000
8,576,400
10,005,800
310
311
312
313
314

4,116,900
4,755,100
6,896,500
3,080,700
3,903,200
4,940,300
5,706,100
8,275,800
3,696,800
4,683,900
5,763,700
6,657,100
9,655,100
4,312,900
5,464,500
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
20,680,800
24,817,000
28,953,100
15,050,700
18,060,800
21,071,000
18,802,500
22,563,000
26,323,400
19,765,300
23,718,300
27,671,400
11,385,000
13,662,000
15,939,000
23,683,300
28,420,000
33,156,700
36,700,700
44,040,800
51,380,900
10,507,100
12,608,600
14,710,000
- 253 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,633,900
6,760,700
7,887,500
316 I-4-22-I
317 I-4-22-II
3,107,600
3,868,500
3,729,200
4,642,200
4,350,700
5,415,900
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,654,600
6,785,500
7,916,400
3,278,000
3,933,600
4,589,200
4,024,500
4,829,400
5,634,300
7,863,600
9,436,300
11,009,000
2,738,800
3,286,600
3,834,400
6,306,800
7,568,200
8,829,600
7,973,900
9,568,700
11,163,400
53,254,300
63,905,200
74,556,100
60,267,200
72,320,600
84,374,100
68,181,100
81,817,400
95,453,600
28,260,100
33,912,200
39,564,200
39,349,300
47,219,200
55,089,000
64,979,200
77,975,000
90,970,900
8,581,900
10,298,200
12,014,600
17,365,400
20,838,500
24,311,600
18,605,100
22,326,100
26,047,200
14,675,100
17,610,100
20,545,100
18,483,700
22,180,400
25,877,100
28,541,800
34,250,100
39,958,500
7,161,800
8,594,100
10,026,500
12,973,500
15,568,200
18,162,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
37,447,500
44,937,000
52,426,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,715,000
5,439,100
8,228,500
2,692,700
3,637,900
5,027,000
4,436,300
5,050,100
7,051,300
4,043,800
5,628,800
10,501,500
4,324,600
7,255,000
8,583,400
4,248,100
5,075,300
6,828,300
3,258,100
6,526,900
9,874,200
3,231,200
4,365,400
6,032,400
5,323,600
6,060,100
8,461,600
4,852,500
6,754,600
12,601,800
5,189,500
8,706,000
10,300,100
5,097,700
6,090,300
8,194,000
3,801,100
7,614,700
11,519,900
3,769,800
5,093,000
7,037,800
6,210,800
7,070,100
9,871,900
5,661,300
7,880,300
14,702,100
6,054,400
10,157,000
12,016,800
5,947,300
7,105,400
9,559,600
3,539,600
4,247,500
4,955,400
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 254 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,974,000
5,968,800
6,963,600
360 J-4-16-III
6,288,900
7,546,600
8,804,400
361 J-4-17-I
362 J-4-17-II

3,613,600
4,327,400
4,336,300
5,192,900
5,059,000
6,058,300
363 J-4-17-III
364 J-4-18-I

5,678,800
2,180,500
6,814,600
2,616,600
7,950,300
3,052,700
365 J-4-18-II
2,909,100
3,490,900
4,072,800
366 J-4-18-III
367 J-4-19-I

3,062,200
5,089,800
3,674,700
6,107,800
4,287,100
7,125,800
368 J-4-19-II
369 J-4-19-III

5,772,200
6,374,700
6,926,700
7,649,600
8,081,100
8,924,600
370 J-4-20-I
4,545,900
5,455,100
6,364,300
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,298,800
7,612,500
7,558,600
9,135,000
8,818,300
10,657,500
2,741,500
3,289,700
3,838,000
4,416,400
5,299,700
6,183,000
6,162,800
7,395,300
8,627,900
7,780,000
9,336,000
10,892,000
10,079,600
12,095,500
14,111,400
11,813,600
14,176,300
16,539,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,101,900
9,722,300
11,342,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,636,800
18,965,500
12,764,200
22,758,600
14,891,500
26,551,700
3,365,300
4,038,400
4,711,500
4,377,000
5,252,400
6,127,800
8,671,500
10,405,800
12,140,100
3,795,400
4,175,000
4,212,900
4,554,500
5,009,900
5,055,500
5,313,600
5,844,900
5,898,100
5,377,000
6,452,500
7,527,900
6,301,800
7,562,100
8,822,500
390 K-1-14-III
11,341,300
13,609,500
15,877,800
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

11,926,300
16,658,400
24,323,000
14,311,600
19,990,100
29,187,700
16,696,900
23,321,800
34,052,300
7,053,100
8,463,800
9,874,400
12,150,400
14,580,500
17,010,600
17,236,300
20,683,500
24,130,800
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,633,600
9,160,300
10,687,000
398 K-1-40-II

(SEDANG)
8,676,600
10,411,900
12,147,200
399 K-1-40-III
14,703,700
17,644,400
20,585,200
400
401
402
403
404

5,832,800
7,808,900
10,704,400
4,815,300
6,918,900
6,999,400
9,370,700
12,845,200
5,778,400
8,302,600
8,166,000
10,932,500
14,986,100
6,741,400
9,686,400
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 255 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
10,873,700
13,048,400
15,223,200
406 K-4-11-I
407 K-4-11-II

2,272,300
3,229,200
2,726,800
3,875,000
3,181,300
4,520,900
408 K-4-11-III
409 K-4-12-I

3,875,000
2,894,600
4,650,100
3,473,500
5,425,100
4,052,500
410 K-4-12-II
4,015,700
4,818,900
5,622,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,643,300
7,972,000
9,300,700
3,902,100
4,682,500
5,463,000
5,047,600
6,057,200
7,066,700
7,775,000
9,330,000
10,885,000
2,550,500
3,060,600
3,570,700
3,423,600
4,108,300
4,793,000
5,493,500
6,592,200
7,690,900
418 K-4-15-I
2,592,600
3,111,200
3,629,700
419 K-4-15-II
3,996,300
4,795,600
5,594,900
420 K-4-15-III
5,608,700
6,730,500
7,852,200
421 K-4-16-I
3,611,900
4,334,300
5,056,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,331,700
5,054,400
5,198,000
6,065,300
6,064,400
7,076,200
1,682,900
2,019,500
2,356,100
2,072,500
2,487,000
2,901,500
2,487,000
2,984,400
3,481,800
1,423,200
1,707,800
1,992,400
2,401,600
2,881,900
3,362,200
429 K-4-18-III
2,881,900
3,458,200
4,034,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,015,100
28,702,700
38,351,500
8,702,300
15,394,500
19,112,500
22,818,100
34,443,300
46,021,800
10,442,800
18,473,400
22,935,000
26,621,100
40,183,800
53,692,100
12,183,300
21,552,300
26,757,500
4,877,000
5,852,400
6,827,800
9,782,100
11,738,600
13,695,000
16,465,500
19,758,600
23,051,700
6,402,500
10,304,200
14,739,100
1,726,400
2,003,900
2,326,000
3,506,900
4,819,900
11,291,100
1,717,000
2,270,900
7,509,000
7,683,000
12,365,000
17,686,900
2,071,700
2,404,700
2,791,200
4,208,300
5,783,900
13,549,300
2,060,400
2,725,100
9,010,800
8,963,500
14,425,800
20,634,700
2,417,000
2,805,400
3,256,400
4,909,600
6,747,900
15,807,500
2,403,700
3,179,300
10,512,600
2,335,200
2,802,200
3,269,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 256 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,744,500
3,293,400
3,842,300
4,038,600
4,846,300
5,654,000
2,884,000
3,460,800
4,037,600
4,331,900
5,198,200
6,064,600
6,106,300
7,327,500
8,548,800
10,194,600
12,233,500
14,272,500
14,490,200
17,388,300
20,286,300
20,354,400
24,425,300
28,496,200
9,315,100
11,178,100
13,041,100
15,281,000
25,183,200
18,337,200
30,219,900
21,393,400
35,256,500
22,804,900
27,365,900
31,926,800
26,673,600
32,008,400
37,343,100
33,013,100
39,615,700
46,218,300
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,329,300
13,595,100
15,861,000
467 M-1-04-II
14,554,800
17,465,800
20,376,800
468 M-1-04-III
17,953,800
21,544,600
25,135,400
469 M-1-05-I
470 M-1-05-II

7,415,300
11,634,700
8,898,400
13,961,700
10,381,500
16,288,600
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,321,500
18,385,800
21,450,100
8,051,600
9,661,900
11,272,200
10,786,300
12,943,600
15,100,900
21,972,800
26,367,300
30,761,900
18,597,000
22,316,400
26,035,800
44,464,700
53,357,700
62,250,600
95,906,300
115,087,500
134,268,800
12,106,200
14,527,400
16,948,600
15,945,200
19,134,300
22,323,300
480 M-1-20-III
39,756,700
47,708,000
55,659,300
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,562,000
13,873,900
19,838,500
10,274,400
16,648,700
23,806,200
11,986,800
19,423,500
27,773,900
4,227,600
5,073,200
5,918,700
7,497,500
8,997,000
10,496,500
10,705,000
12,846,000
14,987,000
5,222,900
8,667,300
14,235,400
6,267,400
10,400,700
17,082,500
7,312,000
12,134,200
19,929,600
7,824,300
9,389,100
10,954,000
9,836,900
11,804,300
13,771,700
15,319,500
18,383,300
21,447,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 257 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,944,200
17,933,100
20,921,900
16,438,700
19,726,400
23,014,100
18,820,100
22,584,100
26,348,100
8,495,200
10,194,200
11,893,200
10,088,800
22,707,700
12,106,600
27,249,300
14,124,300
31,790,800
2,902,800
3,483,300
4,063,900
4,329,000
8,190,500
5,194,800
9,828,500
6,060,600
11,466,600
3,617,100
4,340,500
5,063,900
7,930,300
9,516,400
11,102,500
11,820,500
14,184,600
16,548,700
2,887,300
3,464,700
4,042,200
4,802,300
5,762,800
6,723,200
6,622,300
7,946,700
9,271,200
4,807,600
5,769,100
6,730,600
7,223,200
8,667,800
10,112,500
14,092,300
16,910,700
19,729,200
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,482,900
6,579,500
7,676,000
512 M-4-14-II
6,762,300
8,114,800
9,467,200
513 M-4-14-III
514 M-4-15-I
10,161,800
3,351,700
12,194,200
4,022,100
14,226,500
4,692,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,333,600
9,834,200
2,783,500
4,595,300
7,719,800
5,200,300
11,801,100
3,340,200
5,514,400
9,263,800
6,067,100
13,767,900
3,896,900
6,433,500
10,807,800
3,612,600
4,335,200
5,057,700
5,052,700
6,063,200
7,073,700
7,055,700
8,466,900
9,878,000
2,730,600
4,115,100
4,954,800
3,276,700
4,938,100
5,945,700
3,822,800
5,761,200
6,936,700
2,935,600
3,522,800
4,109,900
4,796,400
5,755,700
6,715,000
9,367,700
11,241,200
13,114,700
2,872,400
3,446,900
4,021,400
4,206,200
5,047,400
5,888,600
4,700,900
5,641,100
6,581,200
2,892,300
3,470,800
4,049,200
3,617,400
4,340,900
5,064,400
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 258 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,110,200
9,732,200
11,354,300
535 N-1-01-I

171,645,400
205,974,400
240,303,500
536 N-1-01-II
171,645,400
205,974,400
240,303,500
537 N-1-01-III
538 N-1-11-I

171,645,400
8,342,800
205,974,400
10,011,300
240,303,500
11,679,900
539 N-1-11-II
540 N-1-11-III

13,191,900
20,566,200
15,830,300
24,679,500
18,468,700
28,792,700
4,252,000
5,102,400
5,952,800
8,727,100
10,472,600
12,218,000
18,938,200
22,725,900
26,513,500
9,584,100
11,500,900
13,417,700

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,412,400
18,206,000
16,094,900
21,847,100
18,777,300
25,488,300
8,508,000
10,209,600
11,911,200
12,870,900
15,445,100
18,019,300
14,813,200
17,775,800
20,738,400
7,877,100
9,452,500
11,027,900
10,696,900
12,836,300
14,975,600
12,449,800
14,939,700
17,429,700
3,246,300
3,895,500
4,544,800
4,047,800
4,857,400
5,667,000
5,953,800
7,144,600
8,335,300
2,569,100
4,353,900
5,417,200
2,343,900
4,120,300
4,959,400
3,347,900
4,038,000
6,379,300
3,082,900
5,224,700
6,500,600
2,812,700
4,944,300
5,951,300
4,017,500
4,845,600
7,655,200
3,596,800
6,095,500
7,584,000
3,281,500
5,768,400
6,943,200
4,687,100
5,653,200
8,931,000
2,502,800
3,003,400
3,503,900
3,551,400
4,261,700
4,971,900
5,692,800
6,831,400
7,970,000
2,956,800
3,548,100
4,139,500
3,782,300
4,538,700
5,295,200
4,316,200
5,179,500
6,042,700
3,620,500
4,344,600
5,068,800
5,167,700
6,201,200
7,234,700
7,091,300
8,509,500
9,927,800
4,885,100
5,295,000
5,862,100
6,354,000
6,839,100
7,413,000
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 259 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

8,868,400
10,642,000
12,415,700
3,365,500
4,038,600
4,711,700
3,740,300
4,488,400
5,236,500
4,796,900
5,756,300
6,715,700
2,458,100
2,949,800
3,441,400
2,952,200
3,542,600
4,133,100
3,709,500
4,451,500
5,193,400
1,640,800
1,969,000
2,297,100

MAYOR (RINGAN)
MAYOR (SEDANG)
1,942,000
2,330,500
2,330,500
2,796,500
2,718,900
3,262,600
53,243,600
63,892,400
74,541,100
65,881,000
79,057,200
92,233,400
77,325,800
92,790,900
108,256,100
83,190,400
99,828,500
116,466,600
95,427,900
114,513,500
133,599,100
109,033,300
130,840,000
152,646,600
12,035,500
14,442,600
16,849,700
16,994,500
20,393,400
23,792,300
23,787,200
28,544,700
33,302,100
34,713,800
41,656,500
48,599,300
44,875,600
53,850,700
62,825,900
64,340,400
77,208,500
90,076,500
18,849,700
22,619,600
26,389,600
29,468,600
35,362,400
41,256,100
39,218,200
47,061,800
54,905,400
5,157,000
6,188,400
7,219,800
14,459,100
17,350,900
20,242,700
19,154,700
22,985,700
26,816,600
4,995,100
5,994,100
6,993,100
14,005,100
16,806,100
19,607,100
18,553,300
22,264,000
25,974,600
4,135,900
4,963,100
5,790,200
5,868,600
7,042,300
8,216,000
9,502,500
11,403,000
13,303,500
10,029,600
12,035,500
14,041,500
14,162,100
16,994,500
19,826,900
- 260 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
19,822,700
23,787,200
27,751,800
9,475,300
11,370,400
13,265,400
10,893,900
13,072,700
15,251,500
15,248,200
18,297,900
21,347,500
5,371,800
6,446,100
7,520,500
8,379,900
10,055,900
11,731,900
13,018,500
15,622,200
18,225,900
3,580,200
4,296,200
5,012,300
7,287,900
8,745,400
10,203,000
13,116,100
15,739,300
18,362,500
2,685,200
3,222,200
3,759,300
5,377,200
6,452,700
7,528,100
6,309,200
7,571,000
8,832,900
2,430,100
2,916,200
3,402,200
4,669,900
5,603,900
6,537,800
11,427,800
13,713,400
15,998,900
3,581,200
4,297,400
5,013,600
6,446,100
7,735,300
9,024,600
9,070,800
10,885,000
12,699,100
2,657,700
3,189,300
3,720,800
3,274,700
3,929,700
4,584,600
4,482,800
5,379,300
6,275,900
1,608,300
2,358,400
4,030,800
1,954,000
2,600,700
4,508,300
1,930,000
2,830,100
4,837,000
2,344,800
3,120,800
5,410,000
2,251,600
3,301,800
5,643,100
2,735,600
3,641,000
6,311,600
2,885,500
3,462,600
4,039,700
5,119,100
6,142,900
7,166,800
8,309,000
9,970,700
11,632,500
1,460,300
1,752,300
2,044,400
3,101,700
3,722,100
4,342,400
5,882,000
7,058,400
8,234,700
976,600
1,172,000
1,367,300
1,843,100
2,211,700
2,580,300
2,387,100
2,864,500
3,342,000
5,057,200
6,068,700
7,080,100
- 261 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,630,500
7,956,600
9,282,700
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,493,500
11,392,300
13,291,000
2,437,500
2,925,000
3,412,500
3,617,500
4,341,000
5,064,500
4,350,900
5,221,000
6,091,200
1,681,300
2,017,600
2,353,800
2,258,200
2,709,900
3,161,500
4,108,000
4,929,700
5,751,300
729,300
875,200
1,021,000
1,389,900
1,667,900
1,945,900
2,020,600
2,424,700
2,828,900
995,400
1,194,400
1,393,500
1,566,400
1,879,700
2,192,900
2,523,000
3,027,600
3,532,200
1,639,800
1,967,800
2,295,800
2,443,400
2,932,100
3,420,800
3,748,800
4,498,600
5,248,300
5,329,500
6,395,400
7,461,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,273,500
21,852,500
9,928,200
26,223,000
11,582,900
30,593,500
8,245,000
9,894,000
11,543,000
10,451,800
12,542,100
14,632,500
15,503,500
18,604,300
21,705,000
6,442,600
9,879,300
14,510,700
6,447,000
7,511,800
12,452,100
7,731,100
11,855,200
17,412,800
7,736,400
9,014,100
14,942,600
9,019,600
13,831,000
20,314,900
9,025,800
10,516,500
17,433,000
3,994,000
4,792,800
5,591,600
4,901,600
5,881,900
6,862,200
5,808,400
6,970,100
8,131,700
3,821,200
5,432,600
7,002,400
4,585,400
6,519,100
8,402,900
5,349,700
7,605,700
9,803,300
6,063,500
7,276,200
8,488,900
9,024,200
10,829,000
12,633,900
22,471,800
26,966,200
31,460,600
5,200,100
7,051,200
13,375,100
6,240,200
8,461,400
16,050,200
7,280,200
9,871,600
18,725,200
3,742,200
4,490,700
5,239,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 262 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,274,400
2,729,300
3,184,200
697 U-4-12-I
698 U-4-12-II

2,482,800
2,888,000
2,979,300
3,465,500
3,475,900
4,043,100
699 U-4-12-III

3,862,300
4,634,800
5,407,300
1,939,800
2,327,700
2,715,700
2,286,800
2,744,200
3,201,500
2,735,100
3,282,200
3,829,200
3,613,000
4,326,500
4,335,600
5,191,800
5,058,200
6,057,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,265,500
8,718,600
10,171,700
2,901,200
3,481,400
4,061,600
3,614,500
4,337,400
5,060,300
5,058,500
6,070,200
7,081,900
4,878,400
5,854,100
6,829,700
9,747,800
11,697,400
13,646,900
11,954,300
14,345,200
16,736,100
9,002,500
10,279,800
16,098,500
10,803,000
12,335,700
19,318,200
12,603,500
14,391,700
22,537,900
8,464,100
10,156,900
11,849,700
11,915,800
14,299,000
16,682,200
14,650,300
17,580,400
20,510,500
4,551,500
5,461,800
6,372,100
8,696,400
10,435,700
12,175,000
13,234,300
15,881,200
18,528,000
8,657,700
10,389,300
12,120,800
12,579,400
15,095,300
17,611,200
15,707,700
18,849,200
21,990,700
1,437,500
1,586,200
1,754,700
1,724,900
1,903,500
2,105,600
2,012,400
2,220,700
2,456,600
4,316,200
5,179,500
6,042,700
7,169,400
8,603,300
10,037,200
11,819,900
14,183,900
16,547,900
3,617,600
4,341,100
5,064,600
4,853,900
5,824,600
6,795,400
6,702,900
8,043,500
9,384,000
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,310,100
9,972,100
11,634,100
12,758,500
15,310,200
17,861,900
1,486,600
2,162,000
1,783,900
2,594,400
2,081,200
3,026,800
- 263 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,165,200
12,198,200
14,231,300
11,818,200
14,181,800
16,545,500
17,385,800
20,863,000
24,340,100
2,156,200
2,587,400
3,018,700
2,379,300
2,632,000
2,855,200
3,158,400
3,331,100
3,684,800
2,253,700
2,704,400
3,155,200
2,486,900
2,984,300
3,481,700
2,751,000
3,301,300
3,851,500
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,424,500
2,909,400
3,394,300
743 W-1-12-II
744 W-1-12-III

3,026,200
5,198,000
3,631,400
6,237,600
4,236,700
7,277,200
745 W-1-13-I
2,417,400
2,900,900
3,384,400
746 W-1-13-II
747 W-1-13-III

2,624,500
3,525,400
3,149,400
4,230,500
3,674,300
4,935,600
748 W-1-20-I
749 W-1-20-II

8,095,700
10,115,700
9,714,900
12,138,800
11,334,000
14,162,000
750 W-1-20-III
11,726,700
14,072,000
16,417,400
751 W-1-30-I
4,570,200
5,484,200
6,398,200
752 W-1-30-II
7,289,400
8,747,300
10,205,100
753 W-1-30-III
17,884,900
21,461,900
25,038,900
754 W-4-10-I
3,405,200
4,086,300
4,767,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,048,100
9,976,100
3,096,800
4,701,400
5,722,500
6,057,700
11,971,300
3,716,200
5,641,700
6,867,000
7,067,400
13,966,500
4,335,500
6,582,000
8,011,600
2,752,100
3,302,500
3,852,900
3,778,400
4,534,100
5,289,800
4,118,700
4,942,400
5,766,100
1,218,400
1,664,400
2,069,800
1,628,300
1,998,000
2,479,500
1,548,500
1,719,800
2,381,100
2,124,000
2,840,400
3,849,700
1,520,300
2,744,900
4,058,400
2,805,000
3,723,300
5,289,300
2,555,500
3,069,300
4,219,000
1,462,100
1,997,300
2,483,700
1,953,900
2,397,600
2,975,400
1,858,200
2,063,700
2,857,300
2,548,900
3,408,500
4,619,600
1,824,400
3,293,900
4,870,000
3,366,000
4,468,000
6,347,200
3,066,600
3,683,200
5,062,800
1,705,800
2,330,200
2,897,700
2,279,600
2,797,200
3,471,300
2,167,900
2,407,700
3,333,500
2,973,700
3,976,600
5,389,500
2,128,400
3,842,900
5,681,700
3,927,000
5,212,600
7,405,000
3,577,800
4,297,100
5,906,600
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 264 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,838,400
2,206,100
2,573,800
3,857,700
4,629,300
5,400,800
5,938,400
7,126,000
8,313,700
- 265 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
923,600
1,198,100
2,227,900
1,841,100
2,392,600
440,100
1,075,700
344,100
923,700
686,300
779,200
1,171,500
1,597,900
1,464,500
474,400
1,095,000
397,200
681,900
2,077,200
743,900
1,756,800
428,600
1,306,100
1,486,800
1,247,000
305,800
975,700
515,300
364,300
286,500
252,900
302,400
421,100
361,800
340,600
306,000
454,100
198,300
233,700
268,000
5,437,800
2,173,200
2,180,500
560,900
1,262,900
790,700
1,607,200
748,900
428,900
323,900
522,400
346,900
259,800
2,648,600
1,236,000
706,300
2,757,100
1,838,100
260,300
2,986,800
2,067,800
3,814,000
1,074,200
660,800
258,400
215,300
242,700
3,701,300
1,801,700
- 266 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,289,800
4,052,500
3,536,800
2,559,600
843,800
2,848,900
1,860,200
457,300
4,277,200
3,872,100
2,596,300
2,459,600
320,000
292,100
1,175,400
338,100
286,200
316,300
1,492,800
1,483,000
1,295,300
1,572,900
952,600
287,900
507,400
348,300
314,500
306,400
389,100
443,700
260,100
746,500
1,360,400
1,044,300
2,455,100
319,700
319,700
3,119,400
1,319,200
253,100
1,170,700
3,201,200
698,200
550,000
269,400
255,400
401,300
559,600
1,339,900
1,181,000
826,700
448,500
259,800
1,435,500
836,500
491,500
407,800
1,336,500
295,500
1,877,500
1,436,400
318,600
353,100
344,900
208,700
1,565,000
1,563,900
309,900
- 267 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
949,900
354,600
383,400
355,000
563,100
433,200
1,084,900
320,100
890,600
1,636,300
260,600
1,586,300
859,600
1,857,700
937,800
414,100
318,600
73,700
412,900
933,000
363,600
491,100
280,800
114,100
283,600
4,223,700
2,400,800
4,007,000
1,353,500
550,000
374,700
847,500
448,300
902,200
522,400
311,000
520,500
322,200
491,800
342,700
887,100
1,721,200
1,384,800
1,221,000
861,700
301,100
301,100
301,100
246,000
156,000
245,300
299,900
324,400
238,900
210,700
103,300
113,600
84,000
98,600
94,000
143,500
128,700
167,400
183,900
108,600
138,700
94,800
148,000
209,900
- 268 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
149,500
188,000
531,300
615,900
141,300
255,700
172,000
245,500
430,100
368,200
264,700
250,600
140,500
131,100
295,100
186,300
267,200
184,900
144,700
2,552,400
1,909,400
303,400
314,200
600,900
787,400
769,200
397,300
1,238,300
293,900
322,900
324,000
259,400
327,700
310,100
145,300
319,200
282,900
255,900
289,400
2,395,800
427,700
862,200
309,300
605,000
481,900
404,600
748,700
766,800
817,500
715,100
1,368,900
213,100
2,034,000
280,800
1,031,000
2,343,200
1,970,400
860,800
312,000
608,400
606,000
280,800
2,201,500
1,731,600
155,100
168,100
218,400
387,700
- 269 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,129,600
608,700
960,400
1,100,800
555,300
733,800
533,900
569,300
713,400
318,200
714,600
200,700
706,100
1,216,100
81,500
- 270 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,557,500
3,069,000
3,580,500
A-4-10-II
SEPTIKEMIA (SEDANG)
4,369,300
5,243,100
6,117,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,891,200
3,323,400
7,069,400
3,988,000
8,247,600
4,652,700
5
6
A-4-11-II
A-4-11-III

4,730,100
6,546,900
5,676,100
7,856,300
6,622,200
9,165,700
A-4-12-I
2,663,000
3,195,600
3,728,300
8
9
A-4-12-II
A-4-12-III

3,316,400
3,649,000
3,979,700
4,378,800
4,643,000
5,108,500
10 A-4-13-I
11 A-4-13-II

2,108,800
2,691,400
2,530,500
3,229,700
2,952,300
3,768,000
12 A-4-13-III
3,229,700
3,875,700
4,521,600
2,289,100
2,747,000
3,204,800
2,778,700
3,334,500
3,890,200
3,334,500
4,001,400
4,668,300
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,597,900
18,179,300
17,517,500
21,815,100
20,437,100
25,451,000
18 A-4-15-III
INFEKSI HIV (BERAT)
20,537,500
24,644,900
28,752,400
19 B-1-01-I
20 B-1-01-II

39,927,100
44,050,100
47,912,500
52,860,100
55,897,900
61,670,100
21 B-1-01-III
22 B-1-10-I

97,098,300
6,454,000
116,517,900
7,744,800
135,937,600
9,035,600
23 B-1-10-II
14,325,000
17,190,000
20,055,000
24 B-1-10-III
25 B-1-11-I

28,279,500
7,055,800
33,935,500
8,466,900
39,591,400
9,878,100
26 B-1-11-II
27 B-1-11-III

9,426,600
12,179,000
11,311,900
14,614,800
13,197,200
17,050,600
28 B-1-12-I
7,102,700
8,523,200
9,943,700
29 B-1-12-II
7,899,400
9,479,300
11,059,200
30 B-1-12-III
12,357,800
14,829,300
17,300,900
5,657,400
6,788,800
7,920,300
9,308,500
11,170,200
13,031,900
12,044,400
14,453,200
16,862,100
7,773,400
9,328,100
10,882,800
8,645,400
10,374,500
12,103,600
13,524,800
2,332,900
3,724,100
5,137,500
16,229,800
2,799,500
4,468,900
6,164,900
18,934,800
3,266,100
5,213,700
7,192,400
4,918,700
5,902,500
6,886,200
6,886,300
8,263,500
9,640,800
8,342,600
10,011,200
11,679,700
4,447,100
6,528,300
9,712,700
4,242,200
5,336,500
7,834,000
11,655,300
5,090,600
6,225,900
9,139,700
13,597,800
5,939,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 271 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,941,900
5,930,300
6,918,700
48 B-4-13-III
49 B-4-14-I

6,807,900
4,237,600
8,169,500
5,085,100
9,531,100
5,932,700
50 B-4-14-II
4,943,700
5,932,500
6,921,200
51 B-4-14-III
52 C-4-10-I

6,622,200
4,041,800
7,946,700
4,850,200
9,271,100
5,658,500
53 C-4-10-II
54 C-4-10-III

7,755,200
13,278,000
9,306,300
15,933,600
10,857,300
18,589,200
55 C-4-11-I
4,467,600
5,361,200
6,254,700
56 C-4-11-II
57 C-4-11-III

5,978,400
9,476,100
7,174,000
11,371,300
8,369,700
13,266,500
58 C-4-12-I
59 C-4-12-II
2,974,700
6,040,200
3,569,600
7,248,300
4,164,600
8,456,300
60 C-4-12-III
RADIOTERAPI (BERAT)
15,513,000
18,615,600
21,718,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,236,400
4,208,900
2,683,600
5,050,600
3,130,900
5,892,400
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,697,400
3,715,800
6,836,900
4,459,000
7,976,400
5,202,200
65 C-4-14-II
5,212,600
6,255,100
7,297,600
66 C-4-14-III
67 D-1-10-I

8,006,800
22,225,500
9,608,200
26,670,600
11,209,500
31,115,700
68 D-1-10-II
69 D-1-10-III

33,851,000
53,902,300
40,621,200
64,682,800
47,391,400
75,463,300
70 D-1-11-I
6,010,800
7,212,900
8,415,100
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,348,300
20,562,600
18,418,000
24,675,100
21,487,600
28,787,600
5,210,600
6,252,800
7,294,900
14,359,800
17,231,700
20,103,700
22,778,800
27,334,500
31,890,300
2,568,700
4,215,500
6,632,000
4,079,200
7,330,200
10,381,300
3,516,900
4,877,900
7,490,300
3,082,400
5,058,600
7,958,400
4,895,100
8,796,200
12,457,600
4,220,200
5,853,500
8,988,400
3,596,200
5,901,700
9,284,800
5,710,900
10,262,300
14,533,900
4,923,600
6,829,100
10,486,400
3,013,900
3,616,600
4,219,400
4,265,600
5,118,800
5,971,900
5,455,900
6,547,000
7,638,200
3,232,500
3,879,000
4,525,500
5,292,400
6,350,900
7,409,400
6,473,200
7,767,800
9,062,400
7,088,000
8,505,600
9,923,100
9,676,100
11,611,300
13,546,600
93 E-1-01-III
23,330,100
27,996,100
32,662,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,369,200
10,229,300
19,326,500
8,843,000
12,275,200
23,191,800
10,316,800
14,321,000
27,057,100
7,584,100
9,100,900
10,617,700
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 272 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,981,400
3,577,700
4,174,000
104 E-4-11-II
105 E-4-11-III

4,545,500
6,349,900
5,454,600
7,619,900
6,363,600
8,889,900
106 E-4-12-I
107 E-4-12-II

3,425,600
5,932,400
4,110,800
7,118,900
4,795,900
8,305,300
108 E-4-12-III

(RINGAN)
(SEDANG)
7,032,000
8,438,400
9,844,800
3,730,400
4,476,500
5,222,500
5,464,400
6,557,200
7,650,100
111 E-4-13-III
7,363,900
8,836,700
10,309,500
112 F-4-10-I
113 F-4-10-II
4,094,300
4,705,600
4,913,100
5,646,700
5,732,000
6,587,800
114 F-4-10-III
115 F-4-11-I
5,646,700
3,959,800
6,776,000
4,751,800
7,905,300
5,543,800
116 F-4-11-II
4,613,600
5,536,400
6,459,100
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,916,400
7,099,700
8,282,900
2,105,500
2,526,600
2,947,700
2,993,400
3,592,100
4,190,700
6,503,000
7,803,600
9,104,200
3,189,800
4,208,900
5,449,000
1,819,900
2,334,300
3,141,000
3,827,700
5,050,700
6,538,800
2,183,900
2,801,100
3,769,200
4,465,700
5,892,500
7,628,600
2,547,900
3,268,000
4,397,400
127 F-4-15-I
2,811,400
3,373,700
3,935,900
128 F-4-15-II
4,189,300
5,027,200
5,865,000
129 F-4-15-III
5,531,200
6,637,400
7,743,700
5,702,600
6,843,100
7,983,600
6,630,200
7,956,200
9,282,300
8,850,200
10,620,200
12,390,200
133 F-4-17-I

1,306,300
1,567,600
1,828,900
134 F-4-17-II
3,828,700
4,594,400
5,360,200
135
136
137
138
139
140
141

(RINGAN)
4,084,800
4,955,100
5,452,100
8,404,700
3,786,900
4,849,300
6,037,300
4,901,800
5,946,200
6,542,500
10,085,700
4,544,200
5,819,100
7,244,800
5,718,800
6,937,200
7,632,900
11,766,600
5,301,600
6,789,000
8,452,200
17,140,600
20,568,800
23,996,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,208,000
12,249,600
14,291,100
14,503,800
17,404,500
20,305,300
3,534,300
4,241,100
4,948,000
4,938,500
5,926,200
6,913,900
6,319,200
7,583,100
8,846,900
- 273 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,766,800
27,320,100
31,873,500
148 G-1-11-I
149 G-1-11-II

11,925,200
21,802,100
14,310,300
26,162,500
16,695,300
30,522,900
150 G-1-11-III
36,171,300
43,405,600
50,639,800
4,979,200
5,975,000
6,970,900
9,622,400
11,546,900
13,471,400
13,113,500
15,736,200
18,358,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,502,100
4,033,800
1,802,500
4,840,600
2,102,900
5,647,400
156 G-1-13-III
157 G-1-20-I

9,102,100
8,888,500
10,922,500
10,666,200
12,743,000
12,443,900
158 G-1-20-II
14,469,900
17,363,900
20,257,800
159 G-1-20-III
22,206,400
26,647,700
31,088,900
160 G-1-30-I
11,309,700
13,571,600
15,833,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
23,614,900
32,171,500
28,337,900
38,605,900
33,060,900
45,040,200
4,274,100
5,128,900
5,983,700
5,224,400
6,269,300
7,314,200
7,390,500
8,868,600
10,346,700
4,612,700
5,535,200
6,457,800
6,127,400
7,352,900
8,578,300
9,003,200
10,803,800
12,604,500
5,117,300
6,140,700
7,164,200
6,269,500
7,523,500
8,777,400
9,105,700
10,926,900
12,748,000
2,981,800
3,578,100
4,174,500
5,199,600
6,239,600
7,279,500
6,166,900
7,400,300
8,633,600
5,058,200
6,069,900
7,081,500
6,971,700
8,366,000
9,760,300
8,750,200
10,500,300
12,250,300
4,133,000
4,959,600
5,786,200
4,932,600
5,919,100
6,905,600
6,961,900
8,354,300
9,746,700
3,407,100
4,088,500
4,770,000
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
24,583,800
29,500,600
34,417,400
37,318,600
44,782,400
52,246,100
17,550,100
20,663,400
21,060,100
24,796,100
24,570,200
28,928,800
- 274 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,523,400
5,428,100
6,332,800
183 G-4-16-III
6,441,700
7,730,100
9,018,400
4,538,100
5,445,700
6,353,300
5,950,400
7,140,500
8,330,600
7,708,200
9,249,800
10,791,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,469,300
5,363,200
6,257,000
188 G-4-18-II
5,974,100
7,168,900
8,363,700
189 G-4-18-III
6,684,500
8,021,400
9,358,300
3,728,800
4,474,600
5,220,400
6,302,600
7,563,100
8,823,700
8,275,000
9,930,100
11,585,100
193 G-4-20-I

2,608,500
3,130,200
3,651,900
194 G-4-20-II
3,687,600
4,425,100
5,162,700
195 G-4-20-III
196 G-4-21-I

6,091,100
2,716,300
7,309,300
3,259,600
8,527,500
3,802,900
197 G-4-21-II
198 G-4-21-III

4,597,400
5,570,200
5,516,900
6,684,200
6,436,400
7,798,200
199 G-4-22-I
2,679,800
3,215,700
3,751,700
200 G-4-22-II
201 G-4-22-III

3,423,900
4,000,700
4,108,700
4,800,800
4,793,500
5,601,000
202 G-4-23-I
203 G-4-23-II

2,674,000
3,354,900
3,208,800
4,025,900
3,743,600
4,696,900
204 G-4-23-III
4,776,600
5,731,900
6,687,200
205 G-4-24-I
206 G-4-24-II

3,070,500
3,836,200
3,684,600
4,603,400
4,298,700
5,370,700
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,390,900
2,545,000
3,218,400
4,265,100
7,669,100
3,054,000
3,862,100
5,118,100
8,947,300
3,563,000
4,505,800
5,971,100
3,619,600
4,343,500
5,067,400
4,340,900
5,209,100
6,077,300
6,296,300
7,555,600
8,814,800
10,273,800
11,354,300
15,441,000
7,521,400
9,344,600
13,088,500
3,445,500
4,674,800
9,188,500
2,973,500
3,391,800
4,856,900
3,505,700
4,318,300
7,236,700
12,328,600
13,625,100
18,529,200
9,025,700
11,213,500
15,706,200
4,134,500
5,609,700
11,026,200
3,568,200
4,070,200
5,828,300
4,206,900
5,181,900
8,684,000
14,383,400
15,896,000
21,617,400
10,530,000
13,082,400
18,323,900
4,823,600
6,544,700
12,863,900
4,162,900
4,748,600
6,799,600
4,908,000
6,045,600
10,131,300
229 I-1-01-I
47,088,400
56,506,000
65,923,700
230 I-1-01-II
48,124,300
57,749,200
67,374,000
231 I-1-01-III

(RINGAN)
75,963,600
91,156,300
106,349,000
26,124,400
31,349,300
36,574,200
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 275 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
22,175,700
26,610,900
31,046,000
245 I-1-06-II
32,123,400
38,548,000
44,972,700
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
38,329,100
45,994,900
53,660,700
49,002,000
58,802,400
68,602,800
61,252,500
73,503,000
85,753,500
91,878,700
110,254,400
128,630,200
4,220,400
5,064,500
5,908,600
4,692,700
5,631,200
6,569,700
6,244,500
7,493,400
8,742,300
12,148,300
14,578,000
17,007,600
19,245,400
23,094,500
26,943,600
25,320,200
30,384,300
35,448,300
11,783,700
14,140,400
16,497,200
15,692,400
18,830,900
21,969,400
19,353,100
23,223,700
27,094,300
24,118,300
28,942,000
33,765,700
29,975,500
35,970,600
41,965,700
39,278,300
47,133,900
54,989,600
4,581,800
6,398,400
12,320,700
5,498,100
7,678,000
14,784,900
6,414,500
8,957,700
17,249,000
11,521,300
13,825,600
16,129,900
26,874,400
32,249,200
37,624,100
30,999,200
37,199,000
43,398,800
13,753,200
16,503,800
19,254,500
17,220,300
20,664,400
24,108,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
33,700,200
40,440,200
47,180,300
41,537,600
49,845,100
58,152,600
15,089,500
18,107,500
21,125,400
20,917,200
25,100,700
29,284,100
27,366,600
32,839,900
38,313,200
23,442,400
28,130,900
32,819,300
36,998,400
44,398,100
51,797,800
59,104,700
70,925,700
82,746,600
55,127,200
66,152,700
77,178,100
67,377,700
80,853,300
94,328,800
91,878,700
110,254,400
128,630,200
- 276 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
25,952,100
31,142,500
36,332,900
279 I-1-40-III
34,663,200
41,595,800
48,528,400
280 I-4-10-I
281 I-4-10-II

4,079,400
7,284,200
4,895,300
8,741,100
5,711,100
10,197,900
282 I-4-10-III
10,495,500
12,594,700
14,693,800
283 I-4-11-I
284 I-4-11-II

6,087,800
7,533,700
7,305,400
9,040,500
8,523,000
10,547,200
285 I-4-11-III
286 I-4-12-I

13,936,600
3,607,800
16,723,900
4,329,400
19,511,300
5,051,000
287 I-4-12-II
4,182,000
5,018,400
5,854,800
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,018,400
6,022,100
7,025,800
3,671,400
4,405,700
5,140,000
6,555,800
7,867,000
9,178,100
9,446,000
11,335,200
13,224,400
3,363,000
3,586,400
6,098,300
4,035,600
4,303,600
7,317,900
4,708,200
5,020,900
8,537,600
4,522,700
5,427,200
6,331,700
6,152,800
7,383,400
8,613,900
297 I-4-15-III
7,383,400
8,860,000
10,336,700
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,188,200
3,513,700
4,216,500
1,923,800
2,239,700
2,687,700
2,625,900
4,216,500
5,059,800
2,308,600
2,687,700
3,225,200
3,063,500
4,919,200
5,903,100
2,693,400
3,135,600
3,762,700
4,094,200
4,913,000
5,731,900
6,426,400
7,711,700
8,996,900
8,463,100
10,155,800
11,848,400
307 I-4-19-I
3,950,100
4,740,100
5,530,100
308 I-4-19-II

(SEDANG)
6,166,300
7,399,600
8,632,800
309 I-4-19-III
7,361,400
8,833,700
10,306,000
310
311
312
313
314

4,240,400
4,897,700
7,103,400
3,173,100
4,020,300
5,088,500
5,877,200
8,524,000
3,807,700
4,824,400
5,936,600
6,856,800
9,944,700
4,442,300
5,628,500
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,301,200
25,561,500
29,821,700
15,502,200
18,602,700
21,703,100
19,366,500
23,239,800
27,113,100
20,358,200
24,429,900
28,501,500
11,726,600
14,071,900
16,417,200
24,393,800
29,272,600
34,151,400
37,801,700
45,362,000
52,922,300
10,822,300
12,986,800
15,151,300
- 277 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,802,900
6,963,500
8,124,100
316 I-4-22-I
317 I-4-22-II
3,200,900
3,984,600
3,841,000
4,781,500
4,481,200
5,578,400
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,824,200
6,989,000
8,153,900
3,376,400
4,051,600
4,726,900
4,145,200
4,974,200
5,803,300
8,099,500
9,719,400
11,339,300
2,821,000
3,385,200
3,949,400
6,496,000
7,795,300
9,094,500
8,213,100
9,855,700
11,498,300
54,852,000
65,822,400
76,792,700
62,075,200
74,490,200
86,905,300
70,226,600
84,271,900
98,317,200
29,107,900
34,929,500
40,751,100
40,529,800
48,635,800
56,741,700
66,928,600
80,314,300
93,700,000
8,839,300
10,607,200
12,375,000
17,886,400
21,463,700
25,040,900
19,163,300
22,995,900
26,828,600
15,115,300
18,138,400
21,161,500
19,038,200
22,845,800
26,653,400
29,398,000
35,277,600
41,157,200
7,376,600
8,852,000
10,327,300
13,362,700
16,035,200
18,707,700
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
38,570,900
46,285,100
53,999,200
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,796,500
5,602,200
8,475,400
2,773,500
3,747,000
5,177,800
4,569,400
5,201,600
7,262,900
4,165,100
5,797,700
10,816,500
4,454,300
7,472,700
8,840,900
4,375,500
5,227,500
7,033,100
3,355,800
6,722,700
10,170,400
3,328,200
4,496,400
6,213,400
5,483,300
6,241,900
8,715,400
4,998,100
6,957,200
12,979,800
5,345,200
8,967,200
10,609,100
5,250,600
6,273,000
8,439,800
3,915,100
7,843,100
11,865,500
3,882,900
5,245,800
7,248,900
6,397,200
7,282,200
10,168,000
5,831,100
8,116,700
15,143,100
6,236,100
10,461,700
12,377,300
6,125,700
7,318,500
9,846,400
3,645,700
4,374,900
5,104,000
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 278 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,123,200
6,147,900
7,172,500
360 J-4-16-III
6,477,500
7,773,000
9,068,500
361 J-4-17-I
362 J-4-17-II

3,722,000
4,457,200
4,466,400
5,348,600
5,210,800
6,240,100
363 J-4-17-III
364 J-4-18-I

5,849,200
2,245,900
7,019,000
2,695,100
8,188,900
3,144,300
365 J-4-18-II
2,996,400
3,595,700
4,195,000
366 J-4-18-III
367 J-4-19-I

3,154,100
5,242,500
3,784,900
6,291,100
4,415,700
7,339,600
368 J-4-19-II
369 J-4-19-III

5,945,400
6,565,900
7,134,500
7,879,100
8,323,500
9,192,300
370 J-4-20-I
4,682,300
5,618,700
6,555,200
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,487,800
7,840,900
7,785,300
9,409,100
9,082,900
10,977,300
2,823,700
3,388,400
3,953,200
4,548,900
5,458,700
6,368,500
6,347,700
7,617,200
8,886,700
8,013,400
9,616,000
11,218,700
10,382,000
12,458,400
14,534,800
12,168,000
14,601,600
17,035,200
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,344,900
10,013,900
11,682,900

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,955,900
19,534,400
13,147,100
23,441,300
15,338,300
27,348,200
3,466,300
4,159,500
4,852,800
4,508,300
5,410,000
6,311,600
8,931,600
10,718,000
12,504,300
3,909,300
4,300,200
4,339,300
4,691,100
5,160,200
5,207,200
5,473,000
6,020,300
6,075,000
5,538,400
6,646,000
7,753,700
6,490,800
7,789,000
9,087,200
390 K-1-14-III
11,681,500
14,017,800
16,354,100
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,284,100
17,158,200
25,052,700
14,740,900
20,589,800
30,063,300
17,197,800
24,021,400
35,073,800
7,264,700
8,717,700
10,170,600
12,514,900
15,017,900
17,520,900
17,753,300
21,304,000
24,854,700
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,862,600
9,435,100
11,007,600
398 K-1-40-II

(SEDANG)
8,936,900
10,724,300
12,511,700
399 K-1-40-III
15,144,800
18,173,800
21,202,700
400
401
402
403
404

6,007,800
8,043,200
11,025,500
4,959,800
7,126,400
7,209,400
9,651,800
13,230,600
5,951,700
8,551,700
8,410,900
11,260,500
15,435,700
6,943,700
9,977,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 279 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,199,900
13,439,900
15,679,800
406 K-4-11-I
407 K-4-11-II

2,340,500
3,326,100
2,808,600
3,991,300
3,276,700
4,656,500
408 K-4-11-III
409 K-4-12-I

3,991,300
2,981,400
4,789,600
3,577,700
5,587,800
4,174,000
410 K-4-12-II
4,136,200
4,963,400
5,790,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,842,600
8,211,100
9,579,700
4,019,200
4,823,000
5,626,900
5,199,100
6,238,900
7,278,700
8,008,200
9,609,900
11,211,500
2,627,000
3,152,400
3,677,800
3,526,300
4,231,500
4,936,800
5,658,300
6,790,000
7,921,600
418 K-4-15-I
2,670,400
3,204,500
3,738,600
419 K-4-15-II
4,116,200
4,939,500
5,762,700
420 K-4-15-III
5,777,000
6,932,400
8,087,800
421 K-4-16-I
3,720,300
4,464,300
5,208,400
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,461,600
5,206,100
5,354,000
6,247,300
6,246,300
7,288,500
1,733,400
2,080,100
2,426,800
2,134,700
2,561,600
2,988,500
2,561,600
3,073,900
3,586,300
1,465,900
1,759,000
2,052,200
2,473,600
2,968,300
3,463,100
429 K-4-18-III
2,968,300
3,562,000
4,155,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,585,500
29,563,800
39,502,100
8,963,400
15,856,300
19,685,900
23,502,600
35,476,600
47,402,500
10,756,100
19,027,600
23,623,100
27,419,700
41,389,300
55,302,900
12,548,800
22,198,900
27,560,200
5,023,300
6,027,900
7,032,600
10,075,600
12,090,700
14,105,900
16,959,500
20,351,400
23,743,300
6,594,600
10,613,300
15,181,200
1,778,200
2,064,000
2,395,700
3,612,100
4,964,500
11,629,800
1,768,500
2,339,000
7,734,300
7,913,500
12,735,900
18,217,500
2,133,800
2,476,800
2,874,900
4,334,500
5,957,400
13,955,800
2,122,200
2,806,900
9,281,100
9,232,400
14,858,600
21,253,700
2,489,500
2,889,600
3,354,000
5,056,900
6,950,300
16,281,700
2,475,900
3,274,700
10,828,000
2,405,200
2,886,300
3,367,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 280 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,826,800
3,392,200
3,957,600
4,159,700
4,991,700
5,823,600
2,970,500
3,564,600
4,158,700
4,461,800
5,354,200
6,246,500
6,289,500
7,547,300
8,805,200
10,500,500
12,600,500
14,700,600
14,924,900
17,909,900
20,894,900
20,965,100
25,158,100
29,351,100
9,594,500
11,513,400
13,432,300
15,739,500
25,938,700
18,887,400
31,126,500
22,035,200
36,314,200
23,489,000
28,186,800
32,884,600
27,473,900
32,968,600
38,463,400
34,003,500
40,804,200
47,604,900
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,669,200
14,003,000
16,336,800
467 M-1-04-II
14,991,500
17,989,800
20,988,100
468 M-1-04-III
18,492,400
22,190,900
25,889,400
469 M-1-05-I
470 M-1-05-II

7,637,800
11,983,800
9,165,300
14,380,500
10,692,900
16,777,300
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,781,200
18,937,400
22,093,700
8,293,100
9,951,800
11,610,400
11,109,900
13,331,900
15,553,900
22,632,000
27,158,400
31,684,800
19,154,900
22,985,900
26,816,800
45,798,700
54,958,400
64,118,100
98,783,400
118,540,100
138,296,800
12,469,300
14,963,200
17,457,100
16,423,600
19,708,300
22,993,000
480 M-1-20-III
40,949,400
49,139,200
57,329,100
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,818,900
14,290,200
20,433,600
10,582,600
17,148,200
24,520,400
12,346,400
20,006,200
28,607,100
4,354,500
5,225,400
6,096,200
7,722,500
9,266,900
10,811,400
11,026,200
13,231,400
15,436,600
5,379,500
8,927,300
14,662,500
6,455,400
10,712,700
17,595,000
7,531,400
12,498,200
20,527,500
8,059,000
9,670,800
11,282,600
10,132,000
12,158,400
14,184,900
15,779,000
18,934,800
22,090,700
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 281 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,392,600
18,471,100
21,549,600
16,931,800
20,318,200
23,704,500
19,384,700
23,261,600
27,138,600
8,750,000
10,500,000
12,250,000
10,391,500
23,388,900
12,469,800
28,066,700
14,548,000
32,744,500
2,989,800
3,587,800
4,185,800
4,458,800
8,436,200
5,350,600
10,123,400
6,242,400
11,810,600
3,725,600
4,470,700
5,215,900
8,168,300
9,801,900
11,435,600
12,175,100
14,610,200
17,045,200
2,973,900
3,568,700
4,163,400
4,946,400
5,935,700
6,924,900
6,820,900
8,185,100
9,549,300
4,951,800
5,942,200
6,932,500
7,439,900
8,927,900
10,415,800
14,515,000
17,418,000
20,321,100
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,647,400
6,776,800
7,906,300
512 M-4-14-II
6,965,200
8,358,200
9,751,300
513 M-4-14-III
514 M-4-15-I
10,466,700
3,452,300
12,560,000
4,142,700
14,653,300
4,833,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,463,600
10,129,300
2,867,000
4,733,200
7,951,400
5,356,300
12,155,100
3,440,400
5,679,800
9,541,700
6,249,100
14,181,000
4,013,800
6,626,500
11,132,000
3,721,000
4,465,200
5,209,400
5,204,300
6,245,100
7,286,000
7,267,400
8,720,900
10,174,400
2,812,500
4,238,600
5,103,400
3,375,000
5,086,300
6,124,100
3,937,500
5,934,000
7,144,800
3,023,700
3,628,500
4,233,200
4,940,300
5,928,300
6,916,400
9,648,700
11,578,400
13,508,200
2,958,600
3,550,300
4,142,000
4,332,300
5,198,800
6,065,300
4,841,900
5,810,300
6,778,700
2,979,100
3,574,900
4,170,700
3,725,900
4,471,100
5,216,300
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 282 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,353,500
10,024,200
11,694,900
535 N-1-01-I

176,794,700
212,153,700
247,512,600
536 N-1-01-II
176,794,700
212,153,700
247,512,600
537 N-1-01-III
538 N-1-11-I

176,794,700
8,593,000
212,153,700
10,311,700
247,512,600
12,030,300
539 N-1-11-II
540 N-1-11-III

13,587,700
21,183,200
16,305,200
25,419,900
19,022,800
29,656,500
4,379,600
5,255,500
6,131,400
8,989,000
10,786,800
12,584,500
19,506,400
23,407,600
27,308,900
9,871,600
11,845,900
13,820,200

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,814,800
18,752,100
16,577,700
22,502,600
19,340,700
26,253,000
8,763,200
10,515,900
12,268,500
13,257,000
15,908,400
18,559,800
15,257,600
18,309,100
21,360,600
8,113,400
9,736,100
11,358,800
11,017,800
13,221,400
15,424,900
12,823,300
15,387,900
17,952,600
3,343,700
4,012,400
4,681,100
4,169,300
5,003,100
5,837,000
6,132,400
7,358,900
8,585,400
2,646,200
4,484,500
5,579,700
2,414,200
4,243,900
5,108,200
3,448,400
4,159,100
6,570,700
3,175,400
5,381,400
6,695,600
2,897,100
5,092,700
6,129,800
4,138,000
4,990,900
7,884,800
3,704,700
6,278,300
7,811,500
3,379,900
5,941,400
7,151,400
4,827,700
5,822,800
9,199,000
2,577,900
3,093,500
3,609,100
3,657,900
4,389,500
5,121,100
5,863,600
7,036,300
8,209,100
3,045,500
3,654,600
4,263,600
3,895,800
4,674,900
5,454,100
4,445,700
5,334,900
6,224,000
3,729,200
4,475,000
5,220,800
5,322,700
6,387,200
7,451,800
7,304,000
8,764,800
10,225,600
5,031,600
5,453,900
6,038,000
6,544,600
7,044,300
7,635,400
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 283 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,134,400
10,961,300
12,788,200
3,466,400
4,159,700
4,853,000
3,852,500
4,623,000
5,393,600
4,940,800
5,929,000
6,917,200
2,531,900
3,038,200
3,544,600
3,040,800
3,648,900
4,257,100
3,820,800
4,585,000
5,349,200
1,690,000
2,028,000
2,366,000

MAYOR (RINGAN)
MAYOR (SEDANG)
2,000,300
2,400,400
2,400,400
2,880,400
2,800,400
3,360,500
54,840,900
65,809,100
76,777,300
67,857,400
81,428,900
95,000,400
79,645,500
95,574,700
111,503,800
85,686,100
102,823,300
119,960,600
98,290,800
117,948,900
137,607,100
112,304,300
134,765,100
157,226,000
12,396,600
14,875,900
17,355,200
17,504,400
21,005,200
24,506,100
24,500,800
29,401,000
34,301,200
35,755,200
42,906,200
50,057,300
46,221,900
55,466,300
64,710,600
66,270,600
79,524,700
92,778,800
19,415,200
23,298,200
27,181,300
30,352,700
36,423,200
42,493,800
40,394,700
48,473,700
56,552,600
5,311,700
6,374,100
7,436,400
14,892,900
17,871,400
20,850,000
19,729,400
23,675,300
27,621,100
5,144,900
6,173,900
7,202,900
14,425,200
17,310,300
20,195,300
19,109,900
22,931,900
26,753,900
4,260,000
5,111,900
5,963,900
6,044,600
7,253,500
8,462,500
9,787,600
11,745,100
13,702,600
10,330,500
12,396,600
14,462,700
14,587,000
17,504,400
20,421,800
- 284 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,417,400
24,500,800
28,584,300
9,759,600
11,711,500
13,663,400
11,220,700
13,464,900
15,709,000
15,705,700
18,846,800
21,987,900
5,532,900
6,639,500
7,746,100
8,631,300
10,357,600
12,083,900
13,409,100
16,090,900
18,772,700
3,687,600
4,425,100
5,162,700
7,506,500
9,007,800
10,509,100
13,509,600
16,211,500
18,913,400
2,765,700
3,318,900
3,872,000
5,538,500
6,646,200
7,754,000
6,498,500
7,798,200
9,097,900
2,503,000
3,003,600
3,504,300
4,810,000
5,772,000
6,734,000
11,770,700
14,124,800
16,478,900
3,688,600
4,426,300
5,164,100
6,639,500
7,967,400
9,295,300
9,342,900
11,211,500
13,080,100
2,737,500
3,285,000
3,832,500
3,373,000
4,047,600
4,722,200
4,617,300
5,540,700
6,464,200
1,656,600
2,429,200
4,151,700
2,012,600
2,678,700
4,643,600
1,987,900
2,915,000
4,982,100
2,415,100
3,214,500
5,572,300
2,319,200
3,400,800
5,812,400
2,817,600
3,750,200
6,501,000
2,972,100
3,566,500
4,160,900
5,272,700
6,327,200
7,381,800
8,558,200
10,269,900
11,981,500
1,504,100
1,804,900
2,105,700
3,194,800
3,833,700
4,472,700
6,058,400
7,270,100
8,481,800
1,005,900
1,207,100
1,408,300
1,898,400
2,278,000
2,657,700
2,458,700
2,950,500
3,442,200
5,208,900
6,250,700
7,292,500
- 285 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,829,400
8,195,300
9,561,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,778,400
11,734,000
13,689,700
2,510,600
3,012,700
3,514,900
3,726,000
4,471,200
5,216,400
4,481,400
5,377,700
6,273,900
1,731,800
2,078,100
2,424,500
2,326,000
2,791,200
3,256,300
4,231,300
5,077,500
5,923,800
751,200
901,400
1,051,600
1,431,600
1,718,000
2,004,300
2,081,200
2,497,500
2,913,700
1,025,200
1,230,300
1,435,300
1,613,400
1,936,000
2,258,700
2,598,700
3,118,400
3,638,100
1,689,000
2,026,900
2,364,700
2,516,700
3,020,100
3,523,400
3,861,300
4,633,500
5,405,800
5,489,400
6,587,300
7,685,200

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,521,700
22,508,100
10,226,100
27,009,700
11,930,400
31,511,300
8,492,400
10,190,800
11,889,300
10,765,300
12,918,400
15,071,500
15,968,700
19,162,400
22,356,100
6,635,800
10,175,700
14,946,000
6,640,400
7,737,100
12,825,700
7,963,000
12,210,800
17,935,200
7,968,500
9,284,500
15,390,900
9,290,200
14,246,000
20,924,400
9,296,600
10,832,000
17,956,000
4,113,800
4,936,600
5,759,300
5,048,600
6,058,400
7,068,100
5,982,600
7,179,200
8,375,700
3,935,800
5,595,600
7,212,500
4,723,000
6,714,700
8,654,900
5,510,100
7,833,800
10,097,400
6,245,400
7,494,500
8,743,600
9,294,900
11,153,900
13,012,900
23,146,000
27,775,200
32,404,400
5,356,100
7,262,700
13,776,400
6,427,400
8,715,200
16,531,700
7,498,600
10,167,800
19,286,900
3,854,500
4,625,400
5,396,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 286 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,342,700
2,811,200
3,279,800
697 U-4-12-I
698 U-4-12-II

2,557,200
2,974,600
3,068,700
3,569,500
3,580,100
4,164,400
699 U-4-12-III

3,978,200
4,773,900
5,569,500
1,998,000
2,397,600
2,797,200
2,355,400
2,826,500
3,297,600
2,817,200
3,380,600
3,944,100
3,721,400
4,456,300
4,465,700
5,347,600
5,210,000
6,238,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,483,500
8,980,200
10,476,900
2,988,200
3,585,800
4,183,500
3,722,900
4,467,500
5,212,100
5,210,300
6,252,300
7,294,400
5,024,700
6,029,700
7,034,600
10,040,200
12,048,300
14,056,300
12,313,000
14,775,500
17,238,100
9,272,500
10,588,100
16,581,500
11,127,100
12,705,800
19,897,800
12,981,600
14,823,400
23,214,100
8,718,000
10,461,600
12,205,200
12,273,300
14,728,000
17,182,600
15,089,800
18,107,800
21,125,800
4,688,100
5,625,700
6,563,300
8,957,300
10,748,800
12,540,300
13,631,400
16,357,600
19,083,900
8,917,400
10,700,900
12,484,400
12,956,800
15,548,100
18,139,500
16,178,900
19,414,700
22,650,500
1,480,600
1,633,800
1,807,300
1,776,700
1,960,600
2,168,800
2,072,800
2,287,300
2,530,200
4,445,700
5,334,800
6,224,000
7,384,500
8,861,400
10,338,300
12,174,500
14,609,400
17,044,300
3,726,100
4,471,300
5,216,600
4,999,500
5,999,400
6,999,300
6,904,000
8,284,800
9,665,600
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,559,400
10,271,300
11,983,100
13,141,300
15,769,500
18,397,800
1,531,200
2,226,900
1,837,400
2,672,300
2,143,700
3,117,600
- 287 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,470,200
12,564,200
14,658,200
12,172,700
14,607,300
17,041,800
17,907,400
21,488,900
25,070,300
2,220,900
2,665,000
3,109,200
2,450,700
2,711,000
2,940,900
3,253,200
3,431,000
3,795,400
2,321,300
2,785,600
3,249,800
2,561,500
3,073,900
3,586,200
2,833,600
3,400,300
3,967,000
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,497,200
2,996,700
3,496,100
743 W-1-12-II
744 W-1-12-III

3,117,000
5,353,900
3,740,400
6,424,700
4,363,800
7,495,500
745 W-1-13-I
2,490,000
2,987,900
3,485,900
746 W-1-13-II
747 W-1-13-III

2,703,200
3,631,200
3,243,900
4,357,400
3,784,500
5,083,600
748 W-1-20-I
749 W-1-20-II

8,338,600
10,419,200
10,006,300
12,503,000
11,674,100
14,586,800
750 W-1-20-III
12,078,500
14,494,200
16,909,900
751 W-1-30-I
4,707,300
5,648,700
6,590,200
752 W-1-30-II
7,508,100
9,009,700
10,511,300
753 W-1-30-III
18,421,500
22,105,800
25,790,000
754 W-4-10-I
3,507,400
4,208,900
4,910,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,199,600
10,275,400
3,189,700
4,842,500
5,894,200
6,239,500
12,330,400
3,827,700
5,811,000
7,073,100
7,279,400
14,385,500
4,465,600
6,779,500
8,251,900
2,834,600
3,401,600
3,968,500
3,891,800
4,670,100
5,448,500
4,242,200
5,090,700
5,939,100
1,255,000
1,714,300
2,131,900
1,677,100
2,058,000
2,553,900
1,595,000
1,771,300
2,452,500
2,187,800
2,925,600
3,965,200
1,565,900
2,827,300
4,180,100
2,889,200
3,835,000
5,448,000
2,632,200
3,161,400
4,345,500
1,506,000
2,057,200
2,558,300
2,012,600
2,469,600
3,064,700
1,914,000
2,125,600
2,943,000
2,625,300
3,510,700
4,758,200
1,879,100
3,392,800
5,016,100
3,467,000
4,602,000
6,537,600
3,158,600
3,793,700
5,214,700
1,757,000
2,400,100
2,984,600
2,348,000
2,881,100
3,575,500
2,233,000
2,479,900
3,433,500
3,062,900
4,095,900
5,551,200
2,192,300
3,958,200
5,852,200
4,044,900
5,369,000
7,627,200
3,685,100
4,426,000
6,083,800
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 288 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,893,500
2,272,300
2,651,000
3,973,400
4,768,100
5,562,800
6,116,500
7,339,800
8,563,100
- 289 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
969,800
1,258,000
2,339,300
1,933,200
2,512,300
462,100
1,129,400
361,300
969,900
720,700
818,200
1,230,100
1,677,800
1,537,700
498,200
1,149,800
417,100
716,000
2,181,100
781,100
1,844,600
450,000
1,371,400
1,561,200
1,309,400
321,100
1,024,500
541,100
382,500
300,800
265,500
317,500
442,100
379,900
357,600
321,300
476,900
208,200
245,400
281,400
5,709,700
2,281,900
2,289,500
589,000
1,326,100
830,200
1,687,500
786,400
450,300
340,100
548,500
364,200
272,800
2,781,000
1,297,800
741,600
2,894,900
1,930,000
273,300
3,136,200
2,171,200
4,004,700
1,127,900
693,800
271,400
226,100
254,900
3,886,400
1,891,800
- 290 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,404,300
4,255,100
3,713,700
2,687,600
886,000
2,991,400
1,953,200
480,100
4,491,100
4,065,700
2,726,100
2,582,600
336,000
306,700
1,234,100
355,000
300,500
332,100
1,567,500
1,557,100
1,360,100
1,651,600
1,000,200
302,300
532,800
365,700
330,300
321,800
408,500
465,900
273,100
783,800
1,428,500
1,096,500
2,577,800
335,700
335,700
3,275,400
1,385,100
265,700
1,229,200
3,361,300
733,100
577,500
282,900
268,100
421,300
587,500
1,406,900
1,240,000
868,000
470,900
272,800
1,507,200
878,300
516,000
428,200
1,403,300
310,200
1,971,400
1,508,200
334,500
370,800
362,200
219,200
1,643,300
1,642,100
325,400
- 291 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
997,400
372,300
402,500
372,700
591,300
454,800
1,139,100
336,100
935,100
1,718,100
273,700
1,665,600
902,600
1,950,600
984,600
434,800
334,500
77,400
433,500
979,700
381,800
515,700
294,900
119,800
297,800
4,434,900
2,520,900
4,207,300
1,421,100
577,500
393,500
889,900
470,700
947,300
548,500
326,500
546,500
338,300
516,400
359,900
931,400
1,807,200
1,454,000
1,282,000
904,800
316,200
316,200
316,200
258,300
163,800
257,600
314,800
340,600
250,900
221,300
108,500
119,300
88,200
103,500
98,700
150,700
135,200
175,800
193,100
114,000
145,700
99,500
155,400
220,400
- 292 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
156,900
197,400
557,900
646,700
148,400
268,500
180,600
257,800
451,600
386,600
277,900
263,200
147,500
137,700
309,900
195,600
280,500
194,200
152,000
2,680,100
2,004,900
318,600
329,900
631,000
826,700
807,600
417,200
1,300,200
308,600
339,100
340,200
272,400
344,000
325,600
152,500
335,100
297,100
268,700
303,900
2,515,600
449,100
905,300
324,700
635,200
506,000
424,900
786,200
805,100
858,400
750,900
1,437,300
223,700
2,135,700
294,900
1,082,600
2,460,300
2,069,000
903,800
327,600
638,800
636,300
294,900
2,311,600
1,818,200
162,900
176,500
229,300
407,000
- 293 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,186,100
639,100
1,008,500
1,155,800
583,000
770,500
560,600
597,800
749,100
334,100
750,300
210,700
741,500
1,276,900
85,600
- 294 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,899,200
2,279,000
2,658,800
A-4-10-II
SEPTIKEMIA (SEDANG)
3,244,500
3,893,500
4,542,400
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,374,700
2,796,400
5,249,600
3,355,600
6,124,500
3,914,900
5
6
A-4-11-II
A-4-11-III

3,980,000
5,508,700
4,776,000
6,610,500
5,572,100
7,712,200
A-4-12-I
2,532,200
3,038,600
3,545,000
8
9
A-4-12-II
A-4-12-III

3,153,400
3,365,500
3,784,100
4,038,700
4,414,800
4,711,800
10 A-4-13-I
11 A-4-13-II

1,522,800
2,294,000
1,827,300
2,752,800
2,131,900
3,211,600
12 A-4-13-III
2,752,800
3,303,300
3,853,900
2,111,400
2,533,600
2,955,900
2,562,900
3,075,400
3,588,000
3,075,400
3,690,500
4,305,600
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,314,800
4,961,900
3,977,800
5,954,300
4,640,800
6,946,700
18 A-4-15-III
INFEKSI HIV (BERAT)
6,226,800
7,472,200
8,717,500
19 B-1-01-I
20 B-1-01-II

22,694,500
25,038,200
27,233,400
30,045,800
31,772,400
35,053,400
21 B-1-01-III
22 B-1-10-I

43,922,100
3,921,200
52,706,600
4,705,500
61,491,000
5,489,700
23 B-1-10-II
8,703,400
10,444,100
12,184,800
24 B-1-10-III
25 B-1-11-I

17,181,700
5,239,500
20,618,100
6,287,400
24,054,400
7,335,300
26 B-1-11-II
27 B-1-11-III

6,790,000
8,772,600
8,148,000
10,527,100
9,506,000
12,281,600
28 B-1-12-I
5,116,100
6,139,300
7,162,500
29 B-1-12-II
5,690,000
6,828,000
7,966,000
30 B-1-12-III
8,901,400
10,681,600
12,461,900
4,075,000
4,890,000
5,705,000
6,704,900
8,045,900
9,386,900
8,675,600
10,410,700
12,145,900
5,599,200
6,719,100
7,838,900
6,227,300
7,472,800
8,718,300
9,742,000
1,732,400
2,765,400
3,815,000
11,690,400
2,078,900
3,318,500
4,578,000
13,638,800
2,425,400
3,871,600
5,341,000
3,652,600
4,383,100
5,113,600
5,113,600
6,136,400
7,159,100
6,195,100
7,434,100
8,673,100
3,302,300
4,702,400
6,996,100
3,150,100
3,962,800
5,642,900
8,395,300
3,780,200
4,623,300
6,583,300
9,794,600
4,410,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 295 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,669,800
4,403,700
5,137,700
48 B-4-13-III
49 B-4-14-I

5,055,500
3,146,800
6,066,500
3,776,100
7,077,600
4,405,500
50 B-4-14-II
3,671,100
4,405,300
5,139,600
51 B-4-14-III
52 C-4-10-I

4,917,600
2,911,300
5,901,100
3,493,600
6,884,600
4,075,900
53 C-4-10-II
54 C-4-10-III

5,586,100
9,860,000
6,703,400
11,832,000
7,820,600
13,804,000
55 C-4-11-I
3,317,600
3,981,100
4,644,600
56 C-4-11-II
57 C-4-11-III

4,439,400
6,825,700
5,327,300
8,190,800
6,215,200
9,556,000
58 C-4-12-I
59 C-4-12-II
2,209,000
4,350,800
2,650,800
5,221,000
3,092,500
6,091,100
60 C-4-12-III
RADIOTERAPI (BERAT)
11,174,100
13,408,900
15,643,700
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,660,700
3,125,400
1,992,800
3,750,500
2,325,000
4,375,600
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,230,800
2,759,300
5,076,900
3,311,200
5,923,100
3,863,000
65 C-4-14-II
3,870,800
4,644,900
5,419,100
66 C-4-14-III
67 D-1-10-I

5,767,300
13,503,500
6,920,800
16,204,200
8,074,300
18,904,900
68 D-1-10-II
69 D-1-10-III

20,566,700
32,749,300
24,680,100
39,299,200
28,793,400
45,849,000
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,463,500
5,356,200
6,248,900
11,397,400
14,811,300
13,676,800
17,773,600
15,956,300
20,735,900
3,869,300
4,643,200
5,417,100
10,663,300
12,796,000
14,928,600
16,915,100
20,298,100
23,681,200
2,313,900
3,478,200
5,472,000
3,029,200
5,443,300
7,477,700
2,611,600
3,622,300
5,562,200
2,776,700
4,173,800
6,566,400
3,635,000
6,531,900
8,973,300
3,133,900
4,346,700
6,674,600
3,239,500
4,869,500
7,660,800
4,240,800
7,620,600
10,468,800
3,656,200
5,071,200
7,787,000
2,238,000
2,685,600
3,133,300
3,167,600
3,801,100
4,434,600
4,051,400
4,861,700
5,672,000
2,400,400
2,880,500
3,360,500
3,930,000
4,716,100
5,502,100
4,806,800
5,768,200
6,729,600
4,273,000
5,127,600
5,982,200
5,597,200
6,716,700
7,836,100
93 E-1-01-III
9,719,600
11,663,500
13,607,400
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,333,300
4,045,800
8,527,400
4,000,000
4,855,000
10,232,900
4,666,600
5,664,200
11,938,400
5,631,800
6,758,200
7,884,500
97 E-1-20-I
- 296 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,214,000
2,656,800
3,099,600
104 E-4-11-II
105 E-4-11-III

3,375,400
4,573,900
4,050,500
5,488,700
4,725,500
6,403,400
106 E-4-12-I
107 E-4-12-II

2,543,800
4,405,300
3,052,600
5,286,300
3,561,300
6,167,400
108 E-4-12-III

(RINGAN)
(SEDANG)
5,221,900
6,266,200
7,310,600
2,770,100
3,324,100
3,878,200
4,057,700
4,869,300
5,680,800
111 E-4-13-III
5,304,300
6,365,100
7,426,000
112 F-4-10-I
113 F-4-10-II
2,949,200
3,389,500
3,539,000
4,067,400
4,128,800
4,745,300
114 F-4-10-III
115 F-4-11-I
4,067,400
2,852,300
4,880,800
3,422,800
5,694,300
3,993,200
116 F-4-11-II
3,323,200
3,987,900
4,652,500
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,261,600
5,113,900
5,966,200
1,563,500
1,876,200
2,188,900
2,222,800
2,667,400
3,112,000
4,829,000
5,794,800
6,760,600
2,297,600
3,031,700
3,925,000
1,310,900
1,681,400
2,262,500
2,757,100
3,638,100
4,710,000
1,573,100
2,017,700
2,714,900
3,216,600
4,244,400
5,494,900
1,835,200
2,354,000
3,167,400
127 F-4-15-I
2,087,700
2,505,200
2,922,700
128 F-4-15-II
3,110,900
3,733,100
4,355,300
129 F-4-15-III
4,107,400
4,928,800
5,750,300
4,107,600
4,929,100
5,750,600
4,775,800
5,730,900
6,686,100
6,374,800
7,649,800
8,924,800
133 F-4-17-I

970,100
1,164,100
1,358,100
134 F-4-17-II
2,843,100
3,411,700
3,980,400
135
136
137
138
139
140
141

(RINGAN)
3,033,300
3,569,200
3,927,100
6,054,000
2,727,700
3,493,000
4,348,700
3,640,000
4,283,000
4,712,600
7,264,800
3,273,200
4,191,500
5,218,400
4,246,700
4,996,900
5,498,000
8,475,600
3,818,800
4,890,100
6,088,200
10,402,500
12,483,000
14,563,400
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,580,300
9,096,300
10,612,400
10,447,100
12,536,600
14,626,000
3,360,600
4,032,700
4,704,800
4,695,800
5,634,900
6,574,100
5,828,400
6,994,100
8,159,800
- 297 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
13,832,400
16,598,800
19,365,300
148 G-1-11-I
149 G-1-11-II

8,855,500
16,189,800
10,626,500
19,427,800
12,397,600
22,665,800
150 G-1-11-III
29,850,100
35,820,100
41,790,100
3,697,500
4,437,000
5,176,400
6,931,100
8,317,300
9,703,500
9,445,700
11,334,800
13,224,000
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,115,400
2,995,500
1,338,500
3,594,500
1,561,600
4,193,600
156 G-1-13-III
157 G-1-20-I

6,759,100
4,684,200
8,110,900
5,621,000
9,462,700
6,557,900
158 G-1-20-II
5,570,400
6,684,400
7,798,500
159 G-1-20-III
13,000,700
15,600,800
18,200,900
160 G-1-30-I
6,871,400
8,245,700
9,619,900
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
13,917,200
19,546,400
16,700,700
23,455,700
19,484,100
27,364,900
3,173,900
3,808,600
4,443,400
3,879,500
4,655,500
5,431,400
5,323,400
6,388,100
7,452,800
3,322,500
3,987,100
4,651,600
4,413,600
5,296,300
6,179,000
6,485,100
7,782,100
9,079,100
3,686,000
4,423,200
5,160,400
4,655,700
5,586,800
6,517,900
6,761,800
8,114,100
9,466,500
2,214,200
2,657,100
3,099,900
3,861,200
4,633,400
5,405,600
4,579,400
5,495,300
6,411,200
3,756,200
4,507,400
5,258,600
5,021,700
6,026,100
7,030,400
6,302,800
7,563,400
8,824,000
3,069,100
3,682,900
4,296,800
3,662,800
4,395,400
5,128,000
5,169,800
6,203,700
7,237,700
2,530,100
3,036,100
3,542,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,198,900
19,438,600
22,678,400
31,153,400
37,384,100
43,614,800
10,662,900
12,554,400
12,795,400
15,065,300
14,928,000
17,576,200
- 298 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,359,000
4,030,800
4,702,600
183 G-4-16-III
4,783,500
5,740,200
6,696,900
3,369,900
4,043,900
4,717,800
4,418,700
5,302,400
6,186,100
5,552,200
6,662,700
7,773,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,318,800
3,982,600
4,646,300
188 G-4-18-II
4,436,200
5,323,500
6,210,700
189 G-4-18-III
4,963,800
5,956,600
6,949,300
2,769,000
3,322,800
3,876,500
4,680,200
5,616,300
6,552,300
6,144,900
7,373,900
8,602,900
193 G-4-20-I

1,937,000
2,324,400
2,711,800
194 G-4-20-II
2,738,400
3,286,000
3,833,700
195 G-4-20-III
196 G-4-21-I

4,523,100
2,017,100
5,427,700
2,420,500
6,332,300
2,823,900
197 G-4-21-II
198 G-4-21-III

3,414,000
4,012,200
4,096,800
4,814,700
4,779,600
5,617,100
199 G-4-22-I
2,548,100
3,057,700
3,567,300
200 G-4-22-II
201 G-4-22-III

3,255,700
3,804,100
3,906,800
4,564,900
4,557,900
5,325,700
202 G-4-23-I
203 G-4-23-II

1,985,600
2,491,300
2,382,800
2,989,600
2,779,900
3,487,800
204 G-4-23-III
3,547,000
4,256,400
4,965,800
205 G-4-24-I
206 G-4-24-II

2,211,700
2,763,200
2,654,100
3,315,900
3,096,400
3,868,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,603,400
1,889,900
2,389,900
3,167,200
5,524,100
2,267,800
2,867,900
3,800,600
6,444,800
2,645,800
3,345,900
4,434,000
2,986,500
3,583,800
4,181,100
3,474,200
4,169,100
4,863,900
5,195,000
6,234,000
7,273,000
4,265,800
5,437,900
7,395,100
6,490,900
8,064,300
11,295,400
2,558,500
3,471,400
6,823,200
2,208,000
2,518,700
3,606,600
2,603,300
3,110,500
5,212,600
5,119,000
6,525,500
8,874,100
7,789,100
9,677,200
13,554,400
3,070,200
4,165,700
8,187,800
2,649,700
3,022,400
4,328,000
3,124,000
3,732,600
6,255,100
5,972,200
7,613,000
10,353,100
9,087,300
11,290,100
15,813,500
3,581,900
4,860,000
9,552,500
3,091,300
3,526,200
5,049,300
3,644,600
4,354,700
7,297,600
229 I-1-01-I
34,967,000
41,960,400
48,953,800
230 I-1-01-II
35,736,200
42,883,500
50,030,700
231 I-1-01-III

(RINGAN)
56,409,200
67,691,000
78,972,900
19,399,500
23,279,500
27,159,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 299 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
15,973,300
19,167,900
22,362,600
245 I-1-06-II
23,138,600
27,766,300
32,394,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
27,608,600
33,130,400
38,652,100
19,014,200
22,817,100
26,619,900
23,457,900
28,149,500
32,841,100
25,592,500
30,711,000
35,829,500
3,040,000
3,648,000
4,256,000
3,380,100
4,056,200
4,732,200
4,497,900
5,397,500
6,297,100
8,750,500
10,500,600
12,250,700
14,291,300
17,149,600
20,007,800
18,802,400
22,562,800
26,323,300
8,487,900
10,185,400
11,883,000
11,303,300
13,564,000
15,824,600
13,940,100
16,728,100
19,516,100
17,372,600
20,847,100
24,321,600
21,591,500
25,909,800
30,228,100
28,292,300
33,950,800
39,609,300
3,300,300
4,608,800
8,874,700
3,960,300
5,530,500
10,649,600
4,620,400
6,452,300
12,424,600
8,555,500
10,266,600
11,977,800
19,357,700
23,229,300
27,100,800
22,328,800
26,794,600
31,260,400
9,906,500
11,887,800
13,869,100
12,403,900
14,884,600
17,365,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,025,200
30,030,200
35,035,200
30,845,100
37,014,100
43,183,100
11,205,200
13,446,300
15,687,300
15,532,800
18,639,300
21,745,900
19,712,300
23,654,700
27,597,200
16,885,700
20,262,800
23,639,900
26,650,100
31,980,200
37,310,200
42,573,400
51,088,100
59,602,800
21,665,900
25,999,000
30,332,200
25,999,100
31,199,000
36,398,800
35,774,600
42,929,500
50,084,400
- 300 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,271,600
23,125,900
26,980,200
279 I-1-40-III
25,740,300
30,888,300
36,036,400
280 I-4-10-I
281 I-4-10-II

2,938,400
5,246,900
3,526,100
6,296,200
4,113,800
7,345,600
282 I-4-10-III
7,560,000
9,072,000
10,584,000
283 I-4-11-I
284 I-4-11-II

4,520,700
5,594,400
5,424,900
6,713,300
6,329,000
7,832,200
285 I-4-11-III
286 I-4-12-I

10,349,100
2,598,800
12,418,900
3,118,600
14,488,700
3,638,300
287 I-4-12-II
3,012,400
3,614,800
4,217,300
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,614,800
4,337,800
5,060,800
2,644,600
3,173,500
3,702,400
4,722,200
5,666,600
6,611,000
6,804,000
8,164,800
9,525,600
2,497,300
2,583,300
4,528,500
2,996,800
3,099,900
5,434,200
3,496,300
3,616,600
6,339,900
4,300,400
5,160,500
6,020,600
5,850,400
7,020,500
8,190,600
297 I-4-15-III
7,020,500
8,424,600
9,828,700
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,576,200
2,531,000
3,037,200
1,774,400
2,065,800
2,478,900
1,891,400
3,037,200
3,644,600
2,129,300
2,478,900
2,974,700
2,206,700
3,543,400
4,252,000
2,484,200
2,892,100
3,470,500
3,040,300
3,648,300
4,256,400
4,629,000
5,554,800
6,480,500
6,284,600
7,541,500
8,798,400
307 I-4-19-I
2,933,300
3,519,900
4,106,600
308 I-4-19-II

(SEDANG)
4,579,000
5,494,800
6,410,600
309 I-4-19-III
5,466,500
6,559,700
7,653,000
310
311
312
313
314

3,054,400
3,527,800
5,274,800
2,285,600
2,895,900
3,665,300
4,233,400
6,329,800
2,742,700
3,475,000
4,276,200
4,939,000
7,384,800
3,199,800
4,054,200
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,343,400
18,412,100
21,480,700
11,166,300
13,399,600
15,632,900
13,949,800
16,739,800
19,529,700
14,664,100
17,597,000
20,529,800
8,446,700
10,136,000
11,825,400
17,571,000
21,085,200
24,599,400
27,228,700
32,674,500
38,120,200
7,795,400
9,354,500
10,913,500
- 301 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,179,900
5,015,800
5,851,800
316 I-4-22-I
317 I-4-22-II
2,561,800
3,189,000
3,074,100
3,826,800
3,586,500
4,464,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,661,300
5,593,600
6,525,900
2,507,200
3,008,700
3,510,100
3,078,200
3,693,800
4,309,400
6,014,500
7,217,400
8,420,400
2,257,800
2,709,300
3,160,900
5,199,000
6,238,800
7,278,700
6,573,300
7,887,900
9,202,600
40,732,100
48,878,500
57,024,900
46,095,900
55,315,100
64,534,300
52,149,000
62,578,800
73,008,600
21,615,000
25,938,100
30,261,100
30,096,700
36,116,100
42,135,400
49,700,000
59,640,000
69,580,000
6,563,900
7,876,700
9,189,500
13,282,100
15,938,500
18,595,000
13,803,400
16,564,100
19,324,700
9,300,400
11,160,500
13,020,600
12,289,000
14,746,800
17,204,600
18,819,200
22,583,100
26,346,900
5,477,800
6,573,300
7,668,900
9,922,900
11,907,500
13,892,000
28,642,100
34,370,500
40,098,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,238,100
4,622,400
6,992,900
1,997,700
2,782,500
3,729,600
3,393,200
3,862,600
5,393,300
3,000,100
4,176,100
7,791,200
3,307,700
5,382,600
6,368,100
4,035,700
4,821,500
6,486,900
2,685,800
5,546,800
8,391,500
2,397,300
3,339,000
4,475,500
4,071,800
4,635,100
6,471,900
3,600,100
5,011,300
9,349,400
3,969,200
6,459,100
7,641,800
4,842,800
5,785,800
7,784,300
3,133,400
6,471,300
9,790,100
2,796,800
3,895,400
5,221,400
4,750,400
5,407,700
7,550,600
4,200,200
5,846,500
10,907,700
4,630,800
7,535,600
8,915,400
5,650,000
6,750,100
9,081,600
3,362,600
4,035,100
4,707,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 302 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,725,300
5,670,300
6,615,400
360 J-4-16-III
5,974,400
7,169,300
8,364,200
361 J-4-17-I
362 J-4-17-II

2,763,900
3,309,800
3,316,700
3,971,800
3,869,400
4,633,800
363 J-4-17-III
364 J-4-18-I

4,343,500
2,071,500
5,212,200
2,485,800
6,080,900
2,900,100
365 J-4-18-II
2,849,100
3,419,000
3,988,800
366 J-4-18-III
367 J-4-19-I

2,999,100
3,893,000
3,598,900
4,671,600
4,198,700
5,450,200
368 J-4-19-II
369 J-4-19-III

4,414,900
4,875,700
5,297,900
5,850,900
6,180,900
6,826,000
370 J-4-20-I
3,863,300
4,636,000
5,408,600
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,353,000
6,275,400
6,423,600
7,530,500
7,494,200
8,785,500
2,684,900
3,221,900
3,758,900
4,325,400
5,190,400
6,055,500
6,035,700
7,242,900
8,450,000
5,950,600
7,140,700
8,330,800
7,478,200
8,973,800
10,469,500
8,764,700
10,517,600
12,270,600
6,682,000
8,018,400
9,354,800

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
8,772,600
13,275,800
10,527,100
15,931,000
12,281,700
18,586,200
2,496,800
2,996,100
3,495,500
3,247,400
3,896,800
4,546,300
6,433,500
7,720,200
9,006,900
2,815,900
3,097,500
3,125,600
3,379,000
3,716,900
3,750,700
3,942,200
4,336,400
4,375,900
4,569,700
5,483,600
6,397,500
5,355,500
6,426,600
7,497,700
8,414,300
10,097,100
11,780,000
8,848,300
12,359,100
18,045,600
10,618,000
14,830,900
21,654,700
12,387,600
17,302,700
25,263,800
5,232,800
6,279,400
7,326,000
9,293,400
11,152,100
13,010,700
12,787,800
15,345,400
17,903,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,838,600
7,006,400
8,174,100
398 K-1-40-II

(SEDANG)
6,437,300
7,724,700
9,012,200
399 K-1-40-III
10,908,900
13,090,700
15,272,400
400
401
402
403
404

4,461,300
5,793,500
8,187,300
3,683,000
5,292,000
5,353,600
6,952,300
9,824,800
4,419,600
6,350,400
6,245,800
8,111,000
11,462,300
5,156,200
7,408,800
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 303 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,067,300
9,680,800
11,294,300
406 K-4-11-I
407 K-4-11-II

2,158,800
3,067,700
2,590,500
3,681,300
3,022,300
4,294,800
408 K-4-11-III
409 K-4-12-I

3,681,300
2,214,000
4,417,600
2,656,800
5,153,800
3,099,600
410 K-4-12-II
2,979,300
3,575,200
4,171,100
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,928,800
5,914,500
6,900,300
2,984,600
3,581,500
4,178,400
3,860,700
4,632,900
5,405,000
5,946,800
7,136,100
8,325,500
1,892,200
2,270,700
2,649,100
2,540,000
3,048,000
3,556,000
4,075,700
4,890,800
5,706,000
418 K-4-15-I
1,955,100
2,346,200
2,737,200
419 K-4-15-II
2,899,000
3,478,700
4,058,500
420 K-4-15-III
4,068,600
4,882,300
5,696,000
421 K-4-16-I
2,762,600
3,315,100
3,867,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,313,100
3,865,900
3,975,800
4,639,100
4,638,400
5,412,300
1,418,900
1,702,700
1,986,500
1,940,700
2,328,800
2,716,900
2,328,800
2,794,600
3,260,300
1,253,800
1,504,500
1,755,300
1,781,700
2,138,000
2,494,400
429 K-4-18-III
2,138,000
2,565,600
2,993,200
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,107,500
21,294,900
28,453,500
6,656,100
11,421,400
14,179,800
16,929,000
25,553,900
34,144,200
7,987,300
13,705,700
17,015,800
19,750,600
29,812,900
39,834,900
9,318,500
15,989,900
19,851,800
3,730,200
4,476,200
5,222,300
7,482,000
8,978,400
10,474,800
12,593,800
15,112,600
17,631,300
4,897,000
7,881,200
11,273,300
1,280,800
1,486,700
1,725,700
2,682,300
3,686,600
8,377,000
1,273,800
1,684,800
4,456,800
5,876,400
9,457,500
13,528,000
1,537,000
1,784,000
2,070,800
3,218,700
4,423,900
10,052,400
1,528,600
2,021,800
5,348,200
6,855,800
11,033,700
15,782,700
1,793,200
2,081,400
2,415,900
3,755,200
5,161,200
11,727,800
1,783,400
2,358,800
6,239,500
2,287,000
2,744,400
3,201,900
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 304 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,687,900
3,225,500
3,763,100
3,955,300
4,746,300
5,537,400
2,205,800
2,647,000
3,088,200
3,313,300
3,975,900
4,638,600
4,670,400
5,604,500
6,538,600
7,797,500
9,356,900
10,916,400
11,083,000
13,299,600
15,516,200
15,568,300
18,681,900
21,795,600
6,911,000
8,293,200
9,675,400
11,337,200
19,261,600
13,604,700
23,114,000
15,872,100
26,966,300
18,763,800
22,516,600
26,269,300
21,946,900
26,336,300
30,725,700
27,163,000
32,595,600
38,028,200
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,665,300
10,398,400
12,131,400
467 M-1-04-II
11,132,400
13,358,900
15,585,400
468 M-1-04-III
13,320,200
15,984,200
18,648,300
469 M-1-05-I
470 M-1-05-II

5,501,500
8,898,900
6,601,800
10,678,700
7,702,200
12,458,500
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,367,300
13,640,700
15,914,200
6,158,300
7,390,000
8,621,700
8,250,000
9,900,100
11,550,100
16,806,100
20,167,300
23,528,500
10,137,600
12,165,200
14,192,700
22,245,800
26,695,000
31,144,200
47,982,200
57,578,600
67,175,100
9,259,500
11,111,400
12,963,300
11,830,000
14,196,000
16,562,000
480 M-1-20-III
29,453,000
35,343,600
41,234,200
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,352,300
10,293,300
14,718,400
7,622,700
12,351,900
17,662,100
8,893,200
14,410,600
20,605,800
3,233,500
3,880,300
4,527,000
5,734,600
6,881,500
8,028,400
8,187,800
9,825,400
11,463,000
3,874,900
6,430,400
10,561,500
4,649,900
7,716,400
12,673,800
5,424,900
9,002,500
14,786,000
5,984,500
7,181,400
8,378,300
7,523,900
9,028,600
10,533,400
11,365,700
13,638,900
15,912,000
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 305 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,220,200
2,664,200
3,108,300
500 M-4-10-II
501 M-4-10-III
3,311,100
6,264,500
3,973,300
7,517,500
4,635,500
8,770,400
2,766,600
3,319,900
3,873,200
6,065,600
7,278,700
8,491,800
8,769,800
10,523,800
12,277,700
2,208,400
2,650,000
3,091,700
3,673,100
4,407,700
5,142,300
4,913,100
5,895,800
6,878,400
3,677,100
4,412,500
5,148,000
5,524,700
6,629,700
7,734,600
10,778,600
12,934,300
15,090,100
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,193,600
5,032,400
5,871,100
512 M-4-14-II
5,172,200
6,206,700
7,241,100
513 M-4-14-III
514 M-4-15-I
7,772,400
2,486,700
9,326,800
2,984,000
10,881,300
3,481,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,314,600
7,521,800
2,129,000
3,409,300
5,727,500
3,977,500
9,026,200
2,554,800
4,091,200
6,872,900
4,640,400
10,530,500
2,980,600
4,773,100
8,018,400
2,763,200
3,315,800
3,868,400
3,864,600
4,637,500
5,410,400
5,396,600
6,476,000
7,555,300
2,088,500
3,147,500
3,789,700
2,506,200
3,777,000
4,547,600
2,923,900
4,406,500
5,305,600
2,178,000
2,613,600
3,049,200
3,668,600
4,402,300
5,136,000
7,165,000
8,597,900
10,030,900
2,197,000
2,636,400
3,075,800
3,217,100
3,860,500
4,504,000
3,595,500
4,314,600
5,033,700
2,212,200
2,654,600
3,097,100
2,766,800
3,320,200
3,873,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,087,300
13,304,800
15,522,300
12,196,100
14,635,300
17,074,500
13,962,900
16,755,500
19,548,000
6,302,700
7,563,200
8,823,800
7,485,000
16,847,200
8,982,000
20,216,600
10,479,000
23,586,000
- 306 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,203,200
7,443,800
8,684,400
535 N-1-01-I

102,987,200
123,584,700
144,182,100
536 N-1-01-II
102,987,200
123,584,700
144,182,100
537 N-1-01-III
538 N-1-11-I

102,987,200
6,381,000
123,584,700
7,657,300
144,182,100
8,933,500
539 N-1-11-II
540 N-1-11-III

10,090,000
15,730,300
12,108,000
18,876,300
14,126,000
22,022,400
3,252,200
3,902,600
4,553,100
6,474,800
7,769,800
9,064,700
14,050,500
16,860,600
19,670,700
7,110,600
8,532,700
9,954,800

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,950,800
13,925,000
11,941,000
16,710,000
13,931,200
19,495,000
6,507,400
7,808,900
9,110,400
9,844,400
11,813,300
13,782,200
11,330,000
13,596,000
15,862,000
5,844,100
7,012,900
8,181,800
7,936,200
9,523,400
11,110,600
9,236,700
11,084,000
12,931,300
2,482,900
2,979,500
3,476,100
3,003,200
3,603,800
4,204,400
4,417,200
5,300,600
6,184,100
1,906,100
3,330,100
4,143,400
2,174,800
4,035,300
4,857,100
3,278,900
3,954,700
6,060,400
2,287,300
3,996,100
4,972,000
2,609,700
4,842,400
5,828,600
3,934,700
4,745,700
7,272,400
2,668,500
4,662,200
5,800,700
3,044,700
5,649,400
6,800,000
4,590,500
5,536,600
8,484,500
1,914,300
2,297,200
2,680,000
2,716,300
3,259,600
3,802,800
4,354,200
5,225,100
6,095,900
2,261,500
2,713,800
3,166,100
2,806,100
3,367,400
3,928,600
3,202,300
3,842,700
4,483,200
2,769,200
3,323,000
3,876,900
3,952,500
4,743,000
5,533,600
5,261,100
6,313,300
7,365,600
4,873,700
5,147,900
5,848,500
6,177,500
6,823,200
7,207,100
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 307 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,453,600
7,744,400
9,035,100
2,574,100
3,088,900
3,603,800
2,860,800
3,433,000
4,005,200
3,558,900
4,270,700
4,982,500
1,823,700
2,188,500
2,553,200
2,190,300
2,628,300
3,066,400
2,752,200
3,302,600
3,853,000
1,558,800
1,870,500
2,182,300

MAYOR (RINGAN)
MAYOR (SEDANG)
1,844,900
2,213,900
2,213,900
2,656,700
2,582,900
3,099,500
40,723,900
48,868,700
57,013,500
50,389,700
60,467,700
70,545,600
59,143,400
70,972,000
82,800,700
68,610,700
82,332,800
96,055,000
78,703,500
94,444,100
110,184,800
89,924,300
107,909,200
125,894,000
7,414,200
8,897,000
10,379,900
11,000,300
13,200,300
15,400,400
12,450,100
14,940,100
17,430,100
21,983,900
26,380,600
30,777,400
37,010,800
44,413,000
51,815,200
53,064,200
63,677,000
74,289,900
15,546,100
18,655,400
21,764,600
22,539,400
27,047,200
31,555,100
32,344,900
38,813,900
45,282,900
3,944,400
4,733,300
5,522,200
11,059,200
13,271,000
15,482,800
14,650,700
17,580,800
20,511,000
3,820,500
4,584,700
5,348,800
10,711,900
12,854,300
14,996,700
14,190,700
17,028,800
19,866,900
3,876,100
4,651,300
5,426,500
5,500,100
6,600,100
7,700,200
8,905,800
10,687,000
12,468,200
6,740,200
8,088,200
9,436,200
10,000,200
12,000,300
14,000,300
- 308 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,318,300
13,581,900
15,845,600
5,861,000
7,033,200
8,205,400
8,333,500
10,000,200
11,666,900
9,431,900
11,318,300
13,204,600
5,034,500
6,041,400
7,048,300
7,853,800
9,424,600
10,995,400
10,720,100
12,864,200
15,008,200
2,656,200
3,187,400
3,718,700
5,407,000
6,488,400
7,569,700
10,032,000
12,038,300
14,044,700
1,992,200
2,390,600
2,789,100
3,989,400
4,787,300
5,585,200
4,680,900
5,617,100
6,553,200
1,803,000
2,163,500
2,524,100
3,464,700
4,157,600
4,850,500
7,065,400
8,478,500
9,891,500
3,356,300
4,027,600
4,698,900
6,041,400
7,249,700
8,458,000
8,246,300
9,895,500
11,544,800
2,032,800
2,439,400
2,845,900
2,504,700
3,005,700
3,506,600
3,428,700
4,114,400
4,800,200
1,575,100
2,309,800
3,947,700
1,494,500
1,989,200
3,448,200
1,890,200
2,771,700
4,737,300
1,793,400
2,387,000
4,137,900
2,205,200
3,233,700
5,526,800
2,092,300
2,784,800
4,827,500
2,207,000
2,648,400
3,089,800
3,915,400
4,698,500
5,481,600
6,355,200
7,626,200
8,897,300
1,116,900
1,340,300
1,563,700
2,372,400
2,846,900
3,321,300
4,498,900
5,398,700
6,298,400
747,000
896,400
1,045,800
1,409,700
1,691,600
1,973,600
1,825,800
2,191,000
2,556,100
3,868,100
4,641,700
5,415,300
- 309 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,919,300
5,903,100
6,887,000
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,043,400
8,452,100
9,860,800
1,864,300
2,237,200
2,610,100
2,766,900
3,320,300
3,873,600
3,327,800
3,993,400
4,658,900
1,247,400
1,496,900
1,746,300
1,675,400
2,010,500
2,345,600
3,047,800
3,657,400
4,266,900
594,800
713,800
832,700
1,133,700
1,360,400
1,587,100
1,648,000
1,977,600
2,307,200
796,300
955,600
1,114,800
1,253,100
1,503,700
1,754,300
2,018,400
2,422,100
2,825,800
1,237,400
1,484,900
1,732,300
1,870,200
2,244,300
2,618,300
2,895,300
3,474,400
4,053,400
4,076,300
4,891,600
5,706,900

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,328,100
16,714,100
7,593,700
20,056,900
8,859,300
23,399,800
6,306,300
7,567,500
8,828,800
7,994,100
9,593,000
11,191,800
11,502,300
13,802,800
16,103,200
4,927,700
7,556,300
11,098,600
4,931,000
5,745,400
9,524,100
5,913,200
9,067,600
13,318,300
5,917,300
6,894,500
11,429,000
6,898,700
10,578,800
15,538,100
6,903,500
8,043,600
13,333,800
2,963,200
3,555,800
4,148,500
3,636,600
4,363,900
5,091,200
4,309,300
5,171,200
6,033,000
3,581,200
5,091,500
6,562,700
4,297,500
6,109,800
7,875,200
5,013,700
7,128,100
9,187,800
4,498,600
5,398,300
6,298,100
6,695,200
8,034,200
9,373,200
17,187,800
20,625,400
24,062,900
3,858,000
5,231,400
10,230,100
4,629,700
6,277,600
12,276,100
5,401,300
7,323,900
14,322,100
2,776,400
3,331,700
3,887,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 310 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,687,400
2,024,900
2,362,400
697 U-4-12-I
698 U-4-12-II

2,431,600
2,828,400
2,917,900
3,394,100
3,404,200
3,959,800
699 U-4-12-III

3,669,200
4,403,100
5,136,900
1,842,800
2,211,300
2,579,900
2,172,500
2,607,000
3,041,500
2,598,400
3,118,000
3,637,700
2,763,500
3,309,200
3,316,200
3,971,000
3,868,800
4,632,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,557,100
6,668,500
7,779,900
2,219,000
2,662,800
3,106,600
2,764,600
3,317,500
3,870,400
3,869,000
4,642,900
5,416,700
3,619,300
4,343,200
5,067,100
7,455,700
8,946,800
10,438,000
9,143,400
10,972,100
12,800,700
6,885,600
7,862,600
12,313,100
8,262,800
9,435,100
14,775,700
9,639,900
11,007,600
17,238,400
6,473,800
7,768,600
9,063,300
8,840,500
10,608,600
12,376,700
11,205,500
13,446,500
15,687,600
3,376,800
4,052,200
4,727,600
6,452,000
7,742,400
9,032,800
10,122,400
12,146,900
14,171,400
6,621,900
7,946,300
9,270,700
9,621,500
11,545,800
13,470,100
12,014,200
14,417,000
16,819,800
1,066,500
1,176,800
1,301,800
1,279,800
1,412,200
1,562,200
1,493,100
1,647,600
1,822,500
3,202,300
3,842,700
4,483,200
5,319,100
6,382,900
7,446,800
8,769,400
10,523,200
12,277,100
2,766,900
3,320,300
3,873,700
3,712,500
4,455,000
5,197,500
4,973,000
5,967,600
6,962,200
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,356,000
7,627,300
8,898,500
9,758,500
11,710,200
13,661,900
1,323,500
1,604,000
1,588,200
1,924,800
1,852,900
2,245,700
- 311 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,541,700
9,050,000
10,558,400
9,039,300
10,847,100
12,655,000
12,898,800
15,478,500
18,058,300
1,599,700
1,919,600
2,239,600
1,765,300
1,952,700
2,118,300
2,343,300
2,471,400
2,733,800
1,672,000
2,006,500
2,340,900
1,845,100
2,214,100
2,583,100
2,041,000
2,449,200
2,857,500
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,798,800
2,158,500
2,518,300
743 W-1-12-II
744 W-1-12-III

2,245,200
3,975,700
2,694,200
4,770,900
3,143,300
5,566,000
745 W-1-13-I
1,849,000
2,218,800
2,588,600
746 W-1-13-II
747 W-1-13-III

2,007,400
2,696,400
2,408,900
3,235,700
2,810,300
3,775,000
748 W-1-20-I
749 W-1-20-II

6,192,100
7,737,100
7,430,500
9,284,500
8,668,900
10,831,900
750 W-1-20-III
8,969,300
10,763,100
12,557,000
751 W-1-30-I
3,495,500
4,194,600
4,893,700
752 W-1-30-II
5,575,400
6,690,400
7,805,500
753 W-1-30-III
13,679,500
16,415,300
19,151,200
754 W-4-10-I
2,604,500
3,125,400
3,646,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,861,100
7,630,300
2,368,600
3,595,900
4,376,900
4,633,300
9,156,400
2,842,400
4,315,100
5,252,300
5,405,500
10,682,400
3,316,100
5,034,300
6,127,700
2,695,300
3,234,400
3,773,500
3,700,500
4,440,600
5,180,700
4,033,800
4,840,500
5,647,300
931,900
1,273,000
1,583,100
1,245,400
1,482,400
1,896,500
1,516,600
1,684,300
2,332,000
2,017,800
2,698,400
3,657,200
1,489,000
2,688,400
3,974,700
2,287,800
3,036,800
4,314,000
2,044,400
2,455,500
3,375,200
1,118,300
1,527,600
1,899,700
1,494,500
1,778,800
2,275,800
1,819,900
2,021,200
2,798,400
2,421,400
3,238,100
4,388,600
1,786,700
3,226,000
4,769,600
2,745,300
3,644,100
5,176,800
2,453,300
2,946,600
4,050,200
1,304,700
1,782,300
2,216,300
1,743,600
2,075,300
2,655,100
2,123,200
2,358,000
3,264,800
2,825,000
3,777,700
5,120,100
2,084,500
3,763,700
5,564,600
3,202,900
4,251,500
6,039,600
2,862,200
3,437,700
4,725,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 312 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,176,700
1,412,000
1,647,400
2,886,600
3,464,000
4,041,300
4,129,500
4,955,400
5,781,300
- 313 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
914,000
1,185,500
2,204,600
1,821,900
2,367,600
435,500
774,100
340,500
739,000
645,200
732,500
1,101,300
1,502,100
1,376,700
446,000
1,029,400
373,400
641,100
1,952,700
699,300
1,651,500
402,900
940,000
1,471,300
1,234,000
302,600
917,200
510,000
262,200
283,500
250,200
299,300
416,700
358,000
337,000
302,900
449,400
196,200
231,300
265,200
5,381,000
2,150,500
2,157,700
555,000
908,900
569,100
1,156,600
741,100
424,400
320,500
516,900
285,300
244,300
1,906,100
889,500
508,300
1,984,200
1,322,800
257,600
2,149,600
1,488,200
3,496,200
773,100
475,500
255,700
213,100
240,200
3,662,700
1,782,900
- 314 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,265,900
4,010,200
3,324,900
2,532,900
835,000
2,819,100
1,840,800
452,500
4,232,500
3,831,700
2,569,200
2,434,000
300,800
289,100
1,163,100
317,900
283,200
313,000
1,074,300
1,467,500
1,281,800
1,132,000
685,600
284,900
502,100
344,700
311,200
303,200
385,000
439,100
257,400
738,700
1,346,200
1,033,400
2,429,400
316,400
316,400
2,244,900
1,305,400
250,400
1,158,500
3,009,400
690,900
544,200
266,600
236,200
288,800
402,700
964,300
849,900
594,900
443,800
244,300
1,033,100
827,800
353,700
403,600
1,322,500
292,400
1,351,200
1,033,700
315,200
349,500
341,300
206,600
1,126,300
1,547,500
306,700
- 315 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
940,000
350,900
379,300
351,300
557,300
428,700
1,073,600
316,700
881,300
1,177,600
257,900
1,569,700
850,600
1,838,300
928,000
409,800
315,200
68,200
408,600
923,300
359,800
486,000
277,900
108,400
280,700
4,179,600
2,375,700
3,965,100
974,100
544,200
370,800
838,700
443,600
892,700
516,900
307,700
515,100
231,900
353,900
339,200
793,300
1,618,000
1,301,800
1,147,800
810,100
298,000
298,000
298,000
243,400
154,400
242,700
296,700
321,000
236,400
208,500
95,600
105,100
77,700
91,200
87,000
132,800
119,100
165,700
182,000
105,700
128,300
87,700
136,900
194,200
- 316 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
138,300
186,000
525,800
609,500
130,700
253,000
159,100
227,100
425,600
364,400
261,900
248,000
130,000
127,700
292,000
184,300
264,400
183,000
143,200
1,836,900
1,889,500
300,200
310,900
594,600
766,700
761,100
393,200
1,225,300
271,900
319,600
320,600
256,700
324,200
306,800
143,800
315,800
280,000
253,200
286,400
2,370,800
307,800
853,200
306,000
435,400
469,200
374,300
740,900
758,800
809,000
707,700
1,296,800
210,800
1,463,800
277,900
742,000
1,686,300
1,949,900
851,800
308,700
602,100
599,700
277,900
2,178,500
1,713,500
139,600
155,500
202,000
265,000
- 317 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,004,100
438,100
902,900
1,089,300
522,000
726,100
501,900
554,400
634,100
299,100
707,100
185,600
687,600
1,081,000
75,400
- 318 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,956,100
2,347,400
2,738,600
A-4-10-II
SEPTIKEMIA (SEDANG)
3,341,900
4,010,300
4,678,600
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,505,900
2,880,200
5,407,100
3,456,300
6,308,300
4,032,300
5
6
A-4-11-II
A-4-11-III

4,099,400
5,674,000
4,919,300
6,808,800
5,739,200
7,943,600
A-4-12-I
2,608,100
3,129,800
3,651,400
8
9
A-4-12-II
A-4-12-III

3,248,000
3,466,500
3,897,600
4,159,800
4,547,200
4,853,100
10 A-4-13-I
11 A-4-13-II

1,568,400
2,362,800
1,882,100
2,835,300
2,195,800
3,307,900
12 A-4-13-III
2,835,300
3,402,400
3,969,500
2,174,700
2,609,600
3,044,600
2,639,700
3,167,700
3,695,600
3,167,700
3,801,200
4,434,800
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,414,300
5,110,800
4,097,200
6,132,900
4,780,000
7,155,100
18 A-4-15-III
INFEKSI HIV (BERAT)
6,413,600
7,696,300
8,979,000
19 B-1-01-I
20 B-1-01-II

23,375,400
25,789,300
28,050,500
30,947,200
32,725,500
36,105,000
21 B-1-01-III
22 B-1-10-I

45,239,800
4,038,900
54,287,800
4,846,600
63,335,700
5,654,400
23 B-1-10-II
8,964,500
10,757,400
12,550,300
24 B-1-10-III
25 B-1-11-I

17,697,200
5,396,700
21,236,600
6,476,000
24,776,100
7,555,400
26 B-1-11-II
27 B-1-11-III

6,993,700
9,035,700
8,392,400
10,842,900
9,791,200
12,650,000
28 B-1-12-I
5,269,600
6,323,500
7,377,400
29 B-1-12-II
5,860,700
7,032,800
8,205,000
30 B-1-12-III
9,168,400
11,002,100
12,835,800
4,197,300
5,036,700
5,876,200
6,906,100
8,287,300
9,668,500
8,935,900
10,723,100
12,510,200
5,767,200
6,920,700
8,074,100
6,414,200
7,697,000
8,979,800
10,034,300
1,784,400
2,848,400
3,929,400
12,041,100
2,141,200
3,418,100
4,715,300
14,048,000
2,498,100
3,987,700
5,501,200
3,762,100
4,514,600
5,267,000
5,267,000
6,320,500
7,373,900
6,381,000
7,657,100
8,933,300
3,401,400
4,843,500
7,206,000
3,244,700
4,081,700
5,812,100
8,647,200
3,893,600
4,762,000
6,780,800
10,088,400
4,542,500
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 319 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,779,900
4,535,900
5,291,800
48 B-4-13-III
49 B-4-14-I

5,207,100
3,241,200
6,248,500
3,889,400
7,290,000
4,537,700
50 B-4-14-II
3,781,300
4,537,500
5,293,800
51 B-4-14-III
52 C-4-10-I

5,065,100
2,998,700
6,078,100
3,598,400
7,091,100
4,198,200
53 C-4-10-II
54 C-4-10-III

5,753,700
10,155,800
6,904,500
12,187,000
8,055,200
14,218,100
55 C-4-11-I
3,417,100
4,100,500
4,784,000
56 C-4-11-II
57 C-4-11-III

4,572,600
7,030,500
5,487,100
8,436,500
6,401,700
9,842,600
58 C-4-12-I
59 C-4-12-II
2,275,200
4,481,300
2,730,300
5,377,600
3,185,300
6,273,800
60 C-4-12-III
RADIOTERAPI (BERAT)
11,509,300
13,811,100
16,113,000
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,710,500
3,219,200
2,052,600
3,863,000
2,394,700
4,506,900
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,357,700
2,842,100
5,229,200
3,410,500
6,100,800
3,978,900
65 C-4-14-II
3,986,900
4,784,300
5,581,600
66 C-4-14-III
67 D-1-10-I

5,940,400
13,908,600
7,128,400
16,690,300
8,316,500
19,472,000
68 D-1-10-II
69 D-1-10-III

21,183,700
33,731,800
25,420,500
40,478,100
29,657,200
47,224,500
70 D-1-11-I
4,597,400
5,516,900
6,436,400
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
11,739,300
15,255,700
14,087,200
18,306,800
16,435,000
21,357,900
3,985,400
4,782,500
5,579,600
10,983,200
13,179,800
15,376,500
17,422,600
20,907,100
24,391,600
2,383,300
3,582,500
5,636,200
3,120,000
5,606,600
7,702,100
2,689,900
3,730,900
5,729,000
2,860,000
4,299,000
6,763,400
3,744,000
6,727,900
9,242,500
3,227,900
4,477,100
6,874,800
3,336,700
5,015,500
7,890,600
4,368,000
7,849,200
10,782,900
3,765,900
5,223,300
8,020,600
2,305,200
2,766,200
3,227,200
3,262,600
3,915,100
4,567,600
4,173,000
5,007,600
5,842,200
2,472,400
2,966,900
3,461,400
4,047,900
4,857,500
5,667,100
4,951,100
5,941,300
6,931,500
4,401,200
5,281,400
6,161,700
5,765,100
6,918,200
8,071,200
93 E-1-01-III
10,011,200
12,013,400
14,015,700
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,433,300
4,167,200
8,783,200
4,120,000
5,000,600
10,539,900
4,806,600
5,834,100
12,296,500
5,800,800
6,960,900
8,121,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 320 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,280,400
2,736,500
3,192,500
104 E-4-11-II
105 E-4-11-III

3,476,600
4,711,100
4,172,000
5,653,300
4,867,300
6,595,500
106 E-4-12-I
107 E-4-12-II

2,620,100
4,537,400
3,144,200
5,444,900
3,668,200
6,352,400
108 E-4-12-III

(RINGAN)
(SEDANG)
5,378,500
6,454,200
7,529,900
2,853,200
3,423,900
3,994,500
4,179,500
5,015,400
5,851,300
111 E-4-13-III
5,463,400
6,556,100
7,648,800
112 F-4-10-I
113 F-4-10-II
3,037,600
3,491,200
3,645,200
4,189,400
4,252,700
4,887,600
114 F-4-10-III
115 F-4-11-I
4,189,400
2,937,900
5,027,300
3,525,400
5,865,100
4,113,000
116 F-4-11-II
3,422,900
4,107,500
4,792,100
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,389,400
5,267,300
6,145,200
1,610,400
1,932,500
2,254,600
2,289,500
2,747,400
3,205,300
4,973,900
5,968,600
6,963,400
2,366,500
3,122,700
4,042,700
1,350,200
1,731,800
2,330,300
2,839,800
3,747,200
4,851,300
1,620,300
2,078,200
2,796,400
3,313,100
4,371,700
5,659,800
1,890,300
2,424,600
3,262,500
127 F-4-15-I
2,150,300
2,580,400
3,010,400
128 F-4-15-II
3,204,200
3,845,100
4,485,900
129 F-4-15-III
4,230,600
5,076,700
5,922,800
4,230,800
5,077,000
5,923,200
4,919,000
5,902,800
6,886,700
6,566,100
7,879,300
9,192,500
133 F-4-17-I

999,200
1,199,000
1,398,800
134 F-4-17-II
2,928,400
3,514,100
4,099,800
135
136
137
138
139
140
141

(RINGAN)
3,124,300
3,676,300
4,045,000
6,235,600
2,809,500
3,597,700
4,479,200
3,749,200
4,411,500
4,853,900
7,482,700
3,371,400
4,317,300
5,375,000
4,374,100
5,146,800
5,662,900
8,729,800
3,933,300
5,036,800
6,270,800
10,714,500
12,857,400
15,000,300
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,807,700
9,369,200
10,930,700
10,760,600
12,912,700
15,064,800
3,461,400
4,153,700
4,845,900
4,836,700
5,804,000
6,771,300
6,003,300
7,203,900
8,404,600
- 321 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,247,300
17,096,800
19,946,300
148 G-1-11-I
149 G-1-11-II

9,121,100
16,675,500
10,945,300
20,010,700
12,769,600
23,345,800
150 G-1-11-III
30,745,600
36,894,700
43,043,800
3,808,400
4,570,100
5,331,700
7,139,000
8,566,800
9,994,600
9,729,100
11,674,900
13,620,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,148,900
3,085,300
1,378,700
3,702,400
1,608,400
4,319,400
156 G-1-13-III
157 G-1-20-I

6,961,800
4,824,700
8,354,200
5,789,700
9,746,600
6,754,600
158 G-1-20-II
5,737,500
6,885,000
8,032,500
159 G-1-20-III
13,390,700
16,068,800
18,747,000
160 G-1-30-I
7,077,500
8,493,000
9,908,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,334,700
20,132,800
17,201,700
24,159,300
20,068,600
28,185,900
3,269,100
3,922,900
4,576,700
3,995,900
4,795,100
5,594,300
5,483,100
6,579,700
7,676,300
3,422,200
4,106,700
4,791,100
4,546,000
5,455,200
6,364,400
6,679,600
8,015,500
9,351,400
3,796,600
4,555,900
5,315,200
4,795,300
5,754,400
6,713,500
6,964,600
8,357,500
9,750,500
2,280,600
2,736,800
3,192,900
3,977,000
4,772,400
5,567,800
4,716,800
5,660,200
6,603,500
3,868,800
4,642,600
5,416,400
5,172,400
6,206,800
7,241,300
6,491,900
7,790,300
9,088,700
3,161,200
3,793,400
4,425,700
3,772,700
4,527,300
5,281,800
5,324,900
6,389,800
7,454,800
2,606,000
3,127,200
3,648,400
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,684,800
20,021,800
23,358,800
32,088,000
38,505,600
44,923,200
10,982,800
12,931,100
13,179,300
15,517,300
15,375,900
18,103,500
- 322 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,459,800
4,151,700
4,843,700
183 G-4-16-III
4,927,000
5,912,400
6,897,800
3,471,000
4,165,200
4,859,400
4,551,200
5,461,500
6,371,700
5,718,800
6,862,600
8,006,300
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,418,400
4,102,100
4,785,700
188 G-4-18-II
4,569,300
5,483,200
6,397,100
189 G-4-18-III
5,112,700
6,135,300
7,157,800
2,852,000
3,422,400
3,992,800
4,820,600
5,784,700
6,748,900
6,329,200
7,595,100
8,860,900
193 G-4-20-I

1,995,100
2,394,200
2,793,200
194 G-4-20-II
2,820,500
3,384,600
3,948,700
195 G-4-20-III
196 G-4-21-I

4,658,800
2,077,600
5,590,600
2,493,100
6,522,300
2,908,700
197 G-4-21-II
198 G-4-21-III

3,516,400
4,132,600
4,219,700
4,959,100
4,923,000
5,785,600
199 G-4-22-I
2,624,500
3,149,400
3,674,300
200 G-4-22-II
201 G-4-22-III

3,353,300
3,918,200
4,024,000
4,701,800
4,694,700
5,485,500
202 G-4-23-I
203 G-4-23-II

2,045,200
2,566,000
2,454,300
3,079,200
2,863,300
3,592,400
204 G-4-23-III
3,653,400
4,384,100
5,114,800
205 G-4-24-I
206 G-4-24-II

2,278,100
2,846,100
2,733,700
3,415,300
3,189,300
3,984,600
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,741,500
1,946,600
2,461,600
3,262,200
5,689,800
2,335,900
2,954,000
3,914,600
6,638,100
2,725,200
3,446,300
4,567,000
3,076,100
3,691,300
4,306,500
3,578,400
4,294,100
5,009,800
5,350,900
6,421,000
7,491,200
4,393,800
5,601,000
7,616,900
6,685,700
8,306,300
11,634,200
2,635,300
3,575,500
7,027,900
2,274,300
2,594,300
3,714,800
2,681,400
3,203,800
5,369,000
5,272,600
6,721,200
9,140,300
8,022,800
9,967,500
13,961,100
3,162,300
4,290,700
8,433,500
2,729,100
3,113,100
4,457,800
3,217,700
3,844,500
6,442,800
6,151,400
7,841,400
10,663,700
9,359,900
11,628,800
16,287,900
3,689,400
5,005,800
9,839,100
3,184,000
3,632,000
5,200,800
3,754,000
4,485,300
7,516,600
229 I-1-01-I
36,016,000
43,219,200
50,422,400
230 I-1-01-II
36,808,300
44,170,000
51,531,700
231 I-1-01-III

(RINGAN)
58,101,500
69,721,800
81,342,000
19,981,500
23,977,800
27,974,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 323 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,452,500
19,743,000
23,033,500
245 I-1-06-II
23,832,800
28,599,300
33,365,900
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
28,436,900
34,124,300
39,811,600
19,584,700
23,501,600
27,418,500
24,161,700
28,994,000
33,826,300
26,360,300
31,632,300
36,904,400
3,131,200
3,757,400
4,383,700
3,481,500
4,177,900
4,874,200
4,632,900
5,559,500
6,486,000
9,013,000
10,815,600
12,618,200
14,720,000
17,664,100
20,608,100
19,366,400
23,239,700
27,113,000
8,742,500
10,491,000
12,239,500
11,642,400
13,970,900
16,299,400
14,358,300
17,230,000
20,101,600
17,893,700
21,472,500
25,051,200
22,239,300
26,687,100
31,135,000
29,141,100
34,969,300
40,797,600
3,399,300
4,747,000
9,140,900
4,079,200
5,696,400
10,969,100
4,759,000
6,645,900
12,797,300
8,812,200
10,574,600
12,337,100
19,938,500
23,926,200
27,913,800
22,998,700
27,598,500
32,198,200
10,203,700
12,244,400
14,285,200
12,776,000
15,331,200
17,886,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,775,900
30,931,100
36,086,300
31,770,400
38,124,500
44,478,600
11,541,400
13,849,700
16,157,900
15,998,700
19,198,500
22,398,200
20,303,600
24,364,400
28,425,100
17,392,200
20,870,700
24,349,100
27,449,600
32,939,600
38,429,500
43,850,600
52,620,800
61,390,900
22,315,800
26,779,000
31,242,200
26,779,100
32,134,900
37,490,800
36,847,800
44,217,400
51,587,000
- 324 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,849,700
23,819,600
27,789,600
279 I-1-40-III
26,512,500
31,815,000
37,117,400
280 I-4-10-I
281 I-4-10-II

3,026,600
5,404,300
3,631,900
6,485,100
4,237,200
7,566,000
282 I-4-10-III
7,786,800
9,344,200
10,901,500
283 I-4-11-I
284 I-4-11-II

4,656,300
5,762,300
5,587,600
6,914,700
6,518,900
8,067,200
285 I-4-11-III
286 I-4-12-I

10,659,600
2,676,800
12,791,500
3,212,100
14,923,400
3,747,500
287 I-4-12-II
3,102,700
3,723,300
4,343,800
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,723,300
4,467,900
5,212,600
2,723,900
3,268,700
3,813,500
4,863,800
5,836,600
6,809,400
7,008,100
8,409,700
9,811,400
2,572,200
2,660,800
4,664,300
3,086,700
3,192,900
5,597,200
3,601,100
3,725,100
6,530,100
4,429,400
5,315,300
6,201,200
6,025,900
7,231,100
8,436,300
297 I-4-15-III
7,231,100
8,677,400
10,123,600
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,623,500
2,606,900
3,128,300
1,827,700
2,127,700
2,553,300
1,948,200
3,128,300
3,753,900
2,193,200
2,553,300
3,063,900
2,272,900
3,649,700
4,379,600
2,558,700
2,978,800
3,574,600
3,131,500
3,757,800
4,384,100
4,767,800
5,721,400
6,675,000
6,473,100
7,767,700
9,062,400
307 I-4-19-I
3,021,300
3,625,500
4,229,800
308 I-4-19-II

(SEDANG)
4,716,400
5,659,600
6,602,900
309 I-4-19-III
5,630,400
6,756,500
7,882,600
310
311
312
313
314

3,146,000
3,633,700
5,433,100
2,354,200
2,982,700
3,775,200
4,360,400
6,519,700
2,825,000
3,579,300
4,404,400
5,087,100
7,606,300
3,295,800
4,175,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,803,700
18,964,400
22,125,200
11,501,300
13,801,600
16,101,800
14,368,300
17,242,000
20,115,600
15,104,100
18,124,900
21,145,700
8,700,100
10,440,100
12,180,100
18,098,100
21,717,800
25,337,400
28,045,600
33,654,700
39,263,800
8,029,200
9,635,100
11,240,900
- 325 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,305,300
5,166,300
6,027,400
316 I-4-22-I
317 I-4-22-II
2,638,600
3,284,700
3,166,300
3,941,600
3,694,100
4,598,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,801,200
5,761,400
6,721,600
2,582,400
3,098,900
3,615,400
3,170,500
3,804,600
4,438,700
6,195,000
7,434,000
8,673,000
2,325,500
2,790,600
3,255,700
5,355,000
6,426,000
7,497,000
6,770,500
8,124,500
9,478,600
41,954,100
50,344,900
58,735,700
47,478,800
56,974,600
66,470,400
53,713,500
64,456,200
75,198,900
22,263,500
26,716,200
31,168,900
30,999,600
37,199,500
43,399,500
51,191,000
61,429,200
71,667,400
6,760,800
8,113,000
9,465,200
13,680,600
16,416,700
19,152,800
14,217,500
17,061,000
19,904,500
9,579,400
11,495,300
13,411,200
12,657,600
15,189,200
17,720,700
19,383,800
23,260,600
27,137,300
5,642,100
6,770,500
7,898,900
10,220,600
12,264,700
14,308,800
29,501,300
35,401,600
41,301,800
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,305,300
4,761,000
7,202,700
2,057,700
2,865,900
3,841,500
3,494,900
3,978,500
5,555,100
3,090,100
4,301,400
8,024,900
3,406,900
5,544,100
6,559,200
4,156,800
4,966,200
6,681,500
2,766,300
5,713,200
8,643,300
2,469,200
3,439,100
4,609,800
4,193,900
4,774,200
6,666,100
3,708,200
5,161,600
9,629,900
4,088,300
6,652,900
7,871,000
4,988,100
5,959,400
8,017,800
3,227,400
6,665,400
10,083,800
2,880,700
4,012,300
5,378,100
4,892,900
5,569,900
7,777,100
4,326,200
6,021,900
11,234,900
4,769,700
7,761,700
9,182,900
5,819,500
6,952,600
9,354,100
3,463,500
4,156,100
4,848,800
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 326 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,867,000
5,840,500
6,813,900
360 J-4-16-III
6,153,600
7,384,400
8,615,100
361 J-4-17-I
362 J-4-17-II

2,846,800
3,409,100
3,416,200
4,091,000
3,985,500
4,772,800
363 J-4-17-III
364 J-4-18-I

4,473,800
2,133,600
5,368,600
2,560,400
6,263,300
2,987,100
365 J-4-18-II
2,934,600
3,521,500
4,108,500
366 J-4-18-III
367 J-4-19-I

3,089,100
4,009,800
3,706,900
4,811,800
4,324,700
5,613,700
368 J-4-19-II
369 J-4-19-III

4,547,400
5,022,000
5,456,900
6,026,400
6,366,300
7,030,800
370 J-4-20-I
3,979,200
4,775,000
5,570,900
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,513,600
6,463,600
6,616,300
7,756,400
7,719,000
9,049,100
2,765,500
3,318,600
3,871,700
4,455,100
5,346,100
6,237,200
6,216,800
7,460,100
8,703,500
6,129,100
7,354,900
8,580,700
7,702,500
9,243,000
10,783,500
9,027,600
10,833,200
12,638,700
6,882,400
8,258,900
9,635,400

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
9,035,800
13,674,100
10,843,000
16,408,900
12,650,100
19,143,800
2,571,700
3,086,000
3,600,400
3,344,800
4,013,700
4,682,700
6,626,500
7,951,800
9,277,100
2,900,300
3,190,400
3,219,400
3,480,400
3,828,500
3,863,300
4,060,500
4,466,500
4,507,100
4,706,700
5,648,100
6,589,400
5,516,200
6,619,400
7,722,700
8,666,700
10,400,000
12,133,400
9,113,800
12,729,900
18,587,000
10,936,500
15,275,900
22,304,400
12,759,300
17,821,800
26,021,800
5,389,800
6,467,800
7,545,700
9,572,200
11,486,600
13,401,000
13,171,500
15,805,700
18,440,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
6,013,800
7,216,500
8,419,300
398 K-1-40-II

(SEDANG)
6,630,400
7,956,500
9,282,600
399 K-1-40-III
11,236,100
13,483,400
15,730,600
400
401
402
403
404

4,595,100
5,967,400
8,433,000
3,793,500
5,450,700
5,514,200
7,160,800
10,119,600
4,552,200
6,540,900
6,433,200
8,354,300
11,806,100
5,310,900
7,631,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 327 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,309,400
9,971,200
11,633,100
406 K-4-11-I
407 K-4-11-II

2,223,500
3,159,800
2,668,200
3,791,700
3,113,000
4,423,700
408 K-4-11-III
409 K-4-12-I

3,791,700
2,280,400
4,550,100
2,736,500
5,308,400
3,192,500
410 K-4-12-II
3,068,700
3,682,400
4,296,200
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,076,600
6,092,000
7,107,300
3,074,100
3,688,900
4,303,800
3,976,600
4,771,900
5,567,200
6,125,200
7,350,200
8,575,200
1,949,000
2,338,800
2,728,600
2,616,200
3,139,400
3,662,700
4,198,000
5,037,600
5,877,200
418 K-4-15-I
2,013,800
2,416,600
2,819,300
419 K-4-15-II
2,985,900
3,583,100
4,180,300
420 K-4-15-III
4,190,600
5,028,800
5,866,900
421 K-4-16-I
2,845,500
3,414,600
3,983,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,412,500
3,981,900
4,095,000
4,778,300
4,777,500
5,574,700
1,461,500
1,753,800
2,046,000
1,998,900
2,398,700
2,798,400
2,398,700
2,878,400
3,358,100
1,291,400
1,549,700
1,808,000
1,835,100
2,202,200
2,569,200
429 K-4-18-III
2,202,200
2,642,600
3,083,000
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,530,800
21,933,800
29,307,100
6,855,800
11,764,000
14,605,200
17,436,900
26,320,600
35,168,600
8,226,900
14,116,800
17,526,300
20,343,100
30,707,300
41,030,000
9,598,100
16,469,600
20,447,300
3,842,100
4,610,500
5,379,000
7,706,400
9,247,700
10,789,000
12,971,600
15,566,000
18,160,300
5,043,900
8,117,700
11,611,500
1,319,300
1,531,300
1,777,400
2,762,700
3,797,200
8,628,300
1,312,100
1,735,400
4,590,500
6,052,700
9,741,200
13,933,800
1,583,100
1,837,600
2,132,900
3,315,300
4,556,600
10,354,000
1,574,500
2,082,400
5,508,600
7,061,500
11,364,700
16,256,100
1,847,000
2,143,800
2,488,400
3,867,800
5,316,000
12,079,600
1,836,900
2,429,500
6,426,700
2,355,700
2,826,800
3,297,900
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 328 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,768,500
3,322,300
3,876,000
4,073,900
4,888,700
5,703,500
2,272,000
2,726,400
3,180,800
3,412,700
4,095,200
4,777,700
4,810,500
5,772,700
6,734,800
8,031,400
9,637,700
11,243,900
11,415,500
13,698,600
15,981,700
16,035,300
19,242,400
22,449,500
7,118,300
8,542,000
9,965,600
11,677,300
19,839,500
14,012,800
23,807,400
16,348,300
27,775,300
19,326,700
23,192,100
27,057,400
22,605,400
27,126,400
31,647,500
27,977,900
33,573,500
39,169,100
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,925,300
10,710,300
12,495,400
467 M-1-04-II
11,466,400
13,759,700
16,052,900
468 M-1-04-III
13,719,800
16,463,800
19,207,700
469 M-1-05-I
470 M-1-05-II

5,666,600
9,165,900
6,799,900
10,999,100
7,933,200
12,832,300
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,708,300
14,049,900
16,391,600
6,343,100
7,611,700
8,880,300
8,497,500
10,197,100
11,896,600
17,310,300
20,772,300
24,234,400
10,441,800
12,530,100
14,618,500
22,913,200
27,495,900
32,078,500
49,421,700
59,306,000
69,190,300
9,537,300
11,444,800
13,352,200
12,184,900
14,621,800
17,058,800
480 M-1-20-III
30,336,600
36,403,900
42,471,300
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,542,800
10,602,100
15,160,000
7,851,400
12,722,500
18,192,000
9,160,000
14,842,900
21,224,000
3,330,600
3,996,700
4,662,800
5,906,600
7,087,900
8,269,200
8,433,500
10,120,200
11,806,900
3,991,200
6,623,300
10,878,300
4,789,400
7,947,900
13,054,000
5,587,600
9,272,600
15,229,600
6,164,000
7,396,800
8,629,600
7,749,600
9,299,500
10,849,400
11,706,700
14,048,000
16,389,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 329 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,286,800
2,744,200
3,201,500
500 M-4-10-II
501 M-4-10-III
3,410,400
6,452,500
4,092,500
7,743,000
4,774,500
9,033,500
2,849,600
3,419,500
3,989,400
6,247,600
7,497,100
8,746,600
9,032,900
10,839,500
12,646,100
2,274,600
2,729,500
3,184,400
3,783,300
4,539,900
5,296,600
5,060,500
6,072,600
7,084,800
3,787,400
4,544,900
5,302,400
5,690,500
6,828,600
7,966,700
11,102,000
13,322,400
15,542,800
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,319,400
5,183,300
6,047,200
512 M-4-14-II
5,327,400
6,392,900
7,458,300
513 M-4-14-III
514 M-4-15-I
8,005,500
2,561,300
9,606,600
3,073,600
11,207,700
3,585,800
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,414,000
7,747,500
2,192,900
3,511,600
5,899,300
4,096,800
9,297,000
2,631,500
4,213,900
7,079,100
4,779,700
10,846,400
3,070,000
4,916,300
8,259,000
2,846,100
3,415,300
3,984,500
3,980,500
4,776,600
5,572,700
5,558,500
6,670,200
7,782,000
2,151,200
3,241,900
3,903,400
2,581,400
3,890,300
4,684,100
3,011,600
4,538,700
5,464,700
2,243,300
2,692,000
3,140,700
3,778,600
4,534,400
5,290,100
7,379,900
8,855,900
10,331,900
2,262,900
2,715,500
3,168,100
3,313,600
3,976,400
4,639,100
3,703,400
4,444,100
5,184,700
2,278,600
2,734,300
3,190,000
2,849,800
3,419,800
3,989,800
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,420,000
13,703,900
15,987,900
12,561,900
15,074,300
17,586,700
14,381,800
17,258,100
20,134,500
6,491,800
7,790,100
9,088,500
7,709,600
17,352,600
9,251,500
20,823,100
10,793,400
24,293,600
- 330 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,389,300
7,667,100
8,945,000
535 N-1-01-I

106,076,800
127,292,200
148,507,600
536 N-1-01-II
106,076,800
127,292,200
148,507,600
537 N-1-01-III
538 N-1-11-I

106,076,800
6,572,500
127,292,200
7,887,000
148,507,600
9,201,500
539 N-1-11-II
540 N-1-11-III

10,392,700
16,202,200
12,471,200
19,442,600
14,549,800
22,683,100
3,349,800
4,019,700
4,689,700
6,669,000
8,002,800
9,336,700
14,472,100
17,366,500
20,260,900
7,323,900
8,788,600
10,253,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,249,400
14,342,700
12,299,200
17,211,300
14,349,100
20,079,800
6,702,600
8,043,200
9,383,700
10,139,800
12,167,700
14,195,700
11,669,900
14,003,900
16,337,900
6,019,400
7,223,300
8,427,200
8,174,300
9,809,100
11,444,000
9,513,800
11,416,500
13,319,300
2,557,400
3,068,900
3,580,400
3,093,200
3,711,900
4,330,500
4,549,700
5,459,700
6,369,600
1,963,200
3,430,000
4,267,700
2,240,000
4,156,400
5,002,900
3,377,300
4,073,400
6,242,200
2,355,900
4,116,000
5,121,200
2,688,000
4,987,600
6,003,400
4,052,700
4,888,000
7,490,600
2,748,500
4,802,000
5,974,700
3,136,000
5,818,900
7,004,000
4,728,200
5,702,700
8,739,000
1,971,700
2,366,100
2,760,400
2,797,800
3,357,400
3,916,900
4,484,800
5,381,800
6,278,800
2,329,300
2,795,200
3,261,100
2,890,300
3,468,400
4,046,400
3,298,300
3,958,000
4,617,700
2,852,300
3,422,700
3,993,200
4,071,100
4,885,300
5,699,600
5,419,000
6,502,700
7,586,500
5,019,900
5,302,400
6,023,900
6,362,800
7,027,900
7,423,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 331 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,647,200
7,976,700
9,306,100
2,651,300
3,181,600
3,711,900
2,946,700
3,536,000
4,125,300
3,665,700
4,398,800
5,131,900
1,878,400
2,254,100
2,629,800
2,256,000
2,707,200
3,158,400
2,834,700
3,401,700
3,968,600
1,605,500
1,926,700
2,247,800

MAYOR (RINGAN)
MAYOR (SEDANG)
1,900,300
2,280,300
2,280,300
2,736,400
2,660,400
3,192,500
41,945,600
50,334,800
58,723,900
51,901,400
62,281,700
72,662,000
60,917,700
73,101,200
85,284,700
70,669,000
84,802,800
98,936,600
81,064,600
97,277,500
113,490,400
92,622,000
111,146,500
129,670,900
7,636,600
9,163,900
10,691,300
11,330,300
13,596,300
15,862,400
12,823,600
15,388,300
17,953,000
22,643,400
27,172,000
31,700,700
38,121,200
45,745,400
53,369,600
54,656,100
65,587,400
76,518,600
16,012,500
19,215,000
22,417,500
23,215,600
27,858,700
32,501,800
33,315,300
39,978,300
46,641,400
4,062,700
4,875,300
5,687,800
11,391,000
13,669,100
15,947,300
15,090,200
18,108,300
21,126,300
3,935,200
4,722,200
5,509,200
11,033,300
13,239,900
15,446,600
14,616,400
17,539,700
20,463,000
3,992,400
4,790,900
5,589,300
5,665,100
6,798,100
7,931,200
9,173,000
11,007,600
12,842,200
6,942,400
8,330,900
9,719,300
10,300,200
12,360,300
14,420,300
- 332 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,657,800
13,989,400
16,320,900
6,036,800
7,244,200
8,451,600
8,583,500
10,300,200
12,016,900
9,714,800
11,657,800
13,600,800
5,185,500
6,222,600
7,259,800
8,089,400
9,707,300
11,325,200
11,041,700
13,250,100
15,458,400
2,735,900
3,283,100
3,830,200
5,569,200
6,683,000
7,796,800
10,332,900
12,399,500
14,466,100
2,051,900
2,462,300
2,872,700
4,109,100
4,930,900
5,752,800
4,821,300
5,785,600
6,749,800
1,857,000
2,228,400
2,599,900
3,568,600
4,282,300
4,996,000
7,277,300
8,732,800
10,188,300
3,457,000
4,148,400
4,839,800
6,222,600
7,467,200
8,711,700
8,493,600
10,192,400
11,891,100
2,093,800
2,512,500
2,931,300
2,579,900
3,095,800
3,611,800
3,531,600
4,237,900
4,944,200
1,622,400
2,379,100
4,066,100
1,539,300
2,048,800
3,551,700
1,946,900
2,854,900
4,879,400
1,847,200
2,458,600
4,262,000
2,271,400
3,330,700
5,692,600
2,155,100
2,868,400
4,972,300
2,273,200
2,727,900
3,182,500
4,032,900
4,839,400
5,646,000
6,545,800
7,855,000
9,164,200
1,150,400
1,380,500
1,610,600
2,443,600
2,932,300
3,421,000
4,633,800
5,560,600
6,487,400
769,400
923,300
1,077,200
1,452,000
1,742,400
2,032,800
1,880,600
2,256,700
2,632,800
3,984,100
4,780,900
5,577,800
- 333 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,066,900
6,080,200
7,093,600
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,254,700
8,705,600
10,156,600
1,920,300
2,304,300
2,688,400
2,849,900
3,419,900
3,989,800
3,427,600
4,113,200
4,798,700
1,284,800
1,541,800
1,798,700
1,725,700
2,070,800
2,415,900
3,139,300
3,767,100
4,395,000
612,600
735,200
857,700
1,167,700
1,401,200
1,634,800
1,697,500
2,037,000
2,376,400
820,200
984,200
1,148,300
1,290,700
1,548,800
1,807,000
2,079,000
2,494,800
2,910,600
1,274,500
1,529,400
1,784,300
1,926,300
2,311,600
2,696,900
2,982,200
3,578,600
4,175,000
4,198,600
5,038,300
5,878,100

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,517,900
17,215,500
7,821,500
20,658,600
9,125,100
24,101,800
6,495,500
7,794,600
9,093,600
8,234,000
9,880,800
11,527,600
11,847,400
14,216,800
16,586,300
5,075,500
7,783,000
11,431,600
5,079,000
5,917,800
9,809,900
6,090,600
9,339,600
13,717,900
6,094,800
7,101,400
11,771,800
7,105,700
10,896,200
16,004,200
7,110,600
8,284,900
13,733,800
3,052,100
3,662,500
4,272,900
3,745,700
4,494,800
5,243,900
4,438,600
5,326,300
6,214,000
3,688,700
5,244,200
6,759,600
4,426,400
6,293,100
8,111,500
5,164,100
7,341,900
9,463,400
4,633,600
5,560,300
6,487,000
6,896,000
8,275,200
9,654,400
17,703,400
21,244,100
24,784,800
3,973,800
5,388,300
10,537,000
4,768,500
6,465,900
12,644,400
5,563,300
7,543,600
14,751,800
2,859,700
3,431,600
4,003,600
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 334 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,738,100
2,085,700
2,433,300
697 U-4-12-I
698 U-4-12-II

2,504,500
2,913,300
3,005,400
3,495,900
3,506,300
4,078,600
699 U-4-12-III

3,779,300
4,535,200
5,291,000
1,898,100
2,277,700
2,657,300
2,237,600
2,685,200
3,132,700
2,676,300
3,211,600
3,746,900
2,846,400
3,408,400
3,415,600
4,090,100
3,984,900
4,771,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,723,800
6,868,600
8,013,300
2,285,500
2,742,700
3,199,800
2,847,500
3,417,000
3,986,500
3,985,100
4,782,100
5,579,200
3,727,900
4,473,500
5,219,100
7,679,400
9,215,300
10,751,100
9,417,700
11,301,200
13,184,800
7,092,200
8,098,400
12,682,500
8,510,600
9,718,100
15,219,000
9,929,100
11,337,800
17,755,500
6,668,000
8,001,600
9,335,200
9,105,700
10,926,900
12,748,000
11,541,600
13,849,900
16,158,300
3,478,100
4,173,800
4,869,400
6,645,600
7,974,700
9,303,800
10,426,100
12,511,300
14,596,500
6,820,600
8,184,700
9,548,800
9,910,100
11,892,200
13,874,200
12,374,600
14,849,500
17,324,400
1,098,500
1,212,100
1,340,900
1,318,200
1,454,600
1,609,100
1,537,800
1,697,000
1,877,200
3,298,300
3,958,000
4,617,700
5,478,700
6,574,400
7,670,200
9,032,400
10,838,900
12,645,400
2,850,000
3,419,900
3,989,900
3,823,900
4,588,700
5,353,500
5,122,200
6,146,600
7,171,000
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,546,700
7,856,100
9,165,400
10,051,200
12,061,500
14,071,700
1,363,200
1,652,200
1,635,900
1,982,600
1,908,500
2,313,000
- 335 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,768,000
9,321,600
10,875,100
9,310,400
11,172,500
13,034,600
13,285,700
15,942,900
18,600,000
1,647,700
1,977,200
2,306,800
1,818,200
2,011,300
2,181,900
2,413,600
2,545,500
2,815,800
1,722,200
2,066,600
2,411,100
1,900,400
2,280,500
2,660,600
2,102,300
2,522,700
2,943,200
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,852,700
2,223,300
2,593,800
743 W-1-12-II
744 W-1-12-III

2,312,500
4,095,000
2,775,000
4,914,000
3,237,600
5,733,000
745 W-1-13-I
1,904,500
2,285,400
2,666,200
746 W-1-13-II
747 W-1-13-III

2,067,600
2,777,300
2,481,100
3,332,800
2,894,600
3,888,300
748 W-1-20-I
749 W-1-20-II

6,377,900
7,969,200
7,653,400
9,563,100
8,929,000
11,156,900
750 W-1-20-III
9,238,400
11,086,000
12,933,700
751 W-1-30-I
3,600,400
4,320,500
5,040,600
752 W-1-30-II
5,742,600
6,891,100
8,039,700
753 W-1-30-III
14,089,800
16,907,800
19,725,800
754 W-4-10-I
2,682,700
3,219,200
3,755,700
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,976,900
7,859,200
2,439,700
3,703,800
4,508,200
4,772,300
9,431,100
2,927,600
4,444,600
5,409,900
5,567,700
11,002,900
3,415,600
5,185,400
6,311,500
2,776,200
3,331,400
3,886,700
3,811,500
4,573,800
5,336,100
4,154,800
4,985,700
5,816,700
959,900
1,311,200
1,630,600
1,282,800
1,526,800
1,953,400
1,562,100
1,734,800
2,402,000
2,078,400
2,779,300
3,766,900
1,533,600
2,769,000
4,093,900
2,356,400
3,127,900
4,443,400
2,105,800
2,529,100
3,476,400
1,151,900
1,573,500
1,956,700
1,539,300
1,832,200
2,344,100
1,874,500
2,081,800
2,882,300
2,494,100
3,335,200
4,520,300
1,840,300
3,322,800
4,912,700
2,827,700
3,753,400
5,332,100
2,526,900
3,035,000
4,171,700
1,343,800
1,835,700
2,282,800
1,795,900
2,137,600
2,734,700
2,186,900
2,428,800
3,362,700
2,909,700
3,891,100
5,273,700
2,147,100
3,876,600
5,731,500
3,299,000
4,379,000
6,220,800
2,948,100
3,540,800
4,867,000
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 336 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,212,000
1,454,400
1,696,800
2,973,200
3,567,900
4,162,500
4,253,400
5,104,100
5,954,800
- 337 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
959,700
1,244,800
2,314,900
1,913,000
2,486,000
457,300
812,800
357,600
775,900
677,500
769,100
1,156,300
1,577,200
1,445,600
468,300
1,080,900
392,100
673,100
2,050,400
734,300
1,734,100
423,100
987,000
1,544,800
1,295,700
317,800
963,100
535,500
275,300
297,700
262,800
314,200
437,500
375,900
353,900
318,000
471,900
206,000
242,800
278,400
5,650,100
2,258,100
2,265,600
582,800
954,300
597,500
1,214,500
778,200
445,600
336,500
542,800
299,500
256,500
2,001,400
934,000
533,700
2,083,400
1,388,900
270,500
2,257,000
1,562,600
3,671,000
811,800
499,300
268,500
223,800
252,200
3,845,800
1,872,000
- 338 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,379,200
4,210,700
3,491,100
2,659,600
876,800
2,960,100
1,932,800
475,100
4,444,200
4,023,200
2,697,600
2,555,600
315,900
303,500
1,221,300
333,800
297,400
328,700
1,128,100
1,540,900
1,345,900
1,188,600
719,900
299,100
527,200
361,900
326,800
318,400
404,200
461,000
270,300
775,600
1,413,500
1,085,100
2,550,900
332,200
332,200
2,357,200
1,370,700
262,900
1,216,400
3,159,900
725,500
571,400
279,900
248,000
303,200
422,800
1,012,500
892,400
624,700
466,000
256,500
1,084,700
869,200
371,400
423,800
1,388,700
307,100
1,418,800
1,085,400
331,000
366,900
358,400
216,900
1,182,600
1,624,900
322,000
- 339 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
987,000
368,400
398,300
368,800
585,100
450,100
1,127,200
332,600
925,300
1,236,500
270,800
1,648,200
893,200
1,930,200
974,400
430,300
331,000
71,600
429,000
969,400
377,800
510,300
291,800
113,800
294,700
4,388,600
2,494,500
4,163,400
1,022,800
571,400
389,400
880,600
465,800
937,400
542,800
323,100
540,800
243,500
371,600
356,100
833,000
1,698,900
1,366,900
1,205,200
850,600
312,900
312,900
312,900
255,600
162,100
254,900
311,600
337,000
248,200
219,000
100,400
110,300
81,600
95,700
91,300
139,400
125,000
174,000
191,100
111,000
134,700
92,100
143,700
203,900
- 340 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
145,200
195,300
552,100
640,000
137,300
265,600
167,000
238,500
446,900
382,600
275,000
260,400
136,500
134,100
306,600
193,500
277,600
192,100
150,400
1,928,800
1,984,000
315,200
326,500
624,400
805,000
799,200
412,800
1,286,600
285,500
335,500
336,600
269,600
340,500
322,200
150,900
331,600
294,000
265,900
300,700
2,489,300
323,200
895,900
321,300
457,100
492,600
393,000
778,000
796,700
849,500
743,100
1,361,600
221,400
1,537,000
291,800
779,100
1,770,600
2,047,400
894,400
324,100
632,200
629,700
291,800
2,287,400
1,799,200
146,600
163,300
212,100
278,300
- 341 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,054,300
460,000
948,000
1,143,700
548,100
762,500
527,000
582,100
665,900
314,100
742,400
194,900
721,900
1,135,000
79,100
- 342 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,656,800
1,988,200
2,319,600
A-4-10-II
SEPTIKEMIA (SEDANG)
2,830,600
3,396,700
3,962,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,816,500
2,151,000
4,579,800
2,581,300
5,343,100
3,011,500
5
6
A-4-11-II
A-4-11-III

3,061,600
4,237,500
3,673,900
5,085,000
4,286,200
5,932,500
A-4-12-I
2,405,600
2,886,700
3,367,800
8
9
A-4-12-II
A-4-12-III

2,995,700
3,197,300
3,594,900
3,836,700
4,194,000
4,476,200
10 A-4-13-I
11 A-4-13-II

1,056,500
1,421,000
1,267,800
1,705,200
1,479,100
1,989,400
12 A-4-13-III
1,705,200
2,046,200
2,387,300
2,111,400
2,533,600
2,955,900
2,562,900
3,075,400
3,588,000
3,075,400
3,690,500
4,305,600
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,891,900
4,328,800
3,470,300
5,194,600
4,048,600
6,060,300
18 A-4-15-III
INFEKSI HIV (BERAT)
5,432,300
6,518,700
7,605,200
19 B-1-01-I
20 B-1-01-II

18,935,500
20,890,900
22,722,600
25,069,000
26,509,700
29,247,200
21 B-1-01-III
22 B-1-10-I

36,646,900
3,420,900
43,976,300
4,105,100
51,305,700
4,789,300
23 B-1-10-II
7,592,900
9,111,500
10,630,100
24 B-1-10-III
25 B-1-11-I

14,989,400
4,571,000
17,987,300
5,485,100
20,985,200
6,399,300
26 B-1-11-II
27 B-1-11-III

5,923,600
7,653,200
7,108,400
9,183,900
8,293,100
10,714,500
28 B-1-12-I
4,463,300
5,356,000
6,248,600
29 B-1-12-II
4,964,000
5,956,800
6,949,600
30 B-1-12-III
7,765,600
9,318,700
10,871,800
3,555,100
4,266,100
4,977,100
5,849,400
7,019,300
8,189,200
7,568,600
9,082,400
10,596,100
4,884,800
5,861,800
6,838,700
5,432,800
6,519,300
7,605,900
8,499,000
1,511,400
2,412,600
3,328,200
10,198,700
1,813,600
2,895,100
3,993,800
11,898,500
2,115,900
3,377,600
4,659,500
3,186,500
3,823,800
4,461,100
4,461,200
5,353,400
6,245,600
5,404,600
6,485,600
7,566,500
2,881,000
4,102,400
6,103,400
2,748,200
3,457,200
4,922,800
7,324,100
3,297,800
4,033,300
5,743,300
8,544,800
3,847,500
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 343 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,201,500
3,841,800
4,482,200
48 B-4-13-III
49 B-4-14-I

4,410,400
2,745,300
5,292,500
3,294,300
6,174,600
3,843,400
50 B-4-14-II
3,202,700
3,843,200
4,483,800
51 B-4-14-III
52 C-4-10-I

4,290,100
2,539,900
5,148,100
3,047,800
6,006,100
3,555,800
53 C-4-10-II
54 C-4-10-III

4,873,400
8,601,900
5,848,000
10,322,300
6,822,700
12,042,700
55 C-4-11-I
2,894,300
3,473,100
4,052,000
56 C-4-11-II
57 C-4-11-III

3,873,000
5,954,700
4,647,600
7,145,700
5,422,200
8,336,600
58 C-4-12-I
59 C-4-12-II
1,927,100
3,795,700
2,312,500
4,554,800
2,697,900
5,313,900
60 C-4-12-III
RADIOTERAPI (BERAT)
9,748,300
11,697,900
13,647,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,448,800
2,726,600
1,738,600
3,272,000
2,028,300
3,817,300
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,691,000
2,407,200
4,429,100
2,888,700
5,167,300
3,370,100
65 C-4-14-II
3,376,900
4,052,200
4,727,600
66 C-4-14-III
67 D-1-10-I

5,031,500
11,780,500
6,037,700
14,136,600
7,044,000
16,492,700
68 D-1-10-II
69 D-1-10-III

17,942,500
28,570,600
21,531,000
34,284,700
25,119,500
39,998,900
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
3,894,000
4,672,800
5,451,600
9,943,100
12,921,500
11,931,700
15,505,800
13,920,400
18,090,000
3,375,600
4,050,700
4,725,900
9,302,700
11,163,200
13,023,800
14,756,800
17,708,200
20,659,500
2,082,500
3,034,400
4,773,800
2,642,600
4,748,700
6,523,600
2,278,300
3,160,100
4,852,500
2,499,000
3,641,300
5,728,600
3,171,200
5,698,500
7,828,300
2,734,000
3,792,100
5,822,900
2,915,500
4,248,100
6,683,300
3,699,700
6,648,200
9,133,000
3,189,700
4,424,100
6,793,400
1,952,500
2,343,000
2,733,500
2,763,400
3,316,100
3,868,800
3,534,500
4,241,400
4,948,300
2,094,100
2,512,900
2,931,800
3,428,600
4,114,300
4,800,000
4,193,500
5,032,200
5,870,900
3,265,800
3,918,900
4,572,100
4,277,800
5,133,400
5,989,000
93 E-1-01-III
8,479,400
10,175,300
11,871,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,781,100
3,375,700
7,114,900
3,337,400
4,050,800
8,537,900
3,893,600
4,726,000
9,960,900
4,913,200
5,895,800
6,878,500
97 E-1-20-I
- 344 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,931,500
2,317,800
2,704,100
104 E-4-11-II
105 E-4-11-III

2,944,700
3,990,300
3,533,600
4,788,300
4,122,600
5,586,400
106 E-4-12-I
107 E-4-12-II

2,219,200
3,843,200
2,663,100
4,611,800
3,106,900
5,380,500
108 E-4-12-III

(RINGAN)
(SEDANG)
4,555,600
5,466,700
6,377,800
2,416,700
2,900,000
3,383,300
3,540,000
4,248,000
4,956,000
111 E-4-13-III
4,627,500
5,553,000
6,478,400
112 F-4-10-I
113 F-4-10-II
2,572,800
2,957,000
3,087,400
3,548,400
3,601,900
4,139,700
114 F-4-10-III
115 F-4-11-I
3,548,400
2,488,400
4,258,000
2,986,000
4,967,700
3,483,700
116 F-4-11-II
2,899,200
3,479,000
4,058,900
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,717,800
4,461,400
5,205,000
1,364,000
1,636,800
1,909,600
1,939,200
2,327,100
2,714,900
4,212,800
5,055,400
5,898,000
2,004,400
2,644,900
3,424,100
1,143,600
1,466,900
1,973,800
2,405,300
3,173,900
4,109,000
1,372,300
1,760,200
2,368,500
2,806,200
3,702,800
4,793,800
1,601,100
2,053,600
2,763,300
127 F-4-15-I
1,821,300
2,185,600
2,549,800
128 F-4-15-II
2,714,000
3,256,800
3,799,500
129 F-4-15-III
3,583,300
4,299,900
5,016,600
3,583,500
4,300,200
5,016,900
4,166,400
4,999,700
5,833,000
5,561,400
6,673,700
7,786,000
133 F-4-17-I

846,300
1,015,500
1,184,800
134 F-4-17-II
2,480,300
2,976,400
3,472,500
135
136
137
138
139
140
141

(RINGAN)
2,646,300
3,113,800
3,426,100
5,281,500
2,379,700
3,047,300
3,793,800
3,175,500
3,736,500
4,111,300
6,337,800
2,855,600
3,656,700
4,552,600
3,704,800
4,359,300
4,796,500
7,394,100
3,331,500
4,266,200
5,311,300
5,280,800
6,336,900
7,393,100
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,613,000
7,935,600
9,258,300
9,114,100
10,937,000
12,759,800
3,192,500
3,831,000
4,469,600
4,461,000
5,353,200
6,245,400
5,537,000
6,644,400
7,751,800
- 345 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,288,300
6,346,000
7,403,600
148 G-1-11-I
149 G-1-11-II

7,725,500
14,124,100
9,270,600
16,948,900
10,815,700
19,773,700
150 G-1-11-III
22,696,800
27,236,100
31,775,500
3,225,700
3,870,800
4,516,000
6,046,700
7,256,000
8,465,400
8,240,500
9,888,500
11,536,600
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
973,100
2,613,200
1,167,700
3,135,900
1,362,300
3,658,500
156 G-1-13-III
157 G-1-20-I

5,896,600
2,912,600
7,076,000
3,495,100
8,255,300
4,077,600
158 G-1-20-II
4,810,600
5,772,700
6,734,800
159 G-1-20-III
9,645,300
11,574,400
13,503,500
160 G-1-30-I
4,552,300
5,462,800
6,373,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
11,887,500
15,270,800
14,265,000
18,325,000
16,642,500
21,379,100
2,768,900
3,322,700
3,876,500
3,384,500
4,061,400
4,738,300
4,644,200
5,573,000
6,501,800
2,898,600
3,478,300
4,058,000
3,850,400
4,620,500
5,390,600
5,657,600
6,789,100
7,920,600
3,215,700
3,858,800
4,501,900
4,061,600
4,873,900
5,686,300
5,899,000
7,078,800
8,258,600
1,931,700
2,318,000
2,704,400
3,368,500
4,042,200
4,715,900
3,995,100
4,794,100
5,593,100
3,276,900
3,932,300
4,587,600
4,381,000
5,257,200
6,133,300
5,498,600
6,598,400
7,698,100
2,677,500
3,213,000
3,748,500
3,195,500
3,834,600
4,473,700
4,510,100
5,412,200
6,314,200
2,207,200
2,648,700
3,090,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,276,500
8,731,800
10,187,100
14,145,500
16,974,600
19,803,700
3,158,400
4,459,400
3,790,100
5,351,300
4,421,800
6,243,100
- 346 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
2,930,400
3,516,500
4,102,600
183 G-4-16-III
4,173,100
5,007,800
5,842,400
2,939,900
3,527,900
4,115,900
3,854,900
4,625,800
5,396,800
4,843,800
5,812,600
6,781,300
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,895,300
3,474,400
4,053,500
188 G-4-18-II
3,870,200
4,644,200
5,418,300
189 G-4-18-III
4,330,400
5,196,500
6,062,600
2,415,700
2,898,800
3,381,900
4,083,000
4,899,600
5,716,200
5,360,800
6,433,000
7,505,200
193 G-4-20-I

1,689,900
2,027,800
2,365,800
194 G-4-20-II
2,389,000
2,866,700
3,344,500
195 G-4-20-III
196 G-4-21-I

3,946,000
1,759,700
4,735,200
2,111,700
5,524,400
2,463,600
197 G-4-21-II
198 G-4-21-III

2,978,400
3,500,300
3,574,000
4,200,300
4,169,700
4,900,400
199 G-4-22-I
2,420,700
2,904,800
3,388,900
200 G-4-22-II
201 G-4-22-III

3,092,900
3,613,900
3,711,400
4,336,700
4,330,000
5,059,400
202 G-4-23-I
203 G-4-23-II

1,732,300
2,173,400
2,078,700
2,608,100
2,425,200
3,042,800
204 G-4-23-III
3,094,400
3,713,300
4,332,200
205 G-4-24-I
206 G-4-24-II

1,929,500
2,410,600
2,315,400
2,892,800
2,701,300
3,374,900
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,016,000
1,648,700
2,085,000
2,763,000
4,819,300
1,978,500
2,502,000
3,315,600
5,622,500
2,308,200
2,919,000
3,868,200
2,605,400
3,126,500
3,647,600
3,030,900
3,637,100
4,243,300
4,532,200
5,438,600
6,345,000
1,860,600
4,180,200
5,684,900
5,679,600
7,056,400
9,883,400
2,232,100
3,028,500
5,952,600
1,926,300
2,197,300
3,146,400
2,271,100
2,713,600
4,547,500
2,232,700
5,016,300
6,821,900
6,815,600
8,467,600
11,860,100
2,678,500
3,634,200
7,143,100
2,311,600
2,636,800
3,775,700
2,725,400
3,256,300
5,457,000
2,604,800
5,852,300
7,958,800
7,951,500
9,878,900
13,836,800
3,124,900
4,239,800
8,333,600
2,696,800
3,076,300
4,405,000
3,179,600
3,799,000
6,366,500
229 I-1-01-I
30,505,300
36,606,400
42,707,500
230 I-1-01-II
31,176,400
37,411,700
43,647,000
231 I-1-01-III

(RINGAN)
49,211,600
59,053,900
68,896,200
16,924,200
20,309,100
23,693,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 347 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
13,935,200
16,722,200
19,509,200
245 I-1-06-II
20,186,200
24,223,400
28,260,700
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,085,900
28,903,000
33,720,200
16,588,100
19,905,700
23,223,300
20,464,800
24,557,700
28,650,700
22,327,000
26,792,400
31,257,800
2,652,100
3,182,500
3,712,900
2,948,800
3,538,600
4,128,400
3,924,000
4,708,800
5,493,600
7,634,000
9,160,700
10,687,500
12,467,800
14,961,300
17,454,900
16,403,300
19,683,900
22,964,600
7,404,800
8,885,800
10,366,800
9,861,000
11,833,300
13,805,500
12,161,400
14,593,700
17,026,000
15,155,900
18,187,000
21,218,200
18,836,500
22,603,800
26,371,100
24,682,300
29,618,800
34,555,300
2,879,200
4,020,700
7,742,300
3,455,000
4,824,900
9,290,800
4,030,900
5,629,000
10,839,200
7,463,900
8,956,700
10,449,400
16,887,800
20,265,300
23,642,900
19,479,800
23,375,700
27,271,700
8,642,500
10,371,000
12,099,500
10,821,200
12,985,400
15,149,600
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
21,832,000
26,198,500
30,564,900
26,909,400
32,291,200
37,673,100
9,775,500
11,730,600
13,685,700
13,550,800
16,261,000
18,971,200
17,197,100
20,636,500
24,075,900
14,731,100
17,677,300
20,623,600
23,249,700
27,899,600
32,549,600
37,141,200
44,569,500
51,997,700
18,901,400
22,681,700
26,461,900
22,681,700
27,218,100
31,754,400
31,209,900
37,451,900
43,693,900
- 348 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
16,812,600
20,175,100
23,537,600
279 I-1-40-III
22,455,900
26,947,100
31,438,200
280 I-4-10-I
281 I-4-10-II

2,563,500
4,577,400
3,076,200
5,492,900
3,588,900
6,408,300
282 I-4-10-III
6,595,400
7,914,400
9,233,500
283 I-4-11-I
284 I-4-11-II

3,943,900
4,880,600
4,732,700
5,856,700
5,521,500
6,832,800
285 I-4-11-III
286 I-4-12-I

9,028,600
2,267,200
10,834,300
2,720,600
12,640,000
3,174,100
287 I-4-12-II
2,627,900
3,153,500
3,679,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,153,500
3,784,200
4,415,000
2,307,100
2,768,500
3,230,000
4,119,600
4,943,600
5,767,500
5,935,800
7,123,000
8,310,200
2,178,700
2,253,700
3,950,700
2,614,400
2,704,400
4,740,800
3,050,200
3,155,100
5,530,900
4,085,400
4,902,500
5,719,500
5,557,900
6,669,500
7,781,100
297 I-4-15-III
6,669,500
8,003,400
9,337,300
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,375,100
2,208,000
2,649,600
1,685,700
1,962,500
2,355,000
1,650,100
2,649,600
3,179,600
2,022,800
2,355,000
2,826,000
1,925,100
3,091,200
3,709,500
2,360,000
2,747,500
3,297,000
2,652,400
3,182,800
3,713,300
4,038,300
4,846,000
5,653,700
5,482,700
6,579,200
7,675,800
307 I-4-19-I
2,559,000
3,070,800
3,582,600
308 I-4-19-II

(SEDANG)
3,994,700
4,793,700
5,592,600
309 I-4-19-III
4,769,000
5,722,700
6,676,500
310
311
312
313
314

2,664,700
3,077,700
4,601,800
1,994,000
2,526,400
3,197,600
3,693,200
5,522,100
2,392,700
3,031,600
3,730,500
4,308,800
6,442,500
2,791,500
3,536,900
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,385,600
16,062,800
18,739,900
9,741,500
11,689,900
13,638,200
12,169,900
14,603,800
17,037,800
12,793,000
15,351,600
17,910,300
7,368,900
8,842,700
10,316,500
15,329,000
18,394,800
21,460,600
23,754,400
28,505,300
33,256,200
6,800,700
8,160,900
9,521,000
- 349 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,646,500
4,375,800
5,105,100
316 I-4-22-I
317 I-4-22-II
2,234,900
2,782,100
2,681,900
3,338,500
3,128,900
3,895,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,066,600
4,879,900
5,693,200
2,187,300
2,624,800
3,062,200
2,685,400
3,222,500
3,759,600
5,247,100
6,296,500
7,345,900
1,969,700
2,363,600
2,757,600
4,535,700
5,442,800
6,349,900
5,734,500
6,881,400
8,028,300
35,534,800
42,641,800
49,748,800
40,214,300
48,257,100
56,300,000
45,495,000
54,594,000
63,693,000
18,857,000
22,628,400
26,399,900
26,256,500
31,507,800
36,759,100
43,358,400
52,030,100
60,701,800
5,726,400
6,871,700
8,016,900
11,587,400
13,904,800
16,222,300
12,042,100
14,450,600
16,859,000
6,729,100
8,074,900
9,420,800
7,966,500
9,559,800
11,153,100
12,301,600
14,761,900
17,222,200
4,778,800
5,734,600
6,690,300
8,656,800
10,388,100
12,119,500
24,987,400
29,984,900
34,982,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
1,952,600
4,032,600
6,100,700
1,742,800
2,427,400
3,253,700
2,960,200
3,369,800
4,705,100
2,617,300
3,643,200
6,797,100
2,885,700
4,695,800
5,555,600
3,833,900
4,580,400
6,162,500
2,343,100
4,839,100
7,320,800
2,091,400
2,912,900
3,904,500
3,552,200
4,043,700
5,646,100
3,140,800
4,371,900
8,156,500
3,462,800
5,634,900
6,666,700
4,600,700
5,496,500
7,395,000
2,733,600
5,645,600
8,540,900
2,440,000
3,398,400
4,555,200
4,144,300
4,717,700
6,587,200
3,664,200
5,100,500
9,515,900
4,039,900
6,574,100
7,777,800
5,367,500
6,412,600
8,627,500
3,194,400
3,833,300
4,472,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 350 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,489,000
5,386,800
6,284,600
360 J-4-16-III
5,675,700
6,810,800
7,946,000
361 J-4-17-I
362 J-4-17-II

2,411,200
2,887,500
2,893,500
3,465,000
3,375,700
4,042,500
363 J-4-17-III
364 J-4-18-I

3,789,300
1,967,900
4,547,100
2,361,500
5,305,000
2,755,100
365 J-4-18-II
2,706,700
3,248,000
3,789,400
366 J-4-18-III
367 J-4-19-I

2,849,100
3,396,300
3,419,000
4,075,500
3,988,800
4,754,800
368 J-4-19-II
369 J-4-19-III

3,851,600
4,253,600
4,621,900
5,104,300
5,392,200
5,955,100
370 J-4-20-I
3,370,400
4,044,400
4,718,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,670,000
5,474,700
5,604,000
6,569,600
6,538,000
7,664,500
2,550,700
3,060,800
3,571,000
4,109,100
4,930,900
5,752,700
5,733,900
6,880,700
8,027,500
5,191,300
6,229,600
7,267,800
6,524,000
7,828,800
9,133,600
7,646,300
9,175,600
10,704,900
5,345,600
6,414,700
7,483,800

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,018,100
9,293,100
8,421,700
11,151,700
9,825,300
13,010,300
2,178,200
2,613,800
3,049,500
2,833,000
3,399,600
3,966,200
5,612,600
6,735,100
7,857,700
2,456,600
2,702,200
2,726,800
2,947,900
3,242,700
3,272,200
3,439,200
3,783,100
3,817,500
3,986,600
4,783,900
5,581,200
4,672,200
5,606,600
6,541,100
390 K-1-14-III
7,340,600
8,808,800
10,276,900
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,719,300
10,782,100
15,743,100
9,263,200
12,938,600
18,891,700
10,807,000
15,095,000
22,040,300
4,565,100
5,478,200
6,391,200
8,107,600
9,729,100
11,350,600
11,156,100
13,387,400
15,618,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,093,600
6,112,400
7,131,100
398 K-1-40-II

(SEDANG)
5,615,900
6,739,100
7,862,300
399 K-1-40-III
9,516,900
11,420,300
13,323,700
400
401
402
403
404

3,892,000
5,054,300
7,142,700
3,213,100
4,616,700
4,670,500
6,065,200
8,571,200
3,855,700
5,540,100
5,448,900
7,076,000
9,999,700
4,498,300
6,463,400
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 351 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,038,000
8,445,600
9,853,200
406 K-4-11-I
407 K-4-11-II

2,050,900
2,914,400
2,461,000
3,497,200
2,871,200
4,080,100
408 K-4-11-III
409 K-4-12-I

3,497,200
1,931,500
4,196,700
2,317,800
4,896,100
2,704,100
410 K-4-12-II
2,599,200
3,119,000
3,638,800
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,299,900
5,159,900
6,019,800
2,603,800
3,124,500
3,645,300
3,368,100
4,041,800
4,715,400
5,188,000
6,225,600
7,263,200
1,650,800
1,981,000
2,311,100
2,215,900
2,659,100
3,102,300
3,555,700
4,266,800
4,977,900
418 K-4-15-I
1,638,900
1,966,700
2,294,500
419 K-4-15-II
2,443,400
2,932,100
3,420,800
420 K-4-15-III
3,429,200
4,115,000
4,800,900
421 K-4-16-I
2,410,100
2,892,100
3,374,200
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,890,400
3,372,600
3,468,500
4,047,200
4,046,600
4,721,700
1,089,300
1,307,200
1,525,000
1,633,400
1,960,100
2,286,800
1,960,100
2,352,100
2,744,100
1,093,800
1,312,600
1,531,300
1,554,400
1,865,300
2,176,200
429 K-4-18-III
1,865,300
2,238,300
2,611,400
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,307,500
18,577,800
24,823,000
5,806,800
9,964,100
12,370,500
14,769,000
22,293,300
29,787,600
6,968,100
11,956,900
14,844,600
17,230,500
26,008,900
34,752,200
8,129,500
13,949,700
17,318,800
3,254,200
3,905,100
4,555,900
6,527,300
7,832,800
9,138,200
10,986,900
13,184,300
15,381,700
4,272,200
6,875,600
9,834,900
1,117,400
1,297,000
1,505,500
2,340,000
3,216,200
7,308,100
1,111,300
1,469,800
3,888,100
5,126,600
8,250,700
11,801,900
1,340,900
1,556,400
1,806,600
2,808,000
3,859,400
8,769,700
1,333,600
1,763,800
4,665,800
5,981,000
9,625,900
13,768,800
1,564,400
1,815,800
2,107,700
3,276,000
4,502,600
10,231,400
1,555,800
2,057,800
5,443,400
2,172,700
2,607,200
3,041,800
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 352 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,553,500
3,064,200
3,574,900
3,757,500
4,509,000
5,260,500
1,924,400
2,309,300
2,694,100
2,890,500
3,468,600
4,046,700
4,074,500
4,889,400
5,704,300
6,802,500
8,163,000
9,523,500
9,668,800
11,602,600
13,536,400
13,581,800
16,298,200
19,014,600
6,029,200
7,235,000
8,440,800
9,890,600
16,803,900
11,868,700
20,164,700
13,846,900
23,525,500
14,760,400
17,712,500
20,664,600
17,264,500
20,717,400
24,170,300
21,367,700
25,641,200
29,914,700
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,559,700
9,071,600
10,583,500
467 M-1-04-II
9,712,000
11,654,300
13,596,700
468 M-1-04-III
11,620,600
13,944,700
16,268,800
469 M-1-05-I
470 M-1-05-II

4,799,600
7,763,500
5,759,500
9,316,200
6,719,400
10,868,800
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
9,916,800
11,900,200
13,883,600
5,372,600
6,447,100
7,521,600
7,197,400
8,636,800
10,076,300
14,661,700
17,594,000
20,526,400
8,844,100
10,612,900
12,381,800
19,407,300
23,288,800
27,170,300
41,859,800
50,231,800
58,603,800
8,078,000
9,693,600
11,309,200
10,320,500
12,384,600
14,448,700
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
25,694,900
30,833,900
35,972,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,541,700
8,979,900
12,840,400
6,650,100
10,775,900
15,408,500
7,758,400
12,571,800
17,976,600
2,821,000
3,385,200
3,949,300
5,002,800
6,003,400
7,004,000
7,143,100
8,571,700
10,000,300
3,380,500
5,609,900
9,213,900
4,056,600
6,731,900
11,056,600
4,732,700
7,853,800
12,899,400
5,220,900
6,265,100
7,309,200
6,563,900
7,876,600
9,189,400
9,915,500
11,898,600
13,881,700
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 353 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,936,900
2,324,300
2,711,700
500 M-4-10-II
501 M-4-10-III
2,888,600
5,465,200
3,466,300
6,558,300
4,044,000
7,651,300
2,413,600
2,896,300
3,379,000
5,291,700
6,350,000
7,408,300
7,650,800
9,181,000
10,711,100
1,926,600
2,311,900
2,697,200
3,204,400
3,845,300
4,486,200
4,286,200
5,143,500
6,000,700
3,207,900
3,849,500
4,491,100
4,819,800
5,783,700
6,747,700
9,403,300
11,284,000
13,164,600
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,658,500
4,390,200
5,122,000
512 M-4-14-II
4,512,300
5,414,700
6,317,200
513 M-4-14-III
514 M-4-15-I
6,780,600
2,169,400
8,136,800
2,603,300
9,492,900
3,037,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,891,700
6,562,100
1,857,400
2,974,300
4,996,700
3,470,000
7,874,500
2,228,800
3,569,200
5,996,000
4,048,300
9,186,900
2,600,300
4,164,100
6,995,300
2,410,600
2,892,700
3,374,800
3,371,500
4,045,800
4,720,100
4,708,000
5,649,700
6,591,300
1,822,000
2,745,900
3,306,100
2,186,400
3,295,100
3,967,400
2,550,800
3,844,200
4,628,600
1,900,100
2,280,100
2,660,100
3,200,500
3,840,600
4,480,700
6,250,700
7,500,900
8,751,000
1,916,700
2,300,000
2,683,300
2,806,600
3,367,900
3,929,300
3,136,700
3,764,100
4,391,400
1,929,900
2,315,900
2,701,900
2,413,800
2,896,500
3,379,300
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,672,600
11,607,200
13,541,700
10,639,900
12,767,900
14,895,800
12,181,300
14,617,500
17,053,800
5,498,500
6,598,200
7,697,900
6,530,000
14,697,500
7,836,000
17,637,000
9,141,900
20,576,500
- 354 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,411,700
6,494,000
7,576,300
535 N-1-01-I

61,792,300
74,150,800
86,509,300
536 N-1-01-II
61,792,300
74,150,800
86,509,300
537 N-1-01-III
538 N-1-11-I

61,792,300
5,566,800
74,150,800
6,680,200
86,509,300
7,793,600
539 N-1-11-II
540 N-1-11-III

8,802,500
13,723,200
10,563,000
16,467,800
12,323,500
19,212,400
2,837,200
3,404,700
3,972,100
5,648,600
6,778,400
7,908,100
12,257,700
14,709,300
17,160,800
6,203,300
7,443,900
8,684,600

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,681,100
12,148,200
10,417,400
14,577,900
12,153,600
17,007,500
5,677,100
6,812,500
7,947,900
8,588,300
10,306,000
12,023,600
9,884,300
11,861,200
13,838,100
5,098,400
6,118,100
7,137,800
6,923,500
8,308,300
9,693,000
8,058,100
9,669,700
11,281,300
2,166,100
2,599,300
3,032,600
2,620,000
3,144,000
3,667,900
3,853,600
4,624,300
5,395,000
1,662,900
2,905,200
3,614,700
1,957,300
3,833,500
4,614,300
3,114,900
3,757,000
5,757,300
1,995,400
3,486,200
4,337,600
2,348,800
4,600,300
5,537,100
3,737,900
4,508,400
6,908,800
2,328,000
4,067,300
5,060,600
2,740,200
5,367,000
6,460,000
4,360,900
5,259,800
8,060,300
1,670,000
2,004,100
2,338,100
2,369,700
2,843,700
3,317,600
3,798,600
4,558,400
5,318,100
1,972,900
2,367,500
2,762,100
2,448,100
2,937,700
3,427,300
2,793,700
3,352,400
3,911,100
2,415,900
2,899,000
3,382,200
3,448,200
4,137,900
4,827,500
4,589,800
5,507,800
6,425,700
4,332,200
4,583,100
5,198,600
5,499,700
6,065,100
6,416,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 355 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,378,000
6,453,600
7,529,200
2,245,700
2,694,800
3,143,900
2,495,800
2,995,000
3,494,100
3,104,800
3,725,800
4,346,700
1,591,000
1,909,200
2,227,400
1,910,800
2,293,000
2,675,100
2,401,000
2,881,200
3,361,400
1,480,800
1,777,000
2,073,100

MAYOR (RINGAN)
MAYOR (SEDANG)
1,752,700
2,103,200
2,103,200
2,523,800
2,453,700
2,944,500
35,527,700
42,633,200
49,738,800
43,960,200
52,752,200
61,544,200
51,596,900
61,916,300
72,235,600
48,493,600
58,192,300
67,891,100
55,627,000
66,752,400
77,877,900
63,557,800
76,269,400
88,981,000
5,910,100
7,092,100
8,274,200
8,392,400
10,070,800
11,749,300
9,483,400
11,380,100
13,276,700
19,178,800
23,014,600
26,850,300
24,889,900
29,867,900
34,845,900
35,685,900
42,823,100
49,960,300
10,428,800
12,514,600
14,600,300
19,663,400
23,596,100
27,528,800
23,996,000
28,795,200
33,594,500
3,441,100
4,129,300
4,817,500
9,648,100
11,577,700
13,507,300
12,781,300
15,337,600
17,893,800
3,333,100
3,999,700
4,666,300
9,345,100
11,214,200
13,083,200
12,380,000
14,856,000
17,332,000
3,523,700
4,228,500
4,933,200
5,000,100
6,000,100
7,000,100
8,096,200
9,715,400
11,334,600
5,583,500
6,700,200
7,816,900
7,928,600
9,514,300
11,100,000
- 356 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,959,300
10,751,100
12,543,000
5,274,900
6,329,900
7,384,900
7,500,200
9,000,200
10,500,200
8,488,700
10,186,400
11,884,200
4,576,800
5,492,200
6,407,600
6,041,400
7,249,700
8,458,000
8,995,900
10,795,100
12,594,200
2,317,300
2,780,700
3,244,200
4,717,100
5,660,500
6,603,900
8,751,900
10,502,300
12,252,700
1,738,000
2,085,600
2,433,200
3,480,400
4,176,500
4,872,600
4,083,600
4,900,300
5,717,100
1,572,900
1,887,500
2,202,100
3,022,600
3,627,100
4,231,600
6,163,900
7,396,600
8,629,400
3,051,200
3,661,500
4,271,700
5,492,200
6,590,600
7,689,100
7,496,600
8,995,900
10,495,200
1,773,400
2,128,100
2,482,800
2,185,100
2,622,200
3,059,200
2,991,200
3,589,500
4,187,700
1,496,400
2,194,300
3,750,300
1,303,800
1,735,400
3,008,200
1,795,700
2,633,100
4,500,400
1,564,600
2,082,400
3,609,900
2,094,900
3,072,000
5,250,500
1,825,300
2,429,500
4,211,500
1,925,400
2,310,500
2,695,600
3,415,800
4,099,000
4,782,100
5,544,300
6,653,100
7,762,000
974,400
1,169,300
1,364,100
2,069,700
2,483,600
2,897,500
3,924,800
4,709,800
5,494,800
651,700
782,000
912,400
1,229,800
1,475,800
1,721,800
1,592,800
1,911,400
2,230,000
3,374,500
4,049,400
4,724,300
- 357 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,291,600
5,149,900
6,008,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,144,700
7,373,600
8,602,600
1,626,500
1,951,700
2,277,000
2,413,800
2,896,600
3,379,400
2,903,200
3,483,800
4,064,400
1,088,200
1,305,900
1,523,500
1,461,600
1,754,000
2,046,300
2,658,900
3,190,700
3,722,500
496,300
595,500
694,800
945,900
1,135,100
1,324,200
1,375,000
1,650,100
1,925,100
587,700
705,300
822,800
924,900
1,109,900
1,294,900
1,489,600
1,787,600
2,085,500
1,027,900
1,233,500
1,439,000
1,553,900
1,864,700
2,175,500
2,425,300
2,910,300
3,395,400
3,556,200
4,267,400
4,978,700

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,520,600
14,581,500
6,624,800
17,497,700
7,728,900
20,414,000
5,501,600
6,601,900
7,702,300
6,974,100
8,368,900
9,763,800
10,034,600
12,041,600
14,048,500
4,298,900
6,592,100
9,682,500
4,075,400
4,748,500
7,871,600
5,158,700
7,910,600
11,619,000
4,890,500
5,698,200
9,445,900
6,018,500
9,229,000
13,555,500
5,705,600
6,647,900
11,020,200
2,585,100
3,102,100
3,619,100
3,172,600
3,807,100
4,441,600
3,759,500
4,511,400
5,263,300
2,865,000
4,073,200
5,250,100
3,438,000
4,887,800
6,300,200
4,011,000
5,702,500
7,350,200
3,924,600
4,709,500
5,494,400
5,840,900
7,009,100
8,177,300
14,994,700
17,993,600
20,992,600
3,365,800
4,563,800
8,924,800
4,038,900
5,476,600
10,709,700
4,712,100
6,389,400
12,494,700
2,422,200
2,906,600
3,391,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 358 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,472,100
1,766,600
2,061,000
697 U-4-12-I
698 U-4-12-II

2,310,000
2,687,000
2,772,000
3,224,400
3,234,000
3,761,800
699 U-4-12-III

3,485,800
4,182,900
4,880,100
1,750,600
2,100,800
2,450,900
2,063,800
2,476,600
2,889,400
2,468,500
2,962,100
3,455,800
2,410,900
2,886,900
2,893,000
3,464,300
3,375,200
4,041,700

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,848,000
5,817,600
6,787,200
1,935,800
2,323,000
2,710,200
2,411,800
2,894,200
3,376,500
3,375,400
4,050,400
4,725,500
3,157,500
3,789,000
4,420,500
6,504,400
7,805,300
9,106,100
7,976,700
9,572,100
11,167,400
6,007,000
6,859,300
10,742,000
7,208,500
8,231,200
12,890,400
8,409,900
9,603,100
15,038,800
5,647,800
6,777,300
7,906,900
7,712,500
9,255,000
10,797,500
9,775,700
11,730,800
13,686,000
2,946,000
3,535,100
4,124,300
5,628,800
6,754,500
7,880,300
8,830,800
10,597,000
12,363,100
5,777,000
6,932,400
8,087,800
8,393,800
10,072,600
11,751,300
10,481,200
12,577,400
14,673,700
930,400
1,026,700
1,135,700
1,116,500
1,232,000
1,362,900
1,302,500
1,437,400
1,590,000
2,793,700
3,352,400
3,911,100
4,640,400
5,568,500
6,496,600
7,650,400
9,180,500
10,710,600
2,413,900
2,896,700
3,379,400
3,238,800
3,886,600
4,534,300
4,338,400
5,206,100
6,073,800
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,545,000
6,654,000
7,763,100
8,513,300
10,216,000
11,918,700
1,154,600
1,399,400
1,385,600
1,679,200
1,616,500
1,959,100
- 359 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,579,400
7,895,300
9,211,200
7,885,900
9,463,000
11,040,200
11,252,900
13,503,500
15,754,100
1,395,600
1,674,700
1,953,800
1,540,000
1,703,600
1,848,000
2,044,300
2,156,000
2,385,000
1,458,700
1,750,400
2,042,200
1,609,700
1,931,600
2,253,500
1,780,600
2,136,700
2,492,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,569,300
1,883,100
2,197,000
743 W-1-12-II
744 W-1-12-III

1,958,700
3,468,400
2,350,400
4,162,100
2,742,200
4,855,800
745 W-1-13-I
1,613,100
1,935,700
2,258,300
746 W-1-13-II
747 W-1-13-III

1,751,200
2,352,400
2,101,500
2,822,900
2,451,700
3,293,300
748 W-1-20-I
749 W-1-20-II

5,402,000
6,749,900
6,482,400
8,099,800
7,562,800
9,449,800
750 W-1-20-III
7,824,800
9,389,800
10,954,800
751 W-1-30-I
3,049,500
3,659,400
4,269,300
752 W-1-30-II
4,864,000
5,836,800
6,809,600
753 W-1-30-III
11,934,000
14,320,800
16,707,600
754 W-4-10-I
2,272,200
2,726,600
3,181,100
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,368,400
6,656,700
2,066,400
3,137,100
3,818,500
4,042,100
7,988,000
2,479,700
3,764,500
4,582,100
4,715,800
9,319,400
2,893,000
4,392,000
5,345,800
2,560,600
3,072,700
3,584,800
3,515,500
4,218,600
4,921,700
3,832,100
4,598,500
5,364,900
813,000
1,110,600
1,381,100
1,086,500
1,293,200
1,654,500
1,440,800
1,600,100
2,215,400
1,917,000
2,563,500
3,474,300
1,414,500
2,553,900
3,776,000
1,908,900
2,533,800
3,599,400
1,635,500
1,964,400
2,700,100
975,600
1,332,700
1,657,300
1,303,800
1,551,900
1,985,400
1,728,900
1,920,100
2,658,500
2,300,300
3,076,200
4,169,200
1,697,400
3,064,700
4,531,100
2,290,600
3,040,500
4,319,300
1,962,700
2,357,300
3,240,200
1,138,200
1,554,800
1,933,500
1,521,100
1,810,500
2,316,300
2,017,100
2,240,100
3,101,600
2,683,700
3,588,800
4,864,100
1,980,300
3,575,500
5,286,300
2,672,400
3,547,300
5,039,100
2,289,800
2,750,100
3,780,200
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 360 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
760,600
912,700
1,064,800
1,853,200
2,223,900
2,594,500
2,350,300
2,820,300
3,290,400
- 361 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
867,800
1,125,700
2,093,300
1,729,900
2,248,100
413,500
735,000
323,300
591,200
612,600
695,500
1,045,700
1,426,300
1,307,200
423,500
977,400
354,500
608,700
1,854,100
664,000
1,568,100
382,600
892,500
1,397,000
1,171,700
287,400
870,900
484,200
249,000
269,200
237,600
284,100
395,600
339,900
320,000
287,600
426,700
186,400
219,600
251,800
5,109,300
2,041,900
2,048,800
527,000
863,000
540,300
1,098,200
703,700
403,000
304,300
490,800
270,900
231,900
1,809,900
844,600
482,600
1,884,000
1,256,000
244,600
2,041,000
1,413,000
3,178,400
734,100
451,500
242,800
202,400
228,100
3,477,700
1,692,800
- 362 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,151,500
3,807,600
3,157,000
2,405,000
792,900
2,676,800
1,747,800
429,600
4,018,800
3,638,200
2,439,400
2,311,000
285,600
274,500
1,104,400
301,800
268,900
297,200
1,020,100
1,393,400
1,217,100
1,074,800
651,000
270,500
476,800
327,300
295,500
287,900
365,600
416,900
244,400
701,400
1,278,200
981,200
2,306,700
300,400
300,400
2,131,600
1,239,500
237,800
1,100,000
2,857,400
656,000
516,700
253,100
218,500
274,200
382,400
915,600
807,000
564,900
421,400
231,900
980,900
786,000
335,800
383,200
1,255,800
277,700
1,283,000
981,500
299,300
331,800
324,100
196,100
1,069,400
1,469,400
291,200
- 363 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
892,500
333,100
360,200
333,500
529,100
407,000
1,019,300
300,700
836,800
1,118,100
244,900
1,490,500
807,700
1,745,400
881,100
389,100
299,300
63,100
387,900
876,600
341,600
461,400
263,900
102,700
266,500
3,968,500
2,255,800
3,764,900
924,900
516,700
352,100
796,300
421,200
847,600
490,800
292,200
489,100
220,200
336,100
322,000
708,900
1,536,300
1,236,100
1,089,800
769,200
282,900
282,900
282,900
231,100
146,600
230,500
281,700
304,800
224,500
198,000
88,400
97,200
71,900
84,300
80,500
122,800
110,100
157,300
172,800
97,800
118,700
81,100
126,600
179,600
- 364 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
127,900
176,600
499,200
578,700
120,900
240,200
147,200
210,100
404,100
346,000
248,700
235,500
120,200
118,100
277,300
175,000
251,000
177,800
136,000
1,744,200
1,794,100
285,100
295,200
564,600
709,200
722,700
373,300
1,163,500
251,500
303,400
304,400
243,800
307,900
291,300
136,500
299,900
265,800
240,400
271,900
2,251,100
292,300
810,100
290,600
413,400
434,000
346,200
703,500
720,400
768,200
671,900
1,167,100
200,200
1,389,900
263,900
704,500
1,601,200
1,851,400
808,800
293,100
571,700
569,400
263,900
2,068,500
1,627,000
131,400
143,800
186,900
251,700
- 365 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
878,600
415,900
857,300
1,034,300
495,600
689,500
476,600
512,800
554,900
284,000
671,400
171,700
636,000
945,900
69,700
- 366 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,706,500
2,047,800
2,389,100
A-4-10-II
SEPTIKEMIA (SEDANG)
2,915,500
3,498,600
4,081,700
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,931,000
2,215,600
4,717,200
2,658,700
5,503,400
3,101,800
5
6
A-4-11-II
A-4-11-III

3,153,400
4,364,600
3,784,100
5,237,500
4,414,800
6,110,400
A-4-12-I
2,477,700
2,973,300
3,468,800
8
9
A-4-12-II
A-4-12-III

3,085,600
3,293,200
3,702,700
3,951,800
4,319,900
4,610,500
10 A-4-13-I
11 A-4-13-II

1,088,200
1,463,600
1,305,900
1,756,400
1,523,500
2,049,100
12 A-4-13-III
1,756,400
2,107,600
2,458,900
2,174,700
2,609,600
3,044,600
2,639,700
3,167,700
3,695,600
3,167,700
3,801,200
4,434,800
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,978,600
4,458,700
3,574,400
5,350,400
4,170,100
6,242,100
18 A-4-15-III
INFEKSI HIV (BERAT)
5,595,300
6,714,300
7,833,400
19 B-1-01-I
20 B-1-01-II

19,503,600
21,517,600
23,404,300
25,821,100
27,305,000
30,124,600
21 B-1-01-III
22 B-1-10-I

37,746,400
3,523,500
45,295,600
4,228,200
52,844,900
4,932,900
23 B-1-10-II
7,820,700
9,384,800
10,949,000
24 B-1-10-III
25 B-1-11-I

15,439,100
4,708,100
18,526,900
5,649,700
21,614,700
6,591,300
26 B-1-11-II
27 B-1-11-III

6,101,300
7,882,800
7,321,600
9,459,400
8,541,900
11,035,900
28 B-1-12-I
4,597,200
5,516,600
6,436,100
29 B-1-12-II
5,112,900
6,135,500
7,158,000
30 B-1-12-III
7,998,500
9,598,300
11,198,000
3,661,700
4,394,100
5,126,400
6,024,900
7,229,900
8,434,900
7,795,700
9,354,800
10,914,000
5,031,300
6,037,600
7,043,900
5,595,700
6,714,900
7,834,000
8,753,900
1,556,700
2,484,900
3,428,100
10,504,700
1,868,000
2,981,900
4,113,700
12,255,500
2,179,400
3,478,900
4,799,300
3,282,100
3,938,500
4,595,000
4,595,000
5,514,000
6,433,000
5,566,800
6,680,100
7,793,500
2,967,400
4,225,400
6,286,500
2,830,600
3,560,900
5,070,500
7,543,800
3,396,800
4,154,300
5,915,600
8,801,100
3,962,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 367 -

REGIONAL 2
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,297,600
3,957,100
4,616,600
48 B-4-13-III
49 B-4-14-I

4,542,700
2,827,600
5,451,200
3,393,100
6,359,800
3,958,700
50 B-4-14-II
3,298,800
3,958,500
4,618,300
51 B-4-14-III
52 C-4-10-I

4,418,800
2,616,100
5,302,600
3,139,300
6,186,300
3,662,500
53 C-4-10-II
54 C-4-10-III

5,019,600
8,860,000
6,023,500
10,632,000
7,027,400
12,404,000
55 C-4-11-I
2,981,100
3,577,300
4,173,600
56 C-4-11-II
57 C-4-11-III

3,989,200
6,133,400
4,787,000
7,360,100
5,584,800
8,586,700
58 C-4-12-I
59 C-4-12-II
1,984,900
3,909,500
2,381,900
4,691,400
2,778,900
5,473,300
60 C-4-12-III
RADIOTERAPI (BERAT)
10,040,700
12,048,900
14,057,000
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,492,300
2,808,400
1,790,700
3,370,100
2,089,200
3,931,800
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,801,700
2,479,400
4,562,000
2,975,300
5,322,400
3,471,200
65 C-4-14-II
3,478,200
4,173,800
4,869,400
66 C-4-14-III
67 D-1-10-I

5,182,400
12,133,900
6,218,900
14,560,700
7,255,400
16,987,500
68 D-1-10-II
69 D-1-10-III

18,480,800
29,427,700
22,176,900
35,313,300
25,873,100
41,198,800
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,010,800
4,812,900
5,615,100
10,241,400
13,309,100
12,289,700
15,970,900
14,338,000
18,632,800
3,476,900
4,172,300
4,867,600
9,581,800
11,498,100
13,414,500
15,199,500
18,239,400
21,279,300
2,145,000
3,125,400
4,917,000
2,721,900
4,891,200
6,719,300
2,346,700
3,254,900
4,998,000
2,574,000
3,750,500
5,900,400
3,266,300
5,869,400
8,063,200
2,816,000
3,905,900
5,997,600
3,003,000
4,375,600
6,883,800
3,810,700
6,847,700
9,407,000
3,285,300
4,556,800
6,997,200
2,011,000
2,413,300
2,815,500
2,846,300
3,415,600
3,984,800
3,640,500
4,368,600
5,096,700
2,156,900
2,588,300
3,019,700
3,531,400
4,237,700
4,944,000
4,319,300
5,183,200
6,047,000
3,363,800
4,036,500
4,709,300
4,406,200
5,287,400
6,168,600
93 E-1-01-III
8,733,800
10,480,500
12,227,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,864,600
3,477,000
7,328,300
3,437,500
4,172,400
8,794,000
4,010,400
4,867,800
10,259,700
5,060,600
6,072,700
7,084,800
97 E-1-20-I
- 368 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,989,400
2,387,300
2,785,200
104 E-4-11-II
105 E-4-11-III

3,033,000
4,110,000
3,639,600
4,932,000
4,246,200
5,754,000
106 E-4-12-I
107 E-4-12-II

2,285,800
3,958,500
2,743,000
4,750,200
3,200,100
5,541,900
108 E-4-12-III

(RINGAN)
(SEDANG)
4,692,200
5,630,700
6,569,100
2,489,200
2,987,000
3,484,800
3,646,200
4,375,400
5,104,700
111 E-4-13-III
4,766,300
5,719,500
6,672,800
112 F-4-10-I
113 F-4-10-II
2,650,000
3,045,700
3,180,000
3,654,800
3,710,000
4,263,900
114 F-4-10-III
115 F-4-11-I
3,654,800
2,563,000
4,385,800
3,075,600
5,116,700
3,588,200
116 F-4-11-II
2,986,200
3,583,400
4,180,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,829,400
4,595,200
5,361,100
1,404,900
1,685,900
1,966,900
1,997,400
2,396,900
2,796,300
4,339,200
5,207,100
6,074,900
2,064,600
2,724,200
3,526,900
1,177,900
1,510,900
2,033,000
2,477,500
3,269,100
4,232,200
1,413,500
1,813,000
2,439,600
2,890,400
3,813,900
4,937,600
1,649,100
2,115,200
2,846,200
127 F-4-15-I
1,875,900
2,251,100
2,626,300
128 F-4-15-II
2,795,400
3,354,500
3,913,500
129 F-4-15-III
3,690,800
4,428,900
5,167,100
3,691,000
4,429,200
5,167,400
4,291,400
5,149,700
6,007,900
5,728,300
6,873,900
8,019,600
133 F-4-17-I

871,700
1,046,000
1,220,300
134 F-4-17-II
2,554,800
3,065,700
3,576,700
135
136
137
138
139
140
141

(RINGAN)
2,725,700
3,207,200
3,528,800
5,440,000
2,451,000
3,138,700
3,907,600
3,270,800
3,848,600
4,234,600
6,527,900
2,941,300
3,766,400
4,689,200
3,816,000
4,490,100
4,940,400
7,615,900
3,431,500
4,394,200
5,470,700
5,439,200
6,527,000
7,614,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,811,400
8,173,700
9,536,000
9,387,500
11,265,100
13,142,600
3,288,300
3,946,000
4,603,600
4,594,800
5,513,800
6,432,800
5,703,100
6,843,700
7,984,300
- 369 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,447,000
6,536,400
7,625,700
148 G-1-11-I
149 G-1-11-II

7,957,300
14,547,800
9,548,800
17,457,400
11,140,200
20,366,900
150 G-1-11-III
23,377,700
28,053,200
32,728,800
3,322,500
3,986,900
4,651,400
6,228,100
7,473,700
8,719,300
8,487,700
10,185,200
11,882,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,002,300
2,691,600
1,202,700
3,230,000
1,403,200
3,768,300
156 G-1-13-III
157 G-1-20-I

6,073,500
2,999,900
7,288,200
3,599,900
8,502,900
4,199,900
158 G-1-20-II
4,954,900
5,945,900
6,936,900
159 G-1-20-III
9,934,700
11,921,600
13,908,600
160 G-1-30-I
4,688,900
5,626,700
6,564,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,244,100
15,728,900
14,692,900
18,874,700
17,141,800
22,020,500
2,852,000
3,422,400
3,992,700
3,486,100
4,183,300
4,880,500
4,783,500
5,740,200
6,696,900
2,985,600
3,582,700
4,179,800
3,965,900
4,759,100
5,552,300
5,827,300
6,992,800
8,158,200
3,312,100
3,974,600
4,637,000
4,183,500
5,020,100
5,856,800
6,075,900
7,291,100
8,506,300
1,989,600
2,387,600
2,785,500
3,469,500
4,163,500
4,857,400
4,115,000
4,938,000
5,760,900
3,375,200
4,050,200
4,725,300
4,512,400
5,414,900
6,317,400
5,663,600
6,796,300
7,929,000
2,757,800
3,309,400
3,861,000
3,291,300
3,949,600
4,607,900
4,645,400
5,574,500
6,503,600
2,273,500
2,728,200
3,182,800
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,494,800
8,993,800
10,492,700
14,569,900
17,483,900
20,397,900
3,253,200
4,593,200
3,903,800
5,511,800
4,554,500
6,430,400
- 370 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,018,300
3,622,000
4,225,700
183 G-4-16-III
4,298,300
5,158,000
6,017,700
3,028,100
3,633,700
4,239,300
3,970,500
4,764,600
5,558,700
4,989,100
5,986,900
6,984,800
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,982,200
3,578,700
4,175,100
188 G-4-18-II
3,986,300
4,783,600
5,580,800
189 G-4-18-III
4,460,400
5,352,400
6,244,500
2,488,100
2,985,700
3,483,400
4,205,500
5,046,600
5,887,700
5,521,700
6,626,000
7,730,300
193 G-4-20-I

1,740,600
2,088,700
2,436,800
194 G-4-20-II
2,460,600
2,952,700
3,444,900
195 G-4-20-III
196 G-4-21-I

4,064,400
1,812,500
4,877,200
2,175,000
5,690,100
2,537,500
197 G-4-21-II
198 G-4-21-III

3,067,700
3,605,300
3,681,300
4,326,300
4,294,800
5,047,400
199 G-4-22-I
2,493,300
2,991,900
3,490,600
200 G-4-22-II
201 G-4-22-III

3,185,700
3,722,300
3,822,800
4,466,800
4,459,900
5,211,200
202 G-4-23-I
203 G-4-23-II

1,784,300
2,238,600
2,141,100
2,686,300
2,498,000
3,134,100
204 G-4-23-III
3,187,300
3,824,700
4,462,200
205 G-4-24-I
206 G-4-24-II

1,987,400
2,483,000
2,384,900
2,979,600
2,782,300
3,476,100
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,136,500
1,698,200
2,147,500
2,845,900
4,963,800
2,037,800
2,577,100
3,415,100
5,791,100
2,377,500
3,006,600
3,984,300
2,683,600
3,220,300
3,757,000
3,121,900
3,746,200
4,370,600
4,668,100
5,601,700
6,535,400
1,916,400
4,305,600
5,855,400
5,850,000
7,268,100
10,179,900
2,299,000
3,119,300
6,131,200
1,984,100
2,263,200
3,240,800
2,339,300
2,795,000
4,683,900
2,299,600
5,166,800
7,026,500
7,020,000
8,721,700
12,215,900
2,758,800
3,743,200
7,357,400
2,380,900
2,715,900
3,889,000
2,807,100
3,354,000
5,620,700
2,682,900
6,027,900
8,197,600
8,190,000
10,175,300
14,251,900
3,218,600
4,367,000
8,583,600
2,777,700
3,168,500
4,537,200
3,275,000
3,913,000
6,557,500
229 I-1-01-I
31,420,500
37,704,600
43,988,700
230 I-1-01-II
32,111,700
38,534,100
44,956,400
231 I-1-01-III

(RINGAN)
50,687,900
60,825,500
70,963,100
17,432,000
20,918,300
24,404,700
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 371 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,353,200
17,223,800
20,094,500
245 I-1-06-II
20,791,800
24,950,100
29,108,500
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,808,400
29,770,100
34,731,800
17,085,700
20,502,900
23,920,000
21,078,700
25,294,500
29,510,200
22,996,800
27,596,200
32,195,500
2,731,700
3,278,000
3,824,300
3,037,300
3,644,800
4,252,200
4,041,700
4,850,100
5,658,400
7,863,000
9,435,600
11,008,200
12,841,800
15,410,200
17,978,500
16,895,400
20,274,400
23,653,500
7,627,000
9,152,400
10,677,800
10,156,900
12,188,300
14,219,600
12,526,200
15,031,500
17,536,700
15,610,600
18,732,700
21,854,800
19,401,600
23,281,900
27,162,300
25,422,800
30,507,400
35,591,900
2,965,600
4,141,300
7,974,600
3,558,700
4,969,600
9,569,500
4,151,800
5,797,900
11,164,400
7,687,800
9,225,400
10,762,900
17,394,400
20,873,300
24,352,100
20,064,200
24,077,000
28,089,800
8,901,700
10,682,100
12,462,400
11,145,800
13,375,000
15,604,100
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,487,000
26,984,400
31,481,800
27,716,600
33,260,000
38,803,300
10,068,700
12,082,500
14,096,200
13,957,400
16,748,800
19,540,300
17,713,000
21,255,600
24,798,200
15,173,000
18,207,700
21,242,300
23,947,200
28,736,600
33,526,000
38,255,400
45,906,500
53,557,600
19,468,400
23,362,100
27,255,800
23,362,200
28,034,600
32,707,100
32,146,200
38,575,400
45,004,700
- 372 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,316,900
20,780,300
24,243,700
279 I-1-40-III
23,129,600
27,755,500
32,381,400
280 I-4-10-I
281 I-4-10-II

2,640,400
4,714,700
3,168,500
5,657,600
3,696,500
6,600,600
282 I-4-10-III
6,793,200
8,151,900
9,510,500
283 I-4-11-I
284 I-4-11-II

4,062,200
5,027,000
4,874,700
6,032,400
5,687,100
7,037,800
285 I-4-11-III
286 I-4-12-I

9,299,400
2,335,200
11,159,300
2,802,300
13,019,200
3,269,300
287 I-4-12-II
2,706,800
3,248,100
3,789,500
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,248,100
3,897,800
4,547,400
2,376,300
2,851,600
3,326,900
4,243,200
5,091,900
5,940,500
6,113,900
7,336,700
8,559,500
2,244,000
2,321,300
4,069,200
2,692,800
2,785,500
4,883,000
3,141,700
3,249,800
5,696,900
4,208,000
5,049,500
5,891,100
5,724,600
6,869,600
8,014,500
297 I-4-15-III
6,869,600
8,243,500
9,617,400
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,416,300
2,274,300
2,729,100
1,736,300
2,021,400
2,425,600
1,699,600
2,729,100
3,274,900
2,083,500
2,425,600
2,910,700
1,982,800
3,184,000
3,820,800
2,430,800
2,829,900
3,395,900
2,731,900
3,278,300
3,824,700
4,159,500
4,991,400
5,823,300
5,647,200
6,776,600
7,906,000
307 I-4-19-I
2,635,800
3,162,900
3,690,100
308 I-4-19-II

(SEDANG)
4,114,600
4,937,500
5,760,400
309 I-4-19-III
4,912,000
5,894,400
6,876,800
310
311
312
313
314

2,744,600
3,170,000
4,739,800
2,053,800
2,602,200
3,293,500
3,804,000
5,687,800
2,464,500
3,122,600
3,842,400
4,438,000
6,635,800
2,875,300
3,643,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,787,200
16,544,600
19,302,100
10,033,800
12,040,500
14,047,300
12,535,000
15,042,000
17,548,900
13,176,800
15,812,200
18,447,600
7,590,000
9,108,000
10,626,000
15,788,900
18,946,700
22,104,400
24,467,100
29,360,500
34,253,900
7,004,700
8,405,700
9,806,600
- 373 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,755,900
4,507,100
5,258,300
316 I-4-22-I
317 I-4-22-II
2,301,900
2,865,600
2,762,300
3,438,700
3,222,700
4,011,800
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,188,600
5,026,300
5,864,000
2,252,900
2,703,500
3,154,100
2,766,000
3,319,100
3,872,300
5,404,500
6,485,400
7,566,300
2,028,800
2,434,500
2,840,300
4,671,700
5,606,100
6,540,400
5,906,600
7,087,900
8,269,200
36,600,900
43,921,000
51,241,200
41,420,700
49,704,800
57,989,000
46,859,800
56,231,800
65,603,800
19,422,800
23,307,300
27,191,900
27,044,200
32,453,000
37,861,800
44,659,200
53,591,000
62,522,900
5,898,200
7,077,800
8,257,400
11,935,000
14,322,000
16,709,000
12,403,400
14,884,100
17,364,700
6,931,000
8,317,200
9,703,400
8,205,500
9,846,600
11,487,700
12,670,600
15,204,700
17,738,800
4,922,200
5,906,600
6,891,000
8,916,500
10,699,800
12,483,100
25,737,100
30,884,500
36,031,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,011,100
4,153,500
6,283,700
1,795,100
2,500,200
3,351,300
3,049,000
3,470,900
4,846,300
2,695,800
3,752,500
7,001,000
2,972,200
4,836,700
5,722,300
3,948,900
4,717,800
6,347,400
2,413,400
4,984,300
7,540,400
2,154,100
3,000,300
4,021,600
3,658,800
4,165,000
5,815,500
3,235,000
4,503,000
8,401,200
3,566,700
5,804,000
6,866,700
4,738,700
5,661,400
7,616,900
2,815,600
5,815,000
8,797,200
2,513,200
3,500,300
4,691,900
4,268,600
4,859,200
6,784,800
3,774,200
5,253,500
9,801,400
4,161,100
6,771,300
8,011,200
5,528,500
6,605,000
8,886,400
3,290,300
3,948,300
4,606,400
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 374 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,623,700
5,548,400
6,473,200
360 J-4-16-III
5,846,000
7,015,200
8,184,300
361 J-4-17-I
362 J-4-17-II

2,483,600
2,974,100
2,980,300
3,569,000
3,477,000
4,163,800
363 J-4-17-III
364 J-4-18-I

3,903,000
2,027,000
4,683,600
2,432,300
5,464,200
2,837,700
365 J-4-18-II
2,787,900
3,345,500
3,903,000
366 J-4-18-III
367 J-4-19-I

2,934,600
3,498,200
3,521,500
4,197,800
4,108,400
4,897,400
368 J-4-19-II
369 J-4-19-III

3,967,100
4,381,200
4,760,600
5,257,500
5,554,000
6,133,700
370 J-4-20-I
3,471,500
4,165,800
4,860,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,810,100
5,638,900
5,772,100
6,766,700
6,734,100
7,894,500
2,627,200
3,152,600
3,678,100
4,232,400
5,078,800
5,925,300
5,905,900
7,087,100
8,268,300
5,347,100
6,416,500
7,485,900
6,719,700
8,063,700
9,407,600
7,875,700
9,450,900
11,026,000
5,505,900
6,607,100
7,708,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,228,600
9,571,900
8,674,400
11,486,300
10,120,100
13,400,600
2,243,500
2,692,300
3,141,000
2,918,000
3,501,600
4,085,200
5,781,000
6,937,200
8,093,400
2,530,300
2,783,300
2,808,600
3,036,300
3,340,000
3,370,300
3,542,400
3,896,600
3,932,000
4,106,200
4,927,400
5,748,600
4,812,300
5,774,800
6,737,300
390 K-1-14-III
7,560,900
9,073,000
10,585,200
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,950,900
11,105,600
16,215,300
9,541,000
13,326,700
19,458,400
11,131,200
15,547,800
22,701,500
4,702,100
5,642,500
6,582,900
8,350,800
10,021,000
11,691,100
11,490,800
13,789,000
16,087,200
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,246,400
6,295,700
7,345,000
398 K-1-40-II

(SEDANG)
5,784,400
6,941,300
8,098,100
399 K-1-40-III
9,802,500
11,762,900
13,723,400
400
401
402
403
404

4,008,800
5,205,900
7,356,900
3,309,500
4,755,200
4,810,600
6,247,100
8,828,300
3,971,400
5,706,300
5,612,300
7,288,300
10,299,700
4,633,300
6,657,300
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 375 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,249,100
8,698,900
10,148,800
406 K-4-11-I
407 K-4-11-II

2,112,400
3,001,800
2,534,900
3,602,100
2,957,300
4,202,500
408 K-4-11-III
409 K-4-12-I

3,602,100
1,989,400
4,322,600
2,387,300
5,043,000
2,785,200
410 K-4-12-II
2,677,100
3,212,600
3,748,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,428,900
5,314,700
6,200,400
2,681,900
3,218,200
3,754,600
3,469,200
4,163,000
4,856,800
5,343,600
6,412,300
7,481,100
1,700,300
2,040,400
2,380,400
2,282,400
2,738,900
3,195,300
3,662,300
4,394,800
5,127,300
418 K-4-15-I
1,688,100
2,025,700
2,363,300
419 K-4-15-II
2,516,700
3,020,000
3,523,400
420 K-4-15-III
3,532,100
4,238,500
4,944,900
421 K-4-16-I
2,482,400
2,978,900
3,475,400
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,977,100
3,473,800
3,572,500
4,168,600
4,167,900
4,863,400
1,122,000
1,346,400
1,570,800
1,682,400
2,018,900
2,355,400
2,018,900
2,422,700
2,826,400
1,126,600
1,351,900
1,577,300
1,601,000
1,921,200
2,241,400
429 K-4-18-III
1,921,200
2,305,500
2,689,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,676,700
19,135,100
25,567,700
5,981,000
10,263,000
12,741,700
15,212,000
22,962,100
30,681,200
7,177,200
12,315,600
15,290,000
17,747,400
26,789,200
35,794,700
8,373,400
14,368,200
17,838,300
3,351,900
4,022,200
4,692,600
6,723,100
8,067,700
9,412,400
11,316,500
13,579,800
15,843,100
4,400,300
7,081,900
10,129,900
1,150,900
1,335,900
1,550,600
2,410,200
3,312,700
7,527,400
1,144,600
1,513,900
4,004,800
5,280,400
8,498,300
12,155,900
1,381,100
1,603,100
1,860,800
2,892,300
3,975,200
9,032,800
1,373,600
1,816,700
4,805,700
6,160,500
9,914,600
14,181,900
1,611,300
1,870,300
2,170,900
3,374,300
4,637,700
10,538,300
1,602,500
2,119,500
5,606,700
2,237,900
2,685,400
3,133,000
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 376 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,630,100
3,156,100
3,682,200
3,870,300
4,644,300
5,418,400
1,982,100
2,378,500
2,775,000
2,977,200
3,572,700
4,168,100
4,196,700
5,036,100
5,875,400
7,006,600
8,407,900
9,809,200
9,958,900
11,950,700
13,942,500
13,989,300
16,787,100
19,585,000
6,210,000
7,452,000
8,694,100
10,187,300
17,308,000
12,224,800
20,769,700
14,262,300
24,231,300
15,203,200
18,243,900
21,284,500
17,782,400
21,338,900
24,895,400
22,008,700
26,410,400
30,812,200
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,786,400
9,343,700
10,901,000
467 M-1-04-II
10,003,300
12,004,000
14,004,600
468 M-1-04-III
11,969,200
14,363,000
16,756,900
469 M-1-05-I
470 M-1-05-II

4,943,500
7,996,400
5,932,300
9,595,600
6,921,000
11,194,900
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,214,300
12,257,200
14,300,100
5,533,700
6,640,500
7,747,200
7,413,300
8,895,900
10,378,600
15,101,600
18,121,900
21,142,200
9,109,400
10,931,300
12,753,200
19,989,600
23,987,500
27,985,400
43,115,600
51,738,800
60,361,900
8,320,400
9,984,400
11,648,500
10,630,100
12,756,200
14,882,200
480 M-1-20-III
26,465,800
31,758,900
37,052,100
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,708,000
9,249,300
13,225,600
6,849,600
11,099,100
15,870,800
7,991,200
12,949,000
18,515,900
2,905,600
3,486,700
4,067,800
5,152,900
6,183,500
7,214,100
7,357,400
8,828,900
10,300,400
3,481,900
5,778,200
9,490,300
4,178,300
6,933,800
11,388,300
4,874,700
8,089,400
13,286,400
5,377,500
6,453,000
7,528,500
6,760,800
8,112,900
9,465,100
10,213,000
12,255,500
14,298,100
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 377 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,995,000
2,394,000
2,793,000
500 M-4-10-II
501 M-4-10-III
2,975,200
5,629,200
3,570,300
6,755,000
4,165,300
7,880,800
2,486,000
2,983,200
3,480,400
5,450,400
6,540,500
7,630,600
7,880,300
9,456,400
11,032,500
1,984,400
2,381,200
2,778,100
3,300,600
3,960,700
4,620,800
4,414,800
5,297,800
6,180,800
3,304,200
3,965,000
4,625,800
4,964,400
5,957,300
6,950,100
9,685,400
11,622,500
13,559,600
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,768,300
4,522,000
5,275,600
512 M-4-14-II
4,647,600
5,577,200
6,506,700
513 M-4-14-III
514 M-4-15-I
6,984,000
2,234,500
8,380,900
2,681,400
9,777,700
3,128,300
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,978,400
6,758,900
1,913,100
3,063,600
5,146,600
3,574,100
8,110,700
2,295,700
3,676,300
6,175,900
4,169,800
9,462,500
2,678,300
4,289,000
7,205,200
2,482,900
2,979,500
3,476,100
3,472,600
4,167,100
4,861,700
4,849,300
5,819,100
6,789,000
1,876,700
2,828,300
3,405,300
2,252,000
3,393,900
4,086,400
2,627,400
3,959,600
4,767,500
1,957,100
2,348,500
2,739,900
3,296,500
3,955,800
4,615,100
6,438,300
7,725,900
9,013,600
1,974,200
2,369,000
2,763,800
2,890,800
3,469,000
4,047,200
3,230,800
3,877,000
4,523,200
1,987,800
2,385,400
2,783,000
2,486,200
2,983,400
3,480,700
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,962,800
11,955,400
13,947,900
10,959,100
13,150,900
15,342,700
12,546,700
15,056,000
17,565,400
5,663,400
6,796,100
7,928,800
6,725,900
15,138,500
8,071,000
18,166,200
9,416,200
21,193,800
- 378 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,574,000
6,688,800
7,803,600
535 N-1-01-I

63,646,100
76,375,300
89,104,500
536 N-1-01-II
63,646,100
76,375,300
89,104,500
537 N-1-01-III
538 N-1-11-I

63,646,100
5,733,900
76,375,300
6,880,600
89,104,500
8,027,400
539 N-1-11-II
540 N-1-11-III

9,066,600
14,134,800
10,879,900
16,961,800
12,693,300
19,788,800
2,922,400
3,506,800
4,091,300
5,818,100
6,981,700
8,145,300
12,625,500
15,150,600
17,675,700
6,389,400
7,667,200
8,945,100

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,941,600
12,512,700
10,729,900
15,015,200
12,518,200
17,517,700
5,847,400
7,016,900
8,186,400
8,846,000
10,615,200
12,384,400
10,180,900
12,217,000
14,253,200
5,251,400
6,301,700
7,351,900
7,131,300
8,557,500
9,983,800
8,299,800
9,959,800
11,619,800
2,231,100
2,677,300
3,123,600
2,698,600
3,238,300
3,778,000
3,969,200
4,763,000
5,556,900
1,712,700
2,992,400
3,723,100
2,016,000
3,948,600
4,752,700
3,208,400
3,869,700
5,930,100
2,055,300
3,590,800
4,467,700
2,419,200
4,738,300
5,703,300
3,850,100
4,643,600
7,116,100
2,397,800
4,189,300
5,212,400
2,822,400
5,528,000
6,653,800
4,491,800
5,417,600
8,302,100
1,720,100
2,064,200
2,408,200
2,440,800
2,929,000
3,417,100
3,912,600
4,695,100
5,477,600
2,032,100
2,438,600
2,845,000
2,521,500
3,025,800
3,530,100
2,877,500
3,453,000
4,028,500
2,488,300
2,986,000
3,483,700
3,551,700
4,262,000
4,972,300
4,727,500
5,673,000
6,618,500
4,462,200
4,720,600
5,354,600
5,664,700
6,247,000
6,608,800
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 379 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,539,400
6,647,200
7,755,100
2,313,000
2,775,600
3,238,200
2,570,700
3,084,800
3,598,900
3,197,900
3,837,500
4,477,100
1,638,700
1,966,500
2,294,200
1,968,100
2,361,700
2,755,400
2,473,000
2,967,600
3,462,200
1,525,200
1,830,300
2,135,300

MAYOR (RINGAN)
MAYOR (SEDANG)
1,805,300
2,166,300
2,166,300
2,599,600
2,527,400
3,032,800
36,593,500
43,912,200
51,230,900
45,279,000
54,334,800
63,390,600
53,144,800
63,773,800
74,402,700
49,948,400
59,938,100
69,927,800
57,295,800
68,755,000
80,214,200
65,464,600
78,557,500
91,650,400
6,087,400
7,304,900
8,522,400
8,644,100
10,373,000
12,101,800
9,767,900
11,721,500
13,675,000
19,754,200
23,705,000
27,655,800
25,636,600
30,763,900
35,891,300
36,756,500
44,107,800
51,459,100
10,741,700
12,890,000
15,038,300
20,253,300
24,304,000
28,354,700
24,715,900
29,659,100
34,602,300
3,544,300
4,253,200
4,962,100
9,937,500
11,925,000
13,912,500
13,164,800
15,797,700
18,430,700
3,433,000
4,119,700
4,806,300
9,625,500
11,550,600
13,475,700
12,751,400
15,301,700
17,852,000
3,629,400
4,355,300
5,081,200
5,150,100
6,180,100
7,210,100
8,339,100
10,006,900
11,674,700
5,751,000
6,901,200
8,051,400
8,166,400
9,799,700
11,433,000
- 380 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,228,100
11,073,700
12,919,300
5,433,200
6,519,800
7,606,400
7,725,200
9,270,200
10,815,300
8,743,400
10,492,000
12,240,700
4,714,100
5,657,000
6,599,800
6,222,600
7,467,200
8,711,700
9,265,800
11,118,900
12,972,100
2,386,800
2,864,200
3,341,500
4,858,600
5,830,300
6,802,000
9,014,500
10,817,400
12,620,300
1,790,100
2,148,200
2,506,200
3,584,800
4,301,800
5,018,700
4,206,100
5,047,400
5,888,600
1,620,100
1,944,100
2,268,100
3,113,300
3,735,900
4,358,600
6,348,800
7,618,500
8,888,300
3,142,800
3,771,300
4,399,900
5,657,000
6,788,300
7,919,700
7,721,500
9,265,800
10,810,100
1,826,600
2,192,000
2,557,300
2,250,700
2,700,800
3,151,000
3,081,000
3,697,100
4,313,300
1,541,300
2,260,100
3,862,800
1,342,900
1,787,400
3,098,500
1,849,500
2,712,100
4,635,400
1,611,500
2,144,900
3,718,200
2,157,800
3,164,200
5,408,000
1,880,100
2,502,400
4,337,900
1,983,200
2,379,800
2,776,400
3,518,300
4,221,900
4,925,600
5,710,600
6,852,700
7,994,900
1,003,600
1,204,300
1,405,100
2,131,800
2,558,100
2,984,500
4,042,600
4,851,100
5,659,600
671,200
805,500
939,700
1,266,700
1,520,100
1,773,400
1,640,600
1,968,700
2,296,900
3,475,700
4,170,900
4,866,000
- 381 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,420,300
5,304,400
6,188,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,329,000
7,594,800
8,860,600
1,675,200
2,010,300
2,345,300
2,486,300
2,983,500
3,480,800
2,990,300
3,588,300
4,186,400
1,120,900
1,345,000
1,569,200
1,505,500
1,806,600
2,107,700
2,738,700
3,286,400
3,834,200
511,200
613,400
715,600
974,300
1,169,100
1,364,000
1,416,300
1,699,600
1,982,800
605,400
726,400
847,500
952,600
1,143,200
1,333,700
1,534,300
1,841,200
2,148,100
1,058,700
1,270,500
1,482,200
1,600,600
1,920,700
2,240,800
2,498,000
2,997,600
3,497,200
3,662,900
4,395,500
5,128,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,686,300
15,018,900
6,823,500
18,022,700
7,960,800
21,026,500
5,666,700
6,800,000
7,933,300
7,183,300
8,620,000
10,056,700
10,335,700
12,402,800
14,470,000
4,427,900
6,789,900
9,973,000
4,197,700
4,891,000
8,107,700
5,313,400
8,147,900
11,967,500
5,037,300
5,869,200
9,729,300
6,199,000
9,505,900
13,962,100
5,876,800
6,847,400
11,350,800
2,662,700
3,195,200
3,727,700
3,267,700
3,921,300
4,574,800
3,872,300
4,646,700
5,421,200
2,950,900
4,195,400
5,407,700
3,541,100
5,034,500
6,489,200
4,131,300
5,873,500
7,570,700
4,042,300
4,850,800
5,659,300
6,016,100
7,219,300
8,422,600
15,444,500
18,533,400
21,622,400
3,466,700
4,700,800
9,192,500
4,160,100
5,640,900
11,031,000
4,853,400
6,581,100
12,869,500
2,494,800
2,993,800
3,492,700
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 382 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,516,300
1,819,600
2,122,800
697 U-4-12-I
698 U-4-12-II

2,379,300
2,767,600
2,855,100
3,321,100
3,331,000
3,874,600
699 U-4-12-III

3,590,300
4,308,400
5,026,500
1,803,200
2,163,800
2,524,400
2,125,800
2,550,900
2,976,100
2,542,500
3,051,000
3,559,500
2,483,200
2,973,500
2,979,800
3,568,200
3,476,500
4,163,000

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,993,500
5,992,200
6,990,900
1,993,900
2,392,700
2,791,500
2,484,200
2,981,000
3,477,800
3,476,600
4,172,000
4,867,300
3,252,300
3,902,700
4,553,200
6,699,500
8,039,400
9,379,300
8,216,000
9,859,200
11,502,400
6,187,300
7,065,100
11,064,300
7,424,700
8,478,100
13,277,100
8,662,200
9,891,200
15,490,000
5,817,200
6,980,700
8,144,100
7,943,900
9,532,600
11,121,400
10,068,900
12,082,700
14,096,500
3,034,300
3,641,200
4,248,100
5,797,600
6,957,100
8,116,700
9,095,700
10,914,900
12,734,000
5,950,300
7,140,400
8,330,400
8,645,600
10,374,800
12,103,900
10,795,600
12,954,800
15,113,900
958,300
1,057,500
1,169,800
1,150,000
1,269,000
1,403,700
1,341,600
1,480,500
1,637,700
2,877,500
3,453,000
4,028,500
4,779,600
5,735,600
6,691,500
7,879,900
9,455,900
11,031,900
2,486,300
2,983,600
3,480,800
3,336,000
4,003,200
4,670,400
4,468,600
5,362,300
6,256,000
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,711,400
6,853,700
7,995,900
8,768,700
10,522,500
12,276,200
1,189,300
1,441,300
1,427,100
1,729,600
1,665,000
2,017,900
- 383 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,776,800
8,132,200
9,487,500
8,122,500
9,746,900
11,371,400
11,590,500
13,908,600
16,226,700
1,437,500
1,724,900
2,012,400
1,586,200
1,754,700
1,903,500
2,105,600
2,220,700
2,456,500
1,502,500
1,802,900
2,103,400
1,658,000
1,989,500
2,321,100
1,834,000
2,200,800
2,567,600
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,616,300
1,939,600
2,262,900
743 W-1-12-II
744 W-1-12-III

2,017,500
3,572,500
2,421,000
4,287,000
2,824,500
5,001,500
745 W-1-13-I
1,661,500
1,993,800
2,326,000
746 W-1-13-II
747 W-1-13-III

1,803,800
2,422,900
2,164,500
2,907,500
2,525,300
3,392,100
748 W-1-20-I
749 W-1-20-II

5,564,100
6,952,400
6,676,900
8,342,800
7,789,700
9,733,300
750 W-1-20-III
8,059,600
9,671,500
11,283,400
751 W-1-30-I
3,141,000
3,769,200
4,397,400
752 W-1-30-II
5,009,900
6,011,900
7,013,800
753 W-1-30-III
12,292,000
14,750,400
17,208,800
754 W-4-10-I
2,340,400
2,808,400
3,276,500
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,469,500
6,856,400
2,128,400
3,231,200
3,933,000
4,163,400
8,227,700
2,554,100
3,877,500
4,719,600
4,857,300
9,599,000
2,979,800
4,523,700
5,506,200
2,637,400
3,164,900
3,692,300
3,620,900
4,345,100
5,069,300
3,947,000
4,736,400
5,525,800
837,400
1,143,900
1,422,500
1,119,100
1,332,000
1,704,100
1,484,000
1,648,100
2,281,900
1,974,500
2,640,400
3,578,600
1,456,900
2,630,600
3,889,200
1,966,100
2,609,800
3,707,400
1,684,600
2,023,300
2,781,200
1,004,900
1,372,700
1,707,000
1,342,900
1,598,400
2,045,000
1,780,800
1,977,700
2,738,200
2,369,400
3,168,400
4,294,300
1,748,300
3,156,700
4,667,100
2,359,400
3,131,700
4,448,800
2,021,500
2,428,000
3,337,400
1,172,400
1,601,500
1,991,500
1,566,700
1,864,800
2,385,800
2,077,600
2,307,300
3,194,600
2,764,200
3,696,500
5,010,000
2,039,700
3,682,800
5,444,900
2,752,600
3,653,700
5,190,300
2,358,500
2,832,600
3,893,600
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 384 -

REGIONAL 2
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
783,400
940,100
1,096,800
1,908,800
2,290,600
2,672,400
2,420,800
2,904,900
3,389,100
- 385 -

REGIONAL 2
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
911,200
1,182,000
2,198,000
1,816,400
2,360,500
434,200
771,800
339,500
620,800
643,300
730,300
1,097,900
1,497,600
1,372,600
444,700
1,026,300
372,300
639,100
1,946,800
697,200
1,646,500
401,700
937,100
1,466,800
1,230,300
301,700
914,400
508,400
261,400
282,600
249,500
298,300
415,400
356,900
336,000
302,000
448,000
195,700
230,600
264,400
5,364,700
2,144,000
2,151,200
553,400
906,100
567,300
1,153,100
738,900
423,100
319,500
515,300
284,400
243,500
1,900,300
886,800
506,800
1,978,200
1,318,800
256,800
2,143,100
1,483,700
3,337,300
770,800
474,100
255,000
212,500
239,500
3,651,600
1,777,500
- 386 -

REGIONAL 2
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,259,000
3,998,000
3,314,800
2,525,200
832,500
2,810,600
1,835,200
451,100
4,219,700
3,820,100
2,561,400
2,426,600
299,900
288,200
1,159,600
316,900
282,400
312,100
1,071,100
1,463,100
1,277,900
1,128,600
683,500
284,000
500,600
343,600
310,300
302,300
383,800
437,700
256,600
736,500
1,342,200
1,030,300
2,422,100
315,400
315,400
2,238,200
1,301,400
249,700
1,155,000
3,000,300
688,800
542,600
265,800
229,400
287,900
401,500
961,300
847,300
593,100
442,500
243,500
1,029,900
825,300
352,600
402,400
1,318,500
291,600
1,347,100
1,030,600
314,300
348,400
340,300
206,000
1,122,900
1,542,900
305,800
- 387 -

REGIONAL 2
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
937,100
349,800
378,200
350,200
555,600
427,400
1,070,300
315,800
878,600
1,174,000
257,100
1,565,000
848,100
1,832,700
925,200
408,600
314,300
66,200
407,300
920,500
358,700
484,500
277,100
107,800
279,800
4,166,900
2,368,500
3,953,100
971,100
542,600
369,700
836,200
442,300
890,000
515,300
306,800
513,500
231,200
352,900
338,100
744,400
1,613,100
1,297,900
1,144,300
807,600
297,100
297,100
297,100
242,700
153,900
242,000
295,800
320,000
235,700
207,900
92,800
102,100
75,500
88,600
84,500
128,900
115,600
165,200
181,400
102,700
124,600
85,200
132,900
188,600
- 388 -

REGIONAL 2
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
134,300
185,400
524,200
607,700
127,000
252,200
154,500
220,600
424,300
363,300
261,100
247,300
126,200
124,000
291,200
183,800
263,600
186,700
142,800
1,831,400
1,883,800
299,300
310,000
592,800
744,600
758,800
392,000
1,221,600
264,100
318,600
319,600
255,900
323,300
305,900
143,300
314,900
279,100
252,500
285,500
2,363,600
306,900
850,600
305,100
434,100
455,700
363,500
738,700
756,500
806,600
705,500
1,225,500
210,200
1,459,400
277,100
739,800
1,681,200
1,944,000
849,200
307,800
600,200
597,900
277,100
2,171,900
1,708,300
138,000
151,000
196,200
264,200
- 389 -

REGIONAL 2
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
922,600
436,700
900,200
1,086,000
520,400
723,900
500,400
538,400
582,600
298,200
705,000
180,300
667,800
993,200
73,200
- 390 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,558,700
4,270,400
A-4-10-II
SEPTIKEMIA (SEDANG)
6,079,700
7,295,700
8,511,600
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,197,400
4,314,900
9,836,900
5,177,900
11,476,400
6,040,800
5
6
A-4-11-II
A-4-11-III

6,141,300
8,500,100
7,369,600
10,200,200
8,597,900
11,900,200
A-4-12-I
2,814,100
3,376,900
3,939,700
8
9
A-4-12-II
A-4-12-III

4,857,600
6,998,900
5,829,100
8,398,600
6,800,600
9,798,400
10 A-4-13-I
11 A-4-13-II

2,094,500
3,701,400
2,513,300
4,441,700
2,932,200
5,182,000
12 A-4-13-III
4,441,700
5,330,100
6,218,400
2,346,400
2,815,700
3,284,900
3,947,900
4,737,500
5,527,100
4,737,500
5,685,000
6,632,500
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,318,100
22,812,200
21,981,800
27,374,600
25,645,400
31,937,000
18 A-4-15-III
INFEKSI HIV (BERAT)
25,771,300
30,925,600
36,079,900
19 B-1-01-I
20 B-1-01-II

50,506,900
55,722,400
60,608,300
66,866,900
70,709,700
78,011,400
21 B-1-01-III
22 B-1-10-I

122,827,200
8,164,200
147,392,700
9,797,000
171,958,100
11,429,800
23 B-1-10-II
18,120,900
21,745,000
25,369,200
24 B-1-10-III
25 B-1-11-I

35,773,000
32,578,500
42,927,600
39,094,200
50,082,200
45,609,900
26 B-1-11-II
27 B-1-11-III

38,819,000
59,986,300
46,582,800
71,983,500
54,346,600
83,980,800
28 B-1-12-I
9,586,700
11,504,000
13,421,400
29 B-1-12-II
10,662,100
12,794,500
14,927,000
30 B-1-12-III
16,679,700
20,015,600
23,351,600
7,635,900
9,163,100
10,690,300
12,564,000
15,076,800
17,589,600
16,256,700
19,508,000
22,759,300
20,006,000
24,007,200
28,008,400
21,012,000
25,214,300
29,416,700
37,194,800
3,246,200
5,181,900
7,148,700
44,633,800
3,895,500
6,218,300
8,578,400
52,072,700
4,544,700
7,254,700
10,008,100
6,844,300
8,213,200
9,582,000
9,582,100
11,498,500
13,415,000
11,608,600
13,930,300
16,252,000
6,188,000
8,811,500
13,109,600
5,902,900
7,425,600
10,573,800
15,731,500
7,083,400
8,663,200
12,336,100
18,353,400
8,264,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
4,982,200
- 391 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,876,600
8,251,900
9,627,200
48 B-4-13-III
49 B-4-14-I

9,473,100
5,896,600
11,367,700
7,075,900
13,262,300
8,255,200
50 B-4-14-II
6,879,100
8,254,900
9,630,700
51 B-4-14-III
52 C-4-10-I

9,214,700
11,942,800
11,057,600
14,331,400
12,900,600
16,720,000
53 C-4-10-II
54 C-4-10-III

19,207,400
35,988,400
23,048,900
43,186,100
26,890,300
50,383,800
55 C-4-11-I
6,216,600
7,460,000
8,703,300
56 C-4-11-II
57 C-4-11-III

8,318,700
12,790,200
9,982,500
15,348,200
11,646,200
17,906,300
58 C-4-12-I
59 C-4-12-II
4,139,200
8,152,700
4,967,100
9,783,200
5,794,900
11,413,700
60 C-4-12-III
RADIOTERAPI (BERAT)
20,938,300
25,126,000
29,313,700
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,111,900
5,856,500
3,734,200
7,027,900
4,356,600
8,199,200
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
7,927,800
5,170,500
9,513,300
6,204,600
11,098,900
7,238,700
65 C-4-14-II
7,253,200
8,703,800
10,154,400
66 C-4-14-III
67 D-1-10-I

10,807,000
31,238,600
12,968,500
37,486,400
15,129,900
43,734,100
68 D-1-10-II
69 D-1-10-III

47,578,600
68,185,300
57,094,400
81,822,400
66,610,100
95,459,400
70 D-1-11-I
8,363,800
10,036,600
11,709,400
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,356,800
27,754,000
25,628,200
33,304,800
29,899,500
38,855,600
7,250,500
8,700,600
10,150,700
19,981,300
23,977,500
27,973,800
31,696,100
38,035,400
44,374,600
2,865,200
4,702,100
7,397,500
5,676,100
10,199,800
14,012,000
4,893,600
6,787,500
10,422,600
3,438,200
5,642,500
8,877,000
6,811,400
12,239,800
16,814,400
5,872,300
8,145,000
12,507,100
4,011,300
6,582,900
10,356,500
7,946,600
14,279,700
19,616,800
6,851,100
9,502,600
14,591,600
4,193,700
5,032,500
5,871,200
5,935,500
7,122,600
8,309,700
7,591,700
9,110,100
10,628,400
4,497,900
5,397,500
6,297,100
7,364,300
8,837,100
10,310,000
9,007,200
10,808,700
12,610,100
8,966,100
10,759,300
12,552,600
12,240,100
14,688,100
17,136,100
93 E-1-01-III
29,512,100
35,414,500
41,316,900
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,321,900
12,939,900
24,447,600
11,186,200
15,527,800
29,337,100
13,050,600
18,115,800
34,226,700
10,553,100
12,663,700
14,774,300
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 392 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,148,600
4,978,300
5,808,100
104 E-4-11-II
105 E-4-11-III

6,324,900
8,570,700
7,589,900
10,284,900
8,854,900
11,999,000
106 E-4-12-I
107 E-4-12-II

4,766,700
8,254,800
5,720,000
9,905,700
6,673,400
11,556,700
108 E-4-12-III

(RINGAN)
(SEDANG)
9,784,900
11,741,900
13,698,900
5,190,700
6,228,900
7,267,000
7,603,500
9,124,200
10,645,000
111 E-4-13-III
9,939,300
11,927,200
13,915,100
112 F-4-10-I
113 F-4-10-II
5,526,200
6,351,300
6,631,500
7,621,500
7,736,700
8,891,800
114 F-4-10-III
115 F-4-11-I
7,621,500
5,344,700
9,145,800
6,413,700
10,670,100
7,482,600
116 F-4-11-II
6,227,200
7,472,600
8,718,100
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,985,500
9,582,600
11,179,700
2,929,800
3,515,700
4,101,700
4,165,200
4,998,300
5,831,300
9,048,700
10,858,500
12,668,200
4,305,300
5,681,000
7,354,700
2,456,400
3,150,700
4,239,500
5,166,400
6,817,100
8,825,700
2,947,700
3,780,800
5,087,400
6,027,400
7,953,300
10,296,600
3,438,900
4,410,900
5,935,300
127 F-4-15-I
3,912,000
4,694,400
5,476,700
128 F-4-15-II
5,829,300
6,995,200
8,161,000
129 F-4-15-III
7,696,500
9,235,800
10,775,200
7,697,000
9,236,400
10,775,800
8,949,000
10,738,800
12,528,600
11,945,400
14,334,400
16,723,500
133 F-4-17-I

1,817,700
2,181,300
2,544,800
134 F-4-17-II
5,327,500
6,393,000
7,458,500
135
136
137
138
139
140
141

(RINGAN)
5,684,000
6,688,100
7,358,800
11,344,200
5,111,300
6,545,200
8,148,700
6,820,800
8,025,700
8,830,600
13,613,000
6,133,500
7,854,300
9,778,500
7,957,600
9,363,300
10,302,300
15,881,800
7,155,800
9,163,300
11,408,200
21,682,600
26,019,100
30,355,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,204,100
17,045,000
19,885,800
19,576,200
23,491,500
27,406,700
3,734,700
4,481,600
5,228,600
7,233,500
8,680,200
10,126,900
12,120,500
14,544,600
16,968,700
- 393 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,739,100
60,887,000
71,034,800
148 G-1-11-I
149 G-1-11-II

16,593,700
30,337,100
19,912,400
36,404,500
23,231,100
42,471,900
150 G-1-11-III
48,750,400
58,500,500
68,250,600
6,928,400
8,314,100
9,699,800
12,987,700
15,585,200
18,182,800
17,699,700
21,239,600
24,779,500
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,090,100
5,613,000
2,508,100
6,735,600
2,926,100
7,858,200
156 G-1-13-III
157 G-1-20-I

12,665,400
11,733,700
15,198,500
14,080,500
17,731,500
16,427,200
158 G-1-20-II
17,755,000
21,306,000
24,857,000
159 G-1-20-III
30,275,400
36,330,500
42,385,600
160 G-1-30-I
29,231,700
35,078,100
40,924,400
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
39,411,500
59,183,300
47,293,800
71,020,000
55,176,100
82,856,600
5,947,300
7,136,800
8,326,200
7,269,600
8,723,600
10,177,500
9,975,200
11,970,200
13,965,200
6,225,900
7,471,100
8,716,300
8,270,300
9,924,400
11,578,500
12,151,900
14,582,300
17,012,700
6,906,900
8,288,300
9,669,700
8,723,900
10,468,700
12,213,500
12,670,400
15,204,500
17,738,600
4,149,100
4,978,900
5,808,700
7,235,200
8,682,200
10,129,300
8,581,100
10,297,300
12,013,500
7,038,400
8,446,100
9,853,800
9,409,900
11,291,800
13,173,800
11,810,500
14,172,600
16,534,700
5,751,000
6,901,200
8,051,400
6,863,500
8,236,200
9,609,000
9,687,300
11,624,800
13,562,200
4,740,900
5,689,100
6,637,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
31,098,000
37,317,600
43,537,200
50,879,000
61,054,700
71,230,500
33,712,600
41,289,500
40,455,100
49,547,400
47,197,600
57,805,300
- 394 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,294,200
7,553,100
8,811,900
183 G-4-16-III
8,963,500
10,756,200
12,548,900
6,314,600
7,577,500
8,840,400
8,279,800
9,935,800
11,591,800
10,404,000
12,484,800
14,565,600
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,218,900
7,462,700
8,706,500
188 G-4-18-II
8,312,800
9,975,400
11,637,900
189 G-4-18-III
9,301,400
11,161,600
13,021,900
5,188,600
6,226,300
7,264,000
8,769,900
10,523,900
12,277,900
11,514,500
13,817,400
16,120,300
193 G-4-20-I

3,629,700
4,355,600
5,081,500
194 G-4-20-II
5,131,200
6,157,500
7,183,700
195 G-4-20-III
196 G-4-21-I

8,475,600
3,779,700
10,170,700
4,535,700
11,865,800
5,291,600
197 G-4-21-II
198 G-4-21-III

6,397,200
7,518,200
7,676,700
9,021,900
8,956,100
10,525,500
199 G-4-22-I
2,831,700
3,398,100
3,964,400
200 G-4-22-II
201 G-4-22-III

5,015,100
7,910,800
6,018,100
9,493,000
7,021,100
11,075,100
202 G-4-23-I
203 G-4-23-II

3,720,800
4,668,300
4,464,900
5,601,900
5,209,100
6,535,600
204 G-4-23-III
6,646,500
7,975,800
9,305,100
205 G-4-24-I
206 G-4-24-II

4,144,400
5,177,800
4,973,300
6,213,400
5,802,100
7,248,900
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,626,100
3,541,300
4,478,400
5,934,700
10,351,300
4,249,600
5,374,000
7,121,700
12,076,500
4,957,800
6,269,700
8,308,600
4,037,400
4,844,800
5,652,300
4,696,700
5,636,000
6,575,400
7,023,000
8,427,600
9,832,200
11,942,600
13,198,400
17,949,100
8,137,900
10,110,500
14,161,200
4,314,800
5,854,300
11,507,000
4,137,500
4,719,600
6,758,200
4,878,200
5,828,500
9,767,500
14,331,100
15,838,100
21,538,900
9,765,400
12,132,600
16,993,400
5,177,800
7,025,200
13,808,400
4,965,000
5,663,600
8,109,900
5,853,800
6,994,200
11,721,100
16,719,600
18,477,800
25,128,700
11,393,000
14,154,700
19,825,700
6,040,800
8,196,100
16,109,800
5,792,500
6,607,500
9,461,500
6,829,400
8,159,900
13,674,600
229 I-1-01-I
65,522,400
78,626,800
91,731,300
230 I-1-01-II
66,963,800
80,356,600
93,749,400
231 I-1-01-III

(RINGAN)
105,701,500
126,841,800
147,982,100
36,351,500
43,621,900
50,892,200
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 395 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,871,700
58,646,100
245 I-1-06-II
70,794,700
84,953,600
99,112,500
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
84,471,100
101,365,300
118,259,500
76,070,000
91,284,000
106,498,000
95,087,500
114,105,000
133,122,500
142,631,300
171,157,500
199,683,800
5,696,400
6,835,700
7,975,000
6,333,800
7,600,600
8,867,400
8,428,400
10,114,100
11,799,800
16,397,000
19,676,400
22,955,800
26,779,600
32,135,500
37,491,400
35,232,500
42,279,000
49,325,500
15,904,800
19,085,800
22,266,800
21,180,500
25,416,600
29,652,700
26,121,500
31,345,700
36,570,000
32,553,300
39,064,000
45,574,600
40,458,900
48,550,700
56,642,500
53,015,200
63,618,200
74,221,200
6,184,200
8,636,100
16,629,700
7,421,000
10,363,300
19,955,600
8,657,900
12,090,500
23,281,600
16,031,700
19,238,000
22,444,300
36,273,200
43,527,800
50,782,500
41,840,600
50,208,700
58,576,800
18,563,100
22,275,800
25,988,400
23,242,800
27,891,400
32,539,900
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
46,893,000
56,271,600
65,650,200
57,798,600
69,358,300
80,918,000
34,283,400
41,140,100
47,996,800
47,523,900
57,028,700
66,533,500
60,311,500
72,373,800
84,436,100
51,663,200
61,995,900
72,328,500
81,538,500
97,846,200
114,153,900
130,257,300
156,308,700
182,360,200
85,578,800
102,694,500
119,810,300
104,596,300
125,515,500
146,434,800
142,631,300
171,157,500
199,683,800
68,420,400
- 396 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,111,700
43,334,000
50,556,400
279 I-1-40-III
48,233,000
57,879,600
67,526,200
280 I-4-10-I
281 I-4-10-II

5,506,100
9,831,800
6,607,300
11,798,100
7,708,500
13,764,500
282 I-4-10-III
14,166,200
16,999,400
19,832,700
283 I-4-11-I
284 I-4-11-II

8,471,100
10,483,000
10,165,300
12,579,600
11,859,500
14,676,200
285 I-4-11-III
286 I-4-12-I

19,392,500
4,869,600
23,271,000
5,843,600
27,149,500
6,817,500
287 I-4-12-II
5,644,600
6,773,600
7,902,500
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,773,600
8,128,300
9,483,000
4,955,500
5,946,600
6,937,700
8,848,600
10,618,300
12,388,000
12,749,600
15,299,500
17,849,400
4,679,600
4,840,600
8,485,600
5,615,500
5,808,700
10,182,800
6,551,400
6,776,900
11,879,900
4,779,200
5,735,000
6,690,800
9,012,100
10,814,500
12,616,900
10,814,500
12,977,400
15,140,300
2,953,500
4,742,600
5,691,100
1,972,000
3,182,100
4,455,000
3,544,200
5,691,100
6,829,400
2,366,400
3,818,600
5,346,000
4,134,900
6,639,700
7,967,600
2,760,800
4,455,000
6,237,000
5,697,000
6,836,400
7,975,800
8,673,900
10,408,700
12,143,500
11,776,300
14,131,500
16,486,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
28,751,000
34,501,200
40,251,400
20,923,900
25,108,600
29,293,400
26,139,600
31,367,600
36,595,500
27,478,200
32,973,800
38,469,400
15,827,700
18,993,300
22,158,800
32,925,200
39,510,200
46,095,200
51,022,100
61,226,600
71,431,000
14,607,300
17,528,700
20,450,200
307 I-4-19-I
5,496,500
6,595,800
7,695,000
308 I-4-19-II

(SEDANG)
8,580,300
10,296,300
12,012,400
309 I-4-19-III
10,243,200
12,291,900
14,340,500
310
311
312
313
314

5,723,400
6,610,600
9,884,200
3,854,500
4,883,700
6,868,100
7,932,700
11,861,000
4,625,400
5,860,500
8,012,800
9,254,800
13,837,900
5,396,300
6,837,200
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 397 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,049,100
8,459,000
9,868,800
316 I-4-22-I
317 I-4-22-II
3,463,200
4,311,100
4,155,800
5,173,400
4,848,500
6,035,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,301,500
7,561,800
8,822,100
4,698,100
5,637,700
6,577,400
5,768,000
6,921,500
8,075,100
11,270,300
13,524,300
15,778,400
3,052,200
3,662,700
4,273,100
7,028,400
8,434,100
9,839,800
8,886,200
10,663,400
12,440,700
96,707,900
116,049,400
135,391,000
109,442,900
131,331,500
153,220,100
150,119,900
180,143,800
210,167,800
63,090,200
75,708,200
88,326,300
79,607,500
95,529,100
111,450,600
93,129,600
111,755,500
130,381,400
12,299,700
14,759,600
17,219,600
24,888,500
29,866,200
34,843,900
25,865,300
31,038,300
36,211,400
33,883,500
40,660,100
47,436,800
35,480,500
42,576,600
49,672,700
39,928,700
47,914,400
55,900,200
10,264,400
12,317,300
14,370,200
18,593,900
22,312,600
26,031,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
53,670,500
64,404,600
75,138,700
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,025,700
6,248,800
9,453,600
3,743,400
5,213,900
6,988,700
6,358,200
7,237,900
10,106,100
5,621,700
7,825,300
14,599,400
6,198,100
10,086,100
11,932,800
4,485,000
7,427,100
13,489,900
3,630,800
7,498,600
11,344,300
4,492,100
6,256,600
8,386,400
7,629,900
8,685,500
12,127,300
6,746,100
9,390,300
17,519,300
7,437,700
12,103,300
14,319,400
5,382,000
8,912,600
16,187,800
4,236,000
8,748,400
13,235,000
5,240,800
7,299,400
9,784,100
8,901,500
10,133,100
14,148,600
7,870,400
10,955,400
20,439,200
8,677,300
14,120,500
16,706,000
6,279,000
10,398,000
18,885,800
3,736,900
4,484,300
5,231,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 398 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,278,900
8,734,700
10,190,500
12,424,100
14,909,000
17,393,800
5,179,100
6,202,100
6,214,900
7,442,500
7,250,700
8,682,900

8,139,000
2,302,100
9,766,800
2,762,500
11,394,600
3,222,900
365 J-4-18-II
4,388,900
5,266,600
6,144,400
366 J-4-18-III
367 J-4-19-I

6,236,800
6,565,400
7,484,100
7,878,500
8,731,500
9,191,500
368 J-4-19-II
369 J-4-19-III

7,445,600
8,222,700
8,934,700
9,867,300
10,423,800
11,511,800
370 J-4-20-I
5,222,700
6,267,200
7,311,800
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,236,600
8,483,500
8,683,900
10,180,200
10,131,200
11,876,900
2,983,800
3,580,600
4,177,400
6,662,900
7,995,400
9,328,000
12,551,600
15,061,900
17,572,300
11,150,400
13,380,500
15,610,600
14,012,900
16,815,500
19,618,000
16,423,600
19,708,300
22,993,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,471,600
12,565,900
14,660,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
13,748,000
27,174,100
16,497,600
32,608,900
19,247,200
38,043,700
4,678,600
5,614,300
6,550,000
6,085,000
7,302,000
8,519,000
12,055,300
14,466,400
16,877,400
5,276,500
5,804,100
9,276,200
6,331,800
6,964,900
11,131,500
7,387,100
8,125,800
12,986,700
7,706,500
9,247,800
10,789,100
9,031,800
10,838,200
12,644,600
390 K-1-14-III
15,766,900
18,920,300
22,073,700
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

16,580,300
23,158,900
33,814,500
19,896,300
27,790,700
40,577,400
23,212,400
32,422,500
47,340,300
9,805,500
11,766,500
13,727,600
17,414,300
20,897,100
24,380,000
23,962,300
28,754,700
33,547,200
397 K-1-40-I
10,940,600
13,128,700
15,316,900
398 K-1-40-II

(SEDANG)
12,062,400
14,474,900
16,887,400
399 K-1-40-III
20,441,400
24,529,700
28,618,000
400
401
402
403
404

8,359,700
10,856,200
15,341,700
6,901,400
9,916,300
10,031,700
13,027,400
18,410,100
8,281,700
11,899,500
11,703,600
15,198,600
21,478,400
9,661,900
13,882,800
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 399 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,116,900
18,140,200
21,163,600
406 K-4-11-I
407 K-4-11-II

2,399,100
4,725,500
2,878,900
5,670,600
3,358,700
6,615,700
408 K-4-11-III
409 K-4-12-I

5,670,600
4,148,600
6,804,700
4,978,300
7,938,900
5,808,100
410 K-4-12-II
5,582,800
6,699,300
7,815,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,235,700
11,082,900
12,930,000
5,592,600
6,711,100
7,829,600
7,234,400
8,681,300
10,128,200
11,143,300
13,371,900
15,600,600
3,191,200
3,829,400
4,467,600
4,283,600
5,140,300
5,997,000
6,873,500
8,248,200
9,622,900
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,548,600
5,458,400
6,368,100
419 K-4-15-II
7,005,400
8,406,400
9,807,500
420 K-4-15-III
9,971,200
11,965,500
13,959,700
421 K-4-16-I
4,119,400
4,943,200
5,767,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,940,300
5,764,500
5,928,300
6,917,500
6,916,400
8,070,400
2,020,600
2,424,700
2,828,800
2,488,400
2,986,100
3,483,700
2,986,100
3,583,300
4,180,500
1,780,600
2,136,800
2,492,900
3,004,800
3,605,800
4,206,700
429 K-4-18-III
3,605,800
4,326,900
5,048,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
26,435,200
39,903,200
53,317,200
12,472,400
21,401,800
26,570,700
31,722,200
47,883,900
63,980,700
14,966,800
25,682,200
31,884,800
37,009,300
55,864,500
74,644,100
17,461,300
29,962,500
37,198,900
6,989,800
8,387,700
9,785,700
14,020,000
16,824,000
19,628,000
23,598,700
28,318,500
33,038,200
9,176,200
14,768,100
21,124,300
2,400,100
2,785,800
3,233,600
5,026,100
6,908,000
15,697,100
2,387,000
3,157,100
10,439,200
11,011,400
17,721,800
25,349,200
2,880,100
3,343,000
3,880,300
6,031,400
8,289,600
18,836,500
2,864,400
3,788,500
12,527,000
12,846,700
20,675,400
29,574,100
3,360,100
3,900,200
4,527,100
7,036,600
9,671,200
21,975,900
3,341,700
4,419,900
14,614,900
2,541,700
3,050,000
3,558,300
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 400 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,140,500
4,968,600
5,796,700
8,225,300
9,870,300
11,515,400
4,133,400
4,960,100
5,786,800
6,208,500
7,450,200
8,691,900
8,751,600
10,502,000
12,252,300
14,611,100
17,533,400
20,455,600
20,767,700
24,921,200
29,074,800
29,172,400
35,006,900
40,841,400
12,950,000
15,540,000
18,130,000
21,244,100
36,093,200
25,492,900
43,311,800
29,741,700
50,530,400
51,766,000
62,119,200
72,472,400
60,547,900
72,657,500
84,767,100
74,938,100
89,925,800
104,913,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,512,300
31,814,800
37,117,200
467 M-1-04-II
34,060,600
40,872,800
47,684,900
468 M-1-04-III
40,754,400
48,905,200
57,056,100
469 M-1-05-I
470 M-1-05-II

10,309,000
16,675,100
12,370,800
20,010,200
14,432,600
23,345,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,300,400
25,560,400
29,820,500
18,842,000
22,610,400
26,378,800
25,241,800
30,290,100
35,338,500
51,419,800
61,703,700
71,987,700
22,266,200
26,719,500
31,172,700
53,237,600
63,885,100
74,532,600
114,828,500
137,794,200
160,759,900
17,350,800
20,821,000
24,291,100
22,167,400
26,600,900
31,034,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
55,190,100
66,228,100
77,266,200
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
11,903,100
19,287,900
27,579,900
14,283,700
23,145,500
33,095,900
16,664,300
27,003,000
38,611,900
7,271,000
8,725,200
10,179,300
10,745,600
12,894,700
15,043,900
15,342,700
18,411,200
21,479,700
7,260,900
12,049,400
19,790,400
8,713,100
14,459,300
23,748,500
10,165,300
16,869,200
27,706,600
11,213,900
13,456,700
15,699,500
14,098,500
16,918,200
19,737,900
21,297,500
25,557,000
29,816,500
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 401 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,858,200
9,429,800
11,001,400
512 M-4-14-II
9,691,900
11,630,300
13,568,600
513 M-4-14-III
514 M-4-15-I
14,564,100
4,659,700
17,476,900
5,591,600
20,389,700
6,523,500
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,211,000
14,094,600
3,989,400
6,388,500
10,732,300
7,453,200
16,913,600
4,787,300
7,666,300
12,878,800
8,695,400
19,732,500
5,585,200
8,944,000
15,025,200
4,659,900
5,591,900
6,523,900
6,517,400
7,820,900
9,124,400
9,101,200
10,921,400
12,741,600
3,913,500
5,897,900
7,101,300
4,696,200
7,077,400
8,521,500
5,478,900
8,257,000
9,941,800
4,081,200
4,897,400
5,713,700
6,874,300
8,249,200
9,624,000
13,425,900
16,111,100
18,796,300
3,705,100
4,446,100
5,187,200
5,425,500
6,510,600
7,595,700
6,063,700
7,276,400
8,489,100
3,730,800
4,476,900
5,223,100
4,666,100
5,599,300
6,532,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
20,775,800
24,931,000
29,086,200
22,853,400
27,424,100
31,994,800
26,164,100
31,397,000
36,629,800
11,810,200
14,172,200
16,534,300
14,025,700
31,568,800
16,830,800
37,882,600
19,636,000
44,196,300
4,160,300
4,992,300
5,824,400
6,204,400
11,738,700
7,445,300
14,086,500
8,686,100
16,434,200
5,184,100
6,220,900
7,257,800
11,365,900
13,639,100
15,912,300
16,433,200
19,719,800
23,006,500
4,138,100
4,965,700
5,793,300
6,882,800
8,259,300
9,635,900
9,206,400
11,047,700
12,889,000
6,890,300
8,268,400
9,646,500
10,352,400
12,422,900
14,493,400
20,197,300
24,236,800
28,276,300
- 402 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,461,300
12,553,600
14,645,900
535 N-1-01-I

286,926,200
344,311,400
401,696,600
536 N-1-01-II
286,926,200
344,311,400
401,696,600
537 N-1-01-III
538 N-1-11-I

286,926,200
11,957,000
344,311,400
14,348,400
401,696,600
16,739,800
539 N-1-11-II
540 N-1-11-III

18,907,000
29,475,900
22,688,300
35,371,100
26,469,700
41,266,300
6,094,100
7,312,900
8,531,700
12,132,700
14,559,200
16,985,800
26,328,400
31,594,100
36,859,700
13,324,000
15,988,800
18,653,600

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
18,646,200
26,093,200
22,375,500
31,311,800
26,104,700
36,530,400
12,193,800
14,632,600
17,071,300
18,446,800
22,136,200
25,825,600
21,230,600
25,476,700
29,722,800
10,950,900
13,141,100
15,331,300
14,871,100
17,845,300
20,819,500
17,308,000
20,769,600
24,231,200
4,652,600
5,583,100
6,513,700
5,627,400
6,752,900
7,878,400
8,277,100
9,932,500
11,588,000
3,571,600
6,240,100
7,764,000
2,692,900
5,594,500
9,090,600
3,643,900
6,091,900
12,602,900
4,286,000
7,488,100
9,316,800
3,231,500
6,713,300
10,908,800
4,372,700
7,310,300
15,123,400
5,000,300
8,736,100
10,869,600
3,770,000
7,832,200
12,726,900
5,101,500
8,528,700
17,644,000
3,587,100
4,304,500
5,021,900
5,089,900
6,107,900
7,125,900
8,159,100
9,790,900
11,422,700
4,237,700
5,085,200
5,932,800
5,258,200
6,309,900
7,361,500
6,000,500
7,200,600
8,400,700
5,189,000
6,226,800
7,264,600
7,406,400
8,887,700
10,369,000
9,858,500
11,830,200
13,801,900
5,317,000
6,843,800
6,380,400
8,212,500
7,443,800
9,581,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 403 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,788,000
12,945,600
15,103,200
4,823,500
5,788,100
6,752,800
5,360,700
6,432,900
7,505,000
6,668,800
8,002,600
9,336,300
3,417,300
4,100,800
4,784,300
4,104,200
4,925,000
5,745,900
5,157,100
6,188,500
7,219,900
1,732,300
2,078,800
2,425,200
2,841,900
3,410,300
3,410,300
4,092,400
3,978,700
4,774,500
76,309,900
91,571,900
106,833,800
94,422,000
113,306,400
132,190,800
110,824,900
132,989,900
155,154,900
104,159,400
124,991,300
145,823,100
119,481,300
143,377,500
167,273,800
136,515,800
163,819,000
191,122,100
15,623,800
18,748,600
21,873,300
20,680,200
24,816,300
28,952,300
29,077,400
34,892,800
40,708,300
50,348,400
60,418,000
70,487,700
65,341,300
78,409,500
91,477,800
93,683,000
112,419,600
131,156,200
27,377,800
32,853,400
38,328,900
42,235,100
50,682,100
59,129,100
57,173,000
68,607,500
80,042,100
7,391,100
8,869,400
10,347,600
20,723,100
24,867,700
29,012,300
27,453,000
32,943,600
38,434,200
8,750,000
10,500,000
12,250,000
24,532,900
29,439,500
34,346,100
32,500,100
39,000,100
45,500,100
5,062,800
6,075,400
7,088,000
7,183,900
8,620,700
10,057,500
13,975,600
16,770,700
19,565,800
13,019,800
15,623,800
18,227,800
17,233,500
20,680,200
24,126,900
- 404 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,231,100
29,077,400
33,923,600
11,836,200
14,203,500
16,570,700
14,361,300
17,233,500
20,105,800
21,070,500
25,284,700
29,498,800
6,575,700
7,890,800
9,205,900
10,258,000
12,309,700
14,361,300
16,208,100
19,449,700
22,691,400
4,977,300
5,972,700
6,968,200
10,131,800
12,158,100
14,184,500
39,615,900
47,539,100
55,462,300
3,733,000
4,479,600
5,226,200
7,475,500
8,970,700
10,465,800
8,771,200
10,525,400
12,279,700
3,378,400
4,054,100
4,729,800
6,492,200
7,790,600
9,089,100
15,225,300
18,270,300
21,315,400
4,383,800
5,260,500
6,137,300
7,890,800
9,469,000
11,047,100
13,506,800
16,208,100
18,909,500
3,809,100
4,571,000
5,332,800
4,693,400
5,632,100
6,570,800
6,424,800
7,709,800
8,994,800
1,750,500
3,558,000
8,209,500
2,800,500
3,727,400
6,461,400
2,100,600
4,269,600
9,851,400
3,360,600
4,472,800
7,753,700
2,450,700
4,981,200
11,493,300
3,920,700
5,218,300
9,046,000
4,135,600
4,962,700
5,789,800
7,336,800
8,804,200
10,271,500
11,908,600
14,290,300
16,672,000
2,092,900
2,511,500
2,930,000
4,445,500
5,334,600
6,223,600
8,430,200
10,116,200
11,802,200
1,399,700
1,679,700
1,959,600
2,641,500
3,169,900
3,698,200
3,421,300
4,105,500
4,789,800
7,248,100
8,697,700
10,147,400
- 405 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,217,900
11,061,500
12,905,100
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,198,200
15,837,800
18,477,400
3,493,500
4,192,200
4,890,800
5,184,700
6,221,600
7,258,600
6,235,700
7,482,900
8,730,000
2,337,400
2,804,900
3,272,400
3,139,400
3,767,300
4,395,200
5,711,100
6,853,300
7,995,500
1,279,900
1,535,800
1,791,800
2,438,800
2,926,500
3,414,300
3,544,800
4,253,800
4,962,800
1,236,000
1,483,300
1,730,500
1,945,200
2,334,200
2,723,300
3,133,200
3,759,800
4,386,400
2,896,200
3,475,400
4,054,600
4,372,000
5,246,400
6,120,800
6,767,200
8,120,700
9,474,100
7,638,400
9,166,000
10,693,700

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
11,857,800
31,319,500
14,229,300
37,583,400
16,600,900
43,847,300
12,054,400
14,465,300
16,876,200
18,181,900
21,818,300
25,454,700
21,553,400
25,864,100
30,174,800
9,233,600
14,159,200
20,797,000
9,240,000
10,766,000
17,846,700
11,080,300
16,991,100
24,956,400
11,088,000
12,919,200
21,416,000
12,927,000
19,822,900
29,115,800
12,935,900
15,072,400
24,985,300
5,552,500
6,663,100
7,773,600
6,814,300
8,177,200
9,540,100
8,075,000
9,689,900
11,304,900
4,346,200
6,179,000
9,412,500
5,215,400
7,414,800
11,295,100
6,084,700
8,650,600
13,177,600
8,429,700
10,115,600
11,801,500
12,545,700
15,054,800
17,563,900
32,207,100
38,648,500
45,089,900
7,229,300
9,802,700
19,169,500
8,675,200
11,763,200
23,003,400
10,121,100
13,723,800
26,837,300
5,202,500
6,243,000
7,283,600
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 406 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,516,200
3,019,400
3,522,600
697 U-4-12-I
698 U-4-12-II

2,702,300
4,356,900
3,242,700
5,228,300
3,783,200
6,099,700
699 U-4-12-III

7,630,400
9,156,400
10,682,500
2,047,900
2,457,500
2,867,100
3,346,500
4,015,800
4,685,100
5,403,500
6,484,200
7,564,900
5,178,300
6,200,800
6,213,900
7,441,000
7,249,600
8,681,200

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,413,100
12,495,700
14,578,300
4,158,000
4,989,600
5,821,200
5,180,300
6,216,400
7,252,500
7,249,900
8,699,900
10,149,900
6,782,000
8,138,500
9,494,900
13,970,800
16,764,900
19,559,100
17,133,200
20,559,800
23,986,500
12,902,500
14,733,200
23,072,700
15,483,000
17,679,800
27,687,300
18,063,500
20,626,400
32,301,800
12,130,900
14,557,000
16,983,200
16,565,700
19,878,800
23,191,900
20,997,200
25,196,600
29,396,000
6,327,600
7,593,100
8,858,700
12,090,000
14,508,000
16,926,000
18,967,700
22,761,200
26,554,800
12,408,400
14,890,100
17,371,800
18,029,100
21,634,900
25,240,700
723 V-1-14-III
22,512,600
27,015,100
31,517,600
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
1,998,400
2,205,200
2,439,400
2,398,100
2,646,300
2,927,300
2,797,700
3,087,300
3,415,200
5,400,400
6,480,500
7,560,600
8,970,400
10,764,500
12,558,600
14,789,100
17,746,900
20,704,700
5,184,800
6,221,800
7,258,700
6,956,700
8,348,000
9,739,300
9,318,500
11,182,200
13,045,900
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
11,910,200
14,292,200
16,674,300
18,285,800
21,943,000
25,600,100
1,644,600
2,391,800
1,973,500
2,870,200
2,302,400
3,348,500
- 407 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,131,900
16,958,300
19,784,700
16,938,100
20,325,700
23,713,300
24,170,200
29,004,200
33,838,200
2,997,600
3,597,100
4,196,600
3,307,800
3,659,100
3,969,400
4,390,900
4,630,900
5,122,700
3,133,100
3,759,800
4,386,400
3,457,400
4,148,900
4,840,400
3,824,600
4,589,500
5,354,400
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,370,600
4,044,700
4,718,900
743 W-1-12-II
744 W-1-12-III

4,207,100
7,449,800
5,048,500
8,939,800
5,889,900
10,429,800
745 W-1-13-I
3,464,700
4,157,600
4,850,600
746 W-1-13-II
747 W-1-13-III

3,761,500
5,052,700
4,513,800
6,063,200
5,266,100
7,073,700
748 W-1-20-I
749 W-1-20-II

11,603,000
14,498,000
13,923,600
17,397,600
16,244,200
20,297,300
750 W-1-20-III
16,807,000
20,168,300
23,529,700
751 W-1-30-I
6,550,000
7,860,100
9,170,100
752 W-1-30-II
10,447,300
12,536,800
14,626,200
753 W-1-30-III
25,633,000
30,759,600
35,886,200
754 W-4-10-I
4,880,500
5,856,500
6,832,600
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,235,100
14,297,900
3,994,600
6,064,400
7,381,500
8,682,100
17,157,500
4,793,500
7,277,300
8,857,800
10,129,100
20,017,100
5,592,400
8,490,100
10,334,100
2,995,400
3,594,500
4,193,600
5,700,300
6,840,400
7,980,400
8,388,400
10,066,100
11,743,800
1,746,300
2,385,500
2,966,500
2,333,700
2,777,700
3,553,700
1,685,400
2,594,500
4,849,500
2,242,500
4,156,600
7,605,300
1,654,700
4,141,200
8,265,600
4,921,500
6,532,300
9,280,300
3,203,900
3,848,100
5,289,400
2,095,500
2,862,600
3,559,800
2,800,400
3,333,200
4,264,500
2,022,500
3,113,400
5,819,400
2,691,000
4,988,000
9,126,400
1,985,700
4,969,400
9,918,700
5,905,900
7,838,700
11,136,300
3,844,700
4,617,700
6,347,300
2,444,800
3,339,600
4,153,100
3,267,200
3,888,800
4,975,200
2,359,600
3,632,300
6,789,300
3,139,500
5,819,300
10,647,500
2,316,600
5,797,600
11,571,800
6,890,200
9,145,200
12,992,400
4,485,500
5,387,300
7,405,200
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 408 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,117,600
2,541,100
2,964,700
4,251,900
5,102,300
5,952,700
8,970,500
10,764,600
12,558,700
- 409 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,406,700
1,824,700
3,393,100
2,804,100
3,644,000
670,300
1,489,300
524,100
1,158,100
993,000
1,127,400
1,695,000
2,311,900
2,118,900
686,400
1,584,400
574,700
986,700
3,005,400
1,076,300
2,541,800
620,100
1,808,400
2,264,400
1,899,200
465,800
1,411,700
784,900
504,400
436,300
385,100
460,600
641,300
472,300
518,700
399,500
691,700
358,700
356,000
362,800
8,281,800
3,309,900
3,320,900
854,300
1,748,600
1,094,800
2,225,200
1,140,700
653,200
493,300
795,600
564,500
376,000
3,667,100
1,466,800
977,900
3,817,300
2,544,900
396,500
4,135,400
2,863,000
4,462,900
1,487,300
914,900
393,600
389,500
369,700
5,637,100
2,744,000
- 410 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,487,400
6,172,000
5,117,300
3,898,400
1,285,200
4,338,900
2,833,100
696,400
6,514,200
5,897,200
3,954,100
3,746,100
463,000
444,900
1,790,100
489,200
435,900
481,800
2,066,900
2,258,600
1,972,800
2,177,800
1,318,900
438,400
772,800
530,500
479,000
466,700
592,500
675,800
396,100
1,136,900
2,072,000
1,590,500
3,739,100
486,900
486,900
4,319,000
2,009,100
385,400
1,783,000
4,631,700
1,063,400
837,600
410,300
276,900
555,600
774,700
1,855,100
1,635,100
1,144,600
683,100
376,000
1,987,500
1,274,000
680,400
621,100
2,035,500
534,400
2,599,500
1,988,800
485,200
537,800
525,400
377,500
2,166,900
2,381,800
472,000
- 411 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,446,700
540,000
583,800
540,600
857,700
659,700
1,652,300
487,500
1,356,300
2,265,500
396,900
2,416,000
1,309,200
2,829,300
1,428,200
630,700
485,200
79,900
628,800
1,421,000
553,700
748,000
427,700
203,400
432,000
6,432,700
3,656,500
6,102,600
1,873,900
837,600
570,700
1,290,800
682,700
1,374,000
795,600
473,600
792,700
446,100
680,900
522,000
994,200
2,490,300
2,003,600
1,766,600
1,246,800
458,600
458,600
458,600
374,600
237,600
373,600
456,700
494,000
363,900
320,900
112,000
123,200
91,100
106,900
102,000
155,600
165,700
255,000
280,100
123,900
150,400
102,800
160,400
227,600
- 412 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
162,100
286,300
809,200
938,100
153,300
389,400
186,500
266,200
655,000
560,800
403,100
381,700
152,400
149,700
449,500
336,900
483,200
381,600
220,400
3,534,000
2,908,100
462,100
478,500
915,200
898,700
1,171,500
605,100
1,885,900
318,700
491,800
493,400
395,100
499,000
472,300
221,200
486,100
430,900
389,700
440,800
3,648,800
592,200
1,313,200
471,000
837,600
550,000
438,800
1,140,300
1,167,800
1,245,100
1,089,200
1,605,800
324,500
2,816,200
427,700
1,427,500
3,244,200
3,001,000
1,311,000
475,100
926,600
923,000
427,700
3,352,900
2,637,300
244,000
182,300
236,800
509,900
- 413 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,258,900
1,505,300
1,389,600
1,676,500
803,400
1,117,600
772,500
649,800
795,000
460,300
1,088,300
217,600
806,000
1,355,300
88,400
- 414 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,665,500
4,398,600
A-4-10-II
SEPTIKEMIA (SEDANG)
6,262,100
7,514,600
8,767,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,443,300
4,444,300
10,132,000
5,333,200
11,820,700
6,222,100
5
6
A-4-11-II
A-4-11-III

6,325,600
8,755,200
7,590,700
10,506,200
8,855,800
12,257,200
A-4-12-I
2,898,500
3,478,200
4,057,900
8
9
A-4-12-II
A-4-12-III

5,003,300
7,208,800
6,003,900
8,650,600
7,004,600
10,092,400
10 A-4-13-I
11 A-4-13-II

2,157,300
3,812,500
2,588,700
4,575,000
3,020,200
5,337,500
12 A-4-13-III
4,575,000
5,490,000
6,404,900
2,416,800
2,900,100
3,383,500
4,066,300
4,879,600
5,692,900
4,879,600
5,855,500
6,831,500
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,867,700
23,496,500
22,641,200
28,195,800
26,414,700
32,895,200
18 A-4-15-III
INFEKSI HIV (BERAT)
26,544,500
31,853,400
37,162,300
19 B-1-01-I
20 B-1-01-II

52,022,100
57,394,100
62,426,600
68,872,900
72,831,000
80,351,700
21 B-1-01-III
22 B-1-10-I

126,512,000
8,409,100
151,814,500
10,090,900
177,116,900
11,772,700
23 B-1-10-II
18,664,500
22,397,400
26,130,300
24 B-1-10-III
25 B-1-11-I

36,846,200
33,555,900
44,215,500
40,267,100
51,584,700
46,978,200
26 B-1-11-II
27 B-1-11-III

39,983,600
61,785,900
47,980,300
74,143,100
55,977,000
86,500,200
28 B-1-12-I
9,874,300
11,849,200
13,824,000
29 B-1-12-II
10,982,000
13,178,400
15,374,800
30 B-1-12-III
17,180,100
20,616,100
24,052,100
7,865,000
9,438,000
11,011,000
12,940,900
15,529,100
18,117,200
16,744,400
20,093,200
23,442,100
20,606,200
24,727,500
28,848,700
21,642,300
25,970,800
30,299,200
38,310,600
3,343,600
5,337,400
7,363,100
45,972,800
4,012,300
6,404,900
8,835,700
53,634,900
4,681,100
7,472,400
10,308,400
7,049,600
8,459,600
9,869,500
9,869,600
11,843,500
13,817,400
11,956,900
14,348,200
16,739,600
6,373,700
9,075,800
13,502,800
6,079,900
7,648,400
10,891,000
16,203,400
7,295,900
8,923,100
12,706,200
18,904,000
8,511,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,131,700
- 415 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,082,900
8,499,400
9,916,000
48 B-4-13-III
49 B-4-14-I

9,757,300
6,073,500
11,708,700
7,288,100
13,660,200
8,502,800
50 B-4-14-II
7,085,500
8,502,500
9,919,600
51 B-4-14-III
52 C-4-10-I

9,491,100
12,301,100
11,389,400
14,761,400
13,287,600
17,221,600
53 C-4-10-II
54 C-4-10-III

19,783,600
37,068,100
23,740,300
44,481,700
27,697,100
51,895,300
55 C-4-11-I
6,403,100
7,683,800
8,964,400
56 C-4-11-II
57 C-4-11-III

8,568,300
13,173,900
10,282,000
15,808,700
11,995,600
18,443,500
58 C-4-12-I
59 C-4-12-II
4,263,400
8,397,300
5,116,100
10,076,700
5,968,800
11,756,200
60 C-4-12-III
RADIOTERAPI (BERAT)
21,566,500
25,879,800
30,193,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,205,200
6,032,200
3,846,300
7,238,700
4,487,300
8,445,100
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,165,600
5,325,600
9,798,700
6,390,700
11,431,900
7,455,800
65 C-4-14-II
7,470,700
8,964,900
10,459,000
66 C-4-14-III
67 D-1-10-I

11,131,300
32,175,800
13,357,500
38,610,900
15,583,800
45,046,100
68 D-1-10-II
69 D-1-10-III

49,006,000
70,230,900
58,807,200
84,277,100
68,608,400
98,323,200
70 D-1-11-I
8,614,800
10,337,700
12,060,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,997,500
28,586,600
26,397,000
34,303,900
30,796,500
40,021,300
7,468,000
8,961,600
10,455,200
20,580,700
24,696,800
28,813,000
32,647,000
39,176,400
45,705,800
2,951,100
4,843,100
7,619,400
5,846,400
10,505,800
14,432,400
5,040,400
6,991,200
10,735,300
3,541,400
5,811,700
9,143,300
7,015,700
12,607,000
17,318,900
6,048,500
8,389,400
12,882,300
4,131,600
6,780,400
10,667,100
8,185,000
14,708,100
20,205,300
7,056,600
9,787,600
15,029,400
4,319,500
5,183,400
6,047,300
6,113,600
7,336,300
8,559,000
7,819,500
9,383,400
10,947,300
4,632,900
5,559,500
6,486,000
7,585,200
9,102,200
10,619,300
9,277,500
11,133,000
12,988,400
9,235,100
11,082,100
12,929,100
12,607,300
15,128,700
17,650,200
93 E-1-01-III
30,397,500
36,477,000
42,556,500
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,601,500
13,328,000
25,181,000
11,521,800
15,993,700
30,217,300
13,442,100
18,659,300
35,253,500
10,869,700
13,043,600
15,217,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 416 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,273,100
5,127,700
5,982,300
104 E-4-11-II
105 E-4-11-III

6,514,700
8,827,800
7,817,600
10,593,400
9,120,500
12,359,000
106 E-4-12-I
107 E-4-12-II

4,909,700
8,502,400
5,891,600
10,202,900
6,873,600
11,903,400
108 E-4-12-III

(RINGAN)
(SEDANG)
10,078,500
12,094,100
14,109,800
5,346,500
6,415,800
7,485,100
7,831,600
9,398,000
10,964,300
111 E-4-13-III
10,237,500
12,285,000
14,332,500
112 F-4-10-I
113 F-4-10-II
5,692,000
6,541,800
6,830,400
7,850,200
7,968,800
9,158,500
114 F-4-10-III
115 F-4-11-I
7,850,200
5,505,100
9,420,200
6,606,100
10,990,200
7,707,100
116 F-4-11-II
6,414,000
7,696,800
8,979,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,225,100
9,870,100
11,515,100
3,017,700
3,621,200
4,224,700
4,290,200
5,148,200
6,006,300
9,320,200
11,184,200
13,048,300
4,434,500
5,851,400
7,575,400
2,530,100
3,245,200
4,366,700
5,321,400
7,021,700
9,090,400
3,036,100
3,894,200
5,240,000
6,208,300
8,191,900
10,605,500
3,542,100
4,543,200
6,113,300
127 F-4-15-I
4,029,300
4,835,200
5,641,100
128 F-4-15-II
6,004,200
7,205,000
8,405,900
129 F-4-15-III
7,927,400
9,512,900
11,098,400
7,927,900
9,513,500
11,099,000
9,217,500
11,061,000
12,904,400
12,303,700
14,764,500
17,225,200
133 F-4-17-I

1,872,300
2,246,700
2,621,200
134 F-4-17-II
5,487,300
6,584,800
7,682,300
135
136
137
138
139
140
141

(RINGAN)
5,854,500
6,888,700
7,579,600
11,684,500
5,264,600
6,741,600
8,393,200
7,025,400
8,266,500
9,095,500
14,021,400
6,317,500
8,089,900
10,071,800
8,196,300
9,644,200
10,611,400
16,358,300
7,370,400
9,438,200
11,750,500
22,333,000
26,799,600
31,266,200
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,630,300
17,556,300
20,482,400
20,163,500
24,196,200
28,228,900
3,846,700
4,616,100
5,385,400
7,450,500
8,940,600
10,430,700
12,484,100
14,981,000
17,477,800
- 417 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
52,261,300
62,713,600
73,165,800
148 G-1-11-I
149 G-1-11-II

17,091,500
31,247,200
20,509,800
37,496,700
23,928,100
43,746,100
150 G-1-11-III
50,212,900
60,255,500
70,298,100
7,136,300
8,563,500
9,990,800
13,377,300
16,052,800
18,728,200
18,230,700
21,876,800
25,522,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,152,800
5,781,400
2,583,400
6,937,600
3,013,900
8,093,900
156 G-1-13-III
157 G-1-20-I

13,045,300
12,085,700
15,654,400
14,502,900
18,263,500
16,920,000
158 G-1-20-II
18,287,600
21,945,200
25,602,700
159 G-1-20-III
31,183,700
37,420,400
43,657,200
160 G-1-30-I
30,108,700
36,130,400
42,152,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
40,593,900
60,958,800
48,712,600
73,150,600
56,831,400
85,342,300
6,125,700
7,350,900
8,576,000
7,487,700
8,985,300
10,482,800
10,274,400
12,329,300
14,384,200
6,412,700
7,695,200
8,977,700
8,518,400
10,222,100
11,925,800
12,516,500
15,019,800
17,523,100
7,114,100
8,537,000
9,959,800
8,985,600
10,782,800
12,579,900
13,050,500
15,660,600
18,270,700
4,273,500
5,128,300
5,983,000
7,452,200
8,942,700
10,433,100
8,838,500
10,606,200
12,373,900
7,249,600
8,699,500
10,149,400
9,692,200
11,630,600
13,569,000
12,164,800
14,597,800
17,030,700
5,923,500
7,108,300
8,293,000
7,069,400
8,483,300
9,897,200
9,977,900
11,973,500
13,969,100
4,883,200
5,859,800
6,836,400
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
32,031,000
38,437,200
44,843,400
52,405,300
62,886,400
73,367,500
34,723,900
42,528,200
41,668,700
51,033,800
48,613,500
59,539,400
- 418 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,483,100
7,779,700
9,076,300
183 G-4-16-III
9,232,400
11,078,900
12,925,400
6,504,000
7,804,900
9,105,700
8,528,200
10,233,900
11,939,500
10,716,100
12,859,300
15,002,600
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,405,500
7,686,600
8,967,700
188 G-4-18-II
8,562,200
10,274,600
11,987,100
189 G-4-18-III
9,580,400
11,496,500
13,412,600
5,344,200
6,413,100
7,481,900
9,033,000
10,839,600
12,646,300
11,860,000
14,232,000
16,604,000
193 G-4-20-I

3,738,600
4,486,300
5,234,000
194 G-4-20-II
5,285,200
6,342,200
7,399,200
195 G-4-20-III
196 G-4-21-I

8,729,800
3,893,100
10,475,800
4,671,700
12,221,800
5,450,400
197 G-4-21-II
198 G-4-21-III

6,589,200
7,743,800
7,907,000
9,292,500
9,224,800
10,841,300
199 G-4-22-I
2,916,700
3,500,000
4,083,400
200 G-4-22-II
201 G-4-22-III

5,165,500
8,148,100
6,198,600
9,777,800
7,231,700
11,407,400
202 G-4-23-I
203 G-4-23-II

3,832,400
4,808,300
4,598,900
5,770,000
5,365,400
6,731,700
204 G-4-23-III
6,845,900
8,215,100
9,584,300
205 G-4-24-I
206 G-4-24-II

4,268,700
5,333,100
5,122,500
6,399,800
5,976,200
7,466,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,884,800
3,647,500
4,612,700
6,112,800
10,661,800
4,377,100
5,535,300
7,335,300
12,438,800
5,106,600
6,457,800
8,557,900
4,158,500
4,990,200
5,821,900
4,837,600
5,805,100
6,772,700
7,233,700
8,680,400
10,127,200
12,300,900
13,594,400
18,487,600
8,382,000
10,413,800
14,586,000
4,444,300
6,030,000
11,852,200
4,261,600
4,861,200
6,961,000
5,024,500
6,003,400
10,060,600
14,761,100
16,313,300
22,185,100
10,058,400
12,496,600
17,503,200
5,333,100
7,236,000
14,222,700
5,114,000
5,833,500
8,353,200
6,029,400
7,204,000
12,072,700
17,221,200
19,032,100
25,882,600
11,734,800
14,579,300
20,420,400
6,222,000
8,442,000
16,593,100
5,966,300
6,805,700
9,745,400
7,034,300
8,404,700
14,084,800
229 I-1-01-I
67,488,000
80,985,600
94,483,300
230 I-1-01-II
68,972,700
82,767,300
96,561,800
231 I-1-01-III

(RINGAN)
108,872,600
130,647,100
152,421,600
37,442,100
44,930,500
52,418,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 419 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
50,337,900
60,405,400
70,473,000
245 I-1-06-II
72,918,500
87,502,200
102,085,900
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
87,005,200
104,406,300
121,807,300
78,352,100
94,022,500
109,693,000
97,940,100
117,528,200
137,116,200
146,910,200
176,292,300
205,674,300
5,867,300
7,040,800
8,214,200
6,523,800
7,828,600
9,133,400
8,681,300
10,417,500
12,153,800
16,888,900
20,266,700
23,644,400
27,582,900
33,099,500
38,616,100
36,289,500
43,547,400
50,805,300
16,382,000
19,658,400
22,934,800
21,815,900
26,179,100
30,542,300
26,905,100
32,286,100
37,667,100
33,529,900
40,235,900
46,941,800
41,672,700
50,007,300
58,341,800
54,605,600
65,526,800
76,447,900
6,369,700
8,895,200
17,128,600
7,643,700
10,674,200
20,554,300
8,917,600
12,453,200
23,980,000
16,512,600
19,815,100
23,117,700
37,361,400
44,833,700
52,305,900
43,095,800
51,714,900
60,334,100
19,120,000
22,944,000
26,768,100
23,940,100
28,728,100
33,516,100
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
48,299,800
57,959,800
67,619,700
59,532,500
71,439,100
83,345,600
35,311,900
42,374,300
49,436,700
48,949,600
58,739,500
68,529,500
62,120,800
74,545,000
86,969,200
53,213,100
63,855,700
74,498,400
83,984,700
100,781,600
117,578,600
134,165,000
160,998,000
187,831,000
88,146,100
105,775,400
123,404,600
107,734,200
129,281,000
150,827,800
146,910,200
176,292,300
205,674,300
- 420 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
37,195,100
44,634,100
52,073,100
279 I-1-40-III
49,680,000
59,616,000
69,552,000
280 I-4-10-I
281 I-4-10-II

5,671,300
10,126,700
6,805,500
12,152,100
7,939,800
14,177,400
282 I-4-10-III
14,591,200
17,509,400
20,427,600
283 I-4-11-I
284 I-4-11-II

8,725,200
10,797,500
10,470,300
12,957,000
12,215,300
15,116,500
285 I-4-11-III
286 I-4-12-I

19,974,300
5,015,700
23,969,100
6,018,900
27,964,000
7,022,000
287 I-4-12-II
5,814,000
6,976,800
8,139,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,976,800
8,372,100
9,767,500
5,104,100
6,125,000
7,145,800
9,114,000
10,936,800
12,759,700
13,132,000
15,758,500
18,384,900
4,820,000
4,985,800
8,740,200
5,784,000
5,983,000
10,488,200
6,748,000
6,980,200
12,236,300
4,922,500
5,907,000
6,891,600
9,282,400
11,138,900
12,995,400
11,138,900
13,366,700
15,594,500
3,042,100
4,884,900
5,861,900
2,031,100
3,277,600
4,588,600
3,650,500
5,861,900
7,034,200
2,437,300
3,933,100
5,506,400
4,259,000
6,838,800
8,206,600
2,843,600
4,588,600
6,424,100
5,867,900
7,041,500
8,215,100
8,934,100
10,721,000
12,507,800
12,129,600
14,555,500
16,981,400
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
29,613,500
35,536,200
41,458,900
21,551,600
25,861,900
30,172,200
26,923,800
32,308,600
37,693,400
28,302,500
33,963,000
39,623,500
16,302,500
19,563,100
22,823,600
33,912,900
40,695,500
47,478,100
52,552,800
63,063,400
73,573,900
15,045,500
18,054,600
21,063,700
307 I-4-19-I
5,661,400
6,793,600
7,925,900
308 I-4-19-II

(SEDANG)
8,837,700
10,605,200
12,372,800
309 I-4-19-III
10,550,500
12,660,600
14,770,700
310
311
312
313
314

5,895,100
6,808,900
10,180,700
3,970,200
5,030,200
7,074,200
8,170,700
12,216,800
4,764,200
6,036,300
8,253,200
9,532,500
14,253,000
5,558,200
7,042,300
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 421 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,260,600
8,712,700
10,164,900
316 I-4-22-I
317 I-4-22-II
3,567,100
4,440,500
4,280,500
5,328,600
4,993,900
6,216,700
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,490,600
7,788,700
9,086,800
4,839,100
5,806,900
6,774,700
5,941,000
7,129,200
8,317,400
11,608,400
13,930,000
16,251,700
3,143,800
3,772,500
4,401,300
7,239,300
8,687,100
10,135,000
9,152,800
10,983,400
12,813,900
99,609,100
119,530,900
139,452,700
112,726,200
135,271,500
157,816,700
154,623,500
185,548,100
216,472,800
64,982,900
77,979,500
90,976,000
81,995,800
98,394,900
114,794,100
95,923,400
115,108,100
134,292,800
12,668,700
15,202,400
17,736,200
25,635,100
30,762,200
35,889,200
26,641,200
31,969,500
37,297,700
34,900,000
41,879,900
48,859,900
36,544,900
43,853,900
51,162,900
41,126,600
49,351,900
57,577,200
10,572,300
12,686,800
14,801,300
19,151,700
22,982,000
26,812,300
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
55,280,600
66,336,700
77,392,800
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,116,500
6,436,300
9,737,200
3,855,700
5,370,300
7,198,300
6,549,000
7,455,000
10,409,300
5,790,400
8,060,000
15,037,400
6,384,000
10,388,700
12,290,800
4,619,500
7,649,900
13,894,500
3,739,700
7,723,600
11,684,600
4,626,900
6,444,300
8,638,000
7,858,700
8,946,100
12,491,200
6,948,500
9,672,100
18,044,900
7,660,800
12,466,400
14,749,000
5,543,400
9,179,900
16,673,500
4,363,000
9,010,800
13,632,100
5,398,000
7,518,400
10,077,700
9,168,500
10,437,100
14,573,000
8,106,500
11,284,100
21,052,400
8,937,600
14,544,100
17,207,200
6,467,300
10,709,900
19,452,400
3,849,000
4,618,800
5,388,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 422 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,497,300
8,996,700
10,496,200
12,796,900
15,356,200
17,915,600
5,334,400
6,388,200
6,401,300
7,665,800
7,468,200
8,943,400

8,383,200
2,371,200
10,059,800
2,845,400
11,736,400
3,319,600
365 J-4-18-II
4,520,500
5,424,600
6,328,700
366 J-4-18-III
367 J-4-19-I

6,423,900
6,762,400
7,708,700
8,114,800
8,993,400
9,467,300
368 J-4-19-II
369 J-4-19-III

7,668,900
8,469,400
9,202,700
10,163,300
10,736,500
11,857,200
370 J-4-20-I
5,379,400
6,455,200
7,531,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,453,700
8,738,000
8,944,400
10,485,600
10,435,100
12,233,200
3,073,400
3,688,000
4,302,700
6,862,700
8,235,300
9,607,800
12,928,200
15,513,800
18,099,400
11,484,900
13,781,900
16,078,900
14,433,300
17,319,900
20,206,600
16,916,300
20,299,500
23,682,800
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,785,800
12,942,900
15,100,100

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
14,160,400
27,989,300
16,992,500
33,587,200
19,824,600
39,185,000
4,818,900
5,782,700
6,746,500
6,267,600
7,521,100
8,774,600
12,417,000
14,900,400
17,383,800
5,434,800
5,978,200
9,554,500
6,521,700
7,173,900
11,465,400
7,608,700
8,369,500
13,376,300
7,937,700
9,525,200
11,112,800
9,302,800
11,163,400
13,023,900
390 K-1-14-III
16,239,900
19,487,900
22,735,900
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

17,077,700
23,853,700
34,828,900
20,493,200
28,624,400
41,794,700
23,908,700
33,395,200
48,760,500
10,099,600
12,119,500
14,139,500
17,936,700
21,524,000
25,111,400
24,681,100
29,617,400
34,553,600
397 K-1-40-I
11,268,800
13,522,600
15,776,400
398 K-1-40-II

(SEDANG)
12,424,300
14,909,100
17,394,000
399 K-1-40-III
21,054,700
25,265,600
29,476,600
400
401
402
403
404

8,610,500
11,181,800
15,802,000
7,108,400
10,213,800
10,332,600
13,418,200
18,962,400
8,530,100
12,256,500
12,054,700
15,654,600
22,122,800
9,951,800
14,299,300
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 423 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,570,400
18,684,400
21,798,500
406 K-4-11-I
407 K-4-11-II

2,471,100
4,867,300
2,965,300
5,840,700
3,459,500
6,814,200
408 K-4-11-III
409 K-4-12-I

5,840,700
4,273,100
7,008,900
5,127,700
8,177,000
5,982,300
410 K-4-12-II
5,750,200
6,900,300
8,050,300
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,512,800
11,415,300
13,317,900
5,760,400
6,912,400
8,064,500
7,451,400
8,941,700
10,432,000
11,477,600
13,773,100
16,068,600
3,286,900
3,944,300
4,601,700
4,412,100
5,294,500
6,176,900
7,079,700
8,495,600
9,911,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,685,100
5,622,100
6,559,100
419 K-4-15-II
7,215,500
8,658,600
10,101,700
420 K-4-15-III
10,270,400
12,324,400
14,378,500
421 K-4-16-I
4,242,900
5,091,500
5,940,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,088,500
5,937,500
6,106,200
7,125,000
7,123,900
8,312,500
2,081,200
2,497,500
2,913,700
2,563,000
3,075,600
3,588,200
3,075,600
3,690,800
4,305,900
1,834,100
2,200,900
2,567,700
3,095,000
3,714,000
4,333,000
429 K-4-18-III
3,714,000
4,456,700
5,199,500
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
27,228,300
41,100,300
54,916,700
12,846,500
22,043,900
27,367,800
32,673,900
49,320,400
65,900,100
15,415,900
26,452,600
32,841,300
38,119,600
57,540,400
76,883,400
17,985,200
30,861,400
38,314,900
7,199,500
8,639,400
10,079,300
14,440,600
17,328,700
20,216,800
24,306,700
29,168,000
34,029,400
9,451,500
15,211,200
21,758,100
2,472,100
2,869,400
3,330,600
5,176,900
7,115,200
16,168,000
2,458,600
3,251,800
10,752,400
11,341,800
18,253,400
26,109,700
2,966,500
3,443,300
3,996,700
6,212,300
8,538,300
19,401,600
2,950,300
3,902,200
12,902,800
13,232,100
21,295,700
30,461,300
3,460,900
4,017,200
4,662,900
7,247,700
9,961,300
22,635,200
3,442,000
4,552,500
15,053,300
2,617,900
3,141,500
3,665,100
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 424 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,264,700
5,117,600
5,970,600
8,472,000
10,166,400
11,860,800
4,257,400
5,108,900
5,960,400
6,394,800
7,673,700
8,952,700
9,014,200
10,817,000
12,619,800
15,049,500
18,059,400
21,069,300
21,390,700
25,668,900
29,947,000
30,047,600
36,057,100
42,066,600
13,338,500
16,006,200
18,673,900
21,881,400
37,175,900
26,257,700
44,611,100
30,633,900
52,046,300
53,319,000
63,982,800
74,646,600
62,364,400
74,837,200
87,310,100
77,186,300
92,623,500
108,060,800
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
27,307,700
32,769,200
38,230,800
467 M-1-04-II
35,082,400
42,098,900
49,115,400
468 M-1-04-III
41,977,000
50,372,400
58,767,800
469 M-1-05-I
470 M-1-05-II

10,618,200
17,175,400
12,741,900
20,610,500
14,865,500
24,045,500
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,939,400
26,327,300
30,715,100
19,407,200
23,288,700
27,170,100
25,999,000
31,198,800
36,398,600
52,962,400
63,554,900
74,147,300
22,934,200
27,521,100
32,107,900
54,834,700
65,801,600
76,768,600
118,273,400
141,928,000
165,582,700
17,871,300
21,445,600
25,019,800
22,832,400
27,398,900
31,965,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
56,845,800
68,215,000
79,584,100
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,260,200
19,866,500
28,407,300
14,712,200
23,839,800
34,088,800
17,164,300
27,813,100
39,770,300
7,489,100
8,986,900
10,484,700
11,068,000
13,281,600
15,495,200
15,802,900
18,963,500
22,124,100
7,478,800
12,410,900
20,384,200
8,974,500
14,893,100
24,461,000
10,470,300
17,375,300
28,537,800
11,550,300
13,860,400
16,170,500
14,521,400
17,425,700
20,330,000
21,936,400
26,323,700
30,711,000
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 425 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,093,900
9,712,700
11,331,500
512 M-4-14-II
9,982,600
11,979,200
13,975,700
513 M-4-14-III
514 M-4-15-I
15,001,000
4,799,500
18,001,200
5,759,300
21,001,400
6,719,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,397,400
14,517,500
4,109,100
6,580,200
11,054,300
7,676,800
17,421,000
4,930,900
7,896,200
13,265,100
8,956,300
20,324,500
5,752,700
9,212,300
15,476,000
4,799,700
5,759,700
6,719,600
6,713,000
8,055,500
9,398,100
9,374,200
11,249,000
13,123,900
4,030,900
6,074,800
7,314,300
4,837,100
7,289,800
8,777,200
5,643,300
8,504,700
10,240,000
4,203,600
5,044,400
5,885,100
7,080,500
8,496,600
9,912,700
13,828,700
16,594,500
19,360,200
3,816,300
4,579,500
5,342,800
5,588,300
6,705,900
7,823,600
6,245,600
7,494,700
8,743,800
3,842,700
4,611,200
5,379,800
4,806,100
5,767,300
6,728,500
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,399,100
25,678,900
29,958,700
23,539,000
28,246,800
32,954,600
26,949,100
32,338,900
37,728,700
12,164,500
14,597,400
17,030,300
14,446,500
32,515,900
17,335,800
39,019,100
20,225,000
45,522,200
4,285,100
5,142,100
5,999,100
6,390,500
12,090,900
7,668,600
14,509,100
8,946,700
16,927,200
5,339,600
6,407,600
7,475,500
11,706,900
14,048,300
16,389,700
16,926,200
20,311,400
23,696,700
4,262,200
5,114,700
5,967,100
7,089,300
8,507,100
9,925,000
9,482,600
11,379,100
13,275,700
7,097,000
8,516,400
9,935,800
10,663,000
12,795,600
14,928,200
20,803,300
24,963,900
29,124,600
- 426 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,775,200
12,930,200
15,085,200
535 N-1-01-I

295,533,900
354,640,700
413,747,500
536 N-1-01-II
295,533,900
354,640,700
413,747,500
537 N-1-01-III
538 N-1-11-I

295,533,900
12,315,700
354,640,700
14,778,900
413,747,500
17,242,000
539 N-1-11-II
540 N-1-11-III

19,474,200
30,360,200
23,369,000
36,432,300
27,263,800
42,504,300
6,276,900
7,532,300
8,787,700
12,496,700
14,996,000
17,495,300
27,118,200
32,541,900
37,965,500
13,723,700
16,468,500
19,213,200

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
19,205,600
26,875,900
23,046,700
32,251,100
26,887,900
37,626,300
12,559,600
15,071,600
17,583,500
19,000,200
22,800,300
26,600,300
21,867,500
26,241,000
30,614,500
11,279,400
13,535,300
15,791,200
15,317,200
18,380,700
21,444,100
17,827,200
21,392,700
24,958,100
4,792,200
5,750,600
6,709,100
5,796,200
6,955,500
8,114,700
8,525,400
10,230,500
11,935,600
3,678,800
6,427,300
7,996,900
2,773,700
5,762,300
9,363,400
3,753,200
6,274,700
12,981,000
4,414,500
7,712,800
9,596,300
3,328,400
6,914,700
11,236,000
4,503,900
7,529,600
15,577,100
5,150,300
8,998,200
11,195,700
3,883,100
8,067,200
13,108,700
5,254,500
8,784,500
18,173,300
3,694,700
4,433,600
5,172,600
5,242,600
6,291,100
7,339,700
8,403,900
10,084,600
11,765,400
4,364,800
5,237,800
6,110,700
5,416,000
6,499,200
7,582,400
6,180,500
7,416,600
8,652,800
5,344,700
6,413,600
7,482,600
7,628,600
9,154,300
10,680,000
10,154,200
12,185,100
14,215,900
5,476,500
7,049,100
6,571,800
8,458,900
7,667,100
9,868,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 427 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,111,700
13,334,000
15,556,300
4,968,200
5,961,800
6,955,400
5,521,500
6,625,800
7,730,200
6,868,900
8,242,600
9,616,400
3,519,900
4,223,800
4,927,800
4,227,300
5,072,800
5,918,300
5,311,800
6,374,200
7,436,500
1,784,300
2,141,100
2,498,000
2,927,200
3,512,600
3,512,600
4,215,200
4,098,100
4,917,700
78,599,200
94,319,000
110,038,900
97,254,700
116,705,600
136,156,600
114,149,700
136,979,600
159,809,500
107,284,200
128,741,000
150,197,800
123,065,700
147,678,900
172,292,000
140,611,300
168,733,600
196,855,800
16,092,500
19,311,000
22,529,500
21,300,600
25,560,800
29,820,900
29,949,700
35,939,600
41,929,500
51,858,800
62,230,600
72,602,300
67,301,500
80,761,800
94,222,100
96,493,500
115,792,200
135,090,900
28,199,200
33,839,000
39,478,800
43,502,100
52,202,500
60,903,000
58,888,100
70,665,800
82,443,400
7,612,900
9,135,500
10,658,000
21,344,800
25,613,700
29,882,700
28,276,600
33,931,900
39,587,200
9,012,500
10,815,000
12,617,500
25,268,900
30,322,700
35,376,500
33,475,100
40,170,100
46,865,100
5,214,700
6,257,700
7,300,600
7,399,400
8,879,300
10,359,200
14,394,800
17,273,800
20,152,800
13,410,400
16,092,500
18,774,600
17,750,500
21,300,600
24,850,700
- 428 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,958,100
29,949,700
34,941,300
12,191,300
14,629,600
17,067,800
14,792,100
17,750,500
20,708,900
21,702,700
26,043,200
30,383,700
6,772,900
8,127,500
9,482,100
10,565,800
12,678,900
14,792,100
16,694,400
20,033,200
23,372,100
5,126,600
6,151,900
7,177,200
10,435,700
12,522,800
14,610,000
40,804,400
48,965,300
57,126,200
3,845,000
4,614,000
5,383,000
7,699,800
9,239,800
10,779,700
9,034,300
10,841,200
12,648,100
3,479,800
4,175,700
4,871,700
6,687,000
8,024,400
9,361,700
15,682,000
18,818,400
21,954,800
4,515,300
5,418,400
6,321,400
8,127,500
9,753,000
11,378,500
13,912,000
16,694,400
19,476,700
3,923,400
4,708,100
5,492,800
4,834,200
5,801,100
6,767,900
6,617,600
7,941,100
9,264,600
1,803,000
3,664,800
8,455,800
2,884,500
3,839,200
6,655,200
2,163,600
4,397,700
10,146,900
3,461,400
4,607,000
7,986,300
2,524,200
5,130,700
11,838,100
4,038,300
5,374,900
9,317,300
4,259,600
5,111,600
5,963,500
7,556,900
9,068,300
10,579,700
12,265,800
14,719,000
17,172,200
2,155,700
2,586,800
3,017,900
4,578,800
5,494,600
6,410,400
8,683,100
10,419,700
12,156,300
1,441,700
1,730,100
2,018,400
2,720,800
3,264,900
3,809,100
3,523,900
4,228,700
4,933,400
7,465,600
8,958,700
10,451,800
- 429 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,494,500
11,393,400
13,292,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,594,100
16,312,900
19,031,700
3,598,300
4,317,900
5,037,600
5,340,200
6,408,300
7,476,300
6,422,800
7,707,400
8,991,900
2,407,500
2,889,000
3,370,500
3,233,600
3,880,300
4,527,100
5,882,400
7,058,900
8,235,400
1,318,300
1,581,900
1,845,600
2,511,900
3,014,300
3,516,700
3,651,200
4,381,400
5,111,700
1,273,100
1,527,800
1,782,400
2,003,600
2,404,300
2,805,000
3,227,100
3,872,600
4,518,000
2,983,000
3,579,700
4,176,300
4,503,200
5,403,800
6,304,500
6,970,300
8,364,300
9,758,400
7,867,500
9,441,000
11,014,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,213,500
32,259,100
14,656,200
38,710,900
17,098,900
45,162,700
12,416,100
14,899,300
17,382,500
18,727,400
22,472,800
26,218,300
22,200,000
26,640,000
31,080,000
9,510,600
14,584,000
21,420,900
9,517,200
11,089,000
18,382,100
11,412,700
17,500,800
25,705,100
11,420,600
13,306,800
22,058,500
13,314,900
20,417,600
29,989,300
13,324,000
15,524,600
25,734,900
5,719,100
6,862,900
8,006,800
7,018,800
8,422,500
9,826,300
8,317,200
9,980,600
11,644,100
4,476,600
6,364,400
9,694,900
5,371,900
7,637,300
11,633,900
6,267,200
8,910,100
13,572,900
8,682,500
10,419,100
12,155,600
12,922,000
15,506,400
18,090,800
33,173,300
39,808,000
46,442,600
7,446,200
10,096,800
19,744,600
8,935,500
12,116,100
23,693,500
10,424,700
14,135,500
27,642,400
5,358,600
6,430,300
7,502,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 430 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,591,700
3,110,000
3,628,300
697 U-4-12-I
698 U-4-12-II

2,783,300
4,487,600
3,340,000
5,385,200
3,896,700
6,282,700
699 U-4-12-III

7,859,300
9,431,100
11,003,000
2,109,400
2,531,300
2,953,100
3,446,900
4,136,300
4,825,700
5,565,600
6,678,700
7,791,800
5,333,600
6,386,900
6,400,300
7,664,200
7,467,100
8,941,600

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,725,500
12,870,600
15,015,700
4,282,700
5,139,300
5,995,800
5,335,700
6,402,900
7,470,000
7,467,400
8,960,900
10,454,400
6,985,500
8,382,600
9,779,700
14,389,900
17,267,900
20,145,800
17,647,200
21,176,600
24,706,100
13,289,600
15,175,200
23,764,900
15,947,500
18,210,200
28,517,900
18,605,500
21,245,200
33,270,900
12,494,800
14,993,700
17,492,700
17,062,600
20,475,200
23,887,700
21,627,100
25,952,500
30,277,900
6,517,400
7,820,900
9,124,400
12,452,700
14,943,200
17,433,800
19,536,700
23,444,100
27,351,400
12,780,700
15,336,800
17,892,900
18,569,900
22,283,900
25,997,900
723 V-1-14-III
23,187,900
27,825,500
32,463,100
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,058,300
2,271,400
2,512,600
2,470,000
2,725,600
3,015,100
2,881,700
3,179,900
3,517,600
5,562,500
6,675,000
7,787,400
9,239,500
11,087,400
12,935,400
15,232,800
18,279,300
21,325,900
5,340,300
6,408,400
7,476,500
7,165,400
8,598,400
10,031,500
9,598,100
11,517,700
13,437,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,267,500
14,721,000
17,174,500
18,834,400
22,601,200
26,368,100
1,693,900
2,463,600
2,032,700
2,956,300
2,371,500
3,449,000
- 431 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,555,900
17,467,000
20,378,200
17,446,200
20,935,400
24,424,700
24,895,300
29,874,300
34,853,400
3,087,500
3,705,000
4,322,500
3,407,000
3,768,900
4,088,500
4,522,600
4,769,900
5,276,400
3,227,100
3,872,600
4,518,000
3,561,100
4,273,300
4,985,600
3,939,300
4,727,200
5,515,000
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,471,700
4,166,100
4,860,400
743 W-1-12-II
744 W-1-12-III

4,333,300
7,673,300
5,200,000
9,208,000
6,066,600
10,742,700
745 W-1-13-I
3,568,600
4,282,400
4,996,100
746 W-1-13-II
747 W-1-13-III

3,874,300
5,204,200
4,649,200
6,245,100
5,424,100
7,285,900
748 W-1-20-I
749 W-1-20-II

11,951,100
14,933,000
14,341,300
17,919,600
16,731,500
20,906,200
750 W-1-20-III
17,311,200
20,773,400
24,235,600
751 W-1-30-I
6,746,500
8,095,900
9,445,200
752 W-1-30-II
10,760,700
12,912,900
15,065,000
753 W-1-30-III
26,402,000
31,682,400
36,962,800
754 W-4-10-I
5,026,900
6,032,200
7,037,600
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,452,100
14,726,900
4,114,400
6,246,300
7,602,900
8,942,500
17,672,200
4,937,300
7,495,600
9,123,500
10,433,000
20,617,600
5,760,200
8,744,800
10,644,100
3,085,300
3,702,300
4,319,400
5,871,300
7,045,600
8,219,800
8,640,100
10,368,100
12,096,100
1,798,700
2,457,000
3,055,500
2,403,700
2,861,000
3,660,300
1,736,000
2,672,400
4,995,000
2,309,800
4,281,300
7,833,500
1,704,400
4,265,400
8,513,600
5,069,200
6,728,200
9,558,700
3,300,000
3,963,500
5,448,100
2,158,400
2,948,400
3,666,600
2,884,400
3,433,200
4,392,400
2,083,200
3,206,800
5,994,000
2,771,700
5,137,600
9,400,200
2,045,200
5,118,500
10,216,300
6,083,000
8,073,900
11,470,400
3,960,000
4,756,200
6,537,700
2,518,100
3,439,800
4,277,600
3,365,200
4,005,400
5,124,500
2,430,400
3,741,300
6,993,000
3,233,700
5,993,900
10,966,900
2,386,100
5,971,600
11,919,000
7,096,900
9,419,500
13,382,100
4,620,100
5,548,900
7,627,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 432 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,181,100
2,617,400
3,053,600
4,379,500
5,255,400
6,131,300
9,239,600
11,087,500
12,935,400
- 433 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,477,000
1,915,900
3,562,800
2,944,300
3,826,200
703,800
1,563,800
550,300
1,216,000
1,042,700
1,183,800
1,779,700
2,427,500
2,224,900
720,800
1,663,600
603,400
1,036,000
3,155,700
1,130,100
2,668,900
651,100
1,898,800
2,377,700
1,994,200
489,100
1,482,200
824,100
529,700
458,100
404,400
483,600
673,400
496,000
544,700
419,500
726,200
376,600
373,800
380,900
8,695,900
3,475,400
3,487,000
897,000
1,836,000
1,149,500
2,336,500
1,197,700
685,900
517,900
835,300
592,700
394,800
3,850,400
1,540,200
1,026,800
4,008,200
2,672,100
416,300
4,342,200
3,006,100
4,686,100
1,561,700
960,600
413,300
408,900
388,200
5,919,000
2,881,200
- 434 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,661,800
6,480,600
5,373,200
4,093,300
1,349,400
4,555,800
2,974,800
731,200
6,839,900
6,192,100
4,151,800
3,933,400
486,100
467,100
1,879,600
513,700
457,700
505,800
2,170,200
2,371,500
2,071,400
2,286,700
1,384,900
460,400
811,500
557,000
503,000
490,100
622,200
709,500
415,900
1,193,700
2,175,600
1,670,000
3,926,000
511,200
511,200
4,534,900
2,109,500
404,700
1,872,100
4,863,300
1,116,600
879,500
430,800
290,700
583,400
813,500
1,947,900
1,716,900
1,201,800
717,200
394,800
2,086,900
1,337,700
714,500
652,200
2,137,300
561,200
2,729,500
2,088,200
509,400
564,700
551,600
396,400
2,275,200
2,500,900
495,600
- 435 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,519,000
567,000
613,000
567,700
900,600
692,700
1,734,900
511,800
1,424,200
2,378,800
416,800
2,536,800
1,374,700
2,970,700
1,499,600
662,300
509,400
83,900
660,300
1,492,000
581,400
785,400
449,100
213,600
453,600
6,754,400
3,839,300
6,407,800
1,967,600
879,500
599,300
1,355,400
716,900
1,442,700
835,300
497,300
832,400
468,400
714,900
548,100
1,043,900
2,614,800
2,103,800
1,854,900
1,309,100
481,600
481,600
481,600
393,300
249,500
392,300
479,500
518,700
382,100
337,000
117,600
129,300
95,600
112,200
107,100
163,400
174,000
267,800
294,100
130,100
157,900
107,900
168,500
239,000
- 436 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
170,200
300,600
849,700
985,000
160,900
408,900
195,800
279,500
687,800
588,800
423,300
400,800
160,000
157,200
471,900
353,700
507,400
400,700
231,500
3,710,700
3,053,500
485,200
502,500
961,000
943,600
1,230,000
635,400
1,980,200
334,600
516,400
518,100
414,900
524,000
495,900
232,300
510,400
452,400
409,200
462,800
3,831,300
621,800
1,378,800
494,600
879,500
577,500
460,700
1,197,400
1,226,200
1,307,400
1,143,600
1,686,000
340,700
2,957,000
449,100
1,498,900
3,406,400
3,151,100
1,376,600
498,900
973,000
969,100
449,100
3,520,500
2,769,100
256,200
191,400
248,700
535,400
- 437 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,321,800
1,580,600
1,459,100
1,760,300
843,500
1,173,500
811,100
682,300
834,800
483,400
1,142,700
228,400
846,300
1,423,000
92,800
- 438 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,490,400
2,988,500
3,486,600
A-4-10-II
SEPTIKEMIA (SEDANG)
4,254,600
5,105,500
5,956,500
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,736,600
3,236,200
6,883,900
3,883,400
8,031,200
4,530,600
5
6
A-4-11-II
A-4-11-III

4,606,000
6,375,100
5,527,200
7,650,100
6,448,400
8,925,200
A-4-12-I
2,593,200
3,111,800
3,630,400
8
9
A-4-12-II
A-4-12-III

3,229,400
3,553,200
3,875,200
4,263,900
4,521,100
4,974,500
10 A-4-13-I
11 A-4-13-II

2,053,400
2,620,800
2,464,100
3,145,000
2,874,800
3,669,100
12 A-4-13-III
3,145,000
3,774,000
4,403,000
2,229,100
2,674,900
3,120,700
2,705,800
3,247,000
3,788,100
3,247,000
3,896,400
4,545,800
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,214,900
17,702,200
17,057,800
21,242,700
19,900,800
24,783,100
18 A-4-15-III
INFEKSI HIV (BERAT)
19,998,600
23,998,300
27,998,000
19 B-1-01-I
20 B-1-01-II

38,879,400
42,894,200
46,655,300
51,473,100
54,431,200
60,051,900
21 B-1-01-III
22 B-1-10-I

94,550,400
6,284,600
113,460,500
7,541,600
132,370,600
8,798,500
23 B-1-10-II
13,949,100
16,739,000
19,528,800
24 B-1-10-III
25 B-1-11-I

27,537,500
6,870,600
33,045,000
8,244,800
38,552,500
9,618,900
26 B-1-11-II
27 B-1-11-III

9,179,200
11,859,400
11,015,100
14,231,300
12,850,900
16,603,200
28 B-1-12-I
6,916,300
8,299,600
9,682,800
29 B-1-12-II
7,692,100
9,230,600
10,769,000
30 B-1-12-III
12,033,500
14,440,200
16,846,900
5,508,900
6,610,700
7,712,500
9,064,200
10,877,100
12,689,900
11,728,300
14,074,000
16,419,700
7,569,500
9,083,400
10,597,300
8,418,600
10,102,300
11,786,000
13,169,900
2,271,700
3,626,300
5,002,700
15,803,900
2,726,100
4,351,600
6,003,200
18,437,900
3,180,400
5,076,900
7,003,700
4,789,700
5,747,600
6,705,500
6,705,600
8,046,700
9,387,800
8,123,700
9,748,500
11,373,200
4,330,400
6,357,000
9,457,900
4,130,800
5,196,500
7,628,400
11,349,400
4,957,000
6,062,600
8,899,800
13,241,000
5,783,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 439 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,812,300
5,774,700
6,737,200
48 B-4-13-III
49 B-4-14-I

6,629,300
4,126,400
7,955,200
4,951,700
9,281,000
5,777,000
50 B-4-14-II
4,814,000
5,776,800
6,739,600
51 B-4-14-III
52 C-4-10-I

6,448,500
3,935,800
7,738,200
4,722,900
9,027,900
5,510,100
53 C-4-10-II
54 C-4-10-III

7,551,700
12,929,600
9,062,100
15,515,500
10,572,400
18,101,400
55 C-4-11-I
4,350,400
5,220,500
6,090,600
56 C-4-11-II
57 C-4-11-III

5,821,500
9,227,500
6,985,800
11,072,900
8,150,100
12,918,400
58 C-4-12-I
59 C-4-12-II
2,896,600
5,881,700
3,476,000
7,058,100
4,055,300
8,234,400
60 C-4-12-III
RADIOTERAPI (BERAT)
15,105,900
18,127,100
21,148,300
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,177,700
4,098,400
2,613,200
4,918,100
3,048,800
5,737,800
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,547,900
3,618,300
6,657,500
4,342,000
7,767,100
5,065,700
65 C-4-14-II
5,075,800
6,090,900
7,106,100
66 C-4-14-III
67 D-1-10-I

7,796,700
21,642,300
9,356,100
25,970,800
10,915,400
30,299,200
68 D-1-10-II
69 D-1-10-III

32,962,700
52,488,000
39,555,300
62,985,600
46,147,800
73,483,200
70 D-1-11-I
5,853,000
7,023,700
8,194,300
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
14,945,600
20,023,000
17,934,700
24,027,700
20,923,800
28,032,300
5,073,900
6,088,700
7,103,500
13,983,000
16,779,600
19,576,100
22,181,100
26,617,300
31,053,500
2,501,300
4,104,900
6,458,000
3,972,200
7,137,900
10,108,900
3,424,600
4,749,900
7,293,800
3,001,600
4,925,900
7,749,600
4,766,600
8,565,400
12,130,700
4,109,500
5,699,900
8,752,500
3,501,800
5,746,900
9,041,200
5,561,100
9,993,000
14,152,500
4,794,400
6,649,900
10,211,300
2,934,800
3,521,700
4,108,700
4,153,700
4,984,400
5,815,200
5,312,700
6,375,300
7,437,800
3,147,700
3,777,200
4,406,700
5,153,500
6,184,200
7,214,900
6,303,300
7,564,000
8,824,600
6,902,000
8,282,400
9,662,800
9,422,200
11,306,700
13,191,100
93 E-1-01-III
22,717,900
27,261,500
31,805,100
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,175,800
9,960,900
18,819,400
8,611,000
11,953,100
22,583,300
10,046,100
13,945,200
26,347,100
7,385,100
8,862,100
10,339,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 440 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,903,200
3,483,900
4,064,500
104 E-4-11-II
105 E-4-11-III

4,426,200
6,183,300
5,311,400
7,420,000
6,196,700
8,656,600
106 E-4-12-I
107 E-4-12-II

3,335,700
5,776,700
4,002,900
6,932,100
4,670,000
8,087,400
108 E-4-12-III

(RINGAN)
(SEDANG)
6,847,500
8,217,000
9,586,500
3,632,500
4,359,000
5,085,500
5,321,000
6,385,200
7,449,400
111 E-4-13-III
7,170,700
8,604,800
10,039,000
112 F-4-10-I
113 F-4-10-II
3,986,800
4,582,100
4,784,200
5,498,500
5,581,600
6,414,900
114 F-4-10-III
115 F-4-11-I
5,498,500
3,855,900
6,598,200
4,627,100
7,697,900
5,398,300
116 F-4-11-II
4,492,600
5,391,100
6,289,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,761,100
6,913,400
8,065,600
2,050,300
2,460,300
2,870,400
2,914,800
3,497,800
4,080,800
6,332,300
7,598,800
8,865,300
3,106,100
4,098,500
5,306,000
1,772,100
2,273,000
3,058,600
3,727,300
4,918,200
6,367,300
2,126,600
2,727,600
3,670,300
4,348,500
5,737,900
7,428,500
2,481,000
3,182,200
4,282,000
127 F-4-15-I
2,737,600
3,285,100
3,832,600
128 F-4-15-II
4,079,400
4,895,300
5,711,100
129 F-4-15-III
5,386,100
6,463,300
7,540,500
5,553,000
6,663,500
7,774,100
6,456,200
7,747,500
9,038,700
8,618,000
10,341,500
12,065,100
133 F-4-17-I

1,272,100
1,526,500
1,780,900
134 F-4-17-II
3,728,200
4,473,900
5,219,500
135
136
137
138
139
140
141

(RINGAN)
3,977,700
4,825,100
5,309,000
8,184,200
3,687,500
4,722,000
5,878,900
4,773,200
5,790,100
6,370,800
9,821,100
4,425,000
5,666,400
7,054,700
5,568,700
6,755,200
7,432,600
11,457,900
5,162,500
6,610,800
8,230,400
16,690,900
20,029,100
23,367,200
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
9,940,100
11,928,100
13,916,200
14,123,200
16,947,800
19,772,500
3,441,500
4,129,800
4,818,100
4,808,900
5,770,700
6,732,500
6,153,400
7,384,100
8,614,800
- 441 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,169,400
26,603,300
31,037,100
148 G-1-11-I
149 G-1-11-II

11,612,300
21,230,000
13,934,800
25,476,000
16,257,200
29,722,000
150 G-1-11-III
35,222,200
42,266,600
49,311,000
4,848,500
5,818,300
6,788,000
9,369,900
11,243,900
13,117,900
12,769,400
15,323,200
17,877,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,462,700
3,928,000
1,755,200
4,713,600
2,047,700
5,499,200
156 G-1-13-III
157 G-1-20-I

8,863,300
8,655,300
10,635,900
10,386,400
12,408,600
12,117,400
158 G-1-20-II
14,090,200
16,908,200
19,726,300
159 G-1-20-III
21,623,700
25,948,400
30,273,200
160 G-1-30-I
11,012,900
13,215,500
15,418,100
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
22,995,200
31,327,400
27,594,300
37,592,900
32,193,300
43,858,300
4,161,900
4,994,300
5,826,700
5,087,300
6,104,800
7,122,200
7,196,600
8,635,900
10,075,200
4,491,700
5,390,000
6,288,300
5,966,600
7,159,900
8,353,300
8,767,000
10,520,400
12,273,800
4,983,000
5,979,600
6,976,200
6,105,000
7,326,000
8,547,100
8,866,800
10,640,200
12,413,500
2,903,500
3,484,200
4,065,000
5,063,200
6,075,800
7,088,500
6,005,100
7,206,100
8,407,100
4,925,500
5,910,600
6,895,700
6,788,700
8,146,500
9,504,200
8,520,600
10,224,800
11,928,900
4,024,600
4,829,500
5,634,400
4,803,100
5,763,800
6,724,400
6,779,200
8,135,100
9,490,900
3,317,700
3,981,300
4,644,800
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
23,938,800
28,726,500
33,514,300
36,339,400
43,607,300
50,875,200
17,089,600
20,121,200
20,507,500
24,145,500
23,925,400
28,169,700
- 442 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,404,700
5,285,700
6,166,600
183 G-4-16-III
6,272,700
7,527,200
8,781,800
4,419,000
5,302,800
6,186,600
5,794,300
6,953,100
8,112,000
7,505,900
9,007,100
10,508,300
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,352,000
5,222,400
6,092,800
188 G-4-18-II
5,817,300
6,980,800
8,144,300
189 G-4-18-III
6,509,100
7,811,000
9,112,800
3,631,000
4,357,200
5,083,400
6,137,200
7,364,700
8,592,100
8,057,900
9,669,500
11,281,100
193 G-4-20-I

2,540,100
3,048,100
3,556,100
194 G-4-20-II
3,590,900
4,309,000
5,027,200
195 G-4-20-III
196 G-4-21-I

5,931,200
2,645,100
7,117,500
3,174,100
8,303,700
3,703,100
197 G-4-21-II
198 G-4-21-III

4,476,800
5,424,000
5,372,200
6,508,800
6,267,500
7,593,600
199 G-4-22-I
2,609,400
3,131,300
3,653,200
200 G-4-22-II
201 G-4-22-III

3,334,100
3,895,700
4,000,900
4,674,900
4,667,700
5,454,000
202 G-4-23-I
203 G-4-23-II

2,603,800
3,266,900
3,124,600
3,920,300
3,645,300
4,573,600
204 G-4-23-III
4,651,200
5,581,500
6,511,700
205 G-4-24-I
206 G-4-24-II

2,990,000
3,735,500
3,587,900
4,482,600
4,185,900
5,229,700
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,223,300
2,478,200
3,134,000
4,153,100
7,467,900
2,973,900
3,760,800
4,983,800
8,712,600
3,469,500
4,387,600
5,814,400
3,524,600
4,229,500
4,934,500
4,227,000
5,072,400
5,917,900
6,131,100
7,357,300
8,583,500
10,004,300
11,056,300
15,035,800
7,324,100
9,099,400
12,745,100
3,355,000
4,552,100
8,947,400
2,895,400
3,302,800
4,729,400
3,413,800
4,205,000
7,046,800
12,005,100
13,267,600
18,043,000
8,788,900
10,919,300
15,294,100
4,026,100
5,462,500
10,736,900
3,474,500
3,963,400
5,675,300
4,096,500
5,045,900
8,456,100
14,006,000
15,478,900
21,050,100
10,253,700
12,739,200
17,843,100
4,697,100
6,372,900
12,526,300
4,053,600
4,624,000
6,621,200
4,779,300
5,886,900
9,865,500
229 I-1-01-I
45,852,800
55,023,400
64,193,900
230 I-1-01-II
46,861,500
56,233,800
65,606,100
231 I-1-01-III

(RINGAN)
73,970,300
88,764,400
103,558,400
25,438,900
30,526,700
35,614,500
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 443 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
21,593,800
25,912,600
30,231,400
245 I-1-06-II
31,280,500
37,536,500
43,792,600
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
37,323,400
44,788,000
52,252,700
47,716,200
57,259,400
66,802,700
59,645,200
71,574,300
83,503,300
89,467,800
107,361,400
125,255,000
4,109,700
4,931,600
5,753,500
4,569,500
5,483,400
6,397,300
6,080,600
7,296,800
8,512,900
11,829,500
14,195,500
16,561,400
18,740,400
22,488,500
26,236,600
24,655,900
29,587,000
34,518,200
11,474,500
13,769,400
16,064,300
15,280,600
18,336,800
21,392,900
18,845,200
22,614,300
26,383,300
23,485,500
28,182,600
32,879,700
29,189,000
35,026,800
40,864,600
38,247,600
45,897,200
53,546,700
4,461,600
6,230,500
11,997,400
5,353,900
7,476,600
14,396,900
6,246,200
8,722,700
16,796,400
11,219,000
13,462,800
15,706,600
26,169,200
31,403,000
36,636,900
30,185,800
36,222,900
42,260,100
13,392,300
16,070,800
18,749,300
16,768,400
20,122,100
23,475,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
32,815,900
39,379,100
45,942,300
40,447,700
48,537,200
56,626,700
14,693,600
17,632,300
20,571,000
20,368,400
24,442,000
28,515,700
26,648,500
31,978,200
37,307,900
22,827,300
27,392,700
31,958,200
36,027,600
43,233,100
50,438,600
57,553,900
69,064,600
80,575,400
53,680,700
64,416,900
75,153,000
65,609,800
78,731,700
91,853,700
89,467,800
107,361,400
125,255,000
- 444 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
25,271,100
30,325,300
35,379,500
279 I-1-40-III
33,753,600
40,504,300
47,255,100
280 I-4-10-I
281 I-4-10-II

3,972,300
7,093,100
4,766,800
8,511,700
5,561,300
9,930,300
282 I-4-10-III
10,220,100
12,264,200
14,308,200
283 I-4-11-I
284 I-4-11-II

5,928,100
7,336,100
7,113,700
8,803,300
8,299,300
10,270,500
285 I-4-11-III
286 I-4-12-I

13,570,900
3,513,200
16,285,100
4,215,800
18,999,300
4,918,400
287 I-4-12-II
4,072,300
4,886,700
5,701,200
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,886,700
5,864,100
6,841,400
3,575,100
4,290,100
5,005,200
6,383,800
7,660,500
8,937,300
9,198,100
11,037,800
12,877,400
3,274,800
3,492,300
5,938,300
3,929,700
4,190,700
7,125,900
4,584,700
4,889,200
8,313,600
4,404,000
5,284,800
6,165,600
5,991,400
7,189,600
8,387,900
297 I-4-15-III
7,189,600
8,627,500
10,065,500
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,130,800
3,421,500
4,105,900
1,873,400
2,181,000
2,617,100
2,557,000
4,105,900
4,927,000
2,248,000
2,617,100
3,140,600
2,983,100
4,790,200
5,748,200
2,622,700
3,053,300
3,664,000
3,986,800
4,784,100
5,581,500
6,257,800
7,509,300
8,760,900
8,241,100
9,889,300
11,537,500
307 I-4-19-I
3,846,400
4,615,700
5,385,000
308 I-4-19-II

(SEDANG)
6,004,500
7,205,400
8,406,300
309 I-4-19-III
7,168,300
8,601,900
10,035,600
310
311
312
313
314

4,129,200
4,769,200
6,917,000
3,089,800
3,914,800
4,955,000
5,723,000
8,300,400
3,707,800
4,697,800
5,780,800
6,676,900
9,683,800
4,325,800
5,480,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
20,742,300
24,890,800
29,039,200
15,095,500
18,114,500
21,133,600
18,858,400
22,630,000
26,401,700
19,824,000
23,788,800
27,753,600
11,418,900
13,702,600
15,986,400
23,753,800
28,504,500
33,255,300
36,809,800
44,171,700
51,533,700
10,538,400
12,646,000
14,753,700
- 445 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,650,600
6,780,800
7,910,900
316 I-4-22-I
317 I-4-22-II
3,116,900
3,880,000
3,740,200
4,656,000
4,363,600
5,432,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,671,400
6,805,700
7,939,900
3,287,800
3,945,300
4,602,900
4,036,400
4,843,700
5,651,000
7,887,000
9,464,400
11,041,800
2,747,000
3,296,400
3,845,800
6,325,600
7,590,700
8,855,800
7,997,600
9,597,100
11,196,600
53,412,700
64,095,200
74,777,700
60,446,400
72,535,600
84,624,900
68,383,800
82,060,600
95,737,400
28,344,200
34,013,000
39,681,800
39,466,300
47,359,600
55,252,800
65,172,400
78,206,900
91,241,400
8,607,400
10,328,800
12,050,300
17,417,100
20,900,500
24,383,900
18,660,400
22,392,500
26,124,600
14,718,700
17,662,500
20,606,200
18,538,600
22,246,300
25,954,100
28,626,600
34,351,900
40,077,300
7,183,100
8,619,700
10,056,300
13,012,000
15,614,500
18,216,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
37,558,800
45,070,600
52,582,300
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,723,100
5,455,200
8,253,000
2,700,700
3,648,700
5,042,000
4,449,500
5,065,100
7,072,300
4,055,800
5,645,500
10,532,700
4,337,400
7,276,600
8,608,900
4,260,700
5,090,400
6,848,600
3,267,700
6,546,300
9,903,600
3,240,800
4,378,400
6,050,300
5,339,400
6,078,100
8,486,800
4,866,900
6,774,600
12,639,300
5,204,900
8,731,900
10,330,700
5,112,900
6,108,400
8,218,300
3,812,400
7,637,300
11,554,200
3,781,000
5,108,200
7,058,700
6,229,300
7,091,200
9,901,200
5,678,100
7,903,700
14,745,800
6,072,400
10,187,200
12,052,500
5,965,000
7,126,500
9,588,000
3,550,100
4,260,100
4,970,100
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 446 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,988,800
5,986,500
6,984,300
360 J-4-16-III
6,307,600
7,569,100
8,830,600
361 J-4-17-I
362 J-4-17-II

3,624,300
4,340,200
4,349,200
5,208,300
5,074,100
6,076,300
363 J-4-17-III
364 J-4-18-I

5,695,700
2,187,000
6,834,800
2,624,400
7,974,000
3,061,800
365 J-4-18-II
2,917,800
3,501,300
4,084,900
366 J-4-18-III
367 J-4-19-I

3,071,300
5,105,000
3,685,600
6,126,000
4,299,900
7,147,000
368 J-4-19-II
369 J-4-19-III

5,789,400
6,393,700
6,947,200
7,672,400
8,105,100
8,951,100
370 J-4-20-I
4,559,400
5,471,300
6,383,200
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,317,500
7,635,200
7,581,000
9,162,200
8,844,500
10,689,200
2,749,600
3,299,500
3,849,500
4,429,600
5,315,500
6,201,400
6,181,100
7,417,300
8,653,500
7,803,100
9,363,700
10,924,300
10,109,600
12,131,500
14,153,400
11,848,700
14,218,500
16,588,200
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,126,000
9,751,200
11,376,400

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,668,400
19,021,900
12,802,100
22,826,200
14,935,800
26,630,600
3,375,300
4,050,400
4,725,500
4,390,000
5,268,000
6,146,000
8,697,300
10,436,700
12,176,200
3,806,700
4,187,400
4,225,400
4,568,000
5,024,800
5,070,500
5,329,400
5,862,300
5,915,600
5,393,000
6,471,600
7,550,200
6,320,500
7,584,600
8,848,700
390 K-1-14-III
11,375,000
13,650,000
15,925,000
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

11,961,800
16,707,900
24,395,400
14,354,100
20,049,500
29,274,400
16,746,500
23,391,100
34,153,500
7,074,100
8,488,900
9,903,800
12,186,600
14,623,900
17,061,200
17,287,500
20,745,000
24,202,500
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,656,300
9,187,500
10,718,800
398 K-1-40-II

(SEDANG)
8,702,400
10,442,900
12,183,400
399 K-1-40-III
14,747,400
17,696,900
20,646,400
400
401
402
403
404

5,850,200
7,832,100
10,736,200
4,829,600
6,939,400
7,020,200
9,398,600
12,883,400
5,795,500
8,327,300
8,190,200
10,965,000
15,030,700
6,761,500
9,715,200
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 447 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
10,906,000
13,087,200
15,268,400
406 K-4-11-I
407 K-4-11-II

2,279,100
3,238,800
2,734,900
3,886,600
3,190,700
4,534,300
408 K-4-11-III
409 K-4-12-I

3,886,600
2,903,200
4,663,900
3,483,900
5,441,200
4,064,500
410 K-4-12-II
4,027,700
4,833,200
5,638,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,663,100
7,995,700
9,328,300
3,913,700
4,696,500
5,479,200
5,062,700
6,075,200
7,087,700
7,798,100
9,357,700
10,917,300
2,558,100
3,069,700
3,581,300
3,433,800
4,120,500
4,807,300
5,509,800
6,611,800
7,713,800
418 K-4-15-I
2,600,300
3,120,400
3,640,500
419 K-4-15-II
4,008,200
4,809,900
5,611,500
420 K-4-15-III
5,625,400
6,750,500
7,875,600
421 K-4-16-I
3,622,700
4,347,200
5,071,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,344,600
5,069,500
5,213,500
6,083,300
6,082,400
7,097,200
1,687,900
2,025,500
2,363,100
2,078,700
2,494,400
2,910,100
2,494,400
2,993,300
3,492,200
1,427,400
1,712,900
1,998,400
2,408,700
2,890,400
3,372,200
429 K-4-18-III
2,890,400
3,468,500
4,046,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,071,600
28,788,100
38,465,600
8,728,200
15,440,300
19,169,300
22,885,900
34,545,700
46,158,700
10,473,900
18,528,300
23,003,200
26,700,200
40,303,300
53,851,800
12,219,500
21,616,400
26,837,100
4,891,500
5,869,800
6,848,100
9,811,200
11,773,500
13,735,700
16,514,500
19,817,400
23,120,300
6,421,500
10,334,800
14,782,900
1,731,500
2,009,800
2,332,900
3,517,300
4,834,200
11,324,600
1,722,100
2,277,700
7,531,300
7,705,800
12,401,800
17,739,500
2,077,800
2,411,800
2,799,500
4,220,800
5,801,100
13,589,600
2,066,500
2,733,200
9,037,600
8,990,200
14,468,700
20,696,100
2,424,100
2,813,800
3,266,000
4,924,200
6,767,900
15,854,500
2,410,900
3,188,700
10,543,800
2,342,100
2,810,600
3,279,000
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 448 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,752,700
3,303,200
3,853,700
4,050,600
4,860,700
5,670,800
2,892,600
3,471,100
4,049,600
4,344,700
5,213,700
6,082,600
6,124,400
7,349,300
8,574,200
10,224,900
12,269,900
14,314,900
14,533,300
17,440,000
20,346,600
20,414,900
24,497,900
28,580,900
9,342,800
11,211,300
13,079,900
15,326,500
25,258,100
18,391,800
30,309,700
21,457,000
35,361,400
22,872,700
27,447,200
32,021,800
26,752,900
32,103,500
37,454,100
33,111,200
39,733,500
46,355,700
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,363,000
13,635,600
15,908,200
467 M-1-04-II
14,598,100
17,517,700
20,437,400
468 M-1-04-III
18,007,200
21,608,700
25,210,100
469 M-1-05-I
470 M-1-05-II

7,437,400
11,669,300
8,924,900
14,003,200
10,412,300
16,337,100
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,367,100
18,440,500
21,513,900
8,075,500
9,690,600
11,305,700
10,818,400
12,982,100
15,145,800
22,038,100
26,445,700
30,853,400
18,652,300
22,382,700
26,113,200
44,596,900
53,516,300
62,435,700
96,191,400
115,429,700
134,668,000
12,142,200
14,570,600
16,999,000
15,992,600
19,191,100
22,389,700
480 M-1-20-III
39,874,900
47,849,800
55,824,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,587,500
13,915,200
19,897,500
10,304,900
16,698,200
23,877,000
12,022,400
19,481,300
27,856,500
4,240,200
5,088,200
5,936,300
7,519,800
9,023,800
10,527,700
10,736,800
12,884,200
15,031,600
5,238,400
8,693,000
14,277,800
6,286,100
10,431,600
17,133,300
7,333,700
12,170,300
19,988,900
7,847,500
9,417,100
10,986,600
9,866,200
11,839,400
13,812,600
15,365,000
18,438,000
21,511,000
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 449 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,988,700
17,986,400
20,984,100
16,487,500
19,785,000
23,082,500
18,876,000
22,651,200
26,426,500
8,520,400
10,224,500
11,928,600
10,118,800
22,775,200
12,142,600
27,330,300
14,166,300
31,885,300
2,911,400
3,493,700
4,075,900
4,341,800
8,214,800
5,210,200
9,857,800
6,078,600
11,500,700
3,627,900
4,353,400
5,079,000
7,953,900
9,544,700
11,135,500
11,855,700
14,226,800
16,597,900
2,895,800
3,475,000
4,054,200
4,816,600
5,779,900
6,743,200
6,641,900
7,970,300
9,298,700
4,821,900
5,786,200
6,750,600
7,244,700
8,693,600
10,142,500
14,134,200
16,961,000
19,787,800
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,499,200
6,599,000
7,698,800
512 M-4-14-II
6,782,400
8,138,900
9,495,400
513 M-4-14-III
514 M-4-15-I
10,192,000
3,361,700
12,230,400
4,034,000
14,268,800
4,706,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,346,500
9,863,500
2,791,800
4,609,000
7,742,800
5,215,800
11,836,200
3,350,200
5,530,800
9,291,400
6,085,100
13,808,900
3,908,500
6,452,600
10,839,900
3,623,400
4,348,000
5,072,700
5,067,700
6,081,200
7,094,800
7,076,700
8,492,000
9,907,400
2,738,700
4,127,300
4,969,500
3,286,400
4,952,800
5,963,400
3,834,200
5,778,300
6,957,300
2,944,400
3,533,200
4,122,100
4,810,700
5,772,800
6,734,900
9,395,500
11,274,600
13,153,700
2,880,900
3,457,100
4,033,300
4,218,700
5,062,400
5,906,100
4,714,900
5,657,800
6,600,800
2,900,900
3,481,100
4,061,300
3,628,200
4,353,800
5,079,500
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 450 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,134,300
9,761,200
11,388,000
535 N-1-01-I

172,155,700
206,586,800
241,018,000
536 N-1-01-II
172,155,700
206,586,800
241,018,000
537 N-1-01-III
538 N-1-11-I

172,155,700
8,367,600
206,586,800
10,041,100
241,018,000
11,714,600
539 N-1-11-II
540 N-1-11-III

13,231,200
20,627,400
15,877,400
24,752,800
18,523,600
28,878,300
4,264,700
5,117,600
5,970,500
8,753,100
10,503,700
12,254,300
18,994,500
22,793,400
26,592,300
9,612,600
11,535,100
13,457,600

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,452,300
18,260,100
16,142,700
21,912,100
18,833,200
25,564,100
8,533,300
10,239,900
11,946,600
12,909,200
15,491,000
18,072,800
14,857,200
17,828,700
20,800,100
7,900,500
9,480,600
11,060,700
10,728,700
12,874,400
15,020,200
12,486,800
14,984,200
17,481,500
3,255,900
3,907,100
4,558,300
4,059,900
4,871,900
5,683,800
5,971,500
7,165,800
8,360,100
2,576,700
4,366,800
5,433,300
2,350,900
4,132,500
4,974,100
3,357,900
4,050,000
6,398,300
3,092,100
5,240,200
6,519,900
2,821,100
4,959,000
5,969,000
4,029,500
4,860,000
7,677,900
3,607,400
6,113,600
7,606,600
3,291,200
5,785,500
6,963,800
4,701,000
5,670,000
8,957,600
2,510,300
3,012,300
3,514,400
3,561,900
4,274,300
4,986,700
5,709,800
6,851,700
7,993,700
2,965,500
3,558,700
4,151,800
3,793,500
4,552,200
5,310,900
4,329,100
5,194,900
6,060,700
3,631,300
4,357,600
5,083,800
5,183,000
6,219,600
7,256,200
7,112,400
8,534,800
9,957,300
4,899,600
5,310,800
5,879,500
6,372,900
6,859,500
7,435,100
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 451 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

8,894,700
10,673,700
12,452,600
3,375,500
4,050,600
4,725,700
3,751,400
4,501,700
5,252,000
4,811,200
5,773,400
6,735,700
2,465,400
2,958,500
3,451,600
2,961,000
3,553,200
4,145,400
3,720,600
4,464,700
5,208,800
1,645,700
1,974,800
2,303,900

MAYOR (RINGAN)
MAYOR (SEDANG)
1,947,800
2,337,400
2,337,400
2,804,900
2,726,900
3,272,300
53,401,900
64,082,300
74,762,700
66,076,900
79,292,300
92,507,600
77,555,700
93,066,800
108,578,000
83,437,800
100,125,300
116,812,900
95,711,700
114,854,000
133,996,300
109,357,500
131,229,000
153,100,500
12,071,300
14,485,600
16,899,800
17,045,100
20,454,100
23,863,100
23,857,900
28,629,500
33,401,100
34,817,000
41,780,400
48,743,800
45,009,000
54,010,800
63,012,700
64,531,700
77,438,000
90,344,300
18,905,700
22,686,900
26,468,000
29,556,200
35,467,500
41,378,700
39,334,800
47,201,700
55,068,700
5,172,300
6,206,800
7,241,300
14,502,100
17,402,500
20,302,900
19,211,700
23,054,000
26,896,400
5,009,900
6,011,900
7,013,900
14,046,700
16,856,100
19,665,400
18,608,500
22,330,200
26,051,900
4,148,200
4,977,800
5,807,400
5,886,000
7,063,200
8,240,400
9,530,800
11,436,900
13,343,100
10,059,400
12,071,300
14,083,200
14,204,200
17,045,100
19,885,900
- 452 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
19,881,600
23,857,900
27,834,300
9,503,500
11,404,200
13,304,900
10,926,300
13,111,600
15,296,800
15,293,600
18,352,300
21,411,000
5,387,700
6,465,300
7,542,800
8,404,900
10,085,800
11,766,800
13,057,200
15,668,700
18,280,100
3,590,800
4,309,000
5,027,200
7,309,500
8,771,400
10,233,300
13,155,100
15,786,100
18,417,100
2,693,200
3,231,800
3,770,400
5,393,200
6,471,900
7,550,500
6,328,000
7,593,500
8,859,100
2,437,400
2,924,800
3,412,300
4,683,800
5,620,500
6,557,300
11,461,800
13,754,200
16,046,500
3,591,800
4,310,200
5,028,500
6,465,300
7,758,300
9,051,400
9,097,800
10,917,300
12,736,900
2,665,600
3,198,800
3,731,900
3,284,500
3,941,400
4,598,300
4,496,100
5,395,300
6,294,600
1,613,100
2,365,400
4,042,800
1,959,800
2,608,400
4,521,700
1,935,700
2,838,500
4,851,400
2,351,700
3,130,100
5,426,100
2,258,300
3,311,600
5,659,900
2,743,700
3,651,800
6,330,400
2,894,100
3,472,900
4,051,700
5,134,300
6,161,200
7,188,100
8,333,700
10,000,400
11,667,100
1,464,600
1,757,500
2,050,500
3,110,900
3,733,100
4,355,300
5,899,400
7,079,300
8,259,200
979,500
1,175,500
1,371,400
1,848,600
2,218,300
2,588,000
2,394,200
2,873,000
3,351,900
5,072,300
6,086,700
7,101,200
- 453 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,650,200
7,980,300
9,310,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,521,800
11,426,100
13,330,500
2,444,700
2,933,700
3,422,600
3,628,300
4,353,900
5,079,600
4,363,800
5,236,500
6,109,300
1,686,300
2,023,600
2,360,800
2,264,900
2,717,900
3,170,900
4,120,300
4,944,300
5,768,400
731,500
877,800
1,024,000
1,394,100
1,672,900
1,951,700
2,026,600
2,431,900
2,837,300
998,300
1,198,000
1,397,700
1,571,000
1,885,200
2,199,500
2,530,500
3,036,600
3,542,700
1,644,700
1,973,700
2,302,600
2,450,700
2,940,800
3,431,000
3,760,000
4,512,000
5,264,000
5,345,400
6,414,400
7,483,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,298,100
21,917,500
9,957,700
26,301,000
11,617,400
30,684,500
8,269,500
9,923,400
11,577,300
10,482,900
12,579,400
14,676,000
15,549,600
18,659,600
21,769,500
6,461,700
9,908,700
14,553,800
6,466,200
7,534,100
12,489,200
7,754,100
11,890,400
17,464,600
7,759,400
9,040,900
14,987,000
9,046,400
13,872,200
20,375,300
9,052,600
10,547,700
17,484,800
4,005,900
4,807,000
5,608,200
4,916,200
5,899,400
6,882,600
5,825,700
6,990,800
8,155,900
3,832,500
5,448,800
7,023,200
4,599,000
6,538,500
8,427,800
5,365,600
7,628,300
9,832,500
6,081,600
7,297,900
8,514,200
9,051,000
10,861,200
12,671,400
22,538,600
27,046,400
31,554,100
5,215,600
7,072,100
13,414,900
6,258,700
8,486,500
16,097,900
7,301,800
9,901,000
18,780,900
3,753,400
4,504,000
5,254,700
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 454 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,281,200
2,737,500
3,193,700
697 U-4-12-I
698 U-4-12-II

2,490,100
2,896,500
2,988,200
3,475,900
3,486,200
4,055,200
699 U-4-12-III

3,873,800
4,648,600
5,423,400
1,945,500
2,334,600
2,723,800
2,293,600
2,752,300
3,211,000
2,743,300
3,291,900
3,840,600
3,623,800
4,339,400
4,348,500
5,207,200
5,073,300
6,075,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,287,100
8,744,500
10,202,000
2,909,800
3,491,700
4,073,700
3,625,200
4,350,300
5,075,300
5,073,500
6,088,200
7,103,000
4,892,900
5,871,500
6,850,000
9,776,800
11,732,100
13,687,500
11,989,900
14,387,800
16,785,800
9,029,200
10,310,300
16,146,400
10,835,100
12,372,400
19,375,700
12,640,900
14,434,400
22,604,900
8,489,200
10,187,100
11,884,900
11,951,300
14,341,500
16,731,800
14,693,900
17,632,700
20,571,500
4,565,000
5,478,000
6,391,100
8,722,300
10,466,700
12,211,200
13,273,700
15,928,400
18,583,100
8,683,500
10,420,100
12,156,800
12,616,800
15,140,200
17,663,500
15,754,400
18,905,200
22,056,100
1,441,700
1,590,900
1,759,900
1,730,100
1,909,100
2,111,900
2,018,400
2,227,300
2,463,900
4,329,000
5,194,800
6,060,700
7,190,800
8,628,900
10,067,100
11,855,000
14,226,100
16,597,100
3,628,300
4,354,000
5,079,700
4,868,300
5,842,000
6,815,600
6,722,800
8,067,400
9,411,900
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,334,800
10,001,800
11,668,700
12,796,500
15,355,800
17,915,100
1,491,000
2,168,500
1,789,200
2,602,100
2,087,400
3,035,800
- 455 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,195,400
12,234,500
14,273,600
11,853,300
14,224,000
16,594,600
17,437,500
20,925,000
24,412,500
2,162,600
2,595,100
3,027,600
2,386,400
2,639,800
2,863,700
3,167,800
3,341,000
3,695,800
2,260,400
2,712,500
3,164,500
2,494,300
2,993,200
3,492,100
2,759,200
3,311,100
3,862,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,431,700
2,918,100
3,404,400
743 W-1-12-II
744 W-1-12-III

3,035,200
5,213,400
3,642,200
6,256,100
4,249,300
7,298,800
745 W-1-13-I
2,424,600
2,909,500
3,394,500
746 W-1-13-II
747 W-1-13-III

2,632,300
3,535,900
3,158,800
4,243,100
3,685,200
4,950,200
748 W-1-20-I
749 W-1-20-II

8,119,800
10,145,800
9,743,800
12,174,900
11,367,700
14,204,100
750 W-1-20-III
11,761,600
14,113,900
16,466,200
751 W-1-30-I
4,583,700
5,500,500
6,417,200
752 W-1-30-II
7,311,100
8,773,300
10,235,500
753 W-1-30-III
17,938,100
21,525,700
25,113,300
754 W-4-10-I
3,415,400
4,098,400
4,781,500
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,063,100
10,005,700
3,106,000
4,715,400
5,739,600
6,075,800
12,006,900
3,727,200
5,658,500
6,887,500
7,088,400
14,008,000
4,348,400
6,601,600
8,035,400
2,760,300
3,312,300
3,864,400
3,789,600
4,547,600
5,305,500
4,130,900
4,957,100
5,783,300
1,222,000
1,669,400
2,075,900
1,633,100
2,004,000
2,486,900
1,553,100
1,724,900
2,388,200
2,130,400
2,848,800
3,861,100
1,524,800
2,753,100
4,070,400
2,813,400
3,734,400
5,305,000
2,563,100
3,078,500
4,231,500
1,466,500
2,003,200
2,491,100
1,959,800
2,404,800
2,984,300
1,863,800
2,069,800
2,865,800
2,556,400
3,418,600
4,633,300
1,829,800
3,303,700
4,884,500
3,376,000
4,481,300
6,366,000
3,075,800
3,694,200
5,077,800
1,710,900
2,337,100
2,906,300
2,286,400
2,805,500
3,481,700
2,174,400
2,414,800
3,343,400
2,982,500
3,988,400
5,405,600
2,134,700
3,854,400
5,698,600
3,938,700
5,228,100
7,427,000
3,588,400
4,309,900
5,924,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 456 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,843,900
2,212,600
2,581,400
3,869,200
4,643,000
5,416,900
5,956,000
7,147,200
8,338,400
- 457 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
926,400
1,201,600
2,234,500
1,846,600
2,399,700
441,400
1,078,900
345,200
926,500
688,400
781,500
1,175,000
1,602,600
1,468,900
475,800
1,098,300
398,400
684,000
2,083,400
746,100
1,762,000
429,900
1,310,000
1,491,200
1,250,700
306,700
978,600
516,900
365,400
287,300
253,600
303,300
422,300
362,900
341,600
306,900
455,500
198,900
234,400
268,700
5,454,000
2,179,700
2,187,000
562,600
1,266,700
793,100
1,611,900
751,200
430,200
324,800
523,900
347,900
260,600
2,656,400
1,239,700
708,400
2,765,300
1,843,500
261,100
2,995,700
2,074,000
3,825,400
1,077,400
662,700
259,200
216,000
243,500
3,712,300
1,807,000
- 458 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,296,600
4,064,500
3,547,400
2,567,300
846,400
2,857,400
1,865,700
458,600
4,289,900
3,883,600
2,604,000
2,467,000
321,000
293,000
1,178,900
339,100
287,100
317,300
1,497,300
1,487,400
1,299,200
1,577,600
955,400
288,700
508,900
349,400
315,500
307,400
390,200
445,000
260,900
748,700
1,364,500
1,047,400
2,462,400
320,600
320,600
3,128,700
1,323,100
253,800
1,174,200
3,210,700
700,300
551,600
270,200
256,100
402,500
561,200
1,343,800
1,184,500
829,100
449,800
260,600
1,439,700
839,000
492,900
409,000
1,340,500
296,300
1,883,100
1,440,700
319,500
354,200
346,000
209,400
1,569,700
1,568,500
310,900
- 459 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
952,700
355,600
384,500
356,000
564,800
434,500
1,088,100
321,000
893,200
1,641,200
261,400
1,591,000
862,200
1,863,200
940,500
415,400
319,500
73,900
414,100
935,800
364,700
492,600
281,700
114,400
284,500
4,236,300
2,408,000
4,018,900
1,357,500
551,600
375,800
850,100
449,600
904,800
523,900
311,900
522,100
323,200
493,200
343,800
889,700
1,726,300
1,388,900
1,224,600
864,300
302,000
302,000
302,000
246,700
156,500
246,000
300,700
325,300
239,600
211,400
103,600
113,900
84,300
98,900
94,300
143,900
129,100
167,900
184,500
108,900
139,100
95,100
148,400
210,600
- 460 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
149,900
188,500
532,900
617,800
141,800
256,400
172,500
246,300
431,400
369,300
265,500
251,400
140,900
131,500
296,000
186,800
268,000
185,500
145,200
2,560,000
1,915,100
304,300
315,100
602,700
789,700
771,500
398,500
1,242,000
294,800
323,900
324,900
260,200
328,600
311,000
145,700
320,100
283,800
256,700
290,300
2,402,900
429,000
864,800
310,200
606,800
483,300
405,800
751,000
769,100
820,000
717,300
1,372,900
213,700
2,040,000
281,700
1,034,100
2,350,100
1,976,300
863,400
312,900
610,200
607,800
281,700
2,208,000
1,736,800
155,600
168,600
219,100
388,800
- 461 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,133,000
610,500
963,300
1,104,000
556,900
736,000
535,500
571,000
715,500
319,100
716,700
201,200
708,200
1,219,700
81,700
- 462 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,565,100
3,078,100
3,591,100
A-4-10-II
SEPTIKEMIA (SEDANG)
4,382,300
5,258,700
6,135,200
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,908,700
3,333,200
7,090,400
3,999,900
8,272,100
4,666,500
5
6
A-4-11-II
A-4-11-III

4,744,200
6,566,400
5,693,000
7,879,600
6,641,900
9,192,900
A-4-12-I
2,671,000
3,205,100
3,739,300
8
9
A-4-12-II
A-4-12-III

3,326,300
3,659,800
3,991,500
4,391,800
4,656,800
5,123,700
10 A-4-13-I
11 A-4-13-II

2,115,000
2,699,400
2,538,000
3,239,300
2,961,000
3,779,200
12 A-4-13-III
3,239,300
3,887,200
4,535,100
2,295,900
2,755,100
3,214,300
2,787,000
3,344,400
3,901,800
3,344,400
4,013,300
4,682,100
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,641,300
18,233,300
17,569,600
21,880,000
20,497,800
25,526,600
18 A-4-15-III
INFEKSI HIV (BERAT)
20,598,500
24,718,200
28,837,900
19 B-1-01-I
20 B-1-01-II

40,045,800
44,181,100
48,055,000
53,017,300
56,064,100
61,853,500
21 B-1-01-III
22 B-1-10-I

97,386,900
6,473,200
116,864,300
7,767,800
136,341,700
9,062,500
23 B-1-10-II
14,367,600
17,241,100
20,114,700
24 B-1-10-III
25 B-1-11-I

28,363,600
7,076,800
34,036,400
8,492,100
39,709,100
9,907,500
26 B-1-11-II
27 B-1-11-III

9,454,600
12,215,200
11,345,500
14,658,200
13,236,400
17,101,300
28 B-1-12-I
7,123,800
8,548,500
9,973,300
29 B-1-12-II
7,922,900
9,507,500
11,092,100
30 B-1-12-III
12,394,500
14,873,400
17,352,300
5,674,200
6,809,000
7,943,900
9,336,200
11,203,400
13,070,600
12,080,200
14,496,200
16,912,200
7,796,600
9,355,900
10,915,200
8,671,100
10,405,400
12,139,600
13,565,000
2,339,900
3,735,100
5,152,700
16,278,000
2,807,900
4,482,200
6,183,300
18,991,100
3,275,800
5,229,200
7,213,800
4,933,400
5,920,000
6,906,700
6,906,800
8,288,100
9,669,500
8,367,400
10,040,900
11,714,400
4,460,300
6,547,700
9,741,600
4,254,800
5,352,400
7,857,300
11,689,900
5,105,700
6,244,400
9,166,800
13,638,200
5,956,700
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 463 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,956,600
5,947,900
6,939,300
48 B-4-13-III
49 B-4-14-I

6,828,200
4,250,200
8,193,800
5,100,300
9,559,400
5,950,300
50 B-4-14-II
4,958,400
5,950,100
6,941,800
51 B-4-14-III
52 C-4-10-I

6,641,900
4,053,800
7,970,300
4,864,600
9,298,700
5,675,400
53 C-4-10-II
54 C-4-10-III

7,778,300
13,317,500
9,334,000
15,981,000
10,889,600
18,644,500
55 C-4-11-I
4,480,900
5,377,100
6,273,300
56 C-4-11-II
57 C-4-11-III

5,996,100
9,504,300
7,195,400
11,405,100
8,394,600
13,306,000
58 C-4-12-I
59 C-4-12-II
2,983,500
6,058,200
3,580,300
7,269,800
4,177,000
8,481,400
60 C-4-12-III
RADIOTERAPI (BERAT)
15,559,100
18,670,900
21,782,700
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,243,000
4,221,400
2,691,600
5,065,700
3,140,200
5,909,900
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,714,300
3,726,900
6,857,200
4,472,300
8,000,100
5,217,600
65 C-4-14-II
5,228,100
6,273,700
7,319,300
66 C-4-14-III
67 D-1-10-I

8,030,600
22,291,600
9,636,700
26,749,900
11,242,900
31,208,200
68 D-1-10-II
69 D-1-10-III

33,951,600
54,062,600
40,741,900
64,875,100
47,532,300
75,687,600
70 D-1-11-I
6,028,600
7,234,400
8,440,100
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,393,900
20,623,700
18,472,700
24,748,500
21,551,500
28,873,200
5,226,100
6,271,400
7,316,600
14,402,500
17,282,900
20,163,400
22,846,500
27,415,800
31,985,100
2,576,300
4,228,000
6,651,700
4,091,300
7,352,000
10,412,200
3,527,300
4,892,400
7,512,600
3,091,600
5,073,700
7,982,100
4,909,600
8,822,400
12,494,600
4,232,800
5,870,900
9,015,100
3,606,900
5,919,300
9,312,400
5,727,900
10,292,800
14,577,100
4,938,200
6,849,400
10,517,600
3,022,800
3,627,400
4,231,900
4,278,300
5,134,000
5,989,600
5,472,100
6,566,500
7,660,900
3,242,100
3,890,500
4,538,900
5,308,100
6,369,800
7,431,400
6,492,400
7,790,900
9,089,400
7,109,000
8,530,800
9,952,600
9,704,900
11,645,900
13,586,800
93 E-1-01-III
23,399,500
28,079,400
32,759,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,391,100
10,259,700
19,384,000
8,869,300
12,311,700
23,260,800
10,347,500
14,363,600
27,137,600
7,606,600
9,128,000
10,649,300
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 464 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,990,300
3,588,400
4,186,400
104 E-4-11-II
105 E-4-11-III

4,559,000
6,368,800
5,470,800
7,642,600
6,382,600
8,916,300
106 E-4-12-I
107 E-4-12-II

3,435,800
5,950,000
4,123,000
7,140,000
4,810,100
8,330,000
108 E-4-12-III

(RINGAN)
(SEDANG)
7,052,900
8,463,500
9,874,100
3,741,500
4,489,800
5,238,100
5,480,600
6,576,700
7,672,900
111 E-4-13-III
7,385,800
8,863,000
10,340,100
112 F-4-10-I
113 F-4-10-II
4,106,500
4,719,500
4,927,700
5,663,500
5,749,000
6,607,400
114 F-4-10-III
115 F-4-11-I
5,663,500
3,971,600
6,796,100
4,765,900
7,928,800
5,560,300
116 F-4-11-II
4,627,400
5,552,800
6,478,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,934,000
7,120,800
8,307,600
2,111,800
2,534,100
2,956,500
3,002,300
3,602,700
4,203,200
6,522,300
7,826,800
9,131,200
3,199,200
4,221,500
5,465,200
1,825,300
2,341,200
3,150,300
3,839,100
5,065,800
6,558,300
2,190,400
2,809,500
3,780,400
4,478,900
5,910,000
7,651,300
2,555,400
3,277,700
4,410,400
127 F-4-15-I
2,819,700
3,383,700
3,947,600
128 F-4-15-II
4,201,800
5,042,100
5,882,500
129 F-4-15-III
5,547,600
6,657,200
7,766,700
5,719,500
6,863,500
8,007,400
6,649,900
7,979,900
9,309,900
8,876,500
10,651,800
12,427,100
133 F-4-17-I

1,310,200
1,572,300
1,834,300
134 F-4-17-II
3,840,100
4,608,100
5,376,100
135
136
137
138
139
140
141

(RINGAN)
4,097,000
4,969,900
5,468,300
8,429,700
3,798,100
4,863,700
6,055,300
4,916,400
5,963,800
6,561,900
10,115,700
4,557,800
5,836,400
7,266,300
5,735,800
6,957,800
7,655,600
11,801,600
5,317,400
6,809,200
8,477,400
17,191,600
20,629,900
24,068,300
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,238,300
12,286,000
14,333,600
14,546,900
17,456,300
20,365,700
3,544,800
4,253,700
4,962,700
4,953,200
5,943,800
6,934,400
6,338,000
7,605,600
8,873,200
- 465 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,834,500
27,401,400
31,968,300
148 G-1-11-I
149 G-1-11-II

11,960,700
21,866,900
14,352,800
26,240,300
16,744,900
30,613,700
150 G-1-11-III
36,278,800
43,534,600
50,790,400
4,994,000
5,992,800
6,991,600
9,651,000
11,581,200
13,511,400
13,152,500
15,782,900
18,413,400
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,506,500
4,045,800
1,807,800
4,855,000
2,109,200
5,664,200
156 G-1-13-III
157 G-1-20-I

9,129,200
8,915,000
10,955,000
10,698,000
12,780,800
12,480,900
158 G-1-20-II
14,512,900
17,415,500
20,318,100
159 G-1-20-III
22,272,400
26,726,900
31,181,400
160 G-1-30-I
11,343,300
13,611,900
15,880,600
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
23,685,100
32,267,200
28,422,100
38,720,600
33,159,100
45,174,100
4,286,800
5,144,200
6,001,500
5,239,900
6,287,900
7,335,900
7,412,500
8,894,900
10,377,400
4,626,400
5,551,700
6,477,000
6,145,600
7,374,700
8,603,800
9,030,000
10,836,000
12,642,000
5,132,500
6,159,000
7,185,500
6,288,200
7,545,800
8,803,500
9,132,800
10,959,400
12,785,900
2,990,600
3,588,800
4,186,900
5,215,100
6,258,100
7,301,100
6,185,200
7,422,300
8,659,300
5,073,300
6,087,900
7,102,600
6,992,400
8,390,900
9,789,300
8,776,300
10,531,500
12,286,800
4,145,300
4,974,400
5,803,400
4,947,200
5,936,700
6,926,100
6,982,600
8,379,100
9,775,600
3,417,300
4,100,700
4,784,200
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
24,656,900
29,588,300
34,519,700
37,429,600
44,915,500
52,401,400
17,602,300
20,724,900
21,122,700
24,869,900
24,643,200
29,014,800
- 466 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,536,900
5,444,200
6,351,600
183 G-4-16-III
6,460,900
7,753,000
9,045,200
4,551,600
5,461,900
6,372,200
5,968,100
7,161,700
8,355,300
7,731,100
9,277,300
10,823,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,482,600
5,379,100
6,275,600
188 G-4-18-II
5,991,800
7,190,200
8,388,600
189 G-4-18-III
6,704,400
8,045,300
9,386,200
3,739,900
4,487,900
5,235,900
6,321,400
7,585,600
8,849,900
8,299,600
9,959,600
11,619,500
193 G-4-20-I

2,616,300
3,139,500
3,662,800
194 G-4-20-II
3,698,600
4,438,300
5,178,000
195 G-4-20-III
196 G-4-21-I

6,109,200
2,724,400
7,331,000
3,269,300
8,552,800
3,814,200
197 G-4-21-II
198 G-4-21-III

4,611,100
5,586,700
5,533,300
6,704,100
6,455,600
7,821,400
199 G-4-22-I
2,687,700
3,225,300
3,762,800
200 G-4-22-II
201 G-4-22-III

3,434,100
4,012,600
4,120,900
4,815,100
4,807,700
5,617,600
202 G-4-23-I
203 G-4-23-II

2,681,900
3,364,900
3,218,300
4,037,900
3,754,700
4,710,800
204 G-4-23-III
4,790,800
5,748,900
6,707,100
205 G-4-24-I
206 G-4-24-II

3,079,600
3,847,600
3,695,600
4,617,100
4,311,500
5,386,600
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,409,900
2,552,600
3,228,000
4,277,700
7,691,900
3,063,100
3,873,600
5,133,300
8,973,900
3,573,600
4,519,200
5,988,800
3,630,400
4,356,400
5,082,500
4,353,800
5,224,600
6,095,400
6,315,000
7,578,000
8,841,000
10,304,400
11,388,000
15,486,900
7,543,800
9,372,400
13,127,400
3,455,700
4,688,700
9,215,800
2,982,300
3,401,900
4,871,300
3,516,200
4,331,100
7,258,200
12,365,300
13,665,600
18,584,300
9,052,500
11,246,900
15,752,900
4,146,800
5,626,400
11,059,000
3,578,800
4,082,300
5,845,600
4,219,400
5,197,300
8,709,800
14,426,100
15,943,200
21,681,600
10,561,300
13,121,300
18,378,400
4,838,000
6,564,100
12,902,100
4,175,200
4,762,700
6,819,900
4,922,600
6,063,500
10,161,400
229 I-1-01-I
47,228,400
56,674,100
66,119,700
230 I-1-01-II
48,267,400
57,920,900
67,574,300
231 I-1-01-III

(RINGAN)
76,189,400
91,427,300
106,665,200
26,202,100
31,442,500
36,683,000
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 467 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
22,241,700
26,690,000
31,138,300
245 I-1-06-II
32,218,900
38,662,600
45,106,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
38,443,100
46,131,700
53,820,300
49,147,700
58,977,200
68,806,700
61,434,600
73,721,500
86,008,400
92,151,900
110,582,300
129,012,600
4,233,000
5,079,500
5,926,100
4,706,600
5,647,900
6,589,300
6,263,100
7,515,700
8,768,300
12,184,400
14,621,300
17,058,200
19,302,600
23,163,200
27,023,700
25,395,500
30,474,600
35,553,700
11,818,700
14,182,500
16,546,200
15,739,100
18,886,900
22,034,700
19,410,600
23,292,700
27,174,800
24,190,000
29,028,000
33,866,100
30,064,700
36,077,600
42,090,500
39,395,100
47,274,100
55,153,100
4,595,400
6,417,400
12,357,400
5,514,500
7,700,900
14,828,800
6,433,600
8,984,400
17,300,300
11,555,600
13,866,700
16,177,800
26,954,300
32,345,100
37,736,000
31,091,300
37,309,600
43,527,900
13,794,100
16,552,900
19,311,700
17,271,500
20,725,800
24,180,100
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
33,800,400
40,560,500
47,320,500
41,661,100
49,993,300
58,325,500
15,134,400
18,161,300
21,188,200
20,979,400
25,175,300
29,371,200
27,447,900
32,937,500
38,427,100
23,512,100
28,214,500
32,916,900
37,108,400
44,530,100
51,951,800
59,280,500
71,136,600
82,992,700
55,291,100
66,349,400
77,407,600
67,578,000
81,093,700
94,609,300
92,151,900
110,582,300
129,012,600
- 468 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
26,029,200
31,235,100
36,440,900
279 I-1-40-III
34,766,200
41,719,500
48,672,700
280 I-4-10-I
281 I-4-10-II

4,091,500
7,305,900
4,909,800
8,767,100
5,728,100
10,228,200
282 I-4-10-III
10,526,800
12,632,100
14,737,500
283 I-4-11-I
284 I-4-11-II

6,105,900
7,556,100
7,327,100
9,067,400
8,548,300
10,578,600
285 I-4-11-III
286 I-4-12-I

13,978,100
3,618,600
16,773,700
4,342,300
19,569,300
5,066,000
287 I-4-12-II
4,194,400
5,033,300
5,872,200
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,033,300
6,040,000
7,046,600
3,682,400
4,418,800
5,155,300
6,575,300
7,890,400
9,205,400
9,474,100
11,368,900
13,263,700
3,373,000
3,597,000
6,116,400
4,047,600
4,316,400
7,339,700
4,722,200
5,035,800
8,563,000
4,536,100
5,443,300
6,350,600
6,171,100
7,405,300
8,639,500
297 I-4-15-III
7,405,300
8,886,400
10,367,400
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,194,700
3,524,200
4,229,000
1,929,600
2,246,400
2,695,700
2,633,700
4,229,000
5,074,800
2,315,500
2,695,700
3,234,800
3,072,600
4,933,900
5,920,600
2,701,400
3,144,900
3,773,900
4,106,400
4,927,700
5,748,900
6,445,500
7,734,600
9,023,700
8,488,300
10,186,000
11,883,600
307 I-4-19-I
3,961,800
4,754,200
5,546,600
308 I-4-19-II

(SEDANG)
6,184,600
7,421,600
8,658,500
309 I-4-19-III
7,383,300
8,860,000
10,336,600
310
311
312
313
314

4,253,000
4,912,300
7,124,500
3,182,500
4,032,300
5,103,600
5,894,700
8,549,400
3,819,000
4,838,700
5,954,200
6,877,200
9,974,300
4,455,500
5,645,200
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,364,600
25,637,500
29,910,400
15,548,300
18,658,000
21,767,600
19,424,100
23,308,900
27,193,800
20,418,800
24,502,500
28,586,300
11,761,400
14,113,700
16,466,000
24,466,400
29,359,600
34,252,900
37,914,100
45,496,900
53,079,700
10,854,500
13,025,400
15,196,300
- 469 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,820,200
6,984,200
8,148,200
316 I-4-22-I
317 I-4-22-II
3,210,400
3,996,400
3,852,400
4,795,700
4,494,500
5,595,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,841,500
7,009,800
8,178,100
3,386,400
4,063,700
4,741,000
4,157,500
4,989,000
5,820,500
8,123,600
9,748,300
11,373,000
2,829,400
3,395,300
3,961,200
6,515,400
7,818,400
9,121,500
8,237,500
9,885,000
11,532,500
55,015,000
66,018,100
77,021,100
62,259,800
74,711,700
87,163,700
70,435,400
84,522,400
98,609,500
29,194,500
35,033,400
40,872,300
40,650,300
48,780,400
56,910,400
67,127,600
80,553,100
93,978,600
8,865,600
10,638,700
12,411,800
17,939,600
21,527,500
25,115,400
19,220,200
23,064,300
26,908,300
15,160,300
18,192,300
21,224,400
19,094,800
22,913,700
26,732,700
29,485,400
35,382,500
41,279,600
7,398,600
8,878,300
10,358,000
13,402,400
16,082,900
18,763,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
38,685,600
46,422,700
54,159,800
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,804,800
5,618,900
8,500,600
2,781,700
3,758,100
5,193,200
4,583,000
5,217,100
7,284,500
4,177,500
5,814,900
10,848,700
4,467,600
7,494,900
8,867,200
4,388,500
5,243,100
7,054,100
3,365,800
6,742,700
10,200,700
3,338,100
4,509,800
6,231,900
5,499,600
6,260,500
8,741,400
5,012,900
6,977,900
13,018,400
5,361,100
8,993,800
10,640,600
5,266,200
6,291,700
8,464,900
3,926,700
7,866,500
11,900,800
3,894,400
5,261,400
7,270,500
6,416,200
7,303,900
10,198,200
5,848,400
8,140,900
15,188,200
6,254,600
10,492,800
12,414,100
6,144,000
7,340,300
9,875,700
3,656,600
4,387,900
5,119,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 470 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,138,400
6,166,100
7,193,800
360 J-4-16-III
6,496,800
7,796,100
9,095,500
361 J-4-17-I
362 J-4-17-II

3,733,100
4,470,500
4,479,700
5,364,500
5,226,300
6,258,600
363 J-4-17-III
364 J-4-18-I

5,866,600
2,252,600
7,039,900
2,703,100
8,213,200
3,153,700
365 J-4-18-II
3,005,300
3,606,400
4,207,400
366 J-4-18-III
367 J-4-19-I

3,163,500
5,258,100
3,796,200
6,309,800
4,428,900
7,361,400
368 J-4-19-II
369 J-4-19-III

5,963,100
6,585,500
7,155,700
7,902,600
8,348,300
9,219,600
370 J-4-20-I
4,696,200
5,635,400
6,574,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,507,100
7,864,200
7,808,500
9,437,100
9,109,900
11,009,900
2,832,100
3,398,500
3,964,900
4,562,400
5,474,900
6,387,400
6,366,500
7,639,800
8,913,100
8,037,200
9,644,600
11,252,100
10,412,800
12,495,400
14,578,000
12,204,200
14,645,000
17,085,900
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,369,800
10,043,700
11,717,700

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,988,500
19,592,500
13,186,200
23,511,000
15,383,900
27,429,500
3,476,600
4,171,900
4,867,200
4,521,700
5,426,000
6,330,400
8,958,200
10,749,800
12,541,500
3,920,900
4,313,000
4,352,200
4,705,100
5,175,600
5,222,600
5,489,300
6,038,200
6,093,100
5,554,800
6,665,800
7,776,800
6,510,100
7,812,200
9,114,200
390 K-1-14-III
11,716,300
14,059,500
16,402,800
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,320,600
17,209,200
25,127,200
14,784,800
20,651,000
30,152,700
17,248,900
24,092,800
35,178,100
7,286,300
8,743,600
10,200,900
12,552,200
15,062,600
17,573,000
17,806,100
21,367,400
24,928,600
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,886,000
9,463,200
11,040,400
398 K-1-40-II

(SEDANG)
8,963,500
10,756,200
12,548,900
399 K-1-40-III
15,189,800
18,227,800
21,265,800
400
401
402
403
404

6,025,700
8,067,100
11,058,300
4,974,500
7,147,600
7,230,800
9,680,500
13,269,900
5,969,400
8,577,200
8,435,900
11,293,900
15,481,600
6,964,300
10,006,700
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 471 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,233,200
13,479,800
15,726,500
406 K-4-11-I
407 K-4-11-II

2,347,500
3,336,000
2,817,000
4,003,200
3,286,500
4,670,400
408 K-4-11-III
409 K-4-12-I

4,003,200
2,990,300
4,803,800
3,588,400
5,604,400
4,186,400
410 K-4-12-II
4,148,500
4,978,200
5,807,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,863,000
8,235,600
9,608,200
4,031,100
4,837,400
5,643,600
5,214,500
6,257,400
7,300,300
8,032,000
9,638,400
11,244,900
2,634,800
3,161,800
3,688,700
3,536,800
4,244,100
4,951,500
5,675,100
6,810,100
7,945,200
418 K-4-15-I
2,678,300
3,214,000
3,749,700
419 K-4-15-II
4,128,500
4,954,200
5,779,900
420 K-4-15-III
5,794,200
6,953,000
8,111,800
421 K-4-16-I
3,731,300
4,477,600
5,223,900
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,474,900
5,221,500
5,369,900
6,265,800
6,264,900
7,310,200
1,738,600
2,086,300
2,434,000
2,141,000
2,569,200
2,997,400
2,569,200
3,083,100
3,596,900
1,470,200
1,764,300
2,058,300
2,481,000
2,977,200
3,473,300
429 K-4-18-III
2,977,200
3,572,600
4,168,000
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,643,700
29,651,700
39,619,500
8,990,100
15,903,500
19,744,400
23,572,500
35,582,000
47,543,400
10,788,100
19,084,200
23,693,300
27,501,200
41,512,400
55,467,300
12,586,100
22,264,900
27,642,200
5,038,200
6,045,900
7,053,500
10,105,600
12,126,700
14,147,800
17,009,900
20,411,900
23,813,900
6,614,200
10,644,800
15,226,400
1,783,500
2,070,100
2,402,900
3,622,800
4,979,300
11,664,400
1,773,700
2,346,000
7,757,300
7,937,000
12,773,800
18,271,700
2,140,200
2,484,200
2,883,400
4,347,400
5,975,100
13,997,200
2,128,500
2,815,200
9,308,700
9,259,900
14,902,800
21,316,900
2,496,900
2,898,200
3,364,000
5,072,000
6,971,000
16,330,100
2,483,200
3,284,400
10,860,200
2,412,400
2,894,900
3,377,400
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 472 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,835,200
3,402,300
3,969,300
4,172,100
5,006,500
5,840,900
2,979,300
3,575,200
4,171,100
4,475,100
5,370,100
6,265,100
6,308,200
7,569,800
8,831,400
10,531,700
12,638,000
14,744,300
14,969,300
17,963,200
20,957,000
21,027,400
25,232,900
29,438,400
9,623,000
11,547,700
13,472,300
15,786,300
26,015,900
18,943,500
31,219,000
22,100,800
36,422,200
23,558,900
28,270,600
32,982,400
27,555,500
33,066,600
38,577,800
34,104,600
40,925,500
47,746,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,703,900
14,044,600
16,385,400
467 M-1-04-II
15,036,100
18,043,300
21,050,500
468 M-1-04-III
18,547,400
22,256,900
25,966,400
469 M-1-05-I
470 M-1-05-II

7,660,500
12,019,400
9,192,600
14,423,300
10,724,700
16,827,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,828,100
18,993,700
22,159,300
8,317,800
9,981,300
11,644,900
11,143,000
13,371,600
15,600,200
22,699,300
27,239,100
31,779,000
19,211,800
23,054,200
26,896,600
45,934,800
55,121,800
64,308,800
99,077,200
118,892,600
138,708,000
12,506,400
15,007,700
17,509,000
16,472,400
19,766,900
23,061,400
480 M-1-20-III
41,071,100
49,285,300
57,499,600
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,845,100
14,332,600
20,494,400
10,614,100
17,199,200
24,593,300
12,383,100
20,065,700
28,692,100
4,367,400
5,240,900
6,114,400
7,745,400
9,294,500
10,843,600
11,059,000
13,270,700
15,482,500
5,395,500
8,953,800
14,706,100
6,474,600
10,744,600
17,647,300
7,553,700
12,535,400
20,588,500
8,083,000
9,699,600
11,316,200
10,162,200
12,194,600
14,227,000
15,826,000
18,991,100
22,156,300
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 473 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,438,300
18,526,000
21,613,700
16,982,200
20,378,600
23,775,000
19,442,300
23,330,800
27,219,200
8,776,000
10,531,200
12,286,500
10,422,400
23,458,500
12,506,800
28,150,200
14,591,300
32,841,900
2,998,700
3,598,500
4,198,200
4,472,100
8,461,300
5,366,500
10,153,500
6,260,900
11,845,800
3,736,700
4,484,000
5,231,400
8,192,500
9,831,100
11,469,600
12,211,300
14,653,600
17,095,900
2,982,700
3,579,300
4,175,800
4,961,100
5,953,300
6,945,500
6,841,200
8,209,400
9,577,700
4,966,500
5,959,800
6,953,100
7,462,000
8,954,400
10,446,800
14,558,200
17,469,800
20,381,500
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,664,200
6,797,000
7,929,800
512 M-4-14-II
6,985,900
8,383,100
9,780,300
513 M-4-14-III
514 M-4-15-I
10,497,800
3,462,600
12,597,300
4,155,100
14,696,900
4,847,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,476,900
10,159,400
2,875,600
4,747,300
7,975,100
5,372,300
12,191,200
3,450,700
5,696,700
9,570,100
6,267,600
14,223,100
4,025,800
6,646,200
11,165,100
3,732,100
4,478,500
5,224,900
5,219,700
6,263,700
7,307,600
7,289,000
8,746,800
10,204,600
2,820,900
4,251,200
5,118,600
3,385,000
5,101,400
6,142,300
3,949,200
5,951,600
7,166,000
3,032,700
3,639,200
4,245,800
4,955,000
5,946,000
6,937,000
9,677,400
11,612,900
13,548,300
2,967,400
3,560,900
4,154,300
4,345,200
5,214,300
6,083,300
4,856,300
5,827,600
6,798,800
2,987,900
3,585,500
4,183,100
3,737,000
4,484,400
5,231,800
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 474 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,378,300
10,054,000
11,729,700
535 N-1-01-I

177,320,400
212,784,400
248,248,500
536 N-1-01-II
177,320,400
212,784,400
248,248,500
537 N-1-01-III
538 N-1-11-I

177,320,400
8,618,600
212,784,400
10,342,300
248,248,500
12,066,000
539 N-1-11-II
540 N-1-11-III

13,628,100
21,246,200
16,353,700
25,495,400
19,079,300
29,744,700
4,392,600
5,271,100
6,149,700
9,015,700
10,818,800
12,622,000
19,564,400
23,477,200
27,390,100
9,900,900
11,881,100
13,861,300

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,855,800
18,807,900
16,627,000
22,569,500
19,398,200
26,331,000
8,789,300
10,547,100
12,305,000
13,296,400
15,955,700
18,615,000
15,302,900
18,363,500
21,424,100
8,137,500
9,765,000
11,392,500
11,050,600
13,260,700
15,470,800
12,861,400
15,433,700
18,006,000
3,353,600
4,024,300
4,695,000
4,181,700
5,018,000
5,854,300
6,150,600
7,380,800
8,610,900
2,654,000
4,497,800
5,596,300
2,421,400
4,256,500
5,123,400
3,458,600
4,171,500
6,590,200
3,184,900
5,397,400
6,715,500
2,905,700
5,107,800
6,148,000
4,150,300
5,005,800
7,908,300
3,715,700
6,297,000
7,834,800
3,390,000
5,959,100
7,172,700
4,842,100
5,840,100
9,226,300
2,585,600
3,102,700
3,619,800
3,668,800
4,402,600
5,136,300
5,881,100
7,057,300
8,233,500
3,054,500
3,665,400
4,276,300
3,907,300
4,688,800
5,470,300
4,458,900
5,350,700
6,242,500
3,740,200
4,488,300
5,236,300
5,338,500
6,406,200
7,473,900
7,325,700
8,790,900
10,256,000
5,046,600
5,470,100
6,055,900
6,564,100
7,065,200
7,658,100
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 475 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,161,600
10,993,900
12,826,200
3,476,700
4,172,100
4,867,400
3,864,000
4,636,800
5,409,600
4,955,500
5,946,600
6,937,700
2,539,400
3,047,300
3,555,200
3,049,800
3,659,800
4,269,700
3,832,200
4,598,600
5,365,100
1,695,000
2,034,100
2,373,100

MAYOR (RINGAN)
MAYOR (SEDANG)
2,006,300
2,407,500
2,407,500
2,889,000
2,808,800
3,370,500
55,004,000
66,004,800
77,005,600
68,059,200
81,671,000
95,282,900
79,882,300
95,858,800
111,835,300
85,940,900
103,129,100
120,317,200
98,583,000
118,299,600
138,016,200
112,638,200
135,165,800
157,693,500
12,433,500
14,920,100
17,406,800
17,556,400
21,067,700
24,579,000
24,573,700
29,488,400
34,403,200
35,861,500
43,033,800
50,206,100
46,359,300
55,631,200
64,903,000
66,467,600
79,761,200
93,054,700
19,472,900
23,367,500
27,262,100
30,442,900
36,531,500
42,620,100
40,514,800
48,617,800
56,720,700
5,327,500
6,393,000
7,458,500
14,937,100
17,924,600
20,912,000
19,788,000
23,745,700
27,703,300
5,160,200
6,192,300
7,224,300
14,468,100
17,361,800
20,255,400
19,166,700
23,000,100
26,833,400
4,272,600
5,127,100
5,981,700
6,062,600
7,275,100
8,487,600
9,816,700
11,780,000
13,743,400
10,361,200
12,433,500
14,505,700
14,630,300
17,556,400
20,482,500
- 476 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,478,100
24,573,700
28,669,300
9,788,600
11,746,300
13,704,000
11,254,100
13,504,900
15,755,800
15,752,400
18,902,800
22,053,300
5,549,400
6,659,200
7,769,100
8,657,000
10,388,400
12,119,800
13,448,900
16,138,700
18,828,500
3,698,600
4,438,300
5,178,000
7,528,800
9,034,600
10,540,300
13,549,700
16,259,700
18,969,600
2,774,000
3,328,800
3,883,600
5,555,000
6,666,000
7,777,000
6,517,800
7,821,400
9,124,900
2,510,500
3,012,600
3,514,700
4,824,300
5,789,100
6,754,000
11,805,700
14,166,800
16,527,900
3,699,600
4,439,500
5,179,400
6,659,200
7,991,100
9,322,900
9,370,700
11,244,900
13,119,000
2,745,600
3,294,700
3,843,900
3,383,000
4,059,600
4,736,200
4,631,000
5,557,200
6,483,400
1,661,500
2,436,400
4,164,100
2,018,600
2,686,700
4,657,400
1,993,800
2,923,700
4,996,900
2,422,300
3,224,000
5,588,800
2,326,100
3,410,900
5,829,700
2,826,000
3,761,300
6,520,300
2,980,900
3,577,100
4,173,300
5,288,400
6,346,000
7,403,700
8,583,700
10,300,400
12,017,100
1,508,500
1,810,300
2,112,000
3,204,300
3,845,100
4,486,000
6,076,400
7,291,700
8,507,000
1,008,900
1,210,700
1,412,500
1,904,000
2,284,800
2,665,600
2,466,000
2,959,200
3,452,400
5,224,400
6,269,300
7,314,200
- 477 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,849,800
8,219,700
9,589,700
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,807,400
11,768,900
13,730,400
2,518,100
3,021,700
3,525,300
3,737,100
4,484,500
5,232,000
4,494,700
5,393,600
6,292,600
1,736,900
2,084,300
2,431,700
2,332,900
2,799,500
3,266,000
4,243,900
5,092,600
5,941,400
753,400
904,100
1,054,800
1,435,900
1,723,100
2,010,200
2,087,400
2,504,900
2,922,400
1,028,300
1,233,900
1,439,600
1,618,200
1,941,800
2,265,400
2,606,400
3,127,700
3,648,900
1,694,100
2,032,900
2,371,700
2,524,200
3,029,100
3,533,900
3,872,800
4,647,300
5,421,900
5,505,700
6,606,900
7,708,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,547,100
22,575,000
10,256,500
27,090,000
11,965,900
31,605,000
8,517,600
10,221,100
11,924,600
10,797,300
12,956,800
15,116,300
16,016,100
19,219,400
22,422,600
6,655,600
10,206,000
14,990,400
6,660,100
7,760,100
12,863,800
7,986,700
12,247,100
17,988,500
7,992,200
9,312,100
15,436,600
9,317,800
14,288,300
20,986,600
9,324,200
10,864,200
18,009,400
4,126,000
4,951,300
5,776,500
5,063,700
6,076,400
7,089,100
6,000,400
7,200,500
8,400,600
3,947,500
5,612,200
7,233,900
4,737,000
6,734,700
8,680,700
5,526,500
7,857,100
10,127,500
6,264,000
7,516,800
8,769,600
9,322,600
11,187,100
13,051,600
23,214,800
27,857,800
32,500,700
5,372,100
7,284,300
13,817,300
6,446,500
8,741,100
16,580,800
7,520,900
10,198,000
19,344,300
3,866,000
4,639,100
5,412,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 478 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,349,600
2,819,600
3,289,500
697 U-4-12-I
698 U-4-12-II

2,564,800
2,983,400
3,077,800
3,580,100
3,590,800
4,176,800
699 U-4-12-III

3,990,000
4,788,000
5,586,100
2,003,900
2,404,700
2,805,500
2,362,400
2,834,900
3,307,400
2,825,600
3,390,700
3,955,800
3,732,500
4,469,500
4,479,000
5,363,500
5,225,500
6,257,400

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,505,700
9,006,900
10,508,000
2,997,100
3,596,500
4,195,900
3,734,000
4,480,800
5,227,600
5,225,700
6,270,900
7,316,000
5,039,700
6,047,600
7,055,500
10,070,100
12,084,100
14,098,100
12,349,600
14,819,500
17,289,400
9,300,100
10,619,600
16,630,800
11,160,100
12,743,600
19,956,900
13,020,200
14,867,500
23,283,100
8,743,900
10,492,700
12,241,500
12,309,800
14,771,800
17,233,700
15,134,700
18,161,700
21,188,600
4,702,000
5,642,400
6,582,800
8,984,000
10,780,700
12,577,500
13,671,900
16,406,300
19,140,600
8,944,000
10,732,800
12,521,500
12,995,300
15,594,400
18,193,400
16,227,000
19,472,400
22,717,800
1,485,000
1,638,700
1,812,700
1,782,000
1,966,400
2,175,200
2,079,000
2,294,100
2,537,800
4,458,900
5,350,700
6,242,500
7,406,500
8,887,800
10,369,100
12,210,700
14,652,800
17,095,000
3,737,200
4,484,600
5,232,100
5,014,300
6,017,200
7,020,100
6,924,500
8,309,400
9,694,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,584,800
10,301,800
12,018,800
13,180,400
15,816,400
18,452,500
1,535,700
2,233,500
1,842,900
2,680,200
2,150,000
3,126,900
- 479 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,501,300
12,601,600
14,701,800
12,208,900
14,650,700
17,092,500
17,960,600
21,552,700
25,144,900
2,227,500
2,673,000
3,118,500
2,458,000
2,719,000
2,949,600
3,262,800
3,441,200
3,806,700
2,328,200
2,793,800
3,259,500
2,569,200
3,083,000
3,596,800
2,842,000
3,410,400
3,978,800
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,504,700
3,005,600
3,506,500
743 W-1-12-II
744 W-1-12-III

3,126,300
5,369,800
3,751,500
6,443,800
4,376,800
7,517,800
745 W-1-13-I
2,497,400
2,996,800
3,496,300
746 W-1-13-II
747 W-1-13-III

2,711,300
3,642,000
3,253,500
4,370,300
3,795,800
5,098,700
748 W-1-20-I
749 W-1-20-II

8,363,400
10,450,200
10,036,100
12,540,200
11,708,800
14,630,200
750 W-1-20-III
12,114,400
14,537,300
16,960,200
751 W-1-30-I
4,721,300
5,665,500
6,609,800
752 W-1-30-II
7,530,400
9,036,500
10,542,600
753 W-1-30-III
18,476,200
22,171,500
25,866,700
754 W-4-10-I
3,517,800
4,221,400
4,924,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,215,000
10,305,900
3,199,200
4,856,900
5,911,700
6,258,000
12,367,100
3,839,000
5,828,300
7,094,100
7,301,000
14,428,300
4,478,900
6,799,600
8,276,400
2,843,100
3,411,700
3,980,300
3,903,300
4,684,000
5,464,700
4,254,800
5,105,800
5,956,800
1,258,700
1,719,400
2,138,200
1,682,100
2,064,100
2,561,500
1,599,700
1,776,600
2,459,800
2,194,300
2,934,300
3,976,900
1,570,600
2,835,700
4,192,500
2,897,800
3,846,400
5,464,200
2,640,000
3,170,800
4,358,500
1,510,400
2,063,300
2,565,900
2,018,500
2,476,900
3,073,800
1,919,700
2,131,900
2,951,800
2,633,100
3,521,200
4,772,300
1,884,700
3,402,800
5,031,100
3,477,300
4,615,700
6,557,000
3,168,000
3,805,000
5,230,200
1,762,200
2,407,200
2,993,500
2,355,000
2,889,700
3,586,100
2,239,600
2,487,300
3,443,700
3,072,000
4,108,000
5,567,700
2,198,800
3,970,000
5,869,600
4,056,900
5,385,000
7,649,800
3,696,000
4,439,200
6,101,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 480 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,899,200
2,279,000
2,658,900
3,985,300
4,782,300
5,579,400
6,134,700
7,361,600
8,588,600
- 481 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
972,700
1,261,700
2,346,300
1,938,900
2,519,700
463,500
1,132,800
362,400
972,800
722,800
820,600
1,233,700
1,682,800
1,542,300
499,600
1,153,200
418,300
718,200
2,187,500
783,400
1,850,100
451,400
1,375,500
1,565,800
1,313,300
322,100
1,027,500
542,700
383,700
301,700
266,300
318,500
443,400
381,000
358,700
322,300
478,300
208,800
246,100
282,200
5,726,700
2,288,700
2,296,300
590,700
1,330,000
832,700
1,692,500
788,700
451,700
341,100
550,100
365,300
273,700
2,789,300
1,301,700
743,800
2,903,600
1,935,700
274,200
3,145,500
2,177,700
4,016,600
1,131,300
695,900
272,200
226,800
255,600
3,897,900
1,897,400
- 482 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,411,500
4,267,800
3,724,700
2,695,600
888,700
3,000,200
1,959,000
481,600
4,504,400
4,077,800
2,734,200
2,590,300
337,000
307,600
1,237,800
356,100
301,400
333,100
1,572,100
1,561,800
1,364,100
1,656,500
1,003,200
303,200
534,400
366,800
331,200
322,700
409,700
467,300
273,900
786,100
1,432,700
1,099,800
2,585,500
336,700
336,700
3,285,100
1,389,200
266,500
1,232,900
3,371,300
735,300
579,200
283,700
268,900
422,600
589,300
1,411,000
1,243,700
870,600
472,300
273,700
1,511,700
880,900
517,600
429,500
1,407,500
311,200
1,977,300
1,512,700
335,500
371,900
363,300
219,800
1,648,200
1,646,900
326,400
- 483 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,000,300
373,400
403,700
373,800
593,100
456,200
1,142,500
337,100
937,900
1,723,200
274,500
1,670,600
905,300
1,956,400
987,600
436,100
335,500
77,600
434,800
982,600
382,900
517,200
295,800
120,100
298,700
4,448,100
2,528,400
4,219,800
1,425,400
579,200
394,600
892,600
472,100
950,100
550,100
327,500
548,200
339,300
517,900
361,000
934,200
1,812,600
1,458,300
1,285,800
907,500
317,100
317,100
317,100
259,000
164,300
258,300
315,800
341,600
251,600
221,900
108,800
119,600
88,500
103,800
99,000
151,100
135,600
176,300
193,700
114,300
146,100
99,800
155,800
221,100
- 484 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
157,400
197,900
559,600
648,700
148,800
269,200
181,100
258,600
452,900
387,800
278,700
263,900
148,000
138,100
310,800
196,200
281,400
194,700
152,400
2,688,000
2,010,900
319,500
330,900
632,800
829,200
810,000
418,400
1,304,100
309,600
340,100
341,200
273,200
345,100
326,500
153,000
336,100
297,900
269,500
304,800
2,523,100
450,400
908,000
325,700
637,100
507,500
426,100
788,500
807,500
861,000
753,100
1,441,600
224,400
2,142,000
295,800
1,085,800
2,467,600
2,075,100
906,500
328,500
640,700
638,200
295,800
2,318,400
1,823,600
163,400
177,000
230,000
408,300
- 485 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,189,600
641,000
1,011,500
1,159,200
584,800
772,800
562,300
599,600
751,300
335,100
752,500
211,300
743,700
1,280,700
85,800
- 486 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,904,800
2,285,800
2,666,700
A-4-10-II
SEPTIKEMIA (SEDANG)
3,254,200
3,905,000
4,555,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,387,700
2,804,700
5,265,200
3,365,600
6,142,700
3,926,500
5
6
A-4-11-II
A-4-11-III

3,991,900
5,525,100
4,790,200
6,630,100
5,588,600
7,735,100
A-4-12-I
2,539,700
3,047,600
3,555,600
8
9
A-4-12-II
A-4-12-III

3,162,800
3,375,600
3,795,300
4,050,700
4,427,900
4,725,800
10 A-4-13-I
11 A-4-13-II

1,527,300
2,300,800
1,832,700
2,760,900
2,138,200
3,221,100
12 A-4-13-III
2,760,900
3,313,100
3,865,300
2,117,600
2,541,200
2,964,700
2,570,500
3,084,600
3,598,700
3,084,600
3,701,500
4,318,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,324,700
4,976,700
3,989,600
5,972,000
4,654,600
6,967,300
18 A-4-15-III
INFEKSI HIV (BERAT)
6,245,300
7,494,400
8,743,400
19 B-1-01-I
20 B-1-01-II

22,762,000
25,112,600
27,314,400
30,135,100
31,866,800
35,157,700
21 B-1-01-III
22 B-1-10-I

44,052,700
3,932,900
52,863,300
4,719,500
61,673,800
5,506,100
23 B-1-10-II
8,729,300
10,475,200
12,221,000
24 B-1-10-III
25 B-1-11-I

17,232,800
5,255,100
20,679,400
6,306,100
24,125,900
7,357,100
26 B-1-11-II
27 B-1-11-III

6,810,200
8,798,700
8,172,200
10,558,400
9,534,300
12,318,100
28 B-1-12-I
5,131,300
6,157,600
7,183,800
29 B-1-12-II
5,706,900
6,848,300
7,989,700
30 B-1-12-III
8,927,800
10,713,400
12,499,000
4,087,100
4,904,600
5,722,000
6,724,900
8,069,900
9,414,800
8,701,400
10,441,700
12,182,000
5,615,900
6,739,100
7,862,300
6,245,900
7,495,000
8,744,200
9,771,000
1,737,600
2,773,600
3,826,300
11,725,200
2,085,100
3,328,400
4,591,600
13,679,300
2,432,600
3,883,100
5,356,900
3,663,400
4,396,100
5,128,800
5,128,800
6,154,600
7,180,400
6,213,500
7,456,200
8,698,900
3,312,100
4,716,400
7,016,900
3,159,500
3,974,600
5,659,600
8,420,300
3,791,400
4,637,000
6,602,900
9,823,700
4,423,300
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 487 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,680,700
4,416,800
5,153,000
48 B-4-13-III
49 B-4-14-I

5,070,500
3,156,100
6,084,600
3,787,400
7,098,700
4,418,600
50 B-4-14-II
3,682,000
4,418,400
5,154,900
51 B-4-14-III
52 C-4-10-I

4,932,200
2,920,000
5,918,600
3,504,000
6,905,100
4,088,000
53 C-4-10-II
54 C-4-10-III

5,602,700
9,889,300
6,723,300
11,867,200
7,843,800
13,845,100
55 C-4-11-I
3,327,500
3,993,000
4,658,400
56 C-4-11-II
57 C-4-11-III

4,452,600
6,846,000
5,343,100
8,215,200
6,233,700
9,584,400
58 C-4-12-I
59 C-4-12-II
2,215,500
4,363,700
2,658,600
5,236,500
3,101,700
6,109,200
60 C-4-12-III
RADIOTERAPI (BERAT)
11,207,300
13,448,700
15,690,200
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,665,600
3,134,700
1,998,800
3,761,700
2,331,900
4,388,600
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,243,400
2,767,500
5,092,000
3,321,000
5,940,700
3,874,500
65 C-4-14-II
3,882,300
4,658,700
5,435,200
66 C-4-14-III
67 D-1-10-I

5,784,500
13,543,600
6,941,400
16,252,400
8,098,300
18,961,100
68 D-1-10-II
69 D-1-10-III

20,627,900
32,846,700
24,753,500
39,416,000
28,879,100
45,985,300
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,476,800
5,372,100
6,267,500
11,431,300
14,855,400
13,717,500
17,826,500
16,003,800
20,797,500
3,880,800
4,657,000
5,433,200
10,695,000
12,834,000
14,973,000
16,965,400
20,358,500
23,751,600
2,320,800
3,488,500
5,488,300
3,038,200
5,459,500
7,500,000
2,619,300
3,633,000
5,578,700
2,785,000
4,186,200
6,585,900
3,645,800
6,551,400
8,999,900
3,143,200
4,359,700
6,694,400
3,249,100
4,883,900
7,683,600
4,253,400
7,643,200
10,499,900
3,667,000
5,086,300
7,810,200
2,244,700
2,693,600
3,142,600
3,177,000
3,812,400
4,447,800
4,063,500
4,876,200
5,688,900
2,407,500
2,889,000
3,370,500
3,941,700
4,730,100
5,518,400
4,821,100
5,785,400
6,749,600
4,285,700
5,142,900
6,000,000
5,613,900
6,736,600
7,859,400
93 E-1-01-III
9,748,500
11,698,200
13,647,900
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,343,200
4,057,900
8,552,800
4,011,800
4,869,400
10,263,300
4,680,500
5,681,000
11,973,900
5,648,500
6,778,300
7,908,000
97 E-1-20-I
- 488 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,220,600
2,664,700
3,108,800
104 E-4-11-II
105 E-4-11-III

3,385,400
4,587,500
4,062,500
5,505,000
4,739,600
6,422,500
106 E-4-12-I
107 E-4-12-II

2,551,400
4,418,400
3,061,700
5,302,100
3,571,900
6,185,700
108 E-4-12-III

(RINGAN)
(SEDANG)
5,237,400
6,284,900
7,332,300
2,778,400
3,334,000
3,889,700
4,069,800
4,883,800
5,697,700
111 E-4-13-III
5,320,000
6,384,000
7,448,100
112 F-4-10-I
113 F-4-10-II
2,957,900
3,399,600
3,549,500
4,079,500
4,141,100
4,759,400
114 F-4-10-III
115 F-4-11-I
4,079,500
2,860,800
4,895,400
3,432,900
5,711,200
4,005,100
116 F-4-11-II
3,333,100
3,999,700
4,666,400
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,274,300
5,129,100
5,984,000
1,568,200
1,881,800
2,195,400
2,229,400
2,675,300
3,121,200
4,843,300
5,812,000
6,780,700
2,304,400
3,040,700
3,936,600
1,314,800
1,686,400
2,269,200
2,765,300
3,648,900
4,724,000
1,577,700
2,023,700
2,723,000
3,226,200
4,257,000
5,511,300
1,840,700
2,361,000
3,176,900
127 F-4-15-I
2,093,900
2,512,700
2,931,400
128 F-4-15-II
3,120,200
3,744,200
4,368,200
129 F-4-15-III
4,119,600
4,943,500
5,767,400
4,119,800
4,943,800
5,767,700
4,790,000
5,748,000
6,705,900
6,393,800
7,672,500
8,951,300
133 F-4-17-I

972,900
1,167,500
1,362,100
134 F-4-17-II
2,851,600
3,421,900
3,992,200
135
136
137
138
139
140
141

(RINGAN)
3,042,400
3,579,800
3,938,800
6,072,000
2,735,800
3,503,300
4,361,600
3,650,800
4,295,800
4,726,600
7,286,400
3,283,000
4,204,000
5,234,000
4,259,300
5,011,700
5,514,300
8,500,800
3,830,100
4,904,700
6,106,300
10,433,400
12,520,100
14,606,700
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,602,800
9,123,300
10,643,900
10,478,200
12,573,800
14,669,500
3,370,600
4,044,700
4,718,800
4,709,800
5,651,700
6,593,700
5,845,700
7,014,900
8,184,000
- 489 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
13,873,500
16,648,200
19,422,900
148 G-1-11-I
149 G-1-11-II

8,881,800
16,238,000
10,658,100
19,485,600
12,434,500
22,733,200
150 G-1-11-III
29,938,800
35,926,600
41,914,400
3,708,500
4,450,100
5,191,800
6,951,700
8,342,000
9,732,300
9,473,800
11,368,500
13,263,300
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,118,700
3,004,400
1,342,500
3,605,200
1,566,200
4,206,100
156 G-1-13-III
157 G-1-20-I

6,779,200
4,698,100
8,135,000
5,637,700
9,490,800
6,577,400
158 G-1-20-II
5,586,900
6,704,300
7,821,700
159 G-1-20-III
13,039,300
15,647,200
18,255,000
160 G-1-30-I
6,891,800
8,270,200
9,648,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
13,958,600
19,604,500
16,750,300
23,525,400
19,542,000
27,446,300
3,183,300
3,820,000
4,456,600
3,891,100
4,669,300
5,447,500
5,339,200
6,407,100
7,474,900
3,332,400
3,998,900
4,665,400
4,426,700
5,312,100
6,197,400
6,504,300
7,805,200
9,106,100
3,696,900
4,436,300
5,175,700
4,669,500
5,603,400
6,537,300
6,781,900
8,138,200
9,494,600
2,220,800
2,665,000
3,109,100
3,872,600
4,647,200
5,421,700
4,593,000
5,511,600
6,430,300
3,767,300
4,520,800
5,274,300
5,036,600
6,044,000
7,051,300
6,321,600
7,585,900
8,850,200
3,078,200
3,693,900
4,309,500
3,673,700
4,408,500
5,143,200
5,185,200
6,222,200
7,259,200
2,537,600
3,045,100
3,552,600
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,247,000
19,496,400
22,745,800
31,246,000
37,495,200
43,744,400
10,694,600
12,591,800
12,833,500
15,110,100
14,972,400
17,628,500
- 490 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,369,000
4,042,800
4,716,600
183 G-4-16-III
4,797,700
5,757,300
6,716,800
3,379,900
4,055,900
4,731,900
4,431,800
5,318,200
6,204,500
5,568,800
6,682,500
7,796,300
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,328,700
3,994,400
4,660,200
188 G-4-18-II
4,449,400
5,339,300
6,229,200
189 G-4-18-III
4,978,600
5,974,300
6,970,000
2,777,200
3,332,600
3,888,100
4,694,100
5,632,900
6,571,800
6,163,200
7,395,800
8,628,400
193 G-4-20-I

1,942,800
2,331,300
2,719,900
194 G-4-20-II
2,746,500
3,295,800
3,845,100
195 G-4-20-III
196 G-4-21-I

4,536,600
2,023,100
5,443,900
2,427,700
6,351,200
2,832,300
197 G-4-21-II
198 G-4-21-III

3,424,100
4,024,100
4,109,000
4,829,000
4,793,800
5,633,800
199 G-4-22-I
2,555,600
3,066,800
3,577,900
200 G-4-22-II
201 G-4-22-III

3,265,300
3,815,400
3,918,400
4,578,500
4,571,500
5,341,600
202 G-4-23-I
203 G-4-23-II

1,991,600
2,498,700
2,389,900
2,998,400
2,788,200
3,498,200
204 G-4-23-III
3,557,600
4,269,100
4,980,600
205 G-4-24-I
206 G-4-24-II

2,218,300
2,771,400
2,661,900
3,325,700
3,105,600
3,880,000
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,617,100
1,895,500
2,397,100
3,176,600
5,540,500
2,274,600
2,876,500
3,811,900
6,464,000
2,653,700
3,355,900
4,447,200
2,995,400
3,594,500
4,193,500
3,484,600
4,181,500
4,878,400
5,210,500
6,252,600
7,294,700
4,278,500
5,454,000
7,417,100
6,510,200
8,088,300
11,328,900
2,566,100
3,481,700
6,843,500
2,214,600
2,526,200
3,617,400
2,611,000
3,119,700
5,228,100
5,134,200
6,544,900
8,900,500
7,812,300
9,706,000
13,594,700
3,079,400
4,178,100
8,212,200
2,657,500
3,031,400
4,340,800
3,133,300
3,743,700
6,273,700
5,989,900
7,635,700
10,383,900
9,114,300
11,323,700
15,860,500
3,592,600
4,874,400
9,580,900
3,100,500
3,536,700
5,064,300
3,655,500
4,367,600
7,319,300
229 I-1-01-I
35,071,000
42,085,100
49,099,300
230 I-1-01-II
35,842,500
43,011,000
50,179,500
231 I-1-01-III

(RINGAN)
56,576,900
67,892,300
79,207,700
19,457,200
23,348,700
27,240,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 491 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,020,800
19,224,900
22,429,100
245 I-1-06-II
23,207,400
27,848,900
32,490,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
27,690,700
33,228,900
38,767,000
19,070,800
22,884,900
26,699,100
23,527,700
28,233,200
32,938,800
25,668,600
30,802,300
35,936,100
3,049,000
3,658,800
4,268,600
3,390,200
4,068,200
4,746,300
4,511,300
5,413,600
6,315,800
8,776,500
10,531,800
12,287,100
14,333,800
17,200,600
20,067,300
18,858,300
22,629,900
26,401,600
8,513,100
10,215,700
11,918,300
11,336,900
13,604,300
15,871,700
13,981,600
16,777,900
19,574,200
17,424,200
20,909,000
24,393,900
21,655,700
25,986,900
30,318,000
28,376,500
34,051,800
39,727,000
3,310,100
4,622,500
8,901,100
3,972,100
5,547,000
10,681,300
4,634,100
6,471,500
12,461,500
8,581,000
10,297,200
12,013,400
19,415,300
23,298,300
27,181,400
22,395,200
26,874,300
31,353,300
9,936,000
11,923,100
13,910,300
12,440,700
14,928,900
17,417,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,099,600
30,119,500
35,139,400
30,936,800
37,124,100
43,311,500
11,238,500
13,486,300
15,734,000
15,578,900
18,694,700
21,810,500
19,770,900
23,725,100
27,679,200
16,935,900
20,323,000
23,710,200
26,729,400
32,075,300
37,421,100
42,700,000
51,240,000
59,780,000
21,730,300
26,076,300
30,422,400
26,076,400
31,291,700
36,507,000
35,881,000
43,057,200
50,233,400
- 492 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,328,800
23,194,600
27,060,400
279 I-1-40-III
25,816,800
30,980,100
36,143,500
280 I-4-10-I
281 I-4-10-II

2,947,100
5,262,500
3,536,600
6,315,000
4,126,000
7,367,500
282 I-4-10-III
7,582,500
9,099,000
10,615,500
283 I-4-11-I
284 I-4-11-II

4,534,200
5,611,100
5,441,000
6,733,300
6,347,800
7,855,500
285 I-4-11-III
286 I-4-12-I

10,379,900
2,606,500
12,455,800
3,127,800
14,531,800
3,649,100
287 I-4-12-II
3,021,300
3,625,600
4,229,800
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,625,600
4,350,700
5,075,800
2,652,400
3,182,900
3,713,400
4,736,200
5,683,500
6,630,700
6,824,200
8,189,100
9,553,900
2,504,800
2,591,000
4,541,900
3,005,700
3,109,100
5,450,300
3,506,700
3,627,300
6,358,700
4,313,200
5,175,800
6,038,500
5,867,800
7,041,400
8,214,900
297 I-4-15-III
7,041,400
8,449,700
9,857,900
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,580,900
2,538,500
3,046,200
1,779,700
2,071,900
2,486,300
1,897,000
3,046,200
3,655,400
2,135,600
2,486,300
2,983,500
2,213,200
3,553,900
4,264,700
2,491,600
2,900,700
3,480,800
3,049,300
3,659,200
4,269,100
4,642,700
5,571,300
6,499,800
6,303,300
7,563,900
8,824,600
307 I-4-19-I
2,942,000
3,530,400
4,118,800
308 I-4-19-II

(SEDANG)
4,592,600
5,511,100
6,429,700
309 I-4-19-III
5,482,700
6,579,200
7,675,800
310
311
312
313
314

3,063,500
3,538,300
5,290,500
2,292,400
2,904,500
3,676,200
4,246,000
6,348,600
2,750,900
3,485,400
4,288,900
4,953,700
7,406,700
3,209,300
4,066,300
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,389,000
18,466,800
21,544,600
11,199,500
13,439,400
15,679,300
13,991,300
16,789,500
19,587,800
14,707,700
17,649,300
20,590,800
8,471,800
10,166,200
11,860,500
17,623,200
21,147,900
24,672,500
27,309,700
32,771,600
38,233,600
7,818,600
9,382,300
10,946,000
- 493 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,192,300
5,030,800
5,869,200
316 I-4-22-I
317 I-4-22-II
2,569,400
3,198,500
3,083,300
3,838,200
3,597,100
4,477,900
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,675,200
5,610,200
6,545,300
2,514,700
3,017,600
3,520,600
3,087,300
3,704,800
4,322,200
6,032,400
7,238,900
8,445,400
2,264,500
2,717,400
3,170,300
5,214,500
6,257,400
7,300,300
6,592,800
7,911,400
9,229,900
40,853,200
49,023,800
57,194,500
46,233,000
55,479,600
64,726,200
52,304,100
62,764,900
73,225,700
21,679,300
26,015,200
30,351,000
30,186,200
36,223,400
42,260,700
49,847,700
59,817,300
69,786,800
6,583,400
7,900,100
9,216,800
13,321,600
15,985,900
18,650,200
13,844,400
16,613,300
19,382,200
9,328,000
11,193,700
13,059,300
12,325,500
14,790,600
17,255,700
18,875,200
22,650,200
26,425,200
5,494,000
6,592,800
7,691,700
9,952,400
11,942,900
13,933,300
28,727,200
34,472,700
40,218,100
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,244,800
4,636,100
7,013,700
2,003,700
2,790,700
3,740,700
3,403,200
3,874,100
5,409,300
3,009,000
4,188,500
7,814,400
3,317,500
5,398,600
6,387,100
4,047,700
4,835,800
6,506,200
2,693,800
5,563,300
8,416,500
2,404,400
3,348,900
4,488,800
4,083,900
4,648,900
6,491,200
3,610,900
5,026,200
9,377,200
3,981,000
6,478,300
7,664,500
4,857,200
5,803,000
7,807,400
3,142,700
6,490,600
9,819,200
2,805,200
3,907,000
5,237,000
4,764,500
5,423,700
7,573,000
4,212,700
5,863,900
10,940,100
4,644,600
7,558,000
8,941,900
5,666,800
6,770,200
9,108,600
3,372,600
4,047,100
4,721,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 494 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,739,300
5,687,200
6,635,100
360 J-4-16-III
5,992,200
7,190,600
8,389,000
361 J-4-17-I
362 J-4-17-II

2,772,100
3,319,700
3,326,500
3,983,600
3,881,000
4,647,600
363 J-4-17-III
364 J-4-18-I

4,356,400
2,077,600
5,227,700
2,493,200
6,099,000
2,908,700
365 J-4-18-II
2,857,600
3,429,100
4,000,700
366 J-4-18-III
367 J-4-19-I

3,008,000
3,904,600
3,609,600
4,685,500
4,211,200
5,466,400
368 J-4-19-II
369 J-4-19-III

4,428,100
4,890,200
5,313,700
5,868,300
6,199,300
6,846,300
370 J-4-20-I
3,874,800
4,649,700
5,424,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,368,900
6,294,000
6,442,700
7,552,800
7,516,500
8,811,700
2,692,900
3,231,500
3,770,100
4,338,200
5,205,900
6,073,500
6,053,700
7,264,400
8,475,100
5,968,300
7,161,900
8,355,600
7,500,400
9,000,500
10,500,600
8,790,700
10,548,900
12,307,000
6,701,800
8,042,200
9,382,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
8,798,700
13,315,300
10,558,400
15,978,400
12,318,200
18,641,400
2,504,200
3,005,000
3,505,900
3,257,000
3,908,400
4,559,800
6,452,600
7,743,200
9,033,700
2,824,200
3,106,700
3,134,900
3,389,100
3,728,000
3,761,900
3,953,900
4,349,300
4,388,900
4,583,200
5,499,900
6,416,500
5,371,500
6,445,700
7,520,000
8,439,300
10,127,100
11,815,000
8,874,600
12,395,900
18,099,300
10,649,500
14,875,000
21,719,100
12,424,500
17,354,200
25,339,000
5,248,400
6,298,100
7,347,700
9,321,000
11,185,200
13,049,400
12,825,800
15,391,000
17,956,200
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,856,000
7,027,200
8,198,400
398 K-1-40-II

(SEDANG)
6,456,400
7,747,700
9,039,000
399 K-1-40-III
10,941,300
13,129,600
15,317,800
400
401
402
403
404

4,474,600
5,810,800
8,211,700
3,694,000
5,307,700
5,369,500
6,972,900
9,854,000
4,432,800
6,369,200
6,264,400
8,135,100
11,496,400
5,171,600
7,430,800
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 495 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,091,300
9,709,600
11,327,900
406 K-4-11-I
407 K-4-11-II

2,165,200
3,076,900
2,598,200
3,692,200
3,031,300
4,307,600
408 K-4-11-III
409 K-4-12-I

3,692,200
2,220,600
4,430,700
2,664,700
5,169,100
3,108,800
410 K-4-12-II
2,988,200
3,585,800
4,183,500
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,943,400
5,932,100
6,920,800
2,993,400
3,592,100
4,190,800
3,872,200
4,646,700
5,421,100
5,964,500
7,157,300
8,350,200
1,897,900
2,277,400
2,657,000
2,547,600
3,057,100
3,566,600
4,087,800
4,905,400
5,722,900
418 K-4-15-I
1,961,000
2,353,100
2,745,300
419 K-4-15-II
2,907,600
3,489,100
4,070,600
420 K-4-15-III
4,080,700
4,896,800
5,713,000
421 K-4-16-I
2,770,800
3,325,000
3,879,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,323,000
3,877,400
3,987,600
4,652,900
4,652,200
5,428,400
1,423,100
1,707,700
1,992,400
1,946,400
2,335,700
2,725,000
2,335,700
2,802,900
3,270,000
1,257,500
1,509,000
1,760,500
1,787,000
2,144,400
2,501,800
429 K-4-18-III
2,144,400
2,573,300
3,002,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,149,500
21,358,300
28,538,100
6,675,900
11,455,300
14,222,000
16,979,400
25,629,900
34,245,800
8,011,000
13,746,400
17,066,400
19,809,300
29,901,600
39,953,400
9,346,200
16,037,500
19,910,800
3,741,300
4,489,600
5,237,800
7,504,200
9,005,100
10,505,900
12,631,300
15,157,500
17,683,800
4,911,600
7,904,700
11,306,800
1,284,600
1,491,100
1,730,800
2,690,200
3,697,500
8,401,900
1,277,600
1,689,800
4,470,100
5,893,900
9,485,600
13,568,200
1,541,600
1,789,400
2,077,000
3,228,300
4,437,000
10,082,300
1,533,100
2,027,800
5,364,100
6,876,200
11,066,500
15,829,600
1,798,500
2,087,600
2,423,100
3,766,300
5,176,500
11,762,700
1,788,700
2,365,800
6,258,100
2,293,800
2,752,600
3,211,400
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 496 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,695,900
3,235,100
3,774,300
3,967,000
4,760,500
5,553,900
2,212,400
2,654,900
3,097,400
3,323,100
3,987,700
4,652,400
4,684,300
5,621,200
6,558,100
7,820,600
9,384,800
10,948,900
11,115,900
13,339,100
15,562,300
15,614,600
18,737,500
21,860,400
6,931,500
8,317,800
9,704,100
11,370,900
19,318,900
13,645,100
23,182,700
15,919,300
27,046,500
18,819,600
22,583,500
26,347,400
22,012,200
26,414,600
30,817,100
27,243,800
32,692,600
38,141,300
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,691,100
10,429,300
12,167,500
467 M-1-04-II
11,165,500
13,398,600
15,631,700
468 M-1-04-III
13,359,800
16,031,800
18,703,700
469 M-1-05-I
470 M-1-05-II

5,517,900
8,925,400
6,621,500
10,710,500
7,725,100
12,495,600
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,401,100
13,681,300
15,961,500
6,176,600
7,412,000
8,647,300
8,274,600
9,929,500
11,584,400
16,856,100
20,227,300
23,598,500
10,167,800
12,201,300
14,234,900
22,312,000
26,774,400
31,236,800
48,124,900
57,749,800
67,374,800
9,287,000
11,144,500
13,001,900
11,865,100
14,238,200
16,611,200
480 M-1-20-III
29,540,600
35,448,700
41,356,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,371,200
10,323,900
14,762,200
7,645,400
12,388,600
17,714,700
8,919,600
14,453,400
20,667,100
3,243,200
3,891,800
4,540,400
5,751,600
6,901,900
8,052,200
8,212,200
9,854,600
11,497,100
3,886,400
6,449,500
10,592,900
4,663,700
7,739,400
12,711,400
5,441,000
9,029,300
14,830,000
6,002,300
7,202,700
8,403,200
7,546,200
9,055,500
10,564,700
11,399,500
13,679,400
15,959,300
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 497 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,226,800
2,672,200
3,117,500
500 M-4-10-II
501 M-4-10-III
3,320,900
6,283,200
3,985,100
7,539,800
4,649,300
8,796,400
2,774,800
3,329,800
3,884,700
6,083,600
7,300,400
8,517,100
8,795,900
10,555,100
12,314,300
2,214,900
2,657,900
3,100,900
3,684,000
4,420,800
5,157,600
4,927,800
5,913,300
6,898,900
3,688,100
4,425,700
5,163,300
5,541,200
6,649,400
7,757,600
10,810,700
12,972,800
15,134,900
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,206,100
5,047,300
5,888,500
512 M-4-14-II
5,187,600
6,225,100
7,262,600
513 M-4-14-III
514 M-4-15-I
7,795,500
2,494,100
9,354,600
2,992,900
10,913,600
3,491,700
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,324,500
7,544,200
2,135,300
3,419,500
5,744,500
3,989,400
9,053,000
2,562,400
4,103,400
6,893,400
4,654,200
10,561,800
2,989,500
4,787,300
8,042,300
2,771,400
3,325,600
3,879,900
3,876,100
4,651,300
5,426,500
5,412,700
6,495,200
7,577,800
2,094,700
3,156,800
3,801,000
2,513,700
3,788,200
4,561,200
2,932,600
4,419,600
5,321,400
2,184,500
2,621,400
3,058,300
3,679,500
4,415,400
5,151,300
7,186,300
8,623,500
10,060,800
2,203,500
2,644,200
3,084,900
3,226,700
3,872,000
4,517,400
3,606,200
4,327,500
5,048,700
2,218,800
2,662,500
3,106,300
2,775,000
3,330,100
3,885,100
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,120,300
13,344,400
15,568,400
12,232,300
14,678,800
17,125,300
14,004,400
16,805,300
19,606,200
6,321,400
7,585,700
8,850,000
7,507,300
16,897,300
9,008,700
20,276,700
10,510,200
23,656,200
- 498 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,221,600
7,465,900
8,710,200
535 N-1-01-I

103,293,400
123,952,100
144,610,800
536 N-1-01-II
103,293,400
123,952,100
144,610,800
537 N-1-01-III
538 N-1-11-I

103,293,400
6,400,000
123,952,100
7,680,000
144,610,800
8,960,000
539 N-1-11-II
540 N-1-11-III

10,120,000
15,777,000
12,144,000
18,932,500
14,168,000
22,087,900
3,261,900
3,914,300
4,566,600
6,494,000
7,792,900
9,091,700
14,092,300
16,910,800
19,729,200
7,131,700
8,558,000
9,984,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,980,400
13,966,400
11,976,500
16,759,700
13,972,600
19,553,000
6,526,800
7,832,100
9,137,500
9,873,700
11,848,400
13,823,200
11,363,700
13,636,400
15,909,200
5,861,500
7,033,800
8,206,100
7,959,800
9,551,700
11,143,700
9,264,100
11,117,000
12,969,800
2,490,300
2,988,400
3,486,400
3,012,100
3,614,500
4,216,900
4,430,300
5,316,400
6,202,500
1,911,700
3,340,000
4,155,700
2,181,200
4,047,300
4,871,600
3,288,600
3,966,500
6,078,400
2,294,100
4,008,000
4,986,800
2,617,500
4,856,800
5,845,900
3,946,400
4,759,800
7,294,000
2,676,400
4,676,000
5,818,000
3,053,700
5,666,200
6,820,200
4,604,100
5,553,100
8,509,700
1,920,000
2,304,000
2,688,000
2,724,400
3,269,300
3,814,100
4,367,200
5,240,600
6,114,000
2,268,200
2,721,900
3,175,500
2,814,500
3,377,400
3,940,300
3,211,800
3,854,100
4,496,500
2,777,400
3,332,900
3,888,400
3,964,300
4,757,100
5,550,000
5,276,800
6,332,100
7,387,500
4,888,200
5,163,200
5,865,800
6,195,900
6,843,500
7,228,500
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 499 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,472,800
7,767,400
9,061,900
2,581,800
3,098,100
3,614,500
2,869,300
3,443,200
4,017,100
3,569,500
4,283,400
4,997,300
1,829,100
2,195,000
2,560,800
2,196,800
2,636,100
3,075,500
2,760,300
3,312,400
3,864,500
1,563,400
1,876,100
2,188,800

MAYOR (RINGAN)
MAYOR (SEDANG)
1,850,400
2,220,500
2,220,500
2,664,600
2,590,600
3,108,700
40,845,000
49,014,000
57,183,000
50,539,500
60,647,500
70,755,400
59,319,200
71,183,100
83,046,900
68,814,700
82,577,600
96,340,600
78,937,500
94,724,900
110,512,400
90,191,700
108,230,000
126,268,400
7,436,200
8,923,500
10,410,700
11,033,000
13,239,600
15,446,200
12,487,100
14,984,500
17,482,000
22,049,200
26,459,100
30,868,900
37,120,900
44,545,100
51,969,200
53,222,000
63,866,400
74,510,800
15,592,400
18,710,800
21,829,300
22,606,400
27,127,700
31,648,900
32,441,100
38,929,300
45,417,500
3,956,100
4,747,300
5,538,600
11,092,100
13,310,500
15,528,900
14,694,200
17,633,100
20,571,900
3,831,900
4,598,300
5,364,700
10,743,800
12,892,500
15,041,300
14,232,900
17,079,400
19,926,000
3,887,600
4,665,200
5,442,700
5,516,500
6,619,800
7,723,000
8,932,300
10,718,800
12,505,200
6,760,200
8,112,300
9,464,300
10,030,000
12,036,000
14,042,000
- 500 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,351,900
13,622,300
15,892,700
5,878,400
7,054,100
8,229,800
8,358,300
10,030,000
11,701,600
9,459,900
11,351,900
13,243,900
5,049,500
6,059,400
7,069,300
7,877,200
9,452,600
11,028,100
10,752,000
12,902,400
15,052,800
2,664,100
3,196,900
3,729,700
5,423,000
6,507,600
7,592,300
10,061,800
12,074,100
14,086,500
1,998,100
2,397,700
2,797,300
4,001,300
4,801,600
5,601,800
4,694,800
5,633,800
6,572,700
1,808,300
2,170,000
2,531,600
3,475,000
4,169,900
4,864,900
7,086,400
8,503,700
9,920,900
3,366,300
4,039,600
4,712,800
6,059,400
7,271,200
8,483,100
8,270,800
9,924,900
11,579,100
2,038,800
2,446,600
2,854,400
2,512,200
3,014,600
3,517,000
3,438,900
4,126,700
4,814,500
1,579,800
2,316,600
3,959,400
1,499,000
1,995,100
3,458,500
1,895,800
2,780,000
4,751,300
1,798,700
2,394,100
4,150,200
2,211,800
3,243,300
5,543,200
2,098,500
2,793,100
4,841,900
2,213,600
2,656,300
3,099,000
3,927,000
4,712,500
5,497,900
6,374,100
7,648,900
8,923,700
1,120,200
1,344,300
1,568,300
2,379,400
2,855,300
3,331,200
4,512,300
5,414,700
6,317,200
749,200
899,100
1,048,900
1,413,900
1,696,700
1,979,400
1,831,200
2,197,500
2,563,700
3,879,600
4,655,500
5,431,400
- 501 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,933,900
5,920,700
6,907,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,064,300
8,477,200
9,890,100
1,869,900
2,243,900
2,617,800
2,775,100
3,330,100
3,885,200
3,337,700
4,005,200
4,672,800
1,251,100
1,501,300
1,751,500
1,680,400
2,016,500
2,352,500
3,056,900
3,668,300
4,279,600
596,600
715,900
835,200
1,137,000
1,364,500
1,591,900
1,652,900
1,983,500
2,314,100
798,700
958,400
1,118,200
1,256,800
1,508,200
1,759,500
2,024,400
2,429,300
2,834,200
1,241,100
1,489,300
1,737,500
1,875,800
2,251,000
2,626,100
2,903,900
3,484,700
4,065,500
4,088,500
4,906,100
5,723,800

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,346,900
16,763,800
7,616,300
20,116,600
8,885,700
23,469,300
6,325,000
7,590,000
8,855,000
8,017,900
9,621,500
11,225,100
11,536,500
13,843,800
16,151,100
4,942,300
7,578,800
11,131,600
4,945,700
5,762,500
9,552,500
5,930,800
9,094,500
13,357,900
5,934,800
6,915,000
11,463,000
6,919,200
10,610,300
15,584,300
6,924,000
8,067,500
13,373,400
2,972,000
3,566,400
4,160,800
3,647,400
4,376,900
5,106,300
4,322,100
5,186,600
6,051,000
3,591,900
5,106,600
6,582,200
4,310,300
6,127,900
7,898,600
5,028,600
7,149,300
9,215,100
4,512,000
5,414,400
6,316,800
6,715,100
8,058,100
9,401,100
17,238,900
20,686,700
24,134,500
3,869,500
5,246,900
10,260,500
4,643,400
6,296,300
12,312,600
5,417,300
7,345,700
14,364,700
2,784,700
3,341,600
3,898,500
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 502 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,692,500
2,031,000
2,369,400
697 U-4-12-I
698 U-4-12-II

2,438,800
2,836,800
2,926,500
3,404,200
3,414,300
3,971,600
699 U-4-12-III

3,680,100
4,416,200
5,152,200
1,848,300
2,217,900
2,587,600
2,178,900
2,614,700
3,050,500
2,606,100
3,127,300
3,648,500
2,771,700
3,319,000
3,326,000
3,982,800
3,880,400
4,646,600

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,573,600
6,688,300
7,803,100
2,225,600
2,670,700
3,115,800
2,772,800
3,327,300
3,881,900
3,880,500
4,656,700
5,432,800
3,630,100
4,356,100
5,082,100
7,477,900
8,973,400
10,469,000
9,170,600
11,004,700
12,838,800
6,906,100
7,885,900
12,349,700
8,287,300
9,463,100
14,819,700
9,668,500
11,040,300
17,289,600
6,493,100
7,791,700
9,090,300
8,866,800
10,640,200
12,413,500
11,238,800
13,486,500
15,734,300
3,386,900
4,064,200
4,741,600
6,471,200
7,765,400
9,059,700
10,152,500
12,183,000
14,213,500
6,641,600
7,970,000
9,298,300
9,650,100
11,580,100
13,510,100
12,049,900
14,459,900
16,869,800
1,069,600
1,180,300
1,305,700
1,283,600
1,416,400
1,566,800
1,497,500
1,652,500
1,828,000
3,211,800
3,854,100
4,496,500
5,334,900
6,401,900
7,468,900
8,795,400
10,554,500
12,313,600
2,775,200
3,330,200
3,885,200
3,723,600
4,468,300
5,213,000
4,987,800
5,985,300
6,982,900
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,374,900
7,649,900
8,924,900
9,787,500
11,745,000
13,702,500
1,327,400
1,608,800
1,592,900
1,930,600
1,858,400
2,252,300
- 503 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,564,100
9,077,000
10,589,800
9,066,100
10,879,400
12,692,600
12,937,100
15,524,500
18,112,000
1,604,500
1,925,300
2,246,200
1,770,500
1,958,500
2,124,600
2,350,200
2,478,700
2,742,000
1,677,000
2,012,400
2,347,800
1,850,600
2,220,700
2,590,800
2,047,100
2,456,500
2,866,000
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,804,100
2,165,000
2,525,800
743 W-1-12-II
744 W-1-12-III

2,251,900
3,987,500
2,702,200
4,785,100
3,152,600
5,582,600
745 W-1-13-I
1,854,500
2,225,400
2,596,300
746 W-1-13-II
747 W-1-13-III

2,013,400
2,704,400
2,416,000
3,245,300
2,818,700
3,786,200
748 W-1-20-I
749 W-1-20-II

6,210,500
7,760,100
7,452,600
9,312,100
8,694,700
10,864,100
750 W-1-20-III
8,996,000
10,795,100
12,594,300
751 W-1-30-I
3,505,900
4,207,100
4,908,300
752 W-1-30-II
5,591,900
6,710,300
7,828,700
753 W-1-30-III
13,720,100
16,464,100
19,208,200
754 W-4-10-I
2,612,300
3,134,700
3,657,200
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,872,600
7,653,000
2,375,700
3,606,600
4,390,000
4,647,100
9,183,600
2,850,800
4,328,000
5,267,900
5,421,600
10,714,200
3,325,900
5,049,300
6,145,900
2,703,300
3,244,000
3,784,700
3,711,500
4,453,800
5,196,100
4,045,700
4,854,900
5,664,000
934,700
1,276,800
1,587,800
1,249,100
1,486,800
1,902,100
1,521,100
1,689,300
2,338,900
2,023,800
2,706,400
3,668,100
1,493,400
2,696,300
3,986,500
2,294,600
3,045,800
4,326,800
2,050,500
2,462,800
3,385,200
1,121,600
1,532,200
1,905,400
1,498,900
1,784,100
2,282,600
1,825,300
2,027,200
2,806,700
2,428,600
3,247,700
4,401,700
1,792,100
3,235,600
4,783,800
2,753,500
3,655,000
5,192,200
2,460,600
2,955,300
4,062,300
1,308,600
1,787,600
2,222,900
1,748,800
2,081,500
2,663,000
2,129,500
2,365,000
3,274,500
2,833,400
3,789,000
5,135,300
2,090,700
3,774,900
5,581,100
3,212,400
4,264,100
6,057,500
2,870,700
3,447,900
4,739,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 504 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,180,200
1,416,200
1,652,300
2,895,200
3,474,300
4,053,300
4,141,800
4,970,200
5,798,500
- 505 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
916,700
1,189,100
2,211,200
1,827,300
2,374,700
436,800
776,400
341,600
741,200
647,100
734,700
1,104,600
1,506,600
1,380,800
447,300
1,032,500
374,500
643,000
1,958,500
701,400
1,656,400
404,100
942,800
1,475,700
1,237,700
303,500
919,900
511,500
263,000
284,300
251,000
300,100
417,900
359,100
338,000
303,800
450,700
196,800
232,000
266,000
5,397,000
2,156,900
2,164,100
556,700
911,600
570,700
1,160,100
743,300
425,700
321,400
518,400
286,100
245,000
1,911,800
892,200
509,800
1,990,100
1,326,700
258,400
2,156,000
1,492,600
3,506,600
775,400
476,900
256,500
213,700
240,900
3,673,500
1,788,200
- 506 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,272,600
4,022,100
3,334,800
2,540,400
837,500
2,827,500
1,846,200
453,800
4,245,100
3,843,100
2,576,800
2,441,200
301,700
289,900
1,166,600
318,800
284,100
313,900
1,077,500
1,471,900
1,285,600
1,135,400
687,600
285,700
503,600
345,700
312,200
304,100
386,100
440,400
258,100
740,900
1,350,200
1,036,500
2,436,600
317,300
317,300
2,251,600
1,309,300
251,200
1,161,900
3,018,300
693,000
545,800
267,400
236,900
289,600
403,900
967,100
852,400
596,700
445,100
245,000
1,036,100
830,200
354,700
404,800
1,326,500
293,300
1,355,200
1,036,800
316,200
350,500
342,400
207,200
1,129,700
1,552,100
307,600
- 507 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
942,800
351,900
380,500
352,300
558,900
429,900
1,076,800
317,700
883,900
1,181,100
258,700
1,574,400
853,200
1,843,700
930,700
411,000
316,200
68,400
409,800
926,000
360,900
487,400
278,700
108,700
281,500
4,192,000
2,382,800
3,976,900
977,000
545,800
371,900
841,200
444,900
895,400
518,400
308,600
516,600
232,600
355,000
340,200
795,700
1,622,800
1,305,700
1,151,200
812,500
298,900
298,900
298,900
244,100
154,800
243,500
297,600
321,900
237,100
209,100
95,900
105,400
77,900
91,500
87,200
133,100
119,400
166,200
182,500
106,000
128,700
88,000
137,300
194,800
- 508 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
138,700
186,500
527,300
611,300
131,100
253,700
159,600
227,800
426,900
365,500
262,700
248,700
130,400
128,100
292,900
184,800
265,100
183,500
143,700
1,842,400
1,895,100
301,100
311,900
596,400
768,900
763,400
394,300
1,229,000
272,700
320,500
321,500
257,500
325,200
307,800
144,200
316,800
280,800
254,000
287,200
2,377,800
308,700
855,700
306,900
436,700
470,600
375,400
743,100
761,000
811,400
709,800
1,300,700
211,500
1,468,200
278,700
744,200
1,691,300
1,955,700
854,300
309,600
603,900
601,500
278,700
2,185,000
1,718,600
140,000
156,000
202,600
265,800
- 509 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,007,000
439,400
905,600
1,092,500
523,500
728,300
503,400
556,000
636,000
300,000
709,200
186,200
689,600
1,084,200
75,600
- 510 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,961,900
2,354,300
2,746,700
A-4-10-II
SEPTIKEMIA (SEDANG)
3,351,800
4,022,200
4,692,500
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,519,300
2,888,800
5,423,200
3,466,600
6,327,000
4,044,300
5
6
A-4-11-II
A-4-11-III

4,111,600
5,690,800
4,934,000
6,829,000
5,756,300
7,967,200
A-4-12-I
2,615,900
3,139,100
3,662,200
8
9
A-4-12-II
A-4-12-III

3,257,700
3,476,800
3,909,200
4,172,200
4,560,700
4,867,500
10 A-4-13-I
11 A-4-13-II

1,573,100
2,369,800
1,887,700
2,843,800
2,202,300
3,317,700
12 A-4-13-III
2,843,800
3,412,500
3,981,300
2,181,200
2,617,400
3,053,600
2,647,600
3,177,100
3,706,600
3,177,100
3,812,500
4,447,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,424,400
5,126,000
4,109,300
6,151,200
4,794,200
7,176,400
18 A-4-15-III
INFEKSI HIV (BERAT)
6,432,700
7,719,200
9,005,700
19 B-1-01-I
20 B-1-01-II

23,444,900
25,866,000
28,133,900
31,039,200
32,822,800
36,212,400
21 B-1-01-III
22 B-1-10-I

45,374,300
4,050,900
54,449,200
4,861,100
63,524,000
5,671,200
23 B-1-10-II
8,991,200
10,789,400
12,587,600
24 B-1-10-III
25 B-1-11-I

17,749,800
5,412,700
21,299,800
6,495,300
24,849,700
7,577,800
26 B-1-11-II
27 B-1-11-III

7,014,500
9,062,600
8,417,400
10,875,100
9,820,300
12,687,700
28 B-1-12-I
5,285,200
6,342,300
7,399,300
29 B-1-12-II
5,878,100
7,053,700
8,229,400
30 B-1-12-III
9,195,700
11,034,800
12,873,900
4,209,800
5,051,700
5,893,700
6,926,600
8,312,000
9,697,300
8,962,500
10,754,900
12,547,400
5,784,400
6,941,200
8,098,100
6,433,200
7,719,900
9,006,500
10,064,100
1,789,700
2,856,800
3,941,100
12,076,900
2,147,600
3,428,200
4,729,300
14,089,700
2,505,600
3,999,600
5,517,600
3,773,300
4,528,000
5,282,700
5,282,700
6,339,200
7,395,800
6,399,900
7,679,900
8,959,900
3,411,500
4,857,900
7,227,400
3,254,300
4,093,800
5,829,400
8,672,900
3,905,200
4,776,100
6,801,000
10,118,400
4,556,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 511 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,791,100
4,549,300
5,307,600
48 B-4-13-III
49 B-4-14-I

5,222,600
3,250,800
6,267,100
3,901,000
7,311,600
4,551,200
50 B-4-14-II
3,792,500
4,551,000
5,309,500
51 B-4-14-III
52 C-4-10-I

5,080,100
3,007,600
6,096,200
3,609,100
7,112,200
4,210,600
53 C-4-10-II
54 C-4-10-III

5,770,800
10,186,000
6,925,000
12,223,200
8,079,200
14,260,400
55 C-4-11-I
3,427,300
4,112,700
4,798,200
56 C-4-11-II
57 C-4-11-III

4,586,200
7,051,400
5,503,400
8,461,600
6,420,700
9,871,900
58 C-4-12-I
59 C-4-12-II
2,282,000
4,494,600
2,738,400
5,393,600
3,194,800
6,292,500
60 C-4-12-III
RADIOTERAPI (BERAT)
11,543,500
13,852,200
16,160,900
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,715,600
3,228,800
2,058,700
3,874,500
2,401,800
4,520,300
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,370,700
2,850,500
5,244,800
3,420,600
6,118,900
3,990,800
65 C-4-14-II
3,998,700
4,798,500
5,598,200
66 C-4-14-III
67 D-1-10-I

5,958,000
13,949,900
7,149,600
16,739,900
8,341,200
19,529,900
68 D-1-10-II
69 D-1-10-III

21,246,700
33,832,100
25,496,100
40,598,500
29,745,400
47,364,900
70 D-1-11-I
4,611,100
5,533,300
6,455,500
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
11,774,200
15,301,000
14,129,000
18,361,200
16,483,900
21,421,500
3,997,300
4,796,700
5,596,200
11,015,900
13,219,000
15,422,200
17,474,400
20,969,200
24,464,100
2,390,400
3,593,200
5,652,900
3,129,300
5,623,200
7,725,000
2,697,900
3,742,000
5,746,100
2,868,500
4,311,800
6,783,500
3,755,200
6,747,900
9,269,900
3,237,500
4,490,400
6,895,300
3,346,600
5,030,400
7,914,100
4,381,000
7,872,500
10,814,900
3,777,100
5,238,800
8,044,500
2,312,000
2,774,400
3,236,800
3,272,300
3,926,800
4,581,200
4,185,400
5,022,500
5,859,500
2,479,800
2,975,700
3,471,700
4,060,000
4,872,000
5,684,000
4,965,800
5,958,900
6,952,100
4,414,300
5,297,100
6,180,000
5,782,300
6,938,700
8,095,200
93 E-1-01-III
10,041,000
12,049,100
14,057,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,443,500
4,179,600
8,809,400
4,132,200
5,015,500
10,571,200
4,820,900
5,851,400
12,333,100
5,818,000
6,981,600
8,145,200
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 512 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,287,200
2,744,600
3,202,000
104 E-4-11-II
105 E-4-11-III

3,487,000
4,725,100
4,184,400
5,670,100
4,881,800
6,615,200
106 E-4-12-I
107 E-4-12-II

2,627,900
4,550,900
3,153,500
5,461,100
3,679,100
6,371,300
108 E-4-12-III

(RINGAN)
(SEDANG)
5,394,500
6,473,400
7,552,300
2,861,700
3,434,000
4,006,400
4,191,900
5,030,300
5,868,700
111 E-4-13-III
5,479,600
6,575,600
7,671,500
112 F-4-10-I
113 F-4-10-II
3,046,700
3,501,500
3,656,000
4,201,800
4,265,300
4,902,200
114 F-4-10-III
115 F-4-11-I
4,201,800
2,946,600
5,042,200
3,535,900
5,882,600
4,125,200
116 F-4-11-II
3,433,100
4,119,700
4,806,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,402,500
5,283,000
6,163,500
1,615,200
1,938,300
2,261,300
2,296,300
2,755,600
3,214,900
4,988,600
5,986,400
6,984,100
2,373,600
3,132,000
4,054,700
1,354,200
1,737,000
2,337,300
2,848,300
3,758,400
4,865,700
1,625,100
2,084,400
2,804,700
3,323,000
4,384,700
5,676,600
1,895,900
2,431,800
3,272,200
127 F-4-15-I
2,156,700
2,588,000
3,019,400
128 F-4-15-II
3,213,800
3,856,500
4,499,300
129 F-4-15-III
4,243,200
5,091,800
5,940,400
4,243,400
5,092,100
5,940,800
4,933,700
5,920,400
6,907,100
6,585,600
7,902,700
9,219,800
133 F-4-17-I

1,002,100
1,202,600
1,403,000
134 F-4-17-II
2,937,100
3,524,500
4,112,000
135
136
137
138
139
140
141

(RINGAN)
3,133,600
3,687,200
4,057,000
6,254,100
2,817,900
3,608,400
4,492,500
3,760,300
4,424,700
4,868,400
7,505,000
3,381,500
4,330,100
5,391,000
4,387,100
5,162,100
5,679,800
8,755,800
3,945,000
5,051,800
6,289,500
10,746,400
12,895,700
15,044,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,830,900
9,397,000
10,963,200
10,792,600
12,951,100
15,109,600
3,471,700
4,166,000
4,860,300
4,851,000
5,821,300
6,791,500
6,021,100
7,225,300
8,429,600
- 513 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,289,700
17,147,600
20,005,600
148 G-1-11-I
149 G-1-11-II

9,148,200
16,725,100
10,977,900
20,070,100
12,807,500
23,415,200
150 G-1-11-III
30,837,000
37,004,400
43,171,800
3,819,700
4,583,700
5,347,600
7,160,200
8,592,300
10,024,300
9,758,000
11,709,600
13,661,200
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,152,300
3,094,500
1,382,800
3,713,400
1,613,200
4,332,300
156 G-1-13-III
157 G-1-20-I

6,982,500
4,839,100
8,379,000
5,806,900
9,775,600
6,774,700
158 G-1-20-II
5,754,500
6,905,400
8,056,300
159 G-1-20-III
13,430,500
16,116,600
18,802,700
160 G-1-30-I
7,098,600
8,518,300
9,938,000
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,377,300
20,192,600
17,252,800
24,231,200
20,128,300
28,269,700
3,278,800
3,934,600
4,590,300
4,007,800
4,809,400
5,610,900
5,499,400
6,599,300
7,699,200
3,432,400
4,118,900
4,805,400
4,559,500
5,471,400
6,383,300
6,699,500
8,039,400
9,379,300
3,807,800
4,569,400
5,331,000
4,809,600
5,771,500
6,733,400
6,985,300
8,382,400
9,779,400
2,287,400
2,744,900
3,202,400
3,988,800
4,786,600
5,584,400
4,730,800
5,677,000
6,623,200
3,880,400
4,656,400
5,432,500
5,187,700
6,225,300
7,262,800
6,511,200
7,813,500
9,115,700
3,170,600
3,804,700
4,438,800
3,783,900
4,540,700
5,297,500
5,340,700
6,408,800
7,477,000
2,613,700
3,136,500
3,659,200
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,734,400
20,081,300
23,428,200
32,183,400
38,620,100
45,056,800
11,015,400
12,969,500
13,218,500
15,563,400
15,421,600
18,157,300
- 514 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,470,100
4,164,100
4,858,100
183 G-4-16-III
4,941,700
5,930,000
6,918,300
3,481,300
4,177,600
4,873,800
4,564,700
5,477,700
6,390,600
5,735,800
6,883,000
8,030,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,428,500
4,114,300
4,800,000
188 G-4-18-II
4,582,900
5,499,500
6,416,100
189 G-4-18-III
5,127,900
6,153,500
7,179,100
2,860,500
3,432,600
4,004,700
4,834,900
5,801,900
6,768,900
6,348,100
7,617,700
8,887,300
193 G-4-20-I

2,001,100
2,401,300
2,801,500
194 G-4-20-II
2,828,900
3,394,700
3,960,500
195 G-4-20-III
196 G-4-21-I

4,672,700
2,083,800
5,607,200
2,500,600
6,541,700
2,917,300
197 G-4-21-II
198 G-4-21-III

3,526,900
4,144,900
4,232,200
4,973,800
4,937,600
5,802,800
199 G-4-22-I
2,632,300
3,158,800
3,685,200
200 G-4-22-II
201 G-4-22-III

3,363,300
3,929,900
4,036,000
4,715,800
4,708,600
5,501,800
202 G-4-23-I
203 G-4-23-II

2,051,300
2,573,700
2,461,600
3,088,400
2,871,800
3,603,100
204 G-4-23-III
3,664,300
4,397,100
5,130,000
205 G-4-24-I
206 G-4-24-II

2,284,800
2,854,600
2,741,800
3,425,500
3,198,800
3,996,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,755,600
1,952,400
2,469,000
3,271,900
5,706,800
2,342,800
2,962,800
3,926,200
6,657,900
2,733,300
3,456,600
4,580,600
3,085,200
3,702,300
4,319,300
3,589,100
4,306,900
5,024,700
5,366,800
6,440,100
7,513,500
4,406,900
5,617,700
7,639,600
6,705,500
8,331,000
11,668,800
2,643,100
3,586,200
7,048,800
2,281,000
2,602,000
3,725,900
2,689,400
3,213,300
5,384,900
5,288,300
6,741,200
9,167,500
8,046,600
9,997,200
14,002,600
3,171,700
4,303,400
8,458,600
2,737,300
3,122,400
4,471,100
3,227,300
3,856,000
6,461,900
6,169,600
7,864,700
10,695,400
9,387,800
11,663,400
16,336,300
3,700,400
5,020,600
9,868,300
3,193,500
3,642,800
5,216,200
3,765,100
4,498,600
7,538,900
229 I-1-01-I
36,123,100
43,347,700
50,572,300
230 I-1-01-II
36,917,800
44,301,300
51,684,900
231 I-1-01-III

(RINGAN)
58,274,200
69,929,100
81,583,900
20,040,900
24,049,100
28,057,300
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 515 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,501,400
19,801,700
23,102,000
245 I-1-06-II
23,903,600
28,684,400
33,465,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
28,521,400
34,225,700
39,930,000
19,642,900
23,571,500
27,500,100
24,233,500
29,080,200
33,926,900
26,438,700
31,726,400
37,014,100
3,140,500
3,768,600
4,396,700
3,491,900
4,190,300
4,888,700
4,646,700
5,576,000
6,505,300
9,039,800
10,847,800
12,655,700
14,763,800
17,716,600
20,669,300
19,424,000
23,308,800
27,193,600
8,768,500
10,522,200
12,275,900
11,677,000
14,012,400
16,347,800
14,401,000
17,281,200
20,161,400
17,946,900
21,536,300
25,125,700
22,305,400
26,766,500
31,227,500
29,227,800
35,073,300
40,918,900
3,409,400
4,761,200
9,168,100
4,091,300
5,713,400
11,001,700
4,773,200
6,665,600
12,835,300
8,838,400
10,606,100
12,373,800
19,997,700
23,997,300
27,996,800
23,067,100
27,680,500
32,293,900
10,234,000
12,280,800
14,327,600
12,814,000
15,376,800
17,939,600
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,852,600
31,023,100
36,193,600
31,864,900
38,237,900
44,610,900
11,575,700
13,890,800
16,206,000
16,046,300
19,255,600
22,464,800
20,364,000
24,436,800
28,509,600
17,443,900
20,932,700
24,421,500
27,531,300
33,037,500
38,543,800
43,981,000
52,777,200
61,573,400
22,382,200
26,858,600
31,335,100
26,858,700
32,230,500
37,602,200
36,957,400
44,348,900
51,740,400
- 516 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,908,700
23,890,500
27,872,200
279 I-1-40-III
26,591,300
31,909,500
37,227,800
280 I-4-10-I
281 I-4-10-II

3,035,600
5,420,300
3,642,700
6,504,400
4,249,800
7,588,500
282 I-4-10-III
7,809,900
9,371,900
10,933,900
283 I-4-11-I
284 I-4-11-II

4,670,200
5,779,400
5,604,200
6,935,300
6,538,300
8,091,100
285 I-4-11-III
286 I-4-12-I

10,691,300
2,684,700
12,829,500
3,221,700
14,967,800
3,758,600
287 I-4-12-II
3,111,900
3,734,300
4,356,700
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,734,300
4,481,200
5,228,100
2,732,000
3,278,400
3,824,800
4,878,300
5,854,000
6,829,600
7,029,000
8,434,700
9,840,500
2,579,900
2,668,700
4,678,200
3,095,900
3,202,400
5,613,800
3,611,900
3,736,200
6,549,500
4,442,600
5,331,100
6,219,600
6,043,900
7,252,600
8,461,400
297 I-4-15-III
7,252,600
8,703,200
10,153,700
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,628,300
2,614,600
3,137,600
1,833,100
2,134,100
2,560,900
1,954,000
3,137,600
3,765,100
2,199,700
2,560,900
3,073,100
2,279,600
3,660,500
4,392,600
2,566,300
2,987,700
3,585,200
3,140,800
3,769,000
4,397,100
4,782,000
5,738,400
6,694,800
6,492,400
7,790,800
9,089,300
307 I-4-19-I
3,030,300
3,636,300
4,242,400
308 I-4-19-II

(SEDANG)
4,730,400
5,676,500
6,622,500
309 I-4-19-III
5,647,200
6,776,600
7,906,100
310
311
312
313
314

3,155,400
3,644,500
5,449,200
2,361,200
2,991,600
3,786,500
4,373,400
6,539,100
2,833,400
3,589,900
4,417,500
5,102,300
7,628,900
3,305,600
4,188,200
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,850,700
19,020,800
22,191,000
11,535,500
13,842,600
16,149,700
14,411,000
17,293,200
20,175,400
15,149,000
18,178,800
21,208,500
8,726,000
10,471,200
12,216,300
18,151,900
21,782,300
25,412,700
28,129,000
33,754,800
39,380,600
8,053,100
9,663,700
11,274,400
- 517 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,318,100
5,181,700
6,045,300
316 I-4-22-I
317 I-4-22-II
2,646,500
3,294,500
3,175,800
3,953,300
3,705,100
4,612,200
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,815,500
5,778,500
6,741,600
2,590,100
3,108,100
3,626,200
3,179,900
3,815,900
4,451,900
6,213,400
7,456,100
8,698,800
2,332,400
2,798,900
3,265,400
5,370,900
6,445,100
7,519,300
6,790,600
8,148,700
9,506,800
42,078,800
50,494,600
58,910,300
47,620,000
57,144,000
66,668,000
53,873,200
64,647,800
75,422,400
22,329,700
26,795,600
31,261,600
31,091,800
37,310,100
43,528,500
51,343,200
61,611,800
71,880,400
6,780,900
8,137,100
9,493,300
13,721,300
16,465,500
19,209,800
14,259,800
17,111,700
19,963,700
9,607,900
11,529,500
13,451,000
12,695,300
15,234,300
17,773,400
19,441,400
23,329,700
27,218,000
5,658,900
6,790,600
7,922,400
10,251,000
12,301,200
14,351,300
29,589,000
35,506,800
41,424,600
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,312,100
4,775,200
7,224,200
2,063,800
2,874,500
3,852,900
3,505,300
3,990,300
5,571,600
3,099,300
4,314,200
8,048,800
3,417,100
5,560,600
6,578,700
4,169,100
4,980,900
6,701,400
2,774,600
5,730,200
8,669,000
2,476,500
3,449,300
4,623,500
4,206,400
4,788,400
6,685,900
3,719,200
5,177,000
9,658,600
4,100,500
6,672,700
7,894,400
5,002,900
5,977,100
8,041,600
3,237,000
6,685,300
10,113,800
2,889,300
4,024,200
5,394,100
4,907,500
5,586,500
7,800,200
4,339,000
6,039,800
11,268,300
4,783,900
7,784,800
9,210,200
5,836,800
6,973,300
9,381,900
3,473,800
4,168,500
4,863,300
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 518 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,881,500
5,857,800
6,834,100
360 J-4-16-III
6,171,900
7,406,300
8,640,700
361 J-4-17-I
362 J-4-17-II

2,855,300
3,419,300
3,426,300
4,103,100
3,997,400
4,787,000
363 J-4-17-III
364 J-4-18-I

4,487,100
2,140,000
5,384,500
2,568,000
6,282,000
2,996,000
365 J-4-18-II
2,943,300
3,532,000
4,120,700
366 J-4-18-III
367 J-4-19-I

3,098,200
4,021,700
3,717,900
4,826,100
4,337,500
5,630,400
368 J-4-19-II
369 J-4-19-III

4,560,900
5,037,000
5,473,100
6,044,300
6,385,300
7,051,700
370 J-4-20-I
3,991,000
4,789,200
5,587,400
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,530,000
6,482,900
6,636,000
7,779,400
7,742,000
9,076,000
2,773,700
3,328,400
3,883,200
4,468,400
5,362,000
6,255,700
6,235,300
7,482,300
8,729,400
6,147,300
7,376,800
8,606,300
7,725,400
9,270,500
10,815,600
9,054,500
10,865,400
12,676,300
6,902,900
8,283,500
9,664,100

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
9,062,700
13,714,800
10,875,200
16,457,700
12,687,700
19,200,700
2,579,300
3,095,200
3,611,100
3,354,700
4,025,700
4,696,600
6,646,200
7,975,400
9,304,700
2,909,000
3,199,900
3,229,000
3,490,800
3,839,800
3,874,700
4,072,600
4,479,800
4,520,500
4,720,700
5,664,900
6,609,000
5,532,600
6,639,100
7,745,600
8,692,500
10,430,900
12,169,400
9,140,900
12,767,700
18,642,200
10,969,000
15,321,300
22,370,700
12,797,200
17,874,800
26,099,100
5,405,800
6,487,000
7,568,200
9,600,600
11,520,800
13,440,900
13,210,600
15,852,700
18,494,900
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
6,031,700
7,238,000
8,444,300
398 K-1-40-II

(SEDANG)
6,650,100
7,980,100
9,310,200
399 K-1-40-III
11,269,600
13,523,500
15,777,400
400
401
402
403
404

4,608,800
5,985,100
8,458,000
3,804,800
5,466,900
5,530,600
7,182,100
10,149,600
4,565,800
6,560,300
6,452,300
8,379,100
11,841,300
5,326,700
7,653,700
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 519 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,334,100
10,000,900
11,667,700
406 K-4-11-I
407 K-4-11-II

2,230,200
3,169,200
2,676,200
3,803,000
3,122,200
4,436,800
408 K-4-11-III
409 K-4-12-I

3,803,000
2,287,200
4,563,600
2,744,600
5,324,200
3,202,000
410 K-4-12-II
3,077,800
3,693,400
4,309,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,091,700
6,110,100
7,128,400
3,083,200
3,699,900
4,316,500
3,988,400
4,786,100
5,583,700
6,143,400
7,372,100
8,600,700
1,954,800
2,345,800
2,736,700
2,624,000
3,148,800
3,673,600
4,210,500
5,052,500
5,894,600
418 K-4-15-I
2,019,800
2,423,700
2,827,700
419 K-4-15-II
2,994,800
3,593,800
4,192,700
420 K-4-15-III
4,203,100
5,043,700
5,884,400
421 K-4-16-I
2,853,900
3,424,700
3,995,500
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,422,700
3,993,700
4,107,200
4,792,500
4,791,700
5,591,200
1,465,800
1,759,000
2,052,100
2,004,800
2,405,800
2,806,800
2,405,800
2,887,000
3,368,100
1,295,200
1,554,300
1,813,300
1,840,600
2,208,700
2,576,800
429 K-4-18-III
2,208,700
2,650,500
3,092,200
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,574,000
21,999,000
29,394,300
6,876,100
11,799,000
14,648,700
17,488,800
26,398,800
35,273,100
8,251,400
14,158,800
17,578,400
20,403,600
30,798,600
41,152,000
9,626,600
16,518,600
20,508,100
3,853,500
4,624,200
5,394,900
7,729,300
9,275,200
10,821,100
13,010,200
15,612,200
18,214,300
5,058,900
8,141,800
11,646,000
1,323,200
1,535,900
1,782,700
2,771,000
3,808,400
8,654,000
1,316,000
1,740,500
4,604,200
6,070,700
9,770,200
13,975,300
1,587,800
1,843,000
2,139,300
3,325,100
4,570,100
10,384,800
1,579,100
2,088,600
5,525,000
7,082,500
11,398,500
16,304,500
1,852,500
2,150,200
2,495,800
3,879,300
5,331,800
12,115,500
1,842,300
2,436,700
6,445,800
2,362,700
2,835,200
3,307,700
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 520 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,776,800
3,332,100
3,887,500
4,086,100
4,903,300
5,720,500
2,278,800
2,734,500
3,190,300
3,422,800
4,107,400
4,791,900
4,824,900
5,789,800
6,754,800
8,055,300
9,666,300
11,277,400
11,449,400
13,739,300
16,029,200
16,083,000
19,299,600
22,516,200
7,139,500
8,567,400
9,995,300
11,712,000
19,898,500
14,054,500
23,878,200
16,396,900
27,857,900
19,384,200
23,261,000
27,137,800
22,672,600
27,207,100
31,741,600
28,061,100
33,673,300
39,285,600
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,951,800
10,742,200
12,532,500
467 M-1-04-II
11,500,500
13,800,600
16,100,700
468 M-1-04-III
13,760,600
16,512,700
19,264,800
469 M-1-05-I
470 M-1-05-II

5,683,400
9,193,200
6,820,100
11,031,800
7,956,800
12,870,400
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,743,100
14,091,700
16,440,300
6,361,900
7,634,300
8,906,700
8,522,800
10,227,400
11,931,900
17,361,800
20,834,100
24,306,500
10,472,800
12,567,400
14,662,000
22,981,300
27,577,600
32,173,900
49,568,600
59,482,300
69,396,000
9,565,700
11,478,800
13,391,900
12,221,100
14,665,300
17,109,500
480 M-1-20-III
30,426,800
36,512,200
42,597,500
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,562,300
10,633,600
15,205,100
7,874,700
12,760,300
18,246,100
9,187,200
14,887,000
21,287,100
3,340,500
4,008,500
4,676,600
5,924,200
7,109,000
8,293,800
8,458,500
10,150,300
11,842,000
4,003,000
6,643,000
10,910,600
4,803,600
7,971,600
13,092,800
5,604,200
9,300,200
15,274,900
6,182,300
7,418,800
8,655,300
7,772,600
9,327,200
10,881,700
11,741,500
14,089,800
16,438,100
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 521 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,293,600
2,752,300
3,211,000
500 M-4-10-II
501 M-4-10-III
3,420,500
6,471,700
4,104,600
7,766,000
4,788,700
9,060,300
2,858,000
3,429,700
4,001,300
6,266,100
7,519,400
8,772,600
9,059,800
10,871,700
12,683,700
2,281,400
2,737,600
3,193,900
3,794,500
4,553,400
5,312,300
5,075,600
6,090,700
7,105,800
3,798,700
4,558,400
5,318,200
5,707,400
6,848,900
7,990,300
11,135,000
13,362,000
15,589,000
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,332,300
5,198,700
6,065,200
512 M-4-14-II
5,343,200
6,411,900
7,480,500
513 M-4-14-III
514 M-4-15-I
8,029,300
2,568,900
9,635,200
3,082,700
11,241,100
3,596,500
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,424,200
7,770,500
2,199,400
3,522,100
5,916,800
4,109,000
9,324,600
2,639,300
4,226,500
7,100,200
4,793,900
10,878,700
3,079,200
4,930,900
8,283,500
2,854,500
3,425,400
3,996,300
3,992,400
4,790,800
5,589,300
5,575,100
6,690,100
7,805,100
2,157,600
3,251,500
3,915,000
2,589,100
3,901,900
4,698,000
3,020,600
4,552,200
5,481,000
2,250,000
2,700,000
3,150,000
3,789,900
4,547,800
5,305,800
7,401,800
8,882,200
10,362,600
2,269,600
2,723,600
3,177,500
3,323,500
3,988,200
4,652,900
3,714,400
4,457,300
5,200,200
2,285,300
2,742,400
3,199,500
2,858,300
3,430,000
4,001,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,453,900
13,744,700
16,035,500
12,599,300
15,119,200
17,639,000
14,424,500
17,309,400
20,194,300
6,511,100
7,813,300
9,115,500
7,732,500
17,404,200
9,279,000
20,885,000
10,825,500
24,365,900
- 522 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,408,300
7,689,900
8,971,600
535 N-1-01-I

106,392,200
127,670,700
148,949,100
536 N-1-01-II
106,392,200
127,670,700
148,949,100
537 N-1-01-III
538 N-1-11-I

106,392,200
6,592,000
127,670,700
7,910,400
148,949,100
9,228,800
539 N-1-11-II
540 N-1-11-III

10,423,600
16,250,400
12,508,300
19,500,400
14,593,000
22,750,500
3,359,700
4,031,700
4,703,600
6,688,900
8,026,600
9,364,400
14,515,100
17,418,100
20,321,100
7,345,600
8,814,800
10,283,900

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,279,800
14,385,400
12,335,800
17,262,500
14,391,800
20,139,600
6,722,600
8,067,100
9,411,600
10,169,900
12,203,900
14,237,900
11,704,600
14,045,500
16,386,400
6,037,300
7,244,800
8,452,300
8,198,600
9,838,300
11,478,000
9,542,100
11,450,500
13,358,900
2,565,000
3,078,000
3,591,000
3,102,400
3,722,900
4,343,400
4,563,200
5,475,900
6,388,500
1,969,100
3,440,200
4,280,400
2,246,700
4,168,700
5,017,700
3,387,300
4,085,500
6,260,700
2,362,900
4,128,300
5,136,400
2,696,000
5,002,500
6,021,300
4,064,800
4,902,600
7,512,900
2,756,700
4,816,300
5,992,500
3,145,300
5,836,200
7,024,800
4,742,200
5,719,700
8,765,000
1,977,600
2,373,100
2,768,600
2,806,100
3,367,300
3,928,600
4,498,200
5,397,800
6,297,500
2,336,300
2,803,500
3,270,800
2,898,900
3,478,700
4,058,500
3,308,100
3,969,800
4,631,400
2,860,800
3,432,900
4,005,100
4,083,200
4,899,900
5,716,500
5,435,100
6,522,100
7,609,100
5,034,900
5,318,100
6,041,800
6,381,800
7,048,800
7,445,400
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 523 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,667,000
8,000,400
9,333,800
2,659,200
3,191,100
3,722,900
2,955,400
3,546,500
4,137,600
3,676,600
4,411,900
5,147,200
1,884,000
2,260,800
2,637,600
2,262,700
2,715,200
3,167,800
2,843,200
3,411,800
3,980,400
1,610,300
1,932,400
2,254,400

MAYOR (RINGAN)
MAYOR (SEDANG)
1,905,900
2,287,100
2,287,100
2,744,500
2,668,300
3,202,000
42,070,300
50,484,400
58,898,500
52,055,700
62,466,900
72,878,000
61,098,800
73,318,600
85,538,300
70,879,100
85,054,900
99,230,800
81,305,600
97,566,700
113,827,800
92,897,400
111,476,900
130,056,400
7,659,300
9,191,200
10,723,000
11,364,000
13,636,700
15,909,500
12,861,700
15,434,100
18,006,400
22,710,700
27,252,800
31,795,000
38,234,500
45,881,400
53,528,300
54,818,600
65,782,400
76,746,100
16,060,100
19,272,200
22,484,200
23,284,600
27,941,500
32,598,400
33,414,300
40,097,200
46,780,100
4,074,800
4,889,800
5,704,700
11,424,800
13,709,800
15,994,700
15,135,100
18,162,100
21,189,100
3,946,900
4,736,200
5,525,600
11,066,100
13,279,300
15,492,500
14,659,900
17,591,800
20,523,800
4,004,300
4,805,100
5,606,000
5,682,000
6,818,300
7,954,700
9,200,300
11,040,300
12,880,400
6,963,000
8,355,600
9,748,200
10,330,900
12,397,000
14,463,200
- 524 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,692,500
14,031,000
16,369,500
6,054,800
7,265,800
8,476,700
8,609,100
10,330,900
12,052,700
9,743,700
11,692,500
13,641,200
5,201,000
6,241,200
7,281,300
8,113,500
9,736,200
11,358,900
11,074,600
13,289,500
15,504,400
2,744,000
3,292,800
3,841,600
5,585,700
6,702,900
7,820,000
10,363,600
12,436,400
14,509,100
2,058,000
2,469,700
2,881,300
4,121,300
4,945,600
5,769,900
4,835,600
5,802,800
6,769,900
1,862,600
2,235,100
2,607,600
3,579,200
4,295,000
5,010,900
7,299,000
8,758,800
10,218,600
3,467,300
4,160,800
4,854,200
6,241,200
7,489,400
8,737,600
8,518,900
10,222,700
11,926,500
2,100,000
2,520,000
2,940,000
2,587,500
3,105,000
3,622,500
3,542,100
4,250,500
4,958,900
1,627,200
2,386,100
4,078,200
1,543,900
2,054,900
3,562,200
1,952,700
2,863,400
4,893,900
1,852,700
2,465,900
4,274,700
2,278,100
3,340,600
5,709,500
2,161,500
2,876,900
4,987,100
2,280,000
2,736,000
3,192,000
4,044,900
4,853,800
5,662,800
6,565,300
7,878,400
9,191,400
1,153,800
1,384,600
1,615,400
2,450,800
2,941,000
3,431,200
4,647,600
5,577,100
6,506,700
771,700
926,000
1,080,400
1,456,300
1,747,600
2,038,800
1,886,200
2,263,400
2,640,600
3,996,000
4,795,100
5,594,300
- 525 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,081,900
6,098,300
7,114,700
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,276,300
8,731,500
10,186,800
1,926,000
2,311,200
2,696,400
2,858,400
3,430,000
4,001,700
3,437,800
4,125,400
4,812,900
1,288,600
1,546,400
1,804,100
1,730,800
2,077,000
2,423,100
3,148,600
3,778,300
4,408,000
614,500
737,400
860,300
1,171,200
1,405,400
1,639,600
1,702,500
2,043,000
2,383,500
822,600
987,200
1,151,700
1,294,500
1,553,400
1,812,300
2,085,200
2,502,200
2,919,200
1,278,300
1,533,900
1,789,600
1,932,100
2,318,500
2,704,900
2,991,000
3,589,200
4,187,400
4,211,100
5,053,300
5,895,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,537,300
17,266,700
7,844,800
20,720,100
9,152,200
24,173,400
6,514,800
7,817,700
9,120,700
8,258,500
9,910,100
11,561,800
11,882,600
14,259,100
16,635,600
5,090,600
7,806,100
11,465,600
5,094,100
5,935,400
9,839,000
6,108,700
9,367,300
13,758,700
6,112,900
7,122,500
11,806,800
7,126,800
10,928,600
16,051,800
7,131,700
8,309,600
13,774,700
3,061,200
3,673,400
4,285,600
3,756,800
4,508,200
5,259,500
4,451,800
5,342,200
6,232,500
3,699,600
5,259,800
6,779,700
4,439,600
6,311,800
8,135,600
5,179,500
7,363,700
9,491,500
4,647,300
5,576,800
6,506,300
6,916,500
8,299,800
9,683,100
17,756,100
21,307,300
24,858,500
3,985,600
5,404,300
10,568,300
4,782,700
6,485,200
12,682,000
5,579,800
7,566,000
14,795,700
2,868,200
3,441,800
4,015,500
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 526 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,743,200
2,091,900
2,440,500
697 U-4-12-I
698 U-4-12-II

2,512,000
2,921,900
3,014,300
3,506,300
3,516,700
4,090,700
699 U-4-12-III

3,790,500
4,548,600
5,306,800
1,903,700
2,284,500
2,665,200
2,244,300
2,693,200
3,142,000
2,684,300
3,221,100
3,758,000
2,854,800
3,418,600
3,425,800
4,102,300
3,996,800
4,786,000

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,740,800
6,889,000
8,037,200
2,292,300
2,750,800
3,209,300
2,856,000
3,427,200
3,998,400
3,997,000
4,796,400
5,595,700
3,739,000
4,486,800
5,234,600
7,702,200
9,242,700
10,783,100
9,445,700
11,334,800
13,224,000
7,113,300
8,122,500
12,720,200
8,535,900
9,747,000
15,264,300
9,958,600
11,371,500
17,808,300
6,687,900
8,025,400
9,363,000
9,132,800
10,959,400
12,785,900
11,575,900
13,891,100
16,206,300
3,488,500
4,186,200
4,883,900
6,665,300
7,998,400
9,331,500
10,457,100
12,548,500
14,639,900
6,840,900
8,209,100
9,577,200
9,939,600
11,927,500
13,915,400
12,411,400
14,893,700
17,375,900
1,101,700
1,215,800
1,344,900
1,322,100
1,458,900
1,613,800
1,542,400
1,702,100
1,882,800
3,308,100
3,969,800
4,631,400
5,495,000
6,594,000
7,693,000
9,059,300
10,871,100
12,683,000
2,858,400
3,430,100
4,001,800
3,835,300
4,602,300
5,369,400
5,137,400
6,164,900
7,192,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,566,200
7,879,400
9,192,700
10,081,100
12,097,400
14,113,600
1,367,300
1,657,100
1,640,700
1,988,500
1,914,200
2,319,900
- 527 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,791,100
9,349,300
10,907,500
9,338,100
11,205,700
13,073,400
13,325,200
15,990,300
18,655,300
1,652,600
1,983,100
2,313,600
1,823,600
2,017,300
2,188,400
2,420,800
2,553,100
2,824,200
1,727,300
2,072,800
2,418,300
1,906,100
2,287,300
2,668,500
2,108,500
2,530,200
2,951,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,858,300
2,229,900
2,601,600
743 W-1-12-II
744 W-1-12-III

2,319,400
4,107,200
2,783,300
4,928,600
3,247,200
5,750,000
745 W-1-13-I
1,910,100
2,292,200
2,674,200
746 W-1-13-II
747 W-1-13-III

2,073,800
2,785,600
2,488,500
3,342,700
2,903,300
3,899,800
748 W-1-20-I
749 W-1-20-II

6,396,800
7,992,900
7,676,200
9,591,500
8,955,600
11,190,100
750 W-1-20-III
9,265,800
11,119,000
12,972,200
751 W-1-30-I
3,611,100
4,333,300
5,055,500
752 W-1-30-II
5,759,700
6,911,600
8,063,600
753 W-1-30-III
14,131,700
16,958,100
19,784,400
754 W-4-10-I
2,690,600
3,228,800
3,766,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,988,800
7,882,600
2,446,900
3,714,800
4,521,700
4,786,500
9,459,100
2,936,300
4,457,800
5,426,000
5,584,300
11,035,600
3,425,700
5,200,800
6,330,300
2,784,500
3,341,300
3,898,200
3,822,900
4,587,400
5,352,000
4,167,100
5,000,500
5,834,000
962,700
1,315,100
1,635,400
1,286,600
1,531,400
1,959,200
1,566,700
1,740,000
2,409,100
2,084,600
2,787,600
3,778,100
1,538,200
2,777,200
4,106,100
2,363,400
3,137,200
4,456,600
2,112,000
2,536,700
3,486,800
1,155,300
1,578,200
1,962,500
1,543,900
1,837,600
2,351,000
1,880,100
2,088,000
2,890,900
2,501,500
3,345,100
4,533,700
1,845,800
3,332,700
4,927,300
2,836,100
3,764,600
5,347,900
2,534,400
3,044,000
4,184,100
1,347,800
1,841,200
2,289,600
1,801,200
2,143,900
2,742,900
2,193,400
2,436,000
3,372,700
2,918,400
3,902,600
5,289,300
2,153,500
3,888,100
5,748,500
3,308,800
4,392,000
6,239,300
2,956,800
3,551,300
4,881,500
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 528 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,215,600
1,458,700
1,701,800
2,982,100
3,578,500
4,174,900
4,266,100
5,119,300
5,972,500
- 529 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
962,500
1,248,500
2,321,800
1,918,700
2,493,400
458,600
815,300
358,600
778,300
679,500
771,400
1,159,800
1,581,900
1,449,900
469,700
1,084,100
393,200
675,100
2,056,500
736,500
1,739,200
424,300
989,900
1,549,400
1,299,500
318,700
965,900
537,000
276,100
298,600
263,500
315,200
438,800
377,000
354,900
319,000
473,300
206,700
243,600
279,300
5,666,800
2,264,800
2,272,400
584,500
957,200
599,300
1,218,100
780,500
447,000
337,500
544,400
300,400
257,300
2,007,400
936,800
535,300
2,089,600
1,393,100
271,300
2,263,800
1,567,200
3,681,900
814,200
500,800
269,300
224,400
253,000
3,857,200
1,877,600
- 530 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,386,300
4,223,200
3,501,500
2,667,500
879,400
2,968,900
1,938,600
476,500
4,457,400
4,035,200
2,705,600
2,563,200
316,800
304,400
1,224,900
334,800
298,300
329,600
1,131,400
1,545,400
1,349,900
1,192,100
722,000
300,000
528,800
363,000
327,800
319,400
405,500
462,400
271,100
777,900
1,417,700
1,088,300
2,558,500
333,200
333,200
2,364,200
1,374,700
263,700
1,220,000
3,169,300
727,600
573,100
280,800
248,800
304,100
424,100
1,015,500
895,100
626,500
467,400
257,300
1,088,000
871,700
372,500
425,000
1,392,800
308,000
1,423,000
1,088,600
332,000
368,000
359,500
217,500
1,186,200
1,629,700
323,000
- 531 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
989,900
369,500
399,500
369,900
586,900
451,400
1,130,600
333,600
928,100
1,240,200
271,600
1,653,100
895,800
1,935,900
977,300
431,600
332,000
71,800
430,300
972,300
378,900
511,800
292,700
114,100
295,600
4,401,600
2,501,900
4,175,800
1,025,800
573,100
390,500
883,200
467,200
940,200
544,400
324,100
542,400
244,200
372,700
357,200
835,500
1,704,000
1,371,000
1,208,800
853,100
313,800
313,800
313,800
256,300
162,600
255,600
312,500
338,000
249,000
219,600
100,700
110,700
81,800
96,000
91,600
139,800
125,400
174,500
191,700
111,300
135,100
92,400
144,100
204,500
- 532 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
145,600
195,900
553,700
641,900
137,700
266,400
167,500
239,200
448,200
383,700
275,800
261,200
136,900
134,500
307,600
194,100
278,400
192,700
150,800
1,934,500
1,989,900
316,200
327,400
626,200
807,400
801,600
414,100
1,290,400
286,300
336,500
337,600
270,400
341,500
323,100
151,400
332,600
294,800
266,700
301,600
2,496,700
324,200
898,500
322,300
458,500
494,100
394,200
780,300
799,100
852,000
745,300
1,365,700
222,000
1,541,600
292,700
781,400
1,775,900
2,053,400
897,100
325,100
634,100
631,600
292,700
2,294,200
1,804,500
147,000
163,800
212,800
279,100
- 533 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,057,400
461,300
950,900
1,147,100
549,700
764,700
528,600
583,800
667,800
315,000
744,700
195,500
724,100
1,138,400
79,400
- 534 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,661,800
1,994,100
2,326,500
A-4-10-II
SEPTIKEMIA (SEDANG)
2,839,000
3,406,800
3,974,600
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,827,800
2,157,400
4,593,400
2,588,900
5,359,000
3,020,400
5
6
A-4-11-II
A-4-11-III

3,070,700
4,250,100
3,684,800
5,100,100
4,298,900
5,950,100
A-4-12-I
2,412,700
2,895,300
3,377,800
8
9
A-4-12-II
A-4-12-III

3,004,600
3,206,800
3,605,600
3,848,100
4,206,500
4,489,500
10 A-4-13-I
11 A-4-13-II

1,059,700
1,425,200
1,271,600
1,710,300
1,483,500
1,995,300
12 A-4-13-III
1,710,300
2,052,300
2,394,400
2,117,600
2,541,200
2,964,700
2,570,500
3,084,600
3,598,700
3,084,600
3,701,500
4,318,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,900,500
4,341,700
3,480,600
5,210,000
4,060,700
6,078,300
18 A-4-15-III
INFEKSI HIV (BERAT)
5,448,400
6,538,100
7,627,800
19 B-1-01-I
20 B-1-01-II

18,991,800
20,953,000
22,790,200
25,143,600
26,588,500
29,334,200
21 B-1-01-III
22 B-1-10-I

36,755,900
3,431,100
44,107,100
4,117,300
51,458,300
4,803,500
23 B-1-10-II
7,615,500
9,138,600
10,661,700
24 B-1-10-III
25 B-1-11-I

15,034,000
4,584,500
18,040,800
5,501,500
21,047,600
6,418,400
26 B-1-11-II
27 B-1-11-III

5,941,200
7,676,000
7,129,500
9,211,200
8,317,700
10,746,400
28 B-1-12-I
4,476,600
5,371,900
6,267,200
29 B-1-12-II
4,978,700
5,974,500
6,970,200
30 B-1-12-III
7,788,700
9,346,400
10,904,100
3,565,600
4,278,800
4,991,900
5,866,800
7,040,200
8,213,500
7,591,100
9,109,400
10,627,600
4,899,300
5,879,200
6,859,100
5,448,900
6,538,700
7,628,500
8,524,200
1,515,800
2,419,700
3,338,100
10,229,100
1,819,000
2,903,700
4,005,700
11,933,900
2,122,200
3,387,600
4,673,300
3,196,000
3,835,200
4,474,400
4,474,400
5,369,300
6,264,200
5,420,700
6,504,800
7,589,000
2,889,500
4,114,600
6,121,600
2,756,400
3,467,400
4,937,500
7,345,900
3,307,600
4,045,300
5,760,400
8,570,200
3,858,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 535 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,211,100
3,853,300
4,495,500
48 B-4-13-III
49 B-4-14-I

4,423,500
2,753,400
5,308,200
3,304,100
6,192,900
3,854,800
50 B-4-14-II
3,212,200
3,854,700
4,497,100
51 B-4-14-III
52 C-4-10-I

4,302,900
2,547,400
5,163,400
3,056,900
6,024,000
3,566,400
53 C-4-10-II
54 C-4-10-III

4,887,900
8,627,500
5,865,400
10,353,000
6,843,000
12,078,500
55 C-4-11-I
2,902,900
3,483,500
4,064,000
56 C-4-11-II
57 C-4-11-III

3,884,500
5,972,500
4,661,400
7,166,900
5,438,300
8,361,400
58 C-4-12-I
59 C-4-12-II
1,932,800
3,806,900
2,319,400
4,568,300
2,706,000
5,329,700
60 C-4-12-III
RADIOTERAPI (BERAT)
9,777,300
11,732,700
13,688,200
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,453,100
2,734,700
1,743,700
3,281,700
2,034,300
3,828,600
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,701,900
2,414,400
4,442,300
2,897,300
5,182,700
3,380,100
65 C-4-14-II
3,386,900
4,064,300
4,741,700
66 C-4-14-III
67 D-1-10-I

5,046,400
11,815,500
6,055,700
14,178,600
7,065,000
16,541,700
68 D-1-10-II
69 D-1-10-III

17,995,800
28,655,600
21,595,000
34,386,700
25,194,200
40,117,800
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
3,905,500
4,686,700
5,467,800
9,972,700
12,959,900
11,967,200
15,551,900
13,961,700
18,143,800
3,385,700
4,062,800
4,739,900
9,330,400
11,196,400
13,062,500
14,800,700
17,760,800
20,721,000
2,088,700
3,043,400
4,788,000
2,650,500
4,762,900
6,543,000
2,285,100
3,169,500
4,866,900
2,506,500
3,652,100
5,745,600
3,180,600
5,715,400
7,851,600
2,742,100
3,803,400
5,840,300
2,924,200
4,260,800
6,703,200
3,710,700
6,668,000
9,160,200
3,199,100
4,437,300
6,813,600
1,958,300
2,349,900
2,741,600
2,771,600
3,325,900
3,880,300
3,545,000
4,254,000
4,963,000
2,100,300
2,520,400
2,940,500
3,438,800
4,126,500
4,814,300
4,206,000
5,047,200
5,888,400
3,275,500
3,930,600
4,585,700
4,290,600
5,148,700
6,006,800
93 E-1-01-III
8,504,600
10,205,500
11,906,500
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,789,400
3,385,700
7,136,100
3,347,300
4,062,900
8,563,300
3,905,200
4,740,000
9,990,500
4,927,800
5,913,400
6,898,900
97 E-1-20-I
- 536 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,937,200
2,324,700
2,712,100
104 E-4-11-II
105 E-4-11-III

2,953,400
4,002,100
3,544,100
4,802,600
4,134,800
5,603,000
106 E-4-12-I
107 E-4-12-II

2,225,800
3,854,600
2,671,000
4,625,500
3,116,200
5,396,500
108 E-4-12-III

(RINGAN)
(SEDANG)
4,569,100
5,482,900
6,396,800
2,423,800
2,908,600
3,393,400
3,550,500
4,260,600
4,970,700
111 E-4-13-III
4,641,200
5,569,500
6,497,700
112 F-4-10-I
113 F-4-10-II
2,580,500
2,965,800
3,096,600
3,558,900
3,612,700
4,152,100
114 F-4-10-III
115 F-4-11-I
3,558,900
2,495,800
4,270,700
2,994,900
4,982,500
3,494,100
116 F-4-11-II
2,907,800
3,489,400
4,070,900
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,728,900
4,474,700
5,220,400
1,368,100
1,641,700
1,915,300
1,945,000
2,334,000
2,723,000
4,225,400
5,070,400
5,915,500
2,010,400
2,652,800
3,434,300
1,147,000
1,471,200
1,979,600
2,412,500
3,183,300
4,121,200
1,376,400
1,765,500
2,375,600
2,814,500
3,713,900
4,808,100
1,605,800
2,059,700
2,771,500
127 F-4-15-I
1,826,700
2,192,100
2,557,400
128 F-4-15-II
2,722,000
3,266,400
3,810,800
129 F-4-15-III
3,593,900
4,312,700
5,031,500
3,594,100
4,313,000
5,031,800
4,178,800
5,014,500
5,850,300
5,578,000
6,693,500
7,809,100
133 F-4-17-I

848,800
1,018,600
1,188,300
134 F-4-17-II
2,487,700
2,985,300
3,482,800
135
136
137
138
139
140
141

(RINGAN)
2,654,200
3,123,000
3,436,200
5,297,200
2,386,700
3,056,300
3,805,100
3,185,000
3,747,700
4,123,500
6,356,700
2,864,100
3,667,600
4,566,100
3,715,800
4,372,300
4,810,700
7,416,100
3,341,400
4,278,900
5,327,100
5,296,500
6,355,800
7,415,000
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,632,700
7,959,200
9,285,800
9,141,200
10,969,500
12,797,700
3,202,000
3,842,400
4,482,800
4,474,300
5,369,100
6,264,000
5,553,400
6,664,100
7,774,800
- 537 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,304,000
6,364,800
7,425,600
148 G-1-11-I
149 G-1-11-II

7,748,500
14,166,100
9,298,200
16,999,300
10,847,900
19,832,500
150 G-1-11-III
22,764,300
27,317,100
31,870,000
3,235,300
3,882,300
4,529,400
6,064,700
7,277,600
8,490,500
8,265,000
9,917,900
11,570,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
976,000
2,621,000
1,171,200
3,145,200
1,366,400
3,669,400
156 G-1-13-III
157 G-1-20-I

5,914,200
2,921,200
7,097,000
3,505,500
8,279,800
4,089,700
158 G-1-20-II
4,824,900
5,789,900
6,754,900
159 G-1-20-III
9,674,000
11,608,800
13,543,600
160 G-1-30-I
4,565,900
5,479,000
6,392,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
11,922,800
15,316,200
14,307,400
18,379,500
16,692,000
21,442,700
2,777,100
3,332,600
3,888,000
3,394,600
4,073,500
4,752,400
4,658,000
5,589,600
6,521,100
2,907,200
3,488,700
4,070,100
3,861,900
4,634,300
5,406,600
5,674,400
6,809,300
7,944,200
3,225,200
3,870,300
4,515,300
4,073,700
4,888,400
5,703,200
5,916,500
7,099,800
8,283,100
1,937,400
2,324,900
2,712,400
3,378,500
4,054,200
4,729,900
4,007,000
4,808,400
5,609,800
3,286,600
3,944,000
4,601,300
4,394,000
5,272,800
6,151,600
5,515,000
6,618,000
7,721,000
2,685,500
3,222,600
3,759,700
3,205,000
3,846,000
4,487,000
4,523,500
5,428,300
6,333,000
2,213,800
2,656,600
3,099,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,298,100
8,757,800
10,217,400
14,187,600
17,025,100
19,862,600
3,167,800
4,472,600
3,801,400
5,367,200
4,435,000
6,261,700
- 538 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
2,939,100
3,527,000
4,114,800
183 G-4-16-III
4,185,600
5,022,700
5,859,800
2,948,600
3,538,400
4,128,100
3,866,300
4,639,600
5,412,800
4,858,200
5,829,800
6,801,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,904,000
3,484,700
4,065,500
188 G-4-18-II
3,881,700
4,658,000
5,434,400
189 G-4-18-III
4,343,300
5,212,000
6,080,700
2,422,800
2,907,400
3,392,000
4,095,200
4,914,200
5,733,200
5,376,800
6,452,100
7,527,500
193 G-4-20-I

1,694,900
2,033,900
2,372,800
194 G-4-20-II
2,396,100
2,875,300
3,354,500
195 G-4-20-III
196 G-4-21-I

3,957,700
1,765,000
4,749,200
2,118,000
5,540,800
2,470,900
197 G-4-21-II
198 G-4-21-III

2,987,200
3,510,700
3,584,700
4,212,800
4,182,100
4,915,000
199 G-4-22-I
2,427,900
2,913,400
3,399,000
200 G-4-22-II
201 G-4-22-III

3,102,100
3,624,600
3,722,500
4,349,500
4,342,900
5,074,500
202 G-4-23-I
203 G-4-23-II

1,737,400
2,179,900
2,084,900
2,615,900
2,432,400
3,051,800
204 G-4-23-III
3,103,600
3,724,300
4,345,100
205 G-4-24-I
206 G-4-24-II

1,935,200
2,417,800
2,322,300
2,901,400
2,709,300
3,384,900
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,028,000
1,653,600
2,091,200
2,771,200
4,833,600
1,984,400
2,509,400
3,325,500
5,639,200
2,315,100
2,927,700
3,879,700
2,613,200
3,135,800
3,658,400
3,039,900
3,647,900
4,255,900
4,545,600
5,454,800
6,363,900
1,866,100
4,192,600
5,701,800
5,696,500
7,077,300
9,912,800
2,238,700
3,037,500
5,970,300
1,932,000
2,203,900
3,155,800
2,277,900
2,721,700
4,561,000
2,239,300
5,031,200
6,842,100
6,835,800
8,492,800
11,895,400
2,686,500
3,645,000
7,164,300
2,318,400
2,644,600
3,787,000
2,733,500
3,266,000
5,473,200
2,612,500
5,869,700
7,982,500
7,975,100
9,908,300
13,877,900
3,134,200
4,252,500
8,358,400
2,704,800
3,085,400
4,418,100
3,189,000
3,810,300
6,385,400
229 I-1-01-I
30,596,000
36,715,200
42,834,400
230 I-1-01-II
31,269,100
37,523,000
43,776,800
231 I-1-01-III

(RINGAN)
49,357,900
59,229,500
69,101,100
16,974,600
20,369,500
23,764,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 539 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
13,976,600
16,771,900
19,567,200
245 I-1-06-II
20,246,200
24,295,500
28,344,700
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,157,500
28,989,000
33,820,500
16,637,400
19,964,900
23,292,400
20,525,600
24,630,800
28,735,900
22,393,400
26,872,100
31,350,700
2,660,000
3,192,000
3,724,000
2,957,600
3,549,100
4,140,700
3,935,700
4,722,800
5,510,000
7,656,700
9,188,000
10,719,300
12,504,900
15,005,800
17,506,800
16,452,000
19,742,400
23,032,800
7,426,800
8,912,200
10,397,600
9,890,400
11,868,400
13,846,500
12,197,600
14,637,100
17,076,600
15,200,900
18,241,100
21,281,300
18,892,500
22,671,000
26,449,500
24,755,700
29,706,900
34,658,000
2,887,700
4,032,700
7,765,300
3,465,300
4,839,200
9,318,400
4,042,800
5,645,700
10,871,500
7,486,100
8,983,300
10,480,500
16,938,000
20,325,600
23,713,200
19,537,700
23,445,200
27,352,800
8,668,200
10,401,800
12,135,400
10,853,400
13,024,000
15,194,700
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
21,897,000
26,276,300
30,655,700
26,989,400
32,387,200
37,785,100
9,804,500
11,765,500
13,726,400
13,591,100
16,309,400
19,027,600
17,248,200
20,697,800
24,147,500
14,774,900
17,729,900
20,684,900
23,318,800
27,982,600
32,646,300
37,251,600
44,702,000
52,152,300
18,957,600
22,749,100
26,540,600
22,749,200
27,299,000
31,848,800
31,302,700
37,563,200
43,823,800
- 540 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
16,862,600
20,235,100
23,607,600
279 I-1-40-III
22,522,700
27,027,200
31,531,700
280 I-4-10-I
281 I-4-10-II

2,571,100
4,591,000
3,085,300
5,509,200
3,599,500
6,427,400
282 I-4-10-III
6,615,000
7,938,000
9,261,000
283 I-4-11-I
284 I-4-11-II

3,955,600
4,895,100
4,746,700
5,874,100
5,537,900
6,853,100
285 I-4-11-III
286 I-4-12-I

9,055,400
2,273,900
10,866,500
2,728,700
12,677,600
3,183,500
287 I-4-12-II
2,635,800
3,162,900
3,690,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,162,900
3,795,500
4,428,100
2,314,000
2,776,800
3,239,600
4,131,900
4,958,300
5,784,700
5,953,500
7,144,200
8,334,900
2,185,200
2,260,400
3,962,400
2,622,200
2,712,400
4,754,900
3,059,200
3,164,500
5,547,400
4,097,500
4,917,000
5,736,600
5,574,400
6,689,300
7,804,200
297 I-4-15-III
6,689,300
8,027,200
9,365,000
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,379,200
2,214,600
2,657,500
1,690,700
1,968,300
2,362,000
1,655,000
2,657,500
3,189,000
2,028,900
2,362,000
2,834,400
1,930,800
3,100,400
3,720,500
2,367,000
2,755,600
3,306,800
2,660,200
3,192,300
3,724,300
4,050,300
4,860,400
5,670,500
5,499,000
6,598,800
7,698,600
307 I-4-19-I
2,566,600
3,079,900
3,593,200
308 I-4-19-II

(SEDANG)
4,006,600
4,807,900
5,609,300
309 I-4-19-III
4,783,100
5,739,800
6,696,400
310
311
312
313
314

2,672,600
3,086,900
4,615,500
1,999,900
2,533,900
3,207,100
3,704,200
5,538,600
2,399,900
3,040,600
3,741,600
4,321,600
6,461,700
2,799,800
3,547,400
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,425,400
16,110,500
18,795,600
9,770,500
11,724,600
13,678,700
12,206,000
14,647,300
17,088,500
12,831,100
15,397,300
17,963,500
7,390,800
8,869,000
10,347,200
15,374,600
18,449,500
21,524,400
23,825,100
28,590,100
33,355,100
6,820,900
8,185,100
9,549,300
- 541 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,657,400
4,388,800
5,120,300
316 I-4-22-I
317 I-4-22-II
2,241,500
2,790,400
2,689,900
3,348,500
3,138,200
3,906,500
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,078,700
4,894,400
5,710,100
2,193,800
2,632,600
3,071,300
2,693,400
3,232,100
3,770,700
5,262,700
6,315,200
7,367,800
1,975,500
2,370,600
2,765,800
4,549,100
5,459,000
6,368,800
5,751,600
6,901,900
8,052,200
35,640,500
42,768,600
49,896,700
40,333,800
48,400,600
56,467,400
45,630,200
54,756,300
63,882,300
18,913,100
22,695,700
26,478,300
26,334,500
31,601,500
36,868,400
43,487,400
52,184,800
60,882,300
5,743,400
6,892,100
8,040,800
11,621,800
13,946,200
16,270,500
12,077,900
14,493,500
16,909,100
6,749,100
8,098,900
9,448,800
7,990,200
9,588,200
11,186,200
12,338,100
14,805,800
17,273,400
4,793,000
5,751,600
6,710,200
8,682,500
10,419,000
12,155,500
25,061,700
30,074,100
35,086,400
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
1,958,400
4,044,600
6,118,800
1,748,000
2,434,600
3,263,400
2,969,000
3,379,800
4,719,100
2,625,100
3,654,100
6,817,300
2,894,200
4,709,800
5,572,100
3,845,300
4,594,100
6,180,900
2,350,000
4,853,500
7,342,600
2,097,600
2,921,600
3,916,100
3,562,800
4,055,700
5,662,900
3,150,100
4,384,900
8,180,700
3,473,100
5,651,700
6,686,500
4,614,400
5,512,900
7,417,000
2,741,700
5,662,400
8,566,300
2,447,200
3,408,500
4,568,800
4,156,600
4,731,700
6,606,700
3,675,100
5,115,700
9,544,200
4,051,900
6,593,700
7,801,000
5,383,400
6,431,700
8,653,200
3,203,900
3,844,700
4,485,500
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 542 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,502,400
5,402,800
6,303,300
360 J-4-16-III
5,692,600
6,831,100
7,969,600
361 J-4-17-I
362 J-4-17-II

2,418,400
2,896,100
2,902,100
3,475,300
3,385,800
4,054,500
363 J-4-17-III
364 J-4-18-I

3,800,600
1,973,800
4,560,700
2,368,500
5,320,800
2,763,300
365 J-4-18-II
2,714,700
3,257,700
3,800,600
366 J-4-18-III
367 J-4-19-I

2,857,600
3,406,400
3,429,100
4,087,700
4,000,600
4,768,900
368 J-4-19-II
369 J-4-19-III

3,863,100
4,266,300
4,635,700
5,119,500
5,408,300
5,972,800
370 J-4-20-I
3,380,400
4,056,500
4,732,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,683,900
5,490,900
5,620,600
6,589,100
6,557,400
7,687,300
2,558,300
3,069,900
3,581,600
4,121,300
4,945,600
5,769,800
5,751,000
6,901,200
8,051,400
5,206,700
6,248,100
7,289,400
6,543,400
7,852,100
9,160,700
7,669,100
9,202,900
10,736,700
5,361,500
6,433,800
7,506,100

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,039,000
9,320,700
8,446,800
11,184,900
9,854,500
13,049,000
2,184,700
2,621,600
3,058,500
2,841,400
3,409,700
3,978,000
5,629,300
6,755,200
7,881,000
2,463,900
2,710,300
2,734,900
2,956,700
3,252,300
3,281,900
3,449,400
3,794,400
3,828,900
3,998,400
4,798,100
5,597,800
4,686,100
5,623,300
6,560,500
390 K-1-14-III
7,362,500
8,834,900
10,307,400
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,742,200
10,814,200
15,789,900
9,290,700
12,977,000
18,947,800
10,839,100
15,139,900
22,105,800
4,578,700
5,494,500
6,410,200
8,131,700
9,758,000
11,384,400
11,189,300
13,427,200
15,665,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,108,800
6,130,500
7,152,300
398 K-1-40-II

(SEDANG)
5,632,600
6,759,100
7,885,700
399 K-1-40-III
9,545,200
11,454,300
13,363,300
400
401
402
403
404

3,903,600
5,069,300
7,163,900
3,222,600
4,630,500
4,684,300
6,083,200
8,596,700
3,867,200
5,556,600
5,465,100
7,097,100
10,029,500
4,511,700
6,482,600
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 543 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,058,900
8,470,700
9,882,500
406 K-4-11-I
407 K-4-11-II

2,057,000
2,923,000
2,468,300
3,507,600
2,879,700
4,092,200
408 K-4-11-III
409 K-4-12-I

3,507,600
1,937,200
4,209,200
2,324,700
4,910,700
2,712,100
410 K-4-12-II
2,606,900
3,128,300
3,649,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,312,700
5,175,200
6,037,700
2,611,500
3,133,800
3,656,100
3,378,100
4,053,800
4,729,400
5,203,400
6,244,100
7,284,800
1,655,700
1,986,800
2,318,000
2,222,500
2,667,000
3,111,500
3,566,200
4,279,500
4,992,700
418 K-4-15-I
1,643,800
1,972,500
2,301,300
419 K-4-15-II
2,450,700
2,940,800
3,430,900
420 K-4-15-III
3,439,400
4,127,300
4,815,100
421 K-4-16-I
2,417,300
2,900,700
3,384,200
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,899,000
3,382,700
3,478,800
4,059,200
4,058,600
4,735,700
1,092,600
1,311,100
1,529,600
1,638,300
1,965,900
2,293,600
1,965,900
2,359,100
2,752,300
1,097,100
1,316,500
1,535,900
1,559,000
1,870,800
2,182,600
429 K-4-18-III
1,870,800
2,245,000
2,619,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,344,100
18,633,000
24,896,800
5,824,000
9,993,700
12,407,300
14,812,900
22,359,600
29,876,100
6,988,900
11,992,400
14,888,800
17,281,700
26,086,200
34,855,500
8,153,700
13,991,200
17,370,200
3,263,900
3,916,700
4,569,500
6,546,700
7,856,000
9,165,400
11,019,600
13,223,500
15,427,400
4,284,900
6,896,100
9,864,100
1,120,700
1,300,900
1,510,000
2,347,000
3,225,700
7,329,800
1,114,600
1,474,200
3,899,700
5,141,900
8,275,300
11,837,000
1,344,900
1,561,000
1,811,900
2,816,400
3,870,900
8,795,800
1,337,500
1,769,100
4,679,600
5,998,800
9,654,500
13,809,800
1,569,000
1,821,200
2,113,900
3,285,800
4,516,000
10,261,800
1,560,400
2,063,900
5,459,600
2,179,100
2,615,000
3,050,800
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 544 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,561,100
3,073,300
3,585,500
3,768,700
4,522,400
5,276,200
1,930,100
2,316,100
2,702,200
2,899,100
3,478,900
4,058,700
4,086,600
4,903,900
5,721,300
6,822,800
8,187,300
9,551,900
9,697,600
11,637,100
13,576,600
13,622,200
16,346,600
19,071,100
6,047,100
7,256,500
8,465,900
9,920,000
16,853,900
11,904,000
20,224,700
13,888,000
23,595,500
14,804,300
17,765,200
20,726,000
17,315,800
20,779,000
24,242,100
21,431,200
25,717,400
30,003,700
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,582,100
9,098,600
10,615,000
467 M-1-04-II
9,740,800
11,689,000
13,637,200
468 M-1-04-III
11,655,100
13,986,200
16,317,200
469 M-1-05-I
470 M-1-05-II

4,813,800
7,786,500
5,776,600
9,343,900
6,739,400
10,901,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
9,946,300
11,935,600
13,924,900
5,388,500
6,466,200
7,543,900
7,218,800
8,662,500
10,106,300
14,705,300
17,646,400
20,587,400
8,870,400
10,644,500
12,418,600
19,465,000
23,358,100
27,251,100
41,984,300
50,381,200
58,778,000
8,102,000
9,722,500
11,342,900
10,351,200
12,421,400
14,491,700
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
25,771,300
30,925,600
36,079,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,558,200
9,006,600
12,878,600
6,669,900
10,807,900
15,454,300
7,781,500
12,609,200
18,030,000
2,829,300
3,395,200
3,961,100
5,017,700
6,021,300
7,024,800
7,164,300
8,597,200
10,030,100
3,390,500
5,626,600
9,241,300
4,068,600
6,751,900
11,089,500
4,746,700
7,877,200
12,937,800
5,236,400
6,283,700
7,331,000
6,583,400
7,900,000
9,216,700
9,945,000
11,934,000
13,923,000
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 545 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,942,700
2,331,200
2,719,700
500 M-4-10-II
501 M-4-10-III
2,897,200
5,481,500
3,476,600
6,577,800
4,056,000
7,674,000
2,420,700
2,904,900
3,389,000
5,307,400
6,368,900
7,430,300
7,673,600
9,208,300
10,743,000
1,932,300
2,318,800
2,705,200
3,213,900
3,856,700
4,499,500
4,299,000
5,158,800
6,018,600
3,217,500
3,861,000
4,504,500
4,834,100
5,800,900
6,767,800
9,431,300
11,317,500
13,203,800
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,669,400
4,403,300
5,137,200
512 M-4-14-II
4,525,700
5,430,800
6,336,000
513 M-4-14-III
514 M-4-15-I
6,800,800
2,175,900
8,160,900
2,611,000
9,521,100
3,046,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,900,300
6,581,600
1,862,900
2,983,200
5,011,500
3,480,300
7,897,900
2,235,400
3,579,800
6,013,800
4,060,400
9,214,200
2,608,000
4,176,400
7,016,100
2,417,800
2,901,300
3,384,900
3,381,500
4,057,800
4,734,100
4,722,000
5,666,500
6,610,900
1,827,400
2,754,000
3,316,000
2,192,900
3,304,800
3,979,200
2,558,400
3,855,700
4,642,400
1,905,700
2,286,900
2,668,000
3,210,000
3,852,000
4,494,000
6,269,300
7,523,200
8,777,000
1,922,400
2,306,800
2,691,300
2,815,000
3,378,000
3,941,000
3,146,100
3,775,300
4,404,500
1,935,700
2,322,800
2,709,900
2,421,000
2,905,200
3,389,300
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,701,400
11,641,700
13,581,900
10,671,500
12,805,800
14,940,100
12,217,500
14,661,000
17,104,500
5,514,800
6,617,800
7,720,800
6,549,400
14,741,200
7,859,200
17,689,500
9,169,100
20,637,700
- 546 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,427,800
6,513,300
7,598,900
535 N-1-01-I

61,976,100
74,371,300
86,766,500
536 N-1-01-II
61,976,100
74,371,300
86,766,500
537 N-1-01-III
538 N-1-11-I

61,976,100
5,583,400
74,371,300
6,700,100
86,766,500
7,816,800
539 N-1-11-II
540 N-1-11-III

8,828,700
13,764,000
10,594,400
16,516,700
12,360,200
19,269,500
2,845,700
3,414,800
3,983,900
5,665,400
6,798,500
7,931,600
12,294,200
14,753,000
17,211,900
6,221,700
7,466,100
8,710,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,707,000
12,184,300
10,448,300
14,621,200
12,189,700
17,058,100
5,694,000
6,832,800
7,971,600
8,613,900
10,336,600
12,059,400
9,913,700
11,896,500
13,879,200
5,113,600
6,136,300
7,159,000
6,944,100
8,333,000
9,721,800
8,082,100
9,698,500
11,314,900
2,172,600
2,607,100
3,041,600
2,627,800
3,153,300
3,678,900
3,865,000
4,638,000
5,411,100
1,667,800
2,913,800
3,625,400
1,963,100
3,844,900
4,628,000
3,124,200
3,768,200
5,774,500
2,001,400
3,496,600
4,350,500
2,355,700
4,613,900
5,553,600
3,749,100
4,521,800
6,929,300
2,334,900
4,079,400
5,075,600
2,748,400
5,382,900
6,479,200
4,373,900
5,275,400
8,084,200
1,675,000
2,010,000
2,345,000
2,376,800
2,852,100
3,327,500
3,809,900
4,571,900
5,333,900
1,978,800
2,374,600
2,770,300
2,455,400
2,946,400
3,437,500
2,802,000
3,362,400
3,922,800
2,423,000
2,907,700
3,392,300
3,458,500
4,150,200
4,841,800
4,603,500
5,524,200
6,444,800
4,345,100
4,596,700
5,214,100
5,516,100
6,083,100
6,435,400
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 547 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,394,000
6,472,800
7,551,600
2,252,300
2,702,800
3,153,300
2,503,200
3,003,900
3,504,500
3,114,000
3,736,800
4,359,600
1,595,700
1,914,900
2,234,000
1,916,500
2,299,800
2,683,100
2,408,100
2,889,800
3,371,400
1,485,200
1,782,300
2,079,300

MAYOR (RINGAN)
MAYOR (SEDANG)
1,757,900
2,109,500
2,109,500
2,531,400
2,461,000
2,953,200
35,633,300
42,760,000
49,886,600
44,090,900
52,909,100
61,727,200
51,750,300
62,100,400
72,450,400
48,637,800
58,365,300
68,092,900
55,792,400
66,950,900
78,109,400
63,746,800
76,496,200
89,245,500
5,927,700
7,113,200
8,298,800
8,417,300
10,100,800
11,784,300
9,511,600
11,413,900
13,316,200
19,235,800
23,083,000
26,930,100
24,963,900
29,956,700
34,949,500
35,792,000
42,950,400
50,108,800
10,459,800
12,551,800
14,643,700
19,721,900
23,666,300
27,610,600
24,067,400
28,880,900
33,694,300
3,451,300
4,141,600
4,831,900
9,676,700
11,612,100
13,547,400
12,819,300
15,383,200
17,947,000
3,343,000
4,011,600
4,680,200
9,372,900
11,247,500
13,122,100
12,416,800
14,900,200
17,383,500
3,534,200
4,241,000
4,947,900
5,015,000
6,018,000
7,021,000
8,120,200
9,744,300
11,368,300
5,600,100
6,720,100
7,840,100
7,952,100
9,542,600
11,133,000
- 548 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,985,900
10,783,100
12,580,300
5,290,600
6,348,700
7,406,800
7,522,500
9,027,000
10,531,500
8,513,900
10,216,700
11,919,500
4,590,400
5,508,500
6,426,600
6,059,400
7,271,200
8,483,100
9,022,600
10,827,200
12,631,700
2,324,200
2,789,000
3,253,800
4,731,100
5,677,300
6,623,500
8,777,900
10,533,500
12,289,100
1,743,200
2,091,800
2,440,400
3,490,700
4,188,900
4,887,000
4,095,800
4,914,900
5,734,100
1,577,600
1,893,100
2,208,600
3,031,600
3,637,900
4,244,200
6,182,200
7,418,600
8,655,100
3,060,300
3,672,300
4,284,400
5,508,500
6,610,200
7,711,900
7,518,900
9,022,600
10,526,400
1,778,700
2,134,400
2,490,200
2,191,600
2,629,900
3,068,300
3,000,100
3,600,100
4,200,200
1,500,800
2,200,800
3,761,500
1,307,700
1,740,500
3,017,200
1,801,000
2,641,000
4,513,800
1,569,200
2,088,600
3,620,600
2,101,200
3,081,100
5,266,100
1,830,800
2,436,700
4,224,100
1,931,100
2,317,400
2,703,600
3,426,000
4,111,200
4,796,400
5,560,800
6,672,900
7,785,100
977,300
1,172,700
1,368,200
2,075,800
2,491,000
2,906,200
3,936,500
4,723,800
5,511,100
653,600
784,300
915,100
1,233,500
1,480,200
1,726,900
1,597,600
1,917,100
2,236,600
3,384,500
4,061,500
4,738,400
- 549 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,304,400
5,165,200
6,026,100
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,163,000
7,395,500
8,628,100
1,631,300
1,957,500
2,283,800
2,421,000
2,905,200
3,389,400
2,911,800
3,494,200
4,076,500
1,091,500
1,309,800
1,528,000
1,466,000
1,759,200
2,052,400
2,666,800
3,200,200
3,733,600
497,800
597,300
696,900
948,700
1,138,400
1,328,200
1,379,100
1,655,000
1,930,800
589,500
707,400
825,300
927,600
1,113,200
1,298,700
1,494,100
1,792,900
2,091,700
1,030,900
1,237,100
1,443,300
1,558,600
1,870,300
2,182,000
2,432,500
2,919,000
3,405,500
3,566,800
4,280,100
4,993,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,537,100
14,624,800
6,644,500
17,549,800
7,751,900
20,474,700
5,518,000
6,621,600
7,725,200
6,994,900
8,393,800
9,792,800
10,064,500
12,077,400
14,090,300
4,311,700
6,611,700
9,711,300
4,087,600
4,762,700
7,895,000
5,174,000
7,934,100
11,653,500
4,905,100
5,715,200
9,474,000
6,036,400
9,256,400
13,595,800
5,722,600
6,667,700
11,053,000
2,592,800
3,111,400
3,629,900
3,182,000
3,818,400
4,454,800
3,770,600
4,524,800
5,278,900
2,873,500
4,085,300
5,265,800
3,448,200
4,902,400
6,318,900
4,022,900
5,719,400
7,372,100
3,936,300
4,723,500
5,510,800
5,858,300
7,029,900
8,201,600
15,039,300
18,047,100
21,055,000
3,375,800
4,577,400
8,951,300
4,050,900
5,492,900
10,741,600
4,726,100
6,408,400
12,531,800
2,429,400
2,915,200
3,401,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 550 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,476,500
1,771,800
2,067,100
697 U-4-12-I
698 U-4-12-II

2,316,900
2,695,000
2,780,200
3,234,000
3,243,600
3,773,000
699 U-4-12-III

3,496,100
4,195,400
4,894,600
1,755,900
2,107,000
2,458,200
2,070,000
2,484,000
2,898,000
2,475,800
2,970,900
3,466,100
2,418,000
2,895,500
2,901,600
3,474,600
3,385,200
4,053,700

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,862,400
5,834,900
6,807,400
1,941,600
2,329,900
2,718,200
2,419,000
2,902,800
3,386,600
3,385,400
4,062,500
4,739,600
3,166,900
3,800,300
4,433,700
6,523,700
7,828,500
9,133,200
8,000,400
9,600,500
11,200,600
6,024,900
6,879,700
10,773,900
7,229,900
8,255,700
12,928,700
8,434,900
9,631,600
15,083,500
5,664,600
6,797,500
7,930,400
7,735,400
9,282,500
10,829,600
9,804,700
11,765,700
13,726,600
2,954,700
3,545,700
4,136,600
5,645,500
6,774,600
7,903,700
8,857,100
10,628,500
12,399,900
5,794,200
6,953,000
8,111,900
8,418,800
10,102,500
11,786,300
10,512,400
12,614,800
14,717,300
933,200
1,029,700
1,139,100
1,119,800
1,235,700
1,366,900
1,306,400
1,441,600
1,594,700
2,802,000
3,362,400
3,922,800
4,654,200
5,585,100
6,515,900
7,673,200
9,207,800
10,742,400
2,421,100
2,905,300
3,389,500
3,248,400
3,898,100
4,547,800
4,351,300
5,221,600
6,091,900
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,561,500
6,673,800
7,786,100
8,538,700
10,246,400
11,954,100
1,158,100
1,403,500
1,389,700
1,684,200
1,621,300
1,964,900
- 551 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,599,000
7,918,800
9,238,600
7,909,300
9,491,200
11,073,000
11,286,400
13,543,700
15,800,900
1,399,700
1,679,700
1,959,600
1,544,600
1,708,600
1,853,500
2,050,400
2,162,400
2,392,100
1,463,000
1,755,600
2,048,200
1,614,500
1,937,300
2,260,200
1,785,900
2,143,100
2,500,300
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,573,900
1,888,700
2,203,500
743 W-1-12-II
744 W-1-12-III

1,964,500
3,478,700
2,357,400
4,174,500
2,750,300
4,870,200
745 W-1-13-I
1,617,900
1,941,400
2,265,000
746 W-1-13-II
747 W-1-13-III

1,756,500
2,359,400
2,107,700
2,831,200
2,459,000
3,303,100
748 W-1-20-I
749 W-1-20-II

5,418,100
6,769,900
6,501,700
8,123,900
7,585,300
9,477,900
750 W-1-20-III
7,848,100
9,417,700
10,987,300
751 W-1-30-I
3,058,600
3,670,300
4,282,000
752 W-1-30-II
4,878,400
5,854,100
6,829,800
753 W-1-30-III
11,969,500
14,363,400
16,757,300
754 W-4-10-I
2,279,000
2,734,700
3,190,500
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,378,500
6,676,500
2,072,500
3,146,400
3,829,800
4,054,100
8,011,800
2,487,100
3,775,700
4,595,800
4,729,800
9,347,100
2,901,600
4,405,000
5,361,700
2,568,200
3,081,800
3,595,500
3,525,900
4,231,100
4,936,300
3,843,500
4,612,200
5,380,800
815,400
1,113,900
1,385,200
1,089,700
1,297,100
1,659,400
1,445,000
1,604,800
2,222,000
1,922,600
2,571,100
3,484,700
1,418,700
2,561,500
3,787,200
1,914,500
2,541,300
3,610,100
1,640,400
1,970,200
2,708,200
978,500
1,336,700
1,662,200
1,307,700
1,556,500
1,991,300
1,734,100
1,925,800
2,666,400
2,307,200
3,085,300
4,181,600
1,702,500
3,073,800
4,544,600
2,297,500
3,049,500
4,332,100
1,968,500
2,364,300
3,249,800
1,141,600
1,559,500
1,939,300
1,525,600
1,815,900
2,323,200
2,023,100
2,246,800
3,110,800
2,691,700
3,599,500
4,878,500
1,986,200
3,586,100
5,302,100
2,680,400
3,557,800
5,054,100
2,296,600
2,758,300
3,791,400
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 552 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
762,800
915,400
1,068,000
1,858,700
2,230,500
2,602,200
2,357,300
2,828,700
3,300,200
- 553 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
870,400
1,129,000
2,099,500
1,735,000
2,254,700
414,700
737,200
324,300
593,000
614,500
697,600
1,048,800
1,430,500
1,311,100
424,700
980,300
355,600
610,500
1,859,600
666,000
1,572,800
383,700
895,200
1,401,100
1,175,200
288,200
873,500
485,600
249,700
270,000
238,300
285,000
396,800
341,000
321,000
288,500
428,000
186,900
220,300
252,600
5,124,400
2,048,000
2,054,900
528,600
865,600
541,900
1,101,500
705,800
404,200
305,200
492,300
271,700
232,600
1,815,200
847,100
484,100
1,889,600
1,259,700
245,300
2,047,100
1,417,200
3,187,800
736,200
452,900
243,600
203,000
228,800
3,488,000
1,697,900
- 554 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,157,900
3,819,000
3,166,400
2,412,100
795,200
2,684,700
1,753,000
430,900
4,030,700
3,649,000
2,446,700
2,317,900
286,500
275,300
1,107,600
302,700
269,700
298,100
1,023,100
1,397,500
1,220,700
1,078,000
652,900
271,300
478,200
328,300
296,400
288,800
366,600
418,100
245,100
703,500
1,282,000
984,100
2,313,600
301,300
301,300
2,137,900
1,243,100
238,500
1,103,200
2,865,900
658,000
518,300
253,900
219,100
275,000
383,500
918,300
809,400
566,600
422,700
232,600
983,800
788,300
336,800
384,300
1,259,500
278,500
1,286,800
984,400
300,200
332,800
325,100
196,700
1,072,600
1,473,800
292,100
- 555 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
895,100
334,100
361,300
334,500
530,700
408,200
1,022,400
301,600
839,300
1,121,500
245,600
1,494,900
810,100
1,750,600
883,700
390,300
300,200
63,300
389,100
879,200
342,600
462,800
264,700
103,000
267,300
3,980,300
2,262,500
3,776,100
927,600
518,300
353,100
798,700
422,400
850,200
492,300
293,100
490,500
220,800
337,100
323,000
711,000
1,540,900
1,239,700
1,093,100
771,400
283,800
283,800
283,800
231,800
147,000
231,200
282,600
305,700
225,100
198,600
88,700
97,500
72,100
84,600
80,700
123,200
110,400
157,800
173,300
98,100
119,000
81,400
127,000
180,200
- 556 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
128,300
177,100
500,700
580,500
121,300
240,900
147,600
210,700
405,300
347,000
249,400
236,200
120,600
118,500
278,100
175,500
251,800
178,300
136,400
1,749,300
1,799,400
285,900
296,100
566,300
711,300
724,900
374,400
1,166,900
252,200
304,300
305,300
244,500
308,800
292,200
136,900
300,800
266,600
241,100
272,700
2,257,700
293,100
812,500
291,400
414,600
435,300
347,300
705,600
722,600
770,400
673,900
1,170,600
200,800
1,394,000
264,700
706,600
1,605,900
1,856,900
811,200
294,000
573,400
571,100
264,700
2,074,600
1,631,800
131,800
144,300
187,400
252,400
- 557 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
881,200
417,200
859,800
1,037,300
497,100
691,500
478,000
514,300
556,500
284,800
673,400
172,200
637,900
948,700
69,900
- 558 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,711,600
2,053,900
2,396,300
A-4-10-II
SEPTIKEMIA (SEDANG)
2,924,100
3,509,000
4,093,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,942,700
2,222,200
4,731,200
2,666,600
5,519,700
3,111,000
5
6
A-4-11-II
A-4-11-III

3,162,800
4,377,600
3,795,300
5,253,100
4,427,900
6,128,600
A-4-12-I
2,485,100
2,982,100
3,479,100
8
9
A-4-12-II
A-4-12-III

3,094,800
3,303,000
3,713,700
3,963,600
4,332,700
4,624,200
10 A-4-13-I
11 A-4-13-II

1,091,500
1,468,000
1,309,800
1,761,600
1,528,000
2,055,200
12 A-4-13-III
1,761,600
2,113,900
2,466,200
2,181,200
2,617,400
3,053,600
2,647,600
3,177,100
3,706,600
3,177,100
3,812,500
4,447,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,987,500
4,471,900
3,585,000
5,366,300
4,182,500
6,260,700
18 A-4-15-III
INFEKSI HIV (BERAT)
5,611,900
6,734,300
7,856,600
19 B-1-01-I
20 B-1-01-II

19,561,500
21,581,600
23,473,900
25,897,900
27,386,200
30,214,200
21 B-1-01-III
22 B-1-10-I

37,858,600
3,534,000
45,430,300
4,240,800
53,002,000
4,947,600
23 B-1-10-II
7,843,900
9,412,700
10,981,500
24 B-1-10-III
25 B-1-11-I

15,485,000
4,722,100
18,582,000
5,666,500
21,679,000
6,610,900
26 B-1-11-II
27 B-1-11-III

6,119,500
7,906,300
7,343,400
9,487,500
8,567,300
11,068,800
28 B-1-12-I
4,610,900
5,533,000
6,455,200
29 B-1-12-II
5,128,100
6,153,700
7,179,300
30 B-1-12-III
8,022,300
9,626,800
11,231,300
3,672,600
4,407,100
5,141,600
6,042,800
7,251,400
8,459,900
7,818,900
9,382,600
10,946,400
5,046,300
6,055,600
7,064,800
5,612,400
6,734,900
7,857,300
8,779,900
1,561,300
2,492,300
3,438,200
10,535,900
1,873,600
2,990,800
4,125,900
12,291,900
2,185,900
3,489,300
4,813,500
3,291,900
3,950,200
4,608,600
4,608,700
5,530,400
6,452,100
5,583,300
6,700,000
7,816,600
2,976,200
4,238,000
6,305,200
2,839,100
3,571,500
5,085,600
7,566,300
3,406,900
4,166,700
5,933,200
8,827,300
3,974,700
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 559 -

REGIONAL 3
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,307,400
3,968,900
4,630,300
48 B-4-13-III
49 B-4-14-I

4,556,200
2,836,000
5,467,500
3,403,200
6,378,700
3,970,400
50 B-4-14-II
3,308,600
3,970,300
4,632,000
51 B-4-14-III
52 C-4-10-I

4,431,900
2,623,800
5,318,300
3,148,600
6,204,700
3,673,400
53 C-4-10-II
54 C-4-10-III

5,034,500
8,886,300
6,041,400
10,663,600
7,048,300
12,440,800
55 C-4-11-I
2,990,000
3,588,000
4,186,000
56 C-4-11-II
57 C-4-11-III

4,001,000
6,151,600
4,801,200
7,382,000
5,601,400
8,612,300
58 C-4-12-I
59 C-4-12-II
1,990,800
3,921,100
2,389,000
4,705,400
2,787,100
5,489,600
60 C-4-12-III
RADIOTERAPI (BERAT)
10,070,600
12,084,700
14,098,800
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,496,700
2,816,800
1,796,000
3,380,100
2,095,400
3,943,500
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,813,000
2,486,800
4,575,600
2,984,200
5,338,200
3,481,500
65 C-4-14-II
3,488,500
4,186,200
4,883,900
66 C-4-14-III
67 D-1-10-I

5,197,800
12,170,000
6,237,400
14,604,000
7,276,900
17,038,000
68 D-1-10-II
69 D-1-10-III

18,535,700
29,515,200
22,242,900
35,418,300
25,950,000
41,321,300
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,022,700
4,827,300
5,631,800
10,271,900
13,348,700
12,326,200
16,018,400
14,380,600
18,688,200
3,487,200
4,184,700
4,882,100
9,610,300
11,532,300
13,454,400
15,244,700
18,293,600
21,342,600
2,151,400
3,134,700
4,931,600
2,730,000
4,905,700
6,739,300
2,353,700
3,264,600
5,012,900
2,581,700
3,761,600
5,918,000
3,276,000
5,886,900
8,087,100
2,824,400
3,917,500
6,015,500
3,011,900
4,388,600
6,904,300
3,822,000
6,868,000
9,435,000
3,295,100
4,570,400
7,018,000
2,017,000
2,420,400
2,823,800
2,854,800
3,425,700
3,996,700
3,651,300
4,381,600
5,111,900
2,163,300
2,596,000
3,028,700
3,541,900
4,250,300
4,958,700
4,332,200
5,198,600
6,065,000
3,373,800
4,048,500
4,723,300
4,419,300
5,303,100
6,187,000
93 E-1-01-III
8,759,700
10,511,700
12,263,600
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,873,100
3,487,300
7,350,100
3,447,700
4,184,800
8,820,200
4,022,300
4,882,200
10,290,200
5,075,600
6,090,800
7,105,900
97 E-1-20-I
- 560 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,995,300
2,394,400
2,793,500
104 E-4-11-II
105 E-4-11-III

3,042,100
4,122,200
3,650,500
4,946,600
4,258,900
5,771,100
106 E-4-12-I
107 E-4-12-II

2,292,600
3,970,200
2,751,100
4,764,300
3,209,600
5,558,300
108 E-4-12-III

(RINGAN)
(SEDANG)
4,706,200
5,647,400
6,588,700
2,496,600
2,995,900
3,495,200
3,657,000
4,388,400
5,119,800
111 E-4-13-III
4,780,500
5,736,600
6,692,600
112 F-4-10-I
113 F-4-10-II
2,657,900
3,054,700
3,189,500
3,665,700
3,721,000
4,276,600
114 F-4-10-III
115 F-4-11-I
3,665,700
2,570,600
4,398,800
3,084,800
5,131,900
3,598,900
116 F-4-11-II
2,995,100
3,594,100
4,193,100
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,840,800
4,608,900
5,377,100
1,409,100
1,690,900
1,972,800
2,003,300
2,404,000
2,804,700
4,352,100
5,222,500
6,093,000
2,070,700
2,732,300
3,537,400
1,181,400
1,515,400
2,039,000
2,484,800
3,278,800
4,244,800
1,417,700
1,818,400
2,446,800
2,899,000
3,825,300
4,952,300
1,654,000
2,121,500
2,854,600
127 F-4-15-I
1,881,500
2,257,800
2,634,100
128 F-4-15-II
2,803,700
3,364,400
3,925,200
129 F-4-15-III
3,701,800
4,442,100
5,182,500
3,702,000
4,442,400
5,182,800
4,304,100
5,165,000
6,025,800
5,745,300
6,894,400
8,043,400
133 F-4-17-I

874,300
1,049,100
1,224,000
134 F-4-17-II
2,562,300
3,074,800
3,587,300
135
136
137
138
139
140
141

(RINGAN)
2,733,800
3,216,700
3,539,300
5,456,100
2,458,300
3,148,000
3,919,300
3,280,500
3,860,100
4,247,200
6,547,400
2,950,000
3,777,600
4,703,100
3,827,300
4,503,400
4,955,100
7,638,600
3,441,700
4,407,200
5,487,000
5,455,400
6,546,400
7,637,500
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,831,700
8,198,000
9,564,400
9,415,500
11,298,600
13,181,600
3,298,100
3,957,700
4,617,300
4,608,500
5,530,200
6,451,900
5,720,100
6,864,100
8,008,100
- 561 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,463,200
6,555,800
7,648,400
148 G-1-11-I
149 G-1-11-II

7,981,000
14,591,100
9,577,100
17,509,300
11,173,300
20,427,500
150 G-1-11-III
23,447,200
28,136,600
32,826,100
3,332,300
3,998,800
4,665,300
6,246,600
7,495,900
8,745,300
8,512,900
10,215,500
11,918,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,005,300
2,699,600
1,206,300
3,239,600
1,407,400
3,779,500
156 G-1-13-III
157 G-1-20-I

6,091,600
3,008,800
7,309,900
3,610,600
8,528,200
4,212,400
158 G-1-20-II
4,969,600
5,963,600
6,957,500
159 G-1-20-III
9,964,200
11,957,100
13,949,900
160 G-1-30-I
4,702,900
5,643,400
6,584,000
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,280,500
15,775,700
14,736,600
18,930,900
17,192,700
22,086,000
2,860,400
3,432,500
4,004,600
3,496,400
4,195,700
4,895,000
4,797,700
5,757,200
6,716,800
2,994,400
3,593,300
4,192,200
3,977,700
4,773,300
5,568,800
5,844,600
7,013,600
8,182,500
3,322,000
3,986,400
4,650,800
4,195,900
5,035,100
5,874,300
6,094,000
7,312,800
8,531,600
1,995,600
2,394,700
2,793,800
3,479,900
4,175,800
4,871,800
4,127,200
4,952,600
5,778,100
3,385,200
4,062,300
4,739,300
4,525,800
5,431,000
6,336,100
5,680,400
6,816,500
7,952,600
2,766,000
3,319,200
3,872,400
3,301,100
3,961,300
4,621,600
4,659,300
5,591,100
6,523,000
2,280,200
2,736,300
3,192,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,517,100
9,020,500
10,523,900
14,613,200
17,535,900
20,458,500
3,262,900
4,606,800
3,915,400
5,528,200
4,568,000
6,449,500
- 562 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,027,300
3,632,800
4,238,200
183 G-4-16-III
4,311,100
5,173,300
6,035,600
3,037,100
3,644,500
4,251,900
3,982,300
4,778,800
5,575,200
5,003,900
6,004,700
7,005,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,991,100
3,589,300
4,187,500
188 G-4-18-II
3,998,200
4,797,800
5,597,400
189 G-4-18-III
4,473,600
5,368,300
6,263,100
2,495,500
2,994,600
3,493,700
4,218,000
5,061,600
5,905,200
5,538,100
6,645,700
7,753,300
193 G-4-20-I

1,745,700
2,094,900
2,444,000
194 G-4-20-II
2,467,900
2,961,500
3,455,100
195 G-4-20-III
196 G-4-21-I

4,076,400
1,817,900
4,891,700
2,181,500
5,707,000
2,545,100
197 G-4-21-II
198 G-4-21-III

3,076,800
3,616,000
3,692,200
4,339,200
4,307,600
5,062,400
199 G-4-22-I
2,500,700
3,000,800
3,501,000
200 G-4-22-II
201 G-4-22-III

3,195,100
3,733,400
3,834,200
4,480,000
4,473,200
5,226,700
202 G-4-23-I
203 G-4-23-II

1,789,600
2,245,300
2,147,500
2,694,300
2,505,400
3,143,400
204 G-4-23-III
3,196,700
3,836,100
4,475,400
205 G-4-24-I
206 G-4-24-II

1,993,300
2,490,300
2,392,000
2,988,400
2,790,600
3,486,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,148,800
1,703,200
2,153,900
2,854,400
4,978,600
2,043,900
2,584,700
3,425,300
5,808,400
2,384,500
3,015,500
3,996,100
2,691,600
3,229,900
3,768,200
3,131,100
3,757,400
4,383,600
4,682,000
5,618,400
6,554,800
1,922,100
4,318,400
5,872,800
5,867,400
7,289,700
10,210,200
2,305,900
3,128,600
6,149,400
1,990,000
2,270,000
3,250,500
2,346,200
2,803,300
4,697,800
2,306,500
5,182,100
7,047,400
7,040,900
8,747,600
12,252,200
2,767,000
3,754,300
7,379,300
2,388,000
2,724,000
3,900,600
2,815,500
3,364,000
5,637,400
2,690,900
6,045,800
8,222,000
8,214,400
10,205,500
14,294,300
3,228,200
4,380,000
8,609,200
2,786,000
3,178,000
4,550,700
3,284,700
3,924,600
6,577,000
229 I-1-01-I
31,513,900
37,816,700
44,119,500
230 I-1-01-II
32,207,200
38,648,600
45,090,100
231 I-1-01-III

(RINGAN)
50,838,600
61,006,400
71,174,100
17,483,800
20,980,500
24,477,300
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 563 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,395,900
17,275,100
20,154,200
245 I-1-06-II
20,853,600
25,024,300
29,195,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,882,200
29,858,600
34,835,100
17,136,500
20,563,800
23,991,100
21,141,400
25,369,700
29,598,000
23,065,200
27,678,200
32,291,300
2,739,800
3,287,700
3,835,700
3,046,300
3,655,600
4,264,900
4,053,800
4,864,500
5,675,300
7,886,400
9,463,600
11,040,900
12,880,000
15,456,000
18,032,000
16,945,600
20,334,700
23,723,800
7,649,700
9,179,600
10,709,500
10,187,100
12,224,500
14,261,900
12,563,500
15,076,200
17,588,900
15,657,000
18,788,400
21,919,800
19,459,300
23,351,200
27,243,000
25,498,400
30,598,100
35,697,800
2,974,400
4,153,600
7,998,300
3,569,200
4,984,400
9,597,900
4,164,100
5,815,100
11,197,600
7,710,700
9,252,800
10,794,900
17,446,100
20,935,300
24,424,500
20,123,800
24,148,600
28,173,300
8,928,200
10,713,800
12,499,500
11,179,000
13,414,700
15,650,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,553,900
27,064,600
31,575,400
27,799,000
33,358,900
38,918,700
10,098,700
12,118,400
14,138,200
13,998,900
16,798,600
19,598,400
17,765,600
21,318,800
24,871,900
15,218,200
18,261,800
21,305,400
24,018,400
28,822,000
33,625,700
38,369,200
46,043,000
53,716,900
19,526,300
23,431,600
27,336,800
23,431,700
28,118,000
32,804,300
32,241,800
38,690,100
45,138,500
- 564 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,368,400
20,842,100
24,315,800
279 I-1-40-III
23,198,300
27,838,000
32,477,700
280 I-4-10-I
281 I-4-10-II

2,648,200
4,728,700
3,177,900
5,674,500
3,707,500
6,620,200
282 I-4-10-III
6,813,400
8,176,100
9,538,800
283 I-4-11-I
284 I-4-11-II

4,074,300
5,042,000
4,889,100
6,050,300
5,704,000
7,058,700
285 I-4-11-III
286 I-4-12-I

9,327,100
2,342,200
11,192,500
2,810,600
13,057,900
3,279,000
287 I-4-12-II
2,714,800
3,257,800
3,800,800
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,257,800
3,909,400
4,560,900
2,383,400
2,860,100
3,336,800
4,255,900
5,107,000
5,958,200
6,132,100
7,358,500
8,584,900
2,250,700
2,328,200
4,081,300
2,700,900
2,793,800
4,897,500
3,151,000
3,259,400
5,713,800
4,220,500
5,064,600
5,908,600
5,741,700
6,890,000
8,038,300
297 I-4-15-III
6,890,000
8,268,000
9,646,000
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,420,500
2,281,000
2,737,200
1,741,400
2,027,400
2,432,800
1,704,600
2,737,200
3,284,700
2,089,700
2,432,800
2,919,400
1,988,700
3,193,400
3,832,100
2,438,000
2,838,300
3,406,000
2,740,000
3,288,100
3,836,100
4,171,800
5,006,200
5,840,600
5,664,000
6,796,800
7,929,600
307 I-4-19-I
2,643,600
3,172,300
3,701,000
308 I-4-19-II

(SEDANG)
4,126,800
4,952,200
5,777,500
309 I-4-19-III
4,926,600
5,912,000
6,897,300
310
311
312
313
314

2,752,800
3,179,500
4,753,900
2,059,900
2,609,900
3,303,300
3,815,300
5,704,700
2,471,900
3,131,900
3,853,900
4,451,200
6,655,500
2,883,800
3,653,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,828,200
16,593,800
19,359,500
10,063,600
12,076,300
14,089,100
12,572,200
15,086,700
17,601,100
13,216,000
15,859,200
18,502,400
7,612,600
9,135,100
10,657,600
15,835,800
19,003,000
22,170,200
24,539,800
29,447,800
34,355,700
7,025,600
8,430,700
9,835,800
- 565 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,767,100
4,520,500
5,273,900
316 I-4-22-I
317 I-4-22-II
2,308,800
2,874,100
2,770,500
3,448,900
3,232,300
4,023,700
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,201,000
5,041,200
5,881,400
2,259,600
2,711,600
3,163,500
2,774,200
3,329,000
3,883,900
5,420,600
6,504,700
7,588,800
2,034,800
2,441,800
2,848,700
4,685,600
5,622,700
6,559,900
5,924,100
7,109,000
8,293,800
36,709,700
44,051,600
51,393,600
41,543,800
49,852,600
58,161,400
46,999,200
56,399,000
65,798,800
19,480,500
23,376,600
27,272,700
27,124,600
32,549,500
37,974,400
44,792,000
53,750,400
62,708,800
5,915,700
7,098,900
8,282,000
11,970,500
14,364,600
16,758,700
12,440,300
14,928,300
17,416,400
6,951,600
8,341,900
9,732,200
8,229,900
9,875,800
11,521,800
12,708,300
15,249,900
17,791,600
4,936,800
5,924,200
6,911,500
8,943,000
10,731,600
12,520,200
25,813,600
30,976,300
36,139,000
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,017,100
4,165,900
6,302,400
1,800,500
2,507,700
3,361,300
3,058,100
3,481,200
4,860,700
2,703,900
3,763,700
7,021,800
2,981,100
4,851,000
5,739,300
3,960,700
4,731,900
6,366,300
2,420,500
4,999,100
7,562,900
2,160,600
3,009,200
4,033,600
3,669,700
4,177,400
5,832,800
3,244,600
4,516,400
8,426,200
3,577,300
5,821,300
6,887,100
4,752,800
5,678,300
7,639,500
2,824,000
5,832,300
8,823,300
2,520,600
3,510,800
4,705,800
4,281,300
4,873,600
6,804,900
3,785,400
5,269,200
9,830,500
4,173,500
6,791,500
8,035,000
5,544,900
6,624,600
8,912,800
3,300,100
3,960,100
4,620,100
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 566 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,637,400
5,564,900
6,492,400
360 J-4-16-III
5,863,300
7,036,000
8,208,700
361 J-4-17-I
362 J-4-17-II

2,490,900
2,983,000
2,989,100
3,579,600
3,487,300
4,176,200
363 J-4-17-III
364 J-4-18-I

3,914,600
2,033,000
4,697,500
2,439,600
5,480,400
2,846,200
365 J-4-18-II
2,796,200
3,355,400
3,914,600
366 J-4-18-III
367 J-4-19-I

2,943,300
3,508,600
3,532,000
4,210,300
4,120,700
4,912,000
368 J-4-19-II
369 J-4-19-III

3,978,900
4,394,300
4,774,700
5,273,100
5,570,500
6,152,000
370 J-4-20-I
3,481,800
4,178,100
4,874,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,824,400
5,655,700
5,789,300
6,786,800
6,754,100
7,917,900
2,635,000
3,162,000
3,689,000
4,245,000
5,093,900
5,942,900
5,923,500
7,108,200
8,292,900
5,363,000
6,435,500
7,508,100
6,739,700
8,087,600
9,435,600
7,899,200
9,479,000
11,058,800
5,522,300
6,626,800
7,731,200

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,250,100
9,600,300
8,700,200
11,520,400
10,150,200
13,440,500
2,250,200
2,700,300
3,150,300
2,926,700
3,512,000
4,097,300
5,798,200
6,957,800
8,117,400
2,537,800
2,791,600
2,817,000
3,045,400
3,349,900
3,380,300
3,552,900
3,908,200
3,943,700
4,118,400
4,942,100
5,765,700
4,826,700
5,792,000
6,757,300
390 K-1-14-III
7,583,300
9,100,000
10,616,700
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,974,500
11,138,600
16,263,600
9,569,400
13,366,300
19,516,300
11,164,300
15,594,100
22,769,000
4,716,100
5,659,300
6,602,500
8,375,600
10,050,800
11,725,900
11,525,000
13,830,000
16,135,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,262,000
6,314,500
7,366,900
398 K-1-40-II

(SEDANG)
5,801,600
6,961,900
8,122,200
399 K-1-40-III
9,831,600
11,797,900
13,764,200
400
401
402
403
404

4,020,700
5,221,400
7,378,800
3,319,300
4,769,400
4,824,900
6,265,700
8,854,600
3,983,200
5,723,200
5,629,000
7,310,000
10,330,300
4,647,000
6,677,100
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 567 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,270,700
8,724,800
10,178,900
406 K-4-11-I
407 K-4-11-II

2,118,700
3,010,700
2,542,400
3,612,900
2,966,100
4,215,000
408 K-4-11-III
409 K-4-12-I

3,612,900
1,995,300
4,335,400
2,394,400
5,058,000
2,793,500
410 K-4-12-II
2,685,100
3,222,100
3,759,200
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,442,000
5,330,500
6,218,900
2,689,800
3,227,800
3,765,800
3,479,500
4,175,400
4,871,300
5,359,500
6,431,400
7,503,300
1,705,400
2,046,400
2,387,500
2,289,200
2,747,000
3,204,800
3,673,200
4,407,900
5,142,500
418 K-4-15-I
1,693,100
2,031,700
2,370,300
419 K-4-15-II
2,524,200
3,029,000
3,533,900
420 K-4-15-III
3,542,600
4,251,100
4,959,600
421 K-4-16-I
2,489,800
2,987,800
3,485,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,986,000
3,484,200
3,583,100
4,181,000
4,180,300
4,877,800
1,125,300
1,350,400
1,575,500
1,687,400
2,024,900
2,362,400
2,024,900
2,429,900
2,834,800
1,130,000
1,356,000
1,582,000
1,605,800
1,926,900
2,248,100
429 K-4-18-III
1,926,900
2,312,300
2,697,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,714,400
19,192,000
25,643,700
5,998,800
10,293,500
12,779,500
15,257,300
23,030,400
30,772,400
7,198,500
12,352,200
15,335,400
17,800,100
26,868,800
35,901,100
8,398,300
14,410,900
17,891,400
3,361,800
4,034,200
4,706,600
6,743,100
8,091,700
9,440,300
11,350,100
13,620,200
15,890,200
4,413,400
7,102,900
10,160,100
1,154,400
1,339,900
1,555,300
2,417,400
3,322,500
7,549,700
1,148,000
1,518,400
4,016,700
5,296,100
8,523,500
12,192,100
1,385,200
1,607,900
1,866,300
2,900,900
3,987,000
9,059,700
1,377,700
1,822,100
4,820,000
6,178,800
9,944,100
14,224,100
1,616,100
1,875,800
2,177,400
3,384,300
4,651,500
10,569,600
1,607,300
2,125,800
5,623,400
2,244,500
2,693,400
3,142,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 568 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,637,900
3,165,500
3,693,100
3,881,800
4,658,100
5,434,500
1,988,000
2,385,600
2,783,200
2,986,100
3,583,300
4,180,500
4,209,200
5,051,100
5,892,900
7,027,400
8,432,900
9,838,400
9,988,500
11,986,200
13,983,900
14,030,900
16,837,000
19,643,200
6,228,500
7,474,200
8,719,900
10,217,600
17,359,500
12,261,200
20,831,400
14,304,700
24,303,300
15,248,400
18,298,100
21,347,800
17,835,300
21,402,300
24,969,400
22,074,100
26,489,000
30,903,800
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,809,600
9,371,500
10,933,400
467 M-1-04-II
10,033,100
12,039,700
14,046,300
468 M-1-04-III
12,004,800
14,405,800
16,806,700
469 M-1-05-I
470 M-1-05-II

4,958,200
8,020,100
5,949,900
9,624,200
6,941,500
11,228,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,244,700
12,293,700
14,342,600
5,550,200
6,660,200
7,770,300
7,435,300
8,922,400
10,409,500
15,146,500
18,175,700
21,205,000
9,136,500
10,963,800
12,791,100
20,049,000
24,058,800
28,068,600
43,243,800
51,892,600
60,541,400
8,345,100
10,014,100
11,683,200
10,661,700
12,794,100
14,926,400
480 M-1-20-III
26,544,500
31,853,400
37,162,300
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,725,000
9,276,800
13,265,000
6,870,000
11,132,100
15,918,000
8,014,900
12,987,500
18,570,900
2,914,200
3,497,100
4,079,900
5,168,300
6,201,900
7,235,600
7,379,300
8,855,100
10,331,000
3,492,200
5,795,400
9,518,500
4,190,700
6,954,400
11,422,200
4,889,100
8,113,500
13,325,900
5,393,500
6,472,200
7,550,900
6,780,900
8,137,000
9,493,200
10,243,300
12,292,000
14,340,600
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 569 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,001,000
2,401,100
2,801,300
500 M-4-10-II
501 M-4-10-III
2,984,100
5,645,900
3,580,900
6,775,100
4,177,700
7,904,300
2,493,400
2,992,000
3,490,700
5,466,600
6,559,900
7,653,300
7,903,800
9,484,500
11,065,300
1,990,300
2,388,300
2,786,400
3,310,400
3,972,400
4,634,500
4,428,000
5,313,600
6,199,100
3,314,000
3,976,800
4,639,600
4,979,100
5,975,000
6,970,800
9,714,200
11,657,000
13,599,900
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,779,500
4,535,400
5,291,300
512 M-4-14-II
4,661,500
5,593,700
6,526,000
513 M-4-14-III
514 M-4-15-I
7,004,800
2,241,100
8,405,800
2,689,400
9,806,700
3,137,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,987,300
6,779,000
1,918,800
3,072,700
5,161,900
3,584,700
8,134,800
2,302,500
3,687,200
6,194,200
4,182,200
9,490,600
2,686,300
4,301,700
7,226,600
2,490,300
2,988,300
3,486,400
3,482,900
4,179,500
4,876,100
4,863,700
5,836,400
6,809,200
1,882,300
2,836,700
3,415,500
2,258,700
3,404,000
4,098,500
2,635,200
3,971,300
4,781,600
1,962,900
2,355,500
2,748,100
3,306,300
3,967,500
4,628,800
6,457,400
7,748,900
9,040,400
1,980,000
2,376,000
2,772,000
2,899,400
3,479,300
4,059,200
3,240,500
3,888,500
4,536,600
1,993,700
2,392,500
2,791,200
2,493,600
2,992,300
3,491,000
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,992,400
11,990,900
13,989,400
10,991,700
13,190,000
15,388,300
12,584,000
15,100,800
17,617,600
5,680,300
6,816,300
7,952,400
6,745,900
15,183,500
8,095,000
18,220,200
9,444,200
21,256,900
- 570 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,590,600
6,708,700
7,826,800
535 N-1-01-I

63,835,300
76,602,400
89,369,500
536 N-1-01-II
63,835,300
76,602,400
89,369,500
537 N-1-01-III
538 N-1-11-I

63,835,300
5,750,900
76,602,400
6,901,100
89,369,500
8,051,300
539 N-1-11-II
540 N-1-11-III

9,093,600
14,176,900
10,912,300
17,012,200
12,731,000
19,847,600
2,931,000
3,517,300
4,103,500
5,835,400
7,002,500
8,169,500
12,663,000
15,195,600
17,728,200
6,408,400
7,690,000
8,971,700

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,968,200
12,549,900
10,761,800
15,059,800
12,555,400
17,569,800
5,864,800
7,037,700
8,210,700
8,872,300
10,646,700
12,421,200
10,211,100
12,253,400
14,295,600
5,267,000
6,320,400
7,373,800
7,152,500
8,582,900
10,013,400
8,324,500
9,989,400
11,654,300
2,237,700
2,685,300
3,132,800
2,706,600
3,247,900
3,789,200
3,981,000
4,777,200
5,573,400
1,717,800
3,001,300
3,734,200
2,022,000
3,960,300
4,766,800
3,217,900
3,881,200
5,947,700
2,061,400
3,601,500
4,481,000
2,426,400
4,752,400
5,720,200
3,861,500
4,657,400
7,137,200
2,405,000
4,201,800
5,227,900
2,830,800
5,544,400
6,673,600
4,505,100
5,433,700
8,326,800
1,725,300
2,070,300
2,415,400
2,448,100
2,937,700
3,427,300
3,924,200
4,709,100
5,493,900
2,038,200
2,445,800
2,853,400
2,529,000
3,034,800
3,540,600
2,886,000
3,463,200
4,040,400
2,495,700
2,994,900
3,494,000
3,562,200
4,274,700
4,987,100
4,741,600
5,689,900
6,638,200
4,475,400
4,734,600
5,370,500
5,681,500
6,265,600
6,628,500
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 571 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,555,800
6,667,000
7,778,200
2,319,900
2,783,900
3,247,900
2,578,300
3,094,000
3,609,600
3,207,500
3,848,900
4,490,400
1,643,600
1,972,300
2,301,100
1,974,000
2,368,800
2,763,600
2,480,400
2,976,500
3,472,500
1,529,800
1,835,700
2,141,700

MAYOR (RINGAN)
MAYOR (SEDANG)
1,810,600
2,172,700
2,172,700
2,607,300
2,534,900
3,041,800
36,702,300
44,042,800
51,383,200
45,413,600
54,496,300
63,579,100
53,302,800
63,963,400
74,623,900
50,096,900
60,116,300
70,135,700
57,466,200
68,959,400
80,452,700
65,659,200
78,791,100
91,922,900
6,105,500
7,326,600
8,547,700
8,669,800
10,403,800
12,137,800
9,796,900
11,756,300
13,715,700
19,812,900
23,775,500
27,738,000
25,712,800
30,855,400
35,998,000
36,865,800
44,238,900
51,612,100
10,773,600
12,928,300
15,083,100
20,313,500
24,376,300
28,439,000
24,789,400
29,747,300
34,705,200
3,554,900
4,265,800
4,976,800
9,967,100
11,960,500
13,953,900
13,203,900
15,844,700
18,485,500
3,443,300
4,131,900
4,820,600
9,654,100
11,584,900
13,515,700
12,789,300
15,347,200
17,905,000
3,640,200
4,368,300
5,096,300
5,165,400
6,198,500
7,231,600
8,363,800
10,036,600
11,709,400
5,768,100
6,921,700
8,075,300
8,190,700
9,828,800
11,467,000
- 572 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,255,500
11,106,600
12,957,700
5,449,300
6,539,200
7,629,000
7,748,100
9,297,800
10,847,400
8,769,400
10,523,200
12,277,100
4,728,100
5,673,800
6,619,400
6,241,200
7,489,400
8,737,600
9,293,300
11,152,000
13,010,600
2,393,900
2,872,700
3,351,500
4,873,000
5,847,600
6,822,200
9,041,300
10,849,500
12,657,800
1,795,400
2,154,500
2,513,600
3,595,500
4,314,600
5,033,700
4,218,600
5,062,400
5,906,100
1,624,900
1,949,900
2,274,900
3,122,500
3,747,000
4,371,500
6,367,700
7,641,200
8,914,700
3,152,100
3,782,500
4,412,900
5,673,800
6,808,500
7,943,300
7,744,400
9,293,300
10,842,200
1,832,100
2,198,500
2,564,900
2,257,400
2,708,800
3,160,300
3,090,100
3,708,100
4,326,200
1,545,900
2,266,800
3,874,300
1,346,900
1,792,700
3,107,700
1,855,000
2,720,200
4,649,200
1,616,300
2,151,300
3,729,200
2,164,200
3,173,600
5,424,000
1,885,700
2,509,800
4,350,800
1,989,100
2,386,900
2,784,700
3,528,700
4,234,500
4,940,200
5,727,600
6,873,100
8,018,600
1,006,600
1,207,900
1,409,200
2,138,100
2,565,700
2,993,300
4,054,600
4,865,500
5,676,400
673,200
807,900
942,500
1,270,500
1,524,600
1,778,700
1,645,500
1,974,600
2,303,700
3,486,100
4,183,300
4,880,500
- 573 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,433,500
5,320,200
6,206,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,347,800
7,617,400
8,887,000
1,680,200
2,016,300
2,352,300
2,493,600
2,992,400
3,491,100
2,999,200
3,599,000
4,198,800
1,124,200
1,349,000
1,573,900
1,510,000
1,811,900
2,113,900
2,746,800
3,296,200
3,845,600
512,700
615,200
717,800
977,100
1,172,600
1,368,000
1,420,500
1,704,600
1,988,700
607,200
728,600
850,000
955,500
1,146,600
1,337,700
1,538,900
1,846,700
2,154,500
1,061,900
1,274,200
1,486,600
1,605,300
1,926,400
2,247,400
2,505,400
3,006,500
3,507,600
3,673,800
4,408,500
5,143,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,703,200
15,063,600
6,843,800
18,076,300
7,984,400
21,089,000
5,683,500
6,820,200
7,956,900
7,204,700
8,645,600
10,086,600
10,366,400
12,439,700
14,513,000
4,441,000
6,810,100
10,002,600
4,210,200
4,905,500
8,131,800
5,329,200
8,172,100
12,003,100
5,052,200
5,886,600
9,758,200
6,217,400
9,534,100
14,003,600
5,894,300
6,867,700
11,384,600
2,670,600
3,204,700
3,738,800
3,277,400
3,932,900
4,588,400
3,883,800
4,660,500
5,437,300
2,959,700
4,207,900
5,423,700
3,551,700
5,049,400
6,508,500
4,143,600
5,891,000
7,593,200
4,054,400
4,865,200
5,676,100
6,034,000
7,240,800
8,447,600
15,490,500
18,588,600
21,686,600
3,477,100
4,714,700
9,219,900
4,172,500
5,657,700
11,063,800
4,867,900
6,600,600
12,907,800
2,502,200
3,002,700
3,503,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 574 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,520,800
1,825,000
2,129,100
697 U-4-12-I
698 U-4-12-II

2,386,400
2,775,800
2,863,600
3,331,000
3,340,900
3,886,200
699 U-4-12-III

3,601,000
4,321,200
5,041,400
1,808,500
2,170,200
2,531,900
2,132,100
2,558,500
2,984,900
2,550,100
3,060,100
3,570,100
2,490,600
2,982,400
2,988,700
3,578,900
3,486,800
4,175,300

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,008,300
6,010,000
7,011,600
1,999,800
2,399,800
2,799,800
2,491,600
2,989,900
3,488,200
3,487,000
4,184,400
4,881,800
3,261,900
3,914,300
4,566,700
6,719,400
8,063,300
9,407,200
8,240,400
9,888,500
11,536,600
6,205,700
7,086,100
11,097,200
7,446,800
8,503,300
13,316,600
8,687,900
9,920,600
15,536,000
5,834,500
7,001,400
8,168,300
7,967,500
9,561,000
11,154,500
10,098,900
12,118,700
14,138,400
3,043,400
3,652,000
4,260,700
5,814,900
6,977,800
8,140,800
9,122,800
10,947,300
12,771,900
5,968,000
7,161,600
8,355,200
8,671,300
10,405,600
12,139,900
10,827,700
12,993,300
15,158,800
961,200
1,060,600
1,173,300
1,153,400
1,272,800
1,407,900
1,345,600
1,484,900
1,642,600
2,886,000
3,463,200
4,040,400
4,793,800
5,752,600
6,711,400
7,903,400
9,484,000
11,064,700
2,493,700
2,992,400
3,491,200
3,345,900
4,015,100
4,684,300
4,481,900
5,378,200
6,274,600
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,728,400
6,874,000
8,019,700
8,794,800
10,553,800
12,312,700
1,192,800
1,445,600
1,431,400
1,734,800
1,669,900
2,023,900
- 575 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,796,900
8,156,300
9,515,700
8,146,600
9,775,900
11,405,200
11,625,000
13,950,000
16,275,000
1,441,700
1,730,100
2,018,400
1,590,900
1,759,900
1,909,100
2,111,900
2,227,300
2,463,900
1,506,900
1,808,300
2,109,700
1,662,900
1,995,500
2,328,000
1,839,500
2,207,400
2,575,300
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,621,100
1,945,400
2,269,600
743 W-1-12-II
744 W-1-12-III

2,023,500
3,583,100
2,428,200
4,299,700
2,832,900
5,016,400
745 W-1-13-I
1,666,400
1,999,700
2,333,000
746 W-1-13-II
747 W-1-13-III

1,809,100
2,430,200
2,171,000
2,916,200
2,532,800
3,402,200
748 W-1-20-I
749 W-1-20-II

5,580,600
6,973,000
6,696,700
8,367,600
7,812,900
9,762,300
750 W-1-20-III
8,083,500
9,700,300
11,317,000
751 W-1-30-I
3,150,300
3,780,400
4,410,500
752 W-1-30-II
5,024,800
6,029,700
7,034,700
753 W-1-30-III
12,328,600
14,794,300
17,260,000
754 W-4-10-I
2,347,300
2,816,800
3,286,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,479,800
6,876,800
2,134,700
3,240,800
3,944,700
4,175,800
8,252,200
2,561,700
3,889,000
4,733,600
4,871,700
9,627,500
2,988,600
4,537,200
5,522,600
2,645,200
3,174,300
3,703,300
3,631,700
4,358,100
5,084,400
3,958,800
4,750,500
5,542,300
839,900
1,147,300
1,426,800
1,122,400
1,336,000
1,709,200
1,488,400
1,653,000
2,288,600
1,980,300
2,648,200
3,589,200
1,461,300
2,638,400
3,900,800
1,972,000
2,617,500
3,718,400
1,689,600
2,029,300
2,789,400
1,007,900
1,376,800
1,712,100
1,346,900
1,603,200
2,051,100
1,786,100
1,983,600
2,746,400
2,376,400
3,177,900
4,307,000
1,753,500
3,166,000
4,681,000
2,366,400
3,141,000
4,462,100
2,027,500
2,435,200
3,347,300
1,175,800
1,606,300
1,997,500
1,571,400
1,870,400
2,392,900
2,083,800
2,314,200
3,204,100
2,772,500
3,707,500
5,024,900
2,045,800
3,693,700
5,461,100
2,760,800
3,664,500
5,205,700
2,365,500
2,841,100
3,905,200
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 576 -

REGIONAL 3
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
785,700
942,900
1,100,000
1,914,500
2,297,400
2,680,300
2,428,000
2,913,600
3,399,200
- 577 -

REGIONAL 3
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
913,900
1,185,500
2,204,500
1,821,800
2,367,500
435,500
774,100
340,500
622,600
645,200
732,500
1,101,200
1,502,000
1,376,700
446,000
1,029,300
373,400
641,000
1,952,600
699,300
1,651,400
402,900
939,900
1,471,200
1,233,900
302,600
917,100
509,900
262,200
283,500
250,200
299,200
416,700
358,000
337,000
302,900
449,400
196,300
231,300
265,200
5,380,700
2,150,400
2,157,600
555,000
908,800
569,000
1,156,600
741,100
424,400
320,500
516,900
285,300
244,300
1,906,000
889,500
508,300
1,984,100
1,322,700
257,600
2,149,400
1,488,100
3,347,200
773,000
475,500
255,700
213,100
240,200
3,662,400
1,782,800
- 578 -

REGIONAL 3
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,265,800
4,009,900
3,324,700
2,532,700
835,000
2,819,000
1,840,700
452,500
4,232,300
3,831,400
2,569,000
2,433,800
300,800
289,000
1,163,000
317,800
283,200
313,000
1,074,300
1,467,400
1,281,700
1,131,900
685,500
284,900
502,100
344,700
311,200
303,200
385,000
439,000
257,400
738,600
1,346,100
1,033,300
2,429,300
316,300
316,300
2,244,800
1,305,300
250,400
1,158,400
3,009,200
690,900
544,200
266,600
230,100
288,800
402,700
964,200
849,900
594,900
443,800
244,300
1,033,000
827,700
353,700
403,600
1,322,500
292,400
1,351,100
1,033,700
315,200
349,400
341,300
206,600
1,126,300
1,547,400
306,700
- 579 -

REGIONAL 3
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
939,900
350,800
379,300
351,200
557,200
428,600
1,073,500
316,700
881,200
1,177,500
257,900
1,569,600
850,600
1,838,200
927,900
409,800
315,200
66,400
408,500
923,200
359,800
486,000
277,900
108,100
280,600
4,179,300
2,375,600
3,964,900
974,000
544,200
370,800
838,600
443,600
892,700
516,900
307,700
515,000
231,900
353,900
339,100
746,600
1,617,900
1,301,700
1,147,700
810,000
298,000
298,000
298,000
243,400
154,400
242,700
296,700
320,900
236,400
208,500
93,100
102,400
75,700
88,800
84,700
129,300
116,000
165,700
182,000
103,000
125,000
85,400
133,300
189,200
- 580 -

REGIONAL 3
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
134,700
186,000
525,700
609,500
127,400
253,000
155,000
221,200
425,600
364,300
261,900
248,000
126,600
124,400
292,000
184,300
264,400
187,300
143,200
1,836,800
1,889,400
300,200
310,900
594,600
746,800
761,100
393,200
1,225,300
264,900
319,500
320,600
256,700
324,200
306,800
143,700
315,800
279,900
253,200
286,400
2,370,600
307,800
853,200
306,000
435,300
457,100
364,600
740,900
758,700
809,000
707,600
1,229,100
210,800
1,463,700
277,900
742,000
1,686,200
1,949,700
851,800
308,700
602,000
599,700
277,900
2,178,300
1,713,400
138,400
151,500
196,800
265,000
- 581 -

REGIONAL 3
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
925,300
438,000
902,800
1,089,200
522,000
726,100
501,900
540,000
584,400
299,100
707,100
180,800
669,800
996,100
73,400
- 582 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,611,500
4,333,700
A-4-10-II
SEPTIKEMIA (SEDANG)
6,169,900
7,403,800
8,637,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,318,900
4,378,800
9,982,700
5,254,600
11,646,500
6,130,400
5
6
A-4-11-II
A-4-11-III

6,232,400
8,626,100
7,478,800
10,351,400
8,725,300
12,076,600
A-4-12-I
2,855,800
3,426,900
3,998,100
8
9
A-4-12-II
A-4-12-III

4,929,600
7,102,600
5,915,500
8,523,100
6,901,400
9,943,600
10 A-4-13-I
11 A-4-13-II

2,125,500
3,756,300
2,550,600
4,507,500
2,975,700
5,258,800
12 A-4-13-III
4,507,500
5,409,100
6,310,600
2,381,200
2,857,400
3,333,600
4,006,400
4,807,700
5,609,000
4,807,700
5,769,200
6,730,800
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,589,600
23,150,300
22,307,600
27,780,400
26,025,500
32,410,400
18 A-4-15-III
INFEKSI HIV (BERAT)
26,153,300
31,384,000
36,614,700
19 B-1-01-I
20 B-1-01-II

51,255,600
56,548,400
61,506,700
67,858,000
71,757,800
79,167,700
21 B-1-01-III
22 B-1-10-I

124,647,800
8,285,200
149,577,300
9,942,200
174,506,900
11,599,300
23 B-1-10-II
18,389,400
22,067,300
25,745,200
24 B-1-10-III
25 B-1-11-I

36,303,300
33,061,400
43,563,900
39,673,700
50,824,600
46,286,000
26 B-1-11-II
27 B-1-11-III

39,394,400
60,875,400
47,273,300
73,050,500
55,152,200
85,225,600
28 B-1-12-I
9,728,800
11,674,600
13,620,300
29 B-1-12-II
10,820,100
12,984,200
15,148,200
30 B-1-12-III
16,926,900
20,312,300
23,697,700
7,749,100
9,298,900
10,848,700
12,750,200
15,300,200
17,850,300
16,497,600
19,797,200
23,096,700
20,302,600
24,363,100
28,423,600
21,323,400
25,588,100
29,852,700
37,746,100
3,294,400
5,258,700
7,254,600
45,295,300
3,953,200
6,310,500
8,705,500
52,844,500
4,612,100
7,362,200
10,156,500
6,945,800
8,334,900
9,724,100
9,724,100
11,669,000
13,613,800
11,780,700
14,136,800
16,492,900
6,279,700
8,942,100
13,303,900
5,990,400
7,535,700
10,730,500
15,964,600
7,188,400
8,791,600
12,518,900
18,625,400
8,386,500
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,056,000
- 583 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,978,500
8,374,200
9,769,900
48 B-4-13-III
49 B-4-14-I

9,613,500
5,984,000
11,536,200
7,180,700
13,458,900
8,377,500
50 B-4-14-II
6,981,000
8,377,200
9,773,500
51 B-4-14-III
52 C-4-10-I

9,351,300
12,119,900
11,221,500
14,543,800
13,091,800
16,967,800
53 C-4-10-II
54 C-4-10-III

19,492,100
36,521,800
23,390,500
43,826,200
27,288,900
51,130,600
55 C-4-11-I
6,308,800
7,570,500
8,832,300
56 C-4-11-II
57 C-4-11-III

8,442,100
12,979,800
10,130,500
15,575,700
11,818,900
18,171,700
58 C-4-12-I
59 C-4-12-II
4,200,600
8,273,500
5,040,700
9,928,200
5,880,800
11,582,900
60 C-4-12-III
RADIOTERAPI (BERAT)
21,248,700
25,498,400
29,748,200
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,158,000
5,943,400
3,789,600
7,132,000
4,421,200
8,320,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,045,300
5,247,100
9,654,400
6,296,600
11,263,400
7,346,000
65 C-4-14-II
7,360,700
8,832,800
10,304,900
66 C-4-14-III
67 D-1-10-I

10,967,200
31,701,700
13,160,700
38,042,000
15,354,100
44,382,300
68 D-1-10-II
69 D-1-10-III

48,283,800
69,196,000
57,940,600
83,035,200
67,597,400
96,874,400
70 D-1-11-I
8,487,800
10,185,400
11,882,900
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
21,673,400
28,165,400
26,008,000
33,798,500
30,342,700
39,431,500
7,358,000
8,829,500
10,301,100
20,277,400
24,332,900
28,388,400
32,165,900
38,599,100
45,032,300
2,907,600
4,771,800
7,507,100
5,760,300
10,351,000
14,219,700
4,966,200
6,888,100
10,577,100
3,489,200
5,726,100
9,008,500
6,912,300
12,421,200
17,063,600
5,959,400
8,265,800
12,692,500
4,070,700
6,680,500
10,510,000
8,064,400
14,491,400
19,907,600
6,952,600
9,643,400
14,807,900
4,255,900
5,107,000
5,958,200
6,023,500
7,228,200
8,432,900
7,704,200
9,245,100
10,785,900
4,564,600
5,477,500
6,390,500
7,473,400
8,968,100
10,462,800
9,140,700
10,968,900
12,797,000
9,099,000
10,918,800
12,738,600
12,421,500
14,905,800
17,390,100
93 E-1-01-III
29,949,500
35,939,400
41,929,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,460,000
13,131,600
24,810,000
11,352,000
15,758,000
29,772,000
13,244,000
18,384,300
34,734,000
10,709,500
12,851,400
14,993,300
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 584 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,210,100
5,052,100
5,894,100
104 E-4-11-II
105 E-4-11-III

6,418,700
8,697,700
7,702,400
10,437,300
8,986,100
12,176,800
106 E-4-12-I
107 E-4-12-II

4,837,300
8,377,100
5,804,800
10,052,500
6,772,300
11,728,000
108 E-4-12-III

(RINGAN)
(SEDANG)
9,929,900
11,915,900
13,901,900
5,267,700
6,321,200
7,374,800
7,716,200
9,259,500
10,802,700
10,086,600
12,104,000
14,121,300
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
14,414,700
17,297,600
20,180,500
19,866,400
23,839,700
27,812,900
3,790,000
4,548,100
5,306,100
7,340,700
8,808,800
10,277,000
12,300,200
14,760,200
17,220,200
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,608,100
6,445,400
6,729,800
7,734,500
7,851,400
9,023,600
114 F-4-10-III
115 F-4-11-I
7,734,500
5,424,000
9,281,400
6,508,700
10,828,300
7,593,500
116 F-4-11-II
6,319,500
7,583,400
8,847,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,103,900
9,724,700
11,345,400
2,973,200
3,567,800
4,162,500
4,227,000
5,072,400
5,917,800
9,182,900
11,019,400
12,856,000
4,369,100
5,765,200
7,463,700
2,492,800
3,197,400
4,302,300
5,243,000
6,918,200
8,956,500
2,991,300
3,836,800
5,162,800
6,116,800
8,071,200
10,449,200
3,489,900
4,476,300
6,023,200
127 F-4-15-I
3,969,900
4,763,900
5,557,900
128 F-4-15-II
5,915,700
7,098,900
8,282,000
129 F-4-15-III
7,810,600
9,372,700
10,934,900
7,811,100
9,373,300
10,935,500
9,081,600
10,898,000
12,714,300
12,122,400
14,546,900
16,971,400
133 F-4-17-I

1,844,700
2,213,600
2,582,500
134 F-4-17-II
5,406,500
6,487,800
7,569,100
135
136
137
138
139
140
141

(RINGAN)
5,768,200
6,787,200
7,467,900
11,512,300
5,187,000
6,642,200
8,269,500
6,921,900
8,144,700
8,961,500
13,814,800
6,224,400
7,970,700
9,923,400
8,075,500
9,502,100
10,455,000
16,117,200
7,261,800
9,299,100
11,577,300
22,003,900
26,404,700
30,805,500
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 585 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
51,491,200
61,789,400
72,087,700
148 G-1-11-I
149 G-1-11-II

16,839,600
30,786,800
20,207,500
36,944,100
23,575,500
43,101,500
150 G-1-11-III
49,473,000
59,367,600
69,262,200
7,031,100
8,437,400
9,843,600
13,180,200
15,816,200
18,452,300
17,962,000
21,554,400
25,146,800
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,121,100
5,696,200
2,545,300
6,835,400
2,969,500
7,974,600
156 G-1-13-III
157 G-1-20-I

12,853,100
11,907,600
15,423,700
14,289,200
17,994,300
16,670,700
158 G-1-20-II
18,018,100
21,621,800
25,225,400
159 G-1-20-III
30,724,200
36,869,000
43,013,800
160 G-1-30-I
29,665,000
35,598,000
41,531,000
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
39,995,700
60,060,500
47,994,800
72,072,600
55,994,000
84,084,700
6,035,500
7,242,600
8,449,600
7,377,400
8,852,900
10,328,300
10,123,000
12,147,600
14,172,200
6,318,200
7,581,800
8,845,500
8,392,900
10,071,500
11,750,100
12,332,000
14,798,400
17,264,900
7,009,300
8,411,200
9,813,000
8,853,200
10,623,900
12,394,500
12,858,200
15,429,900
18,001,500
4,210,600
5,052,700
5,894,800
7,342,400
8,810,900
10,279,400
8,708,300
10,449,900
12,191,600
7,142,800
8,571,300
9,999,900
9,549,300
11,459,200
13,369,100
11,985,600
14,382,700
16,779,800
5,836,300
7,003,500
8,170,800
6,965,300
8,358,300
9,751,400
9,830,900
11,797,100
13,763,300
4,811,200
5,773,400
6,735,700
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
31,559,000
37,870,800
44,182,600
51,633,100
61,959,700
72,286,300
34,212,300
41,901,500
41,054,700
50,281,800
47,897,200
58,662,100
- 586 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,387,500
7,665,000
8,942,500
183 G-4-16-III
9,096,400
10,915,600
12,734,900
6,408,200
7,689,800
8,971,500
8,402,600
10,083,100
11,763,600
10,558,200
12,669,800
14,781,500
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,311,100
7,573,300
8,835,500
188 G-4-18-II
8,436,000
10,123,200
11,810,400
189 G-4-18-III
9,439,200
11,327,100
13,214,900
5,265,500
6,318,600
7,371,700
8,899,900
10,679,900
12,459,900
11,685,200
14,022,200
16,359,300
193 G-4-20-I

3,683,500
4,420,200
5,156,900
194 G-4-20-II
5,207,300
6,248,700
7,290,200
195 G-4-20-III
196 G-4-21-I

8,601,200
3,835,700
10,321,400
4,602,900
12,041,700
5,370,000
197 G-4-21-II
198 G-4-21-III

6,492,100
7,629,700
7,790,500
9,155,600
9,088,900
10,681,500
199 G-4-22-I
2,873,700
3,448,500
4,023,200
200 G-4-22-II
201 G-4-22-III

5,089,400
8,028,100
6,107,300
9,633,700
7,125,100
11,239,300
202 G-4-23-I
203 G-4-23-II

3,775,900
4,737,500
4,531,100
5,685,000
5,286,300
6,632,500
204 G-4-23-III
6,745,000
8,094,000
9,443,000
205 G-4-24-I
206 G-4-24-II

4,205,800
5,254,600
5,047,000
6,305,500
5,888,100
7,356,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
8,753,900
3,593,800
4,544,700
6,022,700
10,504,700
4,312,600
5,453,700
7,227,200
12,255,500
5,031,300
6,362,600
8,431,800
4,097,200
4,916,600
5,736,100
4,766,300
5,719,600
6,672,900
7,127,100
8,552,500
9,977,900
12,119,600
13,394,100
18,215,100
8,258,500
10,260,300
14,371,100
4,378,800
5,941,100
11,677,600
4,198,800
4,789,600
6,858,400
4,950,500
5,914,900
9,912,300
14,543,500
16,072,900
21,858,200
9,910,200
12,312,400
17,245,300
5,254,600
7,129,300
14,013,100
5,038,600
5,747,500
8,230,100
5,940,600
7,097,900
11,894,800
16,967,500
18,751,700
25,501,200
11,561,900
14,364,500
20,119,500
6,130,300
8,317,600
16,348,600
5,878,400
6,705,400
9,601,800
6,930,700
8,280,900
13,877,300
229 I-1-01-I
66,493,600
79,792,300
93,091,000
230 I-1-01-II
67,956,400
81,547,700
95,138,900
231 I-1-01-III

(RINGAN)
107,268,200
128,721,900
150,175,500
36,890,300
44,268,400
51,646,500
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 587 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
49,596,100
59,515,300
69,434,500
245 I-1-06-II
71,844,000
86,212,800
100,581,600
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
85,723,100
102,867,800
120,012,400
77,197,500
92,637,000
108,076,600
96,496,900
115,796,300
135,095,700
144,745,400
173,694,500
202,643,500
5,780,900
6,937,000
8,093,200
6,427,700
7,713,300
8,998,800
8,553,300
10,264,000
11,974,700
16,640,000
19,968,000
23,296,000
27,176,500
32,611,800
38,047,100
35,754,800
42,905,700
50,056,700
16,140,600
19,368,700
22,596,800
21,494,500
25,793,400
30,092,300
26,508,600
31,810,400
37,112,100
33,035,800
39,643,000
46,250,100
41,058,600
49,270,400
57,482,100
53,801,000
64,561,200
75,321,400
6,275,800
8,764,100
16,876,200
7,531,000
10,516,900
20,251,400
8,786,200
12,269,700
23,626,700
16,269,300
19,523,100
22,777,000
36,810,800
44,173,000
51,535,200
42,460,700
50,952,900
59,445,000
18,838,300
22,605,900
26,373,600
23,587,300
28,304,800
33,022,200
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
47,588,100
57,105,700
66,623,300
58,655,300
70,386,300
82,117,400
34,791,600
41,749,900
48,708,200
48,228,300
57,874,000
67,519,600
61,205,400
73,446,500
85,687,600
52,429,000
62,914,800
73,400,600
82,747,100
99,296,500
115,845,900
132,187,900
158,625,500
185,063,100
86,847,200
104,216,700
121,586,100
106,146,600
127,375,900
148,605,300
144,745,400
173,694,500
202,643,500
- 588 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,647,000
43,976,300
51,305,700
279 I-1-40-III
48,947,900
58,737,500
68,527,100
280 I-4-10-I
281 I-4-10-II

5,587,700
9,977,500
6,705,200
11,973,000
7,822,800
13,968,500
282 I-4-10-III
14,376,200
17,251,400
20,126,600
283 I-4-11-I
284 I-4-11-II

8,596,700
10,638,400
10,316,000
12,766,100
12,035,300
14,893,800
285 I-4-11-III
286 I-4-12-I

19,679,900
4,941,800
23,615,900
5,930,200
27,551,900
6,918,600
287 I-4-12-II
5,728,300
6,874,000
8,019,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,874,000
8,248,700
9,623,500
5,028,900
6,034,700
7,040,500
8,979,700
10,775,700
12,571,600
12,938,500
15,526,200
18,114,000
4,748,900
4,912,400
8,611,400
5,698,700
5,894,800
10,333,700
6,648,500
6,877,300
12,056,000
4,850,000
5,820,000
6,790,000
9,145,700
10,974,800
12,803,900
10,974,800
13,169,800
15,364,700
2,997,300
4,812,900
5,775,500
2,001,200
3,229,300
4,521,000
3,596,700
5,775,500
6,930,600
2,401,400
3,875,200
5,425,200
4,196,200
6,738,100
8,085,700
2,801,700
4,521,000
6,329,400
5,781,400
6,937,700
8,094,000
8,802,500
10,563,000
12,323,500
11,950,800
14,341,000
16,731,200
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
29,177,100
35,012,600
40,848,000
21,234,000
25,480,800
29,727,600
26,527,100
31,832,500
37,137,900
27,885,400
33,462,500
39,039,600
16,062,300
19,274,800
22,487,200
33,413,200
40,095,800
46,778,500
51,778,400
62,134,100
72,489,800
14,823,800
17,788,500
20,753,300
307 I-4-19-I
5,577,900
6,693,500
7,809,100
308 I-4-19-II

(SEDANG)
8,707,500
10,449,000
12,190,400
309 I-4-19-III
10,395,100
12,474,100
14,553,100
310
311
312
313
314

5,808,300
6,708,600
10,030,700
3,911,700
4,956,100
6,969,900
8,050,300
12,036,800
4,694,000
5,947,300
8,131,600
9,392,000
14,043,000
5,476,300
6,938,600
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 589 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,153,600
8,584,400
10,015,100
316 I-4-22-I
317 I-4-22-II
3,514,500
4,375,000
4,217,400
5,250,100
4,920,300
6,125,100
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,394,900
7,673,900
8,952,900
4,767,800
5,721,300
6,674,900
5,853,400
7,024,100
8,194,800
11,437,300
13,724,800
16,012,200
3,097,500
3,716,900
4,336,400
7,132,600
8,559,100
9,985,700
9,017,900
10,821,500
12,625,100
98,141,300
117,769,500
137,397,800
111,065,100
133,278,200
155,491,200
152,345,000
182,813,900
213,282,900
64,025,300
76,830,400
89,635,400
80,787,500
96,945,000
113,102,500
94,509,900
113,411,900
132,313,900
12,482,000
14,978,400
17,474,800
25,257,400
30,308,900
35,360,300
26,248,700
31,498,400
36,748,100
34,385,700
41,262,800
48,140,000
36,006,400
43,207,700
50,409,000
40,520,500
48,624,600
56,728,700
10,416,500
12,499,900
14,583,200
18,869,500
22,643,300
26,417,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
54,466,000
65,359,200
76,252,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,070,500
6,341,500
9,593,700
3,798,900
5,291,100
7,092,300
6,452,500
7,345,200
10,255,900
5,705,100
7,941,300
14,815,800
6,290,000
10,235,600
12,109,700
4,551,400
7,537,200
13,689,800
3,684,600
7,609,800
11,512,400
4,558,700
6,349,400
8,510,700
7,742,900
8,814,200
12,307,100
6,846,100
9,529,500
17,779,000
7,547,900
12,282,700
14,531,700
5,461,700
9,044,700
16,427,800
4,298,700
8,878,100
13,431,200
5,318,500
7,407,600
9,929,200
9,033,400
10,283,300
14,358,300
7,987,100
11,117,800
20,742,100
8,805,900
14,329,800
16,953,600
6,372,000
10,552,100
19,165,700
3,792,300
4,550,800
5,309,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 590 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,386,800
8,864,200
10,341,500
12,608,300
15,130,000
17,651,600
5,255,800
6,294,000
6,307,000
7,552,800
7,358,200
8,811,600

8,259,600
2,336,200
9,911,600
2,803,500
11,563,500
3,270,700
365 J-4-18-II
4,453,900
5,344,700
6,235,500
366 J-4-18-III
367 J-4-19-I

6,329,200
6,662,700
7,595,100
7,995,200
8,860,900
9,327,800
368 J-4-19-II
369 J-4-19-III

7,555,900
8,344,600
9,067,100
10,013,500
10,578,300
11,682,400
370 J-4-20-I
5,300,100
6,360,100
7,420,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,343,800
8,609,300
8,812,600
10,331,100
10,281,400
12,053,000
3,028,100
3,633,700
4,239,300
6,761,600
8,113,900
9,466,300
12,737,700
15,285,200
17,832,700
11,315,700
13,578,800
15,842,000
14,220,600
17,064,700
19,908,800
16,667,000
20,000,400
23,333,800
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,626,800
12,752,200
14,877,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
13,951,700
27,576,900
16,742,100
33,092,200
19,532,400
38,607,600
4,747,900
5,697,500
6,647,100
6,175,200
7,410,200
8,645,300
12,234,000
14,680,800
17,127,600
5,354,700
5,890,200
9,413,700
6,425,600
7,068,200
11,296,400
7,496,600
8,246,200
13,179,200
7,820,700
9,384,900
10,949,000
9,165,700
10,998,900
12,832,000
390 K-1-14-III
16,000,600
19,200,800
22,400,900
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

16,826,000
23,502,200
34,315,700
20,191,200
28,202,600
41,178,800
23,556,400
32,903,100
48,042,000
9,950,800
11,941,000
13,931,100
17,672,400
21,206,800
24,741,300
24,317,400
29,180,900
34,044,400
397 K-1-40-I
11,102,800
13,323,300
15,543,900
398 K-1-40-II

(SEDANG)
12,241,200
14,689,400
17,137,700
399 K-1-40-III
20,744,400
24,893,300
29,042,200
400
401
402
403
404

8,483,600
11,017,100
15,569,100
7,003,700
10,063,300
10,180,400
13,220,500
18,683,000
8,404,400
12,075,900
11,877,100
15,423,900
21,796,800
9,805,100
14,088,600
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 591 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,340,900
18,409,100
21,477,300
406 K-4-11-I
407 K-4-11-II

2,434,600
4,795,600
2,921,600
5,754,700
3,408,500
6,713,800
408 K-4-11-III
409 K-4-12-I

5,754,700
4,210,100
6,905,600
5,052,100
8,056,500
5,894,100
410 K-4-12-II
5,665,500
6,798,600
7,931,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,372,600
11,247,100
13,121,600
5,675,500
6,810,600
7,945,700
7,341,600
8,809,900
10,278,300
11,308,400
13,570,100
15,831,800
3,238,500
3,886,200
4,533,800
4,347,100
5,216,500
6,085,900
6,975,300
8,370,400
9,765,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,616,100
5,539,300
6,462,500
419 K-4-15-II
7,109,200
8,531,000
9,952,900
420 K-4-15-III
10,119,000
12,142,800
14,166,600
421 K-4-16-I
4,180,400
5,016,500
5,852,600
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,013,500
5,850,000
6,016,200
7,020,000
7,018,900
8,190,000
2,050,500
2,460,700
2,870,800
2,525,300
3,030,300
3,535,400
3,030,300
3,636,400
4,242,400
1,807,000
2,168,400
2,529,800
3,049,400
3,659,200
4,269,100
429 K-4-18-III
3,659,200
4,391,100
5,122,900
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
26,827,000
40,494,700
54,107,500
12,657,200
21,719,000
26,964,500
32,192,400
48,593,600
64,929,000
15,188,700
26,062,800
32,357,400
37,557,800
56,692,500
75,750,500
17,720,100
30,406,600
37,750,300
7,093,400
8,512,100
9,930,700
14,227,800
17,073,300
19,918,900
23,948,500
28,738,200
33,527,900
9,312,200
14,987,000
21,437,500
2,435,700
2,827,100
3,281,500
5,100,600
7,010,400
15,929,800
2,422,300
3,203,900
10,593,900
11,174,700
17,984,400
25,724,900
2,922,800
3,392,600
3,937,900
6,120,800
8,412,500
19,115,700
2,906,800
3,844,700
12,712,700
13,037,100
20,981,800
30,012,400
3,409,900
3,958,000
4,594,200
7,140,900
9,814,500
22,301,700
3,391,300
4,485,400
14,831,500
2,579,300
3,095,200
3,611,100
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 592 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,201,900
5,042,200
5,882,600
8,347,200
10,016,600
11,686,000
4,194,700
5,033,600
5,872,500
6,300,500
7,560,600
8,820,700
8,881,300
10,657,600
12,433,900
14,827,700
17,793,200
20,758,800
21,075,500
25,290,600
29,505,700
29,604,800
35,525,700
41,446,700
13,142,000
15,770,400
18,398,800
21,558,900
36,628,100
25,870,700
43,953,800
30,182,500
51,279,400
52,533,300
63,040,000
73,546,600
61,445,400
73,734,400
86,023,500
76,048,900
91,258,700
106,468,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,905,300
32,286,300
37,667,400
467 M-1-04-II
34,565,500
41,478,600
48,391,700
468 M-1-04-III
41,358,400
49,630,100
57,901,800
469 M-1-05-I
470 M-1-05-II

10,461,800
16,922,300
12,554,100
20,306,800
14,646,500
23,691,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
21,616,100
25,939,300
30,262,500
19,121,300
22,945,500
26,769,800
25,615,900
30,739,100
35,862,200
52,181,900
62,618,300
73,054,700
22,596,300
27,115,500
31,634,800
54,026,700
64,832,000
75,637,300
116,530,500
139,836,600
163,142,700
17,608,000
21,129,600
24,651,200
22,496,000
26,995,200
31,494,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
56,008,200
67,209,800
78,411,400
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,079,500
19,573,800
27,988,700
14,495,400
23,488,500
33,586,500
16,911,300
27,403,300
39,184,200
7,378,700
8,854,500
10,330,200
10,904,900
13,085,900
15,266,800
15,570,100
18,684,100
21,798,100
7,368,600
12,228,000
20,083,800
8,842,300
14,673,700
24,100,500
10,316,000
17,119,300
28,117,300
11,380,100
13,656,200
15,932,200
14,307,500
17,169,000
20,030,500
21,613,100
25,935,800
30,258,400
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 593 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,974,600
9,569,600
11,164,500
512 M-4-14-II
9,835,500
11,802,700
13,769,800
513 M-4-14-III
514 M-4-15-I
14,780,000
4,728,700
17,736,000
5,674,500
20,692,000
6,620,200
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,303,100
14,303,500
4,048,500
6,483,200
10,891,400
7,563,700
17,164,200
4,858,200
7,779,900
13,069,700
8,824,300
20,025,000
5,668,000
9,076,500
15,247,900
4,729,000
5,674,800
6,620,600
6,614,000
7,936,800
9,259,600
9,236,100
11,083,300
12,930,500
3,971,500
5,985,300
7,206,500
4,765,800
7,182,300
8,647,800
5,560,100
8,379,400
10,089,100
4,141,700
4,970,000
5,798,400
6,976,200
8,371,400
9,766,700
13,624,900
16,349,900
19,074,900
3,760,000
4,512,000
5,264,000
5,505,900
6,607,100
7,708,300
6,153,500
7,384,300
8,615,000
3,786,100
4,543,300
5,300,500
4,735,300
5,682,300
6,629,400
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,083,800
25,300,500
29,517,300
23,192,200
27,830,600
32,469,000
26,551,900
31,862,300
37,172,700
11,985,200
14,382,300
16,779,300
14,233,600
32,036,700
17,080,300
38,444,100
19,927,000
44,851,400
4,222,000
5,066,300
5,910,700
6,296,300
11,912,700
7,555,600
14,295,300
8,814,900
16,677,800
5,260,900
6,313,100
7,365,300
11,534,400
13,841,300
16,148,200
16,676,800
20,012,100
23,347,500
4,199,400
5,039,300
5,879,200
6,984,800
8,381,700
9,778,700
9,342,900
11,211,500
13,080,000
6,992,500
8,390,900
9,789,400
10,505,900
12,607,000
14,708,200
20,496,700
24,596,000
28,695,400
- 594 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,616,400
12,739,700
14,862,900
535 N-1-01-I

291,179,000
349,414,800
407,650,600
536 N-1-01-II
291,179,000
349,414,800
407,650,600
537 N-1-01-III
538 N-1-11-I

291,179,000
12,134,300
349,414,800
14,561,100
407,650,600
16,988,000
539 N-1-11-II
540 N-1-11-III

19,187,200
29,912,800
23,024,600
35,895,400
26,862,100
41,878,000
6,184,400
7,421,300
8,658,200
12,312,500
14,775,000
17,237,500
26,718,600
32,062,400
37,406,100
13,521,500
16,225,800
18,930,100

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
18,922,600
26,479,900
22,707,100
31,775,900
26,491,600
37,071,900
12,374,600
14,849,500
17,324,400
18,720,300
22,464,300
26,208,400
21,545,200
25,854,300
30,163,300
11,113,200
13,335,900
15,558,500
15,091,500
18,109,800
21,128,100
17,564,500
21,077,400
24,590,300
4,721,600
5,665,900
6,610,200
5,710,800
6,853,000
7,995,200
8,399,800
10,079,800
11,759,700
3,624,600
6,332,600
7,879,100
2,732,800
5,677,400
9,225,400
3,697,900
6,182,200
12,789,700
4,349,500
7,599,100
9,454,900
3,279,400
6,812,800
11,070,500
4,437,500
7,418,700
15,347,600
5,074,400
8,865,600
11,030,700
3,825,900
7,948,300
12,915,500
5,177,100
8,655,100
17,905,500
3,640,300
4,368,300
5,096,400
5,165,400
6,198,400
7,231,500
8,280,000
9,936,000
11,592,000
4,300,500
5,160,600
6,020,700
5,336,200
6,403,400
7,470,600
6,089,500
7,307,400
8,525,200
5,265,900
6,319,100
7,372,300
7,516,200
9,019,400
10,522,700
10,004,600
12,005,500
14,006,400
5,395,800
6,945,200
6,475,000
8,334,200
7,554,100
9,723,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 595 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,947,900
13,137,500
15,327,100
4,894,900
5,873,900
6,852,900
5,440,200
6,528,200
7,616,200
6,767,700
8,121,200
9,474,700
3,468,000
4,161,600
4,855,200
4,165,000
4,998,000
5,831,100
5,233,500
6,280,200
7,327,000
1,758,000
2,109,600
2,461,200
2,884,100
3,460,900
3,460,900
4,153,000
4,037,700
4,845,200
77,441,000
92,929,200
108,417,300
95,821,600
114,985,900
134,150,200
112,467,600
134,961,100
157,454,600
105,703,200
126,843,900
147,984,500
121,252,200
145,502,700
169,753,100
138,539,300
166,247,100
193,955,000
15,855,400
19,026,500
22,197,500
20,986,800
25,184,100
29,381,500
29,508,300
35,410,000
41,311,700
51,094,600
61,313,600
71,532,500
66,309,800
79,571,700
92,833,700
95,071,600
114,085,900
133,100,200
27,783,600
33,340,300
38,897,100
42,861,100
51,433,300
60,005,500
58,020,400
69,624,500
81,228,500
7,500,700
9,000,800
10,501,000
21,030,200
25,236,300
29,442,300
27,859,900
33,431,900
39,003,800
8,879,700
10,655,600
12,431,500
24,896,600
29,875,900
34,855,200
32,981,800
39,578,200
46,174,500
5,137,900
6,165,500
7,193,000
7,290,400
8,748,500
10,206,600
14,182,700
17,019,300
19,855,800
13,212,800
15,855,400
18,497,900
17,489,000
20,986,800
24,484,500
- 596 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
24,590,300
29,508,300
34,426,400
12,011,600
14,414,000
16,816,300
14,574,100
17,489,000
20,403,800
21,382,900
25,659,400
29,936,000
6,673,100
8,007,800
9,342,400
10,410,100
12,492,100
14,574,100
16,448,300
19,738,000
23,027,700
5,051,100
6,061,300
7,071,500
10,281,900
12,338,300
14,394,700
40,203,100
48,243,800
56,284,400
3,788,400
4,546,000
5,303,700
7,586,300
9,103,600
10,620,900
8,901,200
10,681,400
12,461,700
3,428,500
4,114,200
4,799,900
6,588,400
7,906,100
9,223,800
15,450,900
18,541,100
21,631,300
4,448,800
5,338,500
6,228,300
8,007,800
9,609,300
11,210,900
13,707,000
16,448,300
19,189,700
3,865,600
4,638,700
5,411,800
4,763,000
5,715,600
6,668,200
6,520,100
7,824,100
9,128,100
1,776,400
3,610,800
8,331,200
2,842,000
3,782,600
6,557,200
2,131,700
4,332,900
9,997,400
3,410,400
4,539,100
7,868,600
2,487,000
5,055,100
11,663,700
3,978,800
5,295,700
9,180,100
4,196,900
5,036,200
5,875,600
7,445,600
8,934,700
10,423,800
12,085,100
14,502,100
16,919,100
2,123,900
2,548,700
2,973,500
4,511,400
5,413,600
6,315,900
8,555,100
10,266,100
11,977,100
1,420,500
1,704,600
1,988,700
2,680,700
3,216,800
3,753,000
3,472,000
4,166,400
4,860,700
7,355,500
8,826,700
10,297,800
- 597 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,354,600
11,225,500
13,096,400
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,393,800
16,072,500
18,751,300
3,545,200
4,254,300
4,963,300
5,261,500
6,313,800
7,366,100
6,328,200
7,593,800
8,859,400
2,372,000
2,846,500
3,320,900
3,186,000
3,823,200
4,460,300
5,795,800
6,954,900
8,114,100
1,298,800
1,558,600
1,818,400
2,474,900
2,969,900
3,464,900
3,597,400
4,316,900
5,036,300
1,254,400
1,505,200
1,756,100
1,974,000
2,368,800
2,763,600
3,179,600
3,815,500
4,451,400
2,939,100
3,526,900
4,114,700
4,436,800
5,324,200
6,211,600
6,867,500
8,241,100
9,614,600
7,751,600
9,301,900
10,852,200

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,033,500
31,783,700
14,440,200
38,140,500
16,847,000
44,497,200
12,233,100
14,679,700
17,126,400
18,451,400
22,141,700
25,831,900
21,872,900
26,247,500
30,622,000
9,370,500
14,369,100
21,105,200
9,376,900
10,925,600
18,111,200
11,244,600
17,242,900
25,326,300
11,252,300
13,110,700
21,733,400
13,118,700
20,116,800
29,547,300
13,127,700
15,295,800
25,355,700
5,634,800
6,761,800
7,888,800
6,915,300
8,298,400
9,681,500
8,194,600
9,833,600
11,472,500
4,410,600
6,270,600
9,552,100
5,292,700
7,524,700
11,462,500
6,174,800
8,778,800
13,372,900
8,554,600
10,265,500
11,976,400
12,731,600
15,277,900
17,824,300
32,684,500
39,221,400
45,758,300
7,336,500
9,948,000
19,453,700
8,803,800
11,937,600
23,344,400
10,271,100
13,927,200
27,235,100
5,279,700
6,335,600
7,391,500
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 598 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,553,500
3,064,200
3,574,900
697 U-4-12-I
698 U-4-12-II

2,742,300
4,421,500
3,290,800
5,305,800
3,839,200
6,190,100
699 U-4-12-III

7,743,500
9,292,200
10,840,900
2,078,300
2,494,000
2,909,600
3,396,100
4,075,300
4,754,500
5,483,600
6,580,300
7,677,000
5,255,000
6,292,700
6,306,000
7,551,300
7,357,000
8,809,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,567,400
12,680,900
14,794,400
4,219,600
5,063,600
5,907,500
5,257,100
6,308,500
7,360,000
7,357,400
8,828,900
10,300,400
6,882,600
8,259,100
9,635,600
14,177,800
17,013,400
19,849,000
17,387,100
20,864,600
24,342,000
13,093,800
14,951,500
23,414,700
15,712,500
17,941,800
28,097,700
18,331,300
20,932,200
32,780,600
12,310,700
14,772,800
17,234,900
16,811,200
20,173,500
23,535,700
21,308,400
25,570,100
29,831,800
6,421,400
7,705,700
8,990,000
12,269,200
14,723,000
17,176,900
19,248,800
23,098,600
26,948,400
12,592,300
15,110,800
17,629,300
18,296,300
21,955,600
25,614,800
723 V-1-14-III
22,846,200
27,415,500
31,984,700
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,028,000
2,237,900
2,475,600
2,433,600
2,685,500
2,970,700
2,839,200
3,133,100
3,465,800
5,480,500
6,576,600
7,672,700
9,103,400
10,924,100
12,744,700
15,008,300
18,009,900
21,011,600
5,261,600
6,314,000
7,366,300
7,059,800
8,471,700
9,883,700
9,456,600
11,348,000
13,239,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,086,700
14,504,100
16,921,400
18,556,800
22,268,200
25,979,600
1,669,000
2,427,300
2,002,800
2,912,700
2,336,500
3,398,200
- 599 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,341,400
17,209,700
20,077,900
17,189,100
20,626,900
24,064,800
24,528,400
29,434,100
34,339,800
3,042,000
3,650,400
4,258,800
3,356,800
3,713,300
4,028,200
4,456,000
4,699,600
5,198,700
3,179,600
3,815,500
4,451,400
3,508,600
4,210,400
4,912,100
3,881,300
4,657,500
5,433,800
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,420,600
4,104,700
4,788,800
743 W-1-12-II
744 W-1-12-III

4,269,500
7,560,300
5,123,400
9,072,300
5,977,200
10,584,400
745 W-1-13-I
3,516,100
4,219,300
4,922,500
746 W-1-13-II
747 W-1-13-III

3,817,300
5,127,600
4,580,700
6,153,100
5,344,200
7,178,600
748 W-1-20-I
749 W-1-20-II

11,775,000
14,712,900
14,130,000
17,655,500
16,485,000
20,598,100
750 W-1-20-III
17,056,100
20,467,300
23,878,500
751 W-1-30-I
6,647,100
7,976,600
9,306,000
752 W-1-30-II
10,602,200
12,722,600
14,843,000
753 W-1-30-III
26,013,000
31,215,600
36,418,200
754 W-4-10-I
4,952,800
5,943,400
6,933,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,342,300
14,509,900
4,053,800
6,154,300
7,490,900
8,810,800
17,411,800
4,864,500
7,385,100
8,989,100
10,279,200
20,313,800
5,675,300
8,616,000
10,487,300
3,039,800
3,647,800
4,255,700
5,784,800
6,941,800
8,098,700
8,512,800
10,215,300
11,917,900
1,772,100
2,420,800
3,010,400
2,368,300
2,818,900
3,606,400
1,710,400
2,633,000
4,921,400
2,275,700
4,218,200
7,718,100
1,679,200
4,202,600
8,388,100
4,994,500
6,629,100
9,417,800
3,251,400
3,905,100
5,367,800
2,126,600
2,905,000
3,612,500
2,841,900
3,382,600
4,327,700
2,052,500
3,159,600
5,905,700
2,730,900
5,061,900
9,261,700
2,015,100
5,043,100
10,065,700
5,993,400
7,954,900
11,301,400
3,901,700
4,686,100
6,441,400
2,481,000
3,389,200
4,214,600
3,315,600
3,946,400
5,049,000
2,394,600
3,686,200
6,890,000
3,186,000
5,905,500
10,805,300
2,350,900
5,883,600
11,743,400
6,992,300
9,280,700
13,184,900
4,552,000
5,467,200
7,514,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 600 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,149,000
2,578,800
3,008,600
4,314,900
5,177,900
6,040,900
9,103,400
10,924,100
12,744,800
- 601 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,427,500
1,851,700
3,443,400
2,845,600
3,698,000
680,200
1,511,400
531,900
1,175,300
1,007,800
1,144,100
1,720,100
2,346,200
2,150,300
696,600
1,607,800
583,200
1,001,300
3,049,900
1,092,300
2,579,500
629,300
1,835,200
2,298,000
1,927,400
472,700
1,432,600
796,500
511,900
442,800
390,900
467,400
650,800
479,300
526,400
405,500
701,900
364,000
361,200
368,200
8,404,600
3,358,900
3,370,200
866,900
1,774,500
1,111,000
2,258,200
1,157,600
662,900
500,600
807,400
572,900
381,500
3,721,400
1,488,600
992,400
3,873,900
2,582,600
402,400
4,196,700
2,905,400
4,529,100
1,509,400
928,400
399,500
395,200
375,200
5,720,700
2,784,700
- 602 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,539,100
6,263,500
5,193,100
3,956,100
1,304,200
4,403,200
2,875,100
706,700
6,610,800
5,984,700
4,012,700
3,801,600
469,900
451,500
1,816,600
496,500
442,300
488,900
2,097,500
2,292,100
2,002,000
2,210,100
1,338,500
444,900
784,300
538,400
486,100
473,600
601,300
685,800
402,000
1,153,800
2,102,700
1,614,100
3,794,500
494,100
494,100
4,383,000
2,038,900
391,100
1,809,400
4,700,400
1,079,200
850,000
416,400
281,000
563,800
786,200
1,882,600
1,659,300
1,161,500
693,200
381,500
2,016,900
1,292,900
690,500
630,300
2,065,700
542,400
2,638,100
2,018,200
492,400
545,800
533,100
383,100
2,199,000
2,417,100
479,000
- 603 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,468,100
548,000
592,500
548,600
870,400
669,500
1,676,800
494,700
1,376,400
2,299,100
402,800
2,451,800
1,328,600
2,871,200
1,449,400
640,100
492,400
81,100
638,100
1,442,000
562,000
759,100
434,100
206,400
438,400
6,528,100
3,710,700
6,193,100
1,901,700
850,000
579,200
1,309,900
692,900
1,394,300
807,400
480,600
804,500
452,700
691,000
529,700
1,008,900
2,527,200
2,033,300
1,792,800
1,265,200
465,400
465,400
465,400
380,200
241,100
379,100
463,500
501,300
369,300
325,700
113,700
125,000
92,400
108,500
103,500
157,900
168,200
258,800
284,300
125,700
152,600
104,300
162,800
231,000
- 604 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
164,500
290,500
821,200
952,000
155,500
395,200
189,200
270,200
664,700
569,100
409,100
387,400
154,600
151,900
456,100
341,900
490,400
387,300
223,700
3,586,400
2,951,200
468,900
485,600
928,800
912,000
1,188,800
614,100
1,913,900
323,400
499,100
500,700
401,000
506,400
479,300
224,500
493,300
437,300
395,500
447,300
3,702,900
601,000
1,332,600
478,000
850,000
558,100
445,300
1,157,200
1,185,100
1,263,600
1,105,300
1,629,600
329,300
2,857,900
434,100
1,448,700
3,292,300
3,045,500
1,330,400
482,200
940,400
936,700
434,100
3,402,600
2,676,300
247,700
185,000
240,300
517,500
- 605 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,277,500
1,527,600
1,410,200
1,701,300
815,300
1,134,200
783,900
659,500
806,800
467,200
1,104,400
220,800
817,900
1,375,300
89,700
- 606 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,719,800
4,463,800
A-4-10-II
SEPTIKEMIA (SEDANG)
6,354,900
7,625,900
8,896,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,568,500
4,510,200
10,282,200
5,412,200
11,995,900
6,314,300
5
6
A-4-11-II
A-4-11-III

6,419,300
8,884,900
7,703,200
10,661,900
8,987,100
12,438,900
A-4-12-I
2,941,500
3,529,700
4,118,000
8
9
A-4-12-II
A-4-12-III

5,077,400
7,315,700
6,092,900
8,778,800
7,108,400
10,241,900
10 A-4-13-I
11 A-4-13-II

2,189,300
3,869,000
2,627,100
4,642,800
3,065,000
5,416,600
12 A-4-13-III
4,642,800
5,571,300
6,499,900
2,452,600
2,943,100
3,433,600
4,126,600
4,951,900
5,777,300
4,951,900
5,942,300
6,932,700
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
19,147,300
23,844,800
22,976,800
28,613,800
26,806,300
33,382,700
18 A-4-15-III
INFEKSI HIV (BERAT)
26,937,900
32,325,500
37,713,100
19 B-1-01-I
20 B-1-01-II

52,793,200
58,244,800
63,351,900
69,893,800
73,910,500
81,542,700
21 B-1-01-III
22 B-1-10-I

128,387,200
8,533,700
154,064,700
10,240,500
179,742,100
11,947,200
23 B-1-10-II
18,941,100
22,729,400
26,517,600
24 B-1-10-III
25 B-1-11-I

37,392,400
34,053,200
44,870,800
40,863,900
52,349,300
47,674,500
26 B-1-11-II
27 B-1-11-III

40,576,200
62,701,700
48,691,500
75,242,000
56,806,700
87,782,300
28 B-1-12-I
10,020,700
12,024,800
14,028,900
29 B-1-12-II
11,144,700
13,373,700
15,602,600
30 B-1-12-III
17,434,700
20,921,700
24,408,600
7,981,600
9,577,900
11,174,200
13,132,700
15,759,200
18,385,800
16,992,600
20,391,100
23,789,600
20,911,600
25,094,000
29,276,300
21,963,100
26,355,700
30,748,300
38,878,500
3,393,200
5,416,500
7,472,200
46,654,200
4,071,800
6,499,800
8,966,700
54,429,900
4,750,500
7,583,100
10,461,100
7,154,100
8,585,000
10,015,800
10,015,900
12,019,000
14,022,200
12,134,100
14,560,900
16,987,700
6,468,100
9,210,400
13,703,000
6,170,100
7,761,800
11,052,400
16,443,600
7,404,100
9,055,400
12,894,500
19,184,200
8,638,100
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,207,700
- 607 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,187,900
8,625,400
10,063,000
48 B-4-13-III
49 B-4-14-I

9,901,900
6,163,500
11,882,300
7,396,200
13,862,700
8,628,900
50 B-4-14-II
7,190,500
8,628,600
10,066,700
51 B-4-14-III
52 C-4-10-I

9,631,800
12,483,500
11,558,200
14,980,200
13,484,500
17,476,800
53 C-4-10-II
54 C-4-10-III

20,076,800
37,617,500
24,092,200
45,141,000
28,107,600
52,664,500
55 C-4-11-I
6,498,000
7,797,600
9,097,200
56 C-4-11-II
57 C-4-11-III

8,695,300
13,369,200
10,434,400
16,043,000
12,173,400
18,716,800
58 C-4-12-I
59 C-4-12-II
4,326,600
8,521,700
5,191,900
10,226,100
6,057,200
11,930,400
60 C-4-12-III
RADIOTERAPI (BERAT)
21,886,200
26,263,400
30,640,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,252,700
6,121,700
3,903,300
7,346,000
4,553,800
8,570,300
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,286,700
5,404,500
9,944,000
6,485,400
11,601,300
7,566,400
65 C-4-14-II
7,581,500
9,097,800
10,614,100
66 C-4-14-III
67 D-1-10-I

11,296,200
32,652,700
13,555,500
39,183,200
15,814,700
45,713,800
68 D-1-10-II
69 D-1-10-III

49,732,400
71,271,800
59,678,800
85,526,200
69,625,300
99,780,600
70 D-1-11-I
8,742,400
10,490,900
12,239,400
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
22,323,600
29,010,300
26,788,300
34,812,400
31,253,000
40,614,500
7,578,700
9,094,400
10,610,200
20,885,800
25,062,900
29,240,100
33,130,900
39,757,100
46,383,300
2,994,900
4,914,900
7,732,300
5,933,100
10,661,500
14,646,300
5,115,100
7,094,800
10,894,400
3,593,900
5,897,900
9,278,800
7,119,700
12,793,800
17,575,600
6,138,200
8,513,700
13,073,300
4,192,800
6,880,900
10,825,300
8,306,300
14,926,100
20,504,800
7,161,200
9,932,700
15,252,100
4,383,500
5,260,300
6,137,000
6,204,200
7,445,000
8,685,900
7,935,400
9,522,400
11,109,500
4,701,500
5,641,900
6,582,200
7,697,600
9,237,100
10,776,700
9,415,000
11,298,000
13,181,000
9,372,000
11,246,400
13,120,800
12,794,100
15,353,000
17,911,800
93 E-1-01-III
30,848,000
37,017,600
43,187,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,743,800
13,525,600
25,554,300
11,692,600
16,230,700
30,665,100
13,641,400
18,935,800
35,776,000
11,030,800
13,236,900
15,443,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 608 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,336,400
5,203,700
6,071,000
104 E-4-11-II
105 E-4-11-III

6,611,200
8,958,700
7,933,500
10,750,400
9,255,700
12,542,200
106 E-4-12-I
107 E-4-12-II

4,982,500
8,628,400
5,978,900
10,354,100
6,975,400
12,079,800
108 E-4-12-III

(RINGAN)
(SEDANG)
10,227,800
12,273,400
14,319,000
5,425,700
6,510,900
7,596,000
7,947,700
9,537,300
11,126,800
111 E-4-13-III
10,389,200
12,467,100
14,544,900
112 F-4-10-I
113 F-4-10-II
5,776,400
6,638,800
6,931,700
7,966,500
8,086,900
9,294,300
114 F-4-10-III
115 F-4-11-I
7,966,500
5,586,700
9,559,800
6,704,000
11,153,100
7,821,300
116 F-4-11-II
6,509,100
7,810,900
9,112,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,347,000
10,016,400
11,685,800
3,062,400
3,674,900
4,287,400
4,353,800
5,224,500
6,095,300
9,458,300
11,350,000
13,241,700
4,500,200
5,938,100
7,687,700
2,567,600
3,293,300
4,431,400
5,400,200
7,125,700
9,225,200
3,081,100
3,951,900
5,317,600
6,300,300
8,313,400
10,762,700
3,594,600
4,610,600
6,203,900
127 F-4-15-I
4,089,000
4,906,900
5,724,700
128 F-4-15-II
6,093,200
7,311,800
8,530,500
129 F-4-15-III
8,044,900
9,653,900
11,262,900
8,045,400
9,654,500
11,263,500
9,354,100
11,224,900
13,095,700
12,486,100
14,983,300
17,480,500
133 F-4-17-I

1,900,000
2,280,000
2,660,000
134 F-4-17-II
5,568,700
6,682,400
7,796,200
135
136
137
138
139
140
141

(RINGAN)
5,941,300
6,990,900
7,691,900
11,857,700
5,342,600
6,841,500
8,517,600
7,129,500
8,389,000
9,230,300
14,229,200
6,411,200
8,209,800
10,221,100
8,317,800
9,787,200
10,768,700
16,600,700
7,479,700
9,578,100
11,924,700
22,664,100
27,196,900
31,729,700
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,847,100
17,816,500
20,786,000
20,462,400
24,554,900
28,647,300
3,903,800
4,684,500
5,465,300
7,560,900
9,073,100
10,585,300
12,669,200
15,203,000
17,736,800
- 609 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
53,035,900
63,643,100
74,250,300
148 G-1-11-I
149 G-1-11-II

17,344,800
31,710,400
20,813,800
38,052,400
24,282,700
44,394,500
150 G-1-11-III
50,957,200
61,148,600
71,340,000
7,242,100
8,690,500
10,138,900
13,575,600
16,290,700
19,005,800
18,500,900
22,201,100
25,901,200
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,184,700
5,867,100
2,621,700
7,040,500
3,058,600
8,213,900
156 G-1-13-III
157 G-1-20-I

13,238,700
12,264,900
15,886,400
14,717,800
18,534,200
17,170,800
158 G-1-20-II
18,558,700
22,270,400
25,982,200
159 G-1-20-III
31,645,900
37,975,100
44,304,300
160 G-1-30-I
30,555,000
36,665,900
42,776,900
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
41,195,600
61,862,300
49,434,700
74,234,800
57,673,800
86,607,300
6,216,500
7,459,800
8,703,100
7,598,700
9,118,400
10,638,200
10,426,700
12,512,100
14,597,400
6,507,700
7,809,300
9,110,800
8,644,700
10,373,600
12,102,600
12,702,000
15,242,400
17,782,800
7,219,600
8,663,500
10,107,400
9,118,800
10,942,600
12,766,400
13,244,000
15,892,800
18,541,500
4,336,900
5,204,300
6,071,600
7,562,700
9,075,200
10,587,800
8,969,500
10,763,400
12,557,300
7,357,000
8,828,400
10,299,900
9,835,800
11,803,000
13,770,200
12,345,100
14,814,100
17,283,200
6,011,300
7,213,600
8,415,900
7,174,200
8,609,100
10,043,900
10,125,800
12,151,000
14,176,200
4,955,500
5,946,600
6,937,800
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
32,505,700
39,006,900
45,508,000
53,182,100
63,818,500
74,454,900
35,238,600
43,158,500
42,286,300
51,790,200
49,334,100
60,421,900
- 610 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,579,100
7,895,000
9,210,800
183 G-4-16-III
9,369,300
11,243,100
13,117,000
6,600,400
7,920,500
9,240,600
8,654,600
10,385,600
12,116,500
10,874,900
13,049,900
15,224,900
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,500,400
7,800,500
9,100,600
188 G-4-18-II
8,689,100
10,426,900
12,164,700
189 G-4-18-III
9,722,400
11,666,900
13,611,400
5,423,400
6,508,100
7,592,800
9,166,900
11,000,300
12,833,700
12,035,800
14,442,900
16,850,100
193 G-4-20-I

3,794,000
4,552,800
5,311,600
194 G-4-20-II
5,363,500
6,436,200
7,508,900
195 G-4-20-III
196 G-4-21-I

8,859,200
3,950,800
10,631,100
4,741,000
12,402,900
5,531,100
197 G-4-21-II
198 G-4-21-III

6,686,800
7,858,600
8,024,200
9,430,300
9,361,600
11,002,000
199 G-4-22-I
2,959,900
3,551,900
4,143,900
200 G-4-22-II
201 G-4-22-III

5,242,100
8,268,900
6,290,500
9,922,700
7,338,900
11,576,500
202 G-4-23-I
203 G-4-23-II

3,889,200
4,879,600
4,667,000
5,855,500
5,444,900
6,831,400
204 G-4-23-III
6,947,400
8,336,800
9,726,300
205 G-4-24-I
206 G-4-24-II

4,332,000
5,412,200
5,198,400
6,494,600
6,064,800
7,577,100
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
9,016,500
3,701,600
4,681,100
6,203,400
10,819,800
4,441,900
5,617,300
7,444,000
12,623,200
5,182,300
6,553,500
8,684,700
4,220,100
5,064,100
5,908,200
4,909,300
5,891,200
6,873,000
7,340,900
8,809,100
10,277,300
12,483,200
13,795,900
18,761,600
8,506,200
10,568,200
14,802,200
4,510,200
6,119,400
12,027,900
4,324,800
4,933,300
7,064,200
5,099,000
6,092,300
10,209,700
14,979,800
16,555,100
22,513,900
10,207,500
12,681,800
17,762,700
5,412,200
7,343,200
14,433,500
5,189,800
5,919,900
8,477,000
6,118,800
7,310,800
12,251,600
17,476,500
19,314,200
26,266,200
11,908,700
14,795,400
20,723,100
6,314,200
8,567,100
16,839,000
6,054,700
6,906,600
9,889,800
7,138,600
8,529,300
14,293,600
229 I-1-01-I
68,488,400
82,186,000
95,883,700
230 I-1-01-II
69,995,100
83,994,100
97,993,100
231 I-1-01-III

(RINGAN)
110,486,300
132,583,500
154,680,800
37,997,100
45,596,500
53,195,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 611 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
51,084,000
61,300,800
71,517,600
245 I-1-06-II
73,999,300
88,799,200
103,599,000
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
88,294,800
105,953,800
123,612,800
79,513,500
95,416,200
111,318,800
99,391,800
119,270,200
139,148,600
149,087,700
178,905,300
208,722,800
5,954,300
7,145,100
8,336,000
6,620,500
7,944,700
9,268,800
8,809,900
10,571,900
12,333,900
17,139,200
20,567,100
23,994,900
27,991,800
33,590,100
39,188,500
36,827,400
44,192,900
51,558,400
16,624,800
19,949,800
23,274,700
22,139,300
26,567,200
30,995,000
27,303,900
32,764,700
38,225,400
34,026,900
40,832,300
47,637,600
42,290,400
50,748,500
59,206,600
55,415,000
66,498,000
77,581,000
6,464,100
9,027,000
17,382,500
7,756,900
10,832,400
20,859,000
9,049,800
12,637,800
24,335,500
16,757,400
20,108,800
23,460,300
37,915,200
45,498,200
53,081,200
43,734,600
52,481,500
61,228,400
19,403,400
23,284,100
27,164,800
24,294,900
29,153,900
34,012,900
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
49,015,700
58,818,900
68,622,000
60,414,900
72,497,900
84,580,900
35,835,300
43,002,400
50,169,400
49,675,200
59,610,200
69,545,200
63,041,600
75,649,900
88,258,200
54,001,900
64,802,200
75,602,600
85,229,500
102,275,400
119,321,300
136,153,600
163,384,300
190,615,000
89,452,600
107,343,200
125,233,700
109,331,000
131,197,200
153,063,400
149,087,700
178,905,300
208,722,800
- 612 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
37,746,400
45,295,600
52,844,900
279 I-1-40-III
50,416,300
60,499,600
70,582,900
280 I-4-10-I
281 I-4-10-II

5,755,300
10,276,800
6,906,400
12,332,200
8,057,400
14,387,500
282 I-4-10-III
14,807,400
17,768,900
20,730,400
283 I-4-11-I
284 I-4-11-II

8,854,600
10,957,600
10,625,500
13,149,100
12,396,400
15,340,600
285 I-4-11-III
286 I-4-12-I

20,270,300
5,090,100
24,324,400
6,108,100
28,378,400
7,126,100
287 I-4-12-II
5,900,100
7,080,200
8,260,200
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,080,200
8,496,200
9,912,200
5,179,800
6,215,700
7,251,700
9,249,100
11,099,000
12,948,800
13,326,700
15,992,000
18,657,400
4,891,400
5,059,700
8,869,700
5,869,700
6,071,700
10,643,700
6,848,000
7,083,600
12,417,600
4,995,500
5,994,600
6,993,700
9,420,000
11,304,000
13,188,000
11,304,000
13,564,800
15,825,700
3,087,200
4,957,300
5,948,800
2,061,200
3,326,200
4,656,700
3,704,600
5,948,800
7,138,500
2,473,500
3,991,400
5,588,000
4,322,100
6,940,200
8,328,300
2,885,700
4,656,700
6,519,300
5,954,900
7,145,900
8,336,800
9,066,600
10,879,900
12,693,200
12,309,300
14,771,200
17,233,100
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
30,052,400
36,062,900
42,073,400
21,871,000
26,245,200
30,619,400
27,322,900
32,787,500
38,252,100
28,722,000
34,466,400
40,210,800
16,544,200
19,853,000
23,161,900
34,415,600
41,298,700
48,181,800
53,331,700
63,998,100
74,664,400
15,268,500
18,322,200
21,375,900
307 I-4-19-I
5,745,300
6,894,300
8,043,400
308 I-4-19-II

(SEDANG)
8,968,700
10,762,400
12,556,200
309 I-4-19-III
10,706,900
12,848,300
14,989,700
310
311
312
313
314

5,982,500
6,909,800
10,331,600
4,029,000
5,104,800
7,179,000
8,291,800
12,397,900
4,834,800
6,125,800
8,375,500
9,673,800
14,464,200
5,640,600
7,146,700
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 613 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,368,200
8,841,900
10,315,500
316 I-4-22-I
317 I-4-22-II
3,620,000
4,506,300
4,343,900
5,407,600
5,067,900
6,308,800
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,586,800
7,904,100
9,221,500
4,910,800
5,893,000
6,875,100
6,029,100
7,234,900
8,440,700
11,780,400
14,136,500
16,492,600
3,190,400
3,828,500
4,466,500
7,346,600
8,815,900
10,285,200
9,288,500
11,146,100
13,003,800
101,085,500
121,302,600
141,519,700
114,397,100
137,276,500
160,155,900
156,915,300
188,298,400
219,681,400
65,946,100
79,135,300
92,324,500
83,211,100
99,853,300
116,495,600
97,345,200
116,814,300
136,283,300
12,856,500
15,427,700
17,999,000
26,015,100
31,218,100
36,421,100
27,036,100
32,443,300
37,850,600
35,417,200
42,500,700
49,584,100
37,086,600
44,503,900
51,921,200
41,736,100
50,083,400
58,430,600
10,729,000
12,874,900
15,020,700
19,435,500
23,322,600
27,209,800
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
56,100,000
67,320,000
78,540,000
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,162,700
6,531,700
9,881,500
3,912,900
5,449,900
7,305,000
6,646,000
7,565,500
10,563,600
5,876,200
8,179,500
15,260,300
6,478,700
10,542,600
12,473,000
4,688,000
7,763,300
14,100,500
3,795,200
7,838,100
11,857,800
4,695,500
6,539,900
8,766,000
7,975,200
9,078,700
12,676,300
7,051,500
9,815,400
18,312,300
7,774,400
12,651,200
14,967,600
5,625,600
9,316,000
16,920,600
4,427,700
9,144,400
13,834,100
5,478,000
7,629,800
10,227,000
9,304,400
10,591,800
14,789,000
8,226,700
11,451,300
21,364,400
9,070,100
14,759,700
17,462,200
6,563,200
10,868,700
19,740,700
3,906,100
4,687,300
5,468,500
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 614 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,608,400
9,130,100
10,651,800
12,986,500
15,583,900
18,181,200
5,413,500
6,482,800
6,496,200
7,779,400
7,578,900
9,076,000

8,507,400
2,406,300
10,208,900
2,887,600
11,910,400
3,368,800
365 J-4-18-II
4,587,500
5,505,000
6,422,500
366 J-4-18-III
367 J-4-19-I

6,519,100
6,862,600
7,822,900
8,235,100
9,126,700
9,607,600
368 J-4-19-II
369 J-4-19-III

7,782,600
8,594,900
9,339,100
10,313,900
10,895,600
12,032,900
370 J-4-20-I
5,459,100
6,550,900
7,642,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,564,200
8,867,500
9,077,000
10,641,000
10,589,800
12,414,600
3,118,900
3,742,700
4,366,500
6,964,500
8,357,400
9,750,200
13,119,800
15,743,800
18,367,700
11,655,200
13,986,200
16,317,200
14,647,200
17,576,600
20,506,100
17,167,000
20,600,400
24,033,800
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,945,600
13,134,800
15,323,900

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
14,370,300
28,404,200
17,244,400
34,085,000
20,118,400
39,765,800
4,890,300
5,868,400
6,846,500
6,360,500
7,632,500
8,904,600
12,601,000
15,121,200
17,641,400
5,515,300
6,066,900
9,696,100
6,618,400
7,280,200
11,635,300
7,721,500
8,493,600
13,574,600
8,055,300
9,666,400
11,277,500
9,440,700
11,328,800
13,217,000
390 K-1-14-III
16,480,700
19,776,800
23,072,900
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

17,330,800
24,207,300
35,345,200
20,797,000
29,048,700
42,414,200
24,263,100
33,890,200
49,483,200
10,249,300
12,299,200
14,349,000
18,202,500
21,843,100
25,483,600
25,047,000
30,056,400
35,065,700
397 K-1-40-I
11,435,900
13,723,000
16,010,200
398 K-1-40-II

(SEDANG)
12,608,400
15,130,100
17,651,800
399 K-1-40-III
21,366,800
25,640,100
29,913,500
400
401
402
403
404

8,738,100
11,347,600
16,036,200
7,213,800
10,365,200
10,485,800
13,617,100
19,243,400
8,656,500
12,438,200
12,233,400
15,886,600
22,450,700
10,099,300
14,511,200
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 615 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,801,100
18,961,400
22,121,600
406 K-4-11-I
407 K-4-11-II

2,507,700
4,939,400
3,009,200
5,927,300
3,510,800
6,915,200
408 K-4-11-III
409 K-4-12-I

5,927,300
4,336,400
7,112,800
5,203,700
8,298,200
6,071,000
410 K-4-12-II
5,835,500
7,002,600
8,169,700
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,653,800
11,584,500
13,515,300
5,845,800
7,014,900
8,184,100
7,561,900
9,074,200
10,586,600
11,647,700
13,977,200
16,306,800
3,335,600
4,002,700
4,669,900
4,477,500
5,373,000
6,268,500
7,184,600
8,621,500
10,058,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,754,500
5,705,400
6,656,400
419 K-4-15-II
7,322,500
8,787,000
10,251,500
420 K-4-15-III
10,422,600
12,507,100
14,591,600
421 K-4-16-I
4,305,800
5,167,000
6,028,200
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,163,900
6,025,500
6,196,700
7,230,600
7,229,500
8,435,700
2,112,100
2,534,500
2,956,900
2,601,000
3,121,200
3,641,400
3,121,200
3,745,500
4,369,700
1,861,200
2,233,500
2,605,700
3,140,800
3,769,000
4,397,200
429 K-4-18-III
3,769,000
4,522,800
5,276,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
27,631,800
41,709,500
55,730,700
13,037,000
22,370,600
27,773,400
33,158,200
50,051,400
66,876,900
15,644,400
26,844,700
33,328,100
38,684,600
58,393,300
78,023,000
18,251,700
31,318,800
38,882,800
7,306,200
8,767,400
10,228,700
14,654,600
17,585,500
20,516,500
24,667,000
29,600,400
34,533,800
9,591,600
15,436,600
22,080,600
2,508,700
2,912,000
3,380,000
5,253,700
7,220,700
16,407,700
2,495,000
3,300,000
10,911,700
11,509,900
18,524,000
26,496,700
3,010,500
3,494,300
4,056,000
6,304,400
8,664,800
19,689,200
2,994,000
3,960,000
13,094,100
13,428,200
21,611,300
30,912,800
3,512,200
4,076,700
4,732,000
7,355,100
10,109,000
22,970,700
3,493,000
4,620,000
15,276,400
2,656,700
3,188,000
3,719,400
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 616 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,327,900
5,193,500
6,059,100
8,597,600
10,317,100
12,036,600
4,320,500
5,184,600
6,048,700
6,489,500
7,787,400
9,085,400
9,147,800
10,977,300
12,806,900
15,272,500
18,327,000
21,381,600
21,707,800
26,049,300
30,390,900
30,492,900
36,591,500
42,690,100
13,536,200
16,243,500
18,950,700
22,205,700
37,727,000
26,646,800
45,272,400
31,088,000
52,817,800
54,109,300
64,931,200
75,753,000
63,288,700
75,946,500
88,604,200
78,330,400
93,996,400
109,662,500
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
27,712,400
33,254,900
38,797,400
467 M-1-04-II
35,602,400
42,722,900
49,843,400
468 M-1-04-III
42,599,200
51,119,000
59,638,800
469 M-1-05-I
470 M-1-05-II

10,775,600
17,430,000
12,930,700
20,916,000
15,085,900
24,402,000
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
22,264,600
26,717,500
31,170,400
19,694,900
23,633,900
27,572,900
26,384,400
31,661,200
36,938,100
53,747,400
64,496,900
75,246,400
23,274,100
27,929,000
32,583,800
55,647,500
66,777,000
77,906,500
120,026,400
144,031,700
168,037,000
18,136,200
21,763,500
25,390,700
23,170,900
27,805,000
32,439,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
57,688,400
69,226,100
80,763,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,441,900
20,161,000
28,828,400
14,930,300
24,193,200
34,594,100
17,418,700
28,225,400
40,359,800
7,600,100
9,120,100
10,640,100
11,232,000
13,478,400
15,724,800
16,037,200
19,244,600
22,452,000
7,589,600
12,594,900
20,686,300
9,107,500
15,113,900
24,823,500
10,625,500
17,632,800
28,960,800
11,721,500
14,065,900
16,410,200
14,736,700
17,684,000
20,631,400
22,261,500
26,713,900
31,166,200
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 617 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
4,348,600
5,218,300
6,088,100
500 M-4-10-II
501 M-4-10-III
6,485,200
12,270,100
7,782,300
14,724,100
9,079,300
17,178,100
5,418,800
6,502,500
7,586,300
11,880,400
14,256,500
16,632,600
17,177,100
20,612,500
24,047,900
4,325,400
5,190,500
6,055,600
7,194,300
8,633,200
10,072,100
9,623,200
11,547,800
13,472,400
7,202,200
8,642,700
10,083,100
10,821,000
12,985,300
15,149,500
21,111,600
25,333,900
29,556,300
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,213,900
9,856,700
11,499,400
512 M-4-14-II
10,130,600
12,156,700
14,182,900
513 M-4-14-III
514 M-4-15-I
15,223,400
4,870,600
18,268,100
5,844,700
21,312,700
6,818,800
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,492,200
14,732,600
4,170,000
6,677,700
11,218,100
7,790,600
17,679,200
5,004,000
8,013,300
13,461,800
9,089,000
20,625,700
5,838,000
9,348,800
15,705,400
4,870,900
5,845,000
6,819,200
6,812,500
8,174,900
9,537,400
9,513,100
11,415,800
13,318,400
4,090,700
6,164,800
7,422,700
4,908,800
7,397,800
8,907,300
5,726,900
8,630,800
10,391,800
4,265,900
5,119,100
5,972,300
7,185,500
8,622,600
10,059,700
14,033,700
16,840,400
19,647,200
3,872,800
4,647,400
5,422,000
5,671,100
6,805,300
7,939,600
6,338,200
7,605,800
8,873,400
3,899,600
4,679,600
5,459,500
4,877,300
5,852,800
6,828,300
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,716,300
26,059,500
30,402,800
23,887,900
28,665,500
33,443,100
27,348,500
32,818,200
38,287,900
12,344,800
14,813,800
17,282,700
14,660,600
32,997,800
17,592,700
39,597,400
20,524,800
46,197,000
- 618 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,934,900
13,121,900
15,308,800
535 N-1-01-I

299,914,400
359,897,300
419,880,100
536 N-1-01-II
299,914,400
359,897,300
419,880,100
537 N-1-01-III
538 N-1-11-I

299,914,400
12,498,300
359,897,300
14,997,900
419,880,100
17,497,600
539 N-1-11-II
540 N-1-11-III

19,762,800
30,810,200
23,715,400
36,972,300
27,667,900
43,134,300
6,370,000
7,644,000
8,917,900
12,681,900
15,218,300
17,754,700
27,520,200
33,024,200
38,528,300
13,927,100
16,712,600
19,498,000

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
19,490,300
27,274,300
23,388,300
32,729,200
27,286,400
38,184,000
12,745,800
15,294,900
17,844,100
19,281,900
23,138,200
26,994,600
22,191,600
26,629,900
31,068,200
11,446,600
13,736,000
16,025,300
15,544,200
18,653,100
21,761,900
18,091,500
21,709,800
25,328,100
4,863,200
5,835,900
6,808,500
5,882,100
7,058,600
8,235,000
8,651,800
10,382,100
12,112,500
3,733,300
6,522,600
8,115,400
2,814,800
5,847,700
9,502,100
3,808,900
6,367,700
13,173,400
4,480,000
7,827,100
9,738,500
3,377,700
7,017,200
11,402,600
4,570,600
7,641,200
15,808,000
5,226,600
9,131,600
11,361,600
3,940,700
8,186,800
13,303,000
5,332,400
8,914,700
18,442,700
3,749,500
4,499,400
5,249,300
5,320,300
6,384,400
7,448,400
8,528,400
10,234,100
11,939,800
4,429,500
5,315,400
6,201,300
5,496,200
6,595,500
7,694,700
6,272,100
7,526,600
8,781,000
5,423,900
6,508,700
7,593,500
7,741,700
9,290,000
10,838,300
10,304,700
12,365,700
14,426,600
5,557,700
7,153,500
6,669,200
8,584,300
7,780,800
10,015,000
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 619 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,276,400
13,531,600
15,786,900
5,041,800
6,050,200
7,058,500
5,603,400
6,724,100
7,844,700
6,970,700
8,364,800
9,759,000
3,572,000
4,286,400
5,000,900
4,290,000
5,148,000
6,006,000
5,390,500
6,468,700
7,546,800
1,810,700
2,172,900
2,535,000
2,970,600
3,564,700
3,564,700
4,277,600
4,158,800
4,990,600
79,764,200
95,717,000
111,669,900
98,696,200
118,435,500
138,174,700
115,841,600
139,009,900
162,178,200
108,874,300
130,649,200
152,424,100
124,889,800
149,867,800
174,845,700
142,695,500
171,234,500
199,773,600
16,331,000
19,597,200
22,863,500
21,616,400
25,939,600
30,262,900
30,393,600
36,472,300
42,551,000
52,627,500
63,153,000
73,678,500
68,299,100
81,958,900
95,618,700
97,923,700
117,508,500
137,093,200
28,617,100
34,340,500
40,064,000
44,146,900
52,976,300
61,805,700
59,761,000
71,713,200
83,665,400
7,725,700
9,270,900
10,816,000
21,661,100
25,993,400
30,325,600
28,695,700
34,434,800
40,174,000
9,146,100
10,975,300
12,804,500
25,643,500
30,772,100
35,900,800
33,971,300
40,765,500
47,559,800
5,292,000
6,350,400
7,408,800
7,509,100
9,010,900
10,512,800
14,608,200
17,529,800
20,451,500
13,609,200
16,331,000
19,052,900
18,013,600
21,616,400
25,219,100
- 620 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
25,328,000
30,393,600
35,459,200
12,372,000
14,846,400
17,320,800
15,011,400
18,013,600
21,015,900
22,024,300
26,429,200
30,834,100
6,873,300
8,248,000
9,622,700
10,722,400
12,866,900
15,011,400
16,941,800
20,330,200
23,718,500
5,202,600
6,243,100
7,283,600
10,590,400
12,708,500
14,826,500
41,409,200
49,691,100
57,972,900
3,902,000
4,682,400
5,462,800
7,813,900
9,376,700
10,939,500
9,168,200
11,001,900
12,835,500
3,531,400
4,237,600
4,943,900
6,786,100
8,143,300
9,500,500
15,914,500
19,097,400
22,280,300
4,582,200
5,498,700
6,415,100
8,248,000
9,897,600
11,547,200
14,118,200
16,941,800
19,765,400
3,981,600
4,777,900
5,574,200
4,905,900
5,887,100
6,868,200
6,715,700
8,058,800
9,401,900
1,829,700
3,719,100
8,581,100
2,927,200
3,896,100
6,753,900
2,195,700
4,462,900
10,297,300
3,512,700
4,675,300
8,104,700
2,561,600
5,206,700
12,013,600
4,098,100
5,454,500
9,455,500
4,322,800
5,187,300
6,051,900
7,668,900
9,202,700
10,736,500
12,447,600
14,937,200
17,426,700
2,187,600
2,625,100
3,062,700
4,646,700
5,576,000
6,505,400
8,811,800
10,574,100
12,336,500
1,463,100
1,755,700
2,048,300
2,761,100
3,313,300
3,865,600
3,576,100
4,291,300
5,006,600
7,576,200
9,091,500
10,606,700
- 621 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,635,200
11,562,200
13,489,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,795,600
16,554,700
19,313,800
3,651,600
4,381,900
5,112,200
5,419,400
6,503,300
7,587,100
6,518,000
7,821,600
9,125,200
2,443,200
2,931,800
3,420,500
3,281,500
3,937,800
4,594,200
5,969,600
7,163,600
8,357,500
1,337,800
1,605,300
1,872,900
2,549,200
3,059,000
3,568,800
3,705,300
4,446,400
5,187,400
1,292,000
1,550,400
1,808,800
2,033,200
2,439,900
2,846,500
3,275,000
3,930,000
4,585,000
3,027,300
3,632,700
4,238,200
4,569,900
5,483,900
6,397,900
7,073,600
8,488,300
9,903,000
7,984,100
9,581,000
11,177,800

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,394,500
32,737,200
14,873,500
39,284,700
17,352,400
45,832,100
12,600,100
15,120,100
17,640,100
19,004,900
22,805,900
26,606,900
22,529,100
27,034,900
31,540,700
9,651,600
14,800,200
21,738,400
9,658,200
11,253,300
18,654,500
11,581,900
17,760,200
26,086,100
11,589,900
13,504,000
22,385,400
13,512,200
20,720,300
30,433,800
13,521,500
15,754,700
26,116,400
5,803,900
6,964,700
8,125,500
7,122,800
8,547,300
9,971,900
8,440,500
10,128,600
11,816,700
4,542,900
6,458,700
9,838,600
5,451,500
7,750,500
11,806,300
6,360,100
9,042,200
13,774,100
8,811,200
10,573,500
12,335,700
13,113,600
15,736,300
18,359,000
33,665,000
40,398,000
47,131,000
7,556,600
10,246,400
20,037,300
9,067,900
12,295,700
24,044,700
10,579,200
14,345,000
28,052,200
5,438,000
6,525,600
7,613,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 622 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,630,100
3,156,100
3,682,100
697 U-4-12-I
698 U-4-12-II

2,824,600
4,554,200
3,389,500
5,465,000
3,954,400
6,375,800
699 U-4-12-III

7,975,800
9,570,900
11,166,100
2,140,600
2,568,800
2,996,900
3,498,000
4,197,600
4,897,200
5,648,100
6,777,700
7,907,300
5,412,700
6,481,500
6,495,200
7,777,800
7,577,700
9,074,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,884,500
13,061,300
15,238,200
4,346,200
5,215,500
6,084,700
5,414,800
6,497,800
7,580,800
7,578,100
9,093,800
10,609,400
7,089,000
8,506,900
9,924,700
14,603,200
17,523,800
20,444,400
17,908,800
21,490,500
25,072,300
13,486,600
15,400,100
24,117,200
16,183,900
18,480,100
28,940,600
18,881,200
21,560,100
33,764,000
12,680,000
15,216,000
17,752,000
17,315,500
20,778,700
24,241,800
21,947,600
26,337,200
30,726,700
6,614,000
7,936,900
9,259,700
12,637,300
15,164,700
17,692,200
19,826,300
23,791,600
27,756,800
12,970,100
15,564,100
18,158,200
18,845,200
22,614,200
26,383,300
723 V-1-14-III
23,531,600
28,237,900
32,944,300
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,088,800
2,305,000
2,549,800
2,506,600
2,766,000
3,059,800
2,924,400
3,227,000
3,569,800
5,644,900
6,773,900
7,902,900
9,376,500
11,251,800
13,127,100
15,458,500
18,550,200
21,642,000
5,419,500
6,503,400
7,587,300
7,271,600
8,725,900
10,180,200
9,740,300
11,688,400
13,636,500
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,449,300
14,939,200
17,429,100
19,113,500
22,936,200
26,759,000
1,719,000
2,500,100
2,062,800
3,000,100
2,406,600
3,500,100
- 623 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,771,600
17,725,900
20,680,300
17,704,800
21,245,800
24,786,700
25,264,300
30,317,100
35,370,000
3,133,300
3,759,900
4,386,600
3,457,500
3,824,700
4,149,100
4,589,700
4,840,600
5,354,600
3,275,000
3,930,000
4,584,900
3,613,900
4,336,700
5,059,500
3,997,700
4,797,200
5,596,800
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,523,200
4,227,800
4,932,500
743 W-1-12-II
744 W-1-12-III

4,397,500
7,787,100
5,277,100
9,344,500
6,156,600
10,901,900
745 W-1-13-I
3,621,500
4,345,900
5,070,200
746 W-1-13-II
747 W-1-13-III

3,931,800
5,281,400
4,718,100
6,337,700
5,504,500
7,393,900
748 W-1-20-I
749 W-1-20-II

12,128,200
15,154,300
14,553,900
18,185,200
16,979,500
21,216,000
750 W-1-20-III
17,567,800
21,081,300
24,594,900
751 W-1-30-I
6,846,500
8,215,800
9,585,200
752 W-1-30-II
10,920,200
13,104,300
15,288,300
753 W-1-30-III
26,793,400
32,152,000
37,510,700
754 W-4-10-I
5,101,400
6,121,700
7,141,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,562,600
14,945,200
4,175,400
6,338,900
7,715,600
9,075,100
17,934,200
5,010,500
7,606,700
9,258,800
10,587,600
20,923,200
5,845,600
8,874,500
10,801,900
3,131,000
3,757,200
4,383,400
5,958,300
7,150,000
8,341,700
8,768,100
10,521,800
12,275,400
1,825,300
2,493,400
3,100,700
2,439,300
2,903,400
3,714,600
1,761,700
2,712,000
5,069,000
2,344,000
4,344,800
7,949,600
1,729,600
4,328,600
8,639,800
5,144,300
6,828,000
9,700,400
3,349,000
4,022,300
5,528,800
2,190,400
2,992,100
3,720,900
2,927,200
3,484,100
4,457,500
2,114,100
3,254,400
6,082,900
2,812,800
5,213,700
9,539,500
2,075,500
5,194,400
10,367,700
6,173,200
8,193,600
11,640,400
4,018,700
4,826,700
6,634,600
2,555,400
3,490,800
4,341,000
3,415,100
4,064,800
5,200,400
2,466,400
3,796,700
7,096,700
3,281,600
6,082,700
11,129,400
2,421,500
6,060,100
12,095,700
7,202,100
9,559,200
13,580,500
4,688,500
5,631,200
7,740,400
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 624 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,213,500
2,656,200
3,098,900
4,444,400
5,333,300
6,222,100
9,376,500
11,251,800
13,127,100
- 625 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,498,900
1,944,300
3,615,600
2,987,900
3,882,900
714,200
1,587,000
558,500
1,234,000
1,058,200
1,201,300
1,806,100
2,463,500
2,257,900
731,400
1,688,200
612,400
1,051,400
3,202,400
1,146,900
2,708,500
660,800
1,927,000
2,412,900
2,023,700
496,300
1,504,200
836,300
537,500
464,900
410,400
490,800
683,300
503,300
552,700
425,700
737,000
382,200
379,300
386,600
8,824,800
3,526,900
3,538,700
910,300
1,863,200
1,166,600
2,371,100
1,215,400
696,000
525,600
847,700
601,500
400,600
3,907,500
1,563,000
1,042,000
4,067,600
2,711,700
422,500
4,406,600
3,050,700
4,755,500
1,584,800
974,800
419,400
415,000
393,900
6,006,700
2,923,900
- 626 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,716,100
6,576,600
5,452,800
4,153,900
1,369,400
4,623,400
3,018,900
742,100
6,941,300
6,283,900
4,213,400
3,991,700
493,400
474,100
1,907,500
521,300
464,500
513,300
2,202,400
2,406,700
2,102,100
2,320,600
1,405,400
467,200
823,500
565,300
510,400
497,300
631,400
720,100
422,100
1,211,400
2,207,800
1,694,800
3,984,200
518,800
518,800
4,602,100
2,140,800
410,700
1,899,900
4,935,400
1,133,100
892,500
437,200
295,000
592,000
825,500
1,976,700
1,742,300
1,219,600
727,900
400,600
2,117,800
1,357,500
725,100
661,900
2,169,000
569,500
2,770,000
2,119,100
517,000
573,100
559,800
402,300
2,309,000
2,537,900
503,000
- 627 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,541,500
575,400
622,100
576,100
913,900
703,000
1,760,600
519,400
1,445,300
2,414,100
423,000
2,574,400
1,395,000
3,014,800
1,521,900
672,100
517,000
85,200
670,100
1,514,200
590,000
797,000
455,800
216,700
460,300
6,854,500
3,896,200
6,502,800
1,996,800
892,500
608,100
1,375,400
727,500
1,464,100
847,700
504,700
844,700
475,400
725,500
556,200
1,059,400
2,653,500
2,134,900
1,882,400
1,328,500
488,700
488,700
488,700
399,200
253,200
398,100
486,600
526,400
387,700
342,000
119,400
131,200
97,100
113,900
108,600
165,800
176,600
271,700
298,500
132,000
160,300
109,500
171,000
242,600
- 628 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
172,700
305,000
862,300
999,600
163,300
414,900
198,700
283,700
698,000
597,600
429,500
406,700
162,300
159,500
478,900
359,000
514,900
406,600
234,900
3,765,700
3,098,800
492,400
509,900
975,200
957,600
1,248,300
644,800
2,009,600
339,600
524,100
525,800
421,000
531,800
503,200
235,800
518,000
459,100
415,300
469,700
3,888,100
631,000
1,399,300
501,900
892,500
586,000
467,500
1,215,100
1,244,400
1,326,800
1,160,600
1,711,000
345,800
3,000,800
455,800
1,521,100
3,456,900
3,197,800
1,397,000
506,300
987,400
983,500
455,800
3,572,700
2,810,200
260,000
194,200
252,400
543,300
- 629 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,341,400
1,604,000
1,480,700
1,786,400
856,000
1,190,900
823,100
692,400
847,200
490,500
1,159,600
231,800
858,800
1,444,100
94,200
- 630 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,527,300
3,032,800
3,538,200
A-4-10-II
SEPTIKEMIA (SEDANG)
4,317,700
5,181,200
6,044,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,821,600
3,284,100
6,985,900
3,941,000
8,150,200
4,597,800
5
6
A-4-11-II
A-4-11-III

4,674,300
6,469,600
5,609,100
7,763,500
6,544,000
9,057,400
A-4-12-I
2,631,600
3,157,900
3,684,200
8
9
A-4-12-II
A-4-12-III

3,277,200
3,605,900
3,932,700
4,327,100
4,588,100
5,048,200
10 A-4-13-I
11 A-4-13-II

2,083,900
2,659,700
2,500,600
3,191,600
2,917,400
3,723,500
12 A-4-13-III
3,191,600
3,829,900
4,468,200
2,262,100
2,714,500
3,167,000
2,745,900
3,295,100
3,844,300
3,295,100
3,954,100
4,613,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,425,600
17,964,600
17,310,700
21,557,600
20,195,800
25,150,500
18 A-4-15-III
INFEKSI HIV (BERAT)
20,295,000
24,354,000
28,413,000
19 B-1-01-I
20 B-1-01-II

39,455,700
43,530,000
47,346,800
52,236,000
55,238,000
60,942,000
21 B-1-01-III
22 B-1-10-I

95,951,900
6,377,800
115,142,200
7,653,400
134,332,600
8,928,900
23 B-1-10-II
14,155,900
16,987,100
19,818,300
24 B-1-10-III
25 B-1-11-I

27,945,700
6,972,500
33,534,800
8,367,000
39,123,900
9,761,500
26 B-1-11-II
27 B-1-11-III

9,315,300
12,035,200
11,178,300
14,442,200
13,041,400
16,849,300
28 B-1-12-I
7,018,800
8,422,600
9,826,300
29 B-1-12-II
7,806,200
9,367,400
10,928,600
30 B-1-12-III
12,211,900
14,654,200
17,096,600
5,590,600
6,708,700
7,826,800
9,198,600
11,038,300
12,878,000
11,902,200
14,282,600
16,663,000
7,681,700
9,218,000
10,754,300
8,543,400
10,252,000
11,960,700
13,365,100
2,305,400
3,680,100
5,076,800
16,038,200
2,766,500
4,416,100
6,092,200
18,711,200
3,227,600
5,152,100
7,107,500
4,860,700
5,832,800
6,804,900
6,805,000
8,166,000
9,527,000
8,244,100
9,893,000
11,541,800
4,394,600
6,451,200
9,598,000
4,192,100
5,273,500
7,741,500
11,517,600
5,030,500
6,152,400
9,031,700
13,437,300
5,868,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 631 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,883,600
5,860,300
6,837,000
48 B-4-13-III
49 B-4-14-I

6,727,600
4,187,600
8,073,100
5,025,100
9,418,600
5,862,600
50 B-4-14-II
4,885,400
5,862,400
6,839,500
51 B-4-14-III
52 C-4-10-I

6,544,100
3,994,100
7,852,900
4,792,900
9,161,700
5,591,700
53 C-4-10-II
54 C-4-10-III

7,663,700
13,121,200
9,196,400
15,745,500
10,729,100
18,369,700
55 C-4-11-I
4,414,900
5,297,900
6,180,900
56 C-4-11-II
57 C-4-11-III

5,907,800
9,364,200
7,089,300
11,237,100
8,270,900
13,109,900
58 C-4-12-I
59 C-4-12-II
2,939,600
5,968,900
3,527,500
7,162,700
4,115,400
8,356,500
60 C-4-12-III
RADIOTERAPI (BERAT)
15,329,800
18,395,800
21,461,700
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,210,000
4,159,200
2,652,000
4,991,000
3,094,000
5,822,900
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,630,100
3,672,000
6,756,200
4,406,400
7,882,200
5,140,700
65 C-4-14-II
5,151,000
6,181,200
7,211,400
66 C-4-14-III
67 D-1-10-I

7,912,300
21,963,100
9,494,700
26,355,700
11,077,200
30,748,300
68 D-1-10-II
69 D-1-10-III

33,451,300
53,266,000
40,141,600
63,919,100
46,831,800
74,572,300
70 D-1-11-I
5,939,800
7,127,800
8,315,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,167,100
20,319,800
18,200,500
24,383,800
21,233,900
28,447,800
5,149,100
6,178,900
7,208,800
14,190,200
17,028,300
19,866,300
22,509,800
27,011,800
31,513,800
2,538,400
4,165,700
6,553,700
4,031,100
7,243,700
10,258,800
3,475,300
4,820,400
7,401,900
3,046,100
4,998,900
7,864,400
4,837,300
8,692,400
12,310,500
4,170,400
5,784,400
8,882,200
3,553,700
5,832,000
9,175,200
5,643,500
10,141,100
14,362,300
4,865,500
6,748,500
10,362,600
2,978,300
3,573,900
4,169,600
4,215,300
5,058,300
5,901,400
5,391,500
6,469,700
7,548,000
3,194,300
3,833,200
4,472,100
5,229,900
6,275,900
7,321,900
6,396,700
7,676,100
8,955,400
7,004,300
8,405,100
9,806,000
9,561,900
11,474,200
13,386,600
93 E-1-01-III
23,054,700
27,665,600
32,276,500
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,282,200
10,108,500
19,098,300
8,738,600
12,130,200
22,918,000
10,195,000
14,151,900
26,737,700
7,494,500
8,993,400
10,492,400
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 632 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,946,200
3,535,500
4,124,700
104 E-4-11-II
105 E-4-11-III

4,491,800
6,275,000
5,390,200
7,530,000
6,288,500
8,785,000
106 E-4-12-I
107 E-4-12-II

3,385,200
5,862,300
4,062,200
7,034,800
4,739,300
8,207,300
108 E-4-12-III

(RINGAN)
(SEDANG)
6,949,000
8,338,800
9,728,600
3,686,300
4,423,600
5,160,900
5,399,900
6,479,800
7,559,800
111 E-4-13-III
7,277,000
8,732,400
10,187,800
112 F-4-10-I
113 F-4-10-II
4,045,900
4,650,000
4,855,100
5,580,000
5,664,300
6,510,000
114 F-4-10-III
115 F-4-11-I
5,580,000
3,913,100
6,696,000
4,695,700
7,812,000
5,478,300
116 F-4-11-II
4,559,200
5,471,000
6,382,800
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
5,846,500
7,015,800
8,185,100
2,080,700
2,496,800
2,912,900
2,958,000
3,549,700
4,141,300
6,426,200
7,711,400
8,996,700
3,152,100
4,159,300
5,384,700
1,798,400
2,306,700
3,103,900
3,782,500
4,991,100
6,461,600
2,158,100
2,768,100
3,724,700
4,412,900
5,823,000
7,538,600
2,517,800
3,229,400
4,345,400
127 F-4-15-I
2,778,200
3,333,800
3,889,500
128 F-4-15-II
4,139,800
4,967,800
5,795,800
129 F-4-15-III
5,465,900
6,559,100
7,652,300
5,635,300
6,762,300
7,889,400
6,551,900
7,862,300
9,172,700
8,745,700
10,494,800
12,244,000
133 F-4-17-I

1,290,900
1,549,100
1,807,300
134 F-4-17-II
3,783,500
4,540,200
5,296,900
135
136
137
138
139
140
141

(RINGAN)
4,036,600
4,896,600
5,387,700
8,305,500
3,742,200
4,792,000
5,966,000
4,843,900
5,876,000
6,465,200
9,966,600
4,490,600
5,750,400
7,159,200
5,651,300
6,855,300
7,542,800
11,627,700
5,239,000
6,708,800
8,352,400
16,938,300
20,325,900
23,713,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,087,400
12,104,900
14,122,400
14,332,500
17,199,100
20,065,600
3,492,500
4,191,000
4,889,500
4,880,200
5,856,200
6,832,300
6,244,600
7,493,500
8,742,500
- 633 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
22,498,000
26,997,600
31,497,200
148 G-1-11-I
149 G-1-11-II

11,784,400
21,544,700
14,141,300
25,853,600
16,498,200
30,162,600
150 G-1-11-III
35,744,200
42,893,100
50,041,900
4,920,400
5,904,500
6,888,600
9,508,800
11,410,600
13,312,300
12,958,600
15,550,400
18,142,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,484,300
3,986,200
1,781,200
4,783,400
2,078,100
5,580,700
156 G-1-13-III
157 G-1-20-I

8,994,600
8,783,600
10,793,600
10,540,300
12,592,500
12,297,000
158 G-1-20-II
14,299,100
17,158,900
20,018,700
159 G-1-20-III
21,944,200
26,333,000
30,721,900
160 G-1-30-I
11,176,100
13,411,400
15,646,600
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
23,336,100
31,791,700
28,003,300
38,150,100
32,670,500
44,508,400
4,223,600
5,068,400
5,913,100
5,162,700
6,195,300
7,227,800
7,303,200
8,763,900
10,224,500
4,558,200
5,469,900
6,381,500
6,055,000
7,266,100
8,477,100
8,896,900
10,676,300
12,455,700
5,056,800
6,068,200
7,079,600
6,195,500
7,434,600
8,673,700
8,998,200
10,797,900
12,597,500
2,946,600
3,535,900
4,125,200
5,138,300
6,165,900
7,193,600
6,094,100
7,312,900
8,531,700
4,998,500
5,998,200
6,997,900
6,889,300
8,267,200
9,645,100
8,646,900
10,376,300
12,105,700
4,084,200
4,901,100
5,717,900
4,874,300
5,849,200
6,824,100
6,879,700
8,255,600
9,631,600
3,366,900
4,040,300
4,713,700
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
24,293,600
29,152,300
34,011,000
36,878,000
44,253,600
51,629,200
17,342,900
20,419,500
20,811,500
24,503,400
24,280,100
28,587,300
- 634 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,470,000
5,364,000
6,258,000
183 G-4-16-III
6,365,700
7,638,800
8,911,900
4,484,500
5,381,400
6,278,300
5,880,100
7,056,200
8,232,200
7,617,200
9,140,600
10,664,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,416,500
5,299,800
6,183,100
188 G-4-18-II
5,903,600
7,084,300
8,265,000
189 G-4-18-III
6,605,600
7,926,700
9,247,900
3,684,800
4,421,800
5,158,700
6,228,200
7,473,800
8,719,500
8,177,300
9,812,800
11,448,300
193 G-4-20-I

2,577,700
3,093,200
3,608,800
194 G-4-20-II
3,644,100
4,372,900
5,101,700
195 G-4-20-III
196 G-4-21-I

6,019,100
2,684,300
7,223,000
3,221,100
8,426,800
3,758,000
197 G-4-21-II
198 G-4-21-III

4,543,200
5,504,400
5,451,800
6,605,300
6,360,400
7,706,200
199 G-4-22-I
2,648,100
3,177,700
3,707,400
200 G-4-22-II
201 G-4-22-III

3,383,500
3,953,500
4,060,200
4,744,200
4,736,900
5,534,800
202 G-4-23-I
203 G-4-23-II

2,642,400
3,315,300
3,170,900
3,978,400
3,699,400
4,641,400
204 G-4-23-III
4,720,200
5,664,200
6,608,300
205 G-4-24-I
206 G-4-24-II

3,034,300
3,790,900
3,641,100
4,549,100
4,248,000
5,307,200
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,315,500
2,515,000
3,180,400
4,214,700
7,578,600
3,017,900
3,816,500
5,057,600
8,841,700
3,520,900
4,452,600
5,900,600
3,576,900
4,292,200
5,007,600
4,289,700
5,147,600
6,005,600
6,222,000
7,466,400
8,710,700
10,152,500
11,220,200
15,258,700
7,432,600
9,234,300
12,934,000
3,404,800
4,619,600
9,080,000
2,938,400
3,351,800
4,799,500
3,464,400
4,267,300
7,151,200
12,183,100
13,464,200
18,310,400
8,919,100
11,081,100
15,520,800
4,085,700
5,543,500
10,896,000
3,526,000
4,022,100
5,759,400
4,157,200
5,120,700
8,581,500
14,213,600
15,708,300
21,362,100
10,405,700
12,928,000
18,107,600
4,766,700
6,467,400
12,712,000
4,113,700
4,692,500
6,719,400
4,850,100
5,974,200
10,011,700
229 I-1-01-I
46,532,400
55,838,900
65,145,400
230 I-1-01-II
47,556,100
57,067,300
66,578,600
231 I-1-01-III

(RINGAN)
75,066,700
90,080,000
105,093,400
25,816,000
30,979,200
36,142,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 635 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
21,913,900
26,296,700
30,679,500
245 I-1-06-II
31,744,100
38,092,900
44,441,700
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
37,876,600
45,451,900
53,027,200
48,423,400
58,108,100
67,792,800
60,529,300
72,635,200
84,741,000
90,794,000
108,952,700
127,111,500
4,170,600
5,004,700
5,838,800
4,637,300
5,564,700
6,492,200
6,170,800
7,404,900
8,639,100
12,004,900
14,405,900
16,806,800
19,018,200
22,821,800
26,625,500
25,021,300
30,025,600
35,029,800
11,644,600
13,973,500
16,302,400
15,507,100
18,608,600
21,710,000
19,124,600
22,949,500
26,774,400
23,833,600
28,600,300
33,367,000
29,621,600
35,546,000
41,470,300
38,814,600
46,577,500
54,340,400
4,527,700
6,322,800
12,175,300
5,433,200
7,587,400
14,610,300
6,338,800
8,852,000
17,045,400
11,385,300
13,662,400
15,939,400
26,557,100
31,868,500
37,179,900
30,633,200
36,759,800
42,886,400
13,590,800
16,309,000
19,027,200
17,017,000
20,420,400
23,823,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
33,302,300
39,962,800
46,623,200
41,047,200
49,256,600
57,466,100
14,911,400
17,893,700
20,875,900
20,670,300
24,804,300
28,938,400
27,043,500
32,452,200
37,860,900
23,165,600
27,798,700
32,431,900
36,561,600
43,873,900
51,186,300
58,406,900
70,088,300
81,769,700
54,476,400
65,371,600
76,266,900
66,582,200
79,898,700
93,215,100
90,794,000
108,952,700
127,111,500
- 636 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
25,645,700
30,774,800
35,903,900
279 I-1-40-III
34,253,900
41,104,700
47,955,500
280 I-4-10-I
281 I-4-10-II

4,031,200
7,198,200
4,837,500
8,637,900
5,643,700
10,077,500
282 I-4-10-III
10,371,600
12,446,000
14,520,300
283 I-4-11-I
284 I-4-11-II

6,016,000
7,444,800
7,219,200
8,933,800
8,422,400
10,422,700
285 I-4-11-III
286 I-4-12-I

13,772,100
3,565,200
16,526,500
4,278,300
19,280,900
4,991,300
287 I-4-12-II
4,132,600
4,959,200
5,785,700
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,959,200
5,951,000
6,942,800
3,628,100
4,353,700
5,079,300
6,478,400
7,774,100
9,069,800
9,334,500
11,201,400
13,068,300
3,323,300
3,544,000
6,026,300
3,988,000
4,252,800
7,231,500
4,652,700
4,961,600
8,436,800
4,469,300
5,363,100
6,257,000
6,080,200
7,296,200
8,512,200
297 I-4-15-III
7,296,200
8,755,400
10,214,700
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,162,400
3,472,300
4,166,700
1,901,100
2,213,300
2,655,900
2,594,900
4,166,700
5,000,100
2,281,400
2,655,900
3,187,100
3,027,300
4,861,200
5,833,400
2,661,600
3,098,600
3,718,300
4,045,900
4,855,000
5,664,200
6,350,500
7,620,600
8,890,700
8,363,200
10,035,900
11,708,500
307 I-4-19-I
3,903,500
4,684,100
5,464,800
308 I-4-19-II

(SEDANG)
6,093,500
7,312,200
8,530,900
309 I-4-19-III
7,274,500
8,729,400
10,184,300
310
311
312
313
314

4,190,400
4,839,900
7,019,500
3,135,600
3,972,900
5,028,400
5,807,900
8,423,400
3,762,700
4,767,400
5,866,500
6,775,800
9,827,300
4,389,900
5,562,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,049,800
25,259,700
29,469,700
15,319,200
18,383,000
21,446,900
19,137,900
22,965,500
26,793,000
20,117,900
24,141,400
28,165,000
11,588,100
13,905,700
16,223,400
24,105,800
28,927,000
33,748,200
37,355,400
44,826,400
52,297,500
10,694,600
12,833,500
14,972,400
- 637 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,734,400
6,881,300
8,028,200
316 I-4-22-I
317 I-4-22-II
3,163,100
3,937,500
3,795,700
4,725,100
4,428,300
5,512,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,755,400
6,906,500
8,057,600
3,336,500
4,003,800
4,671,100
4,096,300
4,915,500
5,734,800
8,003,900
9,604,600
11,205,400
2,787,700
3,345,200
3,902,800
6,419,400
7,703,200
8,987,100
8,116,100
9,739,400
11,362,600
54,204,400
65,045,200
75,886,100
61,342,300
73,610,800
85,879,200
69,397,400
83,276,900
97,156,400
28,764,300
34,517,100
40,270,000
40,051,300
48,061,500
56,071,800
66,138,400
79,366,100
92,593,700
8,734,900
10,481,900
12,228,900
17,675,200
21,210,300
24,745,300
18,937,000
22,724,400
26,511,800
14,936,900
17,924,200
20,911,600
18,813,400
22,576,100
26,338,800
29,050,900
34,861,100
40,671,300
7,289,500
8,747,400
10,205,400
13,204,900
15,845,900
18,486,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
38,115,500
45,738,600
53,361,700
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,763,500
5,536,100
8,375,300
2,740,700
3,702,800
5,116,700
4,515,500
5,140,200
7,177,100
4,115,900
5,729,200
10,688,800
4,401,700
7,384,400
8,736,500
4,323,900
5,165,800
6,950,100
3,316,200
6,643,300
10,050,400
3,288,900
4,443,300
6,140,000
5,418,500
6,168,200
8,612,500
4,939,100
6,875,000
12,826,600
5,282,100
8,861,300
10,483,800
5,188,600
6,199,000
8,340,100
3,868,900
7,750,500
11,725,400
3,837,000
5,183,900
7,163,400
6,321,600
7,196,300
10,048,000
5,762,300
8,020,900
14,964,400
6,162,400
10,338,200
12,231,100
6,053,400
7,232,100
9,730,100
3,602,700
4,323,200
5,043,800
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 638 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,062,700
6,075,300
7,087,800
360 J-4-16-III
6,401,000
7,681,300
8,961,500
361 J-4-17-I
362 J-4-17-II

3,678,100
4,404,600
4,413,700
5,285,500
5,149,300
6,166,400
363 J-4-17-III
364 J-4-18-I

5,780,100
2,219,400
6,936,200
2,663,300
8,092,200
3,107,200
365 J-4-18-II
2,961,000
3,553,200
4,145,400
366 J-4-18-III
367 J-4-19-I

3,116,900
5,180,600
3,740,200
6,216,800
4,363,600
7,252,900
368 J-4-19-II
369 J-4-19-III

5,875,200
6,488,400
7,050,200
7,786,100
8,225,300
9,083,800
370 J-4-20-I
4,627,000
5,552,400
6,477,800
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,411,200
7,748,300
7,693,400
9,298,000
8,975,600
10,847,700
2,790,400
3,348,400
3,906,500
4,495,200
5,394,300
6,293,300
6,272,700
7,527,300
8,781,800
7,918,800
9,502,500
11,086,300
10,259,400
12,311,300
14,363,200
12,024,400
14,429,200
16,834,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,246,400
9,895,700
11,545,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
10,826,600
19,303,800
12,991,900
23,164,600
15,157,200
27,025,300
3,425,400
4,110,400
4,795,500
4,455,100
5,346,100
6,237,100
8,826,200
10,591,400
12,356,700
3,863,100
4,249,400
4,288,100
4,635,700
5,099,300
5,145,700
5,408,400
5,949,200
6,003,300
5,473,000
6,567,600
7,662,200
6,414,200
7,697,000
8,979,900
390 K-1-14-III
11,543,600
13,852,300
16,161,100
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,139,100
16,955,600
24,757,000
14,566,900
20,346,700
29,708,300
16,994,700
23,737,800
34,659,700
7,179,000
8,614,800
10,050,600
12,367,200
14,840,600
17,314,100
17,543,700
21,052,500
24,561,200
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
7,769,800
9,323,700
10,877,700
398 K-1-40-II

(SEDANG)
8,831,400
10,597,700
12,363,900
399 K-1-40-III
14,966,000
17,959,200
20,952,400
400
401
402
403
404

5,936,900
7,948,200
10,895,300
4,901,200
7,042,300
7,124,300
9,537,900
13,074,400
5,881,400
8,450,800
8,311,600
11,127,500
15,253,500
6,861,700
9,859,200
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 639 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,067,700
13,281,200
15,494,700
406 K-4-11-I
407 K-4-11-II

2,312,900
3,286,800
2,775,500
3,944,200
3,238,000
4,601,500
408 K-4-11-III
409 K-4-12-I

3,944,200
2,946,200
4,733,000
3,535,500
5,521,800
4,124,700
410 K-4-12-II
4,087,400
4,904,800
5,722,300
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,761,800
8,114,200
9,466,600
3,971,700
4,766,100
5,560,400
5,137,700
6,165,200
7,192,800
7,913,700
9,496,400
11,079,200
2,596,000
3,115,200
3,634,400
3,484,700
4,181,600
4,878,500
5,591,500
6,709,800
7,828,100
418 K-4-15-I
2,638,900
3,166,700
3,694,400
419 K-4-15-II
4,067,600
4,881,200
5,694,700
420 K-4-15-III
5,708,800
6,850,500
7,992,300
421 K-4-16-I
3,676,300
4,411,600
5,146,900
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,409,000
5,144,600
5,290,800
6,173,500
6,172,600
7,202,400
1,713,000
2,055,500
2,398,100
2,109,500
2,531,400
2,953,300
2,531,400
3,037,600
3,543,900
1,448,600
1,738,300
2,028,000
2,444,400
2,933,300
3,422,200
429 K-4-18-III
2,933,300
3,519,900
4,106,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,354,300
29,214,800
39,035,700
8,857,600
15,669,100
19,453,500
23,225,100
35,057,700
46,842,800
10,629,100
18,802,900
23,344,200
27,096,000
40,900,700
54,650,000
12,400,600
21,936,800
27,234,800
4,964,000
5,956,800
6,949,600
9,956,700
11,948,000
13,939,300
16,759,300
20,111,100
23,463,000
6,516,700
10,488,000
15,002,000
1,757,200
2,039,600
2,367,500
3,569,400
4,905,900
11,492,500
1,747,600
2,311,400
7,642,900
7,820,100
12,585,600
18,002,400
2,108,600
2,447,600
2,841,000
4,283,300
5,887,100
13,791,000
2,097,100
2,773,700
9,171,500
9,123,400
14,683,200
21,002,800
2,460,100
2,855,500
3,314,400
4,997,200
6,868,300
16,089,500
2,446,600
3,236,000
10,700,100
2,376,800
2,852,200
3,327,600
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 640 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,793,500
3,352,100
3,910,800
4,110,600
4,932,700
5,754,800
2,935,400
3,522,500
4,109,600
4,409,100
5,291,000
6,172,800
6,215,200
7,458,200
8,701,300
10,376,500
12,451,800
14,527,100
14,748,700
17,698,500
20,648,200
20,717,500
24,861,000
29,004,600
9,481,200
11,377,500
13,273,700
15,553,600
25,632,500
18,664,400
30,759,000
21,775,100
35,885,500
23,211,700
27,854,100
32,496,400
27,149,500
32,579,400
38,009,300
33,602,000
40,322,400
47,042,800
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,531,400
13,837,700
16,144,000
467 M-1-04-II
14,814,500
17,777,400
20,740,300
468 M-1-04-III
18,274,100
21,928,900
25,583,800
469 M-1-05-I
470 M-1-05-II

7,547,600
11,842,300
9,057,100
14,210,700
10,566,700
16,579,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
15,594,900
18,713,800
21,832,800
8,195,200
9,834,300
11,473,300
10,978,800
13,174,500
15,370,300
22,364,800
26,837,700
31,310,700
18,928,700
22,714,500
26,500,200
45,257,900
54,309,500
63,361,100
97,617,200
117,140,600
136,664,000
12,322,100
14,786,500
17,251,000
16,229,700
19,475,600
22,721,500
480 M-1-20-III
40,465,900
48,559,100
56,652,300
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,714,700
14,121,400
20,192,400
10,457,700
16,945,700
24,230,900
12,200,600
19,770,000
28,269,300
4,303,100
5,163,700
6,024,300
7,631,300
9,157,500
10,683,800
10,896,000
13,075,200
15,254,400
5,316,000
8,821,900
14,489,400
6,379,200
10,586,300
17,387,300
7,442,400
12,350,600
20,285,100
7,963,900
9,556,600
11,149,400
10,012,400
12,014,900
14,017,400
15,592,700
18,711,300
21,829,800
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 641 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,210,800
18,253,000
21,295,200
16,731,900
20,078,300
23,424,700
19,155,800
22,987,000
26,818,100
8,646,700
10,376,100
12,105,400
10,268,800
23,112,800
12,322,500
27,735,400
14,376,300
32,357,900
2,954,500
3,545,400
4,136,400
4,406,200
8,336,600
5,287,400
10,003,900
6,168,700
11,671,200
3,681,600
4,418,000
5,154,300
8,071,800
9,686,200
11,300,600
12,031,400
14,437,700
16,844,000
2,938,800
3,526,500
4,114,300
4,888,000
5,865,600
6,843,200
6,740,400
8,088,500
9,436,600
4,893,300
5,872,000
6,850,700
7,352,000
8,822,500
10,292,900
14,343,700
17,212,400
20,081,100
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,580,700
6,696,800
7,813,000
512 M-4-14-II
6,883,000
8,259,500
9,636,100
513 M-4-14-III
514 M-4-15-I
10,343,100
3,411,500
12,411,700
4,093,800
14,480,300
4,776,100
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,410,900
10,009,700
2,833,200
4,677,300
7,857,600
5,293,100
12,011,600
3,399,800
5,612,800
9,429,100
6,175,300
14,013,500
3,966,500
6,548,200
11,000,600
3,677,100
4,412,500
5,147,900
5,142,800
6,171,400
7,199,900
7,181,600
8,617,900
10,054,200
2,779,300
4,188,500
5,043,200
3,335,100
5,026,200
6,051,800
3,891,000
5,863,900
7,060,400
2,988,000
3,585,600
4,183,200
4,882,000
5,858,400
6,834,700
9,534,800
11,441,700
13,348,700
2,923,700
3,508,400
4,093,100
4,281,200
5,137,400
5,993,700
4,784,700
5,741,700
6,698,600
2,943,900
3,532,700
4,121,400
3,682,000
4,418,300
5,154,700
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 642 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,254,900
9,905,900
11,556,800
535 N-1-01-I

174,707,400
209,648,900
244,590,400
536 N-1-01-II
174,707,400
209,648,900
244,590,400
537 N-1-01-III
538 N-1-11-I

174,707,400
8,491,600
209,648,900
10,189,900
244,590,400
11,888,200
539 N-1-11-II
540 N-1-11-III

13,427,300
20,933,100
16,112,700
25,119,700
18,798,200
29,306,400
4,327,900
5,193,500
6,059,000
8,882,800
10,659,400
12,436,000
19,276,100
23,131,300
26,986,500
9,755,000
11,706,000
13,657,100

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
13,651,700
18,530,700
16,382,000
22,236,900
19,112,300
25,943,000
8,659,800
10,391,700
12,123,700
13,100,500
15,720,600
18,340,700
15,077,400
18,092,900
21,108,400
8,017,600
9,621,100
11,224,700
10,887,700
13,065,300
15,242,800
12,671,900
15,206,300
17,740,600
3,304,200
3,965,000
4,625,800
4,120,100
4,944,100
5,768,100
6,060,000
7,272,000
8,484,000
2,614,900
4,431,600
5,513,800
2,385,700
4,193,800
5,047,900
3,407,600
4,110,000
6,493,100
3,137,900
5,317,900
6,616,500
2,862,900
5,032,500
6,057,400
4,089,200
4,932,000
7,791,700
3,660,900
6,204,200
7,719,300
3,340,000
5,871,300
7,067,000
4,770,700
5,754,000
9,090,400
2,547,500
3,057,000
3,566,500
3,614,700
4,337,700
5,060,600
5,794,400
6,953,300
8,112,200
3,009,500
3,611,400
4,213,300
3,849,800
4,619,700
5,389,700
4,393,200
5,271,900
6,150,500
3,685,100
4,422,200
5,159,200
5,259,900
6,311,800
7,363,800
7,217,800
8,661,300
10,104,900
4,972,200
5,389,500
5,966,700
6,467,400
6,961,100
7,545,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 643 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,026,600
10,831,900
12,637,200
3,425,500
4,110,600
4,795,700
3,807,100
4,568,500
5,329,900
4,882,500
5,859,000
6,835,500
2,502,000
3,002,400
3,502,800
3,004,900
3,605,800
4,206,800
3,775,700
4,530,900
5,286,000
1,670,100
2,004,100
2,338,100

MAYOR (RINGAN)
MAYOR (SEDANG)
1,976,700
2,372,000
2,372,000
2,846,400
2,767,400
3,320,800
54,193,500
65,032,200
75,870,900
67,056,300
80,467,500
93,878,800
78,705,200
94,446,300
110,187,300
84,674,500
101,609,400
118,544,300
97,130,300
116,556,400
135,982,400
110,978,400
133,174,100
155,369,700
12,250,200
14,700,300
17,150,300
17,297,700
20,757,200
24,216,800
24,211,600
29,053,900
33,896,200
35,333,000
42,399,700
49,466,300
45,676,200
54,811,400
63,946,600
65,488,200
78,585,800
91,683,400
19,186,000
23,023,200
26,860,400
29,994,300
35,993,200
41,992,100
39,917,800
47,901,400
55,884,900
5,249,000
6,298,800
7,348,600
14,717,000
17,660,400
20,603,800
19,496,400
23,395,700
27,295,000
5,084,200
6,101,000
7,117,900
14,254,900
17,105,900
19,956,900
18,884,300
22,661,100
26,438,000
4,209,700
5,051,600
5,893,500
5,973,300
7,167,900
8,362,600
9,672,000
11,606,500
13,540,900
10,208,500
12,250,200
14,291,900
14,414,800
17,297,700
20,180,700
- 644 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,176,300
24,211,600
28,246,800
9,644,300
11,573,200
13,502,100
11,088,300
13,305,900
15,523,600
15,520,200
18,624,300
21,728,300
5,467,600
6,561,100
7,654,600
8,529,400
10,235,300
11,941,200
13,250,800
15,900,900
18,551,100
3,644,100
4,372,900
5,101,700
7,417,900
8,901,400
10,385,000
13,350,100
16,020,100
18,690,100
2,733,100
3,279,700
3,826,300
5,473,100
6,567,800
7,662,400
6,421,700
7,706,100
8,990,400
2,473,500
2,968,200
3,462,900
4,753,200
5,703,800
6,654,500
11,631,700
13,958,000
16,284,400
3,645,100
4,374,100
5,103,100
6,561,100
7,873,300
9,185,500
9,232,600
11,079,200
12,925,700
2,705,200
3,246,200
3,787,200
3,333,200
3,999,800
4,666,400
4,562,800
5,475,300
6,387,900
1,637,000
2,400,500
4,102,700
1,988,800
2,647,100
4,588,700
1,964,400
2,880,600
4,923,300
2,386,600
3,176,500
5,506,500
2,291,800
3,360,700
5,743,800
2,784,400
3,705,900
6,424,200
2,937,000
3,524,400
4,111,800
5,210,400
6,252,500
7,294,600
8,457,200
10,148,600
11,840,100
1,486,300
1,783,600
2,080,800
3,157,100
3,788,500
4,419,900
5,986,900
7,184,300
8,381,600
994,100
1,192,900
1,391,700
1,876,000
2,251,200
2,626,300
2,429,700
2,915,600
3,401,600
5,147,400
6,176,900
7,206,400
- 645 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,748,800
8,098,600
9,448,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,662,900
11,595,500
13,528,100
2,481,000
2,977,200
3,473,400
3,682,000
4,418,400
5,154,900
4,428,500
5,314,200
6,199,900
1,711,300
2,053,600
2,395,800
2,298,500
2,758,200
3,217,900
4,181,300
5,017,600
5,853,900
742,300
890,800
1,039,200
1,414,700
1,697,700
1,980,600
2,056,700
2,468,000
2,879,300
1,013,100
1,215,800
1,418,400
1,594,300
1,913,200
2,232,100
2,568,000
3,081,600
3,595,200
1,669,100
2,002,900
2,336,700
2,487,000
2,984,400
3,481,800
3,815,700
4,578,800
5,342,000
5,424,600
6,509,500
7,594,400

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,421,100
22,242,400
10,105,300
26,690,800
11,789,600
31,139,300
8,392,100
10,070,500
11,748,900
10,638,200
12,765,900
14,893,500
15,780,100
18,936,100
22,092,200
6,557,500
10,055,600
14,769,500
6,562,000
7,645,800
12,674,300
7,869,000
12,066,700
17,723,400
7,874,400
9,174,900
15,209,100
9,180,500
14,077,800
20,677,300
9,186,800
10,704,100
17,744,000
4,065,200
4,878,300
5,691,300
4,989,000
5,986,900
6,984,700
5,912,000
7,094,400
8,276,800
3,889,300
5,529,500
7,127,300
4,667,200
6,635,400
8,552,800
5,445,100
7,741,300
9,978,200
6,171,700
7,406,000
8,640,400
9,185,200
11,022,200
12,859,300
22,872,700
27,447,300
32,021,800
5,292,900
7,176,900
13,613,700
6,351,500
8,612,300
16,336,500
7,410,100
10,047,700
19,059,200
3,809,000
4,570,800
5,332,600
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 646 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,315,000
2,778,000
3,241,000
697 U-4-12-I
698 U-4-12-II

2,527,000
2,939,500
3,032,500
3,527,400
3,537,900
4,115,300
699 U-4-12-III

3,931,200
4,717,500
5,503,700
1,974,400
2,369,300
2,764,100
2,327,600
2,793,100
3,258,600
2,783,900
3,340,700
3,897,500
3,677,500
4,403,700
4,413,000
5,284,400
5,148,500
6,165,200

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,395,100
8,874,200
10,353,200
2,952,900
3,543,500
4,134,100
3,678,900
4,414,700
5,150,500
5,148,700
6,178,500
7,208,200
4,965,400
5,958,500
6,951,600
9,921,700
11,906,000
13,890,400
12,167,600
14,601,100
17,034,600
9,163,100
10,463,100
16,385,700
10,995,700
12,555,800
19,662,900
12,828,300
14,648,400
22,940,000
8,615,000
10,338,100
12,061,100
12,128,400
14,554,100
16,979,800
14,911,700
17,894,000
20,876,400
4,632,700
5,559,200
6,485,800
8,851,600
10,621,900
12,392,200
13,470,400
16,164,500
18,858,600
8,812,200
10,574,600
12,337,000
12,803,800
15,364,600
17,925,300
15,987,900
19,185,500
22,383,000
1,463,100
1,614,500
1,786,000
1,755,700
1,937,400
2,143,200
2,048,300
2,260,300
2,500,400
4,393,200
5,271,800
6,150,500
7,297,300
8,756,800
10,216,300
12,030,800
14,436,900
16,843,100
3,682,100
4,418,500
5,155,000
4,940,500
5,928,500
6,916,600
6,822,500
8,187,000
9,551,400
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,458,300
10,150,000
11,841,700
12,986,100
15,583,400
18,180,600
1,513,100
2,200,600
1,815,700
2,640,700
2,118,400
3,080,800
- 647 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,346,500
12,415,900
14,485,200
12,029,000
14,434,800
16,840,600
17,696,000
21,235,100
24,774,300
2,194,600
2,633,600
3,072,500
2,421,800
2,679,000
2,906,100
3,214,800
3,390,500
3,750,600
2,293,900
2,752,700
3,211,500
2,531,300
3,037,600
3,543,800
2,800,100
3,360,100
3,920,200
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,467,800
2,961,300
3,454,900
743 W-1-12-II
744 W-1-12-III

3,080,200
5,290,700
3,696,200
6,348,800
4,312,300
7,407,000
745 W-1-13-I
2,460,600
2,952,700
3,444,800
746 W-1-13-II
747 W-1-13-III

2,671,300
3,588,300
3,205,600
4,305,900
3,739,900
5,023,600
748 W-1-20-I
749 W-1-20-II

8,240,200
10,296,200
9,888,200
12,355,400
11,536,200
14,414,600
750 W-1-20-III
11,935,900
14,323,100
16,710,300
751 W-1-30-I
4,651,700
5,582,000
6,512,400
752 W-1-30-II
7,419,400
8,903,300
10,387,200
753 W-1-30-III
18,204,000
21,844,800
25,485,600
754 W-4-10-I
3,466,000
4,159,200
4,852,400
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,138,200
10,154,100
3,152,100
4,785,300
5,824,600
6,165,800
12,184,900
3,782,500
5,742,400
6,989,500
7,193,400
14,215,700
4,412,900
6,699,400
8,154,500
2,801,200
3,361,400
3,921,600
3,845,800
4,615,000
5,384,100
4,192,100
5,030,600
5,869,000
1,240,200
1,694,100
2,106,700
1,657,300
2,033,700
2,523,800
1,576,100
1,750,400
2,423,600
2,161,900
2,891,100
3,918,300
1,547,400
2,793,900
4,130,800
2,855,100
3,789,700
5,383,700
2,601,100
3,124,100
4,294,200
1,488,200
2,032,900
2,528,100
1,988,800
2,440,400
3,028,500
1,891,400
2,100,500
2,908,300
2,594,300
3,469,300
4,702,000
1,856,900
3,352,700
4,956,900
3,426,100
4,547,700
6,460,400
3,121,400
3,748,900
5,153,100
1,736,200
2,371,700
2,949,400
2,320,300
2,847,100
3,533,300
2,206,600
2,450,600
3,393,000
3,026,700
4,047,500
5,485,700
2,166,400
3,911,500
5,783,100
3,997,100
5,305,600
7,537,100
3,641,600
4,373,700
6,011,900
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 648 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,871,200
2,245,400
2,619,700
3,926,500
4,711,800
5,497,100
6,044,300
7,253,200
8,462,000
- 649 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
940,100
1,219,400
2,267,700
1,874,000
2,435,300
448,000
1,094,900
350,300
940,200
698,600
793,100
1,192,400
1,626,400
1,490,600
482,900
1,114,600
404,300
694,100
2,114,300
757,200
1,788,100
436,200
1,329,400
1,513,300
1,269,300
311,300
993,100
524,500
370,800
291,600
257,400
307,800
428,600
368,200
346,700
311,500
462,200
201,800
237,900
272,700
5,534,800
2,212,000
2,219,400
570,900
1,285,400
804,800
1,635,800
762,300
436,500
329,700
531,700
353,000
264,500
2,695,800
1,258,000
718,900
2,806,300
1,870,800
265,000
3,040,100
2,104,700
3,882,100
1,093,400
672,500
263,100
219,200
247,100
3,767,300
1,833,800
- 650 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,330,700
4,124,800
3,599,900
2,605,300
858,900
2,899,700
1,893,400
465,400
4,353,500
3,941,200
2,642,600
2,503,500
325,700
297,300
1,196,300
344,200
291,300
322,000
1,519,500
1,509,400
1,318,400
1,601,000
969,600
293,000
516,500
354,500
320,100
311,900
396,000
451,600
264,700
759,800
1,384,700
1,062,900
2,498,900
325,400
325,400
3,175,000
1,342,700
257,600
1,191,600
3,258,300
710,700
559,800
274,200
259,900
408,400
569,500
1,363,800
1,202,000
841,400
456,500
264,500
1,461,100
851,400
500,200
415,100
1,360,300
300,700
1,911,000
1,462,000
324,300
359,400
351,100
212,500
1,593,000
1,591,800
315,500
- 651 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
966,800
360,900
390,200
361,300
573,200
440,900
1,104,300
325,800
906,500
1,665,500
265,300
1,614,600
874,900
1,890,800
954,500
421,500
324,300
75,000
420,300
949,700
370,100
499,900
285,900
116,100
288,700
4,299,000
2,443,600
4,078,500
1,377,600
559,800
381,400
862,700
456,300
918,200
531,700
316,500
529,800
328,000
500,600
348,900
902,900
1,751,900
1,409,500
1,242,800
877,100
306,500
306,500
306,500
250,400
158,800
249,700
305,200
330,100
243,200
214,500
105,200
115,600
85,500
100,300
95,700
146,100
131,000
170,400
187,200
110,500
141,200
96,500
150,600
213,700
- 652 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
152,100
191,300
540,800
626,900
143,900
260,200
175,100
249,900
437,800
374,800
269,400
255,100
143,000
133,500
300,400
189,600
271,900
188,200
147,300
2,598,000
1,943,500
308,800
319,800
611,600
801,400
782,900
404,400
1,260,400
299,200
328,700
329,800
264,100
333,500
315,600
147,900
324,900
288,000
260,500
294,600
2,438,500
435,400
877,600
314,800
615,800
490,500
411,900
762,100
780,500
832,100
727,900
1,393,300
216,900
2,070,300
285,900
1,049,400
2,385,000
2,005,600
876,200
317,500
619,300
616,800
285,900
2,240,800
1,762,500
157,900
171,100
222,300
394,600
- 653 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,149,700
619,500
977,600
1,120,400
565,200
746,900
543,400
579,500
726,100
323,800
727,300
204,200
718,700
1,237,800
82,900
- 654 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,603,100
3,123,800
3,644,400
A-4-10-II
SEPTIKEMIA (SEDANG)
4,447,200
5,336,700
6,226,100
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
5,996,300
3,382,600
7,195,500
4,059,200
8,394,800
4,735,700
5
6
A-4-11-II
A-4-11-III

4,814,500
6,663,700
5,777,400
7,996,400
6,740,300
9,329,200
A-4-12-I
2,710,500
3,252,700
3,794,800
8
9
A-4-12-II
A-4-12-III

3,375,600
3,714,100
4,050,700
4,456,900
4,725,800
5,199,700
10 A-4-13-I
11 A-4-13-II

2,146,400
2,739,400
2,575,700
3,287,300
3,004,900
3,835,200
12 A-4-13-III
3,287,300
3,944,800
4,602,300
2,330,000
2,796,000
3,262,000
2,828,300
3,394,000
3,959,600
3,394,000
4,072,800
4,751,500
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,858,300
18,503,600
17,830,000
22,204,300
20,801,700
25,905,000
18 A-4-15-III
INFEKSI HIV (BERAT)
20,903,800
25,084,600
29,265,400
19 B-1-01-I
20 B-1-01-II

40,639,400
44,835,900
48,767,200
53,803,100
56,895,100
62,770,300
21 B-1-01-III
22 B-1-10-I

98,830,400
6,569,100
118,596,500
7,883,000
138,362,600
9,196,800
23 B-1-10-II
14,580,600
17,496,700
20,412,800
24 B-1-10-III
25 B-1-11-I

28,784,000
7,181,600
34,540,800
8,618,000
40,297,700
10,054,300
26 B-1-11-II
27 B-1-11-III

9,594,700
12,396,200
11,513,700
14,875,500
13,432,600
17,354,700
28 B-1-12-I
7,229,400
8,675,300
10,121,100
29 B-1-12-II
8,040,300
9,648,400
11,256,500
30 B-1-12-III
12,578,200
15,093,900
17,609,500
5,758,300
6,909,900
8,061,600
9,474,500
11,369,500
13,264,400
12,259,200
14,711,100
17,162,900
7,912,100
9,494,500
11,077,000
8,799,700
10,559,600
12,319,500
13,766,100
2,374,600
3,790,500
5,229,100
16,519,300
2,849,500
4,548,600
6,274,900
19,272,500
3,324,400
5,306,700
7,320,800
5,006,500
6,007,800
7,009,100
7,009,100
8,411,000
9,812,800
8,491,500
10,189,800
11,888,100
4,526,400
6,644,800
9,886,000
4,317,800
5,431,700
7,973,700
11,863,200
5,181,400
6,337,000
9,302,700
13,840,400
6,045,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 655 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,030,100
6,036,100
7,042,100
48 B-4-13-III
49 B-4-14-I

6,929,400
4,313,200
8,315,300
5,175,900
9,701,100
6,038,500
50 B-4-14-II
5,031,900
6,038,300
7,044,700
51 B-4-14-III
52 C-4-10-I

6,740,400
4,113,900
8,088,500
4,936,700
9,436,500
5,759,500
53 C-4-10-II
54 C-4-10-III

7,893,600
13,514,900
9,472,300
16,217,900
11,051,000
18,920,800
55 C-4-11-I
4,547,300
5,456,800
6,366,300
56 C-4-11-II
57 C-4-11-III

6,085,000
9,645,200
7,302,000
11,574,200
8,519,000
13,503,200
58 C-4-12-I
59 C-4-12-II
3,027,800
6,148,000
3,633,300
7,377,600
4,238,900
8,607,200
60 C-4-12-III
RADIOTERAPI (BERAT)
15,789,700
18,947,600
22,105,600
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,276,300
4,284,000
2,731,500
5,140,700
3,186,800
5,997,500
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,799,000
3,782,100
6,958,800
4,538,500
8,118,600
5,295,000
65 C-4-14-II
5,305,500
6,366,700
7,427,800
66 C-4-14-III
67 D-1-10-I

8,149,600
22,622,000
9,779,600
27,146,400
11,409,500
31,670,800
68 D-1-10-II
69 D-1-10-III

34,454,900
54,863,900
41,345,800
65,836,700
48,236,800
76,809,500
70 D-1-11-I
6,118,000
7,341,600
8,565,200
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,622,100
20,929,400
18,746,500
25,115,300
21,870,900
29,301,200
5,303,600
6,364,300
7,425,000
14,615,900
17,539,100
20,462,300
23,185,100
27,822,200
32,459,200
2,614,500
4,290,700
6,750,300
4,152,000
7,461,000
10,566,500
3,579,600
4,965,000
7,623,900
3,137,400
5,148,900
8,100,400
4,982,400
8,953,200
12,679,800
4,295,500
5,958,000
9,148,700
3,660,300
6,007,000
9,450,400
5,812,800
10,445,400
14,793,100
5,011,400
6,950,900
10,673,500
3,067,600
3,681,100
4,294,700
4,341,700
5,210,100
6,078,400
5,553,200
6,663,800
7,774,500
3,290,200
3,948,200
4,606,200
5,386,800
6,464,200
7,541,500
6,588,600
7,906,400
9,224,100
7,214,400
8,657,300
10,100,200
9,848,700
11,818,500
13,788,200
93 E-1-01-III
23,746,300
28,495,600
33,244,800
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,500,600
10,411,800
19,671,300
9,000,800
12,494,100
23,605,500
10,500,900
14,576,500
27,539,800
7,719,400
9,263,200
10,807,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 656 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
3,034,600
3,641,600
4,248,500
104 E-4-11-II
105 E-4-11-III

4,626,600
6,463,200
5,551,900
7,755,900
6,477,200
9,048,500
106 E-4-12-I
107 E-4-12-II

3,486,700
6,038,200
4,184,100
7,245,900
4,881,400
8,453,500
108 E-4-12-III

(RINGAN)
(SEDANG)
7,157,500
8,589,000
10,020,500
3,796,900
4,556,300
5,315,700
5,561,800
6,674,200
7,786,600
111 E-4-13-III
7,495,300
8,994,400
10,493,400
112 F-4-10-I
113 F-4-10-II
4,167,300
4,789,500
5,000,800
5,747,400
5,834,200
6,705,300
114 F-4-10-III
115 F-4-11-I
5,747,400
4,030,500
6,896,900
4,836,600
8,046,400
5,642,700
116 F-4-11-II
4,696,000
5,635,100
6,574,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
6,021,900
7,226,300
8,430,700
2,143,100
2,571,700
3,000,300
3,046,800
3,656,100
4,265,500
6,619,000
7,942,800
9,266,600
3,246,700
4,284,000
5,546,200
1,852,400
2,375,900
3,197,000
3,896,000
5,140,800
6,655,500
2,222,800
2,851,100
3,836,400
4,545,300
5,997,600
7,764,700
2,593,300
3,326,300
4,475,800
127 F-4-15-I
2,861,500
3,433,800
4,006,100
128 F-4-15-II
4,264,000
5,116,800
5,969,700
129 F-4-15-III
5,629,900
6,755,900
7,881,800
5,804,300
6,965,200
8,126,100
6,748,500
8,098,200
9,447,900
9,008,100
10,809,700
12,611,300
133 F-4-17-I

1,329,600
1,595,600
1,861,500
134 F-4-17-II
3,897,000
4,676,400
5,455,800
135
136
137
138
139
140
141

(RINGAN)
4,157,700
5,043,500
5,549,300
8,554,700
3,854,400
4,935,800
6,145,000
4,989,300
6,052,200
6,659,200
10,265,600
4,625,300
5,922,900
7,374,000
5,820,800
7,060,900
7,769,000
11,976,600
5,396,200
6,910,100
8,603,000
17,446,400
20,935,700
24,425,000
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,390,100
12,468,100
14,546,100
14,762,500
17,715,000
20,667,500
3,597,300
4,316,800
5,036,200
5,026,600
6,031,900
7,037,200
6,432,000
7,718,300
9,004,700
- 657 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
23,172,900
27,807,500
32,442,100
148 G-1-11-I
149 G-1-11-II

12,138,000
22,191,000
14,565,500
26,629,200
16,993,100
31,067,400
150 G-1-11-III
36,816,600
44,179,900
51,543,200
5,068,000
6,081,600
7,095,200
9,794,100
11,752,900
13,711,700
13,347,400
16,016,900
18,686,400
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,528,900
4,105,800
1,834,600
4,927,000
2,140,400
5,748,100
156 G-1-13-III
157 G-1-20-I

9,264,500
9,047,100
11,117,400
10,856,500
12,970,300
12,665,900
158 G-1-20-II
14,728,000
17,673,600
20,619,200
159 G-1-20-III
22,602,500
27,123,000
31,643,500
160 G-1-30-I
11,511,400
13,813,700
16,116,000
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
24,036,200
32,745,500
28,843,400
39,294,600
33,650,600
45,843,700
4,350,300
5,220,400
6,090,500
5,317,600
6,381,100
7,444,600
7,522,300
9,026,800
10,531,300
4,695,000
5,634,000
6,573,000
6,236,700
7,484,000
8,731,400
9,163,800
10,996,600
12,829,300
5,208,500
6,250,200
7,292,000
6,381,400
7,657,700
8,933,900
9,268,200
11,121,800
12,975,400
3,035,000
3,642,000
4,249,000
5,292,400
6,350,900
7,409,400
6,276,900
7,532,300
8,787,700
5,148,500
6,178,200
7,207,900
7,096,000
8,515,200
9,934,400
8,906,300
10,687,600
12,468,900
4,206,800
5,048,100
5,889,500
5,020,600
6,024,700
7,028,800
7,086,100
8,503,300
9,920,500
3,467,900
4,161,500
4,855,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
25,022,400
30,026,900
35,031,400
37,984,400
45,581,300
53,178,100
17,863,200
21,032,100
21,435,800
25,238,500
25,008,500
29,444,900
- 658 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,604,100
5,524,900
6,445,800
183 G-4-16-III
6,556,600
7,868,000
9,179,300
4,619,000
5,542,800
6,466,600
6,056,500
7,267,900
8,479,200
7,845,700
9,414,800
10,984,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,549,000
5,458,800
6,368,600
188 G-4-18-II
6,080,700
7,296,800
8,512,900
189 G-4-18-III
6,803,800
8,164,500
9,525,300
3,795,300
4,554,400
5,313,500
6,415,000
7,698,100
8,981,100
8,422,700
10,107,200
11,791,700
193 G-4-20-I

2,655,000
3,186,000
3,717,000
194 G-4-20-II
3,753,400
4,504,100
5,254,800
195 G-4-20-III
196 G-4-21-I

6,199,700
2,764,800
7,439,700
3,317,800
8,679,600
3,870,700
197 G-4-21-II
198 G-4-21-III

4,679,500
5,669,500
5,615,400
6,803,400
6,551,200
7,937,400
199 G-4-22-I
2,727,600
3,273,100
3,818,600
200 G-4-22-II
201 G-4-22-III

3,485,000
4,072,100
4,182,000
4,886,500
4,879,000
5,700,900
202 G-4-23-I
203 G-4-23-II

2,721,700
3,414,800
3,266,000
4,097,700
3,810,300
4,780,700
204 G-4-23-III
4,861,800
5,834,200
6,806,500
205 G-4-24-I
206 G-4-24-II

3,125,300
3,904,600
3,750,400
4,685,500
4,375,400
5,466,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,505,000
2,590,400
3,275,800
4,341,100
7,805,900
3,108,500
3,931,000
5,209,400
9,106,900
3,626,600
4,586,200
6,077,600
3,684,200
4,421,000
5,157,800
4,418,400
5,302,100
6,185,700
6,408,600
7,690,300
8,972,100
10,457,100
11,556,800
15,716,400
7,655,600
9,511,300
13,322,000
3,506,900
4,758,200
9,352,400
3,026,500
3,452,300
4,943,500
3,568,300
4,395,300
7,365,800
12,548,500
13,868,200
18,859,700
9,186,700
11,413,600
15,986,400
4,208,300
5,709,800
11,222,900
3,631,800
4,142,800
5,932,200
4,281,900
5,274,400
8,838,900
14,640,000
16,179,500
22,003,000
10,717,800
13,315,800
18,650,800
4,909,700
6,661,400
13,093,400
4,237,100
4,833,300
6,920,900
4,995,600
6,153,400
10,312,100
229 I-1-01-I
47,928,400
57,514,100
67,099,800
230 I-1-01-II
48,982,800
58,779,400
68,575,900
231 I-1-01-III

(RINGAN)
77,318,700
92,782,400
108,246,200
26,590,500
31,908,600
37,226,700
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 659 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
22,571,300
27,085,600
31,599,900
245 I-1-06-II
32,696,400
39,235,700
45,775,000
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
39,012,900
46,815,400
54,618,000
49,876,100
59,851,400
69,826,600
62,345,200
74,814,200
87,283,300
93,517,800
112,221,300
130,924,900
4,295,700
5,154,800
6,014,000
4,776,400
5,731,600
6,686,900
6,355,900
7,627,100
8,898,300
12,365,000
14,838,000
17,311,000
19,588,700
23,506,500
27,424,200
25,771,900
30,926,300
36,080,700
11,993,900
14,392,700
16,791,500
15,972,300
19,166,800
22,361,300
19,698,300
23,638,000
27,577,600
24,548,600
29,458,300
34,368,000
30,510,300
36,612,300
42,714,400
39,979,000
47,974,800
55,970,600
4,663,500
6,512,500
12,540,500
5,596,200
7,815,000
15,048,600
6,528,900
9,117,500
17,556,700
11,726,900
14,072,200
16,417,600
27,353,800
32,824,500
38,295,300
31,552,200
37,862,600
44,173,000
13,998,600
16,798,300
19,598,000
17,527,500
21,033,000
24,538,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
34,301,400
41,161,700
48,021,900
42,278,600
50,734,300
59,190,000
15,358,700
18,430,500
21,502,200
21,290,400
25,548,500
29,806,500
27,854,800
33,425,700
38,996,700
23,860,600
28,632,700
33,404,800
37,658,500
45,190,100
52,721,800
60,159,100
72,191,000
84,222,800
56,110,700
67,332,800
78,554,900
68,579,700
82,295,600
96,011,600
93,517,800
112,221,300
130,924,900
- 660 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
26,415,000
31,698,100
36,981,100
279 I-1-40-III
35,281,500
42,337,800
49,394,200
280 I-4-10-I
281 I-4-10-II

4,152,200
7,414,200
4,982,600
8,897,000
5,813,000
10,379,800
282 I-4-10-III
10,682,800
12,819,300
14,955,900
283 I-4-11-I
284 I-4-11-II

6,196,400
7,668,100
7,435,700
9,201,800
8,675,000
10,735,400
285 I-4-11-III
286 I-4-12-I

14,185,200
3,672,200
17,022,300
4,406,600
19,859,300
5,141,100
287 I-4-12-II
4,256,600
5,107,900
5,959,200
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,107,900
6,129,500
7,151,100
3,736,900
4,484,300
5,231,700
6,672,800
8,007,300
9,341,900
9,614,500
11,537,400
13,460,300
3,423,000
3,650,300
6,207,100
4,107,600
4,380,400
7,448,500
4,792,200
5,110,500
8,689,900
4,603,400
5,524,000
6,444,700
6,262,600
7,515,100
8,767,600
297 I-4-15-III
7,515,100
9,018,100
10,521,100
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,227,300
3,576,400
4,291,700
1,958,200
2,279,700
2,735,600
2,672,700
4,291,700
5,150,100
2,349,800
2,735,600
3,282,700
3,118,200
5,007,000
6,008,400
2,741,400
3,191,600
3,829,900
4,167,200
5,000,700
5,834,100
6,541,000
7,849,200
9,157,500
8,614,100
10,337,000
12,059,800
307 I-4-19-I
4,020,600
4,824,700
5,628,800
308 I-4-19-II

(SEDANG)
6,276,300
7,531,600
8,786,800
309 I-4-19-III
7,492,700
8,991,300
10,489,800
310
311
312
313
314

4,316,100
4,985,100
7,230,100
3,229,700
4,092,000
5,179,300
5,982,100
8,676,100
3,875,600
4,910,500
6,042,500
6,979,100
10,122,100
4,521,600
5,728,900
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,681,200
26,017,500
30,353,700
15,778,800
18,934,500
22,090,300
19,712,000
23,654,400
27,596,800
20,721,400
24,865,700
29,010,000
11,935,800
14,322,900
16,710,100
24,829,000
29,794,800
34,760,600
38,476,000
46,171,200
53,866,400
11,015,400
13,218,500
15,421,600
- 661 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,906,400
7,087,700
8,269,000
316 I-4-22-I
317 I-4-22-II
3,258,000
4,055,700
3,909,600
4,866,800
4,561,100
5,677,900
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,928,100
7,113,700
8,299,300
3,436,600
4,123,900
4,811,200
4,219,200
5,063,000
5,906,800
8,244,000
9,892,800
11,541,600
2,871,300
3,445,600
4,019,900
6,611,900
7,934,300
9,256,700
8,359,600
10,031,500
11,703,500
55,830,500
66,996,600
78,162,700
63,182,600
75,819,100
88,455,600
71,479,400
85,775,200
100,071,100
29,627,200
35,552,700
41,478,100
41,252,800
49,503,400
57,754,000
68,122,500
81,747,100
95,371,600
8,997,000
10,796,400
12,595,800
18,205,500
21,846,600
25,487,700
19,505,100
23,406,200
27,307,200
15,385,000
18,462,000
21,539,000
19,377,800
23,253,400
27,128,900
29,922,500
35,907,000
41,891,400
7,508,200
9,009,900
10,511,500
13,601,100
16,321,300
19,041,500
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
39,259,000
47,110,800
54,962,600
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,846,400
5,702,200
8,626,600
2,822,900
3,813,800
5,270,200
4,650,900
5,294,400
7,392,400
4,239,400
5,901,100
11,009,500
4,533,800
7,606,000
8,998,600
4,453,600
5,320,800
7,158,600
3,415,700
6,842,600
10,351,900
3,387,500
4,576,600
6,324,200
5,581,100
6,353,300
8,870,900
5,087,200
7,081,300
13,211,400
5,440,500
9,127,200
10,798,300
5,344,300
6,384,900
8,590,300
3,984,900
7,983,100
12,077,200
3,952,100
5,339,400
7,378,300
6,511,300
7,412,200
10,349,400
5,935,100
8,261,500
15,413,300
6,347,300
10,648,300
12,598,100
6,235,000
7,449,100
10,022,100
3,710,800
4,452,900
5,195,100
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 662 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,214,600
6,257,500
7,300,400
360 J-4-16-III
6,593,100
7,911,700
9,230,300
361 J-4-17-I
362 J-4-17-II

3,788,400
4,536,700
4,546,100
5,444,100
5,303,800
6,351,400
363 J-4-17-III
364 J-4-18-I

5,953,500
2,286,000
7,144,200
2,743,200
8,334,900
3,200,400
365 J-4-18-II
3,049,900
3,659,800
4,269,800
366 J-4-18-III
367 J-4-19-I

3,210,400
5,336,100
3,852,400
6,403,300
4,494,500
7,470,500
368 J-4-19-II
369 J-4-19-III

6,051,400
6,683,100
7,261,700
8,019,700
8,472,000
9,356,300
370 J-4-20-I
4,765,800
5,719,000
6,672,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,603,500
7,980,800
7,924,200
9,576,900
9,244,900
11,173,100
2,874,100
3,448,900
4,023,700
4,630,100
5,556,100
6,482,100
6,460,900
7,753,100
9,045,300
8,156,300
9,787,600
11,418,900
10,567,200
12,680,600
14,794,000
12,385,100
14,862,100
17,339,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,493,800
10,192,600
11,891,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
11,151,300
19,882,900
13,381,600
23,859,500
15,611,900
27,836,100
3,528,100
4,233,700
4,939,400
4,588,700
5,506,500
6,424,200
9,091,000
10,909,200
12,727,400
3,979,000
4,376,900
4,416,700
4,774,800
5,252,300
5,300,000
5,570,600
6,127,700
6,183,400
5,637,200
6,764,600
7,892,000
6,606,600
7,927,900
9,249,300
390 K-1-14-III
11,889,900
14,267,900
16,645,900
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,503,300
17,464,300
25,499,700
15,003,900
20,957,100
30,599,600
17,504,600
24,450,000
35,699,500
7,394,300
8,873,200
10,352,100
12,738,200
15,285,800
17,833,500
18,070,100
21,684,100
25,298,100
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
8,002,900
9,603,400
11,204,000
398 K-1-40-II

(SEDANG)
9,096,300
10,915,600
12,734,900
399 K-1-40-III
15,415,000
18,498,000
21,581,000
400
401
402
403
404

6,115,000
8,186,700
11,222,200
5,048,200
7,253,600
7,338,000
9,824,000
13,466,600
6,057,900
8,704,300
8,561,000
11,461,300
15,711,100
7,067,500
10,155,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 663 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,399,700
13,679,600
15,959,600
406 K-4-11-I
407 K-4-11-II

2,382,300
3,385,400
2,858,700
4,062,500
3,335,200
4,739,600
408 K-4-11-III
409 K-4-12-I

4,062,500
3,034,600
4,875,000
3,641,600
5,687,500
4,248,500
410 K-4-12-II
4,210,000
5,052,000
5,894,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,964,700
8,357,600
9,750,600
4,090,900
4,909,100
5,727,200
5,291,800
6,350,200
7,408,600
8,151,100
9,781,300
11,411,500
2,673,900
3,208,600
3,743,400
3,589,200
4,307,000
5,024,900
5,759,200
6,911,100
8,062,900
418 K-4-15-I
2,718,000
3,261,700
3,805,300
419 K-4-15-II
4,189,700
5,027,600
5,865,500
420 K-4-15-III
5,880,000
7,056,100
8,232,100
421 K-4-16-I
3,786,600
4,544,000
5,301,300
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,541,200
5,298,900
5,449,500
6,358,700
6,357,700
7,418,500
1,764,300
2,117,200
2,470,100
2,172,800
2,607,300
3,041,900
2,607,300
3,128,800
3,650,200
1,492,000
1,790,400
2,088,800
2,517,700
3,021,300
3,524,800
429 K-4-18-III
3,021,300
3,625,500
4,229,800
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,934,900
30,091,200
40,206,800
9,123,300
16,139,200
20,037,100
23,921,900
36,109,400
48,248,100
10,948,000
19,367,000
24,044,500
27,908,900
42,127,700
56,289,500
12,772,600
22,594,900
28,051,900
5,112,900
6,135,500
7,158,100
10,255,400
12,306,400
14,357,500
17,262,000
20,714,500
24,166,900
6,712,200
10,802,600
15,452,100
1,809,900
2,100,800
2,438,500
3,676,500
5,053,100
11,837,300
1,800,000
2,380,800
7,872,200
8,054,700
12,963,100
18,542,500
2,171,900
2,521,000
2,926,200
4,411,800
6,063,700
14,204,700
2,160,000
2,856,900
9,446,700
9,397,100
15,123,700
21,632,900
2,533,900
2,941,100
3,413,900
5,147,100
7,074,300
16,572,200
2,520,000
3,333,100
11,021,100
2,448,200
2,937,800
3,427,400
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 664 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,877,300
3,452,700
4,028,200
4,233,900
5,080,700
5,927,500
3,023,500
3,628,200
4,232,900
4,541,400
5,449,700
6,358,000
6,401,700
7,682,000
8,962,300
10,687,800
12,825,300
14,962,900
15,191,200
18,229,400
21,267,700
21,339,100
25,606,900
29,874,700
9,765,700
11,718,800
13,671,900
16,020,200
26,401,500
19,224,300
31,681,800
22,428,300
36,962,100
23,908,100
28,689,700
33,471,300
27,964,000
33,556,800
39,149,600
34,610,100
41,532,100
48,454,100
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,877,300
14,252,800
16,628,300
467 M-1-04-II
15,258,900
18,310,700
21,362,500
468 M-1-04-III
18,822,300
22,586,800
26,351,300
469 M-1-05-I
470 M-1-05-II

7,774,000
12,197,600
9,328,900
14,637,100
10,883,700
17,076,600
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
16,062,700
19,275,300
22,487,800
8,441,100
10,129,300
11,817,500
11,308,100
13,569,800
15,831,400
23,035,700
27,642,900
32,250,000
19,496,600
23,395,900
27,295,200
46,615,700
55,938,800
65,261,900
100,545,700
120,654,800
140,764,000
12,691,800
15,230,100
17,768,500
16,716,600
20,059,900
23,403,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
41,679,900
50,015,800
58,351,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,976,200
14,545,100
20,798,200
10,771,400
17,454,100
24,957,800
12,566,700
20,363,100
29,117,400
4,432,100
5,318,600
6,205,000
7,860,200
9,432,300
11,004,300
11,222,900
13,467,400
15,712,000
5,475,500
9,086,500
14,924,100
6,570,600
10,903,900
17,908,900
7,665,700
12,721,200
20,893,700
8,202,800
9,843,300
11,483,900
10,312,800
12,375,300
14,437,900
16,060,500
19,272,600
22,484,700
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 665 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,667,200
18,800,600
21,934,000
17,233,900
20,680,600
24,127,400
19,730,500
23,676,600
27,622,700
8,906,100
10,687,300
12,468,600
10,576,800
23,806,200
12,692,200
28,567,400
14,807,600
33,328,700
3,043,200
3,651,800
4,260,400
4,538,400
8,586,700
5,446,100
10,304,000
6,353,700
12,021,300
3,792,100
4,550,500
5,308,900
8,314,000
9,976,800
11,639,600
12,392,300
14,870,800
17,349,300
3,026,900
3,632,300
4,237,700
5,034,600
6,041,500
7,048,500
6,942,600
8,331,100
9,719,600
5,040,100
6,048,200
7,056,200
7,572,600
9,087,100
10,601,700
14,774,000
17,728,800
20,683,600
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,748,100
6,897,700
8,047,400
512 M-4-14-II
7,089,400
8,507,300
9,925,200
513 M-4-14-III
514 M-4-15-I
10,653,400
3,513,900
12,784,000
4,216,700
14,914,700
4,919,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,543,200
10,310,000
2,918,200
4,817,600
8,093,300
5,451,900
12,371,900
3,501,800
5,781,200
9,711,900
6,360,500
14,433,900
4,085,400
6,744,700
11,330,600
3,787,400
4,544,900
5,302,300
5,297,100
6,356,500
7,415,900
7,397,000
8,876,400
10,355,900
2,862,700
4,314,200
5,194,400
3,435,200
5,177,000
6,233,300
4,007,700
6,039,900
7,272,200
3,077,700
3,693,200
4,308,700
5,028,400
6,034,100
7,039,800
9,820,800
11,785,000
13,749,200
3,011,400
3,613,600
4,215,900
4,409,600
5,291,500
6,173,500
4,928,300
5,913,900
6,899,600
3,032,200
3,638,600
4,245,100
3,792,400
4,550,900
5,309,400
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 666 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,502,500
10,203,000
11,903,500
535 N-1-01-I

179,948,600
215,938,400
251,928,100
536 N-1-01-II
179,948,600
215,938,400
251,928,100
537 N-1-01-III
538 N-1-11-I

179,948,600
8,746,300
215,938,400
10,495,600
251,928,100
12,244,900
539 N-1-11-II
540 N-1-11-III

13,830,100
21,561,100
16,596,100
25,873,300
19,362,100
30,185,600
4,457,700
5,349,300
6,240,800
9,149,300
10,979,200
12,809,000
19,854,400
23,825,200
27,796,100
10,047,700
12,057,200
14,066,800

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
14,061,200
19,086,700
16,873,400
22,904,000
19,685,700
26,721,300
8,919,500
10,703,500
12,487,400
13,493,500
16,192,200
18,890,900
15,529,800
18,635,700
21,741,700
8,258,100
9,909,800
11,561,400
11,214,400
13,457,200
15,700,100
13,052,000
15,662,400
18,272,800
3,403,300
4,084,000
4,764,600
4,243,700
5,092,400
5,941,100
6,241,800
7,490,200
8,738,500
2,693,400
4,564,500
5,679,200
2,457,300
4,319,600
5,199,300
3,509,900
4,233,300
6,687,900
3,232,100
5,477,400
6,815,000
2,948,800
5,183,500
6,239,200
4,211,900
5,080,000
8,025,500
3,770,700
6,390,300
7,950,900
3,440,200
6,047,400
7,279,000
4,913,800
5,926,600
9,363,100
2,623,900
3,148,700
3,673,400
3,723,200
4,467,800
5,212,400
5,968,200
7,161,900
8,355,500
3,099,800
3,719,700
4,339,700
3,965,200
4,758,300
5,551,300
4,525,000
5,430,000
6,335,000
3,795,700
4,554,800
5,314,000
5,417,600
6,501,200
7,584,700
7,434,300
8,921,200
10,408,000
5,121,400
5,551,200
6,145,700
6,661,400
7,170,000
7,771,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 667 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,297,400
11,156,800
13,016,300
3,528,300
4,233,900
4,939,600
3,921,300
4,705,500
5,489,800
5,029,000
6,034,800
7,040,600
2,577,000
3,092,400
3,607,900
3,095,000
3,714,000
4,333,000
3,889,000
4,666,800
5,444,600
1,720,200
2,064,200
2,408,200

MAYOR (RINGAN)
MAYOR (SEDANG)
2,036,000
2,443,200
2,443,200
2,931,800
2,850,400
3,420,500
55,819,300
66,983,100
78,147,000
69,068,000
82,881,600
96,695,200
81,066,400
97,279,700
113,492,900
87,214,700
104,657,700
122,100,600
100,044,200
120,053,100
140,061,900
114,307,700
137,169,300
160,030,800
12,617,700
15,141,300
17,664,800
17,816,600
21,380,000
24,943,300
24,937,900
29,925,500
34,913,100
36,393,000
43,671,600
50,950,300
47,046,500
56,455,700
65,865,000
67,452,800
80,943,400
94,433,900
19,761,600
23,713,900
27,666,200
30,894,200
37,073,000
43,251,800
41,115,300
49,338,400
57,561,500
5,406,500
6,487,800
7,569,100
15,158,500
18,190,200
21,222,000
20,081,300
24,097,600
28,113,900
5,236,700
6,284,100
7,331,400
14,682,600
17,619,100
20,555,600
19,450,800
23,341,000
27,231,100
4,335,900
5,203,100
6,070,300
6,152,500
7,382,900
8,613,400
9,962,200
11,954,700
13,947,100
10,514,800
12,617,700
14,720,700
14,847,200
17,816,600
20,786,100
- 668 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,781,600
24,937,900
29,094,200
9,933,700
11,920,400
13,907,200
11,420,900
13,705,100
15,989,300
15,985,800
19,183,000
22,380,200
5,631,600
6,757,900
7,884,300
8,785,300
10,542,400
12,299,500
13,648,300
16,377,900
19,107,600
3,753,400
4,504,100
5,254,800
7,640,400
9,168,500
10,696,600
13,750,600
16,500,700
19,250,800
2,815,100
3,378,100
3,941,100
5,637,300
6,764,800
7,892,300
6,614,400
7,937,300
9,260,200
2,547,700
3,057,200
3,566,800
4,895,800
5,875,000
6,854,100
11,980,600
14,376,800
16,772,900
3,754,400
4,505,300
5,256,200
6,757,900
8,109,500
9,461,100
9,509,600
11,411,500
13,313,400
2,786,300
3,343,600
3,900,800
3,433,200
4,119,800
4,806,400
4,699,600
5,639,600
6,579,500
1,686,100
2,472,500
4,225,800
2,048,500
2,726,500
4,726,400
2,023,300
2,967,000
5,071,000
2,458,200
3,271,800
5,671,700
2,360,600
3,461,500
5,916,100
2,867,900
3,817,100
6,617,000
3,025,100
3,630,100
4,235,100
5,366,700
6,440,100
7,513,400
8,710,900
10,453,100
12,195,300
1,530,900
1,837,100
2,143,300
3,251,800
3,902,100
4,552,500
6,166,500
7,399,800
8,633,100
1,023,900
1,228,700
1,433,400
1,932,200
2,318,700
2,705,100
2,502,600
3,003,100
3,503,600
5,301,900
6,362,200
7,422,600
- 669 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,951,300
8,341,500
9,731,800
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,952,800
11,943,400
13,933,900
2,555,400
3,066,500
3,577,600
3,792,500
4,551,000
5,309,500
4,561,300
5,473,600
6,385,900
1,762,600
2,115,200
2,467,700
2,367,500
2,840,900
3,314,400
4,306,800
5,168,100
6,029,500
764,600
917,500
1,070,400
1,457,200
1,748,600
2,040,000
2,118,400
2,542,000
2,965,700
1,043,500
1,252,200
1,460,900
1,642,200
1,970,600
2,299,000
2,645,000
3,174,000
3,703,000
1,719,200
2,063,000
2,406,800
2,561,600
3,073,900
3,586,300
3,930,200
4,716,200
5,502,200
5,587,300
6,704,800
7,822,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,673,700
22,909,600
10,408,500
27,491,600
12,143,200
32,073,500
8,643,900
10,372,600
12,101,400
10,957,400
13,148,900
15,340,300
16,253,500
19,504,200
22,754,900
6,754,200
10,357,200
15,212,600
6,758,900
7,875,100
13,054,500
8,105,100
12,428,700
18,255,100
8,110,600
9,450,200
15,665,400
9,455,900
14,500,100
21,297,700
9,462,400
11,025,200
18,276,300
4,187,200
5,024,600
5,862,100
5,138,700
6,166,500
7,194,200
6,089,400
7,307,200
8,525,100
4,006,000
5,695,400
7,341,100
4,807,200
6,834,500
8,809,300
5,608,400
7,973,600
10,277,600
6,356,800
7,628,200
8,899,600
9,460,700
11,352,900
13,245,000
23,558,900
28,270,700
32,982,500
5,451,700
7,392,300
14,022,100
6,542,000
8,870,700
16,826,600
7,632,400
10,349,200
19,631,000
3,923,300
4,707,900
5,492,600
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 670 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,384,500
2,861,400
3,338,300
697 U-4-12-I
698 U-4-12-II

2,602,900
3,027,700
3,123,400
3,633,200
3,644,000
4,238,700
699 U-4-12-III

4,049,200
4,859,000
5,668,900
2,033,600
2,440,300
2,847,100
2,397,400
2,876,900
3,356,400
2,867,400
3,440,900
4,014,400
3,787,800
4,535,800
4,545,400
5,443,000
5,302,900
6,350,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,617,000
9,140,400
10,663,800
3,041,500
3,649,800
4,258,100
3,789,300
4,547,200
5,305,000
5,303,200
6,363,800
7,424,500
5,114,400
6,137,200
7,160,100
10,219,400
12,263,200
14,307,100
12,532,600
15,039,100
17,545,700
9,438,000
10,777,000
16,877,300
11,325,600
12,932,400
20,252,700
13,213,100
15,087,800
23,628,200
8,873,500
10,648,200
12,422,900
12,492,300
14,990,700
17,489,200
15,359,000
18,430,900
21,502,700
4,771,700
5,726,000
6,680,400
9,117,100
10,940,500
12,764,000
13,874,500
16,649,400
19,424,300
9,076,500
10,891,800
12,707,100
13,187,900
15,825,500
18,463,100
16,467,500
19,761,000
23,054,500
1,507,000
1,663,000
1,839,600
1,808,400
1,995,500
2,207,500
2,109,800
2,328,100
2,575,400
4,525,000
5,430,000
6,335,000
7,516,300
9,019,500
10,522,800
12,391,700
14,870,000
17,348,400
3,792,600
4,551,100
5,309,600
5,088,700
6,106,400
7,124,100
7,027,100
8,432,600
9,838,000
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,712,100
10,454,500
12,196,900
13,375,700
16,050,900
18,726,000
1,558,500
2,266,600
1,870,200
2,719,900
2,181,900
3,173,300
- 671 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,656,900
12,788,300
14,919,700
12,389,900
14,867,900
17,345,800
18,226,800
21,872,200
25,517,600
2,260,500
2,712,600
3,164,700
2,494,400
2,759,300
2,993,300
3,311,200
3,492,200
3,863,100
2,362,700
2,835,300
3,307,800
2,607,200
3,128,700
3,650,100
2,884,100
3,461,000
4,037,800
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,541,800
3,050,200
3,558,500
743 W-1-12-II
744 W-1-12-III

3,172,600
5,449,400
3,807,100
6,539,300
4,441,600
7,629,200
745 W-1-13-I
2,534,400
3,041,200
3,548,100
746 W-1-13-II
747 W-1-13-III

2,751,500
3,695,900
3,301,800
4,435,100
3,852,100
5,174,300
748 W-1-20-I
749 W-1-20-II

8,487,400
10,605,000
10,184,800
12,726,100
11,882,300
14,847,100
750 W-1-20-III
12,294,000
14,752,800
17,211,600
751 W-1-30-I
4,791,200
5,749,500
6,707,700
752 W-1-30-II
7,642,000
9,170,400
10,698,800
753 W-1-30-III
18,750,100
22,500,100
26,250,100
754 W-4-10-I
3,570,000
4,284,000
4,997,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,292,300
10,458,700
3,246,600
4,928,900
5,999,400
6,350,800
12,550,400
3,895,900
5,914,700
7,199,200
7,409,200
14,642,100
4,545,300
6,900,400
8,399,100
2,885,200
3,462,300
4,039,300
3,961,200
4,753,400
5,545,700
4,317,900
5,181,500
6,045,100
1,277,400
1,744,900
2,169,900
1,707,100
2,094,700
2,599,500
1,623,400
1,802,900
2,496,300
2,226,800
2,977,800
4,035,900
1,593,800
2,877,700
4,254,700
2,940,700
3,903,400
5,545,200
2,679,200
3,217,800
4,423,100
1,532,800
2,093,900
2,603,900
2,048,500
2,513,600
3,119,400
1,948,100
2,163,500
2,995,500
2,672,200
3,573,400
4,843,100
1,912,600
3,453,300
5,105,600
3,528,900
4,684,100
6,654,200
3,215,000
3,861,400
5,307,700
1,788,300
2,442,900
3,037,900
2,389,900
2,932,500
3,639,300
2,272,800
2,524,100
3,494,800
3,117,500
4,168,900
5,650,300
2,231,400
4,028,800
5,956,600
4,117,000
5,464,800
7,763,200
3,750,800
4,504,900
6,192,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 672 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,927,300
2,312,800
2,698,300
4,044,300
4,853,200
5,662,100
6,225,600
7,470,800
8,715,900
- 673 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
987,100
1,280,400
2,381,000
1,967,700
2,557,100
470,400
1,149,600
367,800
987,200
733,500
832,800
1,252,000
1,707,700
1,565,200
507,000
1,170,300
424,500
728,800
2,220,000
795,000
1,877,500
458,100
1,395,900
1,589,000
1,332,700
326,900
1,042,700
550,800
389,400
306,200
270,300
323,200
450,000
386,700
364,000
327,100
485,400
211,900
249,800
286,400
5,811,500
2,322,600
2,330,400
599,500
1,349,700
845,100
1,717,600
800,400
458,400
346,100
558,300
370,700
277,700
2,830,600
1,321,000
754,800
2,946,600
1,964,400
278,200
3,192,100
2,209,900
4,076,200
1,148,100
706,200
276,200
230,100
259,400
3,955,700
1,925,500
- 674 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,447,200
4,331,000
3,779,900
2,735,600
901,800
3,044,700
1,988,100
488,700
4,571,200
4,138,200
2,774,700
2,628,700
342,000
312,200
1,256,200
361,400
305,900
338,100
1,595,400
1,584,900
1,384,400
1,681,100
1,018,100
307,700
542,300
372,300
336,100
327,500
415,800
474,200
278,000
797,800
1,453,900
1,116,100
2,623,800
341,700
341,700
3,333,800
1,409,800
270,400
1,251,200
3,421,300
746,200
587,800
287,900
272,900
428,800
598,000
1,432,000
1,262,100
883,500
479,300
277,700
1,534,100
894,000
525,200
435,900
1,428,400
315,800
2,006,600
1,535,100
340,500
377,400
368,700
223,100
1,672,600
1,671,400
331,200
- 675 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,015,200
378,900
409,700
379,400
601,800
463,000
1,159,500
342,100
951,800
1,748,800
278,500
1,695,300
918,700
1,985,400
1,002,200
442,600
340,500
78,800
441,300
997,100
388,600
524,900
300,100
121,900
303,100
4,514,000
2,565,800
4,282,400
1,446,500
587,800
400,500
905,800
479,100
964,200
558,300
332,300
556,300
344,400
525,600
366,300
948,000
1,839,500
1,480,000
1,304,900
920,900
321,800
321,800
321,800
262,900
166,700
262,200
320,500
346,700
255,300
225,200
110,400
121,400
89,800
105,400
100,500
153,400
137,600
178,900
196,600
116,000
148,300
101,300
158,100
224,400
- 676 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
159,700
200,900
567,800
658,300
151,100
273,200
183,800
262,400
459,700
393,500
282,900
267,900
150,200
140,200
315,400
199,100
285,500
197,600
154,700
2,727,900
2,040,700
324,200
335,800
642,200
841,500
822,000
424,600
1,323,400
314,100
345,100
346,200
277,300
350,200
331,400
155,300
341,100
302,400
273,500
309,300
2,560,500
457,100
921,500
330,500
646,500
515,000
432,500
800,200
819,500
873,700
764,300
1,462,900
227,700
2,173,800
300,100
1,101,900
2,504,200
2,105,900
920,000
333,400
650,200
647,700
300,100
2,352,800
1,850,600
165,800
179,700
233,400
414,300
- 677 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,207,200
650,500
1,026,500
1,176,400
593,400
784,200
570,600
608,500
762,400
340,000
763,700
214,400
754,700
1,299,600
87,100
- 678 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,933,000
2,319,600
2,706,200
A-4-10-II
SEPTIKEMIA (SEDANG)
3,302,400
3,962,900
4,623,400
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,452,700
2,846,200
5,343,300
3,415,500
6,233,800
3,984,700
5
6
A-4-11-II
A-4-11-III

4,051,000
5,607,000
4,861,200
6,728,400
5,671,500
7,849,800
A-4-12-I
2,577,300
3,092,800
3,608,300
8
9
A-4-12-II
A-4-12-III

3,209,700
3,425,600
3,851,600
4,110,700
4,493,500
4,795,800
10 A-4-13-I
11 A-4-13-II

1,549,900
2,334,900
1,859,900
2,801,900
2,169,900
3,268,800
12 A-4-13-III
2,801,900
3,362,200
3,922,600
2,149,000
2,578,800
3,008,600
2,608,600
3,130,300
3,652,000
3,130,300
3,756,300
4,382,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,374,000
5,050,400
4,048,800
6,060,500
4,723,600
7,070,600
18 A-4-15-III
INFEKSI HIV (BERAT)
6,337,900
7,605,500
8,873,000
19 B-1-01-I
20 B-1-01-II

23,099,400
25,484,800
27,719,300
30,581,800
32,339,200
35,678,800
21 B-1-01-III
22 B-1-10-I

44,705,700
3,991,200
53,646,800
4,789,400
62,588,000
5,587,700
23 B-1-10-II
8,858,700
10,630,400
12,402,200
24 B-1-10-III
25 B-1-11-I

17,488,200
5,333,000
20,985,900
6,399,600
24,483,500
7,466,200
26 B-1-11-II
27 B-1-11-III

6,911,100
8,929,100
8,293,400
10,714,900
9,675,600
12,500,700
28 B-1-12-I
5,207,400
6,248,800
7,290,300
29 B-1-12-II
5,791,500
6,949,800
8,108,100
30 B-1-12-III
9,060,200
10,872,200
12,684,200
4,147,700
4,977,300
5,806,800
6,824,600
8,189,500
9,554,400
8,830,400
10,596,500
12,362,500
5,699,100
6,839,000
7,978,800
6,338,400
7,606,100
8,873,800
9,915,800
1,763,300
2,814,800
3,883,000
11,898,900
2,116,000
3,377,700
4,659,700
13,882,100
2,468,600
3,940,700
5,436,300
3,717,700
4,461,300
5,204,800
5,204,900
6,245,800
7,286,800
6,305,600
7,566,700
8,827,900
3,361,200
4,786,300
7,120,900
3,206,300
4,033,500
5,743,500
8,545,100
3,847,600
4,705,700
6,700,800
9,969,300
4,488,900
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 679 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,735,300
4,482,300
5,229,400
48 B-4-13-III
49 B-4-14-I

5,145,600
3,202,900
6,174,800
3,843,500
7,203,900
4,484,100
50 B-4-14-II
3,736,600
4,483,900
5,231,300
51 B-4-14-III
52 C-4-10-I

5,005,300
2,963,300
6,006,300
3,555,900
7,007,400
4,148,600
53 C-4-10-II
54 C-4-10-III

5,685,800
10,035,900
6,822,900
12,043,100
7,960,100
14,050,300
55 C-4-11-I
3,376,800
4,052,100
4,727,500
56 C-4-11-II
57 C-4-11-III

4,518,600
6,947,400
5,422,300
8,336,900
6,326,100
9,726,400
58 C-4-12-I
59 C-4-12-II
2,248,400
4,428,400
2,698,000
5,314,100
3,147,700
6,199,800
60 C-4-12-III
RADIOTERAPI (BERAT)
11,373,400
13,648,100
15,922,800
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,690,300
3,181,200
2,028,400
3,817,400
2,366,400
4,453,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,306,300
2,808,500
5,167,500
3,370,200
6,028,800
3,931,900
65 C-4-14-II
3,939,800
4,727,800
5,515,700
66 C-4-14-III
67 D-1-10-I

5,870,200
13,744,400
7,044,300
16,493,200
8,218,300
19,242,100
68 D-1-10-II
69 D-1-10-III

20,933,600
33,333,500
25,120,400
40,000,200
29,307,100
46,666,900
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,543,100
5,451,700
6,360,400
11,600,700
15,075,600
13,920,800
18,090,700
16,241,000
21,105,800
3,938,400
4,726,000
5,513,700
10,853,500
13,024,200
15,194,900
17,216,900
20,660,300
24,103,600
2,355,200
3,540,200
5,569,600
3,083,200
5,540,400
7,611,100
2,658,100
3,686,900
5,661,400
2,826,200
4,248,300
6,683,600
3,699,800
6,648,500
9,133,300
3,189,800
4,424,300
6,793,700
3,297,300
4,956,300
7,797,500
4,316,500
7,756,500
10,655,600
3,721,400
5,161,600
7,926,000
2,278,000
2,733,600
3,189,100
3,224,100
3,868,900
4,513,700
4,123,700
4,948,500
5,773,200
2,443,200
2,931,900
3,420,500
4,000,200
4,800,200
5,600,200
4,892,600
5,871,100
6,849,600
4,349,200
5,219,100
6,088,900
5,697,100
6,836,500
7,975,900
93 E-1-01-III
9,893,000
11,871,600
13,850,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,392,800
4,118,000
8,679,500
4,071,300
4,941,600
10,415,400
4,749,900
5,765,200
12,151,400
5,732,300
6,878,700
8,025,200
97 E-1-20-I
- 680 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,253,500
2,704,200
3,154,900
104 E-4-11-II
105 E-4-11-III

3,435,600
4,655,500
4,122,700
5,586,600
4,809,800
6,517,700
106 E-4-12-I
107 E-4-12-II

2,589,200
4,483,900
3,107,000
5,380,600
3,624,900
6,277,400
108 E-4-12-III

(RINGAN)
(SEDANG)
5,315,000
6,378,000
7,441,000
2,819,500
3,383,400
3,947,400
4,130,100
4,956,200
5,782,200
111 E-4-13-III
5,398,900
6,478,700
7,558,500
112 F-4-10-I
113 F-4-10-II
3,001,800
3,449,900
3,602,100
4,139,900
4,202,500
4,829,900
114 F-4-10-III
115 F-4-11-I
4,139,900
2,903,200
4,967,900
3,483,800
5,795,900
4,064,500
116 F-4-11-II
3,382,500
4,059,000
4,735,500
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,337,600
5,205,100
6,072,700
1,591,400
1,909,700
2,228,000
2,262,500
2,715,000
3,167,500
4,915,100
5,898,200
6,881,200
2,338,600
3,085,800
3,995,000
1,334,300
1,711,400
2,302,800
2,806,300
3,703,000
4,794,000
1,601,100
2,053,700
2,763,400
3,274,000
4,320,100
5,593,000
1,868,000
2,395,900
3,223,900
127 F-4-15-I
2,124,900
2,549,900
2,974,900
128 F-4-15-II
3,166,400
3,799,700
4,433,000
129 F-4-15-III
4,180,600
5,016,800
5,852,900
4,180,900
5,017,100
5,853,200
4,861,000
5,833,200
6,805,300
6,488,500
7,786,300
9,084,000
133 F-4-17-I

987,400
1,184,800
1,382,300
134 F-4-17-II
2,893,800
3,472,600
4,051,400
135
136
137
138
139
140
141

(RINGAN)
3,087,400
3,632,900
3,997,200
6,162,000
2,776,400
3,555,300
4,426,300
3,704,900
4,359,500
4,796,600
7,394,400
3,331,600
4,266,300
5,311,500
4,322,400
5,086,000
5,596,100
8,626,800
3,886,900
4,977,400
6,196,800
10,588,000
12,705,600
14,823,200
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,715,500
9,258,600
10,801,700
10,633,500
12,760,200
14,886,900
3,420,500
4,104,600
4,788,700
4,779,600
5,735,500
6,691,400
5,932,400
7,118,900
8,305,300
- 681 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,079,100
16,894,900
19,710,800
148 G-1-11-I
149 G-1-11-II

9,013,400
16,478,700
10,816,100
19,774,400
12,618,800
23,070,100
150 G-1-11-III
30,382,600
36,459,100
42,535,600
3,763,400
4,516,100
5,268,800
7,054,700
8,465,700
9,876,600
9,614,200
11,537,000
13,459,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,135,300
3,048,900
1,362,400
3,658,700
1,589,400
4,268,400
156 G-1-13-III
157 G-1-20-I

6,879,600
4,767,800
8,255,600
5,721,300
9,631,500
6,674,900
158 G-1-20-II
5,669,700
6,803,700
7,937,600
159 G-1-20-III
13,232,600
15,879,100
18,525,600
160 G-1-30-I
6,994,000
8,392,800
9,791,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,165,500
19,895,100
16,998,600
23,874,100
19,831,700
27,853,100
3,230,500
3,876,600
4,522,700
3,948,800
4,738,500
5,528,300
5,418,400
6,502,000
7,585,700
3,381,800
4,058,200
4,734,500
4,492,300
5,390,800
6,289,300
6,600,700
7,920,900
9,241,000
3,751,700
4,502,100
5,252,400
4,738,700
5,686,500
6,634,200
6,882,400
8,258,900
9,635,300
2,253,700
2,704,500
3,155,200
3,930,000
4,716,100
5,502,100
4,661,100
5,593,300
6,525,600
3,823,200
4,587,800
5,352,400
5,111,300
6,133,600
7,155,800
6,415,300
7,698,300
8,981,400
3,123,900
3,748,600
4,373,400
3,728,200
4,473,800
5,219,400
5,262,000
6,314,400
7,366,800
2,575,200
3,090,200
3,605,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,487,800
19,785,400
23,083,000
31,709,200
38,051,000
44,392,800
10,853,100
12,778,400
13,023,700
15,334,100
15,194,300
17,889,800
- 682 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,418,900
4,102,700
4,786,500
183 G-4-16-III
4,868,800
5,842,600
6,816,400
3,430,000
4,116,000
4,802,000
4,497,500
5,397,000
6,296,500
5,651,300
6,781,600
7,911,800
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,378,000
4,053,600
4,729,200
188 G-4-18-II
4,515,400
5,418,500
6,321,500
189 G-4-18-III
5,052,400
6,062,800
7,073,300
2,818,400
3,382,000
3,945,700
4,763,700
5,716,400
6,669,200
6,254,500
7,505,400
8,756,300
193 G-4-20-I

1,971,600
2,365,900
2,760,200
194 G-4-20-II
2,787,200
3,344,700
3,902,100
195 G-4-20-III
196 G-4-21-I

4,603,800
2,053,100
5,524,600
2,463,700
6,445,300
2,874,300
197 G-4-21-II
198 G-4-21-III

3,474,900
4,083,800
4,169,900
4,900,600
4,864,800
5,717,300
199 G-4-22-I
2,593,500
3,112,200
3,630,900
200 G-4-22-II
201 G-4-22-III

3,313,700
3,871,900
3,976,500
4,646,300
4,639,200
5,420,700
202 G-4-23-I
203 G-4-23-II

2,021,100
2,535,700
2,425,300
3,042,900
2,829,500
3,550,000
204 G-4-23-III
3,610,300
4,332,300
5,054,400
205 G-4-24-I
206 G-4-24-II

2,251,200
2,812,500
2,701,400
3,375,000
3,151,600
3,937,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,685,600
1,923,600
2,432,600
3,223,700
5,622,700
2,308,300
2,919,100
3,868,400
6,559,800
2,693,000
3,405,600
4,513,100
3,039,800
3,647,700
4,255,700
3,536,200
4,243,400
4,950,700
5,287,700
6,345,200
7,402,800
4,341,900
5,534,900
7,527,000
6,606,700
8,208,200
11,496,900
2,604,200
3,533,300
6,944,900
2,247,400
2,563,600
3,671,000
2,649,700
3,166,000
5,305,600
5,210,300
6,641,900
9,032,400
7,928,100
9,849,900
13,796,200
3,125,000
4,240,000
8,333,900
2,696,900
3,076,400
4,405,200
3,179,700
3,799,100
6,366,700
6,078,700
7,748,800
10,537,800
9,249,400
11,491,500
16,095,600
3,645,800
4,946,700
9,722,900
3,146,400
3,589,100
5,139,400
3,709,600
4,432,300
7,427,800
229 I-1-01-I
35,590,800
42,708,900
49,827,100
230 I-1-01-II
36,373,800
43,648,500
50,923,300
231 I-1-01-III

(RINGAN)
57,415,500
68,898,600
80,381,700
19,745,600
23,694,700
27,643,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 683 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,258,200
19,509,900
22,761,500
245 I-1-06-II
23,551,400
28,261,700
32,971,900
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
28,101,200
33,721,400
39,341,600
19,353,400
23,224,100
27,094,800
23,876,400
28,651,700
33,427,000
26,049,100
31,258,900
36,468,700
3,094,200
3,713,100
4,331,900
3,440,400
4,128,500
4,816,600
4,578,200
5,493,800
6,409,500
8,906,600
10,687,900
12,469,200
14,546,300
17,455,500
20,364,800
19,137,800
22,965,400
26,792,900
8,639,300
10,367,100
12,095,000
11,505,000
13,805,900
16,106,900
14,188,800
17,026,500
19,864,300
17,682,500
21,219,000
24,755,500
21,976,700
26,372,000
30,767,400
28,797,100
34,556,500
40,315,900
3,359,200
4,691,000
9,033,000
4,031,000
5,629,200
10,839,600
4,702,800
6,567,400
12,646,200
8,708,200
10,449,800
12,191,400
19,703,100
23,643,700
27,584,300
22,727,200
27,272,600
31,818,100
10,083,200
12,099,900
14,116,500
12,625,100
15,150,200
17,675,200
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
25,471,600
30,565,900
35,660,200
31,395,300
37,674,400
43,953,500
11,405,100
13,686,100
15,967,200
15,809,900
18,971,800
22,133,800
20,063,900
24,076,700
28,089,500
17,186,900
20,624,300
24,061,700
27,125,600
32,550,700
37,975,800
43,332,900
51,999,500
60,666,100
22,052,400
26,462,900
30,873,300
26,462,900
31,755,500
37,048,100
36,412,800
43,695,400
50,977,900
- 684 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
19,615,300
23,538,400
27,461,500
279 I-1-40-III
26,199,400
31,439,300
36,679,200
280 I-4-10-I
281 I-4-10-II

2,990,800
5,340,500
3,589,000
6,408,600
4,187,100
7,476,700
282 I-4-10-III
7,694,900
9,233,800
10,772,800
283 I-4-11-I
284 I-4-11-II

4,601,400
5,694,200
5,521,600
6,833,100
6,441,900
7,971,900
285 I-4-11-III
286 I-4-12-I

10,533,700
2,645,200
12,640,500
3,174,200
14,747,200
3,703,200
287 I-4-12-II
3,066,100
3,679,300
4,292,500
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,679,300
4,415,200
5,151,000
2,691,700
3,230,100
3,768,400
4,806,400
5,767,700
6,729,000
6,925,400
8,310,400
9,695,500
2,541,900
2,629,400
4,609,300
3,050,300
3,155,200
5,531,100
3,558,600
3,681,100
6,453,000
4,377,100
5,252,600
6,128,000
5,954,800
7,145,800
8,336,700
297 I-4-15-III
7,145,800
8,574,900
10,004,100
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,604,300
2,576,100
3,091,300
1,806,100
2,102,600
2,523,100
1,925,200
3,091,300
3,709,600
2,167,300
2,523,100
3,027,800
2,246,000
3,606,600
4,327,900
2,528,500
2,943,700
3,532,400
3,094,500
3,713,400
4,332,300
4,711,500
5,653,800
6,596,200
6,396,700
7,676,000
8,955,400
307 I-4-19-I
2,985,600
3,582,700
4,179,800
308 I-4-19-II

(SEDANG)
4,660,700
5,592,800
6,525,000
309 I-4-19-III
5,564,000
6,676,800
7,789,600
310
311
312
313
314

3,108,900
3,590,800
5,368,900
2,326,400
2,947,500
3,730,700
4,308,900
6,442,700
2,791,600
3,537,000
4,352,400
5,027,100
7,516,500
3,256,900
4,126,500
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
15,617,100
18,740,500
21,863,900
11,365,500
13,638,600
15,911,700
14,198,700
17,038,400
19,878,100
14,925,700
17,910,900
20,896,000
8,597,400
10,316,900
12,036,300
17,884,500
21,461,400
25,038,200
27,714,500
33,257,400
38,800,300
7,934,500
9,521,300
11,108,200
- 685 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,254,400
5,105,300
5,956,200
316 I-4-22-I
317 I-4-22-II
2,607,500
3,245,900
3,129,000
3,895,100
3,650,500
4,544,300
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,744,500
5,693,400
6,642,300
2,552,000
3,062,300
3,572,700
3,133,100
3,759,700
4,386,300
6,121,800
7,346,200
8,570,600
2,298,000
2,757,700
3,217,300
5,291,800
6,350,100
7,408,500
6,690,500
8,028,600
9,366,700
41,458,700
49,750,500
58,042,200
46,918,300
56,301,900
65,685,600
53,079,300
63,695,200
74,311,000
22,000,600
26,400,800
30,800,900
30,633,600
36,760,300
42,887,100
50,586,600
60,703,900
70,821,200
6,681,000
8,017,200
9,353,400
13,519,100
16,222,900
18,926,700
14,049,600
16,859,600
19,669,500
9,466,300
11,359,600
13,252,800
12,508,200
15,009,800
17,511,500
19,154,900
22,985,900
26,816,900
5,575,500
6,690,600
7,805,700
10,099,900
12,119,900
14,139,900
29,153,000
34,983,600
40,814,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,278,100
4,704,800
7,117,700
2,033,400
2,832,100
3,796,100
3,453,700
3,931,500
5,489,500
3,053,600
4,250,600
7,930,200
3,366,700
5,478,600
6,481,700
4,107,700
4,907,500
6,602,600
2,733,700
5,645,800
8,541,200
2,440,100
3,398,500
4,555,400
4,144,400
4,717,800
6,587,400
3,664,400
5,100,700
9,516,200
4,040,100
6,574,300
7,778,100
4,929,200
5,889,000
7,923,100
3,189,300
6,586,800
9,964,800
2,846,700
3,964,900
5,314,600
4,835,200
5,504,100
7,685,300
4,275,100
5,950,800
11,102,300
4,713,400
7,670,100
9,074,400
5,750,800
6,870,500
9,243,600
3,422,600
4,107,100
4,791,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 686 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,809,600
5,771,500
6,733,400
360 J-4-16-III
6,081,000
7,297,200
8,513,400
361 J-4-17-I
362 J-4-17-II

2,813,200
3,368,900
3,375,800
4,042,700
3,938,500
4,716,400
363 J-4-17-III
364 J-4-18-I

4,421,000
2,108,400
5,305,200
2,530,100
6,189,400
2,951,800
365 J-4-18-II
2,900,000
3,480,000
4,060,000
366 J-4-18-III
367 J-4-19-I

3,052,600
3,962,500
3,663,100
4,755,000
4,273,600
5,547,500
368 J-4-19-II
369 J-4-19-III

4,493,700
4,962,700
5,392,400
5,955,300
6,291,200
6,947,800
370 J-4-20-I
3,932,200
4,718,700
5,505,100
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,448,500
6,387,300
6,538,200
7,664,800
7,627,900
8,942,300
2,732,800
3,279,400
3,826,000
4,402,500
5,283,000
6,163,500
6,143,400
7,372,100
8,600,700
6,056,700
7,268,100
8,479,400
7,611,600
9,133,900
10,656,200
8,921,000
10,705,300
12,489,500
6,801,200
8,161,400
9,521,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
8,929,100
13,512,700
10,714,900
16,215,200
12,500,800
18,917,700
2,541,300
3,049,600
3,557,800
3,305,300
3,966,300
4,627,400
6,548,300
7,857,900
9,167,600
2,866,100
3,152,700
3,181,400
3,439,300
3,783,300
3,817,700
4,012,500
4,413,800
4,453,900
4,651,200
5,581,400
6,511,600
5,451,100
6,541,300
7,631,500
8,564,400
10,277,200
11,990,100
9,006,200
12,579,600
18,367,500
10,807,400
15,095,500
22,041,000
12,608,600
17,611,400
25,714,500
5,326,200
6,391,400
7,456,700
9,459,200
11,351,000
13,242,800
13,016,000
15,619,100
18,222,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,942,800
7,131,300
8,319,900
398 K-1-40-II

(SEDANG)
6,552,100
7,862,600
9,173,000
399 K-1-40-III
11,103,500
13,324,200
15,544,900
400
401
402
403
404

4,540,900
5,896,900
8,333,400
3,748,700
5,386,400
5,449,100
7,076,300
10,000,100
4,498,500
6,463,600
6,357,200
8,255,700
11,666,800
5,248,200
7,540,900
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 687 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,211,300
9,853,500
11,495,800
406 K-4-11-I
407 K-4-11-II

2,197,300
3,122,500
2,636,700
3,747,000
3,076,200
4,371,500
408 K-4-11-III
409 K-4-12-I

3,747,000
2,253,500
4,496,400
2,704,200
5,245,800
3,154,900
410 K-4-12-II
3,032,500
3,639,000
4,245,500
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,016,700
6,020,000
7,023,400
3,037,800
3,645,400
4,252,900
3,929,600
4,715,500
5,501,500
6,052,900
7,263,400
8,474,000
1,926,000
2,311,200
2,696,400
2,585,300
3,102,400
3,619,400
4,148,400
4,978,100
5,807,800
418 K-4-15-I
1,990,000
2,388,000
2,786,000
419 K-4-15-II
2,950,700
3,540,800
4,130,900
420 K-4-15-III
4,141,200
4,969,400
5,797,600
421 K-4-16-I
2,811,900
3,374,300
3,936,600
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,372,200
3,934,900
4,046,700
4,721,900
4,721,100
5,508,900
1,444,200
1,733,100
2,021,900
1,975,300
2,370,300
2,765,400
2,370,300
2,844,400
3,318,500
1,276,200
1,531,400
1,786,600
1,813,500
2,176,200
2,538,900
429 K-4-18-III
2,176,200
2,611,400
3,046,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,359,200
21,674,800
28,961,100
6,774,800
11,625,100
14,432,800
17,231,100
26,009,800
34,753,400
8,129,800
13,950,200
17,319,400
20,102,900
30,344,800
40,545,600
9,484,700
16,275,200
20,205,900
3,796,700
4,556,100
5,315,400
7,615,400
9,138,500
10,661,600
12,818,500
15,382,200
17,945,900
4,984,400
8,021,800
11,474,400
1,303,700
1,513,200
1,756,500
2,730,100
3,752,300
8,526,400
1,296,600
1,714,900
4,536,300
5,981,300
9,626,200
13,769,300
1,564,400
1,815,900
2,107,700
3,276,100
4,502,800
10,231,700
1,555,900
2,057,900
5,443,600
6,978,100
11,230,600
16,064,200
1,825,200
2,118,500
2,459,000
3,822,200
5,253,300
11,937,000
1,815,200
2,400,800
6,350,900
2,327,800
2,793,400
3,259,000
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 688 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,735,900
3,283,000
3,830,200
4,025,800
4,831,000
5,636,200
2,245,200
2,694,200
3,143,300
3,372,400
4,046,800
4,721,300
4,753,800
5,704,500
6,655,300
7,936,600
9,523,900
11,111,200
11,280,700
13,536,800
15,793,000
15,846,000
19,015,200
22,184,400
7,034,300
8,441,100
9,848,000
11,539,500
19,605,300
13,847,300
23,526,300
16,155,200
27,447,400
19,098,500
22,918,200
26,738,000
22,338,500
26,806,200
31,273,900
27,647,600
33,177,100
38,706,700
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,819,900
10,583,900
12,347,900
467 M-1-04-II
11,331,000
13,597,200
15,863,400
468 M-1-04-III
13,557,800
16,269,400
18,981,000
469 M-1-05-I
470 M-1-05-II

5,599,700
9,057,700
6,719,600
10,869,200
7,839,600
12,680,800
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,570,000
13,884,100
16,198,100
6,268,200
7,521,800
8,775,500
8,397,200
10,076,700
11,756,100
17,105,900
20,527,100
23,948,300
10,318,500
12,382,200
14,445,900
22,642,700
27,171,200
31,699,800
48,838,200
58,605,800
68,373,400
9,424,700
11,309,600
13,194,600
12,041,000
14,449,200
16,857,400
480 M-1-20-III
29,978,500
35,974,100
41,969,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,465,600
10,476,900
14,981,000
7,758,700
12,572,300
17,977,200
9,051,800
14,667,700
20,973,400
3,291,200
3,949,500
4,607,700
5,836,900
7,004,200
8,171,600
8,333,900
10,000,700
11,667,500
3,944,000
6,545,100
10,749,900
4,732,800
7,854,100
12,899,800
5,521,600
9,163,100
15,049,800
6,091,200
7,309,500
8,527,700
7,658,100
9,189,700
10,721,300
11,568,500
13,882,200
16,195,900
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 689 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,259,800
2,711,800
3,163,700
500 M-4-10-II
501 M-4-10-III
3,370,100
6,376,300
4,044,200
7,651,600
4,718,200
8,926,800
2,815,900
3,379,100
3,942,300
6,173,800
7,408,600
8,643,300
8,926,300
10,711,500
12,496,800
2,247,700
2,697,300
3,146,800
3,738,600
4,486,300
5,234,100
5,000,800
6,001,000
7,001,100
3,742,700
4,491,300
5,239,800
5,623,300
6,747,900
7,872,600
10,970,900
13,165,100
15,359,300
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,268,400
5,122,100
5,975,800
512 M-4-14-II
5,264,500
6,317,400
7,370,300
513 M-4-14-III
514 M-4-15-I
7,911,000
2,531,100
9,493,200
3,037,300
11,075,400
3,543,500
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,373,700
7,656,000
2,167,000
3,470,200
5,829,600
4,048,500
9,187,200
2,600,400
4,164,200
6,995,600
4,723,200
10,718,400
3,033,800
4,858,200
8,161,500
2,812,500
3,374,900
3,937,400
3,933,500
4,720,200
5,506,900
5,492,900
6,591,500
7,690,100
2,125,800
3,203,600
3,857,300
2,550,900
3,844,400
4,628,800
2,976,100
4,485,100
5,400,200
2,216,800
2,660,200
3,103,600
3,734,000
4,480,800
5,227,600
7,292,800
8,751,300
10,209,900
2,236,200
2,683,400
3,130,700
3,274,500
3,929,400
4,584,300
3,659,700
4,391,600
5,123,500
2,251,700
2,702,000
3,152,300
2,816,200
3,379,400
3,942,700
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,285,100
13,542,100
15,799,200
12,413,600
14,896,400
17,379,100
14,212,000
17,054,400
19,896,800
6,415,100
7,698,100
8,981,200
7,618,500
17,147,700
9,142,300
20,577,300
10,666,000
24,006,800
- 690 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,313,800
7,576,600
8,839,400
535 N-1-01-I

104,824,400
125,789,300
146,754,200
536 N-1-01-II
104,824,400
125,789,300
146,754,200
537 N-1-01-III
538 N-1-11-I

104,824,400
6,494,900
125,789,300
7,793,900
146,754,200
9,092,800
539 N-1-11-II
540 N-1-11-III

10,270,000
16,010,900
12,324,000
19,213,100
14,378,000
22,415,300
3,310,200
3,972,300
4,634,300
6,590,300
7,908,400
9,226,400
14,301,200
17,161,400
20,021,700
7,237,400
8,684,900
10,132,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,128,400
14,173,400
12,154,000
17,008,100
14,179,700
19,842,800
6,623,500
7,948,200
9,272,900
10,020,000
12,024,100
14,028,100
11,532,100
13,838,500
16,145,000
5,948,400
7,138,100
8,327,700
8,077,800
9,693,300
11,308,900
9,401,400
11,281,700
13,162,000
2,527,200
3,032,700
3,538,100
3,056,700
3,668,100
4,279,400
4,496,000
5,395,200
6,294,400
1,940,100
3,389,500
4,217,300
2,213,600
4,107,300
4,943,800
3,337,400
4,025,300
6,168,500
2,328,100
4,067,400
5,060,700
2,656,300
4,928,800
5,932,500
4,004,900
4,830,300
7,402,200
2,716,100
4,745,300
5,904,200
3,099,000
5,750,200
6,921,300
4,672,300
5,635,400
8,635,900
1,948,500
2,338,100
2,727,800
2,764,800
3,317,700
3,870,700
4,431,900
5,318,300
6,204,700
2,301,800
2,762,200
3,222,600
2,856,200
3,427,400
3,998,700
3,259,400
3,911,300
4,563,200
2,818,600
3,382,300
3,946,000
4,023,000
4,827,700
5,632,300
5,355,000
6,426,000
7,497,000
4,960,700
5,239,800
5,952,800
6,287,700
6,944,900
7,335,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 691 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,568,800
7,882,500
9,196,300
2,620,000
3,144,000
3,668,000
2,911,900
3,494,200
4,076,600
3,622,400
4,346,900
5,071,400
1,856,300
2,227,500
2,598,800
2,229,300
2,675,200
3,121,100
2,801,300
3,361,500
3,921,800
1,586,600
1,903,900
2,221,200

MAYOR (RINGAN)
MAYOR (SEDANG)
1,877,800
2,253,400
2,253,400
2,704,100
2,629,000
3,154,800
41,450,400
49,740,500
58,030,600
51,288,700
61,546,400
71,804,100
60,198,500
72,238,100
84,277,800
69,834,700
83,801,600
97,768,500
80,107,500
96,129,000
112,150,500
91,528,500
109,834,200
128,139,900
7,546,500
9,055,700
10,565,000
11,196,500
13,435,800
15,675,100
12,672,200
15,206,600
17,741,100
22,376,000
26,851,200
31,326,500
37,671,100
45,205,300
52,739,500
54,010,800
64,813,000
75,615,200
15,823,500
18,988,200
22,152,900
22,941,500
27,529,800
32,118,000
32,921,900
39,506,300
46,090,700
4,014,800
4,817,700
5,620,700
11,256,500
13,507,800
15,759,100
14,912,000
17,894,500
20,876,900
3,888,700
4,666,400
5,444,200
10,903,000
13,083,600
15,264,200
14,443,800
17,332,600
20,221,400
3,945,300
4,734,300
5,523,400
5,598,200
6,717,900
7,837,500
9,064,700
10,877,700
12,690,600
6,860,400
8,232,500
9,604,600
10,178,600
12,214,400
14,250,100
- 692 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,520,200
13,824,200
16,128,200
5,965,600
7,158,700
8,351,800
8,482,200
10,178,600
11,875,100
9,600,100
11,520,200
13,440,200
5,124,300
6,149,200
7,174,000
7,993,900
9,592,700
11,191,500
10,911,400
13,093,600
15,275,900
2,703,600
3,244,300
3,785,000
5,503,400
6,604,100
7,704,800
10,210,900
12,253,100
14,295,300
2,027,700
2,433,300
2,838,800
4,060,600
4,872,700
5,684,800
4,764,400
5,717,300
6,670,100
1,835,100
2,202,100
2,569,200
3,526,500
4,231,800
4,937,100
7,191,400
8,629,700
10,068,000
3,416,200
4,099,500
4,782,700
6,149,200
7,379,000
8,608,900
8,393,400
10,072,000
11,750,700
2,069,100
2,482,900
2,896,700
2,549,400
3,059,300
3,569,200
3,489,900
4,187,800
4,885,800
1,603,200
2,351,000
4,018,100
1,521,200
2,024,700
3,509,700
1,923,900
2,821,200
4,821,800
1,825,400
2,429,600
4,211,700
2,244,500
3,291,400
5,625,400
2,129,600
2,834,500
4,913,600
2,246,400
2,695,700
3,144,900
3,985,300
4,782,300
5,579,400
6,468,600
7,762,300
9,056,000
1,136,800
1,364,200
1,591,600
2,414,700
2,897,700
3,380,600
4,579,100
5,495,000
6,410,800
760,300
912,400
1,064,400
1,434,800
1,721,800
2,008,800
1,858,400
2,230,000
2,601,700
3,937,100
4,724,500
5,511,900
- 693 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,007,000
6,008,400
7,009,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,169,000
8,602,900
10,036,700
1,897,600
2,277,100
2,656,600
2,816,200
3,379,500
3,942,700
3,387,200
4,064,600
4,742,000
1,269,600
1,523,600
1,777,500
1,705,300
2,046,300
2,387,400
3,102,200
3,722,600
4,343,100
605,400
726,500
847,600
1,153,900
1,384,700
1,615,500
1,677,400
2,012,900
2,348,400
810,500
972,600
1,134,700
1,275,400
1,530,500
1,785,600
2,054,400
2,465,300
2,876,200
1,259,500
1,511,300
1,763,200
1,903,600
2,284,300
2,665,000
2,946,900
3,536,300
4,125,700
4,149,000
4,978,900
5,808,700

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,441,000
17,012,300
7,729,200
20,414,700
9,017,400
23,817,200
6,418,800
7,702,500
8,986,300
8,136,800
9,764,100
11,391,500
11,707,500
14,049,000
16,390,500
5,015,600
7,691,100
11,296,600
5,019,000
5,847,900
9,694,100
6,018,700
9,229,300
13,555,900
6,022,800
7,017,500
11,632,900
7,021,800
10,767,500
15,815,300
7,026,600
8,187,100
13,571,700
3,016,100
3,619,300
4,222,500
3,701,400
4,441,700
5,182,000
4,386,200
5,263,400
6,140,700
3,645,100
5,182,300
6,679,800
4,374,100
6,218,800
8,015,700
5,103,200
7,255,200
9,351,700
4,578,900
5,494,600
6,410,400
6,814,600
8,177,500
9,540,500
17,494,400
20,993,300
24,492,200
3,926,900
5,324,700
10,412,600
4,712,200
6,389,600
12,495,100
5,497,600
7,454,500
14,577,600
2,825,900
3,391,100
3,956,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 694 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,717,500
2,061,100
2,404,600
697 U-4-12-I
698 U-4-12-II

2,474,900
2,878,900
2,969,900
3,454,600
3,464,900
4,030,400
699 U-4-12-III

3,734,700
4,481,600
5,228,600
1,875,700
2,250,800
2,625,900
2,211,200
2,653,500
3,095,700
2,644,700
3,173,700
3,702,600
2,812,800
3,368,200
3,375,300
4,041,800
3,937,900
4,715,500

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,656,200
6,787,500
7,918,700
2,258,600
2,710,300
3,162,000
2,813,900
3,376,700
3,939,400
3,938,100
4,725,700
5,513,300
3,683,900
4,420,700
5,157,500
7,588,700
9,106,500
10,624,200
9,306,500
11,167,800
13,029,100
7,008,500
8,002,800
12,532,800
8,410,200
9,603,400
15,039,300
9,811,800
11,204,000
17,545,900
6,589,300
7,907,200
9,225,000
8,998,200
10,797,900
12,597,500
11,405,400
13,686,400
15,967,500
3,437,100
4,124,500
4,811,900
6,567,100
7,880,500
9,193,900
10,303,000
12,363,600
14,424,200
6,740,100
8,088,100
9,436,100
9,793,100
11,751,700
13,710,400
12,228,500
14,674,200
17,119,900
1,085,500
1,197,800
1,325,000
1,302,600
1,437,400
1,590,100
1,519,700
1,677,000
1,855,100
3,259,400
3,911,300
4,563,100
5,414,000
6,496,800
7,579,600
8,925,800
10,711,000
12,496,100
2,816,300
3,379,600
3,942,800
3,778,800
4,534,500
5,290,300
5,061,700
6,074,000
7,086,400
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,469,400
7,763,300
9,057,200
9,932,600
11,919,100
13,905,600
1,347,100
1,632,700
1,616,500
1,959,200
1,886,000
2,285,700
- 695 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,676,200
9,211,500
10,746,700
9,200,500
11,040,600
12,880,700
13,128,900
15,754,700
18,380,400
1,628,200
1,953,900
2,279,500
1,796,800
1,987,600
2,156,100
2,385,100
2,515,500
2,782,600
1,701,900
2,042,200
2,382,600
1,878,000
2,253,600
2,629,200
2,077,400
2,492,900
2,908,400
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,830,900
2,197,000
2,563,200
743 W-1-12-II
744 W-1-12-III

2,285,200
4,046,600
2,742,300
4,856,000
3,199,300
5,665,300
745 W-1-13-I
1,882,000
2,258,400
2,634,800
746 W-1-13-II
747 W-1-13-III

2,043,200
2,744,500
2,451,800
3,293,400
2,860,500
3,842,300
748 W-1-20-I
749 W-1-20-II

6,302,600
7,875,100
7,563,100
9,450,100
8,823,600
11,025,200
750 W-1-20-III
9,129,300
10,955,100
12,781,000
751 W-1-30-I
3,557,900
4,269,500
4,981,000
752 W-1-30-II
5,674,800
6,809,800
7,944,800
753 W-1-30-III
13,923,500
16,708,200
19,492,900
754 W-4-10-I
2,651,000
3,181,200
3,711,400
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,930,000
7,766,400
2,410,900
3,660,100
4,455,000
4,716,000
9,319,700
2,893,100
4,392,100
5,346,000
5,502,000
10,873,000
3,375,200
5,124,100
6,237,000
2,743,400
3,292,100
3,840,800
3,766,500
4,519,800
5,273,100
4,105,700
4,926,900
5,748,000
948,500
1,295,700
1,611,300
1,267,600
1,508,800
1,930,300
1,543,700
1,714,300
2,373,600
2,053,800
2,746,500
3,722,400
1,515,500
2,736,300
4,045,600
2,328,600
3,090,900
4,390,900
2,080,900
2,499,300
3,435,400
1,138,300
1,554,900
1,933,600
1,521,200
1,810,600
2,316,400
1,852,400
2,057,200
2,848,300
2,464,600
3,295,800
4,466,900
1,818,600
3,283,600
4,854,700
2,794,300
3,709,100
5,269,100
2,497,100
2,999,100
4,122,500
1,328,000
1,814,000
2,255,900
1,774,700
2,112,300
2,702,500
2,161,100
2,400,100
3,323,000
2,875,400
3,845,100
5,211,400
2,121,700
3,830,800
5,663,800
3,260,000
4,327,300
6,147,300
2,913,300
3,499,000
4,809,600
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 696 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,197,700
1,437,200
1,676,800
2,938,100
3,525,800
4,113,400
4,203,200
5,043,800
5,884,500
- 697 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
930,300
1,206,700
2,244,000
1,854,400
2,409,900
443,300
787,900
346,600
752,200
656,700
745,600
1,120,900
1,528,900
1,401,300
454,000
1,047,800
380,100
652,500
1,987,600
711,800
1,681,000
410,100
956,800
1,497,500
1,256,000
308,000
933,600
519,100
266,900
288,600
254,700
304,600
424,100
364,400
343,000
308,300
457,400
199,700
235,400
269,900
5,477,000
2,188,900
2,196,200
564,900
925,100
579,200
1,177,300
754,300
432,000
326,200
526,100
290,400
248,600
1,940,100
905,400
517,400
2,019,600
1,346,400
262,200
2,187,900
1,514,700
3,558,600
786,900
484,000
260,300
216,900
244,500
3,728,000
1,814,700
- 698 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,306,300
4,081,700
3,384,200
2,578,100
849,900
2,869,400
1,873,600
460,600
4,308,000
3,900,000
2,615,000
2,477,400
306,200
294,200
1,183,800
323,500
288,300
318,600
1,093,500
1,493,700
1,304,700
1,152,200
697,800
290,000
511,100
350,800
316,800
308,700
391,900
446,900
262,000
751,900
1,370,200
1,051,800
2,472,800
322,000
322,000
2,285,000
1,328,700
254,900
1,179,100
3,063,100
703,300
553,900
271,400
240,400
293,900
409,900
981,500
865,100
605,600
451,700
248,600
1,051,500
842,500
360,000
410,800
1,346,100
297,700
1,375,300
1,052,200
320,900
355,700
347,400
210,200
1,146,400
1,575,100
312,200
- 699 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
956,700
357,100
386,100
357,500
567,200
436,300
1,092,700
322,400
897,000
1,198,600
262,500
1,597,700
865,800
1,871,100
944,500
417,100
320,900
69,400
415,900
939,700
366,200
494,700
282,900
110,300
285,700
4,254,100
2,418,100
4,035,900
991,400
553,900
377,400
853,700
451,500
908,700
526,100
313,200
524,300
236,000
360,200
345,200
807,500
1,646,900
1,325,000
1,168,300
824,500
303,300
303,300
303,300
247,700
157,100
247,100
302,000
326,700
240,600
212,200
97,300
106,900
79,100
92,800
88,500
135,100
121,200
168,600
185,200
107,600
130,600
89,300
139,300
197,700
- 700 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
140,700
189,300
535,200
620,400
133,100
257,500
161,900
231,200
433,200
370,900
266,600
252,400
132,300
130,000
297,200
187,600
269,100
186,300
145,800
1,869,700
1,923,200
305,600
316,500
605,200
780,300
774,700
400,200
1,247,200
276,700
325,300
326,300
261,300
330,000
312,300
146,300
321,500
285,000
257,700
291,500
2,413,100
313,300
868,400
311,500
443,100
477,600
381,000
754,100
772,300
823,400
720,300
1,319,900
214,600
1,489,900
282,900
755,200
1,716,400
1,984,600
867,000
314,200
612,800
610,400
282,900
2,217,300
1,744,100
142,100
158,300
205,600
269,800
- 701 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,022,000
445,900
919,000
1,108,700
531,300
739,100
510,900
564,300
645,500
304,400
719,700
188,900
699,800
1,100,200
76,700
- 702 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,991,000
2,389,200
2,787,400
A-4-10-II
SEPTIKEMIA (SEDANG)
3,401,500
4,081,800
4,762,100
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,586,300
2,931,600
5,503,600
3,518,000
6,420,800
4,104,300
5
6
A-4-11-II
A-4-11-III

4,172,600
5,775,200
5,007,100
6,930,200
5,841,600
8,085,300
A-4-12-I
2,654,700
3,185,600
3,716,500
8
9
A-4-12-II
A-4-12-III

3,306,000
3,528,400
3,967,100
4,234,000
4,628,300
4,939,700
10 A-4-13-I
11 A-4-13-II

1,596,400
2,404,900
1,915,700
2,885,900
2,235,000
3,366,900
12 A-4-13-III
2,885,900
3,463,100
4,040,300
2,213,500
2,656,200
3,098,900
2,686,800
3,224,200
3,761,600
3,224,200
3,869,000
4,513,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,475,200
5,201,900
4,170,200
6,242,300
4,865,300
7,282,700
18 A-4-15-III
INFEKSI HIV (BERAT)
6,528,000
7,833,600
9,139,200
19 B-1-01-I
20 B-1-01-II

23,792,400
26,249,400
28,550,900
31,499,300
33,309,300
36,749,100
21 B-1-01-III
22 B-1-10-I

46,046,900
4,110,900
55,256,200
4,933,100
64,465,600
5,755,300
23 B-1-10-II
9,124,400
10,949,300
12,774,200
24 B-1-10-III
25 B-1-11-I

18,012,900
5,493,000
21,615,500
6,591,500
25,218,000
7,690,100
26 B-1-11-II
27 B-1-11-III

7,118,500
9,196,900
8,542,200
11,036,300
9,965,900
12,875,700
28 B-1-12-I
5,363,600
6,436,300
7,509,000
29 B-1-12-II
5,965,200
7,158,300
8,351,300
30 B-1-12-III
9,332,000
11,198,400
13,064,700
4,272,200
5,126,600
5,981,000
7,029,300
8,435,200
9,841,000
9,095,300
10,914,400
12,733,400
5,870,100
7,044,100
8,218,200
6,528,600
7,834,300
9,140,000
10,213,300
1,816,200
2,899,200
3,999,500
12,255,900
2,179,400
3,479,000
4,799,400
14,298,600
2,542,700
4,058,900
5,599,300
3,829,300
4,595,100
5,361,000
5,361,000
6,433,200
7,505,400
6,494,800
7,793,700
9,092,700
3,462,100
4,929,900
7,334,500
3,302,500
4,154,500
5,915,800
8,801,500
3,963,000
4,846,900
6,901,800
10,268,400
4,623,600
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 703 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,847,300
4,616,800
5,386,200
48 B-4-13-III
49 B-4-14-I

5,300,000
3,299,000
6,360,000
3,958,800
7,420,000
4,618,600
50 B-4-14-II
3,848,700
4,618,500
5,388,200
51 B-4-14-III
52 C-4-10-I

5,155,400
3,052,200
6,186,500
3,662,600
7,217,600
4,273,000
53 C-4-10-II
54 C-4-10-III

5,856,400
10,337,000
7,027,600
12,404,400
8,198,900
14,471,800
55 C-4-11-I
3,478,100
4,173,700
4,869,300
56 C-4-11-II
57 C-4-11-III

4,654,200
7,155,900
5,585,000
8,587,000
6,515,900
10,018,200
58 C-4-12-I
59 C-4-12-II
2,315,800
4,561,300
2,779,000
5,473,500
3,242,100
6,385,800
60 C-4-12-III
RADIOTERAPI (BERAT)
11,714,600
14,057,500
16,400,400
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,741,000
3,276,600
2,089,200
3,931,900
2,437,400
4,587,300
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,435,400
2,892,800
5,322,500
3,471,300
6,209,600
4,049,900
65 C-4-14-II
4,058,000
4,869,600
5,681,200
66 C-4-14-III
67 D-1-10-I

6,046,300
14,156,700
7,255,600
16,988,000
8,464,900
19,819,400
68 D-1-10-II
69 D-1-10-III

21,561,700
34,333,500
25,874,000
41,200,200
30,186,300
48,067,000
70 D-1-11-I
4,679,400
5,615,300
6,551,200
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
11,948,700
15,527,800
14,338,500
18,633,400
16,728,200
21,739,000
4,056,500
4,867,800
5,679,100
11,179,100
13,415,000
15,650,800
17,733,400
21,280,100
24,826,700
2,425,900
3,646,400
5,736,700
3,175,700
5,706,600
7,839,500
2,737,900
3,797,500
5,831,200
2,911,000
4,375,700
6,884,100
3,810,800
6,847,900
9,407,300
3,285,500
4,557,000
6,997,500
3,396,200
5,105,000
8,031,400
4,446,000
7,989,200
10,975,200
3,833,000
5,316,500
8,163,700
2,346,300
2,815,600
3,284,800
3,320,800
3,985,000
4,649,100
4,247,400
5,096,900
5,946,400
2,516,500
3,019,800
3,523,100
4,120,200
4,944,200
5,768,200
5,039,400
6,047,300
7,055,100
4,479,700
5,375,700
6,271,600
5,868,000
7,041,600
8,215,200
93 E-1-01-III
10,189,800
12,227,700
14,265,700
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,494,500
4,241,500
8,939,900
4,193,500
5,089,900
10,727,900
4,892,400
5,938,200
12,515,900
5,904,200
7,085,100
8,265,900
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 704 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,321,100
2,785,300
3,249,500
104 E-4-11-II
105 E-4-11-III

3,538,700
4,795,100
4,246,400
5,754,200
4,954,100
6,713,200
106 E-4-12-I
107 E-4-12-II

2,666,900
4,618,400
3,200,200
5,542,100
3,733,600
6,465,700
108 E-4-12-III

(RINGAN)
(SEDANG)
5,474,500
6,569,400
7,664,300
2,904,100
3,484,900
4,065,800
4,254,000
5,104,800
5,955,600
111 E-4-13-III
5,560,900
6,673,000
7,785,200
112 F-4-10-I
113 F-4-10-II
3,091,800
3,553,400
3,710,200
4,264,100
4,328,500
4,974,800
114 F-4-10-III
115 F-4-11-I
4,264,100
2,990,300
5,116,900
3,588,300
5,969,800
4,186,400
116 F-4-11-II
3,484,000
4,180,800
4,877,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,467,700
5,361,300
6,254,800
1,639,200
1,967,000
2,294,800
2,330,400
2,796,400
3,262,500
5,062,600
6,075,100
7,087,600
2,408,700
3,178,400
4,114,800
1,374,300
1,762,700
2,371,900
2,890,500
3,814,100
4,937,800
1,649,200
2,115,300
2,846,300
3,372,200
4,449,700
5,760,800
1,924,000
2,467,800
3,320,700
127 F-4-15-I
2,188,700
2,626,400
3,064,100
128 F-4-15-II
3,261,400
3,913,700
4,566,000
129 F-4-15-III
4,306,100
5,167,300
6,028,500
4,306,300
5,167,600
6,028,800
5,006,800
6,008,100
7,009,500
6,683,200
8,019,800
9,356,500
133 F-4-17-I

1,017,000
1,220,400
1,423,800
134 F-4-17-II
2,980,600
3,576,800
4,172,900
135
136
137
138
139
140
141

(RINGAN)
3,180,100
3,741,900
4,117,100
6,346,800
2,859,700
3,661,900
4,559,100
3,816,100
4,490,200
4,940,500
7,616,200
3,431,600
4,394,300
5,470,900
4,452,100
5,238,600
5,764,000
8,885,600
4,003,500
5,126,700
6,382,700
10,905,700
13,086,800
15,267,900
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,946,900
9,536,300
11,125,700
10,952,500
13,143,000
15,333,500
3,523,100
4,227,800
4,932,400
4,922,900
5,907,500
6,892,100
6,110,400
7,332,400
8,554,500
- 705 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,501,500
17,401,800
20,302,100
148 G-1-11-I
149 G-1-11-II

9,283,800
16,973,000
11,140,600
20,367,600
12,997,400
23,762,200
150 G-1-11-III
31,294,100
37,552,900
43,811,700
3,876,300
4,651,600
5,426,900
7,266,400
8,719,600
10,172,900
9,902,600
11,883,200
13,863,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,169,400
3,140,400
1,403,200
3,768,400
1,637,100
4,396,500
156 G-1-13-III
157 G-1-20-I

7,086,000
4,910,800
8,503,200
5,892,900
9,920,400
6,875,100
158 G-1-20-II
5,839,800
7,007,800
8,175,800
159 G-1-20-III
13,629,600
16,355,500
19,081,400
160 G-1-30-I
7,203,800
8,644,500
10,085,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,590,400
20,491,900
17,508,500
24,590,300
20,426,600
28,688,700
3,327,400
3,992,900
4,658,400
4,067,200
4,880,700
5,694,100
5,580,900
6,697,100
7,813,300
3,483,300
4,179,900
4,876,600
4,627,100
5,552,500
6,477,900
6,798,800
8,158,500
9,518,300
3,864,300
4,637,100
5,410,000
4,880,900
5,857,000
6,833,200
7,088,900
8,506,600
9,924,400
2,321,300
2,785,600
3,249,900
4,047,900
4,857,500
5,667,100
4,801,000
5,761,100
6,721,300
3,937,900
4,725,400
5,513,000
5,264,600
6,317,600
7,370,500
6,607,700
7,929,300
9,250,800
3,217,600
3,861,100
4,504,600
3,840,000
4,608,000
5,376,000
5,419,900
6,503,800
7,587,800
2,652,500
3,183,000
3,713,400
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
16,982,500
20,379,000
23,775,500
32,660,400
39,192,500
45,724,600
11,178,700
13,161,800
13,414,400
15,794,100
15,650,200
18,426,500
- 706 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,521,500
4,225,800
4,930,100
183 G-4-16-III
5,014,900
6,017,900
7,020,900
3,532,900
4,239,500
4,946,100
4,632,400
5,558,900
6,485,400
5,820,800
6,985,000
8,149,200
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,479,400
4,175,200
4,871,100
188 G-4-18-II
4,650,900
5,581,000
6,511,200
189 G-4-18-III
5,203,900
6,244,700
7,285,500
2,902,900
3,483,500
4,064,100
4,906,600
5,887,900
6,869,300
6,442,200
7,730,600
9,019,000
193 G-4-20-I

2,030,700
2,436,900
2,843,000
194 G-4-20-II
2,870,800
3,445,000
4,019,200
195 G-4-20-III
196 G-4-21-I

4,741,900
2,114,700
5,690,300
2,537,600
6,638,700
2,960,600
197 G-4-21-II
198 G-4-21-III

3,579,100
4,206,300
4,295,000
5,047,600
5,010,800
5,888,800
199 G-4-22-I
2,671,300
3,205,600
3,739,900
200 G-4-22-II
201 G-4-22-III

3,413,100
3,988,100
4,095,800
4,785,700
4,778,400
5,583,300
202 G-4-23-I
203 G-4-23-II

2,081,700
2,611,800
2,498,000
3,134,200
2,914,400
3,656,500
204 G-4-23-III
3,718,600
4,462,300
5,206,000
205 G-4-24-I
206 G-4-24-II

2,318,700
2,896,900
2,782,400
3,476,300
3,246,200
4,055,600
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,826,100
1,981,300
2,505,600
3,320,400
5,791,300
2,377,600
3,006,700
3,984,400
6,756,600
2,773,800
3,507,800
4,648,500
3,131,000
3,757,200
4,383,400
3,642,300
4,370,700
5,099,200
5,446,300
6,535,600
7,624,900
4,472,200
5,700,900
7,752,800
6,804,900
8,454,500
11,841,800
2,682,300
3,639,300
7,153,300
2,314,900
2,640,500
3,781,100
2,729,200
3,260,900
5,464,800
5,366,600
6,841,100
9,303,400
8,165,900
10,145,300
14,210,100
3,218,800
4,367,200
8,583,900
2,777,800
3,168,700
4,537,300
3,275,100
3,913,100
6,557,700
6,261,100
7,981,300
10,853,900
9,526,900
11,836,200
16,578,500
3,755,200
5,095,100
10,014,600
3,240,800
3,696,800
5,293,500
3,820,900
4,565,300
7,650,700
229 I-1-01-I
36,658,500
43,990,200
51,321,900
230 I-1-01-II
37,465,000
44,958,000
52,451,000
231 I-1-01-III

(RINGAN)
59,138,000
70,965,600
82,793,100
20,338,000
24,405,600
28,473,200
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 707 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,746,000
20,095,200
23,444,400
245 I-1-06-II
24,257,900
29,109,500
33,961,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
28,944,200
34,733,000
40,521,900
19,934,000
23,920,900
27,907,700
24,592,700
29,511,300
34,429,800
26,830,500
32,196,700
37,562,800
3,187,000
3,824,400
4,461,900
3,543,700
4,252,400
4,961,100
4,715,500
5,658,600
6,601,700
9,173,800
11,008,500
12,843,300
14,982,600
17,979,200
20,975,700
19,711,900
23,654,300
27,596,700
8,898,400
10,678,100
12,457,800
11,850,100
14,220,100
16,590,100
14,614,500
17,537,300
20,460,200
18,212,900
21,855,500
25,498,100
22,636,000
27,163,200
31,690,400
29,661,000
35,593,200
41,525,400
3,459,900
4,831,700
9,304,000
4,151,900
5,798,100
11,164,800
4,843,900
6,764,400
13,025,600
8,969,400
10,763,300
12,557,200
20,294,200
24,353,000
28,411,800
23,409,000
28,090,800
32,772,600
10,385,700
12,462,900
14,540,000
13,003,900
15,604,700
18,205,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
26,235,700
31,482,900
36,730,000
32,337,200
38,804,600
45,272,100
11,747,300
14,096,700
16,446,200
16,284,200
19,541,000
22,797,800
20,665,800
24,799,000
28,932,200
17,702,500
21,243,000
24,783,500
27,939,300
33,527,200
39,115,100
44,632,900
53,559,500
62,486,100
22,713,900
27,256,700
31,799,500
27,256,800
32,708,200
38,159,600
37,505,200
45,006,200
52,507,300
- 708 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
20,203,800
24,244,600
28,285,300
279 I-1-40-III
26,985,400
32,382,500
37,779,600
280 I-4-10-I
281 I-4-10-II

3,080,500
5,500,700
3,696,700
6,600,800
4,312,800
7,701,000
282 I-4-10-III
7,925,700
9,510,800
11,096,000
283 I-4-11-I
284 I-4-11-II

4,739,400
5,865,000
5,687,300
7,038,100
6,635,200
8,211,100
285 I-4-11-III
286 I-4-12-I

10,849,700
2,724,500
13,019,700
3,269,400
15,189,600
3,814,300
287 I-4-12-II
3,158,100
3,789,700
4,421,300
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,789,700
4,547,600
5,305,600
2,772,500
3,327,000
3,881,500
4,950,600
5,940,700
6,930,900
7,133,100
8,559,800
9,986,400
2,618,100
2,708,200
4,747,500
3,141,800
3,249,900
5,697,100
3,665,400
3,791,500
6,646,600
4,508,400
5,410,100
6,311,800
6,133,400
7,360,100
8,586,800
297 I-4-15-III
7,360,100
8,832,200
10,304,200
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,652,400
2,653,400
3,184,100
1,860,300
2,165,700
2,598,800
1,982,900
3,184,100
3,820,900
2,232,300
2,598,800
3,118,600
2,313,400
3,714,800
4,457,700
2,604,400
3,032,000
3,638,400
3,187,400
3,824,800
4,462,300
4,852,900
5,823,500
6,794,000
6,588,600
7,906,300
9,224,000
307 I-4-19-I
3,075,200
3,690,200
4,305,200
308 I-4-19-II

(SEDANG)
4,800,500
5,760,600
6,720,700
309 I-4-19-III
5,730,900
6,877,100
8,023,200
310
311
312
313
314

3,202,200
3,698,500
5,530,000
2,396,200
3,035,900
3,842,600
4,438,200
6,636,000
2,875,400
3,643,100
4,483,000
5,177,900
7,742,000
3,354,600
4,250,300
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
16,085,600
19,302,700
22,519,900
11,706,500
14,047,800
16,389,100
14,624,600
17,549,600
20,474,500
15,373,500
18,448,200
21,522,900
8,855,300
10,626,400
12,397,400
18,421,000
22,105,200
25,789,400
28,545,900
34,255,100
39,964,300
8,172,500
9,807,000
11,441,500
- 709 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,382,100
5,258,500
6,134,900
316 I-4-22-I
317 I-4-22-II
2,685,700
3,343,300
3,222,800
4,011,900
3,760,000
4,680,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,886,800
5,864,200
6,841,600
2,628,500
3,154,200
3,679,900
3,227,100
3,872,500
4,517,900
6,305,500
7,566,600
8,827,700
2,367,000
2,840,400
3,313,800
5,450,500
6,540,600
7,630,800
6,891,200
8,269,500
9,647,700
42,702,500
51,243,000
59,783,500
48,325,800
57,991,000
67,656,100
54,671,700
65,606,000
76,540,400
22,660,700
27,192,800
31,724,900
31,552,600
37,863,200
44,173,700
52,104,200
62,525,000
72,945,900
6,881,400
8,257,700
9,634,000
13,924,600
16,709,600
19,494,500
14,471,100
17,365,400
20,259,600
9,750,300
11,700,400
13,650,400
12,883,400
15,460,100
18,036,800
19,729,600
23,675,500
27,621,400
5,742,700
6,891,300
8,039,800
10,402,900
12,483,500
14,564,100
30,027,600
36,033,100
42,038,600
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,346,400
4,846,000
7,331,200
2,094,400
2,917,100
3,910,000
3,557,300
4,049,500
5,654,200
3,145,300
4,378,100
8,168,100
3,467,700
5,643,000
6,676,200
4,230,900
5,054,800
6,800,700
2,815,700
5,815,200
8,797,500
2,513,300
3,500,500
4,692,000
4,268,800
4,859,400
6,785,000
3,774,300
5,253,700
9,801,700
4,161,300
6,771,600
8,011,400
5,077,100
6,065,700
8,160,800
3,285,000
6,784,400
10,263,700
2,932,100
4,083,900
5,474,000
4,980,200
5,669,300
7,915,800
4,403,400
6,129,300
11,435,300
4,854,800
7,900,200
9,346,700
5,923,300
7,076,700
9,521,000
3,525,200
4,230,300
4,935,300
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 710 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,953,900
5,944,600
6,935,400
360 J-4-16-III
6,263,400
7,516,100
8,768,800
361 J-4-17-I
362 J-4-17-II

2,897,600
3,470,000
3,477,100
4,163,900
4,056,600
4,857,900
363 J-4-17-III
364 J-4-18-I

4,553,600
2,171,700
5,464,300
2,606,000
6,375,100
3,040,400
365 J-4-18-II
2,987,000
3,584,400
4,181,800
366 J-4-18-III
367 J-4-19-I

3,144,200
4,081,300
3,773,000
4,897,600
4,401,800
5,713,900
368 J-4-19-II
369 J-4-19-III

4,628,500
5,111,600
5,554,200
6,133,900
6,479,900
7,156,300
370 J-4-20-I
4,050,200
4,860,200
5,670,300
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,612,000
6,578,900
6,734,300
7,894,700
7,856,700
9,210,500
2,814,800
3,377,800
3,940,700
4,534,600
5,441,500
6,348,400
6,327,700
7,593,200
8,858,800
6,238,400
7,486,100
8,733,800
7,839,900
9,407,900
10,975,900
9,188,700
11,026,400
12,864,100
7,005,200
8,406,300
9,807,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
9,197,000
13,918,000
11,036,400
16,701,700
12,875,800
19,485,300
2,617,600
3,141,100
3,664,600
3,404,400
4,085,300
4,766,200
6,744,700
8,093,700
9,442,600
2,952,100
3,247,300
3,276,800
3,542,500
3,896,800
3,932,200
4,132,900
4,546,200
4,587,500
4,790,700
5,748,800
6,707,000
5,614,600
6,737,500
7,860,400
8,821,300
10,585,600
12,349,800
9,276,300
12,957,000
18,918,600
11,131,600
15,548,400
22,702,300
12,986,900
18,139,800
26,486,000
5,486,000
6,583,200
7,680,400
9,742,900
11,691,500
13,640,100
13,406,400
16,087,700
18,769,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
6,121,100
7,345,300
8,569,500
398 K-1-40-II

(SEDANG)
6,748,700
8,098,400
9,448,200
399 K-1-40-III
11,436,600
13,723,900
16,011,200
400
401
402
403
404

4,677,100
6,073,800
8,583,400
3,861,200
5,548,000
5,612,500
7,288,600
10,300,100
4,633,400
6,657,600
6,547,900
8,503,300
12,016,800
5,405,700
7,767,200
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 711 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,457,600
10,149,100
11,840,600
406 K-4-11-I
407 K-4-11-II

2,263,200
3,216,100
2,715,800
3,859,400
3,168,500
4,502,600
408 K-4-11-III
409 K-4-12-I

3,859,400
2,321,100
4,631,300
2,785,300
5,403,100
3,249,500
410 K-4-12-II
3,123,400
3,748,100
4,372,800
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,167,200
6,200,600
7,234,100
3,129,000
3,754,700
4,380,500
4,047,500
4,857,000
5,666,500
6,234,400
7,481,300
8,728,200
1,983,800
2,380,500
2,777,300
2,662,900
3,195,400
3,728,000
4,272,900
5,127,400
5,982,000
418 K-4-15-I
2,049,700
2,459,700
2,869,600
419 K-4-15-II
3,039,200
3,647,000
4,254,900
420 K-4-15-III
4,265,400
5,118,500
5,971,600
421 K-4-16-I
2,896,200
3,475,500
4,054,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,473,400
4,052,900
4,168,100
4,863,500
4,862,800
5,674,100
1,487,500
1,785,000
2,082,500
2,034,500
2,441,500
2,848,400
2,441,500
2,929,700
3,418,000
1,314,400
1,577,300
1,840,200
1,867,900
2,241,500
2,615,000
429 K-4-18-III
2,241,500
2,689,700
3,138,000
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,790,000
22,325,100
29,830,000
6,978,100
11,973,900
14,865,800
17,748,000
26,790,100
35,796,000
8,373,700
14,368,700
17,838,900
20,706,000
31,255,100
41,762,000
9,769,300
16,763,500
20,812,100
3,910,700
4,692,800
5,474,900
7,843,900
9,412,700
10,981,500
13,203,000
15,843,700
18,484,300
5,133,900
8,262,500
11,818,700
1,342,800
1,558,600
1,809,100
2,812,000
3,864,900
8,782,200
1,335,500
1,766,300
4,672,400
6,160,700
9,915,000
14,182,400
1,611,400
1,870,400
2,171,000
3,374,400
4,637,900
10,538,700
1,602,600
2,119,600
5,606,900
7,187,500
11,567,500
16,546,100
1,879,900
2,182,100
2,532,800
3,936,800
5,410,900
12,295,100
1,869,600
2,472,900
6,541,400
2,397,700
2,877,200
3,356,700
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 712 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,817,900
3,381,500
3,945,100
4,146,600
4,975,900
5,805,300
2,312,600
2,775,100
3,237,600
3,473,500
4,168,200
4,863,000
4,896,400
5,875,600
6,854,900
8,174,700
9,809,600
11,444,500
11,619,100
13,942,900
16,266,800
16,321,400
19,585,700
22,850,000
7,245,300
8,694,400
10,143,400
11,885,600
20,193,400
14,262,800
24,232,100
16,639,900
28,270,800
19,671,500
23,605,800
27,540,100
23,008,600
27,610,300
32,212,100
28,477,000
34,172,400
39,867,900
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
9,084,500
10,901,400
12,718,300
467 M-1-04-II
11,670,900
14,005,100
16,339,300
468 M-1-04-III
13,964,600
16,757,500
19,550,400
469 M-1-05-I
470 M-1-05-II

5,767,700
9,329,400
6,921,200
11,195,300
8,074,700
13,061,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,917,100
14,300,600
16,684,000
6,456,200
7,747,500
9,038,700
8,649,100
10,379,000
12,108,800
17,619,100
21,142,900
24,666,700
10,628,100
12,753,700
14,879,300
23,322,000
27,986,400
32,650,800
50,303,300
60,364,000
70,424,600
9,707,400
11,648,900
13,590,400
12,402,200
14,882,700
17,363,100
480 M-1-20-III
30,877,800
37,053,400
43,228,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,659,600
10,791,200
15,430,400
7,991,500
12,949,400
18,516,500
9,323,400
15,107,700
21,602,600
3,390,000
4,068,000
4,746,000
6,012,000
7,214,400
8,416,700
8,583,900
10,300,700
12,017,500
4,062,400
6,741,400
11,072,400
4,874,800
8,089,700
13,286,800
5,687,300
9,438,000
15,501,300
6,274,000
7,528,800
8,783,600
7,887,800
9,465,400
11,043,000
11,915,500
14,298,600
16,681,700
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 713 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,327,600
2,793,100
3,258,600
500 M-4-10-II
501 M-4-10-III
3,471,200
6,567,600
4,165,500
7,881,100
4,859,700
9,194,600
2,900,400
3,480,500
4,060,600
6,359,000
7,630,800
8,902,600
9,194,100
11,032,900
12,871,700
2,315,200
2,778,200
3,241,300
3,850,800
4,620,900
5,391,100
5,150,800
6,181,000
7,211,100
3,855,000
4,626,000
5,397,000
5,792,000
6,950,400
8,108,800
11,300,000
13,560,000
15,820,000
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,396,500
5,275,800
6,155,100
512 M-4-14-II
5,422,400
6,506,900
7,591,400
513 M-4-14-III
514 M-4-15-I
8,148,300
2,607,000
9,778,000
3,128,400
11,407,700
3,649,800
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,474,900
7,885,700
2,232,000
3,574,300
6,004,500
4,169,900
9,462,800
2,678,400
4,289,100
7,205,400
4,864,900
11,039,900
3,124,800
5,004,000
8,406,300
2,896,800
3,476,200
4,055,600
4,051,500
4,861,800
5,672,100
5,657,700
6,789,200
7,920,800
2,189,500
3,299,700
3,973,000
2,627,400
3,959,700
4,767,600
3,065,400
4,619,600
5,562,200
2,283,400
2,740,000
3,196,700
3,846,000
4,615,200
5,384,500
7,511,600
9,013,900
10,516,200
2,303,300
2,763,900
3,224,600
3,372,700
4,047,300
4,721,800
3,769,500
4,523,300
5,277,200
2,319,200
2,783,100
3,246,900
2,900,700
3,480,800
4,060,900
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,623,700
13,948,400
16,273,100
12,786,000
15,343,300
17,900,500
14,638,300
17,566,000
20,493,700
6,607,600
7,929,100
9,250,600
7,847,100
17,662,100
9,416,500
21,194,600
10,985,900
24,727,000
- 714 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,503,200
7,803,900
9,104,500
535 N-1-01-I

107,969,200
129,563,000
151,156,900
536 N-1-01-II
107,969,200
129,563,000
151,156,900
537 N-1-01-III
538 N-1-11-I

107,969,200
6,689,700
129,563,000
8,027,700
151,156,900
9,365,600
539 N-1-11-II
540 N-1-11-III

10,578,100
16,491,200
12,693,700
19,789,500
14,809,300
23,087,700
3,409,500
4,091,400
4,773,300
6,788,000
8,145,600
9,503,200
14,730,200
17,676,300
20,622,300
7,454,500
8,945,400
10,436,300

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,432,200
14,598,600
12,518,600
17,518,300
14,605,100
20,438,100
6,822,200
8,186,600
9,551,100
10,320,700
12,384,800
14,448,900
11,878,100
14,253,700
16,629,300
6,126,800
7,352,200
8,577,600
8,320,100
9,984,100
11,648,100
9,683,500
11,620,200
13,556,900
2,603,000
3,123,700
3,644,300
3,148,400
3,778,100
4,407,800
4,630,900
5,557,100
6,483,200
1,998,300
3,491,200
4,343,800
2,280,000
4,230,500
5,092,100
3,437,500
4,146,000
6,353,500
2,397,900
4,189,500
5,212,600
2,736,000
5,076,600
6,110,500
4,125,000
4,975,200
7,624,200
2,797,600
4,887,700
6,081,300
3,192,000
5,922,700
7,128,900
4,812,500
5,804,400
8,894,900
2,006,900
2,408,300
2,809,700
2,847,700
3,417,200
3,986,800
4,564,900
5,477,800
6,390,800
2,370,900
2,845,100
3,319,300
2,941,900
3,530,200
4,118,600
3,357,200
4,028,600
4,700,000
2,903,200
3,483,800
4,064,400
4,143,700
4,972,500
5,801,200
5,515,600
6,618,700
7,721,900
5,109,500
5,397,000
6,131,400
6,476,300
7,153,300
7,555,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 715 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,765,800
8,119,000
9,472,100
2,698,600
3,238,400
3,778,100
2,999,200
3,599,100
4,198,900
3,731,100
4,477,300
5,223,500
1,911,900
2,294,300
2,676,700
2,296,200
2,755,500
3,214,700
2,885,300
3,462,400
4,039,400
1,634,200
1,961,000
2,287,900

MAYOR (RINGAN)
MAYOR (SEDANG)
1,934,200
2,321,000
2,321,000
2,785,200
2,707,900
3,249,400
42,693,900
51,232,700
59,771,500
52,827,300
63,392,800
73,958,200
62,004,400
74,405,300
86,806,200
71,929,700
86,315,600
100,701,600
82,510,700
99,012,800
115,515,000
94,274,400
113,129,300
131,984,100
7,772,800
9,327,400
10,882,000
11,532,400
13,838,900
16,145,300
13,052,400
15,662,800
18,273,300
23,047,300
27,656,800
32,266,200
38,801,200
46,561,500
54,321,700
55,631,200
66,757,400
77,883,600
16,298,200
19,557,800
22,817,500
23,629,700
28,355,600
33,081,600
33,909,600
40,691,500
47,473,400
4,135,200
4,962,200
5,789,300
11,594,200
13,913,000
16,231,800
15,359,400
18,431,300
21,503,200
4,005,400
4,806,400
5,607,500
11,230,100
13,476,100
15,722,200
14,877,100
17,852,600
20,828,000
4,063,600
4,876,300
5,689,100
5,766,200
6,919,400
8,072,600
9,336,700
11,204,000
13,071,300
7,066,200
8,479,500
9,892,700
10,484,000
12,580,800
14,677,600
- 716 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,865,800
14,238,900
16,612,100
6,144,500
7,373,500
8,602,400
8,736,700
10,484,000
12,231,300
9,888,200
11,865,800
13,843,400
5,278,000
6,333,700
7,389,300
8,233,800
9,880,500
11,527,300
11,238,700
13,486,500
15,734,200
2,784,700
3,341,600
3,898,600
5,668,500
6,802,200
7,935,900
10,517,200
12,620,700
14,724,100
2,088,600
2,506,300
2,924,000
4,182,400
5,018,900
5,855,400
4,907,300
5,888,800
6,870,200
1,890,200
2,268,200
2,646,200
3,632,300
4,358,700
5,085,200
7,407,200
8,888,600
10,370,000
3,518,700
4,222,400
4,926,200
6,333,700
7,600,400
8,867,100
8,645,200
10,374,200
12,103,200
2,131,100
2,557,400
2,983,600
2,625,900
3,151,100
3,676,200
3,594,600
4,313,500
5,032,400
1,651,300
2,421,500
4,138,700
1,566,800
2,085,400
3,615,000
1,981,600
2,905,800
4,966,400
1,880,200
2,502,500
4,338,000
2,311,900
3,390,100
5,794,200
2,193,500
2,919,500
5,061,000
2,313,800
2,776,500
3,239,300
4,104,800
4,925,800
5,746,700
6,662,600
7,995,100
9,327,700
1,170,900
1,405,100
1,639,300
2,487,100
2,984,600
3,482,000
4,716,500
5,659,800
6,603,100
783,100
939,800
1,096,400
1,477,900
1,773,500
2,069,000
1,914,100
2,297,000
2,679,800
4,055,200
4,866,200
5,677,300
- 717 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,157,300
6,188,700
7,220,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,384,100
8,860,900
10,337,800
1,954,500
2,345,400
2,736,300
2,900,700
3,480,900
4,061,000
3,488,800
4,186,500
4,884,300
1,307,700
1,569,300
1,830,800
1,756,400
2,107,700
2,459,000
3,195,300
3,834,300
4,473,400
623,600
748,300
873,000
1,188,500
1,426,200
1,663,900
1,727,700
2,073,300
2,418,800
834,800
1,001,800
1,168,800
1,313,700
1,576,400
1,839,200
2,116,100
2,539,300
2,962,500
1,297,200
1,556,700
1,816,100
1,960,700
2,352,800
2,745,000
3,035,400
3,642,400
4,249,500
4,273,500
5,128,200
5,982,900

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,634,200
17,522,700
7,961,000
21,027,200
9,287,900
24,531,700
6,611,300
7,933,600
9,255,900
8,380,900
10,057,000
11,733,200
12,058,700
14,470,500
16,882,200
5,166,000
7,921,800
11,635,500
5,169,600
6,023,400
9,984,900
6,199,200
9,506,200
13,962,600
6,203,500
7,228,000
11,981,800
7,232,400
11,090,600
16,289,700
7,237,400
8,432,700
13,978,800
3,106,500
3,727,900
4,349,200
3,812,500
4,575,000
5,337,500
4,517,800
5,421,300
6,324,900
3,754,500
5,337,800
6,880,200
4,505,400
6,405,300
8,256,200
5,256,300
7,472,900
9,632,200
4,716,200
5,659,500
6,602,700
7,019,100
8,422,900
9,826,700
18,019,300
21,623,100
25,227,000
4,044,700
5,484,400
10,725,000
4,853,600
6,581,300
12,870,000
5,662,600
7,678,200
15,015,000
2,910,700
3,492,900
4,075,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 718 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,769,100
2,122,900
2,476,700
697 U-4-12-I
698 U-4-12-II

2,549,200
2,965,200
3,059,000
3,558,300
3,568,900
4,151,300
699 U-4-12-III

3,846,700
4,616,100
5,385,400
1,931,900
2,318,300
2,704,700
2,277,600
2,733,100
3,188,600
2,724,100
3,268,900
3,813,700
2,897,100
3,469,200
3,476,600
4,163,100
4,056,000
4,856,900

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,825,900
6,991,100
8,156,300
2,326,300
2,791,600
3,256,900
2,898,300
3,478,000
4,057,600
4,056,200
4,867,400
5,678,700
3,794,400
4,553,300
5,312,200
7,816,400
9,379,600
10,942,900
9,585,700
11,502,800
13,420,000
7,218,700
8,242,900
12,908,800
8,662,500
9,891,500
15,490,500
10,106,200
11,540,100
18,072,300
6,787,000
8,144,400
9,501,800
9,268,200
11,121,800
12,975,400
11,747,500
14,097,000
16,446,500
3,540,200
4,248,200
4,956,300
6,764,100
8,116,900
9,469,800
10,612,100
12,734,500
14,856,900
6,942,300
8,330,700
9,719,200
10,086,900
12,104,300
14,121,700
12,595,300
15,114,400
17,633,500
1,118,100
1,233,800
1,364,800
1,341,700
1,480,500
1,637,800
1,565,300
1,727,300
1,910,700
3,357,200
4,028,600
4,700,000
5,576,400
6,691,700
7,807,000
9,193,600
11,032,300
12,871,000
2,900,800
3,481,000
4,061,100
3,892,100
4,670,500
5,449,000
5,213,500
6,256,200
7,298,900
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,663,500
7,996,200
9,328,900
10,230,600
12,276,700
14,322,800
1,387,500
1,681,600
1,665,000
2,018,000
1,942,500
2,354,300
- 719 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,906,500
9,487,800
11,069,100
9,476,500
11,371,800
13,267,100
13,522,700
16,227,300
18,931,800
1,677,100
2,012,500
2,347,900
1,850,700
2,047,200
2,220,800
2,456,600
2,590,900
2,866,100
1,752,900
2,103,500
2,454,100
1,934,300
2,321,200
2,708,100
2,139,800
2,567,700
2,995,700
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,885,800
2,263,000
2,640,100
743 W-1-12-II
744 W-1-12-III

2,353,800
4,168,000
2,824,600
5,001,700
3,295,300
5,835,300
745 W-1-13-I
1,938,400
2,326,100
2,713,800
746 W-1-13-II
747 W-1-13-III

2,104,500
2,826,900
2,525,400
3,392,200
2,946,300
3,957,600
748 W-1-20-I
749 W-1-20-II

6,491,600
8,111,400
7,790,000
9,733,700
9,088,300
11,355,900
750 W-1-20-III
9,403,200
11,283,800
13,164,400
751 W-1-30-I
3,664,600
4,397,500
5,130,500
752 W-1-30-II
5,845,100
7,014,100
8,183,100
753 W-1-30-III
14,341,200
17,209,400
20,077,700
754 W-4-10-I
2,730,500
3,276,600
3,822,700
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
4,047,900
7,999,400
2,483,200
3,769,900
4,588,700
4,857,500
9,599,300
2,979,900
4,523,900
5,506,400
5,667,000
11,199,200
3,476,500
5,277,900
6,424,100
2,825,700
3,390,900
3,956,000
3,879,500
4,655,400
5,431,300
4,228,900
5,074,700
5,920,400
977,000
1,334,600
1,659,700
1,305,700
1,554,100
1,988,200
1,590,000
1,765,800
2,444,800
2,115,500
2,828,900
3,834,100
1,561,000
2,818,400
4,167,000
2,398,500
3,183,700
4,522,700
2,143,300
2,574,300
3,538,500
1,172,400
1,601,500
1,991,600
1,566,800
1,864,900
2,385,900
1,908,000
2,118,900
2,933,800
2,538,500
3,394,700
4,600,900
1,873,200
3,382,100
5,000,400
2,878,100
3,820,400
5,427,200
2,572,000
3,089,100
4,246,100
1,367,800
1,868,500
2,323,600
1,827,900
2,175,700
2,783,500
2,225,900
2,472,100
3,422,700
2,961,600
3,960,500
5,367,700
2,185,400
3,945,800
5,833,800
3,357,800
4,457,100
6,331,700
3,000,700
3,604,000
4,953,800
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 720 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,233,600
1,480,300
1,727,100
3,026,300
3,631,500
4,236,800
4,329,300
5,195,200
6,061,000
- 721 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
976,800
1,267,000
2,356,200
1,947,100
2,530,400
465,400
827,300
363,900
789,800
689,600
782,900
1,177,000
1,605,400
1,471,400
476,700
1,100,200
399,100
685,100
2,086,900
747,400
1,765,000
430,600
1,004,600
1,572,400
1,318,800
323,400
980,200
545,000
280,200
303,000
267,400
319,800
445,300
382,600
360,200
323,700
480,300
209,700
247,200
283,400
5,750,800
2,298,400
2,306,000
593,200
971,400
608,200
1,236,100
792,100
453,600
342,500
552,400
304,900
261,100
2,037,100
950,700
543,200
2,120,600
1,413,700
275,300
2,297,300
1,590,400
3,736,500
826,200
508,200
273,300
227,700
256,700
3,914,400
1,905,400
- 722 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,421,600
4,285,800
3,553,400
2,707,000
892,400
3,012,900
1,967,300
483,600
4,523,400
4,095,000
2,745,700
2,601,200
321,500
308,900
1,243,000
339,700
302,700
334,500
1,148,200
1,568,400
1,369,900
1,209,800
732,700
304,500
536,600
368,400
332,600
324,100
411,500
469,200
275,100
789,500
1,438,800
1,104,400
2,596,400
338,100
338,100
2,399,200
1,395,100
267,600
1,238,100
3,216,200
738,400
581,600
284,900
252,400
308,600
430,400
1,030,500
908,300
635,800
474,300
261,100
1,104,100
884,700
378,000
431,300
1,413,400
312,500
1,444,100
1,104,800
336,900
373,500
364,800
220,800
1,203,700
1,653,900
327,800
- 723 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,004,600
375,000
405,400
375,400
595,600
458,100
1,147,400
338,500
941,800
1,258,500
275,600
1,677,600
909,100
1,964,600
991,700
438,000
336,900
72,900
436,700
986,700
384,500
519,400
297,000
115,800
300,000
4,466,900
2,539,000
4,237,600
1,041,000
581,600
396,300
896,300
474,100
954,100
552,400
328,900
550,500
247,800
378,300
362,500
847,800
1,729,200
1,391,300
1,226,700
865,700
318,500
318,500
318,500
260,100
165,000
259,400
317,100
343,000
252,700
222,900
102,100
112,300
83,000
97,500
93,000
141,900
127,200
177,100
194,500
113,000
137,100
93,700
146,300
207,500
- 724 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
147,800
198,800
561,900
651,400
139,700
270,400
170,000
242,700
454,900
389,400
279,900
265,100
138,900
136,500
312,100
196,900
282,500
195,600
153,100
1,963,200
2,019,400
320,900
332,300
635,500
819,300
813,500
420,200
1,309,600
290,600
341,500
342,600
274,400
346,500
327,900
153,600
337,500
299,200
270,600
306,100
2,533,700
329,000
911,900
327,100
465,300
501,400
400,000
791,800
810,900
864,600
756,300
1,385,900
225,300
1,564,400
297,000
793,000
1,802,200
2,083,900
910,400
329,900
643,400
640,900
297,000
2,328,200
1,831,300
149,200
166,200
215,900
283,300
- 725 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,073,100
468,200
964,900
1,164,100
557,900
776,100
536,400
592,500
677,700
319,700
755,700
198,400
734,800
1,155,300
80,600
- 726 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,686,400
2,023,700
2,360,900
A-4-10-II
SEPTIKEMIA (SEDANG)
2,881,000
3,457,300
4,033,500
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
3,884,600
2,189,400
4,661,500
2,627,300
5,438,400
3,065,200
5
6
A-4-11-II
A-4-11-III

3,116,200
4,313,100
3,739,400
5,175,700
4,362,700
6,038,300
A-4-12-I
2,448,500
2,938,200
3,427,900
8
9
A-4-12-II
A-4-12-III

3,049,200
3,254,300
3,659,000
3,905,200
4,268,900
4,556,000
10 A-4-13-I
11 A-4-13-II

1,075,400
1,446,400
1,290,500
1,735,600
1,505,500
2,024,900
12 A-4-13-III
1,735,600
2,082,800
2,429,900
2,149,000
2,578,800
3,008,600
2,608,600
3,130,300
3,652,000
3,130,300
3,756,300
4,382,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
2,943,500
4,406,000
3,532,200
5,287,200
4,120,900
6,168,400
18 A-4-15-III
INFEKSI HIV (BERAT)
5,529,200
6,635,000
7,740,900
19 B-1-01-I
20 B-1-01-II

19,273,300
21,263,500
23,128,000
25,516,300
26,982,600
29,769,000
21 B-1-01-III
22 B-1-10-I

37,300,700
3,481,900
44,760,800
4,178,300
52,221,000
4,874,700
23 B-1-10-II
7,728,300
9,274,000
10,819,700
24 B-1-10-III
25 B-1-11-I

15,256,800
4,652,500
18,308,200
5,583,000
21,359,500
6,513,500
26 B-1-11-II
27 B-1-11-III

6,029,300
7,789,800
7,235,200
9,347,700
8,441,000
10,905,700
28 B-1-12-I
4,542,900
5,451,500
6,360,100
29 B-1-12-II
5,052,500
6,063,000
7,073,500
30 B-1-12-III
7,904,100
9,484,900
11,065,800
3,618,500
4,342,200
5,065,900
5,953,800
7,144,500
8,335,300
7,703,700
9,244,400
10,785,100
4,971,900
5,966,300
6,960,700
5,529,700
6,635,600
7,741,600
8,650,600
1,538,300
2,455,600
3,387,600
10,380,700
1,846,000
2,946,700
4,065,100
12,110,800
2,153,600
3,437,800
4,742,600
3,243,400
3,892,000
4,540,700
4,540,700
5,448,900
6,357,000
5,501,000
6,601,300
7,701,500
2,932,400
4,175,600
6,212,300
2,797,200
3,518,800
5,010,700
7,454,800
3,356,700
4,105,300
5,845,800
8,697,200
3,916,100
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 727 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,258,600
3,910,400
4,562,100
48 B-4-13-III
49 B-4-14-I

4,489,100
2,794,200
5,386,900
3,353,100
6,284,700
3,911,900
50 B-4-14-II
3,259,800
3,911,800
4,563,800
51 B-4-14-III
52 C-4-10-I

4,366,600
2,585,200
5,240,000
3,102,200
6,113,300
3,619,200
53 C-4-10-II
54 C-4-10-III

4,960,300
8,755,400
5,952,400
10,506,400
6,944,400
12,257,500
55 C-4-11-I
2,945,900
3,535,100
4,124,300
56 C-4-11-II
57 C-4-11-III

3,942,100
6,061,000
4,730,500
7,273,200
5,518,900
8,485,400
58 C-4-12-I
59 C-4-12-II
1,961,500
3,863,400
2,353,800
4,636,000
2,746,100
5,408,700
60 C-4-12-III
RADIOTERAPI (BERAT)
9,922,200
11,906,600
13,891,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,474,600
2,775,300
1,769,600
3,330,300
2,064,500
3,885,400
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,756,800
2,450,200
4,508,200
2,940,200
5,259,500
3,430,200
65 C-4-14-II
3,437,100
4,124,500
4,811,900
66 C-4-14-III
67 D-1-10-I

5,121,200
11,990,600
6,145,500
14,388,800
7,169,700
16,786,900
68 D-1-10-II
69 D-1-10-III

18,262,600
29,080,300
21,915,100
34,896,300
25,567,600
40,712,400
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
3,963,400
4,756,100
5,548,800
10,120,500
13,152,000
12,144,600
15,782,400
14,168,700
18,412,800
3,435,800
4,123,000
4,810,200
9,468,700
11,362,400
13,256,100
15,020,100
18,024,100
21,028,100
2,119,700
3,088,500
4,859,000
2,689,800
4,833,400
6,640,000
2,319,000
3,216,500
4,939,000
2,543,600
3,706,200
5,830,800
3,227,700
5,800,100
7,968,000
2,782,800
3,859,700
5,926,800
2,967,500
4,323,900
6,802,600
3,765,700
6,766,800
9,296,000
3,246,600
4,503,000
6,914,600
1,987,300
2,384,800
2,782,200
2,812,700
3,375,200
3,937,800
3,597,500
4,317,000
5,036,600
2,131,500
2,557,800
2,984,100
3,489,700
4,187,700
4,885,600
4,268,300
5,122,000
5,975,700
3,324,100
3,988,900
4,653,700
4,354,200
5,225,000
6,095,800
93 E-1-01-III
8,630,700
10,356,800
12,082,900
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,830,800
3,435,900
7,241,800
3,396,900
4,123,100
8,690,200
3,963,100
4,810,300
10,138,600
5,000,900
6,001,000
7,001,200
97 E-1-20-I
- 728 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
1,965,900
2,359,100
2,752,300
104 E-4-11-II
105 E-4-11-III

2,997,200
4,061,500
3,596,700
4,873,800
4,196,100
5,686,000
106 E-4-12-I
107 E-4-12-II

2,258,800
3,911,700
2,710,600
4,694,100
3,162,300
5,476,400
108 E-4-12-III

(RINGAN)
(SEDANG)
4,636,800
5,564,200
6,491,600
2,459,800
2,951,700
3,443,700
3,603,100
4,323,800
5,044,400
111 E-4-13-III
4,710,000
5,652,000
6,594,000
112 F-4-10-I
113 F-4-10-II
2,618,700
3,009,700
3,142,500
3,611,700
3,666,200
4,213,600
114 F-4-10-III
115 F-4-11-I
3,611,700
2,532,700
4,334,000
3,039,300
5,056,300
3,545,800
116 F-4-11-II
2,950,900
3,541,100
4,131,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,784,200
4,541,000
5,297,800
1,388,400
1,666,000
1,943,700
1,973,800
2,368,600
2,763,300
4,288,000
5,145,600
6,003,200
2,040,200
2,692,100
3,485,200
1,164,000
1,493,000
2,009,000
2,448,200
3,230,500
4,182,300
1,396,800
1,791,600
2,410,800
2,856,300
3,768,900
4,879,300
1,629,600
2,090,200
2,812,600
127 F-4-15-I
1,853,800
2,224,500
2,595,300
128 F-4-15-II
2,762,400
3,314,900
3,867,300
129 F-4-15-III
3,647,200
4,376,700
5,106,100
3,647,400
4,376,900
5,106,400
4,240,700
5,088,900
5,937,000
5,660,600
6,792,800
7,924,900
133 F-4-17-I

861,400
1,033,700
1,205,900
134 F-4-17-II
2,524,600
3,029,500
3,534,400
135
136
137
138
139
140
141

(RINGAN)
2,693,500
3,169,300
3,487,200
5,375,700
2,422,100
3,101,600
3,861,500
3,232,200
3,803,200
4,184,600
6,450,900
2,906,500
3,722,000
4,633,800
3,770,900
4,437,100
4,882,000
7,526,000
3,391,000
4,342,300
5,406,100
5,375,000
6,450,000
7,525,000
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,731,000
8,077,200
9,423,400
9,276,700
11,132,100
12,987,400
3,249,500
3,899,400
4,549,300
4,540,600
5,448,700
6,356,800
5,635,800
6,762,900
7,890,100
- 729 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,382,700
6,459,200
7,535,700
148 G-1-11-I
149 G-1-11-II

7,863,300
14,376,000
9,436,000
17,251,300
11,008,700
20,126,500
150 G-1-11-III
23,101,700
27,722,000
32,342,400
3,283,200
3,939,900
4,596,500
6,154,600
7,385,500
8,616,400
8,387,500
10,065,000
11,742,400
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
990,500
2,659,900
1,188,500
3,191,800
1,386,600
3,723,800
156 G-1-13-III
157 G-1-20-I

6,001,800
2,964,500
7,202,200
3,557,400
8,402,600
4,150,300
158 G-1-20-II
4,896,400
5,875,700
6,855,000
159 G-1-20-III
9,817,400
11,780,900
13,744,400
160 G-1-30-I
4,633,500
5,560,300
6,487,000
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,099,600
15,543,200
14,519,500
18,651,900
16,939,400
21,760,500
2,818,300
3,382,000
3,945,600
3,444,900
4,133,900
4,822,900
4,727,000
5,672,400
6,617,800
2,950,300
3,540,400
4,130,400
3,919,100
4,702,900
5,486,800
5,758,500
6,910,200
8,061,900
3,273,000
3,927,600
4,582,200
4,134,100
4,960,900
5,787,700
6,004,200
7,205,100
8,405,900
1,966,100
2,359,400
2,752,600
3,428,600
4,114,300
4,800,000
4,066,400
4,879,700
5,692,900
3,335,300
4,002,400
4,669,500
4,459,100
5,350,900
6,242,800
5,596,700
6,716,100
7,835,400
2,725,300
3,270,300
3,815,400
3,252,500
3,903,000
4,553,500
4,590,600
5,508,700
6,426,800
2,246,600
2,695,900
3,145,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,406,300
8,887,600
10,368,800
14,397,900
17,277,500
20,157,000
3,214,800
4,538,900
3,857,700
5,446,700
4,500,700
6,354,500
- 730 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
2,982,700
3,579,200
4,175,800
183 G-4-16-III
4,247,600
5,097,100
5,946,600
2,992,300
3,590,800
4,189,300
3,923,600
4,708,300
5,493,100
4,930,200
5,916,200
6,902,300
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
2,947,000
3,536,400
4,125,800
188 G-4-18-II
3,939,200
4,727,100
5,514,900
189 G-4-18-III
4,407,700
5,289,200
6,170,800
2,458,700
2,950,500
3,442,200
4,155,900
4,987,000
5,818,200
5,456,500
6,547,800
7,639,100
193 G-4-20-I

1,720,000
2,064,000
2,408,000
194 G-4-20-II
2,431,600
2,917,900
3,404,200
195 G-4-20-III
196 G-4-21-I

4,016,400
1,791,100
4,819,600
2,149,300
5,622,900
2,507,600
197 G-4-21-II
198 G-4-21-III

3,031,500
3,562,700
3,637,800
4,275,300
4,244,100
4,987,800
199 G-4-22-I
2,463,800
2,956,600
3,449,400
200 G-4-22-II
201 G-4-22-III

3,148,000
3,678,300
3,777,700
4,414,000
4,407,300
5,149,700
202 G-4-23-I
203 G-4-23-II

1,763,200
2,212,200
2,115,800
2,654,600
2,468,500
3,097,100
204 G-4-23-III
3,149,600
3,779,500
4,409,500
205 G-4-24-I
206 G-4-24-II

1,963,900
2,453,600
2,356,700
2,944,400
2,749,500
3,435,100
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,087,700
1,678,100
2,122,200
2,812,300
4,905,200
2,013,800
2,546,600
3,374,800
5,722,800
2,349,400
2,971,100
3,937,300
2,651,900
3,182,300
3,712,700
3,085,000
3,702,000
4,319,000
4,613,000
5,535,600
6,458,200
1,893,700
4,254,800
5,786,300
5,781,000
7,182,200
10,059,700
2,271,900
3,082,500
6,058,800
1,960,700
2,236,500
3,202,600
2,311,600
2,762,000
4,628,600
2,272,500
5,105,800
6,943,600
6,937,100
8,618,700
12,071,700
2,726,300
3,699,000
7,270,500
2,352,800
2,683,800
3,843,100
2,774,000
3,314,400
5,554,300
2,651,200
5,956,700
8,100,800
8,093,300
10,055,100
14,083,600
3,180,600
4,315,500
8,482,300
2,744,900
3,131,100
4,483,600
3,236,300
3,866,800
6,480,100
229 I-1-01-I
31,049,500
37,259,400
43,469,300
230 I-1-01-II
31,732,600
38,079,100
44,425,600
231 I-1-01-III

(RINGAN)
50,089,500
60,107,400
70,125,300
17,226,100
20,671,400
24,116,600
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 731 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,183,700
17,020,500
19,857,200
245 I-1-06-II
20,546,300
24,655,600
28,764,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
24,515,500
29,418,700
34,321,800
16,884,000
20,260,800
23,637,600
20,829,900
24,995,800
29,161,800
22,725,300
27,270,400
31,815,400
2,699,400
3,239,300
3,779,200
3,001,500
3,601,700
4,202,000
3,994,000
4,792,800
5,591,600
7,770,100
9,324,200
10,878,200
12,690,200
15,228,200
17,766,300
16,695,900
20,035,100
23,374,200
7,536,900
9,044,300
10,551,700
10,037,000
12,044,400
14,051,700
12,378,300
14,854,000
17,329,700
15,426,200
18,511,500
21,596,700
19,172,600
23,007,100
26,841,600
25,122,700
30,147,200
35,171,700
2,930,500
4,092,400
7,880,400
3,516,700
4,910,900
9,456,500
4,102,800
5,729,400
11,032,600
7,597,000
9,116,400
10,635,800
17,189,000
20,626,800
24,064,600
19,827,300
23,792,700
27,758,200
8,796,600
10,556,000
12,315,300
11,014,200
13,217,100
15,419,900
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,221,500
26,665,800
31,110,100
27,389,400
32,867,300
38,345,200
9,949,900
11,939,800
13,929,800
13,792,600
16,551,100
19,309,600
17,503,800
21,004,600
24,505,400
14,993,900
17,992,700
20,991,500
23,664,400
28,397,300
33,130,200
37,803,800
45,364,500
52,925,300
19,238,600
23,086,300
26,934,000
23,086,400
27,703,600
32,320,900
31,766,700
38,120,000
44,473,300
- 732 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,112,500
20,535,000
23,957,500
279 I-1-40-III
22,856,500
27,427,800
31,999,100
280 I-4-10-I
281 I-4-10-II

2,609,200
4,659,000
3,131,000
5,590,900
3,652,900
6,522,700
282 I-4-10-III
6,713,000
8,055,600
9,398,200
283 I-4-11-I
284 I-4-11-II

4,014,300
4,967,700
4,817,100
5,961,200
5,620,000
6,954,700
285 I-4-11-III
286 I-4-12-I

9,189,600
2,307,600
11,027,600
2,769,200
12,865,500
3,230,700
287 I-4-12-II
2,674,800
3,209,800
3,744,800
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,209,800
3,851,800
4,493,700
2,348,300
2,817,900
3,287,600
4,193,100
5,031,800
5,870,400
6,041,700
7,250,100
8,458,400
2,217,500
2,293,900
4,021,100
2,661,100
2,752,600
4,825,400
3,104,600
3,211,400
5,629,600
4,158,300
4,989,900
5,821,600
5,657,100
6,788,500
7,919,900
297 I-4-15-III
6,788,500
8,146,200
9,503,900
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,399,600
2,247,400
2,696,900
1,715,800
1,997,500
2,397,000
1,679,500
2,696,900
3,236,300
2,058,900
2,397,000
2,876,400
1,959,400
3,146,400
3,775,700
2,402,100
2,796,500
3,355,800
2,699,700
3,239,600
3,779,500
4,110,400
4,932,400
5,754,500
5,580,500
6,696,600
7,812,700
307 I-4-19-I
2,604,600
3,125,600
3,646,500
308 I-4-19-II

(SEDANG)
4,066,000
4,879,200
5,692,400
309 I-4-19-III
4,854,000
5,824,800
6,795,600
310
311
312
313
314

2,712,200
3,132,600
4,683,900
2,029,500
2,571,400
3,254,600
3,759,100
5,620,700
2,435,400
3,085,700
3,797,100
4,385,600
6,557,400
2,841,300
3,600,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
13,624,400
16,349,300
19,074,200
9,915,300
11,898,400
13,881,500
12,387,000
14,864,400
17,341,800
13,021,300
15,625,500
18,229,800
7,500,400
9,000,500
10,500,500
15,602,500
18,723,000
21,843,500
24,178,200
29,013,800
33,849,500
6,922,000
8,306,500
9,690,900
- 733 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,711,600
4,453,900
5,196,200
316 I-4-22-I
317 I-4-22-II
2,274,800
2,831,700
2,729,700
3,398,100
3,184,700
3,964,400
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,139,100
4,966,900
5,794,800
2,226,300
2,671,600
3,116,900
2,733,300
3,280,000
3,826,600
5,340,700
6,408,900
7,477,000
2,004,800
2,405,800
2,806,800
4,616,600
5,539,900
6,463,200
5,836,800
7,004,200
8,171,600
36,168,700
43,402,500
50,636,200
40,931,700
49,118,000
57,304,300
46,306,600
55,567,900
64,829,200
19,193,400
23,032,100
26,870,800
26,724,900
32,069,900
37,414,800
44,131,900
52,958,300
61,784,700
5,828,500
6,994,200
8,160,000
11,794,100
14,152,900
16,511,700
12,257,000
14,708,300
17,159,700
6,849,200
8,219,000
9,588,800
8,108,600
9,730,300
11,352,000
12,521,000
15,025,200
17,529,400
4,864,100
5,836,900
6,809,700
8,811,200
10,573,400
12,335,700
25,433,200
30,519,800
35,606,500
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
1,987,400
4,104,500
6,209,500
1,773,900
2,470,700
3,311,800
3,013,000
3,429,900
4,789,100
2,664,000
3,708,200
6,918,300
2,937,100
4,779,600
5,654,700
3,902,300
4,662,100
6,272,500
2,384,900
4,925,400
7,451,400
2,128,700
2,964,900
3,974,100
3,615,600
4,115,900
5,746,900
3,196,800
4,449,900
8,302,000
3,524,600
5,735,500
6,785,600
4,682,800
5,594,600
7,527,000
2,782,400
5,746,300
8,693,300
2,483,500
3,459,000
4,636,500
4,218,200
4,801,800
6,704,700
3,729,600
5,191,500
9,685,700
4,112,000
6,691,400
7,916,600
5,463,200
6,527,000
8,781,500
3,251,400
3,901,700
4,552,000
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 734 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,569,100
5,482,900
6,396,700
360 J-4-16-III
5,776,900
6,932,300
8,087,700
361 J-4-17-I
362 J-4-17-II

2,454,200
2,939,000
2,945,100
3,526,800
3,435,900
4,114,600
363 J-4-17-III
364 J-4-18-I

3,856,900
2,003,000
4,628,300
2,403,600
5,399,600
2,804,200
365 J-4-18-II
2,755,000
3,306,000
3,857,000
366 J-4-18-III
367 J-4-19-I

2,900,000
3,456,900
3,480,000
4,148,200
4,059,900
4,839,600
368 J-4-19-II
369 J-4-19-III

3,920,300
4,329,500
4,704,400
5,195,400
5,488,400
6,061,300
370 J-4-20-I
3,430,500
4,116,600
4,802,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,753,300
5,572,300
5,703,900
6,686,800
6,654,600
7,801,300
2,596,200
3,115,400
3,634,700
4,182,400
5,018,900
5,855,400
5,836,200
7,003,500
8,170,700
5,283,900
6,340,700
7,397,500
6,640,400
7,968,500
9,296,500
7,782,800
9,339,300
10,895,900
5,440,900
6,529,100
7,617,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,143,300
9,458,900
8,572,000
11,350,600
10,000,600
13,242,400
2,217,100
2,660,500
3,103,900
2,883,500
3,460,200
4,037,000
5,712,700
6,855,300
7,997,800
2,500,400
2,750,400
2,775,400
3,000,500
3,300,500
3,330,500
3,500,600
3,850,600
3,885,600
4,057,700
4,869,200
5,680,800
4,755,500
5,706,600
6,657,700
390 K-1-14-III
7,471,600
8,965,900
10,460,200
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

7,857,000
10,974,500
16,023,900
9,428,400
13,169,400
19,228,700
10,999,800
15,364,300
22,433,500
4,646,600
5,575,900
6,505,200
8,252,200
9,902,700
11,553,100
11,355,200
13,626,200
15,897,200
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,184,500
6,221,400
7,258,300
398 K-1-40-II

(SEDANG)
5,716,100
6,859,300
8,002,500
399 K-1-40-III
9,686,700
11,624,100
13,561,400
400
401
402
403
404

3,961,500
5,144,500
7,270,100
3,270,400
4,699,100
4,753,800
6,173,400
8,724,100
3,924,500
5,638,900
5,546,100
7,202,300
10,178,100
4,578,600
6,578,700
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 735 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,163,500
8,596,200
10,028,900
406 K-4-11-I
407 K-4-11-II

2,087,400
2,966,400
2,504,900
3,559,600
2,922,400
4,152,900
408 K-4-11-III
409 K-4-12-I

3,559,600
1,965,900
4,271,500
2,359,100
4,983,500
2,752,300
410 K-4-12-II
2,645,500
3,174,700
3,703,800
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,376,600
5,251,900
6,127,200
2,650,200
3,180,200
3,710,300
3,428,200
4,113,900
4,799,500
5,280,500
6,336,600
7,392,700
1,680,200
2,016,300
2,352,300
2,255,400
2,706,500
3,157,600
3,619,100
4,342,900
5,066,700
418 K-4-15-I
1,668,200
2,001,800
2,335,400
419 K-4-15-II
2,487,000
2,984,400
3,481,800
420 K-4-15-III
3,490,400
4,188,400
4,886,500
421 K-4-16-I
2,453,100
2,943,700
3,434,300
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
2,942,000
3,432,800
3,530,300
4,119,400
4,118,700
4,805,900
1,108,700
1,330,500
1,552,200
1,662,500
1,995,100
2,327,600
1,995,100
2,394,100
2,793,100
1,113,300
1,336,000
1,558,600
1,582,100
1,898,500
2,215,000
429 K-4-18-III
1,898,500
2,278,300
2,658,000
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,527,000
18,909,200
25,265,800
5,910,400
10,141,800
12,591,200
15,032,400
22,691,000
30,319,000
7,092,400
12,170,200
15,109,500
17,537,800
26,472,900
35,372,100
8,274,500
14,198,500
17,627,700
3,312,300
3,974,800
4,637,200
6,643,700
7,972,500
9,301,200
11,182,900
13,419,500
15,656,100
4,348,400
6,998,300
10,010,300
1,137,300
1,320,100
1,532,300
2,381,800
3,273,500
7,438,500
1,131,100
1,496,100
3,957,500
5,218,100
8,397,900
12,012,400
1,364,800
1,584,200
1,838,800
2,858,100
3,928,200
8,926,200
1,357,400
1,795,300
4,749,000
6,087,700
9,797,600
14,014,500
1,592,300
1,848,200
2,145,300
3,334,500
4,583,000
10,413,900
1,583,600
2,094,500
5,540,500
2,211,400
2,653,700
3,096,000
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 736 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,599,100
3,118,900
3,638,700
3,824,600
4,589,500
5,354,400
1,958,700
2,350,500
2,742,200
2,942,100
3,530,500
4,118,900
4,147,200
4,976,600
5,806,100
6,923,900
8,308,700
9,693,400
9,841,300
11,809,600
13,777,900
13,824,100
16,588,900
19,353,800
6,136,700
7,364,100
8,591,400
10,067,100
17,103,700
12,080,500
20,524,400
14,093,900
23,945,200
15,023,700
18,028,500
21,033,200
17,572,500
21,087,000
24,601,400
21,748,800
26,098,600
30,448,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,694,500
9,233,400
10,772,300
467 M-1-04-II
9,885,200
11,862,300
13,839,300
468 M-1-04-III
11,827,900
14,193,500
16,559,100
469 M-1-05-I
470 M-1-05-II

4,885,200
7,902,000
5,862,200
9,482,400
6,839,300
11,062,700
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,093,700
12,112,500
14,131,200
5,468,400
6,562,100
7,655,800
7,325,800
8,790,900
10,256,100
14,923,300
17,907,900
20,892,600
9,001,900
10,802,300
12,602,700
19,753,600
23,704,300
27,655,000
42,606,600
51,127,900
59,649,200
8,222,100
9,866,600
11,511,000
10,504,600
12,605,500
14,706,500
480 M-1-20-III
26,153,300
31,384,000
36,614,600
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,640,600
9,140,100
13,069,500
6,768,700
10,968,100
15,683,400
7,896,800
12,796,100
18,297,300
2,871,300
3,445,500
4,019,800
5,092,100
6,110,500
7,128,900
7,270,500
8,724,600
10,178,700
3,440,800
5,710,000
9,378,200
4,128,900
6,851,900
11,253,900
4,817,100
7,993,900
13,129,500
5,314,000
6,376,800
7,439,600
6,680,900
8,017,100
9,353,300
10,092,400
12,110,900
14,129,300
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 737 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
1,971,500
2,365,800
2,760,100
500 M-4-10-II
501 M-4-10-III
2,940,100
5,562,700
3,528,100
6,675,300
4,116,200
7,787,800
2,456,600
2,948,000
3,439,300
5,386,100
6,463,300
7,540,500
7,787,300
9,344,800
10,902,200
1,960,900
2,353,100
2,745,300
3,261,600
3,913,900
4,566,200
4,362,700
5,235,300
6,107,800
3,265,200
3,918,200
4,571,200
4,905,800
5,886,900
6,868,100
9,571,000
11,485,300
13,399,500
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,723,800
4,468,600
5,213,300
512 M-4-14-II
4,592,800
5,511,300
6,429,900
513 M-4-14-III
514 M-4-15-I
6,901,600
2,208,100
8,281,900
2,649,700
9,662,200
3,091,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
2,943,300
6,679,100
1,890,500
3,027,400
5,085,800
3,531,900
8,014,900
2,268,600
3,632,900
6,102,900
4,120,600
9,350,800
2,646,700
4,238,300
7,120,100
2,453,600
2,944,300
3,435,000
3,431,600
4,117,900
4,804,300
4,792,000
5,750,400
6,708,800
1,854,500
2,794,900
3,365,100
2,225,400
3,353,800
4,038,200
2,596,300
3,912,800
4,711,200
1,934,000
2,320,800
2,707,600
3,257,600
3,909,100
4,560,600
6,362,200
7,634,700
8,907,100
1,950,900
2,341,000
2,731,200
2,856,700
3,428,000
3,999,400
3,192,700
3,831,200
4,469,800
1,964,400
2,357,200
2,750,100
2,456,800
2,948,200
3,439,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
9,845,200
11,814,200
13,783,300
10,829,700
12,995,600
15,161,600
12,398,600
14,878,300
17,358,000
5,596,600
6,715,900
7,835,200
6,646,400
14,959,700
7,975,700
17,951,700
9,305,000
20,943,600
- 738 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,508,200
6,609,800
7,711,500
535 N-1-01-I

62,894,700
75,473,600
88,052,500
536 N-1-01-II
62,894,700
75,473,600
88,052,500
537 N-1-01-III
538 N-1-11-I

62,894,700
5,666,200
75,473,600
6,799,400
88,052,500
7,932,600
539 N-1-11-II
540 N-1-11-III

8,959,600
13,968,000
10,751,500
16,761,600
12,543,400
19,555,100
2,887,900
3,465,400
4,043,000
5,749,400
6,899,300
8,049,200
12,476,400
14,971,700
17,467,000
6,313,900
7,576,700
8,839,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,836,000
12,364,900
10,603,200
14,837,900
12,370,400
17,310,900
5,778,400
6,934,000
8,089,700
8,741,500
10,489,800
12,238,100
10,060,700
12,072,800
14,084,900
5,189,400
6,227,300
7,265,100
7,047,100
8,456,500
9,865,900
8,201,900
9,842,200
11,482,600
2,204,800
2,645,700
3,086,700
2,666,700
3,200,000
3,733,400
3,922,300
4,706,800
5,491,300
1,692,500
2,957,000
3,679,200
1,992,200
3,901,900
4,696,600
3,170,500
3,824,000
5,860,000
2,031,000
3,548,400
4,415,000
2,390,700
4,682,300
5,635,900
3,804,600
4,588,800
7,032,000
2,369,500
4,139,800
5,150,800
2,789,100
5,462,700
6,575,200
4,438,700
5,353,600
8,204,100
1,699,800
2,039,800
2,379,800
2,412,000
2,894,400
3,376,800
3,866,400
4,639,700
5,413,000
2,008,100
2,409,800
2,811,400
2,491,700
2,990,100
3,488,400
2,843,500
3,412,200
3,980,900
2,459,000
2,950,800
3,442,500
3,509,700
4,211,700
4,913,600
4,671,700
5,606,000
6,540,400
4,409,500
4,664,900
5,291,400
5,597,800
6,173,300
6,530,800
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 739 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,474,000
6,568,800
7,663,600
2,285,700
2,742,900
3,200,000
2,540,300
3,048,400
3,556,400
3,160,200
3,792,200
4,424,300
1,619,400
1,943,300
2,267,200
1,944,900
2,333,900
2,722,800
2,443,800
2,932,600
3,421,400
1,507,200
1,808,700
2,110,100

MAYOR (RINGAN)
MAYOR (SEDANG)
1,783,900
2,140,700
2,140,700
2,568,900
2,497,500
2,997,000
36,161,500
43,393,800
50,626,100
44,744,400
53,693,300
62,642,200
52,517,300
63,020,800
73,524,300
49,358,700
59,230,400
69,102,200
56,619,400
67,943,300
79,267,200
64,691,700
77,630,000
90,568,300
6,015,600
7,218,700
8,421,800
8,542,100
10,250,500
11,958,900
9,652,600
11,583,100
13,513,600
19,520,900
23,425,100
27,329,300
25,333,900
30,400,700
35,467,500
36,322,500
43,587,000
50,851,500
10,614,900
12,737,800
14,860,800
20,014,200
24,017,100
28,019,900
24,424,100
29,308,900
34,193,800
3,502,500
4,203,000
4,903,500
9,820,200
11,784,200
13,748,300
13,009,300
15,611,200
18,213,100
3,392,500
4,071,000
4,749,500
9,511,800
11,414,200
13,316,600
12,600,900
15,121,000
17,641,200
3,586,600
4,303,900
5,021,200
5,089,300
6,107,200
7,125,000
8,240,600
9,888,700
11,536,800
5,683,100
6,819,700
7,956,300
8,070,000
9,684,000
11,298,000
- 740 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,119,100
10,942,900
12,766,700
5,369,000
6,442,800
7,516,600
7,634,000
9,160,800
10,687,600
8,640,100
10,368,200
12,096,200
4,658,500
5,590,200
6,521,900
6,149,200
7,379,000
8,608,900
9,156,400
10,987,600
12,818,900
2,358,600
2,830,300
3,302,100
4,801,200
5,761,400
6,721,700
8,908,000
10,689,700
12,471,300
1,769,000
2,122,800
2,476,600
3,542,500
4,251,000
4,959,500
4,156,500
4,987,800
5,819,100
1,601,000
1,921,200
2,241,300
3,076,500
3,691,800
4,307,100
6,273,800
7,528,600
8,783,400
3,105,600
3,726,800
4,347,900
5,590,200
6,708,200
7,826,200
7,630,300
9,156,400
10,682,400
1,805,100
2,166,100
2,527,100
2,224,100
2,668,900
3,113,800
3,044,600
3,653,500
4,262,400
1,523,100
2,233,400
3,817,200
1,327,100
1,766,300
3,061,900
1,827,700
2,680,100
4,580,700
1,592,500
2,119,600
3,674,300
2,132,300
3,126,800
5,344,100
1,857,900
2,472,800
4,286,700
1,959,700
2,351,700
2,743,600
3,476,700
4,172,100
4,867,400
5,643,200
6,771,800
7,900,500
991,800
1,190,100
1,388,500
2,106,600
2,527,900
2,949,200
3,994,900
4,793,800
5,592,800
663,300
796,000
928,600
1,251,800
1,502,100
1,752,500
1,621,300
1,945,500
2,269,800
3,434,700
4,121,700
4,808,600
- 741 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,368,200
5,241,800
6,115,400
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,254,300
7,505,200
8,756,000
1,655,500
1,986,600
2,317,700
2,456,900
2,948,300
3,439,700
2,955,000
3,546,000
4,137,000
1,107,600
1,329,200
1,550,700
1,487,700
1,785,200
2,082,800
2,706,400
3,247,600
3,788,900
505,100
606,200
707,200
962,800
1,155,300
1,347,900
1,399,600
1,679,500
1,959,400
598,200
717,800
837,500
941,400
1,129,700
1,318,000
1,516,200
1,819,500
2,122,700
1,046,200
1,255,500
1,464,700
1,581,700
1,898,000
2,214,300
2,468,500
2,962,200
3,455,900
3,619,600
4,343,600
5,067,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,619,100
14,841,600
6,743,000
17,809,900
7,866,800
20,778,200
5,599,800
6,719,700
7,839,700
7,098,500
8,518,200
9,937,900
10,213,700
12,256,400
14,299,100
4,375,600
6,709,700
9,855,200
4,148,200
4,833,200
8,012,000
5,250,700
8,051,700
11,826,300
4,977,800
5,799,900
9,614,400
6,125,800
9,393,600
13,797,300
5,807,400
6,766,500
11,216,800
2,631,200
3,157,500
3,683,700
3,229,100
3,875,000
4,520,800
3,826,500
4,591,800
5,357,100
2,916,100
4,145,900
5,343,800
3,499,300
4,975,000
6,412,600
4,082,500
5,804,200
7,481,300
3,994,600
4,793,500
5,592,500
5,945,100
7,134,100
8,323,100
15,262,200
18,314,600
21,367,100
3,425,800
4,645,300
9,084,000
4,111,000
5,574,300
10,900,800
4,796,100
6,503,400
12,717,600
2,465,400
2,958,400
3,451,500
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 742 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,498,400
1,798,100
2,097,800
697 U-4-12-I
698 U-4-12-II

2,351,200
2,734,900
2,821,400
3,281,900
3,291,700
3,828,900
699 U-4-12-III

3,547,900
4,257,500
4,967,100
1,781,900
2,138,300
2,494,600
2,100,700
2,520,800
2,940,900
2,512,500
3,015,000
3,517,500
2,453,900
2,938,400
2,944,600
3,526,100
3,435,400
4,113,800

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
4,934,500
5,921,400
6,908,300
1,970,400
2,364,500
2,758,500
2,454,800
2,945,800
3,436,800
3,435,600
4,122,700
4,809,800
3,213,900
3,856,600
4,499,400
6,620,400
7,944,500
9,268,600
8,119,000
9,742,800
11,366,600
6,114,200
6,981,700
10,933,600
7,337,100
8,378,000
13,120,400
8,559,900
9,774,400
15,307,100
5,748,500
6,898,200
8,047,900
7,850,100
9,420,100
10,990,100
9,950,100
11,940,100
13,930,100
2,998,500
3,598,200
4,197,900
5,729,200
6,875,000
8,020,800
8,988,400
10,786,000
12,583,700
5,880,100
7,056,100
8,232,100
8,543,600
10,252,300
11,961,000
10,668,200
12,801,800
14,935,400
947,000
1,045,000
1,156,000
1,136,400
1,254,000
1,387,200
1,325,800
1,463,000
1,618,400
2,843,500
3,412,200
3,980,900
4,723,200
5,667,800
6,612,500
7,786,900
9,344,300
10,901,600
2,457,000
2,948,300
3,439,700
3,296,600
3,955,900
4,615,200
4,415,800
5,299,000
6,182,200
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,644,000
6,772,800
7,901,500
8,665,200
10,398,300
12,131,300
1,175,200
1,424,300
1,410,300
1,709,200
1,645,300
1,994,100
- 743 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,696,800
8,036,100
9,375,500
8,026,600
9,631,900
11,237,200
11,453,700
13,744,400
16,035,200
1,420,500
1,704,600
1,988,700
1,567,500
1,734,000
1,881,000
2,080,800
2,194,500
2,427,500
1,484,700
1,781,700
2,078,600
1,638,400
1,966,100
2,293,700
1,812,400
2,174,800
2,537,300
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,597,300
1,916,700
2,236,200
743 W-1-12-II
744 W-1-12-III

1,993,600
3,530,300
2,392,400
4,236,400
2,791,100
4,942,400
745 W-1-13-I
1,641,800
1,970,200
2,298,600
746 W-1-13-II
747 W-1-13-III

1,782,500
2,394,300
2,139,000
2,873,200
2,495,500
3,352,100
748 W-1-20-I
749 W-1-20-II

5,498,400
6,870,300
6,598,100
8,244,300
7,697,700
9,618,400
750 W-1-20-III
7,964,400
9,557,300
11,150,200
751 W-1-30-I
3,103,900
3,724,700
4,345,500
752 W-1-30-II
4,950,700
5,940,900
6,931,000
753 W-1-30-III
12,146,900
14,576,300
17,005,700
754 W-4-10-I
2,312,700
2,775,300
3,237,800
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,428,500
6,775,500
2,103,300
3,193,100
3,886,600
4,114,200
8,130,600
2,523,900
3,831,700
4,663,900
4,799,900
9,485,600
2,944,600
4,470,300
5,441,200
2,606,200
3,127,500
3,648,700
3,578,200
4,293,800
5,009,500
3,900,400
4,680,500
5,460,600
827,500
1,130,400
1,405,700
1,105,900
1,316,300
1,684,000
1,466,500
1,628,600
2,254,900
1,951,100
2,609,200
3,536,300
1,439,700
2,599,500
3,843,300
1,942,900
2,579,000
3,663,600
1,664,700
1,999,400
2,748,300
993,000
1,356,500
1,686,900
1,327,100
1,579,500
2,020,800
1,759,800
1,954,400
2,705,900
2,341,400
3,131,000
4,243,600
1,727,700
3,119,400
4,612,000
2,331,500
3,094,700
4,396,300
1,997,700
2,399,300
3,298,000
1,158,500
1,582,600
1,968,000
1,548,200
1,842,800
2,357,600
2,053,100
2,280,100
3,156,900
2,731,600
3,652,900
4,950,800
2,015,600
3,639,300
5,380,600
2,720,100
3,610,500
5,129,000
2,330,600
2,799,200
3,847,600
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 744 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
774,200
929,000
1,083,800
1,886,300
2,263,500
2,640,800
2,392,200
2,870,600
3,349,100
- 745 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
883,300
1,145,800
2,130,600
1,760,700
2,288,200
420,900
748,100
329,100
601,700
623,600
707,900
1,064,300
1,451,700
1,330,500
431,000
994,900
360,900
619,600
1,887,200
675,900
1,596,100
389,400
908,400
1,421,900
1,192,600
292,500
886,400
492,800
253,400
274,000
241,800
289,200
402,700
346,000
325,700
292,700
434,300
189,700
223,500
256,300
5,200,400
2,078,400
2,085,300
536,400
878,400
550,000
1,117,800
716,300
410,200
309,700
499,600
275,700
236,100
1,842,100
859,700
491,200
1,917,600
1,278,400
249,000
2,077,400
1,438,200
3,235,100
747,200
459,600
247,200
206,000
232,100
3,539,700
1,723,000
- 746 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,189,900
3,875,600
3,213,300
2,447,900
807,000
2,724,500
1,779,000
437,300
4,090,500
3,703,100
2,482,900
2,352,300
290,700
279,400
1,124,100
307,200
273,700
302,500
1,038,300
1,418,200
1,238,800
1,094,000
662,600
275,300
485,300
333,100
300,800
293,100
372,100
424,300
248,700
713,900
1,301,000
998,700
2,347,900
305,700
305,700
2,169,600
1,261,600
242,000
1,119,600
2,908,400
667,700
526,000
257,700
222,400
279,100
389,200
931,900
821,400
575,000
428,900
236,100
998,400
800,000
341,800
390,000
1,278,200
282,600
1,305,900
999,000
304,700
337,700
329,900
199,600
1,088,500
1,495,600
296,400
- 747 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
908,400
339,100
366,600
339,500
538,600
414,300
1,037,500
306,100
851,700
1,138,100
249,200
1,517,100
822,100
1,776,600
896,800
396,100
304,700
64,200
394,900
892,300
347,700
469,700
268,600
104,500
271,200
4,039,300
2,296,000
3,832,000
941,400
526,000
358,400
810,500
428,700
862,800
499,600
297,400
497,800
224,100
342,000
327,800
721,600
1,563,700
1,258,100
1,109,300
782,900
288,000
288,000
288,000
235,200
149,200
234,600
286,800
310,200
228,500
201,500
90,000
98,900
73,200
85,900
81,900
125,000
112,100
160,100
175,900
99,500
120,800
82,600
128,900
182,800
- 748 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
130,200
179,700
508,100
589,100
123,100
244,500
149,800
213,800
411,300
352,100
253,100
239,700
122,400
120,200
282,200
178,100
255,500
181,000
138,400
1,775,300
1,826,100
290,100
300,500
574,700
721,800
735,600
380,000
1,184,200
256,000
308,800
309,800
248,100
313,400
296,500
138,900
305,200
270,600
244,700
276,800
2,291,200
297,500
824,600
295,800
420,800
441,700
352,400
716,100
733,300
781,900
683,900
1,187,900
203,800
1,414,700
268,600
717,100
1,629,700
1,884,400
823,200
298,300
581,900
579,600
268,600
2,105,400
1,656,000
133,700
146,400
190,200
256,100
- 749 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
894,300
423,300
872,600
1,052,700
504,500
701,800
485,100
521,900
564,800
289,100
683,400
174,700
647,300
962,700
71,000
- 750 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,737,000
2,084,400
2,431,800
A-4-10-II
SEPTIKEMIA (SEDANG)
2,967,500
3,561,000
4,154,500
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,001,100
2,255,100
4,801,300
2,706,100
5,601,500
3,157,100
5
6
A-4-11-II
A-4-11-III

3,209,700
4,442,500
3,851,600
5,331,000
4,493,500
6,219,400
A-4-12-I
2,521,900
3,026,300
3,530,700
8
9
A-4-12-II
A-4-12-III

3,140,700
3,351,900
3,768,800
4,022,300
4,396,900
4,692,700
10 A-4-13-I
11 A-4-13-II

1,107,600
1,489,700
1,329,200
1,787,700
1,550,700
2,085,600
12 A-4-13-III
1,787,700
2,145,200
2,502,800
2,213,500
2,656,200
3,098,900
2,686,800
3,224,200
3,761,600
3,224,200
3,869,000
4,513,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,031,800
4,538,200
3,638,100
5,445,800
4,244,500
6,353,500
18 A-4-15-III
INFEKSI HIV (BERAT)
5,695,100
6,834,100
7,973,100
19 B-1-01-I
20 B-1-01-II

19,851,500
21,901,400
23,821,800
26,281,700
27,792,100
30,662,000
21 B-1-01-III
22 B-1-10-I

38,419,700
3,586,400
46,103,700
4,303,700
53,787,600
5,020,900
23 B-1-10-II
7,960,200
9,552,200
11,144,300
24 B-1-10-III
25 B-1-11-I

15,714,500
4,792,100
18,857,400
5,750,500
22,000,300
6,708,900
26 B-1-11-II
27 B-1-11-III

6,210,200
8,023,400
7,452,200
9,628,100
8,694,300
11,232,800
28 B-1-12-I
4,679,200
5,615,000
6,550,900
29 B-1-12-II
5,204,100
6,244,900
7,285,700
30 B-1-12-III
8,141,200
9,769,500
11,397,700
3,727,000
4,472,400
5,217,900
6,132,400
7,358,900
8,585,300
7,934,800
9,521,700
11,108,700
5,121,100
6,145,300
7,169,500
5,695,600
6,834,700
7,973,800
8,910,100
1,584,500
2,529,300
3,489,200
10,692,100
1,901,400
3,035,100
4,187,000
12,474,100
2,218,300
3,541,000
4,884,900
3,340,700
4,008,800
4,676,900
4,677,000
5,612,400
6,547,700
5,666,100
6,799,300
7,932,500
3,020,300
4,300,800
6,398,700
2,881,100
3,624,400
5,161,000
7,678,400
3,457,400
4,228,500
6,021,200
8,958,200
4,033,600
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 751 -

REGIONAL 4
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,356,400
4,027,700
4,699,000
48 B-4-13-III
49 B-4-14-I

4,623,700
2,878,100
5,548,500
3,453,700
6,473,200
4,029,300
50 B-4-14-II
3,357,600
4,029,200
4,700,700
51 B-4-14-III
52 C-4-10-I

4,497,600
2,662,700
5,397,200
3,195,300
6,296,700
3,727,800
53 C-4-10-II
54 C-4-10-III

5,109,100
9,018,000
6,130,900
10,821,600
7,152,800
12,625,200
55 C-4-11-I
3,034,300
3,641,200
4,248,000
56 C-4-11-II
57 C-4-11-III

4,060,300
6,242,800
4,872,400
7,491,400
5,684,500
8,739,900
58 C-4-12-I
59 C-4-12-II
2,020,300
3,979,300
2,424,400
4,775,100
2,828,500
5,571,000
60 C-4-12-III
RADIOTERAPI (BERAT)
10,219,900
12,263,800
14,307,800
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,518,900
2,858,500
1,822,700
3,430,200
2,126,400
4,002,000
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,869,500
2,523,700
4,643,400
3,028,400
5,417,300
3,533,200
65 C-4-14-II
3,540,200
4,248,300
4,956,300
66 C-4-14-III
67 D-1-10-I

5,274,800
12,350,400
6,329,800
14,820,400
7,384,800
17,290,500
68 D-1-10-II
69 D-1-10-III

18,810,500
29,952,700
22,572,600
35,943,200
26,334,600
41,933,800
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,082,300
4,898,800
5,715,300
10,424,100
13,546,500
12,508,900
16,255,800
14,593,700
18,965,100
3,538,900
4,246,700
4,954,500
9,752,700
11,703,300
13,653,800
15,470,700
18,564,800
21,658,900
2,183,300
3,181,200
5,004,700
2,770,500
4,978,500
6,839,200
2,388,500
3,313,000
5,087,200
2,619,900
3,817,400
6,005,700
3,324,600
5,974,100
8,207,000
2,866,200
3,975,500
6,104,600
3,056,600
4,453,600
7,006,600
3,878,700
6,969,800
9,574,800
3,344,000
4,638,100
7,122,100
2,046,900
2,456,300
2,865,700
2,897,100
3,476,500
4,055,900
3,705,500
4,446,600
5,187,600
2,195,400
2,634,500
3,073,600
3,594,400
4,313,300
5,032,200
4,396,400
5,275,600
6,154,900
3,423,800
4,108,500
4,793,300
4,484,800
5,381,700
6,278,700
93 E-1-01-III
8,889,600
10,667,500
12,445,400
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,915,700
3,539,000
7,459,100
3,498,800
4,246,800
8,950,900
4,081,900
4,954,600
10,442,700
5,150,900
6,181,100
7,211,200
97 E-1-20-I
- 752 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,024,900
2,429,900
2,834,900
104 E-4-11-II
105 E-4-11-III

3,087,100
4,183,300
3,704,600
5,020,000
4,322,000
5,856,600
106 E-4-12-I
107 E-4-12-II

2,326,600
4,029,100
2,791,900
4,834,900
3,257,200
5,640,700
108 E-4-12-III

(RINGAN)
(SEDANG)
4,775,900
5,731,100
6,686,300
2,533,600
3,040,300
3,547,000
3,711,200
4,453,500
5,195,700
111 E-4-13-III
4,851,300
5,821,600
6,791,800
112 F-4-10-I
113 F-4-10-II
2,697,300
3,100,000
3,236,700
3,720,000
3,776,200
4,340,000
114 F-4-10-III
115 F-4-11-I
3,720,000
2,608,700
4,464,000
3,130,500
5,208,000
3,652,200
116 F-4-11-II
3,039,400
3,647,300
4,255,200
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,897,700
4,677,200
5,456,800
1,430,000
1,716,000
2,002,000
2,033,000
2,439,600
2,846,200
4,416,600
5,299,900
6,183,300
2,101,400
2,772,800
3,589,800
1,198,900
1,537,800
2,069,300
2,521,700
3,327,400
4,307,800
1,438,700
1,845,400
2,483,100
2,941,900
3,882,000
5,025,700
1,678,500
2,152,900
2,897,000
127 F-4-15-I
1,909,400
2,291,300
2,673,200
128 F-4-15-II
2,845,300
3,414,300
3,983,400
129 F-4-15-III
3,756,600
4,508,000
5,259,300
3,756,800
4,508,200
5,259,600
4,367,900
5,241,500
6,115,100
5,830,500
6,996,500
8,162,600
133 F-4-17-I

887,200
1,064,700
1,242,100
134 F-4-17-II
2,600,300
3,120,400
3,640,500
135
136
137
138
139
140
141

(RINGAN)
2,774,300
3,264,400
3,591,800
5,537,000
2,494,800
3,194,700
3,977,300
3,329,200
3,917,300
4,310,100
6,644,400
2,993,700
3,833,600
4,772,800
3,884,000
4,570,200
5,028,500
7,751,800
3,492,700
4,472,500
5,568,300
5,536,200
6,643,500
7,750,700
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,932,900
8,319,500
9,706,100
9,555,000
11,466,000
13,377,000
3,347,000
4,016,400
4,685,800
4,676,800
5,612,200
6,547,500
5,804,800
6,965,800
8,126,800
- 753 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,544,100
6,653,000
7,761,800
148 G-1-11-I
149 G-1-11-II

8,099,300
14,807,300
9,719,100
17,768,800
11,339,000
20,730,300
150 G-1-11-III
23,794,700
28,553,700
33,312,600
3,381,700
4,058,100
4,734,400
6,339,200
7,607,000
8,874,900
8,639,100
10,366,900
12,094,700
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,020,200
2,739,700
1,224,200
3,287,600
1,428,200
3,835,500
156 G-1-13-III
157 G-1-20-I

6,181,900
3,053,400
7,418,300
3,664,100
8,654,600
4,274,800
158 G-1-20-II
5,043,300
6,052,000
7,060,600
159 G-1-20-III
10,111,900
12,134,300
14,156,700
160 G-1-30-I
4,772,600
5,727,100
6,681,600
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,462,500
16,009,500
14,955,000
19,211,400
17,447,600
22,413,400
2,902,800
3,483,400
4,064,000
3,548,300
4,257,900
4,967,600
4,868,800
5,842,600
6,816,300
3,038,800
3,646,600
4,254,300
4,036,700
4,844,000
5,651,400
5,931,300
7,117,500
8,303,800
3,371,200
4,045,500
4,719,700
4,258,100
5,109,700
5,961,300
6,184,300
7,421,200
8,658,100
2,025,100
2,430,200
2,835,200
3,531,400
4,237,700
4,944,000
4,188,400
5,026,000
5,863,700
3,435,400
4,122,500
4,809,600
4,592,900
5,511,500
6,430,000
5,764,600
6,917,500
8,070,500
2,807,000
3,368,400
3,929,800
3,350,000
4,020,100
4,690,100
4,728,300
5,674,000
6,619,600
2,314,000
2,776,800
3,239,600
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,628,500
9,154,200
10,679,900
14,829,800
17,795,800
20,761,700
3,311,200
4,675,100
3,973,500
5,610,100
4,635,700
6,545,100
- 754 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,072,200
3,686,600
4,301,000
183 G-4-16-III
4,375,000
5,250,000
6,125,000
3,082,100
3,698,500
4,315,000
4,041,300
4,849,600
5,657,900
5,078,100
6,093,700
7,109,400
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,035,400
3,642,500
4,249,600
188 G-4-18-II
4,057,400
4,868,900
5,680,400
189 G-4-18-III
4,539,900
5,447,900
6,355,900
2,532,500
3,039,000
3,545,500
4,280,500
5,136,700
5,992,800
5,620,200
6,744,200
7,868,200
193 G-4-20-I

1,771,600
2,125,900
2,480,300
194 G-4-20-II
2,504,500
3,005,400
3,506,300
195 G-4-20-III
196 G-4-21-I

4,136,900
1,844,900
4,964,200
2,213,800
5,791,600
2,582,800
197 G-4-21-II
198 G-4-21-III

3,122,400
3,669,600
3,746,900
4,403,500
4,371,400
5,137,400
199 G-4-22-I
2,537,800
3,045,300
3,552,900
200 G-4-22-II
201 G-4-22-III

3,242,500
3,788,700
3,891,000
4,546,400
4,539,500
5,304,200
202 G-4-23-I
203 G-4-23-II

1,816,100
2,278,600
2,179,300
2,734,300
2,542,500
3,190,000
204 G-4-23-III
3,244,100
3,892,900
4,541,800
205 G-4-24-I
206 G-4-24-II

2,022,800
2,527,300
2,427,400
3,032,700
2,832,000
3,538,200
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,210,300
1,728,500
2,185,900
2,896,700
5,052,400
2,074,200
2,623,000
3,476,000
5,894,500
2,419,900
3,060,200
4,055,400
2,731,500
3,277,800
3,824,100
3,177,500
3,813,100
4,448,600
4,751,400
5,701,700
6,652,000
1,950,600
4,382,400
5,959,900
5,954,400
7,397,700
10,361,500
2,340,000
3,175,000
6,240,500
2,019,500
2,303,600
3,298,600
2,381,000
2,844,900
4,767,500
2,340,700
5,258,900
7,151,900
7,145,300
8,877,300
12,433,800
2,808,100
3,810,000
7,488,600
2,423,400
2,764,300
3,958,400
2,857,200
3,413,800
5,721,000
2,730,800
6,135,400
8,343,800
8,336,100
10,356,800
14,506,100
3,276,100
4,444,900
8,736,800
2,827,300
3,225,100
4,618,100
3,333,400
3,982,800
6,674,500
229 I-1-01-I
31,981,000
38,377,200
44,773,400
230 I-1-01-II
32,684,600
39,221,500
45,758,400
231 I-1-01-III

(RINGAN)
51,592,200
61,910,600
72,229,000
17,742,900
21,291,500
24,840,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 755 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,609,300
17,531,100
20,453,000
245 I-1-06-II
21,162,700
25,395,200
29,627,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
25,251,000
30,301,200
35,351,400
17,390,500
20,868,600
24,346,700
21,454,800
25,745,700
30,036,700
23,407,100
28,088,500
32,769,900
2,780,400
3,336,500
3,892,500
3,091,500
3,709,800
4,328,100
4,113,800
4,936,600
5,759,400
8,003,200
9,603,900
11,204,500
13,070,900
15,685,100
18,299,300
17,196,800
20,636,100
24,075,500
7,763,000
9,315,600
10,868,300
10,338,100
12,405,700
14,473,300
12,749,700
15,299,600
17,849,600
15,889,000
19,066,800
22,244,600
19,747,700
23,697,300
27,646,800
25,876,300
31,051,600
36,226,900
3,018,500
4,215,200
8,116,800
3,622,100
5,058,300
9,740,200
4,225,800
5,901,300
11,363,600
7,824,900
9,389,900
10,954,900
17,704,700
21,245,600
24,786,600
20,422,100
24,506,500
28,590,900
9,060,500
10,872,600
12,684,800
11,344,600
13,613,600
15,882,500
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,888,200
27,465,800
32,043,400
28,211,100
33,853,300
39,495,500
10,248,400
12,298,000
14,347,700
14,206,400
17,047,600
19,888,900
18,029,000
21,634,800
25,240,500
15,443,700
18,532,500
21,621,200
24,374,400
29,249,200
34,124,100
38,937,900
46,725,500
54,513,100
19,815,700
23,778,900
27,742,000
23,779,000
28,534,800
33,290,500
32,719,700
39,263,600
45,807,500
- 756 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,625,900
21,151,000
24,676,200
279 I-1-40-III
23,542,200
28,250,600
32,959,100
280 I-4-10-I
281 I-4-10-II

2,687,500
4,798,800
3,225,000
5,758,600
3,762,500
6,718,300
282 I-4-10-III
6,914,400
8,297,300
9,680,200
283 I-4-11-I
284 I-4-11-II

4,134,700
5,116,700
4,961,600
6,140,000
5,788,600
7,163,400
285 I-4-11-III
286 I-4-12-I

9,465,300
2,376,900
11,358,400
2,852,200
13,251,500
3,327,600
287 I-4-12-II
2,755,100
3,306,100
3,857,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,306,100
3,967,300
4,628,500
2,418,700
2,902,500
3,386,200
4,318,900
5,182,700
6,046,500
6,223,000
7,467,600
8,712,200
2,284,100
2,362,700
4,141,800
2,740,900
2,835,200
4,970,100
3,197,700
3,307,700
5,798,500
4,283,000
5,139,600
5,996,200
5,826,800
6,992,100
8,157,500
297 I-4-15-III
6,992,100
8,390,500
9,789,000
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,441,600
2,314,800
2,777,800
1,767,200
2,057,400
2,468,900
1,729,900
2,777,800
3,333,400
2,120,700
2,468,900
2,962,700
2,018,200
3,240,800
3,888,900
2,474,100
2,880,400
3,456,500
2,780,700
3,336,800
3,892,900
4,233,700
5,080,400
5,927,100
5,747,900
6,897,500
8,047,100
307 I-4-19-I
2,682,800
3,219,300
3,755,900
308 I-4-19-II

(SEDANG)
4,188,000
5,025,600
5,863,200
309 I-4-19-III
4,999,700
5,999,600
6,999,500
310
311
312
313
314

2,793,600
3,226,600
4,824,400
2,090,400
2,648,600
3,352,300
3,871,900
5,789,300
2,508,500
3,178,300
3,911,000
4,517,200
6,754,200
2,926,600
3,708,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
14,033,200
16,839,800
19,646,400
10,212,800
12,255,300
14,297,900
12,758,600
15,310,300
17,862,000
13,411,900
16,094,300
18,776,700
7,725,400
9,270,500
10,815,600
16,070,500
19,284,700
22,498,800
24,903,600
29,884,300
34,865,000
7,129,700
8,555,600
9,981,600
- 757 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,822,900
4,587,500
5,352,100
316 I-4-22-I
317 I-4-22-II
2,343,000
2,916,700
2,811,600
3,500,000
3,280,200
4,083,400
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,263,300
5,115,900
5,968,600
2,293,100
2,751,700
3,210,400
2,815,300
3,378,400
3,941,400
5,500,900
6,601,100
7,701,300
2,065,000
2,478,000
2,891,000
4,755,100
5,706,100
6,657,100
6,011,900
7,214,300
8,416,700
37,253,800
44,704,600
52,155,300
42,159,600
50,591,500
59,023,500
47,695,800
57,234,900
66,774,100
19,769,200
23,723,100
27,676,900
27,526,600
33,032,000
38,537,300
45,455,900
54,547,100
63,638,200
6,003,400
7,204,100
8,404,700
12,147,900
14,577,500
17,007,100
12,624,700
15,149,600
17,674,500
7,054,600
8,465,600
9,876,500
8,351,900
10,022,200
11,692,600
12,896,600
15,476,000
18,055,300
5,010,000
6,012,000
7,014,000
9,075,500
10,890,600
12,705,700
26,196,200
31,435,400
36,674,700
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,047,000
4,227,600
6,395,800
1,827,100
2,544,900
3,411,100
3,103,400
3,532,800
4,932,700
2,743,900
3,819,500
7,125,900
3,025,200
4,922,900
5,824,300
4,019,400
4,802,000
6,460,600
2,456,400
5,073,200
7,674,900
2,192,600
3,053,800
4,093,300
3,724,100
4,239,300
5,919,300
3,292,700
4,583,400
8,551,100
3,630,300
5,907,500
6,989,200
4,823,200
5,762,400
7,752,800
2,865,800
5,918,700
8,954,100
2,558,000
3,562,800
4,775,600
4,344,800
4,945,900
6,905,800
3,841,500
5,347,300
9,976,200
4,235,300
6,892,100
8,154,100
5,627,100
6,722,800
9,044,900
3,349,000
4,018,800
4,688,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 758 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,706,200
5,647,400
6,588,700
360 J-4-16-III
5,950,200
7,140,300
8,330,300
361 J-4-17-I
362 J-4-17-II

2,527,900
3,027,200
3,033,400
3,632,600
3,539,000
4,238,100
363 J-4-17-III
364 J-4-18-I

3,972,600
2,063,100
4,767,100
2,475,700
5,561,600
2,888,400
365 J-4-18-II
2,837,600
3,405,100
3,972,700
366 J-4-18-III
367 J-4-19-I

2,987,000
3,560,600
3,584,300
4,272,700
4,181,700
4,984,800
368 J-4-19-II
369 J-4-19-III

4,037,900
4,459,400
4,845,500
5,351,300
5,653,100
6,243,100
370 J-4-20-I
3,533,400
4,240,100
4,946,800
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,895,900
5,739,500
5,875,100
6,887,400
6,854,200
8,035,300
2,674,100
3,208,900
3,743,700
4,307,900
5,169,400
6,031,000
6,011,300
7,213,600
8,415,800
5,442,400
6,530,900
7,619,400
6,839,600
8,207,500
9,575,400
8,016,200
9,619,500
11,222,700
5,604,200
6,725,000
7,845,800

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,357,600
9,742,600
8,829,100
11,691,200
10,300,600
13,639,700
2,283,600
2,740,300
3,197,000
2,970,000
3,564,100
4,158,100
5,884,100
7,060,900
8,237,800
2,575,400
2,833,000
2,858,700
3,090,500
3,399,500
3,430,400
3,605,600
3,966,100
4,002,200
4,179,400
5,015,300
5,851,200
4,898,200
5,877,800
6,857,500
390 K-1-14-III
7,695,700
9,234,900
10,774,000
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

8,092,700
11,303,700
16,504,600
9,711,300
13,564,500
19,805,500
11,329,800
15,825,200
23,106,500
4,786,000
5,743,200
6,700,400
8,499,800
10,199,700
11,899,700
11,695,800
14,035,000
16,374,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,340,000
6,408,000
7,476,100
398 K-1-40-II

(SEDANG)
5,887,600
7,065,100
8,242,600
399 K-1-40-III
9,977,300
11,972,800
13,968,300
400
401
402
403
404

4,080,300
5,298,800
7,488,200
3,368,500
4,840,100
4,896,400
6,358,600
8,985,800
4,042,200
5,808,100
5,712,500
7,418,300
10,483,500
4,715,900
6,776,100
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 759 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,378,400
8,854,100
10,329,800
406 K-4-11-I
407 K-4-11-II

2,150,100
3,055,300
2,580,100
3,666,400
3,010,100
4,277,500
408 K-4-11-III
409 K-4-12-I

3,666,400
2,024,900
4,399,700
2,429,900
5,133,000
2,834,900
410 K-4-12-II
2,724,900
3,269,900
3,814,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,507,900
5,409,500
6,311,000
2,729,700
3,275,600
3,821,600
3,531,100
4,237,300
4,943,500
5,439,000
6,526,700
7,614,500
1,730,600
2,076,800
2,422,900
2,323,100
2,787,700
3,252,300
3,727,700
4,473,200
5,218,700
418 K-4-15-I
1,718,200
2,061,800
2,405,500
419 K-4-15-II
2,561,600
3,073,900
3,586,200
420 K-4-15-III
3,595,100
4,314,100
5,033,100
421 K-4-16-I
2,526,700
3,032,000
3,537,400
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,030,200
3,535,800
3,636,300
4,243,000
4,242,300
4,950,100
1,142,000
1,370,400
1,598,800
1,712,400
2,054,900
2,397,400
2,054,900
2,465,900
2,876,900
1,146,700
1,376,100
1,605,400
1,629,600
1,955,500
2,281,400
429 K-4-18-III
1,955,500
2,346,600
2,737,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,902,800
19,476,500
26,023,800
6,087,700
10,446,100
12,969,000
15,483,400
23,371,800
31,228,500
7,305,200
12,535,300
15,562,700
18,064,000
27,267,100
36,433,300
8,522,800
14,624,500
18,156,500
3,411,700
4,094,000
4,776,300
6,843,100
8,211,700
9,580,300
11,518,400
13,822,100
16,125,700
4,478,800
7,208,200
10,310,600
1,171,500
1,359,800
1,578,300
2,453,200
3,371,700
7,661,600
1,165,100
1,540,900
4,076,200
5,374,600
8,649,900
12,372,800
1,405,800
1,631,700
1,894,000
2,943,900
4,046,100
9,194,000
1,398,100
1,849,100
4,891,500
6,270,400
10,091,500
14,434,900
1,640,000
1,903,700
2,209,600
3,434,500
4,720,400
10,726,300
1,631,100
2,157,300
5,706,700
2,277,800
2,733,400
3,188,900
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 760 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,677,000
3,212,400
3,747,800
3,939,300
4,727,200
5,515,000
2,017,500
2,421,000
2,824,500
3,030,300
3,636,400
4,242,500
4,271,600
5,125,900
5,980,300
7,131,600
8,557,900
9,984,200
10,136,600
12,163,900
14,191,200
14,238,800
17,086,600
19,934,400
6,320,800
7,585,000
8,849,100
10,369,100
17,616,800
12,442,900
21,140,200
14,516,700
24,663,500
15,474,500
18,569,300
21,664,200
18,099,600
21,719,600
25,339,500
22,401,300
26,881,600
31,361,800
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,925,300
9,510,400
11,095,500
467 M-1-04-II
10,181,800
12,218,100
14,254,500
468 M-1-04-III
12,182,700
14,619,300
17,055,800
469 M-1-05-I
470 M-1-05-II

5,031,700
8,139,000
6,038,100
9,766,800
7,044,400
11,394,600
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,396,600
12,475,900
14,555,200
5,632,400
6,758,900
7,885,400
7,545,500
9,054,600
10,563,800
15,371,000
18,445,100
21,519,300
9,272,000
11,126,300
12,980,700
20,346,200
24,415,400
28,484,600
43,884,800
52,661,800
61,438,700
8,468,800
10,162,600
11,856,300
10,819,800
12,983,700
15,147,700
480 M-1-20-III
26,937,900
32,325,500
37,713,100
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,809,800
9,414,300
13,461,600
6,971,800
11,297,100
16,153,900
8,133,700
13,180,000
18,846,200
2,957,400
3,548,900
4,140,400
5,244,900
6,293,800
7,342,800
7,488,600
8,986,400
10,484,100
3,544,000
5,881,300
9,659,600
4,252,800
7,057,500
11,591,500
4,961,600
8,233,800
13,523,400
5,473,400
6,568,100
7,662,800
6,881,400
8,257,700
9,633,900
10,395,100
12,474,200
14,553,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 761 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,030,600
2,436,700
2,842,900
500 M-4-10-II
501 M-4-10-III
3,028,300
5,729,600
3,634,000
6,875,500
4,239,600
8,021,400
2,530,300
3,036,400
3,542,500
5,547,600
6,657,200
7,766,700
8,020,900
9,625,100
11,229,300
2,019,800
2,423,700
2,827,700
3,359,400
4,031,300
4,703,200
4,493,600
5,392,300
6,291,000
3,363,100
4,035,700
4,708,400
5,052,900
6,063,500
7,074,100
9,858,200
11,829,800
13,801,500
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,835,500
4,602,600
5,369,700
512 M-4-14-II
4,730,500
5,676,700
6,622,800
513 M-4-14-III
514 M-4-15-I
7,108,600
2,274,400
8,530,400
2,729,200
9,952,100
3,184,100
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,031,600
6,879,500
1,947,200
3,118,200
5,238,400
3,637,900
8,255,400
2,336,600
3,741,800
6,286,000
4,244,200
9,631,300
2,726,100
4,365,500
7,333,700
2,527,200
3,032,600
3,538,100
3,534,600
4,241,500
4,948,400
4,935,800
5,923,000
6,910,100
1,910,200
2,878,700
3,466,100
2,292,200
3,454,400
4,159,300
2,674,200
4,030,200
4,852,500
1,992,000
2,390,400
2,788,800
3,355,300
4,026,400
4,697,400
6,553,100
7,863,700
9,174,400
2,009,400
2,411,300
2,813,100
2,942,400
3,530,900
4,119,400
3,288,500
3,946,200
4,603,900
2,023,300
2,427,900
2,832,600
2,530,600
3,036,700
3,542,800
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
10,140,500
12,168,600
14,196,800
11,154,600
13,385,500
15,616,400
12,770,500
15,324,600
17,878,700
5,764,500
6,917,400
8,070,300
6,845,800
15,408,500
8,215,000
18,490,200
9,584,200
21,571,900
- 762 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,673,400
6,808,100
7,942,800
535 N-1-01-I

64,781,500
77,737,800
90,694,100
536 N-1-01-II
64,781,500
77,737,800
90,694,100
537 N-1-01-III
538 N-1-11-I

64,781,500
5,836,100
77,737,800
7,003,400
90,694,100
8,170,600
539 N-1-11-II
540 N-1-11-III

9,228,400
14,387,000
11,074,000
17,264,400
12,919,700
20,141,800
2,974,500
3,569,400
4,164,300
5,921,900
7,106,300
8,290,600
12,850,700
15,420,800
17,991,000
6,503,400
7,804,000
9,104,700

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,101,100
12,735,900
10,921,300
15,283,100
12,741,500
17,830,200
5,951,700
7,142,100
8,332,400
9,003,800
10,804,500
12,605,300
10,362,500
12,435,000
14,507,500
5,345,100
6,414,100
7,483,100
7,258,500
8,710,200
10,161,900
8,447,900
10,137,500
11,827,100
2,270,900
2,725,100
3,179,300
2,746,700
3,296,000
3,845,400
4,040,000
4,848,000
5,656,000
1,743,300
3,045,700
3,789,500
2,052,000
4,019,000
4,837,500
3,265,600
3,938,700
6,035,800
2,091,900
3,654,900
4,547,500
2,462,400
4,822,800
5,805,000
3,918,800
4,726,500
7,243,000
2,440,600
4,264,000
5,305,400
2,872,800
5,626,600
6,772,500
4,571,900
5,514,200
8,450,200
1,750,800
2,101,000
2,451,200
2,484,400
2,981,200
3,478,100
3,982,400
4,778,900
5,575,400
2,068,400
2,482,100
2,895,700
2,566,500
3,079,800
3,593,100
2,928,800
3,514,600
4,100,300
2,532,700
3,039,300
3,545,800
3,615,000
4,338,000
5,061,000
4,811,800
5,774,200
6,736,600
4,541,800
4,804,800
5,450,100
5,765,800
6,358,500
6,726,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 763 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,638,200
6,765,800
7,893,500
2,354,300
2,825,200
3,296,000
2,616,500
3,139,800
3,663,100
3,255,000
3,906,000
4,557,000
1,668,000
2,001,600
2,335,200
2,003,200
2,403,900
2,804,500
2,517,100
3,020,600
3,524,000
1,552,400
1,862,900
2,173,400

MAYOR (RINGAN)
MAYOR (SEDANG)
1,837,500
2,204,900
2,204,900
2,645,900
2,572,400
3,086,900
37,246,300
44,695,600
52,144,900
46,086,700
55,304,100
64,521,400
54,092,900
64,911,400
75,730,000
50,839,500
61,007,400
71,175,300
58,318,000
69,981,600
81,645,200
66,632,400
79,958,900
93,285,400
6,196,000
7,435,200
8,674,400
8,798,300
10,558,000
12,317,700
9,942,100
11,930,600
13,919,000
20,106,600
24,127,900
28,149,200
26,094,000
31,312,800
36,531,500
37,412,200
44,894,600
52,377,100
10,933,300
13,120,000
15,306,600
20,614,600
24,737,600
28,860,500
25,156,800
30,188,200
35,219,600
3,607,600
4,329,100
5,050,600
10,114,800
12,137,700
14,160,700
13,399,600
16,079,500
18,759,400
3,494,300
4,193,200
4,892,000
9,797,200
11,756,600
13,716,100
12,978,900
15,574,700
18,170,400
3,694,200
4,433,000
5,171,800
5,242,000
6,290,400
7,338,800
8,487,800
10,185,400
11,882,900
5,853,600
7,024,300
8,195,000
8,312,100
9,974,500
11,636,900
- 764 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,392,700
11,271,200
13,149,700
5,530,100
6,636,100
7,742,100
7,863,000
9,435,600
11,008,200
8,899,300
10,679,200
12,459,100
4,798,200
5,757,900
6,717,500
6,333,700
7,600,400
8,867,100
9,431,100
11,317,300
13,203,500
2,429,400
2,915,300
3,401,100
4,945,200
5,934,300
6,923,300
9,175,300
11,010,300
12,845,400
1,822,100
2,186,500
2,550,900
3,648,800
4,378,500
5,108,300
4,281,200
5,137,400
5,993,600
1,649,000
1,978,800
2,308,600
3,168,800
3,802,600
4,436,300
6,462,000
7,754,400
9,046,900
3,198,800
3,838,600
4,478,300
5,757,900
6,909,400
8,061,000
7,859,200
9,431,100
11,002,900
1,859,200
2,231,100
2,602,900
2,290,800
2,749,000
3,207,200
3,135,900
3,763,100
4,390,300
1,568,800
2,300,400
3,931,700
1,366,900
1,819,300
3,153,800
1,882,500
2,760,500
4,718,100
1,640,300
2,183,200
3,784,500
2,196,300
3,220,600
5,504,400
1,913,600
2,547,000
4,415,300
2,018,500
2,422,300
2,826,000
3,581,100
4,297,300
5,013,500
5,812,500
6,975,000
8,137,500
1,021,500
1,225,800
1,430,100
2,169,800
2,603,800
3,037,700
4,114,700
4,937,600
5,760,600
683,200
819,800
956,500
1,289,300
1,547,200
1,805,000
1,669,900
2,003,900
2,337,800
3,537,800
4,245,300
4,952,900
- 765 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,499,200
5,399,000
6,298,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,441,900
7,730,300
9,018,700
1,705,100
2,046,200
2,387,200
2,530,600
3,036,700
3,542,900
3,043,600
3,652,300
4,261,100
1,140,900
1,369,000
1,597,200
1,532,300
1,838,800
2,145,300
2,787,600
3,345,100
3,902,600
520,300
624,300
728,400
991,600
1,190,000
1,388,300
1,441,600
1,729,900
2,018,200
616,200
739,400
862,600
969,600
1,163,600
1,357,500
1,561,700
1,874,100
2,186,400
1,077,600
1,293,100
1,508,600
1,629,100
1,954,900
2,280,800
2,542,600
3,051,100
3,559,600
3,728,200
4,473,900
5,219,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,787,700
15,286,800
6,945,200
18,344,200
8,102,800
21,401,600
5,767,800
6,921,300
8,074,900
7,311,500
8,773,800
10,236,100
10,520,100
12,624,100
14,728,100
4,506,900
6,911,000
10,150,900
4,272,600
4,978,200
8,252,400
5,408,200
8,293,200
12,181,000
5,127,100
5,973,900
9,902,800
6,309,600
9,675,400
14,211,200
5,981,600
6,969,500
11,553,300
2,710,200
3,252,200
3,794,200
3,326,000
3,991,200
4,656,400
3,941,300
4,729,600
5,517,900
3,003,600
4,270,200
5,504,100
3,604,300
5,124,300
6,604,900
4,205,000
5,978,300
7,705,800
4,114,500
4,937,300
5,760,200
6,123,400
7,348,100
8,572,800
15,720,100
18,864,100
22,008,100
3,528,600
4,784,600
9,356,500
4,234,300
5,741,500
11,227,800
4,940,000
6,698,500
13,099,100
2,539,300
3,047,200
3,555,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 766 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,543,300
1,852,000
2,160,700
697 U-4-12-I
698 U-4-12-II

2,421,700
2,817,000
2,906,100
3,380,400
3,390,400
3,943,800
699 U-4-12-III

3,654,400
4,385,300
5,116,100
1,835,300
2,202,400
2,569,500
2,163,700
2,596,400
3,029,200
2,587,900
3,105,400
3,623,000
2,527,500
3,026,600
3,033,000
3,631,900
3,538,500
4,237,200

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,082,600
6,099,100
7,115,600
2,029,500
2,435,400
2,841,300
2,528,500
3,034,200
3,539,900
3,538,600
4,246,400
4,954,100
3,310,300
3,972,300
4,634,400
6,819,000
8,182,800
9,546,600
8,362,600
10,035,100
11,707,600
6,297,600
7,191,200
11,261,600
7,557,200
8,629,400
13,514,000
8,816,700
10,067,600
15,766,300
5,921,000
7,105,200
8,289,400
8,085,600
9,702,700
11,319,800
10,248,600
12,298,300
14,348,000
3,088,500
3,706,200
4,323,900
5,901,000
7,081,200
8,261,500
9,258,000
11,109,600
12,961,200
6,056,500
7,267,800
8,479,000
8,799,900
10,559,800
12,319,800
10,988,200
13,185,900
15,383,500
975,400
1,076,300
1,190,700
1,170,500
1,291,600
1,428,800
1,365,600
1,506,900
1,666,900
2,928,800
3,514,600
4,100,300
4,864,900
5,837,900
6,810,800
8,020,500
9,624,600
11,228,700
2,530,700
3,036,800
3,542,900
3,395,500
4,074,600
4,753,700
4,548,300
5,458,000
6,367,600
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,813,300
6,975,900
8,138,600
8,925,200
10,710,200
12,495,200
1,210,500
1,467,100
1,452,600
1,760,500
1,694,700
2,053,900
- 767 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,897,700
8,277,200
9,656,800
8,267,400
9,920,800
11,574,300
11,797,300
14,156,700
16,516,200
1,463,100
1,755,700
2,048,300
1,614,500
1,786,000
1,937,400
2,143,200
2,260,300
2,500,400
1,529,300
1,835,100
2,141,000
1,687,500
2,025,000
2,362,500
1,866,700
2,240,100
2,613,400
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,645,200
1,974,200
2,303,200
743 W-1-12-II
744 W-1-12-III

2,053,500
3,636,200
2,464,100
4,363,500
2,874,800
5,090,700
745 W-1-13-I
1,691,100
2,029,300
2,367,500
746 W-1-13-II
747 W-1-13-III

1,836,000
2,466,200
2,203,200
2,959,400
2,570,300
3,452,600
748 W-1-20-I
749 W-1-20-II

5,663,300
7,076,400
6,796,000
8,491,700
7,928,700
9,906,900
750 W-1-20-III
8,203,400
9,844,000
11,484,700
751 W-1-30-I
3,197,000
3,836,400
4,475,800
752 W-1-30-II
5,099,300
6,119,100
7,139,000
753 W-1-30-III
12,511,300
15,013,600
17,515,800
754 W-4-10-I
2,382,100
2,858,500
3,335,000
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,531,400
6,978,700
2,166,400
3,288,900
4,003,200
4,237,700
8,374,500
2,599,600
3,946,600
4,803,800
4,943,900
9,770,200
3,032,900
4,604,400
5,604,400
2,684,400
3,221,300
3,758,200
3,685,500
4,422,600
5,159,800
4,017,400
4,820,900
5,624,400
852,300
1,164,300
1,447,900
1,139,100
1,355,800
1,734,500
1,510,500
1,677,500
2,322,600
2,009,700
2,687,500
3,642,400
1,482,900
2,677,500
3,958,600
2,001,200
2,656,300
3,773,500
1,714,700
2,059,400
2,830,800
1,022,800
1,397,200
1,737,500
1,366,900
1,626,900
2,081,500
1,812,600
2,013,000
2,787,100
2,411,600
3,225,000
4,370,900
1,779,500
3,213,000
4,750,300
2,401,500
3,187,600
4,528,200
2,057,600
2,471,300
3,396,900
1,193,300
1,630,100
2,027,100
1,594,700
1,898,100
2,428,400
2,114,600
2,348,500
3,251,600
2,813,600
3,762,500
5,099,400
2,076,100
3,748,500
5,542,100
2,801,700
3,718,900
5,282,900
2,400,500
2,883,200
3,963,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 768 -

REGIONAL 4
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
797,400
956,900
1,116,300
1,942,900
2,331,500
2,720,000
2,464,000
2,956,700
3,449,500
- 769 -

REGIONAL 4
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
927,400
1,203,000
2,237,200
1,848,800
2,402,600
441,900
785,600
345,600
631,800
654,700
743,300
1,117,500
1,524,300
1,397,100
452,600
1,044,600
378,900
650,500
1,981,500
709,700
1,675,900
408,900
953,900
1,493,000
1,252,200
307,100
930,700
517,500
266,100
287,700
253,900
303,700
422,800
363,300
342,000
307,400
456,000
199,200
234,700
269,100
5,460,400
2,182,300
2,189,600
563,200
922,300
577,500
1,173,700
752,100
430,700
325,200
524,500
289,500
247,900
1,934,200
902,600
515,800
2,013,500
1,342,300
261,400
2,181,300
1,510,100
3,396,800
784,500
482,600
259,500
216,300
243,800
3,716,700
1,809,200
- 770 -

REGIONAL 4
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,299,300
4,069,300
3,374,000
2,570,300
847,400
2,860,800
1,867,900
459,200
4,295,000
3,888,200
2,607,100
2,469,900
305,300
293,300
1,180,300
322,600
287,400
317,600
1,090,200
1,489,200
1,300,700
1,148,700
695,700
289,100
509,500
349,800
315,800
307,700
390,700
445,500
261,200
749,600
1,366,100
1,048,700
2,465,300
321,000
321,000
2,278,100
1,324,600
254,100
1,175,600
3,053,800
701,100
552,300
270,500
233,500
293,000
408,600
978,500
862,500
603,700
450,400
247,900
1,048,300
840,000
358,900
409,500
1,342,100
296,800
1,371,200
1,049,000
319,900
354,600
346,400
209,600
1,142,900
1,570,400
311,200
- 771 -

REGIONAL 4
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
953,800
356,000
384,900
356,500
565,500
435,000
1,089,400
321,400
894,300
1,195,000
261,700
1,592,900
863,200
1,865,400
941,700
415,900
319,900
67,400
414,600
936,900
365,100
493,200
282,000
109,700
284,800
4,241,300
2,410,800
4,023,600
988,400
552,300
376,300
851,100
450,100
905,900
524,500
312,300
522,700
235,300
359,200
344,200
757,700
1,641,900
1,321,000
1,164,800
822,000
302,400
302,400
302,400
247,000
156,700
246,300
301,100
325,700
239,900
211,600
94,500
103,900
76,800
90,100
86,000
131,200
117,700
168,100
184,700
104,500
126,900
86,700
135,300
192,000
- 772 -

REGIONAL 4
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
136,700
188,700
533,500
618,500
129,200
256,700
157,300
224,500
431,900
369,700
265,800
251,700
128,500
126,200
296,300
187,000
268,300
190,000
145,300
1,864,000
1,917,400
304,700
315,500
603,400
757,900
772,400
399,000
1,243,400
268,800
324,300
325,300
260,500
329,000
311,400
145,900
320,500
284,100
257,000
290,600
2,405,800
312,400
865,800
310,500
441,800
463,800
370,000
751,900
770,000
820,900
718,100
1,247,300
213,900
1,485,400
282,000
753,000
1,711,200
1,978,600
864,400
313,300
611,000
608,500
282,000
2,210,600
1,738,800
140,400
153,700
199,700
269,000
- 773 -

REGIONAL 4
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
939,000
444,500
916,200
1,105,400
529,700
736,900
509,300
548,000
593,000
303,500
717,500
183,500
679,700
1,010,900
74,500
- 774 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,727,500
4,473,000
A-4-10-II
SEPTIKEMIA (SEDANG)
6,368,100
7,641,700
8,915,300
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,586,200
4,519,500
10,303,500
5,423,400
12,020,700
6,327,400
5
6
A-4-11-II
A-4-11-III

6,432,600
8,903,300
7,719,200
10,684,000
9,005,700
12,464,600
A-4-12-I
2,947,500
3,537,000
4,126,600
8
9
A-4-12-II
A-4-12-III

5,088,000
7,330,800
6,105,600
8,797,000
7,123,100
10,263,100
10 A-4-13-I
11 A-4-13-II

2,193,800
3,877,000
2,632,600
4,652,400
3,071,300
5,427,800
12 A-4-13-III
4,652,400
5,582,900
6,513,300
2,457,700
2,949,200
3,440,700
4,135,200
4,962,200
5,789,200
4,962,200
5,954,600
6,947,100
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
19,187,000
23,894,200
23,024,400
28,673,000
26,861,800
33,451,800
18 A-4-15-III
INFEKSI HIV (BERAT)
26,993,700
32,392,400
37,791,200
19 B-1-01-I
20 B-1-01-II

52,902,500
58,365,400
63,483,000
70,038,500
74,063,500
81,711,500
21 B-1-01-III
22 B-1-10-I

128,653,000
8,551,400
154,383,600
10,261,700
180,114,200
11,972,000
23 B-1-10-II
18,980,300
22,776,400
26,572,500
24 B-1-10-III
25 B-1-11-I

37,469,800
34,123,700
44,963,700
40,948,500
52,457,700
47,773,200
26 B-1-11-II
27 B-1-11-III

40,660,300
62,831,500
48,792,300
75,397,800
56,924,400
87,964,100
28 B-1-12-I
10,041,400
12,049,700
14,058,000
29 B-1-12-II
11,167,800
13,401,400
15,635,000
30 B-1-12-III
17,470,800
20,965,000
24,459,100
7,998,100
9,597,700
11,197,300
13,159,900
15,791,900
18,423,800
17,027,700
20,433,300
23,838,800
20,954,900
25,145,900
29,336,900
22,008,600
26,410,300
30,812,000
38,959,000
3,400,200
5,427,700
7,487,700
46,750,800
4,080,200
6,513,300
8,985,300
54,542,600
4,760,300
7,598,800
10,482,800
7,168,900
8,602,700
10,036,500
10,036,600
12,043,900
14,051,200
12,159,200
14,591,000
17,022,900
6,481,500
9,229,400
13,731,400
6,182,800
7,777,800
11,075,300
16,477,600
7,419,400
9,074,100
12,921,200
19,223,900
8,656,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,218,500
- 775 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,202,700
8,643,300
10,083,800
48 B-4-13-III
49 B-4-14-I

9,922,400
6,176,200
11,906,900
7,411,500
13,891,400
8,646,700
50 B-4-14-II
7,205,400
8,646,400
10,087,500
51 B-4-14-III
52 C-4-10-I

9,651,800
12,509,300
11,582,100
15,011,200
13,512,500
17,513,000
53 C-4-10-II
54 C-4-10-III

20,118,400
37,695,400
24,142,100
45,234,400
28,165,800
52,773,500
55 C-4-11-I
6,511,500
7,813,800
9,116,100
56 C-4-11-II
57 C-4-11-III

8,713,300
13,396,900
10,456,000
16,076,200
12,198,600
18,755,600
58 C-4-12-I
59 C-4-12-II
4,335,600
8,539,400
5,202,700
10,247,200
6,069,800
11,955,100
60 C-4-12-III
RADIOTERAPI (BERAT)
21,931,500
26,317,800
30,704,100
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,259,500
6,134,300
3,911,400
7,361,200
4,563,200
8,588,100
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,303,800
5,415,700
9,964,600
6,498,900
11,625,300
7,582,000
65 C-4-14-II
7,597,200
9,116,600
10,636,000
66 C-4-14-III
67 D-1-10-I

11,319,600
32,720,300
13,583,600
39,264,400
15,847,500
45,808,400
68 D-1-10-II
69 D-1-10-III

49,835,300
71,419,400
59,802,400
85,703,300
69,769,400
99,987,200
70 D-1-11-I
8,760,500
10,512,700
12,264,800
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
22,369,800
29,070,400
26,843,700
34,884,500
31,317,700
40,698,600
7,594,400
9,113,300
10,632,100
20,929,000
25,114,800
29,300,600
33,199,500
39,839,400
46,479,300
3,001,100
4,925,100
7,748,300
5,945,400
10,683,600
14,676,600
5,125,700
7,109,500
10,916,900
3,601,300
5,910,100
9,298,000
7,134,400
12,820,300
17,611,900
6,150,900
8,531,400
13,100,300
4,201,500
6,895,100
10,847,700
8,323,500
14,957,000
20,547,300
7,176,000
9,953,300
15,283,700
4,392,600
5,271,100
6,149,700
6,217,000
7,460,500
8,703,900
7,951,800
9,542,200
11,132,500
4,711,300
5,653,500
6,595,800
7,713,500
9,256,300
10,799,000
9,434,500
11,321,400
13,208,200
9,391,400
11,269,700
13,147,900
12,820,600
15,384,800
17,948,900
93 E-1-01-III
30,911,900
37,094,300
43,276,600
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
9,764,000
13,553,600
25,607,200
11,716,800
16,264,300
30,728,600
13,669,600
18,975,000
35,850,100
11,053,600
13,264,300
15,475,100
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 776 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,345,400
5,214,500
6,083,500
104 E-4-11-II
105 E-4-11-III

6,624,900
8,977,200
7,949,900
10,772,700
9,274,900
12,568,100
106 E-4-12-I
107 E-4-12-II

4,992,800
8,646,300
5,991,300
10,375,600
6,989,900
12,104,800
108 E-4-12-III

(RINGAN)
(SEDANG)
10,249,000
12,298,800
14,348,600
5,436,900
6,524,300
7,611,700
7,964,200
9,557,000
11,149,900
111 E-4-13-III
10,410,800
12,492,900
14,575,100
112 F-4-10-I
113 F-4-10-II
5,788,300
6,652,500
6,946,000
7,983,000
8,103,700
9,313,500
114 F-4-10-III
115 F-4-11-I
7,983,000
5,598,200
9,579,600
6,717,900
11,176,200
7,837,500
116 F-4-11-II
6,522,500
7,827,100
9,131,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,364,300
10,037,100
11,710,000
3,068,700
3,682,500
4,296,200
4,362,800
5,235,300
6,107,900
9,477,900
11,373,500
13,269,100
4,509,500
5,950,400
7,703,600
2,572,900
3,300,100
4,440,500
5,411,400
7,140,500
9,244,300
3,087,500
3,960,100
5,328,700
6,313,300
8,330,600
10,785,000
3,602,000
4,620,100
6,216,800
127 F-4-15-I
4,097,500
4,917,000
5,736,500
128 F-4-15-II
6,105,800
7,327,000
8,548,100
129 F-4-15-III
8,061,600
9,673,900
11,286,200
8,062,000
9,674,500
11,286,900
9,373,500
11,248,100
13,122,800
12,511,900
15,014,300
17,516,700
133 F-4-17-I

1,903,900
2,284,700
2,665,500
134 F-4-17-II
5,580,200
6,696,300
7,812,300
135
136
137
138
139
140
141

(RINGAN)
5,953,600
7,005,300
7,707,900
11,882,200
5,353,700
6,855,700
8,535,200
7,144,300
8,406,400
9,249,400
14,258,700
6,424,400
8,226,800
10,242,300
8,335,000
9,807,500
10,791,000
16,635,100
7,495,200
9,597,900
11,949,300
22,711,000
27,253,200
31,795,400
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
14,877,900
17,853,400
20,829,000
20,504,700
24,605,700
28,706,600
3,911,800
4,694,200
5,476,600
7,576,600
9,091,900
10,607,200
12,695,400
15,234,500
17,773,600
- 777 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
53,145,700
63,774,900
74,404,000
148 G-1-11-I
149 G-1-11-II

17,380,700
31,776,000
20,856,900
38,131,200
24,333,000
44,486,400
150 G-1-11-III
51,062,700
61,275,200
71,487,700
7,257,100
8,708,500
10,159,900
13,603,700
16,324,400
19,045,200
18,539,200
22,247,000
25,954,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,189,200
5,879,200
2,627,100
7,055,100
3,064,900
8,230,900
156 G-1-13-III
157 G-1-20-I

13,266,100
12,290,300
15,919,300
14,748,300
18,572,500
17,206,400
158 G-1-20-II
18,597,100
22,316,500
26,036,000
159 G-1-20-III
31,711,400
38,053,700
44,396,000
160 G-1-30-I
30,618,200
36,741,900
42,865,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
41,280,800
61,990,400
49,537,000
74,388,500
57,793,200
86,786,600
6,229,400
7,475,300
8,721,200
7,614,400
9,137,300
10,660,200
10,448,300
12,538,000
14,627,600
6,521,200
7,825,400
9,129,700
8,662,600
10,395,100
12,127,600
12,728,300
15,274,000
17,819,600
7,234,500
8,681,400
10,128,300
9,137,700
10,965,300
12,792,800
13,271,400
15,925,700
18,579,900
4,345,900
5,215,000
6,084,200
7,578,400
9,094,000
10,609,700
8,988,100
10,785,700
12,583,300
7,372,300
8,846,700
10,321,200
9,856,200
11,827,400
13,798,700
12,370,700
14,844,800
17,318,900
6,023,800
7,228,600
8,433,300
7,189,100
8,626,900
10,064,700
10,146,800
12,176,100
14,205,500
4,965,800
5,959,000
6,952,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
32,573,000
39,087,600
45,602,300
53,292,200
63,950,600
74,609,100
35,311,600
43,247,900
42,373,900
51,897,400
49,436,200
60,547,000
- 778 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,592,800
7,911,300
9,229,900
183 G-4-16-III
9,388,700
11,266,400
13,144,100
6,614,100
7,936,900
9,259,800
8,672,600
10,407,100
12,141,600
10,897,500
13,076,900
15,256,400
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
6,513,900
7,816,700
9,119,400
188 G-4-18-II
8,707,100
10,448,500
12,189,900
189 G-4-18-III
9,742,500
11,691,000
13,639,600
5,434,700
6,521,600
7,608,500
9,185,900
11,023,100
12,860,300
12,060,700
14,472,800
16,884,900
193 G-4-20-I

3,801,800
4,562,200
5,322,600
194 G-4-20-II
5,374,600
6,449,500
7,524,500
195 G-4-20-III
196 G-4-21-I

8,877,600
3,959,000
10,653,100
4,750,800
12,428,600
5,542,600
197 G-4-21-II
198 G-4-21-III

6,700,700
7,874,800
8,040,800
9,449,800
9,380,900
11,024,800
199 G-4-22-I
2,966,000
3,559,300
4,152,500
200 G-4-22-II
201 G-4-22-III

5,252,900
8,286,000
6,303,500
9,943,200
7,354,100
11,600,400
202 G-4-23-I
203 G-4-23-II

3,897,300
4,889,700
4,676,700
5,867,600
5,456,200
6,845,600
204 G-4-23-III
6,961,800
8,354,100
9,746,500
205 G-4-24-I
206 G-4-24-II

4,341,000
5,423,400
5,209,100
6,508,100
6,077,300
7,592,800
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
9,035,200
3,709,300
4,690,800
6,216,200
10,842,300
4,451,100
5,628,900
7,459,500
12,649,300
5,193,000
6,567,100
8,702,700
4,228,900
5,074,600
5,920,400
4,919,500
5,903,400
6,887,300
7,356,100
8,827,300
10,298,600
12,509,100
13,824,400
18,800,400
8,523,900
10,590,000
14,832,900
4,519,500
6,132,000
12,052,800
4,333,800
4,943,500
7,078,800
5,109,500
6,105,000
10,230,800
15,010,900
16,589,300
22,560,500
10,228,600
12,708,000
17,799,400
5,423,400
7,358,400
14,463,300
5,200,500
5,932,200
8,494,500
6,131,400
7,325,900
12,277,000
17,512,700
19,354,200
26,320,600
11,933,400
14,826,000
20,766,000
6,327,300
8,584,800
16,873,900
6,067,300
6,920,900
9,910,300
7,153,400
8,546,900
14,323,200
229 I-1-01-I
68,630,200
82,356,200
96,082,200
230 I-1-01-II
70,140,000
84,168,000
98,196,000
231 I-1-01-III

(RINGAN)
110,715,000
132,858,000
155,001,000
38,075,700
45,690,900
53,306,000
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 779 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
51,189,700
61,427,700
71,665,600
245 I-1-06-II
74,152,500
88,983,000
103,813,500
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
88,477,600
106,173,200
123,868,700
79,678,100
95,613,700
111,549,300
99,597,600
119,517,100
139,436,600
149,396,400
179,275,700
209,155,000
5,966,600
7,159,900
8,353,200
6,634,300
7,961,100
9,288,000
8,828,200
10,593,800
12,359,400
17,174,700
20,609,600
24,044,600
28,049,700
33,659,700
39,269,600
36,903,600
44,284,400
51,665,100
16,659,200
19,991,100
23,322,900
22,185,100
26,622,200
31,059,200
27,360,400
32,832,500
38,304,600
34,097,300
40,916,800
47,736,200
42,377,900
50,853,500
59,329,100
55,529,700
66,635,700
77,741,600
6,477,500
9,045,700
17,418,500
7,773,000
10,854,800
20,902,100
9,068,500
12,664,000
24,385,800
16,792,100
20,150,500
23,508,900
37,993,700
45,592,400
53,191,100
43,825,100
52,590,100
61,355,100
19,443,600
23,332,300
27,221,100
24,345,200
29,214,300
34,083,300
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
49,117,200
58,940,600
68,764,100
60,540,000
72,648,000
84,756,000
35,909,500
43,091,400
50,273,300
49,778,000
59,733,600
69,689,200
63,172,100
75,806,500
88,441,000
54,113,700
64,936,400
75,759,100
85,406,000
102,487,200
119,568,400
136,435,500
163,722,600
191,009,700
89,637,800
107,565,400
125,493,000
109,557,400
131,468,800
153,380,300
149,396,400
179,275,700
209,155,000
- 780 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
37,824,500
45,389,400
52,954,300
279 I-1-40-III
50,520,700
60,624,900
70,729,000
280 I-4-10-I
281 I-4-10-II

5,767,200
10,298,100
6,920,700
12,357,700
8,074,100
14,417,300
282 I-4-10-III
14,838,100
17,805,700
20,773,300
283 I-4-11-I
284 I-4-11-II

8,872,900
10,980,200
10,647,500
13,176,300
12,422,000
15,372,300
285 I-4-11-III
286 I-4-12-I

20,312,300
5,100,600
24,374,700
6,120,700
28,437,200
7,140,900
287 I-4-12-II
5,912,400
7,094,800
8,277,300
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,094,800
8,513,800
9,932,800
5,190,500
6,228,600
7,266,700
9,268,300
11,121,900
12,975,600
13,354,300
16,025,100
18,696,000
4,901,500
5,070,200
8,888,100
5,881,800
6,084,300
10,665,700
6,862,200
7,098,300
12,443,400
5,005,800
6,007,000
7,008,200
9,439,500
11,327,400
13,215,300
11,327,400
13,592,900
15,858,400
3,093,600
4,967,600
5,961,100
2,065,500
3,333,100
4,666,300
3,712,300
5,961,100
7,153,300
2,478,600
3,999,700
5,599,600
4,331,000
6,954,600
8,345,500
2,891,700
4,666,300
6,532,800
5,967,200
7,160,600
8,354,100
9,085,300
10,902,400
12,719,400
12,334,800
14,801,800
17,268,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
30,114,700
36,137,600
42,160,500
21,916,300
26,299,500
30,682,800
27,379,500
32,855,400
38,331,200
28,781,500
34,537,800
40,294,100
16,578,400
19,894,100
23,209,800
34,486,800
41,384,200
48,281,600
53,442,200
64,130,600
74,819,000
15,300,100
18,360,100
21,420,100
307 I-4-19-I
5,757,200
6,908,600
8,060,000
308 I-4-19-II

(SEDANG)
8,987,300
10,784,700
12,582,200
309 I-4-19-III
10,729,100
12,874,900
15,020,700
310
311
312
313
314

5,994,900
6,924,100
10,353,000
4,037,400
5,115,400
7,193,900
8,309,000
12,423,600
4,844,800
6,138,400
8,392,900
9,693,800
14,494,200
5,652,300
7,161,500
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 781 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,383,500
8,860,200
10,336,900
316 I-4-22-I
317 I-4-22-II
3,627,400
4,515,600
4,352,900
5,418,800
5,078,400
6,321,900
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,600,400
7,920,500
9,240,600
4,921,000
5,905,200
6,889,300
6,041,500
7,249,800
8,458,100
11,804,800
14,165,800
16,526,700
3,197,000
3,836,400
4,475,800
7,361,800
8,834,200
10,306,500
9,307,700
11,169,200
13,030,800
101,294,800
121,553,800
141,812,700
114,633,900
137,560,700
160,487,500
157,240,200
188,688,200
220,136,200
66,082,600
79,299,100
92,515,600
83,383,400
100,060,100
116,736,800
97,546,800
117,056,100
136,565,500
12,883,100
15,459,700
18,036,300
26,069,000
31,282,800
36,496,600
27,092,100
32,510,500
37,928,900
35,490,600
42,588,700
49,686,800
37,163,400
44,596,100
52,028,700
41,822,500
50,187,000
58,551,600
10,751,300
12,901,500
15,051,800
19,475,800
23,370,900
27,266,100
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
56,216,100
67,459,300
78,702,600
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,169,200
6,545,200
9,902,000
3,921,000
5,461,200
7,320,100
6,659,800
7,581,200
10,585,500
5,888,400
8,196,400
15,291,900
6,492,100
10,564,500
12,498,800
4,697,700
7,779,400
14,129,700
3,803,000
7,854,300
11,882,400
4,705,200
6,553,400
8,784,200
7,991,700
9,097,400
12,702,500
7,066,100
9,835,700
18,350,300
7,790,500
12,677,400
14,998,600
5,637,200
9,335,300
16,955,600
4,436,900
9,163,300
13,862,800
5,489,400
7,645,600
10,248,200
9,323,700
10,613,700
14,819,600
8,243,700
11,475,000
21,408,600
9,088,900
14,790,300
17,498,400
6,576,800
10,891,200
19,781,600
3,914,200
4,697,000
5,479,800
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 782 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,624,200
9,149,000
10,673,800
13,013,400
15,616,100
18,218,800
5,424,700
6,496,300
6,509,700
7,795,500
7,594,600
9,094,800

8,525,000
2,411,300
10,230,100
2,893,600
11,935,100
3,375,800
365 J-4-18-II
4,597,000
5,516,400
6,435,800
366 J-4-18-III
367 J-4-19-I

6,532,600
6,876,800
7,839,100
8,252,200
9,145,600
9,627,500
368 J-4-19-II
369 J-4-19-III

7,798,700
8,612,700
9,358,500
10,335,300
10,918,200
12,057,800
370 J-4-20-I
5,470,400
6,564,500
7,658,600
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,579,800
8,885,900
9,095,800
10,663,100
10,611,700
12,440,300
3,125,400
3,750,400
4,375,500
6,978,900
8,374,700
9,770,400
13,147,000
15,776,300
18,405,700
11,679,300
14,015,200
16,351,000
14,677,500
17,613,000
20,548,500
17,202,600
20,643,100
24,083,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
10,968,300
13,162,000
15,355,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
14,400,000
28,463,000
17,280,100
34,155,600
20,160,100
39,848,200
4,900,500
5,880,600
6,860,600
6,373,600
7,648,300
8,923,100
12,627,100
15,152,500
17,678,000
5,526,700
6,079,400
9,716,200
6,632,100
7,295,300
11,659,400
7,737,400
8,511,200
13,602,700
8,072,000
9,686,400
11,300,800
9,460,200
11,352,300
13,244,300
390 K-1-14-III
16,514,800
19,817,700
23,120,700
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

17,366,700
24,257,400
35,418,300
20,840,000
29,108,800
42,502,000
24,313,400
33,960,300
49,585,700
10,270,500
12,324,600
14,378,800
18,240,200
21,888,300
25,536,300
25,098,800
30,118,600
35,138,300
397 K-1-40-I
11,459,500
13,751,500
16,043,400
398 K-1-40-II

(SEDANG)
12,634,500
15,161,500
17,688,400
399 K-1-40-III
21,411,000
25,693,200
29,975,400
400
401
402
403
404

8,756,200
11,371,100
16,069,400
7,228,700
10,386,600
10,507,500
13,645,300
19,283,300
8,674,500
12,463,900
12,258,700
15,919,500
22,497,200
10,120,200
14,541,300
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 783 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
15,833,900
19,000,600
22,167,400
406 K-4-11-I
407 K-4-11-II

2,512,900
4,949,700
3,015,500
5,939,600
3,518,000
6,929,500
408 K-4-11-III
409 K-4-12-I

5,939,600
4,345,400
7,127,500
5,214,500
8,315,400
6,083,500
410 K-4-12-II
5,847,600
7,017,100
8,186,600
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,673,800
11,608,500
13,543,300
5,857,900
7,029,400
8,201,000
7,577,500
9,093,000
10,608,500
11,671,800
14,006,200
16,340,500
3,342,500
4,011,000
4,679,500
4,486,800
5,384,100
6,281,500
7,199,500
8,639,400
10,079,300
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,764,400
5,717,300
6,670,100
419 K-4-15-II
7,337,600
8,805,200
10,272,700
420 K-4-15-III
10,444,200
12,533,000
14,621,900
421 K-4-16-I
4,314,800
5,177,700
6,040,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,174,600
6,038,000
6,209,500
7,245,600
7,244,400
8,453,100
2,116,400
2,539,700
2,963,000
2,606,400
3,127,700
3,649,000
3,127,700
3,753,200
4,378,800
1,865,100
2,238,100
2,611,100
3,147,300
3,776,800
4,406,300
429 K-4-18-III
3,776,800
4,532,200
5,287,500
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
27,689,000
41,795,900
55,846,100
13,063,900
22,416,900
27,830,900
33,226,900
50,155,000
67,015,300
15,676,700
26,900,300
33,397,100
38,764,700
58,514,200
78,184,600
18,289,500
31,383,700
38,963,300
7,321,300
8,785,600
10,249,800
14,685,000
17,621,900
20,558,900
24,718,000
29,661,700
34,605,300
9,611,400
15,468,600
22,126,300
2,513,900
2,918,000
3,387,000
5,264,500
7,235,700
16,441,600
2,500,200
3,306,800
10,934,300
11,533,700
18,562,300
26,551,600
3,016,700
3,501,600
4,064,400
6,317,400
8,682,800
19,730,000
3,000,200
3,968,200
13,121,200
13,456,000
21,656,000
30,976,800
3,519,500
4,085,200
4,741,800
7,370,300
10,129,900
23,018,300
3,500,200
4,629,600
15,308,000
2,662,200
3,194,600
3,727,100
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 784 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,336,900
5,204,300
6,071,600
8,615,400
10,338,500
12,061,500
4,329,400
5,195,300
6,061,200
6,503,000
7,803,600
9,104,200
9,166,700
11,000,100
12,833,400
15,304,200
18,365,000
21,425,800
21,752,700
26,103,300
30,453,800
30,556,100
36,667,300
42,778,500
13,564,300
16,277,100
18,990,000
22,251,700
37,805,100
26,702,000
45,366,100
31,152,400
52,927,100
54,221,300
65,065,600
75,909,900
63,419,800
76,103,700
88,787,700
78,492,500
94,191,000
109,889,500
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
27,769,800
33,323,800
38,877,700
467 M-1-04-II
35,676,200
42,811,400
49,946,600
468 M-1-04-III
42,687,400
51,224,800
59,762,300
469 M-1-05-I
470 M-1-05-II

10,797,900
17,466,100
12,957,500
20,959,300
15,117,100
24,452,500
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
22,310,700
26,772,800
31,234,900
19,735,700
23,682,800
27,629,900
26,439,000
31,726,800
37,014,600
53,858,700
64,630,400
75,402,100
23,322,300
27,986,800
32,651,300
55,762,700
66,915,200
78,067,700
120,274,900
144,329,900
168,384,900
18,173,800
21,808,500
25,443,300
23,218,800
27,862,600
32,506,400
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
57,807,800
69,369,400
80,931,000
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,467,700
20,202,700
28,888,100
14,961,200
24,243,300
34,665,700
17,454,700
28,283,800
40,443,300
7,615,800
9,139,000
10,662,200
11,255,300
13,506,300
15,757,400
16,070,400
19,284,400
22,498,500
7,605,300
12,621,000
20,729,100
9,126,400
15,145,200
24,874,900
10,647,500
17,669,300
29,020,800
11,745,800
14,095,000
16,444,100
14,767,200
17,720,600
20,674,100
22,307,600
26,769,200
31,230,700
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 785 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
4,357,600
5,229,100
6,100,700
500 M-4-10-II
501 M-4-10-III
6,498,700
12,295,500
7,798,400
14,754,600
9,098,100
17,213,700
5,430,000
6,516,000
7,602,000
11,905,000
14,286,000
16,667,100
17,212,600
20,655,200
24,097,700
4,334,400
5,201,200
6,068,100
7,209,200
8,651,100
10,092,900
9,643,100
11,571,700
13,500,300
7,217,100
8,660,600
10,104,000
10,843,400
13,012,100
15,180,800
21,155,300
25,386,400
29,617,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,230,900
9,877,100
11,523,300
512 M-4-14-II
10,151,600
12,181,900
14,212,200
513 M-4-14-III
514 M-4-15-I
15,254,900
4,880,700
18,305,900
5,856,800
21,356,900
6,833,000
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,505,600
14,763,100
4,178,600
6,691,600
11,241,400
7,806,700
17,715,800
5,014,400
8,029,900
13,489,600
9,107,900
20,668,400
5,850,100
9,368,200
15,737,900
4,881,000
5,857,100
6,833,300
6,826,600
8,191,900
9,557,200
9,532,800
11,439,400
13,346,000
4,099,100
6,177,600
7,438,100
4,919,000
7,413,100
8,925,700
5,738,800
8,648,600
10,413,300
4,274,800
5,129,700
5,984,700
7,200,400
8,640,400
10,080,500
14,062,700
16,875,300
19,687,800
3,880,900
4,657,000
5,433,200
5,682,800
6,819,400
7,956,000
6,351,300
7,621,500
8,891,800
3,907,700
4,689,300
5,470,800
4,887,400
5,864,900
6,842,400
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
21,761,200
26,113,500
30,465,700
23,937,400
28,724,800
33,512,300
27,405,100
32,886,100
38,367,200
12,370,400
14,844,400
17,318,500
14,690,900
33,066,200
17,629,100
39,679,400
20,567,300
46,292,600
- 786 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,957,500
13,149,000
15,340,500
535 N-1-01-I

300,535,300
360,642,400
420,749,400
536 N-1-01-II
300,535,300
360,642,400
420,749,400
537 N-1-01-III
538 N-1-11-I

300,535,300
12,524,200
360,642,400
15,029,000
420,749,400
17,533,800
539 N-1-11-II
540 N-1-11-III

19,803,700
30,874,000
23,764,500
37,048,800
27,725,200
43,223,600
6,383,100
7,659,800
8,936,400
12,708,200
15,249,800
17,791,400
27,577,200
33,092,600
38,608,000
13,956,000
16,747,200
19,538,400

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
19,530,600
27,330,800
23,436,800
32,796,900
27,342,900
38,263,100
12,772,200
15,326,600
17,881,000
19,321,800
23,186,100
27,050,500
22,237,500
26,685,000
31,132,500
11,470,300
13,764,400
16,058,500
15,576,400
18,691,700
21,807,000
18,128,900
21,754,700
25,380,500
4,873,300
5,848,000
6,822,600
5,894,300
7,073,200
8,252,100
8,669,700
10,403,600
12,137,600
3,741,000
6,536,100
8,132,200
2,820,600
5,859,800
9,521,800
3,816,800
6,380,900
13,200,600
4,489,300
7,843,300
9,758,700
3,384,700
7,031,800
11,426,200
4,580,100
7,657,000
15,840,800
5,237,500
9,150,500
11,385,100
3,948,900
8,203,700
13,330,500
5,343,500
8,933,200
18,480,900
3,757,200
4,508,700
5,260,100
5,331,300
6,397,600
7,463,900
8,546,100
10,255,300
11,964,500
4,438,700
5,326,400
6,214,200
5,507,600
6,609,100
7,710,700
6,285,100
7,542,200
8,799,200
5,435,200
6,522,200
7,609,200
7,757,700
9,309,200
10,860,800
10,326,100
12,391,300
14,456,500
5,569,200
7,168,400
6,683,000
8,602,000
7,796,900
10,035,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 787 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,299,700
13,559,700
15,819,600
5,052,200
6,062,700
7,073,100
5,615,000
6,738,000
7,861,000
6,985,100
8,382,100
9,779,200
3,579,400
4,295,300
5,011,200
4,298,900
5,158,600
6,018,400
5,401,700
6,482,000
7,562,400
1,814,500
2,177,400
2,540,300
2,976,700
3,572,100
3,572,100
4,286,500
4,167,400
5,000,900
79,929,300
95,915,200
111,901,100
98,900,500
118,680,700
138,460,800
116,081,400
139,297,700
162,514,000
109,099,700
130,919,700
152,739,600
125,148,400
150,178,000
175,207,700
142,990,900
171,589,100
200,187,200
16,364,800
19,637,800
22,910,800
21,661,100
25,993,300
30,325,500
30,456,500
36,547,800
42,639,100
52,736,400
63,283,700
73,831,000
68,440,500
82,128,600
95,816,700
98,126,500
117,751,800
137,377,100
28,676,400
34,411,600
40,146,900
44,238,300
53,086,000
61,933,600
59,884,700
71,861,700
83,838,600
7,741,700
9,290,100
10,838,400
21,706,000
26,047,200
30,388,400
28,755,100
34,506,100
40,257,100
9,165,000
10,998,000
12,831,000
25,696,500
30,835,800
35,975,200
34,041,600
40,849,900
47,658,200
5,303,000
6,363,600
7,424,200
7,524,700
9,029,600
10,534,500
14,638,400
17,566,100
20,493,800
13,637,400
16,364,800
19,092,300
18,050,900
21,661,100
25,271,300
- 788 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
25,380,400
30,456,500
35,532,600
12,397,600
14,877,100
17,356,700
15,042,400
18,050,900
21,059,400
22,069,900
26,483,900
30,897,900
6,887,600
8,265,100
9,642,600
10,744,600
12,893,500
15,042,400
16,976,900
20,372,300
23,767,600
5,213,400
6,256,000
7,298,700
10,612,300
12,734,800
14,857,200
41,495,000
49,794,000
58,092,900
3,910,100
4,692,100
5,474,100
7,830,100
9,396,100
10,962,200
9,187,200
11,024,700
12,862,100
3,538,700
4,246,400
4,954,100
6,800,100
8,160,200
9,520,200
15,947,400
19,136,900
22,326,400
4,591,700
5,510,000
6,428,400
8,265,100
9,918,100
11,571,100
14,147,400
16,976,900
19,806,400
3,989,800
4,787,800
5,585,700
4,916,000
5,899,300
6,882,500
6,729,600
8,075,500
9,421,400
1,833,500
3,726,800
8,598,900
2,933,300
3,904,200
6,767,900
2,200,200
4,472,100
10,318,700
3,520,000
4,685,000
8,121,500
2,566,900
5,217,500
12,038,400
4,106,600
5,465,800
9,475,000
4,331,700
5,198,100
6,064,400
7,684,800
9,221,800
10,758,700
12,473,400
14,968,100
17,462,800
2,192,200
2,630,600
3,069,000
4,656,300
5,587,600
6,518,800
8,830,000
10,596,000
12,362,000
1,466,100
1,759,400
2,052,600
2,766,800
3,320,200
3,873,600
3,583,500
4,300,200
5,016,900
7,591,900
9,110,300
10,628,700
- 789 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,655,100
11,586,200
13,517,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
13,824,200
16,589,000
19,353,800
3,659,200
4,391,000
5,122,800
5,430,600
6,516,700
7,602,800
6,531,500
7,837,800
9,144,100
2,448,300
2,937,900
3,427,600
3,288,300
3,946,000
4,603,700
5,982,000
7,178,400
8,374,800
1,340,600
1,608,700
1,876,800
2,554,400
3,065,300
3,576,200
3,713,000
4,455,600
5,198,200
1,294,700
1,553,600
1,812,500
2,037,500
2,444,900
2,852,400
3,281,800
3,938,100
4,594,500
3,033,500
3,640,200
4,246,900
4,579,400
5,495,300
6,411,100
7,088,200
8,505,900
9,923,500
8,000,700
9,600,800
11,200,900

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,420,200
32,805,000
14,904,200
39,366,000
17,388,300
45,927,000
12,626,200
15,151,400
17,676,700
19,044,300
22,853,100
26,662,000
22,575,700
27,090,800
31,606,000
9,671,600
14,830,800
21,783,400
9,678,200
11,276,600
18,693,200
11,605,900
17,797,000
26,140,100
11,613,900
13,532,000
22,431,800
13,540,200
20,763,200
30,496,800
13,549,500
15,787,300
26,170,400
5,815,900
6,979,100
8,142,300
7,137,500
8,565,000
9,992,500
8,458,000
10,149,500
11,841,100
4,552,300
6,472,100
9,859,000
5,462,800
7,766,500
11,830,800
6,373,300
9,060,900
13,802,600
8,829,500
10,595,400
12,361,300
13,140,700
15,768,800
18,397,000
33,734,700
40,481,700
47,228,600
7,572,200
10,267,600
20,078,700
9,086,700
12,321,200
24,094,500
10,601,100
14,374,700
28,110,200
5,449,300
6,539,200
7,629,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 790 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,635,500
3,162,600
3,689,700
697 U-4-12-I
698 U-4-12-II

2,830,400
4,563,600
3,396,500
5,476,300
3,962,600
6,389,000
699 U-4-12-III

7,992,300
9,590,700
11,189,200
2,145,100
2,574,100
3,003,100
3,505,200
4,206,300
4,907,300
5,659,800
6,791,700
7,923,700
5,423,900
6,494,900
6,508,700
7,793,900
7,593,400
9,092,900

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
10,907,000
13,088,400
15,269,800
4,355,200
5,226,300
6,097,300
5,426,000
6,511,200
7,596,500
7,593,800
9,112,600
10,631,300
7,103,700
8,524,500
9,945,200
14,633,400
17,560,100
20,486,800
17,945,800
21,535,000
25,124,200
13,514,500
15,432,000
24,167,100
16,217,400
18,518,400
29,000,500
18,920,300
21,604,800
33,833,900
12,706,200
15,247,500
17,788,700
17,351,400
20,821,700
24,292,000
21,993,100
26,391,700
30,790,300
6,627,700
7,953,300
9,278,800
12,663,400
15,196,100
17,728,800
19,867,400
23,840,800
27,814,300
12,997,000
15,596,400
18,195,700
18,884,200
22,661,000
26,437,900
723 V-1-14-III
23,580,300
28,296,400
33,012,500
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,093,200
2,309,800
2,555,100
2,511,800
2,771,800
3,066,100
2,930,400
3,233,700
3,577,100
5,656,600
6,787,900
7,919,200
9,395,900
11,275,100
13,154,300
15,490,500
18,588,700
21,686,800
5,430,700
6,516,900
7,603,000
7,286,600
8,743,900
10,201,300
9,760,500
11,712,600
13,664,700
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,475,100
14,970,100
17,465,100
19,153,100
22,983,700
26,814,400
1,722,600
2,505,300
2,067,100
3,006,300
2,411,600
3,507,400
- 791 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
14,802,200
17,762,600
20,723,100
17,741,400
21,289,700
24,838,000
25,316,600
30,379,900
35,443,200
3,139,800
3,767,700
4,395,700
3,464,700
3,832,700
4,157,600
4,599,200
4,850,600
5,365,700
3,281,700
3,938,100
4,594,400
3,621,400
4,345,700
5,069,900
4,006,000
4,807,200
5,608,400
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,530,500
4,236,600
4,942,700
743 W-1-12-II
744 W-1-12-III

4,406,600
7,803,200
5,288,000
9,363,800
6,169,300
10,924,500
745 W-1-13-I
3,629,000
4,354,800
5,080,700
746 W-1-13-II
747 W-1-13-III

3,939,900
5,292,300
4,727,900
6,350,800
5,515,900
7,409,200
748 W-1-20-I
749 W-1-20-II

12,153,300
15,185,700
14,584,000
18,222,800
17,014,700
21,260,000
750 W-1-20-III
17,604,100
21,124,900
24,645,800
751 W-1-30-I
6,860,700
8,232,900
9,605,000
752 W-1-30-II
10,942,800
13,131,400
15,320,000
753 W-1-30-III
26,848,800
32,218,600
37,588,400
754 W-4-10-I
5,111,900
6,134,300
7,156,700
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,578,200
14,976,100
4,184,000
6,352,000
7,731,600
9,093,900
17,971,300
5,020,900
7,622,400
9,277,900
10,609,500
20,966,500
5,857,700
8,892,800
10,824,200
3,137,500
3,765,000
4,392,500
5,970,700
7,164,800
8,359,000
8,786,300
10,543,600
12,300,800
1,829,100
2,498,600
3,107,200
2,444,400
2,909,400
3,722,300
1,765,400
2,717,600
5,079,500
2,348,800
4,353,800
7,966,100
1,733,200
4,337,600
8,657,700
5,155,000
6,842,100
9,720,400
3,355,900
4,030,600
5,540,300
2,194,900
2,998,300
3,728,600
2,933,300
3,491,300
4,466,700
2,118,500
3,261,100
6,095,400
2,818,600
5,224,500
9,559,300
2,079,800
5,205,100
10,389,200
6,186,000
8,210,500
11,664,500
4,027,100
4,836,700
6,648,300
2,560,700
3,498,100
4,350,000
3,422,100
4,073,200
5,211,200
2,471,500
3,804,600
7,111,400
3,288,400
6,095,300
11,152,500
2,426,500
6,072,600
12,120,700
7,217,000
9,578,900
13,608,600
4,698,200
5,642,800
7,756,400
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 792 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,218,100
2,661,700
3,105,300
4,453,600
5,344,300
6,235,000
9,395,900
11,275,100
13,154,300
- 793 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,473,400
1,911,200
3,554,100
2,937,100
3,816,800
702,100
1,559,900
549,000
1,213,000
1,040,200
1,180,900
1,775,400
2,421,600
2,219,400
719,000
1,659,500
602,000
1,033,500
3,147,900
1,127,400
2,662,400
649,500
1,894,200
2,371,800
1,989,300
487,900
1,478,600
822,100
528,400
457,000
403,400
482,400
671,700
494,700
543,300
418,500
724,500
375,700
372,800
380,000
8,674,600
3,466,900
3,478,400
894,800
1,831,500
1,146,700
2,330,700
1,194,800
684,200
516,700
833,300
591,300
393,800
3,841,000
1,536,400
1,024,300
3,998,400
2,665,600
415,300
4,331,600
2,998,800
4,674,600
1,557,900
958,200
412,300
407,900
387,200
5,904,500
2,874,100
- 794 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,652,800
6,464,700
5,360,000
4,083,300
1,346,100
4,544,700
2,967,500
729,500
6,823,200
6,177,000
4,141,700
3,923,700
485,000
466,000
1,875,000
512,400
456,600
504,600
2,164,900
2,365,700
2,066,400
2,281,100
1,381,500
459,200
809,500
555,700
501,800
488,900
620,600
707,800
414,900
1,190,800
2,170,200
1,665,900
3,916,400
510,000
510,000
4,523,800
2,104,400
403,700
1,867,500
4,851,400
1,113,800
877,300
429,800
290,000
581,900
811,500
1,943,100
1,712,700
1,198,900
715,500
393,800
2,081,800
1,334,400
712,700
650,600
2,132,100
559,800
2,722,800
2,083,100
508,200
563,300
550,300
395,400
2,269,700
2,494,800
494,400
- 795 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,515,300
565,600
611,500
566,300
898,300
691,000
1,730,700
510,600
1,420,700
2,373,000
415,800
2,530,600
1,371,300
2,963,500
1,496,000
660,700
508,200
83,700
658,700
1,488,400
580,000
783,500
448,000
213,000
452,400
6,737,800
3,829,900
6,392,100
1,962,800
877,300
597,800
1,352,000
715,100
1,439,200
833,300
496,100
830,300
467,300
713,200
546,800
1,041,300
2,608,400
2,098,600
1,850,400
1,305,900
480,400
480,400
480,400
392,400
248,900
391,300
478,300
517,400
381,100
336,200
117,400
129,000
95,400
112,000
106,800
163,000
173,600
267,100
293,400
129,800
157,500
107,700
168,100
238,400
- 796 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
169,800
299,800
847,600
982,600
160,500
407,900
195,300
278,900
686,100
587,400
422,200
399,800
159,600
156,800
470,800
352,900
506,100
399,700
230,900
3,701,600
3,046,000
484,000
501,200
958,600
941,300
1,227,000
633,800
1,975,400
333,800
515,200
516,800
413,800
522,700
494,600
231,700
509,200
451,300
408,200
461,700
3,821,900
620,300
1,375,400
493,300
877,300
576,100
459,600
1,194,400
1,223,200
1,304,200
1,140,800
1,681,900
339,900
2,949,700
448,000
1,495,200
3,398,100
3,143,300
1,373,200
497,600
970,600
966,800
448,000
3,511,900
2,762,300
255,600
190,900
248,100
534,100
- 797 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,318,600
1,576,700
1,455,500
1,756,000
841,500
1,170,600
809,100
680,700
832,700
482,200
1,139,900
227,900
844,200
1,419,500
92,600
- 798 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
3,839,300
4,607,200
A-4-10-II
SEPTIKEMIA (SEDANG)
6,559,100
7,871,000
9,182,800
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
8,843,800
4,655,100
10,612,600
5,586,100
12,381,300
6,517,200
5
6
A-4-11-II
A-4-11-III

6,625,600
9,170,400
7,950,700
11,004,500
9,275,800
12,838,600
A-4-12-I
3,036,000
3,643,200
4,250,400
8
9
A-4-12-II
A-4-12-III

5,240,600
7,550,700
6,288,700
9,060,900
7,336,800
10,571,000
10 A-4-13-I
11 A-4-13-II

2,259,600
3,993,300
2,711,500
4,792,000
3,163,400
5,590,600
12 A-4-13-III
4,792,000
5,750,400
6,708,700
2,531,400
3,037,700
3,544,000
4,259,200
5,111,100
5,962,900
5,111,100
6,133,300
7,155,500
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
19,762,600
24,611,000
23,715,100
29,533,200
27,667,600
34,455,400
18 A-4-15-III
INFEKSI HIV (BERAT)
27,803,500
33,364,200
38,924,900
19 B-1-01-I
20 B-1-01-II

54,489,600
60,116,400
65,387,500
72,139,600
76,285,400
84,162,900
21 B-1-01-III
22 B-1-10-I

132,512,600
8,807,900
159,015,100
10,569,500
185,517,700
12,331,100
23 B-1-10-II
19,549,800
23,459,700
27,369,700
24 B-1-10-III
25 B-1-11-I

38,593,900
35,147,500
46,312,600
42,177,000
54,031,400
49,206,400
26 B-1-11-II
27 B-1-11-III

41,880,100
64,716,400
50,256,100
77,659,700
58,632,100
90,603,000
28 B-1-12-I
10,342,700
12,411,200
14,479,700
29 B-1-12-II
11,502,900
13,803,400
16,104,000
30 B-1-12-III
17,994,900
21,593,900
25,192,900
8,238,000
9,885,600
11,533,300
13,554,700
16,265,600
18,976,600
17,538,600
21,046,300
24,554,000
21,583,600
25,900,300
30,217,000
22,668,800
27,202,600
31,736,400
40,127,700
3,502,200
5,590,600
7,712,400
48,153,300
4,202,700
6,708,700
9,254,800
56,178,800
4,903,100
7,826,800
10,797,300
7,384,000
8,860,800
10,337,600
10,337,700
12,405,200
14,472,800
12,524,000
15,028,800
17,533,600
6,676,000
9,506,300
14,143,300
6,368,300
8,011,200
11,407,600
16,972,000
7,642,000
9,346,300
13,308,800
19,800,600
8,915,700
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
5,375,000
- 799 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 2
TARIF
KELAS 1
7,418,800
8,902,600
10,386,300
48 B-4-13-III
49 B-4-14-I

10,220,100
6,361,500
12,264,100
7,633,800
14,308,100
8,906,100
50 B-4-14-II
7,421,500
8,905,800
10,390,100
51 B-4-14-III
52 C-4-10-I

9,941,300
12,884,600
11,929,600
15,461,500
13,917,800
18,038,400
53 C-4-10-II
54 C-4-10-III

20,722,000
38,826,200
24,866,400
46,591,500
29,010,700
54,356,700
55 C-4-11-I
6,706,800
8,048,200
9,389,600
56 C-4-11-II
57 C-4-11-III

8,974,700
13,798,800
10,769,700
16,558,500
12,564,600
19,318,300
58 C-4-12-I
59 C-4-12-II
4,465,600
8,795,500
5,358,700
10,554,700
6,251,900
12,313,800
60 C-4-12-III
RADIOTERAPI (BERAT)
22,589,400
27,107,300
31,625,200
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
3,357,200
6,318,400
4,028,700
7,582,000
4,700,100
8,845,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
8,552,900
5,578,200
10,263,500
6,693,800
11,974,100
7,809,500
65 C-4-14-II
7,825,100
9,390,100
10,955,100
66 C-4-14-III
67 D-1-10-I

11,659,200
33,701,900
13,991,100
40,442,300
16,322,900
47,182,700
68 D-1-10-II
69 D-1-10-III

51,330,400
73,562,000
61,596,500
88,274,400
71,862,500
102,986,800
70 D-1-11-I
9,023,400
10,828,000
12,632,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
23,040,900
29,942,500
27,649,000
35,931,000
32,257,200
41,919,500
7,822,200
9,386,700
10,951,100
21,556,900
25,868,200
30,179,600
34,195,500
41,034,600
47,873,700
3,091,100
5,072,800
7,980,800
6,123,700
11,004,100
15,116,900
5,279,500
7,322,800
11,244,400
3,709,300
6,087,400
9,576,900
7,348,500
13,204,900
18,140,300
6,335,400
8,787,300
13,493,300
4,327,600
7,102,000
11,173,100
8,573,200
15,405,700
21,163,700
7,391,300
10,251,900
15,742,200
4,524,400
5,429,300
6,334,200
6,403,600
7,684,300
8,965,000
8,190,400
9,828,400
11,466,500
4,852,600
5,823,100
6,793,700
7,945,000
9,533,900
11,122,900
9,717,500
11,661,000
13,604,500
9,673,100
11,607,800
13,542,400
13,205,300
15,846,300
18,487,400
93 E-1-01-III
31,839,200
38,207,100
44,574,900
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
10,056,900
13,960,200
26,375,400
12,068,300
16,752,200
31,650,500
14,079,700
19,544,300
36,925,600
11,385,200
13,662,300
15,939,300
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
TARIF
KELAS 3
- 800 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,475,700
5,370,900
6,266,000
104 E-4-11-II
105 E-4-11-III

6,823,600
9,246,500
8,188,400
11,095,900
9,553,100
12,945,200
106 E-4-12-I
107 E-4-12-II

5,142,600
8,905,700
6,171,100
10,686,800
7,199,600
12,468,000
108 E-4-12-III

(RINGAN)
(SEDANG)
10,556,500
12,667,800
14,779,100
5,600,100
6,720,100
7,840,100
8,203,100
9,843,700
11,484,400
111 E-4-13-III
10,723,100
12,867,700
15,012,300
112 F-4-10-I
113 F-4-10-II
5,962,000
6,852,100
7,154,400
8,222,500
8,346,800
9,592,900
114 F-4-10-III
115 F-4-11-I
8,222,500
5,766,200
9,867,000
6,919,400
11,511,500
8,072,700
116 F-4-11-II
6,718,200
8,061,900
9,405,500
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
8,615,200
10,338,300
12,061,300
3,160,800
3,793,000
4,425,100
4,493,700
5,392,400
6,291,100
9,762,300
11,714,700
13,667,200
4,644,800
6,128,900
7,934,700
2,650,100
3,399,100
4,573,800
5,573,800
7,354,700
9,521,600
3,180,100
4,078,900
5,488,500
6,502,700
8,580,500
11,108,500
3,710,100
4,758,700
6,403,300
127 F-4-15-I
4,220,400
5,064,500
5,908,600
128 F-4-15-II
6,289,000
7,546,800
8,804,600
129 F-4-15-III
8,303,400
9,964,100
11,624,800
8,303,900
9,964,700
11,625,500
9,654,700
11,585,600
13,516,500
12,887,300
15,464,800
18,042,200
133 F-4-17-I

1,961,100
2,353,300
2,745,500
134 F-4-17-II
5,747,600
6,897,100
8,046,700
135
136
137
138
139
140
141

(RINGAN)
6,132,200
7,215,500
7,939,100
12,238,700
5,514,300
7,061,300
8,791,300
7,358,600
8,658,600
9,526,900
14,686,400
6,617,200
8,473,600
10,549,600
8,585,000
10,101,700
11,114,700
17,134,200
7,720,000
9,885,900
12,307,800
23,392,300
28,070,800
32,749,200
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
15,324,200
18,389,000
21,453,900
21,119,900
25,343,900
29,567,800
4,029,200
4,835,000
5,640,900
7,803,900
9,364,600
10,925,400
13,076,300
15,691,500
18,306,800
- 801 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
54,740,100
65,688,100
76,636,100
148 G-1-11-I
149 G-1-11-II

17,902,100
32,729,300
21,482,600
39,275,200
25,063,000
45,821,000
150 G-1-11-III
52,594,600
63,113,500
73,632,400
7,474,800
8,969,700
10,464,700
14,011,800
16,814,200
19,616,500
19,095,400
22,914,400
26,733,500
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
2,254,900
6,055,600
2,705,900
7,266,700
3,156,900
8,477,800
156 G-1-13-III
157 G-1-20-I

13,664,100
12,659,000
16,396,900
15,190,800
19,129,700
17,722,500
158 G-1-20-II
19,155,000
22,986,000
26,817,000
159 G-1-20-III
32,662,800
39,195,300
45,727,900
160 G-1-30-I
31,536,800
37,844,100
44,151,500
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
42,519,300
63,850,100
51,023,100
76,620,200
59,527,000
89,390,200
6,416,300
7,699,500
8,982,800
7,842,900
9,411,400
10,980,000
10,761,800
12,914,100
15,066,500
6,716,800
8,060,200
9,403,600
8,922,500
10,707,000
12,491,500
13,110,100
15,732,200
18,354,200
7,451,600
8,941,900
10,432,200
9,411,800
11,294,200
13,176,600
13,669,500
16,403,400
19,137,300
4,476,200
5,371,500
6,266,700
7,805,700
9,366,800
10,928,000
9,257,700
11,109,300
12,960,800
7,593,400
9,112,100
10,630,800
10,151,900
12,182,200
14,212,600
12,741,800
15,290,200
17,838,500
6,204,500
7,445,400
8,686,300
7,404,800
8,885,700
10,366,700
10,451,200
12,541,400
14,631,700
5,114,800
6,137,700
7,160,700
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
33,550,200
40,260,300
46,970,300
54,891,000
65,869,100
76,847,300
36,370,900
44,545,300
43,645,100
53,454,400
50,919,300
62,363,400
- 802 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
6,790,600
8,148,700
9,506,800
183 G-4-16-III
9,670,300
11,604,400
13,538,400
6,812,500
8,175,000
9,537,500
8,932,700
10,719,300
12,505,800
11,224,400
13,469,300
15,714,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
188 G-4-18-II
189 G-4-18-III
193 G-4-20-I

194 G-4-20-II
195 G-4-20-III
196 G-4-21-I
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
6,709,300
8,051,200
9,393,000
8,968,300
10,762,000
12,555,600
10,034,800
12,041,800
14,048,700
5,597,700
6,717,300
7,836,800
9,461,500
11,353,800
13,246,100
12,422,500
14,907,000
17,391,500
3,915,900
4,699,100
5,482,200
5,535,800
6,643,000
7,750,200

9,143,900
4,077,800
10,972,700
4,893,300
12,801,400
5,708,900
197 G-4-21-II
198 G-4-21-III

6,901,700
8,111,100
8,282,000
9,733,300
9,662,400
11,355,500
199 G-4-22-I
3,055,000
3,666,000
4,277,000
200 G-4-22-II
201 G-4-22-III

5,410,500
8,534,600
6,492,600
10,241,500
7,574,700
11,948,500
202 G-4-23-I
203 G-4-23-II

4,014,200
5,036,400
4,817,000
6,043,700
5,619,800
7,050,900
204 G-4-23-III
7,170,600
8,604,700
10,038,900
205 G-4-24-I
206 G-4-24-II

4,471,200
5,586,100
5,365,400
6,703,300
6,259,700
7,820,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
9,306,300
3,820,600
4,831,500
6,402,700
11,167,500
4,584,700
5,797,800
7,683,200
13,028,800
5,348,800
6,764,100
8,963,800
4,355,700
5,226,900
6,098,000
5,067,100
6,080,500
7,093,900
7,576,800
9,092,200
10,607,500
12,884,300
14,239,200
19,364,500
8,779,600
10,907,700
15,277,900
4,655,100
6,316,000
12,414,400
4,463,800
5,091,800
7,291,200
5,262,800
6,288,100
10,537,800
15,461,200
17,087,000
23,237,400
10,535,500
13,089,300
18,333,400
5,586,100
7,579,200
14,897,200
5,356,500
6,110,200
8,749,400
6,315,400
7,545,700
12,645,300
18,038,100
19,934,800
27,110,200
12,291,400
15,270,800
21,389,000
6,517,100
8,842,400
17,380,100
6,249,300
7,128,500
10,207,600
7,368,000
8,803,300
14,752,900
229 I-1-01-I
70,689,100
84,826,900
98,964,700
230 I-1-01-II
72,244,200
86,693,000
101,141,900
231 I-1-01-III

(RINGAN)
114,036,500
136,843,800
159,651,100
39,218,000
47,061,600
54,905,200
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 803 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
52,725,400
63,270,500
73,815,600
245 I-1-06-II
76,377,100
91,652,500
106,927,900
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
91,132,000
109,358,400
127,584,800
82,068,400
98,482,100
114,895,800
102,585,500
123,102,600
143,619,700
153,878,300
184,654,000
215,429,600
6,145,600
7,374,700
8,603,800
6,833,300
8,199,900
9,566,600
9,093,000
10,911,600
12,730,200
17,689,900
21,227,900
24,765,900
28,891,200
34,669,500
40,447,700
38,010,800
45,612,900
53,215,100
17,159,000
20,590,800
24,022,600
22,850,700
27,420,800
31,991,000
28,181,200
33,817,500
39,453,700
35,120,200
42,144,300
49,168,300
43,649,300
52,379,100
61,109,000
57,195,600
68,634,700
80,073,900
6,671,800
9,317,100
17,941,000
8,006,200
11,180,500
21,529,200
9,340,600
13,043,900
25,117,400
17,295,800
20,755,000
24,214,200
39,133,500
46,960,200
54,786,900
45,139,900
54,167,800
63,195,800
20,026,900
24,032,300
28,037,700
25,075,600
30,090,700
35,105,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
50,590,700
60,708,900
70,827,000
62,356,200
74,827,500
87,298,700
36,986,800
44,384,100
51,781,500
51,271,300
61,525,600
71,779,900
65,067,300
78,080,700
91,094,200
55,737,100
66,884,500
78,031,900
87,968,200
105,561,800
123,155,400
140,528,500
168,634,200
196,739,900
92,327,000
110,792,400
129,257,800
112,844,100
135,412,900
157,981,700
153,878,300
184,654,000
215,429,600
- 804 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
38,959,200
46,751,100
54,542,900
279 I-1-40-III
52,036,300
62,443,600
72,850,900
280 I-4-10-I
281 I-4-10-II

5,940,300
10,607,000
7,128,300
12,728,400
8,316,400
14,849,800
282 I-4-10-III
15,283,200
18,339,900
21,396,500
283 I-4-11-I
284 I-4-11-II

9,139,100
11,309,600
10,966,900
13,571,600
12,794,700
15,833,500
285 I-4-11-III
286 I-4-12-I

20,921,700
5,253,600
25,106,000
6,304,400
29,290,300
7,355,100
287 I-4-12-II
6,089,700
7,307,700
8,525,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,307,700
8,769,200
10,230,700
5,346,200
6,415,500
7,484,700
9,546,300
11,455,600
13,364,900
13,754,900
16,505,900
19,256,900
5,048,600
5,222,300
9,154,800
6,058,300
6,266,800
10,985,700
7,068,000
7,311,300
12,816,700
5,156,000
6,187,200
7,218,400
9,722,700
11,667,300
13,611,800
11,667,300
14,000,700
16,334,200
3,186,400
5,116,600
6,139,900
2,127,500
3,433,100
4,806,300
3,823,700
6,139,900
7,367,900
2,553,000
4,119,700
5,767,500
4,461,000
7,163,200
8,595,900
2,978,400
4,806,300
6,728,800
6,146,200
7,375,500
8,604,700
9,357,900
11,229,500
13,101,000
12,704,900
15,245,900
17,786,800
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
31,018,100
37,221,700
43,425,300
22,573,800
27,088,500
31,603,300
28,200,800
33,841,000
39,481,200
29,644,900
35,573,900
41,502,900
17,075,800
20,490,900
23,906,100
35,521,400
42,625,700
49,730,000
55,045,400
66,054,500
77,063,600
15,759,100
18,910,900
22,062,700
307 I-4-19-I
5,929,900
7,115,900
8,301,800
308 I-4-19-II

(SEDANG)
9,256,900
11,108,200
12,959,600
309 I-4-19-III
11,051,000
13,261,100
15,471,300
310
311
312
313
314

6,174,700
7,131,900
10,663,600
4,158,500
5,268,800
7,409,700
8,558,200
12,796,300
4,990,200
6,322,600
8,644,600
9,984,600
14,929,000
5,821,900
7,376,400
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 805 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
7,605,000
9,126,000
10,647,000
316 I-4-22-I
317 I-4-22-II
3,736,300
4,651,100
4,483,500
5,581,300
5,230,800
6,511,500
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,798,400
8,158,100
9,517,800
5,068,600
6,082,300
7,096,000
6,222,800
7,467,300
8,711,900
12,159,000
14,590,800
17,022,500
3,292,900
3,951,500
4,610,000
7,582,700
9,099,200
10,615,700
9,586,900
11,504,300
13,421,700
104,333,600
125,200,400
146,067,100
118,072,900
141,687,500
165,302,100
161,957,400
194,348,800
226,740,300
68,065,100
81,678,100
95,291,100
85,884,900
103,061,900
120,238,900
100,473,200
120,567,800
140,662,400
13,269,600
15,923,500
18,577,400
26,851,000
32,221,200
37,591,400
27,904,900
33,485,800
39,066,800
36,555,300
43,866,300
51,177,400
38,278,300
45,933,900
53,589,600
43,077,200
51,692,700
60,308,100
11,073,800
13,288,600
15,503,300
20,060,000
24,072,100
28,084,100
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
57,902,600
69,483,100
81,063,600
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
3,264,300
6,741,600
10,199,000
4,038,600
5,625,000
7,539,700
6,859,600
7,808,600
10,903,000
6,065,000
8,442,300
15,750,600
6,686,800
10,881,400
12,873,800
4,838,600
8,012,800
14,553,600
3,917,100
8,089,900
12,238,800
4,846,300
6,750,000
9,047,700
8,231,500
9,370,400
13,083,600
7,278,000
10,130,800
18,900,800
8,024,200
13,057,700
15,448,600
5,806,300
9,615,300
17,464,300
4,570,000
9,438,200
14,278,600
5,654,100
7,875,000
10,555,600
9,603,400
10,932,100
15,264,200
8,491,000
11,819,300
22,050,900
9,361,600
15,234,000
18,023,300
6,774,100
11,217,900
20,375,000
4,031,600
4,837,900
5,644,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 806 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,852,900
9,423,400
10,994,000
13,403,800
16,084,600
18,765,400
5,587,500
6,691,200
6,705,000
8,029,400
7,822,400
9,367,600

8,780,800
2,483,600
10,537,000
2,980,400
12,293,100
3,477,100
365 J-4-18-II
4,734,900
5,681,900
6,628,900
366 J-4-18-III
367 J-4-19-I

6,728,600
7,083,100
8,074,300
8,499,700
9,420,000
9,916,300
368 J-4-19-II
369 J-4-19-III

8,032,700
8,871,100
9,639,200
10,645,300
11,245,700
12,419,500
370 J-4-20-I
5,634,500
6,761,400
7,888,300
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
7,807,200
9,152,500
9,368,700
10,983,000
10,930,100
12,813,500
3,219,100
3,863,000
4,506,800
7,188,200
8,625,900
10,063,500
13,541,400
16,249,600
18,957,900
12,029,700
14,435,600
16,841,500
15,117,800
18,141,400
21,165,000
17,718,600
21,262,400
24,806,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
11,297,400
13,556,800
15,816,300

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
14,832,000
29,316,900
17,798,500
35,180,200
20,764,900
41,043,600
5,047,500
6,057,000
7,066,500
6,564,800
7,877,800
9,190,800
13,005,900
15,607,100
18,208,300
5,692,500
6,261,800
10,007,700
6,831,100
7,514,200
12,009,200
7,969,600
8,766,500
14,010,700
8,314,200
9,977,000
11,639,900
9,744,000
11,692,800
13,641,600
390 K-1-14-III
17,010,200
20,412,300
23,814,300
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

17,887,700
24,985,100
36,480,900
21,465,200
29,982,100
43,777,100
25,042,800
34,979,100
51,073,200
10,578,700
12,694,400
14,810,100
18,787,400
22,544,900
26,302,400
25,851,800
31,022,100
36,192,500
397 K-1-40-I
11,803,300
14,164,000
16,524,700
398 K-1-40-II

(SEDANG)
13,013,600
15,616,300
18,219,000
399 K-1-40-III
22,053,300
26,464,000
30,874,700
400
401
402
403
404

9,018,900
11,712,200
16,551,500
7,445,600
10,698,200
10,822,700
14,054,600
19,861,800
8,934,700
12,837,900
12,626,500
16,397,100
23,172,100
10,423,800
14,977,500
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 807 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
16,308,900
19,570,700
22,832,400
406 K-4-11-I
407 K-4-11-II

2,588,300
5,098,100
3,105,900
6,117,800
3,623,600
7,137,400
408 K-4-11-III
409 K-4-12-I

6,117,800
4,475,700
7,341,300
5,370,900
8,564,900
6,266,000
410 K-4-12-II
6,023,000
7,227,600
8,432,200
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
9,964,000
11,956,800
13,949,600
6,033,600
7,240,300
8,447,000
7,804,900
9,365,800
10,926,800
12,022,000
14,426,300
16,830,700
3,442,800
4,131,400
4,819,900
4,621,400
5,545,600
6,469,900
7,415,500
8,898,600
10,381,700
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
418 K-4-15-I
4,907,300
5,888,800
6,870,200
419 K-4-15-II
7,557,800
9,069,300
10,580,900
420 K-4-15-III
10,757,500
12,909,000
15,060,500
421 K-4-16-I
4,444,200
5,333,000
6,221,900
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,329,800
6,219,100
6,395,800
7,462,900
7,461,800
8,706,700
2,179,900
2,615,900
3,051,900
2,684,600
3,221,500
3,758,400
3,221,500
3,865,800
4,510,100
1,921,000
2,305,300
2,689,500
3,241,800
3,890,100
4,538,500
429 K-4-18-III
3,890,100
4,668,100
5,446,200
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
28,519,700
43,049,700
57,521,500
13,455,900
23,089,400
28,665,900
34,223,700
51,659,700
69,025,800
16,147,000
27,707,300
34,399,000
39,927,600
60,269,600
80,530,100
18,838,200
32,325,200
40,132,200
7,541,000
9,049,100
10,557,300
15,125,500
18,150,600
21,175,700
25,459,600
30,551,500
35,643,400
9,899,800
15,932,700
22,790,100
2,589,300
3,005,500
3,488,600
5,422,500
7,452,700
16,934,900
2,575,200
3,406,000
11,262,300
11,879,700
19,119,200
27,348,100
3,107,200
3,606,600
4,186,300
6,507,000
8,943,300
20,321,900
3,090,200
4,087,200
13,514,800
13,859,700
22,305,700
31,906,100
3,625,100
4,207,700
4,884,000
7,591,500
10,433,800
23,708,800
3,605,300
4,768,400
15,767,300
2,742,100
3,290,500
3,838,900
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 808 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,467,000
5,360,400
6,253,800
8,873,900
10,648,600
12,423,400
4,459,300
5,351,200
6,243,100
6,698,100
8,037,700
9,377,300
9,441,700
11,330,100
13,218,400
15,763,300
18,915,900
22,068,600
22,405,300
26,886,400
31,367,400
31,472,700
37,767,300
44,061,800
13,971,200
16,765,400
19,559,700
22,919,200
38,939,200
27,503,100
46,727,100
32,086,900
54,514,900
55,848,000
67,017,600
78,187,200
65,322,300
78,386,800
91,451,300
80,847,300
97,016,800
113,186,200
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
28,602,900
34,323,500
40,044,100
467 M-1-04-II
36,746,400
44,095,700
51,445,000
468 M-1-04-III
43,968,000
52,761,600
61,555,200
469 M-1-05-I
470 M-1-05-II

11,121,900
17,990,000
13,346,200
21,588,000
15,570,600
25,186,000
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
22,980,000
27,576,000
32,172,000
20,327,700
24,393,300
28,458,800
27,232,200
32,678,600
38,125,000
55,474,400
66,569,300
77,664,200
24,022,000
28,826,400
33,630,800
57,435,600
68,922,700
80,409,800
123,883,200
148,659,800
173,436,400
18,719,000
22,462,800
26,206,600
23,915,400
28,698,500
33,481,600
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
59,542,100
71,450,500
83,358,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,841,700
20,808,800
29,754,700
15,410,000
24,970,600
35,705,700
17,978,400
29,132,300
41,656,600
7,844,300
9,413,200
10,982,000
11,592,900
13,911,500
16,230,100
16,552,500
19,863,000
23,173,500
7,833,500
12,999,600
21,351,000
9,400,200
15,599,500
25,621,200
10,966,900
18,199,400
29,891,400
12,098,200
14,517,800
16,937,500
15,210,200
18,252,300
21,294,300
22,976,900
27,572,200
32,167,600
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 809 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
4,488,300
5,386,000
6,283,700
500 M-4-10-II
501 M-4-10-III
6,693,600
12,664,400
8,032,300
15,197,200
9,371,100
17,730,100
5,592,900
6,711,500
7,830,100
12,262,200
14,714,600
17,167,100
17,729,000
21,274,800
24,820,600
4,464,400
5,357,300
6,250,100
7,425,500
8,910,600
10,395,700
9,932,400
11,918,900
13,905,300
7,433,700
8,920,400
10,407,100
11,168,800
13,402,500
15,636,300
21,790,000
26,148,000
30,506,000
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,477,800
10,173,400
11,868,900
512 M-4-14-II
10,456,100
12,547,400
14,638,600
513 M-4-14-III
514 M-4-15-I
15,712,500
5,027,100
18,855,000
6,032,500
21,997,600
7,037,900
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,700,800
15,206,000
4,304,000
6,892,300
11,578,600
8,040,900
18,247,200
5,164,800
8,270,800
13,894,300
9,381,100
21,288,500
6,025,600
9,649,200
16,210,000
5,027,400
6,032,900
7,038,300
7,031,400
8,437,600
9,843,900
9,818,800
11,782,600
13,746,400
4,222,100
6,362,900
7,661,200
5,066,500
7,635,500
9,193,500
5,911,000
8,908,100
10,725,700
4,403,000
5,283,600
6,164,200
7,416,400
8,899,600
10,382,900
14,484,600
17,381,600
20,278,500
3,997,300
4,796,700
5,596,200
5,853,300
7,024,000
8,194,700
6,541,800
7,850,200
9,158,500
4,025,000
4,829,900
5,634,900
5,034,100
6,040,900
7,047,700
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
22,414,100
26,896,900
31,379,700
24,655,500
29,586,600
34,517,700
28,227,300
33,872,700
39,518,200
12,741,500
15,289,800
17,838,100
15,131,700
34,058,100
18,158,000
40,869,800
21,184,300
47,681,400
- 810 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,286,200
13,543,500
15,800,700
535 N-1-01-I

309,551,400
371,461,600
433,371,900
536 N-1-01-II
309,551,400
371,461,600
433,371,900
537 N-1-01-III
538 N-1-11-I

309,551,400
12,899,900
371,461,600
15,479,900
433,371,900
18,059,800
539 N-1-11-II
540 N-1-11-III

20,397,800
31,800,200
24,477,400
38,160,300
28,557,000
44,520,300
6,574,600
7,889,600
9,204,500
13,089,400
15,707,300
18,325,200
28,404,500
34,085,400
39,766,300
14,374,600
17,249,600
20,124,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
20,116,500
28,150,700
24,139,900
33,780,800
28,163,200
39,411,000
13,155,300
15,786,400
18,417,500
19,901,400
23,881,700
27,862,000
22,904,700
27,485,600
32,066,500
11,814,400
14,177,300
16,540,200
16,043,700
19,252,500
22,461,200
18,672,800
22,407,300
26,141,900
5,019,500
6,023,400
7,027,300
6,071,200
7,285,400
8,499,600
8,929,800
10,715,700
12,501,700
3,853,300
6,732,100
8,376,200
2,905,200
6,035,600
9,807,500
3,931,300
6,572,300
13,596,600
4,623,900
8,078,600
10,051,400
3,486,300
7,242,700
11,769,000
4,717,500
7,886,700
16,316,000
5,394,600
9,425,000
11,726,700
4,067,300
8,449,800
13,730,500
5,503,800
9,201,200
19,035,300
3,869,900
4,643,900
5,417,900
5,491,300
6,589,500
7,687,800
8,802,500
10,563,000
12,323,500
4,571,800
5,486,200
6,400,600
5,672,900
6,807,400
7,942,000
6,473,700
7,768,400
9,063,200
5,598,200
6,717,800
7,837,500
7,990,400
9,588,500
11,186,600
10,635,800
12,763,000
14,890,200
5,736,300
7,383,400
6,883,500
8,860,100
8,030,800
10,336,800
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 811 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,638,700
13,966,400
16,294,200
5,203,800
6,244,600
7,285,300
5,783,400
6,940,100
8,096,800
7,194,700
8,633,600
10,072,500
3,686,800
4,424,200
5,161,500
4,427,800
5,313,400
6,199,000
5,563,800
6,676,500
7,789,300
1,868,900
2,242,700
2,616,500
3,066,000
3,679,200
3,679,200
4,415,100
4,292,500
5,150,900
82,327,200
98,792,600
115,258,100
101,867,600
122,241,100
142,614,600
119,563,900
143,476,700
167,389,400
112,372,700
134,847,300
157,321,800
128,902,800
154,683,400
180,463,900
147,280,600
176,736,700
206,192,800
16,855,800
20,227,000
23,598,100
22,310,900
26,773,100
31,235,300
31,370,200
37,644,300
43,918,300
54,318,500
65,182,200
76,045,900
70,493,700
84,592,400
98,691,200
101,070,300
121,284,300
141,498,400
29,536,700
35,444,000
41,351,300
45,565,500
54,678,500
63,791,600
61,681,300
74,017,500
86,353,800
7,974,000
9,568,800
11,163,500
22,357,200
26,828,600
31,300,000
29,617,700
35,541,300
41,464,800
9,439,900
11,327,900
13,215,900
26,467,400
31,760,900
37,054,400
35,062,900
42,075,400
49,088,000
5,462,100
6,554,500
7,646,900
7,750,400
9,300,500
10,850,600
15,077,600
18,093,100
21,108,600
14,046,500
16,855,800
19,665,100
18,592,500
22,310,900
26,029,400
- 812 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
26,141,800
31,370,200
36,598,600
12,769,500
15,323,400
17,877,400
15,493,700
18,592,500
21,691,200
22,732,000
27,278,400
31,824,900
7,094,200
8,513,000
9,931,900
11,066,900
13,280,300
15,493,700
17,486,200
20,983,400
24,480,700
5,369,800
6,443,700
7,517,700
10,930,700
13,116,800
15,302,900
42,739,800
51,287,800
59,835,700
4,027,400
4,832,900
5,638,300
8,065,000
9,678,000
11,291,000
9,462,800
11,355,400
13,248,000
3,644,800
4,373,800
5,102,800
7,004,100
8,405,000
9,805,800
16,425,800
19,711,000
22,996,200
4,729,500
5,675,400
6,621,200
8,513,000
10,215,600
11,918,200
14,571,800
17,486,200
20,400,500
4,109,500
4,931,400
5,753,300
5,063,500
6,076,200
7,088,900
6,931,400
8,317,700
9,704,000
1,888,500
3,838,600
8,856,800
3,021,300
4,021,300
6,970,900
2,266,200
4,606,300
10,628,200
3,625,600
4,825,500
8,365,100
2,644,000
5,374,000
12,399,600
4,229,800
5,629,800
9,759,300
4,461,700
5,354,000
6,246,300
7,915,400
9,498,400
11,081,500
12,847,600
15,417,100
17,986,600
2,257,900
2,709,500
3,161,100
4,796,000
5,755,200
6,714,400
9,094,900
10,913,900
12,732,900
1,510,100
1,812,100
2,114,200
2,849,800
3,419,800
3,989,800
3,691,000
4,429,200
5,167,400
7,819,700
9,383,600
10,947,500
- 813 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
9,944,800
11,933,800
13,922,700
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
14,238,900
17,086,700
19,934,400
3,768,900
4,522,700
5,276,500
5,593,500
6,712,200
7,830,900
6,727,400
8,072,900
9,418,400
2,521,700
3,026,100
3,530,400
3,387,000
4,064,400
4,741,800
6,161,400
7,393,700
8,626,000
1,380,800
1,656,900
1,933,100
2,631,100
3,157,300
3,683,500
3,824,400
4,589,200
5,354,100
1,333,500
1,600,200
1,866,900
2,098,600
2,518,300
2,938,000
3,380,200
4,056,300
4,732,300
3,124,500
3,749,400
4,374,300
4,716,800
5,660,100
6,603,500
7,300,900
8,761,000
10,221,200
8,240,700
9,888,800
11,537,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,792,800
33,789,200
15,351,400
40,547,000
17,909,900
47,304,800
13,005,000
15,606,000
18,207,000
19,615,600
23,538,700
27,461,800
23,253,000
27,903,600
32,554,200
9,961,700
15,275,800
22,436,900
9,968,600
11,614,900
19,254,000
11,954,100
18,330,900
26,924,300
11,962,300
13,937,900
23,104,700
13,946,400
21,386,100
31,411,700
13,956,000
16,260,900
26,955,500
5,990,400
7,188,500
8,386,500
7,351,700
8,822,000
10,292,300
8,711,700
10,454,000
12,196,400
4,688,900
6,666,300
10,154,800
5,626,700
7,999,500
12,185,700
6,564,400
9,332,800
14,216,700
9,094,400
10,913,200
12,732,100
13,534,900
16,241,900
18,948,900
34,746,800
41,696,100
48,645,500
7,799,400
10,575,700
20,681,100
9,359,300
12,690,800
24,817,300
10,919,200
14,805,900
28,953,600
5,612,800
6,735,300
7,857,900
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 814 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,714,600
3,257,500
3,800,400
697 U-4-12-I
698 U-4-12-II

2,915,300
4,700,500
3,498,400
5,640,600
4,081,500
6,580,700
699 U-4-12-III

8,232,100
9,878,500
11,524,900
2,209,400
2,651,300
3,093,200
3,610,400
4,332,500
5,054,500
5,829,600
6,995,500
8,161,400
5,586,600
6,689,800
6,703,900
8,027,800
7,821,200
9,365,700

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
11,234,200
13,481,000
15,727,900
4,485,900
5,383,100
6,280,200
5,588,800
6,706,600
7,824,400
7,821,600
9,386,000
10,950,300
7,316,800
8,780,200
10,243,600
15,072,400
18,086,900
21,101,400
18,484,200
22,181,000
25,877,900
13,919,900
15,894,900
24,892,100
16,703,900
19,073,900
29,870,500
19,487,900
22,252,900
34,849,000
13,087,400
15,704,900
18,322,400
17,871,900
21,446,300
25,020,700
22,652,900
27,183,500
31,714,000
6,826,600
8,191,900
9,557,200
13,043,300
15,652,000
18,260,700
20,463,400
24,556,100
28,648,700
13,386,900
16,064,200
18,741,600
19,450,700
23,340,900
27,231,000
723 V-1-14-III
24,287,800
29,145,300
34,002,900
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,156,000
2,379,100
2,631,800
2,587,200
2,854,900
3,158,100
3,018,400
3,330,700
3,684,500
5,826,300
6,991,600
8,156,800
9,677,800
11,613,300
13,548,900
15,955,300
19,146,300
22,337,400
5,593,600
6,712,400
7,831,100
7,505,200
9,006,300
10,507,300
10,053,300
12,064,000
14,074,600
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
12,849,400
15,419,200
17,989,100
19,727,700
23,673,200
27,618,800
1,774,300
2,580,400
2,129,100
3,096,500
2,484,000
3,612,600
- 815 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,246,300
18,295,500
21,344,800
18,273,700
21,928,400
25,583,200
26,076,100
31,291,300
36,506,500
3,233,900
3,880,700
4,527,500
3,568,600
3,947,600
4,282,400
4,737,200
4,996,100
5,526,700
3,380,200
4,056,200
4,732,300
3,730,000
4,476,000
5,222,000
4,126,200
4,951,400
5,776,600
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
3,636,400
4,363,700
5,091,000
743 W-1-12-II
744 W-1-12-III

4,538,800
8,037,300
5,446,600
9,644,800
6,354,400
11,252,200
745 W-1-13-I
3,737,900
4,485,500
5,233,100
746 W-1-13-II
747 W-1-13-III

4,058,100
5,451,100
4,869,700
6,541,300
5,681,400
7,631,500
748 W-1-20-I
749 W-1-20-II

12,517,900
15,641,300
15,021,500
18,769,500
17,525,100
21,897,800
750 W-1-20-III
18,132,200
21,758,700
25,385,100
751 W-1-30-I
7,066,500
8,479,800
9,893,200
752 W-1-30-II
11,271,100
13,525,300
15,779,600
753 W-1-30-III
27,654,300
33,185,200
38,716,000
754 W-4-10-I
5,265,300
6,318,400
7,371,400
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
7,805,600
15,425,400
4,309,600
6,542,600
7,963,600
9,366,700
18,510,500
5,171,500
7,851,100
9,556,300
10,927,800
21,595,500
6,033,400
9,159,600
11,149,000
3,231,600
3,877,900
4,524,200
6,149,800
7,379,800
8,609,700
9,049,900
10,859,900
12,669,800
1,884,000
2,573,600
3,200,400
2,517,700
2,996,700
3,833,900
1,818,300
2,799,100
5,231,900
2,419,300
4,484,400
8,205,000
1,785,200
4,467,700
8,917,400
5,309,600
7,047,400
10,012,100
3,456,600
4,151,500
5,706,500
2,260,800
3,088,300
3,840,500
3,021,300
3,596,100
4,600,700
2,182,000
3,358,900
6,278,300
2,903,200
5,381,300
9,846,100
2,142,200
5,361,300
10,700,900
6,371,600
8,456,800
12,014,500
4,147,900
4,981,800
6,847,800
2,637,500
3,603,000
4,480,500
3,524,800
4,195,400
5,367,500
2,545,700
3,918,700
7,324,700
3,387,000
6,278,200
11,487,100
2,499,300
6,254,800
12,484,300
7,433,500
9,866,300
14,016,900
4,839,200
5,812,100
7,989,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 816 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,284,600
2,741,500
3,198,400
4,587,200
5,504,600
6,422,100
9,677,800
11,613,400
13,549,000
- 817 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,547,000
2,006,800
3,731,800
3,083,900
4,007,700
737,200
1,637,900
576,400
1,273,700
1,092,200
1,239,900
1,864,100
2,542,700
2,330,400
754,900
1,742,500
632,100
1,085,100
3,305,300
1,183,700
2,795,500
682,000
1,988,900
2,490,400
2,088,800
512,300
1,552,500
863,200
554,800
479,900
423,600
506,500
705,300
519,500
570,500
439,400
760,700
394,500
391,500
399,000
9,108,300
3,640,200
3,652,400
939,500
1,923,100
1,204,000
2,447,300
1,254,500
718,400
542,500
875,000
620,900
413,500
4,033,100
1,613,200
1,075,500
4,198,300
2,798,900
436,000
4,548,200
3,148,700
4,908,300
1,635,800
1,006,200
432,900
428,300
406,600
6,199,700
3,017,800
- 818 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
3,835,500
6,787,900
5,628,000
4,287,400
1,413,500
4,771,900
3,115,900
765,900
7,164,400
6,485,800
4,348,800
4,119,900
509,200
489,300
1,968,800
538,100
479,400
529,800
2,273,200
2,484,000
2,169,700
2,395,200
1,450,600
482,200
850,000
583,500
526,800
513,300
651,700
743,200
435,700
1,250,400
2,278,700
1,749,200
4,112,300
535,500
535,500
4,750,000
2,209,600
423,900
1,960,900
5,094,000
1,169,500
921,200
451,300
304,500
611,000
852,100
2,040,200
1,798,300
1,258,800
751,300
413,500
2,185,800
1,401,200
748,400
683,100
2,238,700
587,800
2,859,000
2,187,200
533,600
591,500
577,800
415,200
2,383,100
2,619,500
519,100
- 819 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,591,100
593,900
642,100
594,600
943,300
725,600
1,817,200
536,100
1,491,700
2,491,600
436,600
2,657,100
1,439,900
3,111,600
1,570,800
693,700
533,600
87,900
691,600
1,562,800
609,000
822,600
470,400
223,700
475,100
7,074,700
4,021,400
6,711,700
2,061,000
921,200
627,700
1,419,600
750,900
1,511,100
875,000
520,900
871,800
490,700
748,900
574,100
1,093,400
2,738,800
2,203,500
1,942,900
1,371,200
504,400
504,400
504,400
412,000
261,300
410,900
502,300
543,300
400,200
353,000
123,200
135,500
100,200
117,600
112,100
171,100
182,300
280,500
308,100
136,300
165,400
113,100
176,500
250,400
- 820 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
178,200
314,800
890,000
1,031,700
168,500
428,200
205,100
292,800
720,400
616,800
443,400
419,800
167,600
164,600
494,300
370,500
531,400
419,700
242,400
3,886,700
3,198,300
508,200
526,300
1,006,500
988,400
1,288,400
665,500
2,074,100
350,500
540,900
542,700
434,500
548,800
519,400
243,300
534,600
473,900
428,600
484,800
4,013,000
651,300
1,444,200
518,000
921,200
604,900
482,500
1,254,100
1,284,400
1,369,400
1,197,900
1,766,000
356,900
3,097,200
470,400
1,570,000
3,568,000
3,300,500
1,441,800
522,500
1,019,100
1,015,100
470,400
3,687,500
2,900,500
268,400
200,500
260,500
560,800
- 821 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,384,500
1,655,500
1,528,300
1,843,800
883,600
1,229,100
849,600
714,700
874,400
506,300
1,196,900
239,300
886,400
1,490,500
97,200
- 822 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,608,500
3,130,200
3,651,900
A-4-10-II
SEPTIKEMIA (SEDANG)
4,456,400
5,347,700
6,239,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
6,008,700
3,389,700
7,210,400
4,067,600
8,412,100
4,745,500
5
6
A-4-11-II
A-4-11-III

4,824,500
6,677,500
5,789,400
8,013,000
6,754,300
9,348,500
A-4-12-I
2,716,200
3,259,400
3,802,600
8
9
A-4-12-II
A-4-12-III

3,382,500
3,721,700
4,059,100
4,466,100
4,735,600
5,210,400
10 A-4-13-I
11 A-4-13-II

2,150,800
2,745,100
2,581,000
3,294,100
3,011,200
3,843,200
12 A-4-13-III
3,294,100
3,953,000
4,611,800
2,334,800
2,801,800
3,268,700
2,834,200
3,401,000
3,967,800
3,401,000
4,081,200
4,761,400
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
14,889,100
18,541,900
17,866,900
22,250,300
20,844,700
25,958,600
18 A-4-15-III
INFEKSI HIV (BERAT)
20,947,100
25,136,500
29,326,000
19 B-1-01-I
20 B-1-01-II

40,723,500
44,928,700
48,868,200
53,914,500
57,012,900
62,900,200
21 B-1-01-III
22 B-1-10-I

99,035,000
6,582,700
118,842,000
7,899,300
138,649,100
9,215,800
23 B-1-10-II
14,610,800
17,532,900
20,455,100
24 B-1-10-III
25 B-1-11-I

28,843,600
7,196,500
34,612,400
8,635,800
40,381,100
10,075,100
26 B-1-11-II
27 B-1-11-III

9,614,600
12,421,900
11,537,500
14,906,300
13,460,400
17,390,700
28 B-1-12-I
7,244,300
8,693,200
10,142,100
29 B-1-12-II
8,057,000
9,668,400
11,279,800
30 B-1-12-III
12,604,300
15,125,100
17,646,000
5,770,200
6,924,200
8,078,300
9,494,200
11,393,000
13,291,800
12,284,600
14,741,500
17,198,500
7,928,500
9,514,200
11,099,900
8,817,900
10,581,500
12,345,000
13,794,600
2,379,500
3,798,300
5,239,900
16,553,500
2,855,400
4,558,000
6,287,900
19,312,400
3,331,300
5,317,700
7,335,900
5,016,900
6,020,200
7,023,600
7,023,700
8,428,400
9,833,100
8,509,100
10,210,900
11,912,700
4,535,800
6,658,500
9,906,400
4,326,800
5,442,900
7,990,200
11,887,700
5,192,100
6,350,100
9,322,000
13,869,000
6,057,500
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 823 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,040,500
6,048,600
7,056,700
48 B-4-13-III
49 B-4-14-I

6,943,700
4,322,200
8,332,500
5,186,600
9,721,200
6,051,000
50 B-4-14-II
5,042,300
6,050,800
7,059,300
51 B-4-14-III
52 C-4-10-I

6,754,300
4,122,400
8,105,200
4,946,900
9,456,100
5,771,400
53 C-4-10-II
54 C-4-10-III

7,909,900
13,542,900
9,491,900
16,251,400
11,073,900
18,960,000
55 C-4-11-I
4,556,800
5,468,100
6,379,500
56 C-4-11-II
57 C-4-11-III

6,097,600
9,665,100
7,317,100
11,598,100
8,536,700
13,531,200
58 C-4-12-I
59 C-4-12-II
3,034,000
6,160,700
3,640,800
7,392,800
4,247,700
8,625,000
60 C-4-12-III
RADIOTERAPI (BERAT)
15,822,400
18,986,900
22,151,300
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,281,000
4,292,800
2,737,200
5,151,400
3,193,400
6,010,000
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,811,000
3,789,900
6,973,200
4,547,900
8,135,500
5,305,900
65 C-4-14-II
5,316,500
6,379,800
7,443,100
66 C-4-14-III
67 D-1-10-I

8,166,500
22,668,800
9,799,800
27,202,600
11,433,100
31,736,300
68 D-1-10-II
69 D-1-10-III

34,526,200
54,977,500
41,431,400
65,973,000
48,336,700
76,968,500
70 D-1-11-I
6,130,700
7,356,800
8,582,900
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
15,654,400
20,972,800
18,785,300
25,167,300
21,916,200
29,361,900
5,314,600
6,377,500
7,440,400
14,646,200
17,575,400
20,504,700
23,233,100
27,879,800
32,526,400
2,619,900
4,299,600
6,764,300
4,160,600
7,476,400
10,588,400
3,587,000
4,975,200
7,639,700
3,143,900
5,159,500
8,117,200
4,992,700
8,971,700
12,706,100
4,304,400
5,970,300
9,167,700
3,667,900
6,019,400
9,470,000
5,824,800
10,467,000
14,823,800
5,021,800
6,965,300
10,695,600
3,074,000
3,688,800
4,303,600
4,350,700
5,220,900
6,091,000
5,564,700
6,677,600
7,790,600
3,297,000
3,956,400
4,615,800
5,398,000
6,477,600
7,557,200
6,602,300
7,922,700
9,243,200
7,229,300
8,675,200
10,121,100
9,869,100
11,842,900
13,816,800
93 E-1-01-III
23,795,500
28,554,600
33,313,700
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,516,200
10,433,300
19,712,000
9,019,400
12,520,000
23,654,400
10,522,600
14,606,700
27,596,800
7,735,400
9,282,400
10,829,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 824 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
3,040,900
3,649,100
4,257,300
104 E-4-11-II
105 E-4-11-III

4,636,100
6,476,600
5,563,400
7,771,900
6,490,600
9,067,200
106 E-4-12-I
107 E-4-12-II

3,494,000
6,050,700
4,192,800
7,260,900
4,891,500
8,471,000
108 E-4-12-III

(RINGAN)
(SEDANG)
7,172,300
8,606,800
10,041,200
3,804,800
4,565,800
5,326,700
5,573,400
6,688,000
7,802,700
111 E-4-13-III
7,510,800
9,013,000
10,515,100
112 F-4-10-I
113 F-4-10-II
4,175,900
4,799,400
5,011,100
5,759,300
5,846,300
6,719,200
114 F-4-10-III
115 F-4-11-I
5,759,300
4,038,800
6,911,200
4,846,600
8,063,000
5,654,400
116 F-4-11-II
4,705,700
5,646,800
6,587,900
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
6,034,400
7,241,300
8,448,100
2,147,500
2,577,000
3,006,500
3,053,100
3,663,700
4,274,300
6,632,700
7,959,200
9,285,800
3,253,400
4,292,900
5,557,700
1,856,200
2,380,800
3,203,600
3,904,100
5,151,500
6,669,300
2,227,400
2,857,000
3,844,300
4,554,700
6,010,100
7,780,800
2,598,700
3,333,200
4,485,100
127 F-4-15-I
2,867,500
3,440,900
4,014,400
128 F-4-15-II
4,272,900
5,127,400
5,982,000
129 F-4-15-III
5,641,500
6,769,800
7,898,100
5,816,300
6,979,600
8,142,900
6,762,400
8,114,900
9,467,400
9,026,700
10,832,000
12,637,400
133 F-4-17-I

1,332,400
1,598,900
1,865,300
134 F-4-17-II
3,905,100
4,686,100
5,467,100
135
136
137
138
139
140
141

(RINGAN)
4,166,300
5,054,000
5,560,800
8,572,400
3,862,400
4,946,000
6,157,700
4,999,600
6,064,800
6,673,000
10,286,900
4,634,900
5,935,200
7,389,300
5,832,900
7,075,600
7,785,100
12,001,300
5,407,400
6,924,400
8,620,800
17,482,500
20,979,100
24,475,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,411,600
12,493,900
14,576,200
14,793,100
17,751,700
20,710,300
3,604,800
4,325,700
5,046,700
5,037,000
6,044,400
7,051,800
6,445,300
7,734,300
9,023,400
- 825 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
23,220,900
27,865,100
32,509,300
148 G-1-11-I
149 G-1-11-II

12,163,100
22,237,000
14,595,700
26,684,400
17,028,300
31,131,800
150 G-1-11-III
36,892,800
44,271,400
51,649,900
5,078,500
6,094,200
7,109,900
9,814,300
11,777,200
13,740,100
13,375,000
16,050,000
18,725,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,532,000
4,114,300
1,838,400
4,937,200
2,144,900
5,760,000
156 G-1-13-III
157 G-1-20-I

9,283,700
9,065,800
11,140,400
10,879,000
12,997,100
12,692,200
158 G-1-20-II
14,758,500
17,710,200
20,661,900
159 G-1-20-III
22,649,300
27,179,200
31,709,100
160 G-1-30-I
11,535,200
13,842,300
16,149,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
24,085,900
32,813,300
28,903,100
39,375,900
33,720,300
45,938,600
4,359,400
5,231,200
6,103,100
5,328,600
6,394,300
7,460,100
7,537,900
9,045,500
10,553,100
4,704,700
5,645,600
6,586,600
6,249,600
7,499,500
8,749,500
9,182,800
11,019,400
12,855,900
5,219,300
6,263,200
7,307,100
6,394,600
7,673,500
8,952,400
9,287,400
11,144,800
13,002,300
3,041,300
3,649,500
4,257,800
5,303,400
6,364,000
7,424,700
6,289,900
7,547,900
8,805,900
5,159,100
6,191,000
7,222,800
7,110,700
8,532,900
9,955,000
8,924,800
10,709,700
12,494,700
4,215,500
5,058,600
5,901,700
5,030,900
6,037,100
7,043,300
7,100,800
8,520,900
9,941,100
3,475,100
4,170,100
4,865,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
25,074,200
30,089,000
35,103,900
38,063,000
45,675,600
53,288,200
17,900,200
21,075,600
21,480,200
25,290,700
25,060,200
29,505,900
- 826 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,613,600
5,536,400
6,459,100
183 G-4-16-III
6,570,200
7,884,300
9,198,300
4,628,600
5,554,300
6,480,000
6,069,100
7,282,900
8,496,700
7,861,900
9,434,300
11,006,700
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,558,400
5,470,100
6,381,800
188 G-4-18-II
6,093,200
7,311,900
8,530,500
189 G-4-18-III
6,817,900
8,181,400
9,545,000
3,803,200
4,563,800
5,324,500
6,428,300
7,714,000
8,999,700
8,440,100
10,128,100
11,816,100
193 G-4-20-I

2,660,500
3,192,600
3,724,700
194 G-4-20-II
3,761,200
4,513,400
5,265,600
195 G-4-20-III
196 G-4-21-I

6,212,500
2,770,500
7,455,100
3,324,600
8,697,600
3,878,700
197 G-4-21-II
198 G-4-21-III

4,689,200
5,681,300
5,627,000
6,817,500
6,564,800
7,953,800
199 G-4-22-I
2,733,200
3,279,900
3,826,500
200 G-4-22-II
201 G-4-22-III

3,492,200
4,080,500
4,190,700
4,896,600
4,889,100
5,712,700
202 G-4-23-I
203 G-4-23-II

2,727,300
3,421,800
3,272,800
4,106,200
3,818,200
4,790,600
204 G-4-23-III
4,871,900
5,846,200
6,820,600
205 G-4-24-I
206 G-4-24-II

3,131,800
3,912,700
3,758,100
4,695,200
4,384,500
5,477,800
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,518,400
2,595,800
3,282,600
4,350,100
7,822,100
3,114,900
3,939,100
5,220,200
9,125,800
3,634,100
4,595,700
6,090,200
3,691,800
4,430,200
5,168,500
4,427,500
5,313,000
6,198,500
6,421,900
7,706,300
8,990,600
10,478,800
11,580,700
15,749,000
7,671,400
9,531,000
13,349,600
3,514,200
4,768,000
9,371,800
3,032,800
3,459,500
4,953,800
3,575,700
4,404,400
7,381,000
12,574,500
13,896,900
18,898,800
9,205,700
11,437,200
16,019,500
4,217,000
5,721,600
11,246,100
3,639,300
4,151,400
5,944,500
4,290,800
5,285,300
8,857,200
14,670,300
16,213,000
22,048,600
10,740,000
13,343,400
18,689,400
4,919,900
6,675,200
13,120,500
4,245,900
4,843,300
6,935,300
5,005,900
6,166,200
10,333,400
229 I-1-01-I
48,027,600
57,633,200
67,238,700
230 I-1-01-II
49,084,200
58,901,100
68,717,900
231 I-1-01-III

(RINGAN)
77,478,800
92,974,500
108,470,300
26,645,500
31,974,600
37,303,700
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 827 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
22,618,100
27,141,700
31,665,300
245 I-1-06-II
32,764,100
39,316,900
45,869,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
39,093,600
46,912,400
54,731,100
49,979,400
59,975,300
69,971,200
62,474,300
74,969,100
87,464,000
93,711,400
112,453,700
131,195,900
4,304,600
5,165,500
6,026,400
4,786,300
5,743,500
6,700,800
6,369,100
7,642,900
8,916,700
12,390,600
14,868,800
17,346,900
19,629,300
23,555,200
27,481,000
25,825,300
30,990,400
36,155,400
12,018,700
14,422,500
16,826,200
16,005,400
19,206,500
22,407,600
19,739,100
23,686,900
27,634,700
24,599,400
29,519,300
34,439,200
30,573,400
36,688,100
42,802,800
40,061,800
48,074,100
56,086,500
4,673,200
6,526,000
12,566,500
5,607,800
7,831,200
15,079,800
6,542,400
9,136,400
17,593,100
11,751,100
14,101,400
16,451,600
27,410,400
32,892,500
38,374,600
31,617,500
37,941,000
44,264,500
14,027,500
16,833,000
19,638,500
17,563,800
21,076,500
24,589,300
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
34,372,400
41,246,900
48,121,400
42,366,100
50,839,400
59,312,600
15,390,500
18,468,600
21,546,700
21,334,500
25,601,400
29,868,200
27,912,400
33,494,900
39,077,400
23,910,000
28,692,000
33,474,000
37,736,400
45,283,700
52,831,000
60,283,700
72,340,400
84,397,200
56,226,800
67,472,200
78,717,600
68,721,700
82,466,000
96,210,400
93,711,400
112,453,700
131,195,900
- 828 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
26,469,700
31,763,700
37,057,600
279 I-1-40-III
35,354,600
42,425,500
49,496,400
280 I-4-10-I
281 I-4-10-II

4,160,800
7,429,500
4,992,900
8,915,400
5,825,100
10,401,300
282 I-4-10-III
10,704,900
12,845,900
14,986,900
283 I-4-11-I
284 I-4-11-II

6,209,300
7,684,000
7,451,100
9,220,800
8,693,000
10,757,600
285 I-4-11-III
286 I-4-12-I

14,214,600
3,679,800
17,057,500
4,415,800
19,900,500
5,151,700
287 I-4-12-II
4,265,400
5,118,500
5,971,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,118,500
6,142,200
7,165,900
3,744,700
4,493,600
5,242,600
6,686,600
8,023,900
9,361,200
9,634,400
11,561,300
13,488,200
3,430,100
3,657,900
6,219,900
4,116,100
4,389,500
7,463,900
4,802,200
5,121,100
8,707,900
4,612,900
5,535,500
6,458,000
6,275,500
7,530,600
8,785,700
297 I-4-15-III
7,530,600
9,036,800
10,542,900
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,231,900
3,583,800
4,300,600
1,962,200
2,284,400
2,741,300
2,678,200
4,300,600
5,160,700
2,354,700
2,741,300
3,289,500
3,124,600
5,017,400
6,020,800
2,747,100
3,198,200
3,837,800
4,175,900
5,011,000
5,846,200
6,554,600
7,865,500
9,176,400
8,632,000
10,358,400
12,084,700
307 I-4-19-I
4,028,900
4,834,700
5,640,400
308 I-4-19-II

(SEDANG)
6,289,300
7,547,200
8,805,000
309 I-4-19-III
7,508,200
9,009,900
10,511,500
310
311
312
313
314

4,325,000
4,995,400
7,245,100
3,236,400
4,100,500
5,190,000
5,994,500
8,694,100
3,883,700
4,920,600
6,055,000
6,993,600
10,143,100
4,530,900
5,740,700
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
21,726,100
26,071,400
30,416,600
15,811,400
18,973,700
22,136,000
19,752,800
23,703,400
27,654,000
20,764,300
24,917,200
29,070,000
11,960,500
14,352,600
16,744,600
24,880,400
29,856,500
34,832,600
38,555,700
46,266,800
53,978,000
11,038,200
13,245,900
15,453,500
- 829 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
5,918,700
7,102,400
8,286,100
316 I-4-22-I
317 I-4-22-II
3,264,700
4,064,100
3,917,600
4,876,900
4,570,600
5,689,700
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,940,400
7,128,500
8,316,500
3,443,700
4,132,400
4,821,200
4,227,900
5,073,500
5,919,000
8,261,100
9,913,300
11,565,500
2,877,300
3,452,700
4,028,200
6,625,600
7,950,700
9,275,900
8,376,900
10,052,300
11,727,700
55,946,100
67,135,300
78,324,500
63,313,400
75,976,100
88,638,800
71,627,400
85,952,800
100,278,300
29,688,500
35,626,300
41,564,000
41,338,200
49,605,900
57,873,500
68,263,600
81,916,300
95,569,000
9,015,600
10,818,700
12,621,900
18,243,200
21,891,800
25,540,400
19,545,500
23,454,600
27,363,700
15,416,800
18,500,200
21,583,600
19,417,900
23,301,500
27,185,100
29,984,400
35,981,300
41,978,200
7,523,800
9,028,500
10,533,300
13,629,200
16,355,100
19,080,900
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
39,340,200
47,208,300
55,076,300
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,852,300
5,714,000
8,644,400
2,828,800
3,821,700
5,281,100
4,660,500
5,305,400
7,407,700
4,248,200
5,913,300
11,032,300
4,543,200
7,621,700
9,017,200
4,462,800
5,331,800
7,173,400
3,422,700
6,856,800
10,373,300
3,394,500
4,586,100
6,337,300
5,592,700
6,366,400
8,889,300
5,097,800
7,096,000
13,238,700
5,451,800
9,146,100
10,820,700
5,355,400
6,398,200
8,608,100
3,993,200
7,999,600
12,102,200
3,960,300
5,350,400
7,393,500
6,524,800
7,427,500
10,370,800
5,947,400
8,278,600
15,445,200
6,360,400
10,670,400
12,624,100
6,247,900
7,464,500
10,042,800
3,718,500
4,462,200
5,205,800
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 830 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,225,400
6,270,500
7,315,600
360 J-4-16-III
6,606,700
7,928,100
9,249,400
361 J-4-17-I
362 J-4-17-II

3,796,200
4,546,100
4,555,500
5,455,300
5,314,700
6,364,600
363 J-4-17-III
364 J-4-18-I

5,965,900
2,290,700
7,159,000
2,748,900
8,352,200
3,207,000
365 J-4-18-II
3,056,200
3,667,400
4,278,600
366 J-4-18-III
367 J-4-19-I

3,217,000
5,347,100
3,860,400
6,416,500
4,503,800
7,486,000
368 J-4-19-II
369 J-4-19-III

6,064,000
6,696,900
7,276,800
8,036,300
8,489,600
9,375,700
370 J-4-20-I
4,775,700
5,730,800
6,685,900
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,617,200
7,997,300
7,940,600
9,596,800
9,264,100
11,196,200
2,880,000
3,456,000
4,032,000
4,639,700
5,567,600
6,495,500
6,474,300
7,769,100
9,064,000
8,173,200
9,807,900
11,442,500
10,589,100
12,706,900
14,824,700
12,410,700
14,892,900
17,375,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,511,400
10,213,700
11,916,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
11,174,400
19,924,100
13,409,300
23,908,900
15,644,200
27,893,700
3,535,400
4,242,500
4,949,600
4,598,200
5,517,900
6,437,500
9,109,800
10,931,800
12,753,700
3,987,300
4,386,000
4,425,900
4,784,700
5,263,200
5,311,000
5,582,200
6,140,400
6,196,200
5,648,800
6,778,600
7,908,400
6,620,300
7,944,400
9,268,400
390 K-1-14-III
11,914,500
14,297,400
16,680,400
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,529,100
17,500,400
25,552,500
15,035,000
21,000,500
30,662,900
17,540,800
24,500,600
35,773,400
7,409,600
8,891,600
10,373,500
12,764,600
15,317,500
17,870,400
18,107,500
21,729,000
25,350,500
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
8,019,400
9,623,300
11,227,200
398 K-1-40-II

(SEDANG)
9,115,200
10,938,200
12,761,200
399 K-1-40-III
15,446,900
18,536,300
21,625,700
400
401
402
403
404

6,127,600
8,203,600
11,245,400
5,058,700
7,268,600
7,353,200
9,844,300
13,494,500
6,070,400
8,722,300
8,578,700
11,485,100
15,743,600
7,082,200
10,176,000
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 831 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,423,300
13,708,000
15,992,600
406 K-4-11-I
407 K-4-11-II

2,387,200
3,392,400
2,864,600
4,070,900
3,342,100
4,749,400
408 K-4-11-III
409 K-4-12-I

4,070,900
3,040,900
4,885,100
3,649,100
5,699,300
4,257,300
410 K-4-12-II
4,218,700
5,062,400
5,906,200
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
6,979,100
8,374,900
9,770,800
4,099,400
4,919,200
5,739,100
5,302,800
6,363,300
7,423,900
8,168,000
9,801,600
11,435,200
2,679,400
3,215,300
3,751,200
3,596,600
4,315,900
5,035,300
5,771,200
6,925,400
8,079,600
418 K-4-15-I
2,723,700
3,268,400
3,813,100
419 K-4-15-II
4,198,300
5,038,000
5,877,700
420 K-4-15-III
5,892,200
7,070,700
8,249,100
421 K-4-16-I
3,794,500
4,553,400
5,312,300
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,550,600
5,309,900
5,460,800
6,371,900
6,370,900
7,433,900
1,768,000
2,121,600
2,475,200
2,177,300
2,612,700
3,048,200
2,612,700
3,135,200
3,657,800
1,495,100
1,794,100
2,093,200
2,522,900
3,027,500
3,532,100
429 K-4-18-III
3,027,500
3,633,000
4,238,600
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
19,976,200
30,153,500
40,290,000
9,142,200
16,172,600
20,078,500
23,971,400
36,184,200
48,348,000
10,970,600
19,407,100
24,094,300
27,966,700
42,214,900
56,406,000
12,799,100
22,641,700
28,110,000
5,123,500
6,148,200
7,172,900
10,276,600
12,331,900
14,387,200
17,297,800
20,757,300
24,216,900
6,726,100
10,825,000
15,484,100
1,813,700
2,105,200
2,443,500
3,684,100
5,063,500
11,861,800
1,803,700
2,385,700
7,888,500
8,071,300
12,990,000
18,580,900
2,176,400
2,526,200
2,932,200
4,421,000
6,076,200
14,234,100
2,164,500
2,862,800
9,466,200
9,416,600
15,155,000
21,677,700
2,539,100
2,947,200
3,420,900
5,157,800
7,089,000
16,606,500
2,525,200
3,340,000
11,043,900
2,453,200
2,943,900
3,434,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 832 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,883,200
3,459,900
4,036,500
4,242,700
5,091,200
5,939,800
3,029,800
3,635,700
4,241,700
4,550,800
5,461,000
6,371,100
6,414,900
7,697,900
8,980,900
10,709,900
12,851,900
14,993,900
15,222,600
18,267,200
21,311,700
21,383,200
25,659,900
29,936,500
9,785,900
11,743,100
13,700,300
16,053,400
26,456,100
19,264,100
31,747,400
22,474,800
37,038,600
23,957,600
28,749,100
33,540,600
28,021,900
33,626,200
39,230,600
34,681,700
41,618,100
48,554,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
11,901,900
14,282,300
16,662,700
467 M-1-04-II
15,290,500
18,348,600
21,406,700
468 M-1-04-III
18,861,300
22,633,600
26,405,800
469 M-1-05-I
470 M-1-05-II

7,790,100
12,222,800
9,348,200
14,667,400
10,906,200
17,111,900
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
16,096,000
19,315,200
22,534,300
8,458,600
10,150,300
11,842,000
11,331,500
13,597,900
15,864,200
23,083,400
27,700,100
32,316,800
19,537,000
23,444,400
27,351,800
46,712,200
56,054,600
65,397,100
100,753,800
120,904,600
141,055,400
12,718,100
15,261,700
17,805,300
16,751,200
20,101,400
23,451,600
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
41,766,200
50,119,400
58,472,600
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
8,994,800
14,575,200
20,841,200
10,793,700
17,490,200
25,009,500
12,592,700
20,405,300
29,177,700
4,441,300
5,329,600
6,217,800
7,876,500
9,451,800
11,027,100
11,246,100
13,495,300
15,744,500
5,486,800
9,105,400
14,955,000
6,584,200
10,926,400
17,945,900
7,681,600
12,747,500
20,936,900
8,219,800
9,863,700
11,507,700
10,334,100
12,401,000
14,467,800
16,093,800
19,312,500
22,531,300
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 833 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
15,699,600
18,839,500
21,979,400
17,269,500
20,723,500
24,177,400
19,771,300
23,725,600
27,679,900
8,924,600
10,709,500
12,494,400
10,598,700
23,855,500
12,718,500
28,626,600
14,838,200
33,397,700
3,049,500
3,659,400
4,269,300
4,547,800
8,604,400
5,457,300
10,325,300
6,366,900
12,046,200
3,799,900
4,559,900
5,319,900
8,331,200
9,997,400
11,663,700
12,418,000
14,901,600
17,385,200
3,033,200
3,639,800
4,246,500
5,045,000
6,054,100
7,063,100
6,957,000
8,348,400
9,739,800
5,050,600
6,060,700
7,070,800
7,588,300
9,105,900
10,623,600
14,804,600
17,765,500
20,726,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,760,000
6,912,000
8,064,000
512 M-4-14-II
7,104,100
8,524,900
9,945,800
513 M-4-14-III
514 M-4-15-I
10,675,400
3,521,200
12,810,500
4,225,400
14,945,600
4,929,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,552,700
10,331,300
2,924,200
4,827,600
8,110,000
5,463,200
12,397,600
3,509,100
5,793,100
9,732,000
6,373,700
14,463,800
4,093,900
6,758,600
11,354,100
3,795,200
4,554,300
5,313,300
5,308,100
6,369,700
7,431,300
7,412,400
8,894,800
10,377,300
2,868,600
4,323,100
5,205,200
3,442,300
5,187,700
6,246,200
4,016,000
6,052,400
7,287,300
3,084,000
3,700,800
4,317,600
5,038,800
6,046,600
7,054,400
9,841,200
11,809,400
13,777,600
3,017,600
3,621,100
4,224,600
4,418,800
5,302,500
6,186,300
4,938,500
5,926,200
6,913,900
3,038,500
3,646,200
4,253,900
3,800,300
4,560,300
5,320,400
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 834 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,520,100
10,224,200
11,928,200
535 N-1-01-I

180,321,200
216,385,400
252,449,700
536 N-1-01-II
180,321,200
216,385,400
252,449,700
537 N-1-01-III
538 N-1-11-I

180,321,200
8,764,400
216,385,400
10,517,300
252,449,700
12,270,200
539 N-1-11-II
540 N-1-11-III

13,858,700
21,605,700
16,630,500
25,926,900
19,402,200
30,248,000
4,467,000
5,360,300
6,253,700
9,168,300
11,001,900
12,835,600
19,895,500
23,874,600
27,853,600
10,068,500
12,082,200
14,095,900

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
14,090,300
19,126,200
16,908,400
22,951,400
19,726,400
26,776,600
8,938,000
10,725,600
12,513,200
13,521,500
16,225,700
18,930,000
15,561,900
18,674,300
21,786,700
8,275,200
9,930,300
11,585,300
11,237,600
13,485,100
15,732,600
13,079,100
15,694,900
18,310,700
3,410,300
4,092,400
4,774,500
4,252,400
5,102,900
5,953,400
6,254,700
7,505,700
8,756,600
2,699,000
4,574,000
5,691,000
2,462,400
4,328,500
5,210,100
3,517,100
4,242,100
6,701,800
3,238,800
5,488,800
6,829,200
2,954,900
5,194,200
6,252,100
4,220,600
5,090,500
8,042,100
3,778,500
6,403,500
7,967,300
3,447,400
6,059,900
7,294,100
4,924,000
5,938,900
9,382,500
2,629,300
3,155,200
3,681,000
3,730,900
4,477,100
5,223,200
5,980,600
7,176,700
8,372,800
3,106,200
3,727,400
4,348,700
3,973,500
4,768,100
5,562,800
4,534,400
5,441,300
6,348,100
3,803,500
4,564,200
5,325,000
5,428,900
6,514,600
7,600,400
7,449,700
8,939,600
10,429,600
5,132,000
5,562,600
6,158,400
6,675,200
7,184,800
7,787,700
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 835 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,316,600
11,179,900
13,043,300
3,535,600
4,242,700
4,949,800
3,929,400
4,715,300
5,501,100
5,039,400
6,047,300
7,055,100
2,582,400
3,098,800
3,615,300
3,101,400
3,721,700
4,342,000
3,897,000
4,676,500
5,455,900
1,723,700
2,068,500
2,413,200

MAYOR (RINGAN)
MAYOR (SEDANG)
2,040,200
2,448,200
2,448,200
2,937,900
2,856,300
3,427,500
55,934,800
67,121,800
78,308,800
69,211,000
83,053,200
96,895,300
81,234,200
97,481,100
113,727,900
87,395,300
104,874,300
122,353,400
100,251,400
120,301,600
140,351,900
114,544,400
137,453,300
160,362,100
12,643,900
15,172,600
17,701,400
17,853,500
21,424,200
24,994,900
24,989,500
29,987,500
34,985,400
36,468,400
43,762,100
51,055,700
47,143,900
56,572,600
66,001,400
67,592,500
81,111,000
94,629,500
19,802,500
23,763,000
27,723,400
30,958,100
37,149,800
43,341,400
41,200,500
49,440,500
57,680,600
5,417,700
6,501,200
7,584,700
15,189,900
18,227,900
21,265,900
20,122,900
24,147,500
28,172,100
5,247,600
6,297,100
7,346,600
14,713,000
17,655,600
20,598,200
19,491,100
23,389,300
27,287,500
4,344,900
5,213,900
6,082,900
6,165,200
7,398,200
8,631,300
9,982,800
11,979,400
13,976,000
10,536,600
12,643,900
14,751,200
14,877,900
17,853,500
20,829,100
- 836 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
20,824,600
24,989,500
29,154,500
9,954,200
11,945,100
13,935,900
11,444,600
13,733,500
16,022,400
16,018,900
19,222,700
22,426,500
5,643,300
6,771,900
7,900,600
8,803,500
10,564,200
12,324,900
13,676,500
16,411,900
19,147,200
3,761,200
4,513,400
5,265,600
7,656,200
9,187,500
10,718,700
13,779,000
16,534,800
19,290,600
2,820,900
3,385,100
3,949,300
5,649,000
6,778,800
7,908,600
6,628,100
7,953,700
9,279,300
2,553,000
3,063,600
3,574,200
4,905,900
5,887,100
6,868,300
12,005,400
14,406,500
16,807,600
3,762,200
4,514,600
5,267,100
6,771,900
8,126,300
9,480,700
9,529,300
11,435,200
13,341,000
2,792,100
3,350,500
3,908,900
3,440,300
4,128,300
4,816,400
4,709,400
5,651,200
6,593,100
1,689,600
2,477,600
4,234,600
2,052,700
2,732,100
4,736,200
2,027,500
2,973,100
5,081,500
2,463,300
3,278,600
5,683,400
2,365,400
3,468,700
5,928,400
2,873,800
3,825,000
6,630,700
3,031,400
3,637,600
4,243,900
5,377,900
6,453,400
7,529,000
8,728,900
10,474,700
12,220,500
1,534,100
1,840,900
2,147,700
3,258,500
3,910,200
4,561,900
6,179,300
7,415,100
8,651,000
1,026,000
1,231,200
1,436,400
1,936,200
2,323,500
2,710,700
2,507,800
3,009,300
3,510,900
5,312,800
6,375,400
7,438,000
- 837 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
6,965,700
8,358,800
9,751,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
9,973,400
11,968,100
13,962,800
2,560,700
3,072,800
3,585,000
3,800,400
4,560,400
5,320,500
4,570,800
5,484,900
6,399,100
1,766,300
2,119,600
2,472,800
2,372,400
2,846,800
3,321,300
4,315,700
5,178,800
6,042,000
766,200
919,400
1,072,600
1,460,200
1,752,200
2,044,300
2,122,700
2,547,300
2,971,800
1,045,700
1,254,800
1,464,000
1,645,600
1,974,700
2,303,800
2,650,500
3,180,600
3,710,700
1,722,700
2,067,300
2,411,800
2,566,900
3,080,300
3,593,700
3,938,300
4,726,000
5,513,600
5,598,900
6,718,700
7,838,500

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,691,700
22,957,100
10,430,000
27,548,500
12,168,400
32,139,900
8,661,800
10,394,100
12,126,500
10,980,100
13,176,100
15,372,100
16,287,200
19,544,600
22,802,000
6,768,200
10,378,700
15,244,100
6,772,900
7,891,400
13,081,500
8,121,800
12,454,400
18,292,900
8,127,400
9,469,700
15,697,800
9,475,500
14,530,100
21,341,700
9,482,000
11,048,000
18,314,200
4,195,900
5,035,000
5,874,200
5,149,400
6,179,200
7,209,100
6,102,000
7,322,400
8,542,800
4,014,300
5,707,200
7,356,300
4,817,200
6,848,600
8,827,600
5,620,000
7,990,100
10,298,900
6,370,000
7,644,000
8,918,000
9,480,300
11,376,400
13,272,500
23,607,700
28,329,200
33,050,700
5,463,000
7,407,600
14,051,200
6,555,600
8,889,100
16,861,400
7,648,200
10,370,600
19,671,700
3,931,400
4,717,700
5,503,900
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 838 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,389,400
2,867,300
3,345,200
697 U-4-12-I
698 U-4-12-II

2,608,200
3,033,900
3,129,900
3,640,700
3,651,500
4,247,500
699 U-4-12-III

4,057,600
4,869,100
5,680,600
2,037,800
2,445,400
2,852,900
2,402,400
2,882,900
3,363,400
2,873,400
3,448,000
4,022,700
3,795,700
4,545,200
4,554,800
5,454,200
5,313,900
6,363,300

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,632,800
9,159,300
10,685,900
3,047,800
3,657,400
4,266,900
3,797,200
4,556,600
5,316,000
5,314,200
6,377,000
7,439,900
5,125,000
6,150,000
7,174,900
10,240,500
12,288,600
14,336,700
12,558,600
15,070,300
17,582,000
9,457,500
10,799,300
16,912,200
11,349,000
12,959,200
20,294,700
13,240,500
15,119,100
23,677,100
8,891,900
10,670,200
12,448,600
12,518,100
15,021,700
17,525,400
15,390,800
18,469,000
21,547,200
4,781,600
5,737,900
6,694,200
9,136,000
10,963,200
12,790,400
13,903,300
16,683,900
19,464,600
9,095,300
10,914,400
12,733,400
13,215,200
15,858,300
18,501,300
16,501,600
19,801,900
23,102,300
1,510,100
1,666,400
1,843,400
1,812,100
1,999,700
2,212,000
2,114,200
2,333,000
2,580,700
4,534,400
5,441,200
6,348,100
7,531,800
9,038,200
10,544,600
12,417,300
14,900,800
17,384,300
3,800,400
4,560,500
5,320,600
5,099,200
6,119,000
7,138,900
7,041,700
8,450,000
9,858,400
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,730,100
10,476,100
12,222,200
13,403,400
16,084,100
18,764,800
1,561,700
2,271,300
1,874,100
2,725,600
2,186,400
3,179,800
- 839 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,679,000
12,814,800
14,950,600
12,415,500
14,898,600
17,381,700
18,264,600
21,917,500
25,570,400
2,265,200
2,718,200
3,171,200
2,499,600
2,765,100
2,999,500
3,318,100
3,499,400
3,871,100
2,367,600
2,841,100
3,314,600
2,612,600
3,135,200
3,657,700
2,890,100
3,468,100
4,046,100
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,547,100
3,056,500
3,565,900
743 W-1-12-II
744 W-1-12-III

3,179,200
5,460,700
3,815,000
6,552,900
4,450,800
7,645,000
745 W-1-13-I
2,539,600
3,047,500
3,555,500
746 W-1-13-II
747 W-1-13-III

2,757,200
3,703,600
3,308,600
4,444,300
3,860,000
5,185,000
748 W-1-20-I
749 W-1-20-II

8,504,900
10,627,000
10,205,900
12,752,400
11,906,900
14,877,800
750 W-1-20-III
12,319,400
14,783,300
17,247,200
751 W-1-30-I
4,801,200
5,761,400
6,721,600
752 W-1-30-II
7,657,800
9,189,400
10,721,000
753 W-1-30-III
18,788,900
22,546,700
26,304,500
754 W-4-10-I
3,577,400
4,292,800
5,008,300
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,303,300
10,480,300
3,253,300
4,939,100
6,011,800
6,363,900
12,576,400
3,904,000
5,926,900
7,214,100
7,424,600
14,672,500
4,554,700
6,914,700
8,416,500
2,891,200
3,469,400
4,047,700
3,969,400
4,763,300
5,557,100
4,326,900
5,192,200
6,057,600
1,280,000
1,748,500
2,174,400
1,710,600
2,099,000
2,604,900
1,626,800
1,806,700
2,501,400
2,231,400
2,984,000
4,044,300
1,597,100
2,883,700
4,263,500
2,946,800
3,911,500
5,556,600
2,684,700
3,224,500
4,432,200
1,536,000
2,098,200
2,609,300
2,052,700
2,518,800
3,125,800
1,952,200
2,168,000
3,001,700
2,677,700
3,580,800
4,853,100
1,916,600
3,460,400
5,116,200
3,536,200
4,693,800
6,668,000
3,221,600
3,869,400
5,318,700
1,792,000
2,447,900
3,044,200
2,394,800
2,938,600
3,646,800
2,277,500
2,529,400
3,502,000
3,124,000
4,177,600
5,662,000
2,236,000
4,037,200
5,968,900
4,125,500
5,476,100
7,779,300
3,758,600
4,514,300
6,205,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 840 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,931,300
2,317,600
2,703,800
4,052,700
4,863,200
5,673,800
6,238,500
7,486,200
8,733,900
- 841 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
970,300
1,258,600
2,340,500
1,934,200
2,513,600
462,400
1,130,000
361,500
970,400
721,000
818,600
1,230,700
1,678,700
1,538,500
498,400
1,150,400
417,300
716,400
2,182,200
781,500
1,845,600
450,300
1,372,200
1,562,000
1,310,000
321,300
1,025,000
541,400
382,700
301,000
265,700
317,700
442,400
380,100
357,800
321,500
477,100
208,300
245,500
281,500
5,712,700
2,283,100
2,290,700
589,300
1,326,700
830,700
1,688,400
786,800
450,600
340,200
548,800
364,400
273,000
2,782,400
1,298,500
742,000
2,896,400
1,931,000
273,500
3,137,800
2,172,300
4,006,800
1,128,500
694,200
271,500
226,200
255,000
3,888,400
1,892,800
- 842 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,405,600
4,257,300
3,715,600
2,689,000
886,500
2,992,900
1,954,200
480,400
4,493,400
4,067,800
2,727,500
2,584,000
336,200
306,900
1,234,800
355,200
300,700
332,300
1,568,300
1,557,900
1,360,800
1,652,400
1,000,800
302,400
533,100
365,900
330,400
321,900
408,700
466,100
273,200
784,200
1,429,200
1,097,100
2,579,200
335,900
335,900
3,277,100
1,385,800
265,800
1,229,900
3,363,000
733,500
577,800
283,000
268,300
421,500
587,800
1,407,600
1,240,700
868,500
471,200
273,000
1,508,000
878,800
516,300
428,400
1,404,100
310,400
1,972,400
1,509,000
334,700
371,000
362,400
219,300
1,644,200
1,642,900
325,600
- 843 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
997,900
372,500
402,700
372,900
591,600
455,100
1,139,700
336,300
935,600
1,719,000
273,800
1,666,500
903,100
1,951,600
985,200
435,100
334,700
77,400
433,800
980,200
382,000
515,900
295,000
119,800
298,000
4,437,200
2,522,200
4,209,500
1,421,900
577,800
393,700
890,400
470,900
947,800
548,800
326,700
546,800
338,500
516,600
360,100
931,900
1,808,200
1,454,800
1,282,700
905,300
316,400
316,400
316,400
258,400
163,900
257,700
315,000
340,800
251,000
221,400
108,500
119,300
88,300
103,600
98,800
150,800
135,300
175,900
193,200
114,000
145,700
99,600
155,400
220,600
- 844 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
157,000
197,500
558,200
647,100
148,500
268,600
180,700
257,900
451,800
386,800
278,100
263,300
147,600
137,800
310,000
195,700
280,700
194,300
152,100
2,681,500
2,006,000
318,700
330,100
631,300
827,200
808,100
417,400
1,300,900
308,800
339,300
340,400
272,500
344,200
325,800
152,600
335,300
297,200
268,800
304,000
2,516,900
449,300
905,800
324,900
635,500
506,200
425,100
786,600
805,500
858,900
751,300
1,438,000
223,800
2,136,800
295,000
1,083,100
2,461,600
2,070,000
904,300
327,700
639,200
636,700
295,000
2,312,800
1,819,100
163,000
176,600
229,500
407,300
- 845 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,186,700
639,400
1,009,000
1,156,400
583,300
770,900
560,900
598,100
749,500
334,300
750,700
210,800
741,800
1,277,500
85,600
- 846 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,686,800
3,224,100
3,761,500
A-4-10-II
SEPTIKEMIA (SEDANG)
4,590,100
5,508,100
6,426,200
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
6,188,900
3,491,300
7,426,700
4,189,600
8,664,500
4,887,900
5
6
A-4-11-II
A-4-11-III

4,969,200
6,877,800
5,963,000
8,253,400
6,956,900
9,628,900
A-4-12-I
2,797,600
3,357,200
3,916,700
8
9
A-4-12-II
A-4-12-III

3,484,000
3,833,400
4,180,800
4,600,100
4,877,600
5,366,800
10 A-4-13-I
11 A-4-13-II

2,215,400
2,827,500
2,658,400
3,393,000
3,101,500
3,958,500
12 A-4-13-III
3,393,000
4,071,600
4,750,200
2,404,800
2,885,800
3,366,800
2,919,200
3,503,000
4,086,900
3,503,000
4,203,600
4,904,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
15,335,800
19,098,100
18,402,900
22,917,800
21,470,100
26,737,400
18 A-4-15-III
INFEKSI HIV (BERAT)
21,575,500
25,890,600
30,205,700
19 B-1-01-I
20 B-1-01-II

41,945,200
46,276,600
50,334,300
55,531,900
58,723,300
64,787,200
21 B-1-01-III
22 B-1-10-I

102,006,100
6,780,200
122,407,300
8,136,300
142,808,500
9,492,300
23 B-1-10-II
15,049,100
18,058,900
21,068,700
24 B-1-10-III
25 B-1-11-I

29,708,900
7,412,400
35,650,700
8,894,900
41,592,500
10,377,400
26 B-1-11-II
27 B-1-11-III

9,903,000
12,794,600
11,883,700
15,353,500
13,864,300
17,912,400
28 B-1-12-I
7,461,700
8,954,000
10,446,300
29 B-1-12-II
8,298,700
9,958,400
11,618,200
30 B-1-12-III
12,982,400
15,578,900
18,175,400
5,943,300
7,132,000
8,320,600
9,779,000
11,734,800
13,690,600
12,653,100
15,183,800
17,714,400
8,166,300
9,799,600
11,432,900
9,082,400
10,898,900
12,715,400
14,208,400
2,450,900
3,912,300
5,397,100
17,050,100
2,941,000
4,694,700
6,476,600
19,891,800
3,431,200
5,477,200
7,556,000
5,167,400
6,200,800
7,234,300
7,234,400
8,681,200
10,128,100
8,764,300
10,517,200
12,270,100
4,671,900
6,858,300
10,203,600
4,456,600
5,606,200
8,230,000
12,244,400
5,347,900
6,540,600
9,601,600
14,285,100
6,239,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 847 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,191,700
6,230,100
7,268,400
48 B-4-13-III
49 B-4-14-I

7,152,000
4,451,800
8,582,400
5,342,200
10,012,900
6,232,500
50 B-4-14-II
5,193,600
6,232,300
7,271,000
51 B-4-14-III
52 C-4-10-I

6,957,000
4,246,100
8,348,400
5,095,300
9,739,700
5,944,600
53 C-4-10-II
54 C-4-10-III

8,147,200
13,949,100
9,776,700
16,739,000
11,406,100
19,528,800
55 C-4-11-I
4,693,500
5,632,200
6,570,900
56 C-4-11-II
57 C-4-11-III

6,280,500
9,955,100
7,536,600
11,946,100
8,792,800
13,937,100
58 C-4-12-I
59 C-4-12-II
3,125,100
6,345,500
3,750,100
7,614,600
4,375,100
8,883,700
60 C-4-12-III
RADIOTERAPI (BERAT)
16,297,100
19,556,500
22,815,900
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
2,349,400
4,421,600
2,819,300
5,305,900
3,289,200
6,190,300
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
5,985,400
3,903,600
7,182,400
4,684,400
8,379,500
5,465,100
65 C-4-14-II
5,476,000
6,571,200
7,666,400
66 C-4-14-III
67 D-1-10-I

8,411,500
23,348,900
10,093,800
28,018,600
11,776,100
32,688,400
68 D-1-10-II
69 D-1-10-III

35,562,000
56,626,800
42,674,400
67,952,200
49,786,800
79,277,600
70 D-1-11-I
6,314,600
7,577,500
8,840,400
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
16,124,100
21,601,900
19,348,900
25,922,300
22,573,700
30,242,700
5,474,000
6,568,800
7,663,600
15,085,600
18,102,700
21,119,800
23,930,100
28,716,200
33,502,200
2,698,500
4,428,600
6,967,200
4,285,400
7,700,700
10,906,100
3,694,600
5,124,500
7,868,900
3,238,200
5,314,300
8,360,700
5,142,500
9,240,800
13,087,300
4,433,500
6,149,400
9,442,700
3,778,000
6,200,000
9,754,100
5,999,600
10,781,000
15,268,500
5,172,500
7,174,300
11,016,500
3,166,200
3,799,400
4,432,700
4,481,200
5,377,500
6,273,700
5,731,600
6,878,000
8,024,300
3,395,900
4,075,100
4,754,200
5,559,900
6,671,900
7,783,900
6,800,300
8,160,400
9,520,500
7,446,200
8,935,500
10,424,700
10,165,200
12,198,200
14,231,300
93 E-1-01-III
24,509,300
29,411,200
34,313,100
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
7,741,700
10,746,300
20,303,400
9,290,000
12,895,600
24,364,000
10,838,300
15,044,900
28,424,700
7,967,400
9,560,900
11,154,400
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 848 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
3,132,100
3,758,600
4,385,000
104 E-4-11-II
105 E-4-11-III

4,775,200
6,670,900
5,730,300
8,005,100
6,685,300
9,339,300
106 E-4-12-I
107 E-4-12-II

3,598,800
6,232,200
4,318,500
7,478,700
5,038,300
8,725,100
108 E-4-12-III

(RINGAN)
(SEDANG)
7,387,500
8,865,000
10,342,500
3,918,900
4,702,700
5,486,500
5,740,600
6,888,700
8,036,800
111 E-4-13-III
7,736,100
9,283,400
10,830,600
112 F-4-10-I
113 F-4-10-II
4,301,200
4,943,400
5,161,500
5,932,100
6,021,700
6,920,800
114 F-4-10-III
115 F-4-11-I
5,932,100
4,160,000
7,118,500
4,992,000
8,304,900
5,824,000
116 F-4-11-II
4,846,800
5,816,200
6,785,600
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
6,215,400
7,458,500
8,701,600
2,211,900
2,654,300
3,096,700
3,144,700
3,773,600
4,402,600
6,831,700
8,198,000
9,564,300
3,351,000
4,421,700
5,724,400
1,911,900
2,452,300
3,299,700
4,021,200
5,306,000
6,869,300
2,294,300
2,942,700
3,959,700
4,691,400
6,190,400
8,014,200
2,676,600
3,433,200
4,619,600
127 F-4-15-I
2,953,500
3,544,200
4,134,900
128 F-4-15-II
4,401,100
5,281,300
6,161,500
129 F-4-15-III
5,810,800
6,972,900
8,135,100
5,990,800
7,189,000
8,387,200
6,965,300
8,358,400
9,751,500
9,297,500
11,157,000
13,016,500
133 F-4-17-I

1,372,400
1,646,800
1,921,300
134 F-4-17-II
4,022,200
4,826,600
5,631,100
135
136
137
138
139
140
141

(RINGAN)
4,291,300
5,205,600
5,727,600
8,829,600
3,978,300
5,094,400
6,342,500
5,149,600
6,246,700
6,873,200
10,595,500
4,773,900
6,113,300
7,610,900
6,007,800
7,287,800
8,018,700
12,361,400
5,569,600
7,132,100
8,879,400
18,007,000
21,608,400
25,209,800
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
10,723,900
12,868,700
15,013,500
15,236,900
18,284,300
21,331,600
3,712,900
4,455,500
5,198,100
5,188,100
6,225,700
7,263,300
6,638,600
7,966,400
9,294,100
- 849 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
23,917,500
28,701,000
33,484,500
148 G-1-11-I
149 G-1-11-II

12,528,000
22,904,100
15,033,600
27,484,900
17,539,200
32,065,700
150 G-1-11-III
37,999,600
45,599,500
53,199,400
5,230,900
6,277,000
7,323,200
10,108,800
12,130,500
14,152,300
13,776,300
16,531,500
19,286,800
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,578,000
4,237,700
1,893,600
5,085,300
2,209,200
5,932,800
156 G-1-13-III
157 G-1-20-I

9,562,200
9,337,800
11,474,600
11,205,400
13,387,100
13,072,900
158 G-1-20-II
15,201,300
18,241,500
21,281,800
159 G-1-20-III
23,328,800
27,994,600
32,660,300
160 G-1-30-I
11,881,300
14,257,600
16,633,800
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
24,808,500
33,797,700
29,770,200
40,557,200
34,731,900
47,316,700
4,490,100
5,388,200
6,286,200
5,488,500
6,586,200
7,683,900
7,764,000
9,316,800
10,869,600
4,845,800
5,815,000
6,784,200
6,437,100
7,724,500
9,011,900
9,458,300
11,349,900
13,241,600
5,375,900
6,451,100
7,526,300
6,586,400
7,903,700
9,221,000
9,566,000
11,479,200
13,392,400
3,132,500
3,759,000
4,385,500
5,462,500
6,555,000
7,647,400
6,478,600
7,774,300
9,070,000
5,313,900
6,376,700
7,439,500
7,324,000
8,788,800
10,253,700
9,192,500
11,031,000
12,869,500
4,341,900
5,210,300
6,078,700
5,181,900
6,218,300
7,254,600
7,313,800
8,776,500
10,239,300
3,579,300
4,295,200
5,011,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
25,826,400
30,991,700
36,157,000
39,204,900
47,045,900
54,886,900
18,437,200
21,707,900
22,124,600
26,049,500
25,812,100
30,391,000
- 850 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
4,752,100
5,702,500
6,652,900
183 G-4-16-III
6,767,300
8,120,800
9,474,200
4,767,400
5,720,900
6,674,400
6,251,200
7,501,400
8,751,600
8,097,800
9,717,400
11,336,900
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
4,695,200
5,634,200
6,573,300
188 G-4-18-II
6,276,000
7,531,300
8,786,500
189 G-4-18-III
7,022,400
8,426,900
9,831,400
3,917,300
4,700,800
5,484,200
6,621,200
7,945,400
9,269,700
8,693,300
10,432,000
12,170,600
193 G-4-20-I

2,740,300
3,288,400
3,836,500
194 G-4-20-II
3,874,000
4,648,800
5,423,600
195 G-4-20-III
196 G-4-21-I

6,398,900
2,853,600
7,678,700
3,424,400
8,958,500
3,995,100
197 G-4-21-II
198 G-4-21-III

4,829,800
5,851,700
5,795,800
7,022,100
6,761,800
8,192,400
199 G-4-22-I
2,815,200
3,378,300
3,941,300
200 G-4-22-II
201 G-4-22-III

3,597,000
4,202,900
4,316,400
5,043,500
5,035,800
5,884,100
202 G-4-23-I
203 G-4-23-II

2,809,100
3,524,500
3,371,000
4,229,400
3,932,800
4,934,300
204 G-4-23-III
5,018,000
6,021,600
7,025,200
205 G-4-24-I
206 G-4-24-II

3,225,700
4,030,100
3,870,900
4,836,100
4,516,000
5,642,100
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
6,714,000
2,673,600
3,381,100
4,480,600
8,056,800
3,208,400
4,057,300
5,376,800
9,399,600
3,743,100
4,733,500
6,272,900
3,802,500
4,563,100
5,323,600
4,560,400
5,472,400
6,384,500
6,614,500
7,937,500
9,260,400
10,793,100
11,928,200
16,221,400
7,901,600
9,816,900
13,750,100
3,619,600
4,911,100
9,652,900
3,123,800
3,563,300
5,102,400
3,682,900
4,536,500
7,602,400
12,951,800
14,313,800
19,465,700
9,481,900
11,780,300
16,500,100
4,343,500
5,893,300
11,583,500
3,748,500
4,275,900
6,122,800
4,419,500
5,443,800
9,122,900
15,110,400
16,699,400
22,710,000
11,062,200
13,743,700
19,250,100
5,067,400
6,875,500
13,514,100
4,373,300
4,988,600
7,143,300
5,156,100
6,351,100
10,643,400
229 I-1-01-I
49,468,500
59,362,100
69,255,800
230 I-1-01-II
50,556,700
60,668,100
70,779,400
231 I-1-01-III

(RINGAN)
79,803,100
95,763,800
111,724,400
27,444,900
32,933,900
38,422,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 851 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
23,296,600
27,955,900
32,615,200
245 I-1-06-II
33,747,000
40,496,400
47,245,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
40,266,400
48,319,700
56,373,000
51,478,800
61,774,500
72,070,300
64,348,500
77,218,200
90,087,900
96,522,700
115,827,300
135,131,800
4,433,700
5,320,500
6,207,200
4,929,800
5,915,800
6,901,800
6,560,100
7,872,200
9,184,200
12,762,400
15,314,800
17,867,300
20,218,200
24,261,800
28,305,500
26,600,100
31,920,100
37,240,100
12,379,300
14,855,200
17,331,000
16,485,600
19,782,700
23,079,800
20,331,300
24,397,500
28,463,800
25,337,400
30,404,900
35,472,400
31,490,600
37,788,800
44,086,900
41,263,600
49,516,300
57,769,100
4,813,400
6,721,800
12,943,500
5,776,000
8,066,100
15,532,200
6,738,700
9,410,500
18,120,900
12,103,700
14,524,400
16,945,200
28,232,700
33,879,300
39,525,800
32,566,000
39,079,200
45,592,400
14,448,400
17,338,000
20,227,700
18,090,700
21,708,800
25,327,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
35,403,600
42,484,300
49,565,000
43,637,100
52,364,500
61,092,000
15,852,200
19,022,700
22,193,100
21,974,500
26,369,400
30,764,300
28,749,800
34,499,800
40,249,700
24,627,300
29,552,700
34,478,200
38,868,500
46,642,200
54,415,900
62,092,200
74,510,600
86,929,100
57,913,600
69,496,400
81,079,100
70,783,300
84,940,000
99,096,700
96,522,700
115,827,300
135,131,800
- 852 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
27,263,800
32,716,600
38,169,400
279 I-1-40-III
36,415,200
43,698,300
50,981,300
280 I-4-10-I
281 I-4-10-II

4,285,600
7,652,400
5,142,700
9,182,900
5,999,800
10,713,400
282 I-4-10-III
11,026,000
13,231,300
15,436,500
283 I-4-11-I
284 I-4-11-II

6,395,600
7,914,500
7,674,700
9,497,400
8,953,800
11,080,300
285 I-4-11-III
286 I-4-12-I

14,641,000
3,790,200
17,569,300
4,548,200
20,497,500
5,306,300
287 I-4-12-II
4,393,400
5,272,100
6,150,700
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,272,100
6,326,500
7,380,900
3,857,000
4,628,400
5,399,800
6,887,200
8,264,600
9,642,000
9,923,400
11,908,100
13,892,800
3,533,000
3,767,600
6,406,500
4,239,600
4,521,200
7,687,800
4,946,200
5,274,700
8,969,100
4,751,300
5,701,500
6,651,800
6,463,800
7,756,600
9,049,300
297 I-4-15-III
7,756,600
9,307,900
10,859,200
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
2,298,800
3,691,300
4,429,600
2,021,100
2,352,900
2,823,500
2,758,600
4,429,600
5,315,500
2,425,300
2,823,500
3,388,200
3,218,400
5,167,900
6,201,500
2,829,500
3,294,100
3,952,900
4,301,100
5,161,400
6,021,600
6,751,200
8,101,500
9,451,700
8,890,900
10,669,100
12,447,300
307 I-4-19-I
4,149,800
4,979,700
5,809,700
308 I-4-19-II

(SEDANG)
6,478,000
7,773,600
9,069,200
309 I-4-19-III
7,733,500
9,280,200
10,826,900
310
311
312
313
314

4,454,800
5,145,300
7,462,400
3,333,500
4,223,500
5,345,700
6,174,300
8,954,900
4,000,200
5,068,200
6,236,700
7,203,400
10,447,400
4,666,900
5,913,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
22,377,900
26,853,500
31,329,100
16,285,800
19,542,900
22,800,100
20,345,400
24,414,500
28,483,600
21,387,200
25,664,700
29,942,100
12,319,300
14,783,100
17,247,000
25,626,800
30,752,200
35,877,600
39,712,400
47,654,800
55,597,300
11,369,400
13,643,200
15,917,100
- 853 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
6,096,200
7,315,500
8,534,700
316 I-4-22-I
317 I-4-22-II
3,362,600
4,186,000
4,035,200
5,023,200
4,707,700
5,860,400
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,118,600
7,342,300
8,566,000
3,547,000
4,256,400
4,965,800
4,354,700
5,225,700
6,096,600
8,508,900
10,210,700
11,912,400
2,963,600
3,556,300
4,149,000
6,824,400
8,189,300
9,554,100
8,628,200
10,353,900
12,079,500
57,624,500
69,149,300
80,674,200
65,212,800
78,255,400
91,297,900
73,776,200
88,531,400
103,286,600
30,579,200
36,695,000
42,810,900
42,578,400
51,094,100
59,609,700
70,311,500
84,373,800
98,436,100
9,286,100
11,143,300
13,000,500
18,790,500
22,548,500
26,306,600
20,131,900
24,158,200
28,184,600
15,879,300
19,055,200
22,231,100
20,000,500
24,000,600
28,000,700
30,883,900
37,060,700
43,237,500
7,749,500
9,299,400
10,849,300
14,038,100
16,845,700
19,653,300
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
40,520,500
48,624,500
56,728,600
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,937,800
5,885,400
8,903,800
2,913,700
3,936,400
5,439,500
4,800,400
5,464,500
7,630,000
4,375,600
6,090,700
11,363,300
4,679,500
7,850,400
9,287,800
4,596,700
5,491,800
7,388,600
3,525,400
7,062,500
10,684,500
3,496,400
4,723,700
6,527,400
5,760,400
6,557,400
9,156,000
5,250,700
7,308,800
13,635,900
5,615,400
9,420,400
11,145,300
5,516,000
6,590,100
8,866,400
4,113,000
8,239,600
12,465,300
4,079,100
5,511,000
7,615,300
6,720,500
7,650,300
10,682,000
6,125,800
8,527,000
15,908,600
6,551,300
10,990,500
13,002,900
6,435,400
7,688,500
10,344,100
3,830,000
4,596,000
5,362,000
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 854 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,382,200
6,458,600
7,535,000
360 J-4-16-III
6,804,900
8,165,900
9,526,900
361 J-4-17-I
362 J-4-17-II

3,910,100
4,682,500
4,692,200
5,619,000
5,474,200
6,555,500
363 J-4-17-III
364 J-4-18-I

6,144,800
2,359,500
7,373,800
2,831,300
8,602,800
3,303,200
365 J-4-18-II
3,147,900
3,777,400
4,407,000
366 J-4-18-III
367 J-4-19-I

3,313,500
5,507,500
3,976,200
6,609,000
4,638,900
7,710,500
368 J-4-19-II
369 J-4-19-III

6,245,900
6,897,800
7,495,100
8,277,400
8,744,200
9,656,900
370 J-4-20-I
4,918,900
5,902,700
6,886,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
6,815,700
8,237,200
8,178,800
9,884,700
9,542,000
11,532,100
2,966,400
3,559,700
4,153,000
4,778,800
5,734,600
6,690,400
6,668,500
8,002,200
9,335,900
8,418,400
10,102,100
11,785,800
10,906,700
13,088,100
15,269,400
12,783,100
15,339,700
17,896,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
8,766,700
10,520,100
12,273,400

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
11,509,700
20,521,800
13,811,600
24,626,200
16,113,500
28,730,500
3,641,500
4,369,800
5,098,100
4,736,200
5,683,400
6,630,600
9,383,100
11,259,700
13,136,300
4,106,900
4,517,600
4,558,600
4,928,200
5,421,100
5,470,400
5,749,600
6,324,600
6,382,100
5,818,300
6,982,000
8,145,600
6,818,900
8,182,700
9,546,500
390 K-1-14-III
12,272,000
14,726,400
17,180,800
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

12,905,000
18,025,400
26,319,000
15,486,000
21,630,500
31,582,800
18,067,000
25,235,600
36,846,600
7,631,900
9,158,300
10,684,700
13,147,500
15,777,000
18,406,500
18,650,700
22,380,800
26,111,000
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
8,260,000
9,912,000
11,564,000
398 K-1-40-II

(SEDANG)
9,388,600
11,266,300
13,144,100
399 K-1-40-III
15,910,300
19,092,400
22,274,400
400
401
402
403
404

6,311,500
8,449,700
11,582,800
5,210,400
7,486,600
7,573,800
10,139,700
13,899,300
6,252,500
8,984,000
8,836,100
11,829,600
16,215,900
7,294,600
10,481,300
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 855 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
11,766,000
14,119,200
16,472,400
406 K-4-11-I
407 K-4-11-II

2,458,800
3,494,200
2,950,600
4,193,000
3,442,300
4,891,900
408 K-4-11-III
409 K-4-12-I

4,193,000
3,132,100
5,031,600
3,758,600
5,870,200
4,385,000
410 K-4-12-II
4,345,300
5,214,300
6,083,400
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
7,188,500
8,626,200
10,063,900
4,222,300
5,066,800
5,911,300
5,461,900
6,554,200
7,646,600
8,413,000
10,095,600
11,778,200
2,759,800
3,311,700
3,863,700
3,704,500
4,445,400
5,186,300
5,944,300
7,133,200
8,322,000
418 K-4-15-I
2,805,400
3,366,500
3,927,500
419 K-4-15-II
4,324,300
5,189,200
6,054,000
420 K-4-15-III
6,069,000
7,282,800
8,496,600
421 K-4-16-I
3,908,300
4,690,000
5,471,600
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,687,200
5,469,200
5,624,600
6,563,000
6,562,000
7,656,900
1,821,000
2,185,200
2,549,400
2,242,600
2,691,100
3,139,600
2,691,100
3,229,300
3,767,500
1,540,000
1,848,000
2,155,900
2,598,600
3,118,400
3,638,100
429 K-4-18-III
3,118,400
3,742,000
4,365,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
20,575,500
31,058,100
41,498,700
9,416,500
16,657,800
20,680,900
24,690,600
37,269,700
49,798,500
11,299,800
19,989,300
24,817,100
28,805,700
43,481,300
58,098,200
13,183,100
23,320,900
28,953,300
5,277,200
6,332,600
7,388,100
10,584,900
12,701,900
14,818,800
17,816,700
21,380,100
24,943,400
6,927,900
11,149,700
15,948,600
1,868,100
2,168,300
2,516,800
3,794,700
5,215,400
12,217,600
1,857,900
2,457,300
8,125,200
8,313,500
13,379,700
19,138,300
2,241,700
2,602,000
3,020,200
4,553,600
6,258,500
14,661,100
2,229,400
2,948,700
9,750,200
9,699,100
15,609,600
22,328,000
2,615,300
3,035,700
3,523,600
5,312,500
7,301,600
17,104,700
2,601,000
3,440,200
11,375,300
2,526,800
3,032,200
3,537,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 856 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,969,700
3,563,700
4,157,600
4,370,000
5,244,000
6,118,000
3,120,700
3,744,800
4,368,900
4,687,300
5,624,800
6,562,300
6,607,400
7,928,800
9,250,300
11,031,200
13,237,400
15,443,700
15,679,300
18,815,200
21,951,000
22,024,700
26,429,700
30,834,600
10,079,500
12,095,400
14,111,300
16,535,000
27,249,800
19,842,000
32,699,800
23,149,000
38,149,700
24,676,300
29,611,500
34,546,800
28,862,500
34,635,000
40,407,500
35,722,200
42,866,600
50,011,100
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
12,259,000
14,710,800
17,162,600
467 M-1-04-II
15,749,200
18,899,100
22,048,900
468 M-1-04-III
19,427,200
23,312,600
27,198,000
469 M-1-05-I
470 M-1-05-II

8,023,800
12,589,500
9,628,600
15,107,400
11,233,400
17,625,300
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
16,578,800
19,894,600
23,210,400
8,712,300
10,454,800
12,197,200
11,671,500
14,005,800
16,340,100
23,775,900
28,531,100
33,286,300
20,123,100
24,147,700
28,172,300
48,113,600
57,736,300
67,359,000
103,776,500
124,531,800
145,287,000
13,099,600
15,719,500
18,339,400
17,253,700
20,704,400
24,155,200
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
43,019,100
51,623,000
60,226,800
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
9,264,600
15,012,500
21,466,500
11,117,500
18,014,900
25,759,700
12,970,400
21,017,400
30,053,000
4,574,600
5,489,500
6,404,400
8,112,800
9,735,300
11,357,900
11,583,500
13,900,200
16,216,900
5,651,400
9,378,500
15,403,600
6,781,700
11,254,200
18,484,300
7,912,000
13,129,900
21,565,000
8,466,400
10,159,600
11,852,900
10,644,200
12,773,000
14,901,800
16,576,600
19,891,900
23,207,200
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 857 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
500 M-4-10-II
501 M-4-10-III
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
16,170,600
19,404,700
22,638,800
17,787,600
21,345,200
24,902,700
20,364,500
24,437,400
28,510,300
9,192,300
11,030,800
12,869,200
10,916,700
24,571,100
13,100,000
29,485,400
15,283,400
34,399,600
3,141,000
3,769,200
4,397,300
4,684,200
8,862,600
5,621,100
10,635,100
6,557,900
12,407,600
3,913,900
4,696,700
5,479,500
8,581,100
10,297,400
12,013,600
12,790,500
15,348,700
17,906,800
3,124,200
3,749,000
4,373,900
5,196,400
6,235,700
7,275,000
7,165,700
8,598,800
10,032,000
5,202,100
6,242,500
7,282,900
7,815,900
9,379,100
10,942,300
15,248,700
18,298,400
21,348,200
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,932,800
7,119,400
8,305,900
512 M-4-14-II
7,317,200
8,780,700
10,244,100
513 M-4-14-III
514 M-4-15-I
10,995,700
3,626,800
13,194,800
4,352,100
15,394,000
5,077,500
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,689,200
10,641,200
3,011,900
4,972,400
8,353,300
5,627,100
12,769,500
3,614,300
5,966,900
10,024,000
6,564,900
14,897,700
4,216,700
6,961,400
11,694,700
3,909,100
4,690,900
5,472,700
5,467,300
6,560,800
7,654,200
7,634,700
9,161,700
10,688,600
2,954,700
4,452,800
5,361,400
3,545,600
5,343,400
6,433,600
4,136,500
6,233,900
7,505,900
3,176,500
3,811,900
4,447,200
5,190,000
6,228,000
7,266,000
10,136,400
12,163,700
14,191,000
3,108,100
3,729,700
4,351,400
4,551,300
5,461,600
6,371,800
5,086,600
6,104,000
7,121,300
3,129,600
3,755,600
4,381,500
3,914,300
4,697,100
5,480,000
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
- 858 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,775,700
10,530,900
12,286,000
535 N-1-01-I

185,730,800
222,877,000
260,023,100
536 N-1-01-II
185,730,800
222,877,000
260,023,100
537 N-1-01-III
538 N-1-11-I

185,730,800
9,027,400
222,877,000
10,832,900
260,023,100
12,638,300
539 N-1-11-II
540 N-1-11-III

14,274,500
22,253,900
17,129,400
26,704,700
19,984,300
31,155,500
4,601,000
5,521,200
6,441,300
9,443,300
11,332,000
13,220,600
20,492,300
24,590,800
28,689,300
10,370,500
12,444,700
14,518,800

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
14,513,000
19,700,000
17,415,600
23,639,900
20,318,200
27,579,900
9,206,200
11,047,400
12,888,600
13,927,100
16,712,500
19,497,900
16,028,800
19,234,500
22,440,300
8,523,500
10,228,200
11,932,900
11,574,700
13,889,600
16,204,600
13,471,400
16,165,700
18,860,000
3,512,700
4,215,200
4,917,700
4,380,000
5,256,000
6,132,000
6,442,400
7,730,800
9,019,300
2,779,900
4,711,200
5,861,700
2,536,300
4,458,400
5,366,400
3,622,700
4,369,300
6,902,800
3,335,900
5,653,400
7,034,000
3,043,500
5,350,100
6,439,600
4,347,200
5,243,200
8,283,400
3,891,900
6,595,700
8,206,400
3,550,800
6,241,700
7,512,900
5,071,700
6,117,100
9,663,900
2,708,200
3,249,800
3,791,500
3,842,800
4,611,400
5,379,900
6,160,000
7,392,000
8,624,000
3,199,400
3,839,300
4,479,200
4,092,700
4,911,200
5,729,700
4,670,400
5,604,500
6,538,600
3,917,600
4,701,200
5,484,700
5,591,700
6,710,100
7,828,400
7,673,200
9,207,800
10,742,500
5,286,000
5,729,500
6,343,200
6,875,400
7,400,400
8,021,300
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 859 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

9,596,100
11,515,300
13,434,600
3,641,600
4,370,000
5,098,300
4,047,300
4,856,700
5,666,200
5,190,600
6,228,700
7,266,800
2,659,800
3,191,800
3,723,800
3,194,500
3,833,300
4,472,200
4,014,000
4,816,700
5,619,500
1,775,400
2,130,500
2,485,600

MAYOR (RINGAN)
MAYOR (SEDANG)
2,101,400
2,521,700
2,521,700
3,026,000
2,942,000
3,530,400
57,612,900
69,135,500
80,658,000
71,287,300
85,544,700
99,802,200
83,671,200
100,405,500
117,139,700
90,017,100
108,020,600
126,024,000
103,258,900
123,910,700
144,562,400
117,980,700
141,576,900
165,173,000
13,023,200
15,627,800
18,232,500
18,389,100
22,066,900
25,744,800
25,739,200
30,887,100
36,034,900
37,562,400
45,074,900
52,587,400
48,558,200
58,269,800
67,981,400
69,620,200
83,544,300
97,468,300
20,396,500
24,475,800
28,555,200
31,886,900
38,264,200
44,641,600
42,436,500
50,923,800
59,411,100
5,580,200
6,696,200
7,812,300
15,645,600
18,774,700
21,903,900
20,726,600
24,871,900
29,017,200
5,405,000
6,486,000
7,567,000
15,154,400
18,185,200
21,216,100
20,075,800
24,091,000
28,106,100
4,475,300
5,370,300
6,265,400
6,350,100
7,620,200
8,890,200
10,282,300
12,338,800
14,395,200
10,852,700
13,023,200
15,193,700
15,324,300
18,389,100
21,454,000
- 860 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
21,449,400
25,739,200
30,029,100
10,252,900
12,303,400
14,354,000
11,787,900
14,145,500
16,503,100
16,499,500
19,799,400
23,099,300
5,812,600
6,975,100
8,137,600
9,067,600
10,881,100
12,694,700
14,086,800
16,904,200
19,721,600
3,874,000
4,648,800
5,423,600
7,885,900
9,463,100
11,040,300
14,192,400
17,030,900
19,869,400
2,905,500
3,486,700
4,067,800
5,818,500
6,982,200
8,145,900
6,826,900
8,192,300
9,557,700
2,629,600
3,155,500
3,681,400
5,053,100
6,063,700
7,074,400
12,365,600
14,838,700
17,311,800
3,875,000
4,650,100
5,425,100
6,975,100
8,370,100
9,765,100
9,815,200
11,778,200
13,741,200
2,875,800
3,451,000
4,026,200
3,543,500
4,252,200
4,960,900
4,850,700
5,820,800
6,790,900
1,740,300
2,551,900
4,361,600
2,114,300
2,814,100
4,878,300
2,088,300
3,062,300
5,233,900
2,537,200
3,376,900
5,853,900
2,436,400
3,572,700
6,106,200
2,960,000
3,939,800
6,829,600
3,122,300
3,746,800
4,371,200
5,539,200
6,647,000
7,754,900
8,990,800
10,789,000
12,587,100
1,580,100
1,896,100
2,212,100
3,356,300
4,027,500
4,698,800
6,364,600
7,637,600
8,910,500
1,056,800
1,268,100
1,479,500
1,994,300
2,393,200
2,792,100
2,583,000
3,099,600
3,616,200
5,472,200
6,566,700
7,661,100
- 861 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
7,174,600
8,609,600
10,044,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
10,272,600
12,327,100
14,381,600
2,637,500
3,165,000
3,692,500
3,914,400
4,697,200
5,480,100
4,707,900
5,649,500
6,591,000
1,819,300
2,183,100
2,547,000
2,443,500
2,932,200
3,420,900
4,445,200
5,334,200
6,223,200
789,100
947,000
1,104,800
1,504,000
1,804,800
2,105,600
2,186,400
2,623,700
3,061,000
1,077,000
1,292,500
1,507,900
1,694,900
2,033,900
2,372,900
2,730,000
3,276,000
3,822,000
1,774,400
2,129,300
2,484,200
2,643,900
3,172,700
3,701,500
4,056,500
4,867,700
5,679,000
5,766,900
6,920,200
8,073,600

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,952,500
23,645,800
10,742,900
28,374,900
12,533,400
33,104,100
8,921,600
10,705,900
12,490,200
11,309,500
13,571,400
15,833,300
16,775,800
20,130,900
23,486,100
6,971,200
10,690,000
15,701,400
6,976,000
8,128,200
13,474,000
8,365,500
12,828,000
18,841,700
8,371,200
9,753,800
16,168,800
9,759,700
14,966,000
21,982,000
9,766,500
11,379,500
18,863,600
4,321,700
5,186,100
6,050,400
5,303,800
6,364,600
7,425,400
6,285,000
7,542,000
8,799,000
4,134,800
5,878,400
7,577,000
4,961,700
7,054,100
9,092,400
5,788,700
8,229,800
10,607,800
6,561,100
7,873,300
9,185,500
9,764,700
11,717,700
13,670,600
24,315,900
29,179,100
34,042,300
5,626,900
7,629,800
14,472,700
6,752,200
9,155,700
17,367,300
7,877,600
10,681,700
20,261,800
4,049,300
4,859,200
5,669,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 862 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
2,461,100
2,953,300
3,445,500
697 U-4-12-I
698 U-4-12-II

2,686,500
3,124,900
3,223,800
3,749,900
3,761,100
4,374,900
699 U-4-12-III

4,179,300
5,015,100
5,851,000
2,099,000
2,518,700
2,938,500
2,474,500
2,969,400
3,464,300
2,959,600
3,551,500
4,143,400
3,909,500
4,681,500
4,691,400
5,617,800
5,473,300
6,554,200

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
7,861,700
9,434,100
11,006,400
3,139,200
3,767,100
4,394,900
3,911,100
4,693,300
5,475,500
5,473,600
6,568,300
7,663,100
5,278,700
6,334,500
7,390,200
10,547,700
12,657,300
14,766,800
12,935,300
15,522,400
18,109,400
9,741,200
11,123,300
17,419,600
11,689,500
13,348,000
20,903,500
13,637,700
15,572,700
24,387,400
9,158,600
10,990,400
12,822,100
12,893,700
15,472,400
18,051,100
15,852,600
19,023,100
22,193,600
4,925,000
5,910,000
6,895,000
9,410,100
11,292,100
13,174,100
14,320,300
17,184,400
20,048,500
9,368,200
11,241,800
13,115,500
13,611,700
16,334,000
19,056,400
16,996,700
20,396,000
23,795,300
1,555,400
1,716,400
1,898,700
1,866,500
2,059,700
2,278,400
2,177,600
2,403,000
2,658,100
4,670,400
5,604,500
6,538,600
7,757,800
9,309,300
10,860,900
12,789,900
15,347,800
17,905,800
3,914,400
4,697,300
5,480,200
5,252,200
6,302,600
7,353,000
7,252,900
8,703,500
10,154,100
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
8,992,000
10,790,400
12,588,800
13,805,500
16,566,600
19,327,700
1,608,600
2,339,400
1,930,300
2,807,300
2,252,000
3,275,200
- 863 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,999,400
13,199,300
15,399,100
12,788,000
15,345,600
17,903,200
18,812,500
22,575,000
26,337,500
2,333,100
2,799,700
3,266,400
2,574,600
2,848,000
3,089,500
3,417,600
3,604,400
3,987,200
2,438,600
2,926,400
3,414,100
2,691,000
3,229,200
3,767,400
2,976,800
3,572,200
4,167,500
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
2,623,500
3,148,200
3,672,900
743 W-1-12-II
744 W-1-12-III

3,274,500
5,624,500
3,929,400
6,749,400
4,584,400
7,874,300
745 W-1-13-I
2,615,800
3,139,000
3,662,100
746 W-1-13-II
747 W-1-13-III

2,839,900
3,814,700
3,407,900
4,577,600
3,975,800
5,340,600
748 W-1-20-I
749 W-1-20-II

8,760,100
10,945,800
10,512,100
13,135,000
12,264,100
15,324,100
750 W-1-20-III
12,689,000
15,226,800
17,764,600
751 W-1-30-I
4,945,200
5,934,200
6,923,300
752 W-1-30-II
7,887,600
9,465,100
11,042,600
753 W-1-30-III
19,352,600
23,223,100
27,093,600
754 W-4-10-I
3,684,700
4,421,600
5,158,500
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
5,462,400
10,794,700
3,350,900
5,087,300
6,192,100
6,554,800
12,953,700
4,021,100
6,104,700
7,430,600
7,647,300
15,112,600
4,691,300
7,122,200
8,669,000
2,977,900
3,573,500
4,169,100
4,088,500
4,906,200
5,723,900
4,456,700
5,348,000
6,239,300
1,318,400
1,801,000
2,239,600
1,761,900
2,162,000
2,683,000
1,675,600
1,860,900
2,576,500
2,298,300
3,073,500
4,165,600
1,645,100
2,970,200
4,391,400
3,035,200
4,028,900
5,723,300
2,765,200
3,321,200
4,565,200
1,582,100
2,161,200
2,687,600
2,114,300
2,594,400
3,219,600
2,010,700
2,233,100
3,091,800
2,758,000
3,688,200
4,998,700
1,974,100
3,564,200
5,269,700
3,642,300
4,834,600
6,868,000
3,318,300
3,985,500
5,478,200
1,845,800
2,521,400
3,135,500
2,466,700
3,026,800
3,756,200
2,345,800
2,605,200
3,607,100
3,217,700
4,302,900
5,831,800
2,303,100
4,158,300
6,148,000
4,249,300
5,640,400
8,012,700
3,871,300
4,649,700
6,391,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 864 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,989,300
2,387,100
2,785,000
4,174,300
5,009,100
5,844,000
6,425,700
7,710,800
8,996,000
- 865 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,018,800
1,321,500
2,457,500
2,030,900
2,639,200
485,500
1,186,500
379,600
1,019,000
757,100
859,500
1,292,200
1,762,600
1,615,500
523,300
1,207,900
438,100
752,200
2,291,300
820,600
1,937,900
472,800
1,440,800
1,640,100
1,375,500
337,400
1,076,200
568,500
401,900
316,000
279,000
333,600
464,500
399,100
375,700
337,600
501,000
218,700
257,800
295,600
5,998,300
2,397,300
2,405,300
618,700
1,393,100
872,200
1,772,800
826,100
473,100
357,300
576,200
382,600
286,600
2,921,600
1,363,400
779,100
3,041,300
2,027,500
287,200
3,294,700
2,281,000
4,207,100
1,185,000
728,900
285,100
237,500
267,800
4,082,800
1,987,400
- 866 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,525,800
4,470,200
3,901,400
2,823,500
930,800
3,142,600
2,051,900
504,400
4,718,100
4,271,200
2,863,900
2,713,200
353,000
322,200
1,296,500
373,000
315,700
348,900
1,646,700
1,635,800
1,428,800
1,735,100
1,050,800
317,600
559,700
384,200
346,900
338,000
429,200
489,400
286,900
823,400
1,500,700
1,152,000
2,708,100
352,600
352,600
3,440,900
1,455,100
279,100
1,291,400
3,531,200
770,200
606,600
297,200
281,700
442,600
617,200
1,478,000
1,302,700
911,900
494,700
286,600
1,583,400
922,700
542,100
449,900
1,474,300
325,900
2,071,000
1,584,400
351,400
389,500
380,500
230,200
1,726,400
1,725,100
341,900
- 867 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,047,800
391,100
422,900
391,600
621,200
477,800
1,196,700
353,100
982,400
1,805,000
287,500
1,749,800
948,200
2,049,200
1,034,400
456,800
351,400
81,300
455,400
1,029,200
401,100
541,700
309,800
125,800
312,900
4,659,000
2,648,300
4,420,000
1,493,000
606,600
413,400
934,900
494,500
995,100
576,200
343,000
574,200
355,400
542,500
378,100
978,500
1,898,600
1,527,500
1,346,800
950,500
332,200
332,200
332,200
271,300
172,100
270,600
330,800
357,800
263,500
232,400
114,000
125,300
92,700
108,700
103,700
158,300
142,000
184,700
202,900
119,700
153,000
104,600
163,200
231,600
- 868 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
164,900
207,300
586,100
679,400
155,900
282,000
189,700
270,800
474,400
406,200
292,000
276,500
155,000
144,700
325,500
205,500
294,700
204,000
159,700
2,815,500
2,106,300
334,700
346,600
662,900
868,500
848,500
438,300
1,365,900
324,200
356,200
357,400
286,200
361,400
342,000
160,200
352,100
312,100
282,300
319,200
2,642,700
471,800
951,100
341,100
667,300
531,500
446,300
825,900
845,800
901,800
788,900
1,509,900
235,000
2,243,600
309,800
1,137,300
2,584,700
2,173,500
949,500
344,100
671,100
668,500
309,800
2,428,400
1,910,100
171,100
185,400
240,900
427,600
- 869 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,246,000
671,400
1,059,400
1,214,200
612,500
809,400
588,900
628,000
786,900
351,000
788,200
221,300
778,900
1,341,400
89,900
- 870 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,995,100
2,394,200
2,793,200
A-4-10-II
SEPTIKEMIA (SEDANG)
3,408,500
4,090,200
4,772,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,595,800
2,937,700
5,514,900
3,525,200
6,434,100
4,112,800
5
6
A-4-11-II
A-4-11-III

4,181,200
5,787,200
5,017,400
6,944,600
5,853,700
8,102,000
A-4-12-I
2,660,200
3,192,200
3,724,200
8
9
A-4-12-II
A-4-12-III

3,312,800
3,535,700
3,975,400
4,242,800
4,637,900
4,949,900
10 A-4-13-I
11 A-4-13-II

1,599,700
2,409,900
1,919,700
2,891,900
2,239,600
3,373,900
12 A-4-13-III
2,891,900
3,470,300
4,048,700
2,218,100
2,661,700
3,105,300
2,692,400
3,230,900
3,769,300
3,230,900
3,877,000
4,523,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,482,400
5,212,700
4,178,900
6,255,300
4,875,400
7,297,800
18 A-4-15-III
INFEKSI HIV (BERAT)
6,541,500
7,849,800
9,158,100
19 B-1-01-I
20 B-1-01-II

23,841,600
26,303,700
28,610,000
31,564,500
33,378,300
36,825,200
21 B-1-01-III
22 B-1-10-I

46,142,200
4,119,400
55,370,600
4,943,300
64,599,100
5,767,200
23 B-1-10-II
9,143,300
10,972,000
12,800,700
24 B-1-10-III
25 B-1-11-I

18,050,200
5,504,300
21,660,200
6,605,200
25,270,300
7,706,100
26 B-1-11-II
27 B-1-11-III

7,133,200
9,216,000
8,559,900
11,059,200
9,986,500
12,902,400
28 B-1-12-I
5,374,700
6,449,600
7,524,600
29 B-1-12-II
5,977,600
7,173,100
8,368,600
30 B-1-12-III
9,351,300
11,221,500
13,091,800
4,281,000
5,137,200
5,993,400
7,043,900
8,452,600
9,861,400
9,114,100
10,936,900
12,759,800
5,882,300
7,058,700
8,235,200
6,542,100
7,850,500
9,159,000
10,234,400
1,820,000
2,905,200
4,007,800
12,281,300
2,184,000
3,486,200
4,809,400
14,328,200
2,548,000
4,067,300
5,610,900
3,837,200
4,604,600
5,372,100
5,372,100
6,446,500
7,521,000
6,508,200
7,809,900
9,111,500
3,469,200
4,940,100
7,349,700
3,309,400
4,163,100
5,928,100
8,819,700
3,971,200
4,856,900
6,916,100
10,289,600
4,633,100
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 871 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,855,300
4,626,300
5,397,400
48 B-4-13-III
49 B-4-14-I

5,311,000
3,305,800
6,373,200
3,967,000
7,435,400
4,628,200
50 B-4-14-II
3,856,700
4,628,000
5,399,400
51 B-4-14-III
52 C-4-10-I

5,166,100
3,058,500
6,199,300
3,670,200
7,232,600
4,281,900
53 C-4-10-II
54 C-4-10-III

5,868,500
10,358,400
7,042,200
12,430,100
8,215,900
14,501,700
55 C-4-11-I
3,485,300
4,182,300
4,879,400
56 C-4-11-II
57 C-4-11-III

4,663,800
7,170,700
5,596,600
8,604,800
6,529,300
10,039,000
58 C-4-12-I
59 C-4-12-II
2,320,600
4,570,700
2,784,700
5,484,800
3,248,900
6,399,000
60 C-4-12-III
RADIOTERAPI (BERAT)
11,738,900
14,086,600
16,434,400
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,744,600
3,283,400
2,093,600
3,940,100
2,442,500
4,596,800
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,444,600
2,898,800
5,333,600
3,478,500
6,222,500
4,058,300
65 C-4-14-II
4,066,400
4,879,700
5,693,000
66 C-4-14-III
67 D-1-10-I

6,058,900
14,186,000
7,270,600
17,023,200
8,482,400
19,860,400
68 D-1-10-II
69 D-1-10-III

21,606,300
34,404,600
25,927,600
41,285,500
30,248,800
48,166,500
70 D-1-11-I
4,689,100
5,626,900
6,564,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
11,973,500
15,560,000
14,368,100
18,672,000
16,762,800
21,784,000
4,064,900
4,877,900
5,690,900
11,202,300
13,442,700
15,683,200
17,770,100
21,324,100
24,878,100
2,430,900
3,654,000
5,748,600
3,182,300
5,718,400
7,855,700
2,743,600
3,805,400
5,843,300
2,917,000
4,384,800
6,898,300
3,818,700
6,862,100
9,426,800
3,292,300
4,566,400
7,012,000
3,403,200
5,115,600
8,048,000
4,455,200
8,005,800
10,998,000
3,841,000
5,327,500
8,180,600
2,351,200
2,821,400
3,291,600
3,327,700
3,993,200
4,658,800
4,256,200
5,107,500
5,958,700
2,521,700
3,026,100
3,530,400
4,128,700
4,954,400
5,780,200
5,049,800
6,059,800
7,069,700
4,489,000
5,386,800
6,284,600
5,880,100
7,056,200
8,232,200
93 E-1-01-III
10,210,900
12,253,100
14,295,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,501,800
4,250,300
8,958,400
4,202,100
5,100,400
10,750,100
4,902,500
5,950,500
12,541,800
5,916,500
7,099,800
8,283,000
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 872 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,325,900
2,791,100
3,256,200
104 E-4-11-II
105 E-4-11-III

3,546,000
4,805,100
4,255,200
5,766,100
4,964,400
6,727,100
106 E-4-12-I
107 E-4-12-II

2,672,400
4,627,900
3,206,900
5,553,500
3,741,300
6,479,100
108 E-4-12-III

(RINGAN)
(SEDANG)
5,485,800
6,583,000
7,680,100
2,910,100
3,492,200
4,074,200
4,262,800
5,115,400
5,968,000
111 E-4-13-III
5,572,400
6,686,800
7,801,300
112 F-4-10-I
113 F-4-10-II
3,098,200
3,560,800
3,717,900
4,273,000
4,337,500
4,985,100
114 F-4-10-III
115 F-4-11-I
4,273,000
2,996,500
5,127,500
3,595,800
5,982,100
4,195,100
116 F-4-11-II
3,491,200
4,189,400
4,887,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,477,000
5,372,400
6,267,800
1,642,500
1,971,100
2,299,600
2,335,200
2,802,200
3,269,300
5,073,100
6,087,700
7,102,300
2,413,700
3,185,000
4,123,300
1,377,100
1,766,400
2,376,800
2,896,500
3,822,000
4,948,000
1,652,600
2,119,700
2,852,200
3,379,200
4,459,000
5,772,700
1,928,000
2,472,900
3,327,500
127 F-4-15-I
2,193,200
2,631,800
3,070,500
128 F-4-15-II
3,268,100
3,921,800
4,575,400
129 F-4-15-III
4,315,000
5,178,000
6,041,000
4,315,200
5,178,300
6,041,300
5,017,200
6,020,600
7,024,000
6,697,000
8,036,400
9,375,900
133 F-4-17-I

1,019,100
1,222,900
1,426,700
134 F-4-17-II
2,986,800
3,584,200
4,181,500
135
136
137
138
139
140
141

(RINGAN)
3,186,700
3,749,600
4,125,600
6,360,000
2,865,600
3,669,500
4,568,500
3,824,000
4,499,500
4,950,800
7,632,000
3,438,700
4,403,400
5,482,200
4,461,300
5,249,500
5,775,900
8,904,000
4,011,800
5,137,300
6,395,900
10,928,300
13,113,900
15,299,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,963,400
9,556,100
11,148,800
10,975,200
13,170,200
15,365,300
3,530,400
4,236,500
4,942,600
4,933,100
5,919,800
6,906,400
6,123,000
7,347,600
8,572,200
- 873 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,531,500
17,437,800
20,344,100
148 G-1-11-I
149 G-1-11-II

9,303,100
17,008,200
11,163,700
20,409,800
13,024,300
23,811,400
150 G-1-11-III
31,358,900
37,630,600
43,902,400
3,884,400
4,661,200
5,438,100
7,281,400
8,737,700
10,194,000
9,923,100
11,907,800
13,892,400
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,171,800
3,146,900
1,406,200
3,776,200
1,640,500
4,405,600
156 G-1-13-III
157 G-1-20-I

7,100,700
4,921,000
8,520,800
5,905,100
9,941,000
6,889,300
158 G-1-20-II
5,851,900
7,022,300
8,192,700
159 G-1-20-III
13,657,800
16,389,300
19,120,900
160 G-1-30-I
7,218,700
8,662,400
10,106,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
14,620,700
20,534,400
17,544,800
24,641,200
20,468,900
28,748,100
3,334,300
4,001,200
4,668,000
4,075,600
4,890,800
5,705,900
5,592,500
6,711,000
7,829,500
3,490,500
4,188,600
4,886,700
4,636,700
5,564,000
6,491,300
6,812,800
8,175,400
9,538,000
3,872,300
4,646,700
5,421,200
4,891,000
5,869,200
6,847,400
7,103,500
8,524,200
9,944,900
2,326,100
2,791,400
3,256,600
4,056,300
4,867,600
5,678,900
4,810,900
5,773,100
6,735,200
3,946,000
4,735,200
5,524,400
5,275,500
6,330,600
7,385,800
6,621,400
7,945,700
9,270,000
3,224,200
3,869,100
4,513,900
3,848,000
4,617,600
5,387,200
5,431,100
6,517,300
7,603,500
2,658,000
3,189,500
3,721,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
17,017,600
20,421,200
23,824,700
32,728,000
39,273,700
45,819,300
11,201,800
13,189,000
13,442,200
15,826,800
15,682,600
18,464,600
- 874 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,528,800
4,234,500
4,940,300
183 G-4-16-III
5,025,300
6,030,300
7,035,400
3,540,200
4,248,300
4,956,300
4,642,000
5,570,400
6,498,800
5,832,900
6,999,500
8,166,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,486,600
4,183,900
4,881,200
188 G-4-18-II
4,660,500
5,592,600
6,524,700
189 G-4-18-III
5,214,700
6,257,600
7,300,600
2,908,900
3,490,700
4,072,500
4,916,800
5,900,100
6,883,500
6,455,500
7,746,600
9,037,700
193 G-4-20-I

2,034,900
2,441,900
2,848,900
194 G-4-20-II
2,876,800
3,452,100
4,027,500
195 G-4-20-III
196 G-4-21-I

4,751,700
2,119,100
5,702,100
2,542,900
6,652,400
2,966,700
197 G-4-21-II
198 G-4-21-III

3,586,500
4,215,000
4,303,900
5,058,000
5,021,200
5,901,000
199 G-4-22-I
2,676,900
3,212,200
3,747,600
200 G-4-22-II
201 G-4-22-III

3,420,200
3,996,400
4,104,300
4,795,600
4,788,300
5,594,900
202 G-4-23-I
203 G-4-23-II

2,086,000
2,617,200
2,503,200
3,140,700
2,920,400
3,664,100
204 G-4-23-III
3,726,300
4,471,500
5,216,800
205 G-4-24-I
206 G-4-24-II

2,323,500
2,902,900
2,788,200
3,483,500
3,252,900
4,064,000
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,836,100
1,985,400
2,510,700
3,327,200
5,803,300
2,382,500
3,012,900
3,992,700
6,770,600
2,779,600
3,515,000
4,658,100
3,137,400
3,764,900
4,392,400
3,649,800
4,379,800
5,109,800
5,457,600
6,549,100
7,640,600
4,481,500
5,712,700
7,768,900
6,819,000
8,472,000
11,866,300
2,687,900
3,646,900
7,168,100
2,319,700
2,646,000
3,788,900
2,734,900
3,267,700
5,476,100
5,377,800
6,855,300
9,322,600
8,182,800
10,166,400
14,239,500
3,225,400
4,376,200
8,601,700
2,783,600
3,175,200
4,546,700
3,281,900
3,921,200
6,571,300
6,274,100
7,997,800
10,876,400
9,546,600
11,860,700
16,612,800
3,763,000
5,105,600
10,035,300
3,247,500
3,704,400
5,304,500
3,828,800
4,574,800
7,666,500
229 I-1-01-I
36,734,400
44,081,300
51,428,200
230 I-1-01-II
37,542,500
45,051,000
52,559,600
231 I-1-01-III

(RINGAN)
59,260,400
71,112,500
82,964,600
20,380,100
24,456,100
28,532,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 875 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
16,780,700
20,136,800
23,492,900
245 I-1-06-II
24,308,200
29,169,800
34,031,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
29,004,100
34,804,900
40,605,800
19,975,300
23,970,400
27,965,400
24,643,600
29,572,300
34,501,100
26,886,100
32,263,300
37,640,500
3,193,600
3,832,400
4,471,100
3,551,000
4,261,200
4,971,400
4,725,300
5,670,300
6,615,400
9,192,800
11,031,300
12,869,900
15,013,700
18,016,400
21,019,100
19,752,700
23,703,300
27,653,800
8,916,900
10,700,200
12,483,600
11,874,600
14,249,600
16,624,500
14,644,700
17,573,700
20,502,600
18,250,600
21,900,800
25,550,900
22,682,900
27,219,400
31,756,000
29,722,400
35,666,900
41,611,300
3,467,100
4,841,700
9,323,300
4,160,500
5,810,100
11,187,900
4,853,900
6,778,400
13,052,600
8,988,000
10,785,600
12,583,200
20,336,200
24,403,400
28,470,600
23,457,500
28,148,900
32,840,400
10,407,200
12,488,700
14,570,100
13,030,800
15,637,000
18,243,100
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
26,290,100
31,548,100
36,806,100
32,404,100
38,885,000
45,365,800
11,771,600
14,125,900
16,480,200
16,317,900
19,581,400
22,845,000
20,708,600
24,850,400
28,992,100
17,739,200
21,287,000
24,834,800
27,997,200
33,596,600
39,196,000
44,725,300
53,670,400
62,615,400
22,761,000
27,313,200
31,865,400
27,313,300
32,775,900
38,238,600
37,582,800
45,099,400
52,616,000
- 876 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
20,245,600
24,294,800
28,343,900
279 I-1-40-III
27,041,300
32,449,600
37,857,800
280 I-4-10-I
281 I-4-10-II

3,086,900
5,512,100
3,704,300
6,614,500
4,321,700
7,716,900
282 I-4-10-III
7,942,100
9,530,500
11,119,000
283 I-4-11-I
284 I-4-11-II

4,749,200
5,877,200
5,699,100
7,052,600
6,648,900
8,228,100
285 I-4-11-III
286 I-4-12-I

10,872,200
2,730,200
13,046,600
3,276,200
15,221,100
3,822,200
287 I-4-12-II
3,164,600
3,797,500
4,430,500
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,797,500
4,557,000
5,316,600
2,778,200
3,333,900
3,889,500
4,960,900
5,953,000
6,945,200
7,147,900
8,577,500
10,007,100
2,623,600
2,713,800
4,757,400
3,148,300
3,256,600
5,708,800
3,673,000
3,799,400
6,660,300
4,517,800
5,421,300
6,324,900
6,146,100
7,375,400
8,604,600
297 I-4-15-III
7,375,400
8,850,400
10,325,500
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,655,900
2,658,900
3,190,700
1,864,100
2,170,200
2,604,200
1,987,000
3,190,700
3,828,800
2,236,900
2,604,200
3,125,100
2,318,200
3,722,500
4,466,900
2,609,800
3,038,300
3,645,900
3,194,000
3,832,700
4,471,500
4,862,900
5,835,500
6,808,100
6,602,200
7,922,700
9,243,100
307 I-4-19-I
3,081,500
3,697,800
4,314,100
308 I-4-19-II

(SEDANG)
4,810,400
5,772,500
6,734,600
309 I-4-19-III
5,742,800
6,891,300
8,039,900
310
311
312
313
314

3,208,800
3,706,200
5,541,500
2,401,100
3,042,200
3,850,500
4,447,400
6,649,700
2,881,300
3,650,700
4,492,300
5,188,600
7,758,000
3,361,600
4,259,100
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
16,118,900
19,342,700
22,566,500
11,730,700
14,076,900
16,423,000
14,654,900
17,585,900
20,516,900
15,405,300
18,486,400
21,567,500
8,873,600
10,648,400
12,423,100
18,459,100
22,151,000
25,842,800
28,605,000
34,326,000
40,047,000
8,189,400
9,827,300
11,465,200
- 877 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,391,100
5,269,400
6,147,600
316 I-4-22-I
317 I-4-22-II
2,691,300
3,350,200
3,229,500
4,020,300
3,767,800
4,690,300
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,896,900
5,876,300
6,855,700
2,634,000
3,160,700
3,687,500
3,233,700
3,880,500
4,527,200
6,318,500
7,582,300
8,846,000
2,371,900
2,846,300
3,320,600
5,461,800
6,554,200
7,646,600
6,905,500
8,286,600
9,667,700
42,790,900
51,349,100
59,907,300
48,425,900
58,111,000
67,796,200
54,784,900
65,741,900
76,698,800
22,707,600
27,249,100
31,790,600
31,618,000
37,941,500
44,265,100
52,212,100
62,654,500
73,096,900
6,895,700
8,274,800
9,654,000
13,953,500
16,744,100
19,534,800
14,501,100
17,401,300
20,301,500
9,770,500
11,724,600
13,678,700
12,910,100
15,492,100
18,074,200
19,770,400
23,724,500
27,678,600
5,754,600
6,905,600
8,056,500
10,424,400
12,509,300
14,594,200
30,089,800
36,107,700
42,125,700
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,351,300
4,856,000
7,346,400
2,098,700
2,923,100
3,918,100
3,564,700
4,057,900
5,665,900
3,151,800
4,387,200
8,185,000
3,474,900
5,654,700
6,690,000
4,239,700
5,065,200
6,814,800
2,821,500
5,827,200
8,815,700
2,518,500
3,507,700
4,701,700
4,277,600
4,869,400
6,799,100
3,782,100
5,264,600
9,822,000
4,169,900
6,785,600
8,028,000
5,087,600
6,078,300
8,177,700
3,291,800
6,798,400
10,285,000
2,938,200
4,092,300
5,485,400
4,990,500
5,681,000
7,932,200
4,412,500
6,142,000
11,459,000
4,864,800
7,916,500
9,366,000
5,935,500
7,091,300
9,540,700
3,532,500
4,239,000
4,945,600
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 878 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,964,100
5,957,000
6,949,800
360 J-4-16-III
6,276,400
7,531,700
8,786,900
361 J-4-17-I
362 J-4-17-II

2,903,600
3,477,100
3,484,300
4,172,600
4,065,000
4,868,000
363 J-4-17-III
364 J-4-18-I

4,563,000
2,176,200
5,475,700
2,611,400
6,388,300
3,046,700
365 J-4-18-II
2,993,200
3,591,800
4,190,400
366 J-4-18-III
367 J-4-19-I

3,150,700
4,089,800
3,780,800
4,907,800
4,410,900
5,725,700
368 J-4-19-II
369 J-4-19-III

4,638,100
5,122,200
5,565,700
6,146,600
6,493,300
7,171,100
370 J-4-20-I
4,058,600
4,870,300
5,682,000
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,623,600
6,592,600
6,748,300
7,911,100
7,873,000
9,229,600
2,820,600
3,384,800
3,948,900
4,544,000
5,452,800
6,361,600
6,340,800
7,608,900
8,877,100
6,251,400
7,501,600
8,751,900
7,856,200
9,427,400
10,998,600
9,207,700
11,049,200
12,890,800
7,019,700
8,423,700
9,827,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
9,216,000
13,946,900
11,059,200
16,736,200
12,902,400
19,525,600
2,623,000
3,147,600
3,672,200
3,411,500
4,093,800
4,776,100
6,758,700
8,110,400
9,462,200
2,958,200
3,254,000
3,283,600
3,549,800
3,904,800
3,940,300
4,141,500
4,555,600
4,597,000
4,800,600
5,760,700
6,720,900
5,626,200
6,751,500
7,876,700
8,839,600
10,607,500
12,375,400
9,295,500
12,983,800
18,957,700
11,154,700
15,580,600
22,749,300
13,013,800
18,177,300
26,540,800
5,497,300
6,596,800
7,696,300
9,763,100
11,715,700
13,668,400
13,434,200
16,121,000
18,807,900
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
6,133,700
7,360,500
8,587,200
398 K-1-40-II

(SEDANG)
6,762,700
8,115,200
9,467,700
399 K-1-40-III
11,460,300
13,752,300
16,044,400
400
401
402
403
404

4,686,800
6,086,400
8,601,200
3,869,200
5,559,500
5,624,100
7,303,700
10,321,400
4,643,000
6,671,300
6,561,500
8,520,900
12,041,600
5,416,900
7,783,200
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 879 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,475,100
10,170,100
11,865,100
406 K-4-11-I
407 K-4-11-II

2,267,900
3,222,800
2,721,500
3,867,400
3,175,000
4,511,900
408 K-4-11-III
409 K-4-12-I

3,867,400
2,325,900
4,640,800
2,791,100
5,414,300
3,256,200
410 K-4-12-II
3,129,900
3,755,900
4,381,900
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,177,900
6,213,500
7,249,100
3,135,400
3,762,500
4,389,600
4,055,900
4,867,100
5,678,200
6,247,400
7,496,800
8,746,300
1,987,900
2,385,500
2,783,000
2,668,400
3,202,100
3,735,700
4,281,700
5,138,000
5,994,400
418 K-4-15-I
2,054,000
2,464,800
2,875,500
419 K-4-15-II
3,045,500
3,654,600
4,263,700
420 K-4-15-III
4,274,200
5,129,100
5,983,900
421 K-4-16-I
2,902,200
3,482,700
4,063,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,480,600
4,061,300
4,176,700
4,873,600
4,872,800
5,685,900
1,490,600
1,788,700
2,086,900
2,038,800
2,446,500
2,854,300
2,446,500
2,935,800
3,425,100
1,317,200
1,580,600
1,844,000
1,871,700
2,246,100
2,620,400
429 K-4-18-III
2,246,100
2,695,300
3,144,500
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
14,820,600
22,371,300
29,891,700
6,992,500
11,998,700
14,896,600
17,784,700
26,845,600
35,870,100
8,391,000
14,398,400
17,875,900
20,748,900
31,319,800
41,848,400
9,789,500
16,798,200
20,855,200
3,918,700
4,702,500
5,486,200
7,860,100
9,432,200
11,004,200
13,230,400
15,876,500
18,522,500
5,144,500
8,279,600
11,843,100
1,345,600
1,561,900
1,812,900
2,817,800
3,872,900
8,800,400
1,338,200
1,770,000
4,682,100
6,173,400
9,935,500
14,211,800
1,614,700
1,874,200
2,175,500
3,381,400
4,647,500
10,560,500
1,605,900
2,124,000
5,618,500
7,202,400
11,591,400
16,580,400
1,883,800
2,186,600
2,538,000
3,945,000
5,422,100
12,320,600
1,873,500
2,478,000
6,554,900
2,402,600
2,883,200
3,363,700
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 880 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,823,800
3,388,500
3,953,300
4,155,200
4,986,300
5,817,300
2,317,300
2,780,800
3,244,300
3,480,700
4,176,900
4,873,000
4,906,500
5,887,800
6,869,100
8,191,600
9,829,900
11,468,200
11,643,200
13,971,800
16,300,400
16,355,200
19,626,200
22,897,300
7,260,300
8,712,400
10,164,400
11,910,200
20,235,200
14,292,300
24,282,300
16,674,300
28,329,300
19,712,200
23,654,700
27,597,100
23,056,300
27,667,500
32,278,800
28,536,000
34,243,200
39,950,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
9,103,300
10,924,000
12,744,600
467 M-1-04-II
11,695,100
14,034,100
16,373,100
468 M-1-04-III
13,993,500
16,792,200
19,590,900
469 M-1-05-I
470 M-1-05-II

5,779,600
9,348,700
6,935,500
11,218,500
8,091,500
13,088,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
11,941,800
14,330,200
16,718,500
6,469,600
7,763,500
9,057,400
8,667,000
10,400,400
12,133,900
17,655,600
21,186,700
24,717,800
10,650,100
12,780,100
14,910,100
23,370,300
28,044,300
32,718,400
50,407,500
60,489,000
70,570,400
9,727,500
11,673,000
13,618,500
12,427,900
14,913,500
17,399,100
480 M-1-20-III
30,941,700
37,130,100
43,318,400
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,673,300
10,813,500
15,462,400
8,008,000
12,976,300
18,554,900
9,342,700
15,139,000
21,647,400
3,397,000
4,076,400
4,755,800
6,024,400
7,229,300
8,434,200
8,601,700
10,322,000
12,042,400
4,070,800
6,755,400
11,095,300
4,884,900
8,106,500
13,314,400
5,699,100
9,457,500
15,533,400
6,287,000
7,544,400
8,801,800
7,904,200
9,485,000
11,065,800
11,940,200
14,328,200
16,716,300
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 881 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,332,400
2,798,900
3,265,400
500 M-4-10-II
501 M-4-10-III
3,478,400
6,581,200
4,174,100
7,897,400
4,869,800
9,213,700
2,906,400
3,487,700
4,069,000
6,372,200
7,646,600
8,921,100
9,213,100
11,055,700
12,898,300
2,320,000
2,784,000
3,248,000
3,858,700
4,630,500
5,402,200
5,161,500
6,193,800
7,226,100
3,863,000
4,635,600
5,408,200
5,804,000
6,964,800
8,125,600
11,323,400
13,588,100
15,852,800
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,405,600
5,286,700
6,167,800
512 M-4-14-II
5,433,700
6,520,400
7,607,100
513 M-4-14-III
514 M-4-15-I
8,165,200
2,612,400
9,798,200
3,134,900
11,431,300
3,657,300
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,482,100
7,902,000
2,236,600
3,581,700
6,017,000
4,178,600
9,482,400
2,683,900
4,298,000
7,220,300
4,875,000
11,062,800
3,131,300
5,014,300
8,423,700
2,902,800
3,483,400
4,063,900
4,059,900
4,871,900
5,683,900
5,669,400
6,803,300
7,937,200
2,194,100
3,306,600
3,981,200
2,632,900
3,967,900
4,777,500
3,071,700
4,629,200
5,573,700
2,288,100
2,745,700
3,203,300
3,854,000
4,624,800
5,395,600
7,527,100
9,032,500
10,538,000
2,308,000
2,769,600
3,231,300
3,379,700
4,055,700
4,731,600
3,777,300
4,532,700
5,288,200
2,324,000
2,788,800
3,253,600
2,906,700
3,488,000
4,069,300
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,647,700
13,977,300
16,306,800
12,812,500
15,375,000
17,937,500
14,668,600
17,602,400
20,536,100
6,621,300
7,945,500
9,269,800
7,863,400
17,698,700
9,436,000
21,238,500
11,008,700
24,778,200
- 882 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,516,700
7,820,000
9,123,400
535 N-1-01-I

108,192,700
129,831,300
151,469,800
536 N-1-01-II
108,192,700
129,831,300
151,469,800
537 N-1-01-III
538 N-1-11-I

108,192,700
6,703,600
129,831,300
8,044,300
151,469,800
9,385,000
539 N-1-11-II
540 N-1-11-III

10,600,000
16,525,400
12,720,000
19,830,400
14,840,000
23,135,500
3,416,600
4,099,900
4,783,200
6,802,100
8,162,500
9,522,900
14,760,700
17,712,900
20,665,000
7,470,000
8,963,900
10,457,900

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,453,800
14,628,800
12,544,600
17,554,600
14,635,300
20,480,400
6,836,300
8,203,600
9,570,900
10,342,000
12,410,400
14,478,800
11,902,700
14,283,200
16,663,700
6,139,500
7,367,400
8,595,300
8,337,300
10,004,800
11,672,200
9,703,500
11,644,200
13,584,900
2,608,400
3,130,100
3,651,800
3,154,900
3,785,900
4,416,900
4,640,500
5,568,600
6,496,700
2,002,400
3,498,400
4,352,800
2,284,700
4,239,300
5,102,600
3,444,600
4,154,600
6,366,700
2,402,900
4,198,100
5,223,300
2,741,600
5,087,100
6,123,200
4,133,600
4,985,500
7,640,000
2,803,400
4,897,800
6,093,900
3,198,600
5,935,000
7,143,700
4,822,500
5,816,500
8,913,300
2,011,100
2,413,300
2,815,500
2,853,600
3,424,300
3,995,000
4,574,300
5,489,200
6,404,000
2,375,800
2,851,000
3,326,100
2,948,000
3,537,600
4,127,100
3,364,100
4,037,000
4,709,800
2,909,200
3,491,000
4,072,800
4,152,300
4,982,800
5,813,200
5,527,000
6,632,400
7,737,900
5,120,100
5,408,100
6,144,100
6,489,800
7,168,100
7,571,400
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 883 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,779,800
8,135,800
9,491,800
2,704,200
3,245,100
3,785,900
3,005,400
3,606,500
4,207,600
3,738,800
4,486,600
5,234,300
1,915,900
2,299,100
2,682,300
2,301,000
2,761,200
3,221,400
2,891,300
3,469,500
4,047,800
1,637,600
1,965,100
2,292,600

MAYOR (RINGAN)
MAYOR (SEDANG)
1,938,200
2,325,800
2,325,800
2,791,000
2,713,500
3,256,200
42,782,300
51,338,800
59,895,200
52,936,700
63,524,000
74,111,400
62,132,800
74,559,300
86,985,900
72,078,600
86,494,300
100,910,100
82,681,500
99,217,800
115,754,100
94,469,600
113,363,500
132,257,400
7,788,900
9,346,700
10,904,500
11,556,300
13,867,500
16,178,800
13,079,400
15,695,300
18,311,100
23,095,000
27,714,000
32,333,000
38,881,600
46,657,900
54,434,200
55,746,300
66,895,600
78,044,900
16,331,900
19,598,300
22,864,700
23,678,600
28,414,400
33,150,100
33,979,800
40,775,800
47,571,700
4,143,800
4,972,500
5,801,300
11,618,200
13,941,800
16,265,400
15,391,200
18,469,500
21,547,700
4,013,700
4,816,400
5,619,100
11,253,400
13,504,000
15,754,700
14,907,900
17,889,500
20,871,100
4,072,000
4,886,400
5,700,800
5,778,100
6,933,700
8,089,400
9,356,000
11,227,200
13,098,400
7,080,900
8,497,000
9,913,200
10,505,700
12,606,800
14,708,000
- 884 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,890,300
14,268,400
16,646,500
6,157,300
7,388,700
8,620,200
8,754,700
10,505,700
12,256,600
9,908,600
11,890,300
13,872,100
5,289,000
6,346,800
7,404,600
8,250,800
9,901,000
11,551,100
11,262,000
13,514,400
15,766,800
2,790,500
3,348,600
3,906,600
5,680,300
6,816,300
7,952,400
10,539,000
12,646,800
14,754,600
2,092,900
2,511,500
2,930,000
4,191,100
5,029,300
5,867,500
4,917,500
5,901,000
6,884,500
1,894,100
2,272,900
2,651,700
3,639,800
4,367,700
5,095,700
7,422,500
8,907,000
10,391,500
3,526,000
4,231,200
4,936,400
6,346,800
7,616,100
8,885,500
8,663,100
10,395,700
12,128,300
2,135,600
2,562,700
2,989,800
2,631,300
3,157,600
3,683,800
3,602,000
4,322,400
5,042,800
1,654,800
2,426,500
4,147,200
1,570,100
2,089,700
3,622,500
1,985,700
2,911,800
4,976,700
1,884,100
2,507,600
4,347,000
2,316,700
3,397,100
5,806,100
2,198,100
2,925,600
5,071,500
2,318,600
2,782,300
3,246,000
4,113,300
4,936,000
5,758,600
6,676,400
8,011,700
9,347,000
1,173,400
1,408,000
1,642,700
2,492,300
2,990,800
3,489,200
4,726,300
5,671,500
6,616,800
784,800
941,700
1,098,700
1,481,000
1,777,100
2,073,300
1,918,100
2,301,700
2,685,300
4,063,600
4,876,300
5,689,000
- 885 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,167,900
6,201,500
7,235,100
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,399,400
8,879,300
10,359,200
1,958,600
2,350,300
2,742,000
2,906,700
3,488,100
4,069,400
3,496,000
4,195,200
4,894,400
1,310,400
1,572,500
1,834,600
1,760,100
2,112,100
2,464,100
3,201,900
3,842,200
4,482,600
624,900
749,800
874,800
1,191,000
1,429,200
1,667,400
1,731,300
2,077,600
2,423,800
836,600
1,003,900
1,171,200
1,316,400
1,579,700
1,843,000
2,120,500
2,544,500
2,968,600
1,299,900
1,559,900
1,819,900
1,964,800
2,357,700
2,750,700
3,041,600
3,650,000
4,258,300
4,282,400
5,138,800
5,995,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,647,900
17,558,900
7,977,500
21,070,700
9,307,100
24,582,500
6,625,000
7,950,000
9,275,000
8,398,200
10,077,900
11,757,500
12,083,700
14,500,400
16,917,200
5,176,700
7,938,200
11,659,600
5,180,300
6,035,800
10,005,500
6,212,100
9,525,900
13,991,500
6,216,300
7,243,000
12,006,700
7,247,400
11,113,500
16,323,400
7,252,400
8,450,200
14,007,800
3,113,000
3,735,600
4,358,200
3,820,400
4,584,500
5,348,500
4,527,100
5,432,600
6,338,000
3,762,300
5,348,800
6,894,400
4,514,700
6,418,600
8,273,300
5,267,200
7,488,400
9,652,200
4,726,000
5,671,200
6,616,400
7,033,600
8,440,300
9,847,000
18,056,600
21,667,900
25,279,200
4,053,100
5,495,800
10,747,200
4,863,700
6,594,900
12,896,600
5,674,300
7,694,100
15,046,100
2,916,700
3,500,100
4,083,400
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 886 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,772,700
2,127,300
2,481,800
697 U-4-12-I
698 U-4-12-II

2,554,500
2,971,400
3,065,400
3,565,600
3,576,200
4,159,900
699 U-4-12-III

3,854,700
4,625,600
5,396,600
1,935,900
2,323,100
2,710,300
2,282,300
2,738,700
3,195,200
2,729,700
3,275,600
3,821,600
2,903,100
3,476,400
3,483,800
4,171,700
4,064,400
4,867,000

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,838,000
7,005,600
8,173,200
2,331,100
2,797,400
3,263,600
2,904,300
3,485,200
4,066,000
4,064,600
4,877,500
5,690,400
3,802,300
4,562,700
5,323,200
7,832,600
9,399,100
10,965,600
9,605,500
11,526,600
13,447,700
7,233,700
8,260,000
12,935,500
8,680,400
9,912,000
15,522,600
10,127,100
11,564,000
18,109,700
6,801,000
8,161,200
9,521,400
9,287,400
11,144,800
13,002,300
11,771,800
14,126,200
16,480,600
3,547,500
4,257,000
4,966,500
6,778,100
8,133,700
9,489,400
10,634,000
12,760,800
14,887,700
6,956,600
8,348,000
9,739,300
10,107,800
12,129,400
14,150,900
12,621,400
15,145,700
17,670,000
1,120,400
1,236,300
1,367,600
1,344,400
1,483,600
1,641,100
1,568,500
1,730,900
1,914,700
3,364,100
4,036,900
4,709,800
5,588,000
6,705,600
7,823,200
9,212,600
11,055,100
12,897,600
2,906,800
3,488,200
4,069,500
3,900,200
4,680,200
5,460,200
5,224,300
6,269,200
7,314,100
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,677,300
8,012,800
9,348,200
10,251,700
12,302,100
14,352,400
1,390,400
1,685,100
1,668,500
2,022,100
1,946,600
2,359,200
- 887 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,922,900
9,507,500
11,092,100
9,496,100
11,395,400
13,294,600
13,550,700
16,260,900
18,971,000
1,680,600
2,016,700
2,352,800
1,854,500
2,051,400
2,225,400
2,461,700
2,596,300
2,872,000
1,756,600
2,107,900
2,459,200
1,938,400
2,326,000
2,713,700
2,144,200
2,573,000
3,001,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,889,700
2,267,600
2,645,600
743 W-1-12-II
744 W-1-12-III

2,358,700
4,176,700
2,830,400
5,012,000
3,302,100
5,847,300
745 W-1-13-I
1,942,500
2,330,900
2,719,400
746 W-1-13-II
747 W-1-13-III

2,108,800
2,832,700
2,530,600
3,399,300
2,952,400
3,965,800
748 W-1-20-I
749 W-1-20-II

6,505,100
8,128,200
7,806,100
9,753,800
9,107,100
11,379,400
750 W-1-20-III
9,422,600
11,307,200
13,191,700
751 W-1-30-I
3,672,200
4,406,700
5,141,100
752 W-1-30-II
5,857,200
7,028,600
8,200,000
753 W-1-30-III
14,370,900
17,245,100
20,119,200
754 W-4-10-I
2,736,200
3,283,400
3,830,600
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
4,056,300
8,016,000
2,488,400
3,777,700
4,598,200
4,867,500
9,619,200
2,986,000
4,533,200
5,517,800
5,678,800
11,222,400
3,483,700
5,288,800
6,437,400
2,831,600
3,397,900
3,964,200
3,887,500
4,665,100
5,442,600
4,237,600
5,085,200
5,932,700
979,000
1,337,400
1,663,100
1,308,400
1,557,300
1,992,400
1,593,300
1,769,400
2,449,900
2,119,800
2,834,800
3,842,000
1,564,200
2,824,200
4,175,600
2,403,400
3,190,300
4,532,000
2,147,800
2,579,600
3,545,800
1,174,800
1,604,900
1,995,700
1,570,000
1,868,700
2,390,800
1,911,900
2,123,300
2,939,800
2,543,800
3,401,700
4,610,400
1,877,100
3,389,100
5,010,700
2,884,100
3,828,300
5,438,400
2,577,300
3,095,500
4,254,900
1,370,600
1,872,300
2,328,400
1,831,700
2,180,200
2,789,300
2,230,600
2,477,200
3,429,800
2,967,800
3,968,700
5,378,900
2,189,900
3,953,900
5,845,800
3,364,800
4,466,400
6,344,800
3,006,900
3,611,400
4,964,100
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 888 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,236,200
1,483,400
1,730,600
3,032,600
3,639,100
4,245,600
4,338,300
5,205,900
6,073,600
- 889 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
960,200
1,245,500
2,316,100
1,914,000
2,487,300
457,500
813,300
357,800
776,300
677,800
769,500
1,156,900
1,578,100
1,446,300
468,500
1,081,400
392,300
673,500
2,051,400
734,700
1,735,000
423,300
987,500
1,545,700
1,296,400
317,900
963,600
535,700
275,500
297,800
262,900
314,400
437,700
376,100
354,100
318,200
472,100
206,100
243,000
278,600
5,653,000
2,259,200
2,266,800
583,100
954,800
597,800
1,215,100
778,600
445,900
336,700
543,000
299,700
256,600
2,002,500
934,500
534,000
2,084,500
1,389,700
270,600
2,258,200
1,563,400
3,672,900
812,200
499,600
268,700
223,900
252,300
3,847,800
1,873,000
- 890 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,380,400
4,212,900
3,493,000
2,660,900
877,200
2,961,600
1,933,800
475,400
4,446,500
4,025,300
2,699,000
2,557,000
316,000
303,700
1,221,900
333,900
297,500
328,800
1,128,600
1,541,700
1,346,600
1,189,200
720,200
299,300
527,500
362,100
327,000
318,600
404,500
461,300
270,400
776,000
1,414,300
1,085,600
2,552,200
332,300
332,300
2,358,400
1,371,400
263,100
1,217,000
3,161,500
725,900
571,700
280,100
248,200
303,400
423,100
1,013,000
892,900
625,000
466,300
256,600
1,085,300
869,600
371,600
424,000
1,389,400
307,200
1,419,500
1,086,000
331,200
367,100
358,600
217,000
1,183,300
1,625,800
322,200
- 891 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
987,500
368,600
398,500
369,000
585,400
450,300
1,127,800
332,700
925,800
1,237,100
270,900
1,649,100
893,600
1,931,200
974,900
430,500
331,200
71,600
429,200
969,900
378,000
510,600
292,000
113,800
294,800
4,390,800
2,495,800
4,165,500
1,023,300
571,700
389,600
881,100
466,000
937,900
543,000
323,300
541,100
243,600
371,800
356,300
833,400
1,699,800
1,367,600
1,205,800
851,000
313,100
313,100
313,100
255,700
162,200
255,000
311,700
337,200
248,400
219,100
100,400
110,400
81,600
95,800
91,400
139,500
125,100
174,100
191,200
111,000
134,800
92,100
143,800
204,000
- 892 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
145,200
195,400
552,400
640,300
137,300
265,800
167,100
238,600
447,100
382,800
275,200
260,500
136,500
134,100
306,800
193,600
277,700
192,200
150,500
1,929,800
1,985,000
315,400
326,600
624,700
805,400
799,600
413,100
1,287,300
285,600
335,700
336,800
269,700
340,600
322,300
151,000
331,800
294,100
266,000
300,900
2,490,600
323,400
896,300
321,500
457,400
492,900
393,200
778,400
797,100
849,900
743,400
1,362,400
221,500
1,537,800
292,000
779,500
1,771,600
2,048,400
894,900
324,300
632,500
630,000
292,000
2,288,600
1,800,100
146,700
163,400
212,300
278,400
- 893 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,054,800
460,200
948,500
1,144,300
548,400
762,800
527,300
582,400
666,200
314,200
742,800
195,000
722,300
1,135,600
79,200
- 894 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
2,055,000
2,466,000
2,877,000
A-4-10-II
SEPTIKEMIA (SEDANG)
3,510,800
4,213,000
4,915,100
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,733,700
3,025,800
5,680,400
3,631,000
6,627,100
4,236,200
5
6
A-4-11-II
A-4-11-III

4,306,600
5,960,800
5,168,000
7,152,900
6,029,300
8,345,100
A-4-12-I
2,740,000
3,288,000
3,835,900
8
9
A-4-12-II
A-4-12-III

3,412,200
3,641,700
4,094,600
4,370,100
4,777,100
5,098,400
10 A-4-13-I
11 A-4-13-II

1,647,700
2,482,200
1,977,300
2,978,700
2,306,800
3,475,100
12 A-4-13-III
2,978,700
3,574,400
4,170,100
2,284,600
2,741,600
3,198,500
2,773,200
3,327,800
3,882,400
3,327,800
3,993,400
4,658,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,586,900
5,369,100
4,304,200
6,442,900
5,021,600
7,516,700
18 A-4-15-III
INFEKSI HIV (BERAT)
6,737,800
8,085,300
9,432,900
19 B-1-01-I
20 B-1-01-II

24,556,900
27,092,800
29,468,300
32,511,400
34,379,600
37,930,000
21 B-1-01-III
22 B-1-10-I

47,526,500
4,243,000
57,031,700
5,091,600
66,537,000
5,940,200
23 B-1-10-II
9,417,600
11,301,200
13,184,700
24 B-1-10-III
25 B-1-11-I

18,591,700
5,669,500
22,310,000
6,803,300
26,028,400
7,937,200
26 B-1-11-II
27 B-1-11-III

7,347,200
9,492,500
8,816,600
11,391,000
10,286,100
13,289,400
28 B-1-12-I
5,535,900
6,643,100
7,750,300
29 B-1-12-II
6,156,900
7,388,300
8,619,700
30 B-1-12-III
9,631,800
11,558,200
13,484,600
4,409,400
5,291,300
6,173,200
7,255,200
8,706,200
10,157,200
9,387,500
11,265,100
13,142,600
6,058,700
7,270,500
8,482,200
6,738,400
8,086,100
9,433,700
10,541,400
1,874,600
2,992,400
4,128,000
12,649,700
2,249,500
3,590,800
4,953,700
14,758,000
2,624,400
4,189,300
5,779,300
3,952,300
4,742,800
5,533,200
5,533,300
6,639,900
7,746,600
6,703,500
8,044,200
9,384,900
3,573,300
5,088,300
7,570,200
3,408,700
4,288,000
6,105,900
9,084,300
4,090,400
5,002,600
7,123,600
10,598,300
4,772,100
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 895 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,970,900
4,765,100
5,559,300
48 B-4-13-III
49 B-4-14-I

5,470,300
3,405,000
6,564,400
4,086,000
7,658,400
4,767,000
50 B-4-14-II
3,972,400
4,766,900
5,561,300
51 B-4-14-III
52 C-4-10-I

5,321,100
3,150,300
6,385,300
3,780,300
7,449,500
4,410,400
53 C-4-10-II
54 C-4-10-III

6,044,500
10,669,100
7,253,500
12,803,000
8,462,400
14,936,800
55 C-4-11-I
3,589,800
4,307,800
5,025,800
56 C-4-11-II
57 C-4-11-III

4,803,700
7,385,800
5,764,500
8,863,000
6,725,200
10,340,100
58 C-4-12-I
59 C-4-12-II
2,390,200
4,707,800
2,868,300
5,649,400
3,346,300
6,591,000
60 C-4-12-III
RADIOTERAPI (BERAT)
12,091,000
14,509,200
16,927,400
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,797,000
3,381,900
2,156,400
4,058,300
2,515,800
4,734,700
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
4,578,000
2,985,700
5,493,600
3,582,900
6,409,200
4,180,000
65 C-4-14-II
4,188,400
5,026,100
5,863,800
66 C-4-14-III
67 D-1-10-I

6,240,600
14,611,600
7,488,700
17,533,900
8,736,900
20,456,200
68 D-1-10-II
69 D-1-10-III

22,254,500
35,436,800
26,705,400
42,524,100
31,156,300
49,611,500
70 D-1-11-I
4,829,800
5,795,700
6,761,700
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
12,332,700
16,026,800
14,799,200
19,232,100
17,265,700
22,437,500
4,186,900
5,024,200
5,861,600
11,538,300
13,846,000
16,153,700
18,303,200
21,963,800
25,624,500
2,503,800
3,763,600
5,921,100
3,277,700
5,890,000
8,091,400
2,825,900
3,919,500
6,018,600
3,004,600
4,516,300
7,105,300
3,933,300
7,068,000
9,709,600
3,391,000
4,703,400
7,222,300
3,505,300
5,269,000
8,289,500
4,588,800
8,245,900
11,327,900
3,956,200
5,487,300
8,426,100
2,421,700
2,906,000
3,390,400
3,427,500
4,113,000
4,798,500
4,383,900
5,260,700
6,137,500
2,597,400
3,116,800
3,636,300
4,252,600
5,103,100
5,953,600
5,201,300
6,241,600
7,281,800
4,623,700
5,548,400
6,473,100
6,056,500
7,267,800
8,479,100
93 E-1-01-III
10,517,200
12,620,600
14,724,100
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,606,800
4,377,800
9,227,200
4,328,200
5,253,400
11,072,600
5,049,600
6,129,000
12,918,100
6,094,000
7,312,700
8,531,500
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 896 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,395,700
2,874,800
3,353,900
104 E-4-11-II
105 E-4-11-III

3,652,400
4,949,200
4,382,800
5,939,100
5,113,300
6,928,900
106 E-4-12-I
107 E-4-12-II

2,752,600
4,766,800
3,303,100
5,720,100
3,853,600
6,673,500
108 E-4-12-III

(RINGAN)
(SEDANG)
5,650,400
6,780,400
7,910,500
2,997,400
3,596,900
4,196,400
4,390,700
5,268,900
6,147,000
111 E-4-13-III
5,739,500
6,887,500
8,035,400
112 F-4-10-I
113 F-4-10-II
3,191,200
3,667,600
3,829,400
4,401,100
4,467,600
5,134,700
114 F-4-10-III
115 F-4-11-I
4,401,100
3,086,400
5,281,400
3,703,600
6,161,600
4,320,900
116 F-4-11-II
3,595,900
4,315,100
5,034,300
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,611,300
5,533,600
6,455,800
1,691,800
2,030,200
2,368,600
2,405,200
2,886,300
3,367,300
5,225,300
6,270,300
7,315,400
2,486,100
3,280,500
4,247,000
1,418,500
1,819,400
2,448,100
2,983,400
3,936,600
5,096,500
1,702,100
2,183,200
2,937,700
3,480,600
4,592,700
5,945,900
1,985,800
2,547,100
3,427,400
127 F-4-15-I
2,259,000
2,710,800
3,162,600
128 F-4-15-II
3,366,200
4,039,400
4,712,700
129 F-4-15-III
4,444,400
5,333,300
6,222,200
4,444,700
5,333,600
6,222,600
5,167,700
6,201,200
7,234,700
6,898,000
8,277,500
9,657,100
133 F-4-17-I

1,049,700
1,259,600
1,469,500
134 F-4-17-II
3,076,400
3,691,700
4,307,000
135
136
137
138
139
140
141

(RINGAN)
3,282,300
3,862,100
4,249,400
6,550,800
2,951,500
3,779,600
4,705,600
3,938,700
4,634,500
5,099,300
7,860,900
3,541,900
4,535,500
5,646,700
4,595,200
5,406,900
5,949,200
9,171,100
4,132,200
5,291,400
6,587,800
11,256,100
13,507,300
15,758,500
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
8,202,300
9,842,800
11,483,200
11,304,500
13,565,300
15,826,200
3,636,300
4,363,600
5,090,900
5,081,100
6,097,400
7,113,600
6,306,700
7,568,000
8,829,400
- 897 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
14,967,500
17,960,900
20,954,400
148 G-1-11-I
149 G-1-11-II

9,582,100
17,518,400
11,498,600
21,022,100
13,415,000
24,525,800
150 G-1-11-III
32,299,600
38,759,500
45,219,500
4,000,900
4,801,100
5,601,200
7,499,800
8,999,800
10,499,800
10,220,800
12,265,000
14,309,100
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,206,900
3,241,300
1,448,300
3,889,500
1,689,700
4,537,800
156 G-1-13-III
157 G-1-20-I

7,313,700
5,068,600
8,776,500
6,082,300
10,239,200
7,096,000
158 G-1-20-II
6,027,500
7,233,000
8,438,500
159 G-1-20-III
14,067,500
16,881,000
19,694,500
160 G-1-30-I
7,435,300
8,922,300
10,409,400
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
15,059,300
21,150,400
18,071,100
25,380,500
21,083,000
29,610,500
3,434,300
4,121,200
4,808,100
4,197,900
5,037,500
5,877,100
5,760,200
6,912,300
8,064,300
3,595,200
4,314,200
5,033,300
4,775,800
5,730,900
6,686,100
7,017,200
8,420,700
9,824,100
3,988,500
4,786,100
5,583,800
5,037,700
6,045,200
7,052,800
7,316,600
8,780,000
10,243,300
2,395,900
2,875,100
3,354,300
4,178,000
5,013,600
5,849,200
4,955,200
5,946,300
6,937,300
4,064,400
4,877,300
5,690,200
5,433,800
6,520,600
7,607,300
6,820,100
8,184,100
9,548,100
3,321,000
3,985,200
4,649,400
3,963,400
4,756,100
5,548,800
5,594,000
6,712,800
7,831,600
2,737,700
3,285,200
3,832,800
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
17,528,200
21,033,800
24,539,400
33,709,900
40,451,900
47,193,800
11,537,900
13,584,700
13,845,500
16,301,600
16,153,000
19,018,500
- 898 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,634,700
4,361,600
5,088,500
183 G-4-16-III
5,176,000
6,211,300
7,246,500
3,646,400
4,375,700
5,105,000
4,781,300
5,737,500
6,693,800
6,007,900
7,209,400
8,411,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,591,200
4,309,400
5,027,600
188 G-4-18-II
4,800,300
5,760,400
6,720,400
189 G-4-18-III
5,371,100
6,445,400
7,519,600
2,996,200
3,595,400
4,194,700
5,064,300
6,077,100
7,090,000
6,649,200
7,979,000
9,308,800
193 G-4-20-I

2,096,000
2,515,200
2,934,400
194 G-4-20-II
2,963,100
3,555,700
4,148,300
195 G-4-20-III
196 G-4-21-I

4,894,300
2,182,600
5,873,100
2,619,200
6,852,000
3,055,700
197 G-4-21-II
198 G-4-21-III

3,694,100
4,341,500
4,433,000
5,209,800
5,171,800
6,078,100
199 G-4-22-I
2,757,200
3,308,600
3,860,000
200 G-4-22-II
201 G-4-22-III

3,522,800
4,116,300
4,227,400
4,939,500
4,931,900
5,762,800
202 G-4-23-I
203 G-4-23-II

2,148,600
2,695,700
2,578,300
3,234,900
3,008,000
3,774,000
204 G-4-23-III
3,838,100
4,605,700
5,373,300
205 G-4-24-I
206 G-4-24-II

2,393,200
2,990,000
2,871,800
3,588,000
3,350,500
4,186,000
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,981,200
2,045,000
2,586,100
3,427,100
5,977,400
2,453,900
3,103,300
4,112,500
6,973,700
2,862,900
3,620,500
4,797,900
3,231,600
3,877,900
4,524,200
3,759,300
4,511,200
5,263,100
5,621,300
6,745,600
7,869,900
4,615,900
5,884,100
8,001,900
7,023,600
8,726,100
12,222,300
2,768,500
3,756,300
7,383,100
2,389,200
2,725,400
3,902,600
2,816,900
3,365,700
5,640,400
5,539,100
7,060,900
9,602,300
8,428,300
10,471,300
14,666,700
3,322,200
4,507,500
8,859,700
2,867,100
3,270,500
4,683,100
3,380,300
4,038,900
6,768,400
6,462,300
8,237,800
11,202,700
9,833,000
12,216,600
17,111,200
3,875,900
5,258,800
10,336,400
3,344,900
3,815,600
5,463,600
3,943,700
4,712,000
7,896,500
229 I-1-01-I
37,836,400
45,403,700
52,971,000
230 I-1-01-II
38,668,800
46,402,600
54,136,300
231 I-1-01-III

(RINGAN)
61,038,200
73,245,800
85,453,500
20,991,500
25,189,800
29,388,100
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 899 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
17,284,100
20,740,900
24,197,700
245 I-1-06-II
25,037,400
30,044,900
35,052,400
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
29,874,200
35,849,100
41,823,900
20,574,600
24,689,500
28,804,400
25,382,900
30,459,500
35,536,100
27,692,700
33,231,200
38,769,700
3,289,400
3,947,300
4,605,200
3,657,500
4,389,000
5,120,500
4,867,000
5,840,500
6,813,900
9,468,600
11,362,300
13,256,000
15,464,100
18,556,900
21,649,700
20,345,300
24,414,400
28,483,400
9,184,400
11,021,300
12,858,100
12,230,900
14,677,000
17,123,200
15,084,000
18,100,900
21,117,700
18,798,200
22,557,800
26,317,400
23,363,400
28,036,000
32,708,700
30,614,100
36,736,900
42,859,700
3,571,100
4,987,000
9,603,000
4,285,300
5,984,400
11,523,500
4,999,600
6,981,800
13,444,100
9,257,600
11,109,100
12,960,700
20,946,300
25,135,500
29,324,800
24,161,200
28,993,400
33,825,700
10,719,400
12,863,300
15,007,200
13,421,700
16,106,100
18,790,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
27,078,800
32,494,500
37,910,300
33,376,300
40,051,500
46,726,800
12,124,700
14,549,700
16,974,600
16,807,400
20,168,900
23,530,400
21,329,900
25,595,900
29,861,800
18,271,300
21,925,600
25,579,900
28,837,100
34,604,500
40,371,900
46,067,100
55,280,500
64,493,900
23,443,800
28,132,600
32,821,300
28,132,700
33,759,200
39,385,700
38,710,300
46,452,400
54,194,500
- 900 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
20,853,000
25,023,600
29,194,200
279 I-1-40-III
27,852,500
33,423,000
38,993,500
280 I-4-10-I
281 I-4-10-II

3,179,500
5,677,400
3,815,400
6,812,900
4,451,300
7,948,400
282 I-4-10-III
8,180,400
9,816,500
11,452,500
283 I-4-11-I
284 I-4-11-II

4,891,700
6,053,500
5,870,000
7,264,200
6,848,400
8,474,900
285 I-4-11-III
286 I-4-12-I

11,198,300
2,812,100
13,438,000
3,374,500
15,677,700
3,936,900
287 I-4-12-II
3,259,600
3,911,500
4,563,400
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,911,500
4,693,800
5,476,000
2,861,600
3,433,900
4,006,200
5,109,700
6,131,600
7,153,600
7,362,300
8,834,800
10,307,300
2,702,300
2,795,300
4,900,100
3,242,700
3,354,300
5,880,100
3,783,200
3,913,400
6,860,100
4,653,300
5,584,000
6,514,600
6,330,500
7,596,600
8,862,700
297 I-4-15-III
7,596,600
9,115,900
10,635,300
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,705,500
2,738,700
3,286,400
1,920,000
2,235,300
2,682,300
2,046,600
3,286,400
3,943,700
2,304,000
2,682,300
3,218,800
2,387,700
3,834,100
4,601,000
2,688,000
3,129,400
3,755,300
3,289,800
3,947,700
4,605,700
5,008,800
6,010,600
7,012,300
6,800,300
8,160,400
9,520,400
307 I-4-19-I
3,174,000
3,808,800
4,443,600
308 I-4-19-II

(SEDANG)
4,954,800
5,945,700
6,936,700
309 I-4-19-III
5,915,000
7,098,000
8,281,100
310
311
312
313
314

3,305,000
3,817,300
5,707,700
2,473,100
3,133,500
3,966,100
4,580,800
6,849,200
2,967,800
3,760,200
4,627,100
5,344,300
7,990,800
3,462,400
4,386,900
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
16,602,500
19,923,000
23,243,500
12,082,600
14,499,200
16,915,700
15,094,500
18,113,500
21,132,400
15,867,500
19,041,000
22,214,500
9,139,800
10,967,800
12,795,800
19,012,900
22,815,500
26,618,100
29,463,200
35,355,800
41,248,400
8,435,100
10,122,100
11,809,100
- 901 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
4,522,900
5,427,400
6,332,000
316 I-4-22-I
317 I-4-22-II
2,772,000
3,450,700
3,326,400
4,140,900
3,880,800
4,831,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,043,900
6,052,600
7,061,400
2,713,000
3,255,600
3,798,200
3,330,800
3,996,900
4,663,100
6,508,100
7,809,700
9,111,300
2,443,000
2,931,700
3,420,300
5,625,700
6,750,800
7,875,900
7,112,700
8,535,200
9,957,700
44,074,600
52,889,600
61,704,500
49,878,600
59,854,400
69,830,100
56,428,400
67,714,100
78,999,800
23,388,800
28,066,600
32,744,300
32,566,500
39,079,800
45,593,100
53,778,400
64,534,100
75,289,800
7,102,600
8,523,100
9,943,600
14,372,100
17,246,500
20,120,900
14,936,100
17,923,300
20,910,600
10,063,600
12,076,300
14,089,000
13,297,400
15,956,900
18,616,400
20,363,600
24,436,300
28,509,000
5,927,300
7,112,700
8,298,200
10,737,200
12,884,600
15,032,000
30,992,500
37,191,000
43,389,500
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,421,800
5,001,700
7,566,800
2,161,700
3,010,800
4,035,700
3,671,600
4,179,600
5,835,900
3,246,300
4,518,800
8,430,600
3,579,100
5,824,300
6,890,700
4,366,900
5,217,200
7,019,200
2,906,200
6,002,000
9,080,200
2,594,000
3,612,900
4,842,800
4,405,900
5,015,500
7,003,000
3,895,600
5,422,500
10,116,700
4,295,000
6,989,200
8,268,900
5,240,200
6,260,600
8,423,000
3,390,500
7,002,400
10,593,500
3,026,400
4,215,100
5,649,900
5,140,200
5,851,400
8,170,200
4,544,800
6,326,300
11,802,800
5,010,800
8,154,000
9,647,000
6,113,600
7,304,000
9,826,900
3,638,500
4,366,200
5,093,900
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 902 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
5,113,100
6,135,700
7,158,300
360 J-4-16-III
6,464,700
7,757,600
9,050,500
361 J-4-17-I
362 J-4-17-II

2,990,700
3,581,400
3,588,800
4,297,700
4,187,000
5,014,000
363 J-4-17-III
364 J-4-18-I

4,699,900
2,241,500
5,639,900
2,689,800
6,579,900
3,138,100
365 J-4-18-II
3,082,900
3,699,500
4,316,100
366 J-4-18-III
367 J-4-19-I

3,245,200
4,212,500
3,894,200
5,055,000
4,543,300
5,897,500
368 J-4-19-II
369 J-4-19-III

4,777,200
5,275,900
5,732,700
6,331,000
6,688,100
7,386,200
370 J-4-20-I
4,180,300
5,016,400
5,852,500
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,792,300
6,790,300
6,950,700
8,148,400
8,109,200
9,506,500
2,905,300
3,486,300
4,067,400
4,680,300
5,616,400
6,552,400
6,531,000
7,837,200
9,143,400
6,438,900
7,726,700
9,014,500
8,091,900
9,710,200
11,328,600
9,483,900
11,380,700
13,277,500
7,230,300
8,676,400
10,122,400

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
9,492,500
14,365,300
11,391,000
17,238,300
13,289,500
20,111,400
2,701,700
3,242,000
3,782,300
3,513,800
4,216,600
4,919,400
6,961,400
8,353,700
9,746,000
3,046,900
3,351,600
3,382,100
3,656,300
4,022,000
4,058,500
4,265,700
4,692,300
4,735,000
4,944,600
5,933,600
6,922,500
5,795,000
6,954,000
8,113,000
9,104,700
10,925,700
12,746,600
9,574,400
13,373,300
19,526,500
11,489,300
16,048,000
23,431,700
13,404,200
18,722,600
27,337,000
5,662,200
6,794,700
7,927,100
10,056,000
12,067,200
14,078,400
13,837,200
16,604,700
19,372,100
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
6,317,800
7,581,300
8,844,900
398 K-1-40-II

(SEDANG)
6,965,500
8,358,600
9,751,800
399 K-1-40-III
11,804,100
14,164,900
16,525,700
400
401
402
403
404

4,827,400
6,269,000
8,859,200
3,985,300
5,726,200
5,792,900
7,522,800
10,631,000
4,782,300
6,871,500
6,758,300
8,776,600
12,402,900
5,579,400
8,016,700
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 903 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
8,729,400
10,475,200
12,221,100
406 K-4-11-I
407 K-4-11-II

2,335,900
3,319,500
2,803,100
3,983,400
3,270,300
4,647,300
408 K-4-11-III
409 K-4-12-I

3,983,400
2,395,700
4,780,100
2,874,800
5,576,700
3,353,900
410 K-4-12-II
3,223,800
3,868,600
4,513,300
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
5,333,200
6,399,900
7,466,500
3,229,500
3,875,400
4,521,300
4,177,600
5,013,100
5,848,600
6,434,800
7,721,700
9,008,700
2,047,500
2,457,000
2,866,500
2,748,400
3,298,100
3,847,800
4,410,200
5,292,200
6,174,200
418 K-4-15-I
2,115,600
2,538,700
2,961,800
419 K-4-15-II
3,136,900
3,764,200
4,391,600
420 K-4-15-III
4,402,500
5,283,000
6,163,500
421 K-4-16-I
2,989,300
3,587,200
4,185,000
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,585,000
4,183,200
4,302,000
5,019,800
5,019,000
5,856,400
1,535,300
1,842,400
2,149,500
2,099,900
2,519,900
2,939,900
2,519,900
3,023,900
3,527,900
1,356,700
1,628,000
1,899,300
1,927,900
2,313,500
2,699,100
429 K-4-18-III
2,313,500
2,776,200
3,238,900
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
15,265,200
23,042,400
30,788,500
7,202,300
12,358,600
15,343,500
18,318,300
27,650,900
36,946,200
8,642,700
14,830,400
18,412,100
21,371,300
32,259,400
43,103,900
10,083,200
17,302,100
21,480,800
4,036,300
4,843,600
5,650,800
8,096,000
9,715,100
11,334,300
13,627,300
16,352,700
19,078,200
5,298,900
8,528,000
12,198,400
1,385,900
1,608,700
1,867,300
2,902,400
3,989,100
9,064,400
1,378,400
1,823,100
4,822,600
6,358,600
10,233,600
14,638,100
1,663,100
1,930,500
2,240,700
3,482,900
4,786,900
10,877,300
1,654,000
2,187,700
5,787,100
7,418,400
11,939,200
17,077,800
1,940,300
2,252,200
2,614,200
4,063,300
5,584,700
12,690,200
1,929,700
2,552,300
6,751,600
2,474,700
2,969,700
3,464,600
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 904 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,908,500
3,490,200
4,071,900
4,279,900
5,135,800
5,991,800
2,386,900
2,864,200
3,341,600
3,585,200
4,302,200
5,019,200
5,053,700
6,064,400
7,075,200
8,437,300
10,124,800
11,812,300
11,992,500
14,391,000
16,789,500
16,845,800
20,215,000
23,584,200
7,478,100
8,973,700
10,469,300
12,267,600
20,842,300
14,721,100
25,010,700
17,174,600
29,179,200
20,303,600
24,364,300
28,425,000
23,747,900
28,497,500
33,247,100
29,392,100
35,270,500
41,148,900
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
9,376,400
11,251,700
13,127,000
467 M-1-04-II
12,046,000
14,455,100
16,864,300
468 M-1-04-III
14,413,300
17,295,900
20,178,600
469 M-1-05-I
470 M-1-05-II

5,953,000
9,629,200
7,143,600
11,555,000
8,334,200
13,480,900
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
12,300,100
14,760,100
17,220,100
6,663,700
7,996,400
9,329,200
8,927,100
10,712,500
12,497,900
18,185,200
21,822,300
25,459,300
10,969,600
13,163,500
15,357,400
24,071,400
28,885,600
33,699,900
51,919,700
62,303,600
72,687,600
10,019,400
12,023,200
14,027,100
12,800,800
15,360,900
17,921,100
480 M-1-20-III
31,870,000
38,244,000
44,618,000
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
6,873,500
11,137,900
15,926,300
8,248,200
13,365,500
19,111,500
9,623,000
15,593,100
22,296,800
3,498,900
4,198,700
4,898,500
6,205,100
7,446,200
8,687,200
8,859,700
10,631,700
12,403,600
4,192,900
6,958,100
11,428,200
5,031,500
8,349,700
13,713,800
5,870,000
9,741,300
15,999,400
6,475,600
7,770,700
9,065,800
8,141,300
9,769,600
11,397,800
12,298,400
14,758,100
17,217,800
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 905 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,402,400
2,882,900
3,363,400
500 M-4-10-II
501 M-4-10-III
3,582,800
6,778,600
4,299,300
8,134,400
5,015,900
9,490,100
2,993,600
3,592,300
4,191,000
6,563,400
7,876,000
9,188,700
9,489,500
11,387,400
13,285,300
2,389,600
2,867,500
3,345,400
3,974,500
4,769,400
5,564,300
5,316,300
6,379,600
7,442,900
3,978,900
4,774,600
5,570,400
5,978,100
7,173,700
8,369,300
11,663,100
13,995,700
16,328,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
4,537,800
5,445,300
6,352,900
512 M-4-14-II
5,596,700
6,716,000
7,835,300
513 M-4-14-III
514 M-4-15-I
8,410,200
2,690,800
10,092,200
3,228,900
11,774,200
3,767,100
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,586,600
8,139,100
2,303,700
3,689,100
6,197,500
4,303,900
9,766,900
2,764,500
4,426,900
7,437,000
5,021,200
11,394,700
3,225,200
5,164,800
8,676,400
2,989,900
3,587,900
4,185,900
4,181,700
5,018,100
5,854,400
5,839,500
7,007,400
8,175,300
2,259,900
3,405,800
4,100,700
2,711,900
4,086,900
4,920,800
3,163,900
4,768,100
5,741,000
2,356,700
2,828,100
3,299,400
3,969,600
4,763,500
5,557,500
7,752,900
9,303,500
10,854,100
2,377,300
2,852,700
3,328,200
3,481,100
4,177,300
4,873,600
3,890,600
4,668,700
5,446,800
2,393,700
2,872,500
3,351,200
2,993,900
3,592,600
4,191,400
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
11,997,200
14,396,600
16,796,000
13,196,900
15,836,300
18,475,600
15,108,700
18,130,400
21,152,200
6,819,900
8,183,900
9,547,800
8,099,300
18,229,700
9,719,100
21,875,600
11,339,000
25,521,500
- 906 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,712,200
8,054,600
9,397,100
535 N-1-01-I

111,438,500
133,726,200
156,013,900
536 N-1-01-II
111,438,500
133,726,200
156,013,900
537 N-1-01-III
538 N-1-11-I

111,438,500
6,904,700
133,726,200
8,285,600
156,013,900
9,666,600
539 N-1-11-II
540 N-1-11-III

10,918,000
17,021,100
13,101,600
20,425,400
15,285,200
23,829,600
3,519,100
4,222,900
4,926,700
7,006,100
8,407,300
9,808,600
15,203,500
18,244,300
21,285,000
7,694,100
9,232,900
10,771,700

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
10,767,400
15,067,700
12,920,900
18,081,200
15,074,400
21,094,800
7,041,400
8,449,700
9,858,000
10,652,300
12,782,700
14,913,200
12,259,800
14,711,700
17,163,700
6,323,700
7,588,400
8,853,200
8,587,400
10,304,900
12,022,400
9,994,600
11,993,600
13,992,500
2,686,700
3,224,000
3,761,400
3,249,600
3,899,500
4,549,400
4,779,700
5,735,600
6,691,600
2,062,500
3,603,400
4,483,400
2,353,200
4,366,500
5,255,700
3,548,000
4,279,300
6,557,700
2,475,000
4,324,100
5,380,000
2,823,900
5,239,700
6,306,900
4,257,600
5,135,100
7,869,200
2,887,500
5,044,700
6,276,700
3,294,500
6,113,000
7,358,000
4,967,200
5,991,000
9,180,700
2,071,400
2,485,700
2,900,000
2,939,200
3,527,100
4,114,900
4,711,500
5,653,800
6,596,200
2,447,100
2,936,500
3,425,900
3,036,400
3,643,700
4,251,000
3,465,100
4,158,100
4,851,100
2,996,400
3,595,700
4,195,000
4,276,900
5,132,300
5,987,600
5,692,900
6,831,400
7,970,000
5,273,700
5,570,400
6,328,400
6,684,400
7,383,100
7,798,500
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 907 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

6,983,200
8,379,900
9,776,500
2,785,300
3,342,400
3,899,500
3,095,600
3,714,700
4,333,800
3,851,000
4,621,100
5,391,300
1,973,400
2,368,100
2,762,700
2,370,000
2,844,000
3,318,000
2,978,000
3,573,600
4,169,200
1,686,700
2,024,000
2,361,400

MAYOR (RINGAN)
MAYOR (SEDANG)
1,996,300
2,395,600
2,395,600
2,874,700
2,794,900
3,353,800
44,065,800
52,878,900
61,692,100
54,524,800
65,429,700
76,334,700
63,996,800
76,796,100
89,595,500
74,241,000
89,089,200
103,937,400
85,162,000
102,194,400
119,226,800
97,303,600
116,764,400
136,225,100
8,022,600
9,627,100
11,231,700
11,903,000
14,283,500
16,664,100
13,471,800
16,166,100
18,860,500
23,787,900
28,545,500
33,303,000
40,048,000
48,057,600
56,067,200
57,418,700
68,902,500
80,386,200
16,821,900
20,186,300
23,550,600
24,389,000
29,266,800
34,144,600
34,999,200
41,999,000
48,998,900
4,268,100
5,121,700
5,975,300
11,966,700
14,360,000
16,753,400
15,852,900
19,023,500
22,194,100
4,134,100
4,960,900
5,787,700
11,591,000
13,909,200
16,227,400
15,355,200
18,426,200
21,497,300
4,194,200
5,033,000
5,871,900
5,951,500
7,141,700
8,332,000
9,636,700
11,564,000
13,491,300
7,293,300
8,751,900
10,210,600
10,820,900
12,985,000
15,149,200
- 908 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
12,247,100
14,696,500
17,145,900
6,342,000
7,610,400
8,878,800
9,017,400
10,820,900
12,624,300
10,205,900
12,247,100
14,288,200
5,447,600
6,537,200
7,626,700
8,498,300
10,198,000
11,897,700
11,599,800
13,919,800
16,239,800
2,874,200
3,449,000
4,023,800
5,850,700
7,020,800
8,190,900
10,855,200
13,026,200
15,197,300
2,155,700
2,586,800
3,017,900
4,316,800
5,180,200
6,043,500
5,065,000
6,078,000
7,091,000
1,950,900
2,341,100
2,731,300
3,749,000
4,498,800
5,248,600
7,645,200
9,174,200
10,703,300
3,631,800
4,358,100
5,084,500
6,537,200
7,844,600
9,152,000
8,923,000
10,707,500
12,492,100
2,199,600
2,639,500
3,079,500
2,710,300
3,252,300
3,794,400
3,710,100
4,452,100
5,194,100
1,704,400
2,499,300
4,271,700
1,617,200
2,152,400
3,731,200
2,045,300
2,999,200
5,126,000
1,940,600
2,582,900
4,477,400
2,386,200
3,499,100
5,980,300
2,264,000
3,013,400
5,223,700
2,388,100
2,865,700
3,343,400
4,236,700
5,084,000
5,931,400
6,876,700
8,252,000
9,627,400
1,208,600
1,450,300
1,692,000
2,567,100
3,080,500
3,593,900
4,868,100
5,841,700
6,815,300
808,300
970,000
1,131,600
1,525,400
1,830,500
2,135,500
1,975,600
2,370,800
2,765,900
4,185,500
5,022,600
5,859,700
- 909 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
5,323,000
6,387,600
7,452,200
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
7,621,400
9,145,700
10,669,900
2,017,300
2,420,800
2,824,300
2,993,900
3,592,700
4,191,500
3,600,900
4,321,100
5,041,200
1,349,800
1,619,700
1,889,700
1,812,900
2,175,500
2,538,000
3,297,900
3,957,500
4,617,100
643,600
772,300
901,100
1,226,700
1,472,000
1,717,400
1,783,300
2,139,900
2,496,600
861,700
1,034,000
1,206,300
1,355,900
1,627,100
1,898,300
2,184,100
2,620,900
3,057,700
1,338,900
1,606,700
1,874,500
2,023,700
2,428,400
2,833,200
3,132,900
3,759,500
4,386,000
4,410,800
5,293,000
6,175,200

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6,847,400
18,085,700
8,216,800
21,702,800
9,586,300
25,320,000
6,823,800
8,188,500
9,553,300
8,650,200
10,380,200
12,110,200
12,446,200
14,935,400
17,424,700
5,332,000
8,176,400
12,009,400
5,335,700
6,216,900
10,305,700
6,398,400
9,811,600
14,411,300
6,402,800
7,460,300
12,366,900
7,464,800
11,446,900
16,813,100
7,470,000
8,703,700
14,428,000
3,206,400
3,847,600
4,488,900
3,935,000
4,722,000
5,509,000
4,662,900
5,595,500
6,528,100
3,875,100
5,509,300
7,101,200
4,650,100
6,611,200
8,521,500
5,425,200
7,713,000
9,941,700
4,867,800
5,841,300
6,814,900
7,244,600
8,693,500
10,142,400
18,598,300
22,317,900
26,037,600
4,174,600
5,660,600
11,069,600
5,009,600
6,792,800
13,283,500
5,844,500
7,924,900
15,497,400
3,004,200
3,605,100
4,205,900
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 910 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,825,900
2,191,100
2,556,300
697 U-4-12-I
698 U-4-12-II

2,631,100
3,060,500
3,157,300
3,672,600
3,683,500
4,284,700
699 U-4-12-III

3,970,300
4,764,400
5,558,500
1,994,000
2,392,800
2,791,600
2,350,700
2,820,900
3,291,000
2,811,600
3,373,900
3,936,200
2,990,200
3,580,700
3,588,300
4,296,900
4,186,300
5,013,000

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
6,013,100
7,215,700
8,418,400
2,401,100
2,881,300
3,361,500
2,991,400
3,589,700
4,188,000
4,186,500
5,023,900
5,861,200
3,916,300
4,699,600
5,482,900
8,067,500
9,681,000
11,294,500
9,893,700
11,872,400
13,851,200
7,450,700
8,507,800
13,323,500
8,940,800
10,209,300
15,988,300
10,430,900
11,910,900
18,653,000
7,005,100
8,406,100
9,807,100
9,566,000
11,479,200
13,392,400
12,125,000
14,550,000
16,975,000
3,653,900
4,384,700
5,115,500
6,981,500
8,377,800
9,774,100
10,953,100
13,143,700
15,334,300
7,165,300
8,598,400
10,031,500
10,411,000
12,493,200
14,575,400
13,000,100
15,600,100
18,200,100
1,154,000
1,273,400
1,408,700
1,384,800
1,528,100
1,690,400
1,615,600
1,782,800
1,972,100
3,465,000
4,158,000
4,851,100
5,755,600
6,906,700
8,057,900
9,489,000
11,386,800
13,284,600
2,994,000
3,592,800
4,191,600
4,017,200
4,820,600
5,624,000
5,381,100
6,457,300
7,533,500
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,877,600
8,253,200
9,628,700
10,559,300
12,671,100
14,783,000
1,432,100
1,735,700
1,718,500
2,082,800
2,005,000
2,429,900
- 911 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
8,160,600
9,792,700
11,424,800
9,781,000
11,737,200
13,693,400
13,957,300
16,748,700
19,540,200
1,731,000
2,077,200
2,423,400
1,910,100
2,113,000
2,292,100
2,535,600
2,674,200
2,958,200
1,809,300
2,171,100
2,533,000
1,996,500
2,395,800
2,795,100
2,208,500
2,650,200
3,091,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,946,400
2,335,700
2,724,900
743 W-1-12-II
744 W-1-12-III

2,429,400
4,302,000
2,915,300
5,162,400
3,401,200
6,022,800
745 W-1-13-I
2,000,700
2,400,900
2,801,000
746 W-1-13-II
747 W-1-13-III

2,172,100
2,917,700
2,606,500
3,501,200
3,041,000
4,084,800
748 W-1-20-I
749 W-1-20-II

6,700,200
8,372,000
8,040,300
10,046,400
9,380,300
11,720,800
750 W-1-20-III
9,705,300
11,646,400
13,587,400
751 W-1-30-I
3,782,400
4,538,900
5,295,300
752 W-1-30-II
6,032,900
7,239,500
8,446,000
753 W-1-30-III
14,802,000
17,762,400
20,722,800
754 W-4-10-I
2,818,300
3,381,900
3,945,600
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
4,178,000
8,256,500
2,563,000
3,891,000
4,736,100
5,013,500
9,907,800
3,075,600
4,669,200
5,683,300
5,849,100
11,559,000
3,588,200
5,447,400
6,630,600
2,916,500
3,499,800
4,083,100
4,004,200
4,805,000
5,605,800
4,364,800
5,237,700
6,110,700
1,008,400
1,377,500
1,713,000
1,347,600
1,604,000
2,052,100
1,641,000
1,822,500
2,523,400
2,183,400
2,919,800
3,957,300
1,611,100
2,909,000
4,300,900
2,475,500
3,286,000
4,668,000
2,212,200
2,657,000
3,652,200
1,210,100
1,653,000
2,055,600
1,617,100
1,924,800
2,462,500
1,969,300
2,187,000
3,028,000
2,620,100
3,503,800
4,748,800
1,933,400
3,490,800
5,161,000
2,970,600
3,943,200
5,601,600
2,654,600
3,188,400
4,382,600
1,411,800
1,928,500
2,398,200
1,886,700
2,245,600
2,873,000
2,297,500
2,551,500
3,532,700
3,056,800
4,087,700
5,540,200
2,255,600
4,072,500
6,021,200
3,465,700
4,600,400
6,535,200
3,097,100
3,719,800
5,113,000
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 912 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
1,273,300
1,527,900
1,782,600
3,123,500
3,748,200
4,372,900
4,468,400
5,362,100
6,255,800
- 913 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
1,008,200
1,307,700
2,431,900
2,009,700
2,611,700
480,400
853,900
375,600
815,200
711,700
808,000
1,214,800
1,657,000
1,518,700
492,000
1,135,500
411,900
707,200
2,154,000
771,400
1,821,700
444,400
1,036,900
1,622,900
1,361,200
333,800
1,011,700
562,500
289,200
312,700
276,000
330,100
459,600
394,900
371,800
334,100
495,700
216,500
255,100
292,500
5,935,600
2,372,200
2,380,100
612,300
1,002,600
627,700
1,275,900
817,500
468,200
353,500
570,200
314,700
269,500
2,102,600
981,200
560,700
2,188,700
1,459,200
284,200
2,371,100
1,641,500
3,856,500
852,800
524,500
282,100
235,100
265,000
4,040,200
1,966,600
- 914 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,499,500
4,423,500
3,667,600
2,794,000
921,100
3,109,700
2,030,500
499,100
4,668,800
4,226,600
2,834,000
2,684,800
331,800
318,900
1,283,000
350,600
312,400
345,300
1,185,100
1,618,800
1,413,900
1,248,700
756,200
314,200
553,900
380,200
343,300
334,500
424,700
484,300
283,900
814,800
1,485,000
1,139,900
2,679,800
349,000
349,000
2,476,300
1,439,900
276,200
1,277,900
3,319,600
762,100
600,300
294,100
260,600
318,500
444,200
1,063,700
937,500
656,300
489,600
269,500
1,139,600
913,100
390,100
445,200
1,458,900
322,600
1,490,500
1,140,300
347,700
385,500
376,500
227,900
1,242,400
1,707,000
338,300
- 915 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
1,036,800
387,000
418,400
387,500
614,700
472,800
1,184,200
349,400
972,100
1,299,000
284,500
1,731,500
938,300
2,027,800
1,023,600
452,100
347,700
75,200
450,700
1,018,400
396,900
536,100
306,600
119,500
309,600
4,610,400
2,620,600
4,373,800
1,074,500
600,300
409,000
925,100
489,300
984,700
570,200
339,400
568,200
255,800
390,400
374,100
875,100
1,784,800
1,436,000
1,266,100
893,600
328,700
328,700
328,700
268,500
170,300
267,800
327,300
354,100
260,800
230,000
105,400
115,900
85,700
100,600
95,900
146,400
131,300
182,800
200,800
116,600
141,500
96,700
151,000
214,200
- 916 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
152,500
205,200
580,000
672,300
144,200
279,100
175,500
250,500
469,500
401,900
288,900
273,600
143,400
140,900
322,100
203,300
291,600
201,800
158,000
2,026,300
2,084,300
331,200
343,000
655,900
845,700
839,600
433,700
1,351,600
299,900
352,500
353,600
283,200
357,700
338,500
158,600
348,400
308,800
279,300
315,900
2,615,100
339,500
941,200
337,600
480,300
517,600
412,900
817,300
837,000
892,400
780,600
1,430,500
232,600
1,614,700
306,600
818,500
1,860,100
2,150,800
939,600
340,500
664,100
661,500
306,600
2,403,000
1,890,100
154,000
171,500
222,900
292,400
- 917 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
1,107,600
483,200
996,000
1,201,500
575,800
801,000
553,600
611,500
699,500
329,900
780,000
204,700
758,400
1,192,400
83,100
- 918 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,740,600
2,088,700
2,436,800
A-4-10-II
SEPTIKEMIA (SEDANG)
2,973,600
3,568,300
4,163,100
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,009,400
2,259,800
4,811,300
2,711,700
5,613,100
3,163,700
5
6
A-4-11-II
A-4-11-III

3,216,300
4,451,700
3,859,600
5,342,000
4,502,800
6,232,300
A-4-12-I
2,527,100
3,032,600
3,538,000
8
9
A-4-12-II
A-4-12-III

3,147,200
3,358,900
3,776,600
4,030,700
4,406,000
4,702,400
10 A-4-13-I
11 A-4-13-II

1,109,900
1,492,800
1,331,900
1,791,400
1,553,900
2,090,000
12 A-4-13-III
1,791,400
2,149,700
2,508,000
2,218,100
2,661,700
3,105,300
2,692,400
3,230,900
3,769,300
3,230,900
3,877,000
4,523,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,038,100
4,547,600
3,645,700
5,457,100
4,253,300
6,366,600
18 A-4-15-III
INFEKSI HIV (BERAT)
5,706,900
6,848,200
7,989,600
19 B-1-01-I
20 B-1-01-II

19,892,600
21,946,800
23,871,100
26,336,200
27,849,600
30,725,500
21 B-1-01-III
22 B-1-10-I

38,499,300
3,593,800
46,199,100
4,312,600
53,899,000
5,031,300
23 B-1-10-II
7,976,700
9,572,000
11,167,400
24 B-1-10-III
25 B-1-11-I

15,747,000
4,802,000
18,896,500
5,762,400
22,045,900
6,722,800
26 B-1-11-II
27 B-1-11-III

6,223,000
8,040,100
7,467,600
9,648,100
8,712,300
11,256,100
28 B-1-12-I
4,688,900
5,626,700
6,564,400
29 B-1-12-II
5,214,900
6,257,900
7,300,800
30 B-1-12-III
8,158,100
9,789,700
11,421,300
3,734,800
4,481,700
5,228,700
6,145,100
7,374,100
8,603,100
7,951,200
9,541,400
11,131,700
5,131,700
6,158,000
7,184,400
5,707,400
6,848,800
7,990,300
8,928,500
1,587,700
2,534,500
3,496,400
10,714,200
1,905,300
3,041,400
4,195,700
12,499,900
2,222,800
3,548,300
4,895,000
3,347,600
4,017,100
4,686,600
4,686,600
5,624,000
6,561,300
5,677,800
6,813,400
7,948,900
3,026,600
4,309,700
6,411,900
2,887,100
3,631,900
5,171,700
7,694,300
3,464,500
4,237,200
6,033,600
8,976,700
4,042,000
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 919 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,363,400
4,036,000
4,708,700
48 B-4-13-III
49 B-4-14-I

4,633,300
2,884,000
5,560,000
3,460,800
6,486,600
4,037,600
50 B-4-14-II
3,364,600
4,037,500
4,710,400
51 B-4-14-III
52 C-4-10-I

4,506,900
2,668,200
5,408,300
3,201,900
6,309,700
3,735,500
53 C-4-10-II
54 C-4-10-III

5,119,700
9,036,700
6,143,600
10,844,000
7,167,600
12,651,400
55 C-4-11-I
3,040,600
3,648,700
4,256,800
56 C-4-11-II
57 C-4-11-III

4,068,700
6,255,700
4,882,500
7,506,900
5,696,200
8,758,000
58 C-4-12-I
59 C-4-12-II
2,024,500
3,987,500
2,429,400
4,785,000
2,834,300
5,582,500
60 C-4-12-III
RADIOTERAPI (BERAT)
10,241,000
12,289,200
14,337,400
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,522,000
2,864,500
1,826,400
3,437,300
2,130,800
4,010,200
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,877,500
2,528,900
4,653,000
3,034,700
5,428,500
3,540,500
65 C-4-14-II
3,547,500
4,257,100
4,966,600
66 C-4-14-III
67 D-1-10-I

5,285,800
12,375,900
6,342,900
14,851,100
7,400,100
17,326,300
68 D-1-10-II
69 D-1-10-III

18,849,400
30,014,700
22,619,300
36,017,700
26,389,200
42,020,600
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,090,800
4,908,900
5,727,100
10,445,700
13,574,600
12,534,800
16,289,500
14,624,000
19,004,400
3,546,200
4,255,500
4,964,700
9,772,900
11,727,500
13,682,100
15,502,700
18,603,200
21,703,800
2,187,800
3,187,800
5,015,100
2,776,200
4,988,800
6,853,300
2,393,500
3,319,800
5,097,700
2,625,300
3,825,300
6,018,100
3,331,500
5,986,500
8,224,000
2,872,200
3,983,800
6,117,300
3,062,900
4,462,900
7,021,100
3,886,700
6,984,300
9,594,700
3,350,900
4,647,700
7,136,800
2,051,200
2,461,400
2,871,600
2,903,100
3,483,700
4,064,300
3,713,100
4,455,800
5,198,400
2,200,000
2,639,900
3,079,900
3,601,900
4,322,300
5,042,600
4,405,500
5,286,600
6,167,700
3,430,900
4,117,000
4,803,200
4,494,100
5,392,900
6,291,700
93 E-1-01-III
8,908,000
10,689,600
12,471,200
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
2,921,700
3,546,300
7,474,500
3,506,100
4,255,600
8,969,400
4,090,400
4,964,800
10,464,300
5,161,500
6,193,900
7,226,200
97 E-1-20-I
- 920 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,029,100
2,434,900
2,840,700
104 E-4-11-II
105 E-4-11-III

3,093,500
4,192,000
3,712,200
5,030,400
4,330,900
5,868,800
106 E-4-12-I
107 E-4-12-II

2,331,400
4,037,400
2,797,700
4,844,900
3,264,000
5,652,400
108 E-4-12-III

(RINGAN)
(SEDANG)
4,785,800
5,743,000
6,700,200
2,538,800
3,046,600
3,554,300
3,718,900
4,462,700
5,206,500
111 E-4-13-III
4,861,400
5,833,600
6,805,900
112 F-4-10-I
113 F-4-10-II
2,702,900
3,106,400
3,243,400
3,727,700
3,784,000
4,349,000
114 F-4-10-III
115 F-4-11-I
3,727,700
2,614,100
4,473,300
3,137,000
5,218,800
3,659,800
116 F-4-11-II
3,045,700
3,654,900
4,264,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
3,905,700
4,686,900
5,468,000
1,433,000
1,719,600
2,006,100
2,037,200
2,444,700
2,852,100
4,425,800
5,310,900
6,196,100
2,105,700
2,778,600
3,597,200
1,201,400
1,541,000
2,073,500
2,526,900
3,334,300
4,316,700
1,441,700
1,849,200
2,488,200
2,948,000
3,890,000
5,036,100
1,682,000
2,157,400
2,903,000
127 F-4-15-I
1,913,400
2,296,000
2,678,700
128 F-4-15-II
2,851,100
3,421,400
3,991,600
129 F-4-15-III
3,764,400
4,517,300
5,270,200
3,764,600
4,517,500
5,270,500
4,377,000
5,252,400
6,127,800
5,842,500
7,011,000
8,179,500
133 F-4-17-I

889,100
1,066,900
1,244,700
134 F-4-17-II
2,605,700
3,126,900
3,648,000
135
136
137
138
139
140
141

(RINGAN)
2,780,000
3,271,200
3,599,200
5,548,500
2,499,900
3,201,300
3,985,600
3,336,100
3,925,400
4,319,100
6,658,200
2,999,900
3,841,600
4,782,700
3,892,100
4,579,600
5,038,900
7,767,900
3,499,900
4,481,800
5,579,800
5,547,700
6,657,200
7,766,700
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
6,947,300
8,336,800
9,726,200
9,574,800
11,489,800
13,404,700
3,353,900
4,024,700
4,695,500
4,686,500
5,623,800
6,561,100
5,816,900
6,980,200
8,143,600
- 921 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,555,600
6,666,700
7,777,900
148 G-1-11-I
149 G-1-11-II

8,116,000
14,838,000
9,739,200
17,805,600
11,362,400
20,773,200
150 G-1-11-III
23,844,000
28,612,800
33,381,600
3,388,700
4,066,500
4,744,200
6,352,300
7,622,800
8,893,200
8,657,000
10,388,400
12,119,800
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,022,300
2,745,300
1,226,700
3,294,400
1,431,200
3,843,500
156 G-1-13-III
157 G-1-20-I

6,194,700
3,059,800
7,433,600
3,671,700
8,672,600
4,283,700
158 G-1-20-II
5,053,700
6,064,500
7,075,200
159 G-1-20-III
10,132,900
12,159,400
14,186,000
160 G-1-30-I
4,782,400
5,738,900
6,695,400
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,488,300
16,042,700
14,986,000
19,251,200
17,483,700
22,459,800
2,908,900
3,490,600
4,072,400
3,555,600
4,266,700
4,977,800
4,878,900
5,854,700
6,830,400
3,045,100
3,654,100
4,263,200
4,045,000
4,854,100
5,663,100
5,943,500
7,132,300
8,321,000
3,378,200
4,053,800
4,729,500
4,266,900
5,120,300
5,973,700
6,197,100
7,436,600
8,676,000
2,029,300
2,435,200
2,841,100
3,538,800
4,246,500
4,954,300
4,197,000
5,036,400
5,875,900
3,442,500
4,131,000
4,819,500
4,602,400
5,522,900
6,443,400
5,776,600
6,931,900
8,087,200
2,812,800
3,375,400
3,938,000
3,357,000
4,028,400
4,699,800
4,738,100
5,685,700
6,633,300
2,318,800
2,782,600
3,246,300
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,644,300
9,173,200
10,702,000
14,860,500
17,832,600
20,804,700
3,318,100
4,684,800
3,981,700
5,621,700
4,645,300
6,558,700
- 922 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,078,500
3,694,200
4,309,900
183 G-4-16-III
4,384,100
5,260,900
6,137,700
3,088,500
3,706,200
4,323,900
4,049,700
4,859,600
5,669,600
5,088,600
6,106,400
7,124,100
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,041,700
3,650,000
4,258,400
188 G-4-18-II
4,065,800
4,879,000
5,692,100
189 G-4-18-III
4,549,300
5,459,200
6,369,100
2,537,700
3,045,300
3,552,800
4,289,400
5,147,300
6,005,200
5,631,800
6,758,200
7,884,500
193 G-4-20-I

1,775,300
2,130,300
2,485,400
194 G-4-20-II
2,509,700
3,011,600
3,513,600
195 G-4-20-III
196 G-4-21-I

4,145,400
1,848,700
4,974,500
2,218,400
5,803,600
2,588,100
197 G-4-21-II
198 G-4-21-III

3,128,900
3,677,200
3,754,700
4,412,600
4,380,500
5,148,100
199 G-4-22-I
2,543,000
3,051,600
3,560,200
200 G-4-22-II
201 G-4-22-III

3,249,200
3,796,500
3,899,000
4,555,900
4,548,900
5,315,200
202 G-4-23-I
203 G-4-23-II

1,819,800
2,283,300
2,183,800
2,739,900
2,547,800
3,196,600
204 G-4-23-III
3,250,800
3,901,000
4,551,200
205 G-4-24-I
206 G-4-24-II

2,027,000
2,532,500
2,432,400
3,039,000
2,837,800
3,545,500
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,219,000
1,732,100
2,190,400
2,902,700
5,062,800
2,078,500
2,628,500
3,483,200
5,906,700
2,424,900
3,066,500
4,063,800
2,737,100
3,284,500
3,832,000
3,184,100
3,820,900
4,457,800
4,761,200
5,713,500
6,665,700
1,954,600
4,391,500
5,972,200
5,966,700
7,413,000
10,383,000
2,344,900
3,181,500
6,253,500
2,023,700
2,308,400
3,305,500
2,385,900
2,850,700
4,777,300
2,345,500
5,269,800
7,166,700
7,160,100
8,895,600
12,459,600
2,813,900
3,817,800
7,504,200
2,428,400
2,770,100
3,966,600
2,863,100
3,420,900
5,732,800
2,736,400
6,148,100
8,361,100
8,353,400
10,378,200
14,536,200
3,282,900
4,454,200
8,754,800
2,833,100
3,231,800
4,627,700
3,340,300
3,991,000
6,688,300
229 I-1-01-I
32,047,200
38,456,700
44,866,100
230 I-1-01-II
32,752,200
39,302,700
45,853,100
231 I-1-01-III

(RINGAN)
51,699,000
62,038,800
72,378,600
17,779,700
21,335,600
24,891,500
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 923 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
14,639,500
17,567,400
20,495,300
245 I-1-06-II
21,206,500
25,447,800
29,689,100
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
25,303,300
30,363,900
35,424,600
17,426,500
20,911,800
24,397,200
21,499,200
25,799,000
30,098,900
23,455,500
28,146,600
32,837,700
2,786,100
3,343,400
3,900,600
3,097,900
3,717,500
4,337,100
4,122,400
4,946,800
5,771,300
8,019,800
9,623,800
11,227,700
13,098,000
15,717,600
18,337,200
17,232,400
20,678,800
24,125,300
7,779,100
9,334,900
10,890,800
10,359,500
12,431,400
14,503,300
12,776,100
15,331,300
17,886,500
15,921,900
19,106,300
22,290,700
19,788,600
23,746,300
27,704,100
25,929,900
31,115,900
36,301,900
3,024,700
4,223,900
8,133,600
3,629,600
5,068,700
9,760,400
4,234,600
5,913,500
11,387,100
7,841,100
9,409,400
10,977,600
17,741,300
21,289,600
24,837,900
20,464,400
24,557,200
28,650,100
9,079,300
10,895,200
12,711,000
11,368,100
13,641,800
15,915,400
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
22,935,500
27,522,700
32,109,800
28,269,500
33,923,400
39,577,300
10,269,600
12,323,500
14,377,400
14,235,800
17,082,900
19,930,100
18,066,300
21,679,500
25,292,800
15,475,700
18,570,800
21,666,000
24,424,800
29,309,800
34,194,800
39,018,500
46,822,200
54,625,900
19,856,800
23,828,100
27,799,500
23,828,200
28,593,800
33,359,500
32,787,400
39,344,900
45,902,400
- 924 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
17,662,400
21,194,800
24,727,300
279 I-1-40-III
23,590,900
28,309,100
33,027,300
280 I-4-10-I
281 I-4-10-II

2,693,000
4,808,700
3,231,700
5,770,500
3,770,300
6,732,200
282 I-4-10-III
6,928,700
8,314,500
9,700,200
283 I-4-11-I
284 I-4-11-II

4,143,200
5,127,300
4,971,900
6,152,700
5,800,500
7,178,200
285 I-4-11-III
286 I-4-12-I

9,484,900
2,381,800
11,381,900
2,858,200
13,278,900
3,334,500
287 I-4-12-II
2,760,800
3,312,900
3,865,100
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,312,900
3,975,500
4,638,100
2,423,700
2,908,500
3,393,200
4,327,900
5,193,400
6,059,000
6,235,900
7,483,000
8,730,200
2,288,800
2,367,600
4,150,400
2,746,600
2,841,100
4,980,400
3,204,300
3,314,600
5,810,500
4,291,900
5,150,300
6,008,600
5,838,800
7,006,600
8,174,400
297 I-4-15-III
7,006,600
8,407,900
9,809,200
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,444,600
2,319,600
2,783,600
1,770,900
2,061,700
2,474,000
1,733,500
2,783,600
3,340,300
2,125,100
2,474,000
2,968,800
2,022,400
3,247,500
3,897,000
2,479,300
2,886,300
3,463,600
2,786,400
3,343,700
3,901,000
4,242,400
5,090,900
5,939,400
5,759,800
6,911,800
8,063,700
307 I-4-19-I
2,688,300
3,226,000
3,763,700
308 I-4-19-II

(SEDANG)
4,196,600
5,036,000
5,875,300
309 I-4-19-III
5,010,000
6,012,000
7,014,000
310
311
312
313
314

2,799,400
3,233,300
4,834,400
2,094,700
2,654,100
3,359,200
3,879,900
5,801,300
2,513,700
3,184,900
3,919,100
4,526,600
6,768,100
2,932,600
3,715,700
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
14,062,200
16,874,600
19,687,100
10,233,900
12,280,700
14,327,500
12,785,000
15,342,000
17,899,000
13,439,700
16,127,600
18,815,500
7,741,400
9,289,700
10,837,900
16,103,800
19,324,600
22,545,300
24,955,100
29,946,100
34,937,200
7,144,500
8,573,400
10,002,300
- 925 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,830,800
4,597,000
5,363,200
316 I-4-22-I
317 I-4-22-II
2,347,900
2,922,700
2,817,400
3,507,300
3,287,000
4,091,800
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,272,100
5,126,500
5,981,000
2,297,900
2,757,400
3,217,000
2,821,100
3,385,400
3,949,600
5,512,300
6,614,800
7,717,300
2,069,200
2,483,100
2,896,900
4,764,900
5,717,900
6,670,900
6,024,400
7,229,300
8,434,100
37,330,900
44,797,100
52,263,300
42,246,900
50,696,300
59,145,700
47,794,500
57,353,400
66,912,300
19,810,200
23,772,200
27,734,200
27,583,600
33,100,300
38,617,100
45,550,000
54,660,000
63,770,000
6,015,800
7,219,000
8,422,100
12,173,000
14,607,700
17,042,300
12,650,800
15,181,000
17,711,100
7,069,200
8,483,100
9,896,900
8,369,100
10,043,000
11,716,800
12,923,300
15,508,000
18,092,700
5,020,400
6,024,400
7,028,500
9,094,300
10,913,200
12,732,000
26,250,400
31,500,500
36,750,600
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,051,300
4,236,400
6,409,000
1,830,900
2,550,100
3,418,200
3,109,800
3,540,100
4,942,900
2,749,600
3,827,400
7,140,600
3,031,500
4,933,100
5,836,400
4,027,700
4,812,000
6,474,000
2,461,500
5,083,700
7,690,800
2,197,100
3,060,100
4,101,800
3,731,800
4,248,100
5,931,500
3,299,500
4,592,800
8,568,800
3,637,800
5,919,800
7,003,700
4,833,200
5,774,300
7,768,800
2,871,800
5,931,000
8,972,600
2,563,300
3,570,200
4,785,500
4,353,800
4,956,100
6,920,100
3,849,500
5,358,300
9,996,900
4,244,100
6,906,400
8,171,000
5,638,800
6,736,700
9,063,600
3,355,900
4,027,100
4,698,300
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 926 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,715,900
5,659,100
6,602,300
360 J-4-16-III
5,962,600
7,155,100
8,347,600
361 J-4-17-I
362 J-4-17-II

2,533,100
3,033,500
3,039,700
3,640,200
3,546,300
4,246,900
363 J-4-17-III
364 J-4-18-I

3,980,800
2,067,400
4,777,000
2,480,900
5,573,100
2,894,300
365 J-4-18-II
2,843,500
3,412,200
3,980,900
366 J-4-18-III
367 J-4-19-I

2,993,100
3,568,000
3,591,800
4,281,500
4,190,400
4,995,100
368 J-4-19-II
369 J-4-19-III

4,046,300
4,468,600
4,855,500
5,362,300
5,664,800
6,256,100
370 J-4-20-I
3,540,700
4,248,900
4,957,000
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
4,906,000
5,751,400
5,887,200
6,901,700
6,868,400
8,051,900
2,679,600
3,215,500
3,751,500
4,316,800
5,180,100
6,043,500
6,023,700
7,228,500
8,433,200
5,453,700
6,544,500
7,635,200
6,853,700
8,224,500
9,595,200
8,032,800
9,639,400
11,246,000
5,615,800
6,738,900
7,862,100

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,372,800
9,762,800
8,847,400
11,715,400
10,322,000
13,667,900
2,288,300
2,746,000
3,203,600
2,976,200
3,571,400
4,166,700
5,896,300
7,075,600
8,254,800
2,580,700
2,838,800
2,864,600
3,096,900
3,406,600
3,437,600
3,613,000
3,974,300
4,010,500
4,188,100
5,025,700
5,863,300
4,908,300
5,890,000
6,871,700
390 K-1-14-III
7,711,700
9,254,000
10,796,300
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

8,109,500
11,327,100
16,538,800
9,731,400
13,592,500
19,846,500
11,353,300
15,858,000
23,154,300
4,795,900
5,755,100
6,714,200
8,517,400
10,220,800
11,924,300
11,720,000
14,064,000
16,408,000
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,351,100
6,421,300
7,491,500
398 K-1-40-II

(SEDANG)
5,899,800
7,079,700
8,259,700
399 K-1-40-III
9,998,000
11,997,600
13,997,200
400
401
402
403
404

4,088,800
5,309,800
7,503,700
3,375,500
4,850,100
4,906,500
6,371,700
9,004,400
4,050,600
5,820,100
5,724,300
7,433,700
10,505,200
4,725,700
6,790,100
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 927 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,393,700
8,872,400
10,351,200
406 K-4-11-I
407 K-4-11-II

2,154,500
3,061,700
2,585,400
3,674,000
3,016,300
4,286,300
408 K-4-11-III
409 K-4-12-I

3,674,000
2,029,100
4,408,800
2,434,900
5,143,600
2,840,700
410 K-4-12-II
2,730,500
3,276,700
3,822,800
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,517,200
5,420,700
6,324,100
2,735,400
3,282,400
3,829,500
3,538,400
4,246,000
4,953,700
5,450,200
6,540,300
7,630,300
1,734,200
2,081,100
2,427,900
2,327,900
2,793,500
3,259,100
3,735,400
4,482,500
5,229,500
418 K-4-15-I
1,721,800
2,066,100
2,410,500
419 K-4-15-II
2,566,900
3,080,300
3,593,700
420 K-4-15-III
3,602,500
4,323,000
5,043,500
421 K-4-16-I
2,531,900
3,038,300
3,544,700
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,036,500
3,543,100
3,643,800
4,251,700
4,251,100
4,960,400
1,144,400
1,373,300
1,602,100
1,716,000
2,059,200
2,402,400
2,059,200
2,471,000
2,882,800
1,149,100
1,378,900
1,608,700
1,633,000
1,959,600
2,286,100
429 K-4-18-III
1,959,600
2,351,500
2,743,400
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
12,929,600
19,516,800
26,077,600
6,100,300
10,467,700
12,995,800
15,515,500
23,420,200
31,293,200
7,320,300
12,561,200
15,595,000
18,101,400
27,323,500
36,508,700
8,540,400
14,654,800
18,194,100
3,418,700
4,102,500
4,786,200
6,857,200
8,228,700
9,600,100
11,542,200
13,850,700
16,159,100
4,488,100
7,223,100
10,332,000
1,173,900
1,362,600
1,581,600
2,458,300
3,378,700
7,677,500
1,167,500
1,544,100
4,084,700
5,385,700
8,667,800
12,398,400
1,408,700
1,635,100
1,897,900
2,950,000
4,054,500
9,213,000
1,401,000
1,853,000
4,901,600
6,283,400
10,112,400
14,464,800
1,643,400
1,907,600
2,214,200
3,441,600
4,730,200
10,748,500
1,634,500
2,161,800
5,718,500
2,282,500
2,739,000
3,195,500
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 928 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,682,600
3,219,100
3,755,600
3,947,400
4,736,900
5,526,400
2,021,700
2,426,000
2,830,300
3,036,600
3,643,900
4,251,200
4,280,500
5,136,500
5,992,600
7,146,400
8,575,600
10,004,900
10,157,500
12,189,100
14,220,600
14,268,300
17,122,000
19,975,600
6,333,900
7,600,700
8,867,500
10,390,500
17,653,300
12,468,700
21,183,900
14,546,800
24,714,600
15,506,500
18,607,800
21,709,100
18,137,100
21,764,500
25,391,900
22,447,700
26,937,200
31,426,800
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
7,941,800
9,530,100
11,118,500
467 M-1-04-II
10,202,800
12,243,400
14,284,000
468 M-1-04-III
12,208,000
14,649,500
17,091,100
469 M-1-05-I
470 M-1-05-II

5,042,200
8,155,900
6,050,600
9,787,000
7,059,000
11,418,200
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,418,100
12,501,700
14,585,300
5,644,100
6,772,900
7,901,800
7,561,200
9,073,400
10,585,600
15,402,800
18,483,300
21,563,900
9,291,100
11,149,400
13,007,600
20,388,300
24,465,900
28,543,600
43,975,600
52,770,800
61,565,900
8,486,300
10,183,600
11,880,900
10,842,200
13,010,600
15,179,000
480 M-1-20-III
26,993,700
32,392,400
37,791,200
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,821,800
9,433,800
13,489,400
6,986,200
11,320,500
16,187,300
8,150,600
13,207,300
18,885,200
2,963,500
3,556,300
4,149,000
5,255,700
6,306,900
7,358,000
7,504,100
9,005,000
10,505,800
3,551,300
5,893,400
9,679,600
4,261,600
7,072,100
11,615,500
4,971,900
8,250,800
13,551,400
5,484,800
6,581,700
7,678,700
6,895,600
8,274,700
9,653,900
10,416,700
12,500,000
14,583,300
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 929 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,034,800
2,441,800
2,848,700
500 M-4-10-II
501 M-4-10-III
3,034,600
5,741,500
3,641,500
6,889,700
4,248,400
8,038,000
2,535,600
3,042,700
3,549,800
5,559,100
6,670,900
7,782,800
8,037,500
9,645,000
11,252,500
2,024,000
2,428,700
2,833,500
3,366,400
4,039,700
4,712,900
4,502,900
5,403,500
6,304,100
3,370,100
4,044,100
4,718,100
5,063,400
6,076,100
7,088,800
9,878,600
11,854,300
13,830,000
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,843,500
4,612,200
5,380,800
512 M-4-14-II
4,740,300
5,688,400
6,636,500
513 M-4-14-III
514 M-4-15-I
7,123,400
2,279,100
8,548,000
2,734,900
9,972,700
3,190,700
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,037,800
6,893,700
1,951,200
3,124,700
5,249,200
3,645,400
8,272,500
2,341,500
3,749,600
6,299,100
4,253,000
9,651,200
2,731,700
4,374,500
7,348,900
2,532,400
3,038,900
3,545,400
3,541,900
4,250,300
4,958,600
4,946,000
5,935,200
6,924,400
1,914,100
2,884,700
3,473,300
2,296,900
3,461,600
4,167,900
2,679,800
4,038,500
4,862,600
1,996,100
2,395,400
2,794,600
3,362,200
4,034,700
4,707,100
6,566,700
7,880,000
9,193,300
2,013,500
2,416,200
2,819,000
2,948,500
3,538,200
4,127,900
3,295,300
3,954,300
4,613,400
2,027,500
2,433,000
2,838,500
2,535,800
3,042,900
3,550,100
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
10,161,500
12,193,800
14,226,100
11,177,700
13,413,200
15,648,800
12,797,000
15,356,400
17,915,800
5,776,400
6,931,700
8,087,000
6,860,000
15,440,400
8,232,000
18,528,500
9,604,000
21,616,600
- 930 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,685,200
6,822,200
7,959,300
535 N-1-01-I

64,915,600
77,898,800
90,881,900
536 N-1-01-II
64,915,600
77,898,800
90,881,900
537 N-1-01-III
538 N-1-11-I

64,915,600
5,848,200
77,898,800
7,017,900
90,881,900
8,187,500
539 N-1-11-II
540 N-1-11-III

9,247,500
14,416,800
11,097,000
17,300,100
12,946,400
20,183,500
2,980,600
3,576,800
4,172,900
5,934,100
7,121,000
8,307,800
12,877,300
15,452,800
18,028,200
6,516,800
7,820,200
9,123,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,119,900
12,762,300
10,943,900
15,314,700
12,767,900
17,867,200
5,964,000
7,156,800
8,349,700
9,022,400
10,826,900
12,631,400
10,383,900
12,460,700
14,537,500
5,356,100
6,427,400
7,498,600
7,273,500
8,728,200
10,182,900
8,465,400
10,158,500
11,851,600
2,275,600
2,730,700
3,185,900
2,752,400
3,302,900
3,853,300
4,048,400
4,858,000
5,667,700
1,746,900
3,052,100
3,797,400
2,056,200
4,027,300
4,847,500
3,272,400
3,946,900
6,048,300
2,096,300
3,662,500
4,556,900
2,467,500
4,832,800
5,817,000
3,926,900
4,736,300
7,258,000
2,445,700
4,272,900
5,316,300
2,878,700
5,638,200
6,786,500
4,581,400
5,525,600
8,467,700
1,754,500
2,105,300
2,456,200
2,489,500
2,987,400
3,485,300
3,990,600
4,788,800
5,586,900
2,072,700
2,487,200
2,901,700
2,571,800
3,086,200
3,600,500
2,934,900
3,521,900
4,108,800
2,538,000
3,045,600
3,553,200
3,622,500
4,347,000
5,071,500
4,821,800
5,786,200
6,750,500
4,551,200
4,814,700
5,461,400
5,777,700
6,371,600
6,740,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 931 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,649,900
6,779,800
7,909,800
2,359,200
2,831,000
3,302,800
2,621,900
3,146,300
3,670,700
3,261,700
3,914,100
4,566,400
1,671,400
2,005,700
2,340,000
2,007,400
2,408,900
2,810,300
2,522,400
3,026,800
3,531,300
1,555,700
1,866,800
2,177,900

MAYOR (RINGAN)
MAYOR (SEDANG)
1,841,300
2,209,500
2,209,500
2,651,400
2,577,800
3,093,300
37,323,400
44,788,100
52,252,800
46,182,100
55,418,600
64,655,000
54,204,900
65,045,800
75,886,800
50,944,700
61,133,700
71,322,600
58,438,700
70,126,500
81,814,200
66,770,400
80,124,400
93,478,500
6,208,800
7,450,600
8,692,400
8,816,600
10,579,900
12,343,200
9,962,700
11,955,300
13,947,800
20,148,200
24,177,800
28,207,500
26,148,000
31,377,600
36,607,200
37,489,700
44,987,600
52,485,500
10,955,900
13,147,100
15,338,300
20,657,300
24,788,800
28,920,200
25,208,900
30,250,700
35,292,500
3,615,000
4,338,000
5,061,000
10,135,700
12,162,900
14,190,000
13,427,300
16,112,800
18,798,300
3,501,500
4,201,800
4,902,100
9,817,500
11,781,000
13,744,500
13,005,700
15,606,900
18,208,000
3,701,800
4,442,200
5,182,500
5,252,800
6,303,400
7,354,000
8,505,400
10,206,500
11,907,500
5,865,700
7,038,900
8,212,000
8,329,300
9,995,200
11,661,000
- 932 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,412,100
11,294,500
13,177,000
5,541,500
6,649,800
7,758,200
7,879,300
9,455,100
11,031,000
8,917,800
10,701,300
12,484,900
4,808,200
5,769,800
6,731,400
6,346,800
7,616,100
8,885,500
9,450,600
11,340,700
13,230,800
2,434,400
2,921,300
3,408,200
4,955,500
5,946,600
6,937,700
9,194,300
11,033,100
12,872,000
1,825,800
2,191,000
2,556,200
3,656,300
4,387,600
5,118,800
4,290,000
5,148,000
6,006,000
1,652,400
1,982,900
2,313,400
3,175,400
3,810,400
4,445,500
6,475,400
7,770,500
9,065,600
3,205,400
3,846,500
4,487,600
5,769,800
6,923,800
8,077,700
7,875,500
9,450,600
11,025,700
1,863,100
2,235,700
2,608,300
2,295,600
2,754,700
3,213,800
3,142,400
3,770,900
4,399,400
1,572,000
2,305,200
3,939,900
1,369,700
1,823,100
3,160,300
1,886,400
2,766,200
4,727,900
1,643,700
2,187,700
3,792,400
2,200,800
3,227,300
5,515,800
1,917,600
2,552,300
4,424,400
2,022,700
2,427,300
2,831,800
3,588,500
4,306,200
5,023,900
5,824,500
6,989,400
8,154,300
1,023,600
1,228,400
1,433,100
2,174,300
2,609,100
3,044,000
4,123,200
4,947,900
5,772,500
684,600
821,500
958,500
1,292,000
1,550,400
1,808,800
1,673,300
2,008,000
2,342,700
3,545,100
4,254,100
4,963,100
- 933 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,508,500
5,410,200
6,311,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,455,300
7,746,300
9,037,400
1,708,700
2,050,400
2,392,100
2,535,800
3,043,000
3,550,200
3,049,900
3,659,900
4,269,900
1,143,200
1,371,900
1,600,500
1,535,500
1,842,600
2,149,700
2,793,300
3,352,000
3,910,700
521,400
625,600
729,900
993,700
1,192,400
1,391,200
1,444,500
1,733,500
2,022,400
617,400
740,900
864,400
971,600
1,166,000
1,360,300
1,564,900
1,877,900
2,190,900
1,079,800
1,295,800
1,511,800
1,632,500
1,959,000
2,285,500
2,547,800
3,057,400
3,567,000
3,736,000
4,483,100
5,230,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,799,700
15,318,500
6,959,600
18,382,200
8,119,600
21,445,900
5,779,700
6,935,600
8,091,600
7,326,600
8,792,000
10,257,300
10,541,800
12,650,200
14,758,600
4,516,200
6,925,300
10,171,900
4,281,400
4,988,500
8,269,500
5,419,400
8,310,400
12,206,300
5,137,700
5,986,300
9,923,300
6,322,700
9,695,500
14,240,600
5,994,000
6,984,000
11,577,200
2,715,800
3,258,900
3,802,100
3,332,900
3,999,500
4,666,100
3,949,500
4,739,400
5,529,300
3,009,800
4,279,100
5,515,500
3,611,800
5,134,900
6,618,600
4,213,700
5,990,700
7,721,700
4,123,000
4,947,600
5,772,200
6,136,100
7,363,300
8,590,600
15,752,600
18,903,100
22,053,700
3,535,900
4,794,500
9,375,900
4,243,100
5,753,400
11,251,100
4,950,300
6,712,300
13,126,200
2,544,600
3,053,500
3,562,400
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 934 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,546,500
1,855,900
2,165,200
697 U-4-12-I
698 U-4-12-II

2,426,700
2,822,800
2,912,100
3,387,400
3,397,400
3,951,900
699 U-4-12-III

3,662,000
4,394,300
5,126,700
1,839,100
2,207,000
2,574,800
2,168,200
2,601,800
3,035,400
2,593,200
3,111,900
3,630,500
2,532,700
3,032,800
3,039,300
3,639,400
3,545,800
4,246,000

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,093,100
6,111,700
7,130,300
2,033,700
2,440,400
2,847,200
2,533,700
3,040,500
3,547,200
3,546,000
4,255,200
4,964,400
3,317,100
3,980,500
4,644,000
6,833,100
8,199,800
9,566,400
8,379,900
10,055,900
11,731,900
6,310,700
7,206,000
11,285,000
7,572,800
8,647,200
13,542,000
8,834,900
10,088,500
15,798,900
5,933,200
7,119,900
8,306,500
8,102,300
9,722,800
11,343,300
10,269,800
12,323,700
14,377,700
3,094,900
3,713,800
4,332,800
5,913,300
7,095,900
8,278,600
9,277,200
11,132,600
12,988,000
6,069,000
7,282,800
8,496,600
8,818,100
10,581,700
12,345,300
11,011,000
13,213,200
15,415,400
977,400
1,078,600
1,193,100
1,172,900
1,294,300
1,431,700
1,368,400
1,510,000
1,670,400
2,934,900
3,521,800
4,108,800
4,875,000
5,850,000
6,824,900
8,037,100
9,644,500
11,251,900
2,535,900
3,043,100
3,550,300
3,402,500
4,083,000
4,763,500
4,557,700
5,469,300
6,380,800
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
5,825,300
6,990,400
8,155,400
8,943,600
10,732,400
12,521,100
1,213,000
1,470,100
1,455,600
1,764,100
1,698,200
2,058,100
- 935 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
6,912,000
8,294,400
9,676,800
8,284,500
9,941,400
11,598,300
11,821,700
14,186,100
16,550,400
1,466,100
1,759,400
2,052,600
1,617,900
1,789,700
1,941,400
2,147,600
2,265,000
2,505,500
1,532,400
1,838,900
2,145,400
1,691,000
2,029,200
2,367,400
1,870,600
2,244,700
2,618,900
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,648,600
1,978,300
2,308,000
743 W-1-12-II
744 W-1-12-III

2,057,700
3,643,700
2,469,300
4,372,500
2,880,800
5,101,200
745 W-1-13-I
1,694,600
2,033,500
2,372,400
746 W-1-13-II
747 W-1-13-III

1,839,800
2,471,300
2,207,700
2,965,500
2,575,700
3,459,800
748 W-1-20-I
749 W-1-20-II

5,675,100
7,091,000
6,810,100
8,509,300
7,945,100
9,927,500
750 W-1-20-III
8,220,300
9,864,400
11,508,500
751 W-1-30-I
3,203,600
3,844,400
4,485,100
752 W-1-30-II
5,109,800
6,131,800
7,153,700
753 W-1-30-III
12,537,200
15,044,600
17,552,100
754 W-4-10-I
2,387,000
2,864,500
3,341,900
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,538,700
6,993,200
2,170,800
3,295,700
4,011,500
4,246,400
8,391,800
2,605,000
3,954,800
4,813,800
4,954,200
9,790,400
3,039,200
4,614,000
5,616,000
2,690,000
3,228,000
3,766,000
3,693,200
4,431,800
5,170,400
4,025,800
4,830,900
5,636,100
854,100
1,166,700
1,450,900
1,141,400
1,358,600
1,738,100
1,513,600
1,681,000
2,327,400
2,013,800
2,693,000
3,649,900
1,486,000
2,683,000
3,966,800
2,005,400
2,661,800
3,781,300
1,718,200
2,063,700
2,836,600
1,024,900
1,400,100
1,741,100
1,369,700
1,630,300
2,085,800
1,816,300
2,017,200
2,792,800
2,416,600
3,231,600
4,379,900
1,783,200
3,219,600
4,760,200
2,406,400
3,194,200
4,537,600
2,061,900
2,476,400
3,403,900
1,195,700
1,633,400
2,031,300
1,598,000
1,902,000
2,433,400
2,119,000
2,353,300
3,258,300
2,819,400
3,770,200
5,109,900
2,080,400
3,756,200
5,553,500
2,807,500
3,726,600
5,293,800
2,405,500
2,889,100
3,971,300
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 936 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
799,000
958,800
1,118,600
1,946,900
2,336,300
2,725,700
2,469,100
2,962,900
3,456,700
- 937 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
911,700
1,182,600
2,199,100
1,817,300
2,361,700
434,400
772,200
339,700
621,100
643,600
730,700
1,098,500
1,498,400
1,373,300
444,900
1,026,800
372,500
639,500
1,947,800
697,600
1,647,400
401,900
937,600
1,467,600
1,230,900
301,900
914,900
508,700
261,500
282,800
249,600
298,500
415,600
357,100
336,200
302,100
448,300
195,800
230,700
264,500
5,367,500
2,145,200
2,152,300
553,700
906,600
567,600
1,153,700
739,300
423,300
319,700
515,600
284,600
243,700
1,901,300
887,300
507,000
1,979,200
1,319,500
257,000
2,144,200
1,484,400
3,339,000
771,200
474,300
255,100
212,600
239,600
3,653,500
1,778,400
- 938 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,260,200
4,000,100
3,316,600
2,526,500
832,900
2,812,100
1,836,200
451,400
4,221,900
3,822,000
2,562,700
2,427,800
300,100
288,300
1,160,200
317,100
282,500
312,200
1,071,700
1,463,800
1,278,600
1,129,200
683,900
284,200
500,900
343,800
310,500
302,500
384,000
438,000
256,700
736,800
1,342,900
1,030,800
2,423,300
315,600
315,600
2,239,300
1,302,100
249,800
1,155,600
3,001,800
689,200
542,900
265,900
229,500
288,100
401,700
961,800
847,800
593,400
442,700
243,700
1,030,500
825,700
352,800
402,600
1,319,200
291,700
1,347,800
1,031,100
314,500
348,600
340,500
206,100
1,123,500
1,543,700
305,900
- 939 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
937,600
350,000
378,400
350,400
555,900
427,600
1,070,900
315,900
879,100
1,174,700
257,300
1,565,800
848,500
1,833,700
925,600
408,800
314,500
66,300
407,500
921,000
358,900
484,800
277,200
107,900
280,000
4,169,100
2,369,800
3,955,200
971,600
542,900
369,900
836,600
442,500
890,500
515,600
307,000
513,800
231,300
353,000
338,300
744,800
1,614,000
1,298,500
1,144,900
808,000
297,200
297,200
297,200
242,800
154,000
242,100
296,000
320,200
235,800
208,000
92,900
102,100
75,500
88,600
84,500
129,000
115,700
165,300
181,500
102,700
124,700
85,200
133,000
188,700
- 940 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
134,400
185,500
524,500
608,000
127,000
252,400
154,600
220,700
424,500
363,500
261,300
247,400
126,300
124,100
291,300
183,800
263,700
186,800
142,900
1,832,300
1,884,800
299,500
310,100
593,100
745,000
759,200
392,200
1,222,300
264,200
318,800
319,800
256,100
323,400
306,100
143,400
315,000
279,300
252,600
285,700
2,364,800
307,000
851,100
305,300
434,300
455,900
363,700
739,100
756,900
807,000
705,900
1,226,100
210,300
1,460,100
277,200
740,100
1,682,100
1,945,000
849,700
307,900
600,600
598,200
277,200
2,173,000
1,709,200
138,000
151,100
196,300
264,400
- 941 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
923,000
437,000
900,600
1,086,500
520,700
724,300
500,600
538,700
582,900
298,400
705,300
180,400
668,100
993,700
73,200
- 942 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
1,792,800
2,151,300
2,509,900
A-4-10-II
SEPTIKEMIA (SEDANG)
3,062,800
3,675,400
4,288,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
4,129,700
2,327,600
4,955,600
2,793,100
5,781,500
3,258,600
5
6
A-4-11-II
A-4-11-III

3,312,800
4,585,200
3,975,400
5,502,200
4,637,900
6,419,300
A-4-12-I
2,603,000
3,123,600
3,644,100
8
9
A-4-12-II
A-4-12-III

3,241,600
3,459,600
3,889,900
4,151,600
4,538,200
4,843,500
10 A-4-13-I
11 A-4-13-II

1,143,200
1,537,600
1,371,900
1,845,100
1,600,500
2,152,700
12 A-4-13-III
1,845,100
2,214,200
2,583,200
2,284,600
2,741,600
3,198,500
2,773,200
3,327,800
3,882,400
3,327,800
3,993,400
4,658,900
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
3,129,200
4,684,000
3,755,000
5,620,800
4,380,900
6,557,600
18 A-4-15-III
INFEKSI HIV (BERAT)
5,878,100
7,053,700
8,229,300
19 B-1-01-I
20 B-1-01-II

20,489,400
22,605,200
24,587,200
27,126,200
28,685,100
31,647,300
21 B-1-01-III
22 B-1-10-I

39,654,200
3,701,600
47,585,100
4,442,000
55,515,900
5,182,300
23 B-1-10-II
8,216,000
9,859,200
11,502,400
24 B-1-10-III
25 B-1-11-I

16,219,500
4,946,100
19,463,300
5,935,300
22,707,200
6,924,500
26 B-1-11-II
27 B-1-11-III

6,409,700
8,281,300
7,691,700
9,937,500
8,973,600
11,593,800
28 B-1-12-I
4,829,600
5,795,500
6,761,400
29 B-1-12-II
5,371,300
6,445,600
7,519,900
30 B-1-12-III
8,402,800
10,083,400
11,764,000
3,846,800
4,616,200
5,385,500
6,329,400
7,595,300
8,861,200
8,189,700
9,827,700
11,465,600
5,285,700
6,342,800
7,399,900
5,878,600
7,054,300
8,230,000
9,196,400
1,635,400
2,610,500
3,601,300
11,035,700
1,962,500
3,132,600
4,321,600
12,874,900
2,289,500
3,654,800
5,041,900
3,448,000
4,137,600
4,827,200
4,827,200
5,792,700
6,758,100
5,848,100
7,017,800
8,187,400
3,117,400
4,439,000
6,604,300
2,973,700
3,740,900
5,326,800
7,925,100
3,568,500
4,364,300
6,214,600
9,246,000
4,163,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 943 -

REGIONAL 5
RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
3,464,300
4,157,100
4,850,000
48 B-4-13-III
49 B-4-14-I

4,772,300
2,970,500
5,726,800
3,564,700
6,681,200
4,158,800
50 B-4-14-II
3,465,500
4,158,600
4,851,700
51 B-4-14-III
52 C-4-10-I

4,642,100
2,748,300
5,570,600
3,297,900
6,499,000
3,847,600
53 C-4-10-II
54 C-4-10-III

5,273,300
9,307,800
6,327,900
11,169,400
7,382,600
13,030,900
55 C-4-11-I
3,131,800
3,758,200
4,384,500
56 C-4-11-II
57 C-4-11-III

4,190,800
6,443,400
5,028,900
7,732,100
5,867,100
9,020,800
58 C-4-12-I
59 C-4-12-II
2,085,200
4,107,100
2,502,300
4,928,600
2,919,300
5,750,000
60 C-4-12-III
RADIOTERAPI (BERAT)
10,548,200
12,657,900
14,767,500
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
1,567,700
2,950,400
1,881,200
3,540,500
2,194,800
4,130,500
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
3,993,800
2,604,800
4,792,600
3,125,700
5,591,400
3,646,700
65 C-4-14-II
3,654,000
4,384,800
5,115,600
66 C-4-14-III
67 D-1-10-I

5,444,300
12,747,200
6,533,200
15,296,600
7,622,100
17,846,100
68 D-1-10-II
69 D-1-10-III

19,414,900
30,915,200
23,297,900
37,098,200
27,180,800
43,281,200
70 D-1-11-I
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
4,213,500
5,056,200
5,898,900
10,759,100
13,981,800
12,910,900
16,778,200
15,062,700
19,574,500
3,652,600
4,383,200
5,113,700
10,066,100
12,079,300
14,092,500
15,967,800
19,161,300
22,354,900
2,253,400
3,283,400
5,165,500
2,859,500
5,138,400
7,058,900
2,465,300
3,419,400
5,250,700
2,704,100
3,940,100
6,198,700
3,431,400
6,166,100
8,470,700
2,958,300
4,103,300
6,300,800
3,154,800
4,596,700
7,231,800
4,003,300
7,193,800
9,882,500
3,451,400
4,787,200
7,350,900
2,112,700
2,535,200
2,957,800
2,990,200
3,588,200
4,186,200
3,824,500
4,589,400
5,354,300
2,266,000
2,719,100
3,172,300
3,709,900
4,451,900
5,193,900
4,537,600
5,445,200
6,352,700
3,533,800
4,240,500
4,947,300
4,628,900
5,554,700
6,480,400
93 E-1-01-III
9,175,200
11,010,300
12,845,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
3,009,400
3,652,700
7,698,800
3,611,200
4,383,300
9,238,500
4,213,100
5,113,800
10,778,300
5,316,400
6,379,700
7,442,900
97 E-1-20-I
- 944 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
2,090,000
2,508,000
2,926,000
104 E-4-11-II
105 E-4-11-III

3,186,300
4,317,700
3,823,600
5,181,300
4,460,900
6,044,800
106 E-4-12-I
107 E-4-12-II

2,401,300
4,158,600
2,881,600
4,990,300
3,361,900
5,822,000
108 E-4-12-III

(RINGAN)
(SEDANG)
4,929,400
5,915,300
6,901,200
2,615,000
3,138,000
3,661,000
3,830,500
4,596,600
5,362,700
111 E-4-13-III
5,007,200
6,008,600
7,010,100
112 F-4-10-I
113 F-4-10-II
2,783,900
3,199,600
3,340,700
3,839,500
3,897,500
4,479,500
114 F-4-10-III
115 F-4-11-I
3,839,500
2,692,600
4,607,400
3,231,100
5,375,400
3,769,600
116 F-4-11-II
3,137,100
3,764,500
4,392,000
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
4,022,900
4,827,500
5,632,100
1,476,000
1,771,100
2,066,300
2,098,300
2,518,000
2,937,700
4,558,500
5,470,200
6,382,000
2,168,900
2,861,900
3,705,100
1,237,500
1,587,200
2,135,700
2,602,700
3,434,300
4,446,200
1,485,000
1,904,700
2,562,900
3,036,500
4,006,700
5,187,200
1,732,500
2,222,100
2,990,000
127 F-4-15-I
1,970,800
2,364,900
2,759,100
128 F-4-15-II
2,936,700
3,524,000
4,111,300
129 F-4-15-III
3,877,300
4,652,800
5,428,300
3,877,600
4,653,100
5,428,600
4,508,300
5,410,000
6,311,600
6,017,800
7,221,400
8,424,900
133 F-4-17-I

915,700
1,098,900
1,282,000
134 F-4-17-II
2,683,900
3,220,700
3,757,400
135
136
137
138
139
140
141

(RINGAN)
2,863,400
3,369,300
3,707,200
5,714,900
2,574,900
3,297,300
4,105,100
3,436,100
4,043,200
4,448,600
6,857,900
3,089,900
3,956,800
4,926,200
4,008,800
4,717,000
5,190,100
8,000,900
3,604,900
4,616,300
5,747,200
5,714,100
6,856,900
7,999,800
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
7,155,700
8,586,900
10,018,000
9,862,000
11,834,500
13,806,900
3,454,500
4,145,400
4,836,300
4,827,100
5,792,500
6,757,900
5,991,400
7,189,600
8,387,900
- 945 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
5,722,300
6,866,700
8,011,200
148 G-1-11-I
149 G-1-11-II

8,359,500
15,283,100
10,031,400
18,339,700
11,703,300
21,396,400
150 G-1-11-III
24,559,300
29,471,200
34,383,000
3,490,400
4,188,500
4,886,500
6,542,900
7,851,500
9,160,000
8,916,700
10,700,000
12,483,400
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
1,052,900
2,827,700
1,263,500
3,393,200
1,474,100
3,958,800
156 G-1-13-III
157 G-1-20-I

6,380,500
3,151,600
7,656,600
3,781,900
8,932,700
4,412,200
158 G-1-20-II
5,205,400
6,246,400
7,287,500
159 G-1-20-III
10,436,800
12,524,200
14,611,600
160 G-1-30-I
4,925,900
5,911,100
6,896,300
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
12,863,000
16,524,000
15,435,600
19,828,800
18,008,200
23,133,500
2,996,100
3,595,300
4,194,600
3,662,300
4,394,700
5,127,200
5,025,300
6,030,300
7,035,400
3,136,500
3,763,800
4,391,000
4,166,400
4,999,700
5,833,000
6,121,900
7,346,200
8,570,600
3,479,500
4,175,500
4,871,400
4,394,900
5,273,900
6,152,900
6,383,100
7,659,700
8,936,300
2,090,200
2,508,200
2,926,300
3,644,900
4,373,900
5,102,900
4,323,000
5,187,500
6,052,100
3,545,800
4,255,000
4,964,100
4,740,500
5,688,600
6,636,700
5,949,900
7,139,800
8,329,800
2,897,200
3,476,700
4,056,100
3,457,700
4,149,200
4,840,800
4,880,200
5,856,300
6,832,300
2,388,400
2,866,000
3,343,700
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
7,873,600
9,448,400
11,023,100
15,306,300
18,367,600
21,428,900
3,417,600
4,825,300
4,101,100
5,790,400
4,784,700
6,755,400
- 946 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
3,170,900
3,805,100
4,439,200
183 G-4-16-III
4,515,600
5,418,700
6,321,800
3,181,100
3,817,400
4,453,600
4,171,200
5,005,400
5,839,700
5,241,300
6,289,500
7,337,800
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
3,132,900
3,759,500
4,386,100
188 G-4-18-II
4,187,800
5,025,400
5,862,900
189 G-4-18-III
4,685,800
5,623,000
6,560,100
2,613,900
3,136,700
3,659,400
4,418,100
5,301,700
6,185,300
5,800,800
6,960,900
8,121,100
193 G-4-20-I

1,828,500
2,194,200
2,560,000
194 G-4-20-II
2,585,000
3,102,000
3,619,000
195 G-4-20-III
196 G-4-21-I

4,269,800
1,904,100
5,123,700
2,285,000
5,977,700
2,665,800
197 G-4-21-II
198 G-4-21-III

3,222,800
3,787,500
3,867,300
4,545,000
4,511,900
5,302,500
199 G-4-22-I
2,619,300
3,143,200
3,667,000
200 G-4-22-II
201 G-4-22-III

3,346,700
3,910,400
4,016,000
4,692,500
4,685,300
5,474,600
202 G-4-23-I
203 G-4-23-II

1,874,400
2,351,800
2,249,300
2,822,100
2,624,200
3,292,500
204 G-4-23-III
3,348,400
4,018,000
4,687,700
205 G-4-24-I
206 G-4-24-II

2,087,800
2,608,500
2,505,400
3,130,200
2,923,000
3,651,800
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
4,345,600
1,784,000
2,256,100
2,989,800
5,214,700
2,140,800
2,707,300
3,587,700
6,083,900
2,497,600
3,158,500
4,185,700
2,819,200
3,383,100
3,946,900
3,279,600
3,935,600
4,591,500
4,904,100
5,884,900
6,865,700
2,013,200
4,523,300
6,151,400
6,145,700
7,635,400
10,694,500
2,415,200
3,277,000
6,441,100
2,084,400
2,377,600
3,404,600
2,457,500
2,936,300
4,920,700
2,415,900
5,427,900
7,381,700
7,374,900
9,162,500
12,833,400
2,898,300
3,932,400
7,729,300
2,501,300
2,853,200
4,085,600
2,949,000
3,523,500
5,904,800
2,818,500
6,332,600
8,611,900
8,604,000
10,689,600
14,972,300
3,381,300
4,587,800
9,017,500
2,918,100
3,328,700
4,766,500
3,440,500
4,110,800
6,888,900
229 I-1-01-I
33,008,600
39,610,400
46,212,100
230 I-1-01-II
33,734,800
40,481,800
47,228,700
231 I-1-01-III

(RINGAN)
53,249,900
63,899,900
74,549,900
18,313,100
21,975,700
25,638,300
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 947 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
15,078,700
18,094,400
21,110,200
245 I-1-06-II
21,842,700
26,211,300
30,579,800
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
26,062,400
31,274,900
36,487,300
17,949,300
21,539,200
25,129,100
22,144,200
26,573,000
31,001,800
24,159,200
28,991,000
33,822,900
2,869,700
3,443,700
4,017,600
3,190,800
3,829,000
4,467,200
4,246,000
5,095,200
5,944,400
8,260,400
9,912,500
11,564,600
13,490,900
16,189,100
18,887,300
17,749,300
21,299,200
24,849,100
8,012,500
9,615,000
11,217,500
10,670,300
12,804,300
14,938,400
13,159,400
15,791,300
18,423,100
16,399,600
19,679,500
22,959,400
20,382,300
24,458,700
28,535,200
26,707,800
32,049,400
37,390,900
3,115,400
4,350,700
8,377,700
3,738,500
5,220,800
10,053,200
4,361,600
6,090,900
11,728,700
8,076,400
9,691,700
11,306,900
18,273,600
21,928,300
25,583,000
21,078,300
25,294,000
29,509,600
9,351,700
11,222,000
13,092,300
11,709,200
14,051,000
16,392,800
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
23,623,600
28,348,300
33,073,100
29,117,600
34,941,100
40,764,600
10,577,700
12,693,200
14,808,700
14,662,800
17,595,400
20,528,000
18,608,300
22,329,900
26,051,600
15,940,000
19,128,000
22,316,000
25,157,600
30,189,100
35,220,600
40,189,100
48,226,900
56,264,700
20,452,500
24,542,900
28,633,400
24,543,000
29,451,600
34,360,200
33,771,000
40,525,200
47,279,400
- 948 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
18,192,200
21,830,700
25,469,100
279 I-1-40-III
24,298,700
29,158,400
34,018,100
280 I-4-10-I
281 I-4-10-II

2,773,800
4,953,000
3,328,600
5,943,600
3,883,400
6,934,200
282 I-4-10-III
7,136,600
8,563,900
9,991,200
283 I-4-11-I
284 I-4-11-II

4,267,500
5,281,100
5,121,000
6,337,300
5,974,600
7,393,500
285 I-4-11-III
286 I-4-12-I

9,769,500
2,453,200
11,723,400
2,943,900
13,677,300
3,434,500
287 I-4-12-II
2,843,600
3,412,300
3,981,000
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,412,300
4,094,800
4,777,300
2,496,500
2,995,700
3,495,000
4,457,700
5,349,300
6,240,800
6,422,900
7,707,500
8,992,100
2,357,500
2,438,600
4,274,900
2,829,000
2,926,300
5,129,800
3,300,500
3,414,000
5,984,800
4,420,600
5,304,800
6,188,900
6,014,000
7,216,800
8,419,600
297 I-4-15-III
7,216,800
8,660,200
10,103,500
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
1,487,900
2,389,200
2,867,100
1,824,000
2,123,500
2,548,200
1,785,500
2,867,100
3,440,500
2,188,800
2,548,200
3,057,900
2,083,100
3,344,900
4,013,900
2,553,600
2,972,900
3,567,500
2,870,000
3,444,000
4,018,000
4,369,700
5,243,700
6,117,600
5,932,600
7,119,100
8,305,700
307 I-4-19-I
2,769,000
3,322,800
3,876,600
308 I-4-19-II

(SEDANG)
4,322,500
5,187,100
6,051,600
309 I-4-19-III
5,160,300
6,192,400
7,224,400
310
311
312
313
314

2,883,300
3,330,300
4,979,400
2,157,600
2,733,700
3,460,000
3,996,300
5,975,300
2,589,100
3,280,400
4,036,700
4,662,400
6,971,200
3,020,600
3,827,100
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
14,484,100
17,380,900
20,277,700
10,540,900
12,649,100
14,757,300
13,168,500
15,802,200
18,436,000
13,842,900
16,611,400
19,380,000
7,973,600
9,568,400
11,163,100
16,586,900
19,904,300
23,221,700
25,703,800
30,844,500
35,985,300
7,358,800
8,830,600
10,302,300
- 949 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
3,945,800
4,734,900
5,524,100
316 I-4-22-I
317 I-4-22-II
2,418,300
3,010,400
2,902,000
3,612,500
3,385,600
4,214,600
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
4,400,300
5,280,300
6,160,400
2,366,800
2,840,200
3,313,500
2,905,800
3,486,900
4,068,100
5,677,700
6,813,200
7,948,800
2,131,300
2,557,600
2,983,800
4,907,900
5,889,400
6,871,000
6,205,100
7,446,100
8,687,200
38,450,900
46,141,000
53,831,200
43,514,300
52,217,200
60,920,000
49,228,400
59,074,000
68,919,700
20,404,500
24,485,400
28,566,300
28,411,100
34,093,300
39,775,600
46,916,500
56,299,800
65,683,100
6,196,300
7,435,600
8,674,800
12,538,200
15,045,900
17,553,500
13,030,300
15,636,400
18,242,500
7,281,300
8,737,600
10,193,800
8,620,200
10,344,300
12,068,300
13,311,000
15,973,200
18,635,400
5,171,000
6,205,200
7,239,400
9,367,100
11,240,600
13,114,000
27,037,900
32,445,500
37,853,100
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,112,800
4,363,500
6,601,300
1,885,900
2,626,600
3,520,700
3,203,100
3,646,300
5,091,200
2,832,100
3,942,200
7,354,800
3,122,500
5,081,100
6,011,500
4,148,500
4,956,300
6,668,200
2,535,400
5,236,200
7,921,600
2,263,000
3,152,000
4,224,900
3,843,700
4,375,500
6,109,500
3,398,500
4,730,600
8,825,800
3,746,900
6,097,400
7,213,800
4,978,200
5,947,600
8,001,900
2,957,900
6,108,900
9,241,800
2,640,200
3,677,300
4,929,000
4,484,400
5,104,800
7,127,700
3,964,900
5,519,100
10,296,800
4,371,400
7,113,600
8,416,100
5,807,900
6,938,800
9,335,500
3,456,600
4,147,900
4,839,200
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 950 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
359 J-4-16-II
4,857,400
5,828,900
6,800,400
360 J-4-16-III
6,141,400
7,369,700
8,598,000
361 J-4-17-I
362 J-4-17-II

2,609,100
3,124,500
3,130,900
3,749,400
3,652,700
4,374,300
363 J-4-17-III
364 J-4-18-I

4,100,200
2,129,400
4,920,300
2,555,300
5,740,300
2,981,200
365 J-4-18-II
2,928,800
3,514,600
4,100,300
366 J-4-18-III
367 J-4-19-I

3,082,900
3,675,000
3,699,500
4,410,000
4,316,100
5,145,000
368 J-4-19-II
369 J-4-19-III

4,167,700
4,602,700
5,001,200
5,523,200
5,834,700
6,443,800
370 J-4-20-I
3,646,900
4,376,300
5,105,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
5,053,200
5,923,900
6,063,800
7,108,700
7,074,500
8,293,500
2,760,000
3,312,000
3,864,000
4,446,300
5,335,600
6,224,800
6,204,500
7,445,400
8,686,200
5,617,300
6,740,800
7,864,200
7,059,400
8,471,200
9,883,100
8,273,800
9,928,600
11,583,300
5,784,200
6,941,100
8,097,900

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
7,594,000
10,055,700
9,112,800
12,066,800
10,631,600
14,078,000
2,356,900
2,828,300
3,299,700
3,065,500
3,678,600
4,291,700
6,073,200
7,287,800
8,502,500
2,658,200
2,924,000
2,950,600
3,189,800
3,508,800
3,540,700
3,721,400
4,093,600
4,130,800
4,313,700
5,176,500
6,039,200
5,055,600
6,066,700
7,077,800
7,943,000
9,531,600
11,120,200
8,352,800
11,666,900
17,034,900
10,023,300
14,000,300
20,441,900
11,693,900
16,333,700
23,848,900
4,939,800
5,927,700
6,915,700
8,772,900
10,527,500
12,282,100
12,071,600
14,486,000
16,900,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
390 K-1-14-III
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
397 K-1-40-I
5,511,600
6,614,000
7,716,300
398 K-1-40-II

(SEDANG)
6,076,800
7,292,100
8,507,500
399 K-1-40-III
10,297,900
12,357,500
14,417,100
400
401
402
403
404

4,211,400
5,469,100
7,728,800
3,476,800
4,995,600
5,053,700
6,562,900
9,274,600
4,172,100
5,994,700
5,896,000
7,656,700
10,820,300
4,867,500
6,993,800
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 951 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
7,615,500
9,138,600
10,661,700
406 K-4-11-I
407 K-4-11-II

2,219,100
3,153,500
2,663,000
3,784,200
3,106,800
4,414,900
408 K-4-11-III
409 K-4-12-I

3,784,200
2,090,000
4,541,100
2,508,000
5,297,900
2,926,000
410 K-4-12-II
2,812,500
3,375,000
3,937,500
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
4,652,700
5,583,300
6,513,800
2,817,400
3,380,900
3,944,400
3,644,500
4,373,400
5,102,300
5,613,700
6,736,500
7,859,200
1,786,300
2,143,500
2,500,800
2,397,700
2,877,300
3,356,800
3,847,400
4,616,900
5,386,400
418 K-4-15-I
1,773,400
2,128,100
2,482,800
419 K-4-15-II
2,643,900
3,172,700
3,701,500
420 K-4-15-III
3,710,600
4,452,700
5,194,800
421 K-4-16-I
2,607,900
3,129,500
3,651,000
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
3,127,600
3,649,400
3,753,100
4,379,300
4,378,600
5,109,200
1,178,700
1,414,400
1,650,200
1,767,400
2,120,900
2,474,400
2,120,900
2,545,100
2,969,300
1,183,600
1,420,300
1,657,000
1,682,000
2,018,300
2,354,700
429 K-4-18-III
2,018,300
2,422,000
2,825,700
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
13,317,400
20,102,300
26,860,000
6,283,300
10,781,700
13,385,700
15,980,900
24,122,800
32,232,000
7,539,900
12,938,100
16,062,800
18,644,400
28,143,200
37,604,000
8,796,600
15,094,400
18,740,000
3,521,300
4,225,500
4,929,800
7,062,900
8,475,500
9,888,100
11,888,500
14,266,200
16,643,900
4,622,800
7,439,800
10,642,000
1,209,100
1,403,400
1,629,000
2,532,000
3,480,100
7,907,800
1,202,500
1,590,500
4,207,200
5,547,300
8,927,800
12,770,300
1,450,900
1,684,100
1,954,800
3,038,500
4,176,100
9,489,400
1,443,000
1,908,600
5,048,700
6,471,900
10,415,800
14,898,700
1,692,700
1,964,800
2,280,600
3,544,900
4,872,100
11,071,000
1,683,500
2,226,600
5,890,100
2,351,000
2,821,200
3,291,400
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 952 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,763,100
3,315,700
3,868,300
4,065,900
4,879,000
5,692,200
2,082,300
2,498,800
2,915,200
3,127,700
3,753,200
4,378,800
4,408,900
5,290,600
6,172,400
7,360,800
8,832,900
10,305,100
10,462,300
12,554,700
14,647,200
14,696,400
17,635,600
20,574,900
6,523,900
7,828,700
9,133,500
10,702,300
18,182,900
12,842,700
21,819,500
14,983,200
25,456,000
15,971,700
19,166,000
22,360,400
18,681,200
22,417,500
26,153,700
23,121,100
27,745,300
32,369,600
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
8,180,000
9,816,000
11,452,000
467 M-1-04-II
10,508,900
12,610,700
14,712,500
468 M-1-04-III
12,574,200
15,089,000
17,603,900
469 M-1-05-I
470 M-1-05-II

5,193,400
8,400,500
6,232,100
10,080,700
7,270,800
11,760,800
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
10,730,600
12,876,800
15,022,900
5,813,400
6,976,100
8,138,800
7,788,000
9,345,600
10,903,200
15,864,900
19,037,800
22,210,800
9,569,900
11,483,900
13,397,800
20,999,900
25,199,900
29,399,900
45,294,900
54,353,900
63,412,900
8,740,900
10,489,100
12,237,300
11,167,400
13,400,900
15,634,400
480 M-1-20-III
27,803,500
33,364,200
38,924,900
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
5,996,500
9,716,800
13,894,100
7,195,800
11,660,100
16,673,000
8,395,100
13,603,500
19,451,800
3,052,500
3,662,900
4,273,400
5,413,400
6,496,100
7,578,700
7,729,300
9,275,100
10,821,000
3,657,900
6,070,200
9,970,000
4,389,500
7,284,300
11,964,000
5,121,000
8,498,300
13,957,900
5,649,300
6,779,200
7,909,000
7,102,500
8,523,000
9,943,500
10,729,200
12,875,000
15,020,800
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 953 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
2,095,900
2,515,000
2,934,200
500 M-4-10-II
501 M-4-10-III
3,125,600
5,913,700
3,750,700
7,096,400
4,375,900
8,279,200
2,611,600
3,134,000
3,656,300
5,725,900
6,871,100
8,016,300
8,278,700
9,934,400
11,590,100
2,084,700
2,501,600
2,918,500
3,467,400
4,160,900
4,854,300
4,638,000
5,565,600
6,493,200
3,471,200
4,165,400
4,859,700
5,215,300
6,258,400
7,301,400
10,174,900
12,209,900
14,244,900
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,958,800
4,750,500
5,542,300
512 M-4-14-II
4,882,500
5,859,100
6,835,600
513 M-4-14-III
514 M-4-15-I
7,337,100
2,347,400
8,804,500
2,816,900
10,271,900
3,286,400
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
3,129,000
7,100,500
2,009,800
3,218,400
5,406,700
3,754,800
8,520,700
2,411,700
3,862,100
6,488,000
4,380,600
9,940,800
2,813,700
4,505,800
7,569,400
2,608,400
3,130,100
3,651,800
3,648,100
4,377,800
5,107,400
5,094,400
6,113,300
7,132,200
1,971,500
2,971,200
3,577,500
2,365,800
3,565,400
4,292,900
2,760,200
4,159,700
5,008,400
2,056,000
2,467,200
2,878,400
3,463,100
4,155,700
4,848,400
6,763,700
8,116,400
9,469,100
2,073,900
2,488,700
2,903,500
3,036,900
3,644,300
4,251,700
3,394,100
4,073,000
4,751,800
2,088,300
2,506,000
2,923,600
2,611,900
3,134,200
3,656,600
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
10,466,400
12,559,700
14,652,900
11,513,000
13,815,600
16,118,200
13,180,900
15,817,100
18,453,200
5,949,700
7,139,600
8,329,600
7,065,800
15,903,600
8,479,000
19,084,400
9,892,100
22,265,100
- 954 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
5,855,700
7,026,900
8,198,000
535 N-1-01-I

66,863,100
80,235,700
93,608,300
536 N-1-01-II
66,863,100
80,235,700
93,608,300
537 N-1-01-III
538 N-1-11-I

66,863,100
6,023,700
80,235,700
7,228,400
93,608,300
8,433,100
539 N-1-11-II
540 N-1-11-III

9,524,900
14,849,300
11,429,900
17,819,200
13,334,800
20,789,000
3,070,100
3,684,100
4,298,100
6,112,200
7,334,600
8,557,000
13,263,600
15,916,300
18,569,100
6,712,300
8,054,800
9,397,200

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
9,393,500
13,145,100
11,272,200
15,774,100
13,150,900
18,403,200
6,143,000
7,371,500
8,600,100
9,293,100
11,151,700
13,010,300
10,695,500
12,834,500
14,973,600
5,516,800
6,620,200
7,723,500
7,491,700
8,990,000
10,488,400
8,719,400
10,463,200
12,207,100
2,343,900
2,812,700
3,281,400
2,835,000
3,402,000
3,968,900
4,169,800
5,003,800
5,837,700
1,799,300
3,143,600
3,911,300
2,117,900
4,148,100
4,992,900
3,370,600
4,065,300
6,229,800
2,159,200
3,772,300
4,693,600
2,541,500
4,977,800
5,991,500
4,044,700
4,878,300
7,475,700
2,519,000
4,401,100
5,475,800
2,965,100
5,807,400
6,990,100
4,718,800
5,691,400
8,721,700
1,807,100
2,168,500
2,529,900
2,564,200
3,077,000
3,589,900
4,110,400
4,932,400
5,754,500
2,134,800
2,561,800
2,988,800
2,649,000
3,178,800
3,708,600
3,022,900
3,627,500
4,232,100
2,614,100
3,136,900
3,659,800
3,731,200
4,477,400
5,223,600
4,966,500
5,959,800
6,953,000
4,687,700
4,959,200
5,625,200
5,951,000
6,562,800
6,942,900
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 955 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1

5,819,400
6,983,200
8,147,100
2,429,900
2,915,900
3,401,900
2,700,600
3,240,700
3,780,800
3,359,600
4,031,500
4,703,400
1,721,600
2,065,900
2,410,200
2,067,600
2,481,100
2,894,600
2,598,000
3,117,600
3,637,200
1,602,300
1,922,800
2,243,300

MAYOR (RINGAN)
MAYOR (SEDANG)
1,896,500
2,275,800
2,275,800
2,731,000
2,655,100
3,186,100
38,443,100
46,131,800
53,820,400
47,567,600
57,081,100
66,594,700
55,831,000
66,997,200
78,163,400
52,473,100
62,967,700
73,462,300
60,191,900
72,230,200
84,268,600
68,773,500
82,528,200
96,282,900
6,395,100
7,674,100
8,953,200
9,081,100
10,897,300
12,713,500
10,261,600
12,313,900
14,366,200
20,752,600
24,903,200
29,053,700
26,932,400
32,318,900
37,705,400
38,614,300
46,337,200
54,060,100
11,284,600
13,541,500
15,798,500
21,277,000
25,532,400
29,787,900
25,965,200
31,158,200
36,351,300
3,723,500
4,468,200
5,212,900
10,439,800
12,527,800
14,615,700
13,830,200
16,596,200
19,362,200
3,606,600
4,327,900
5,049,200
10,112,000
12,134,400
14,156,800
13,395,900
16,075,100
18,754,300
3,812,900
4,575,400
5,338,000
5,410,400
6,492,500
7,574,600
8,760,500
10,512,700
12,264,800
6,041,700
7,250,000
8,458,400
8,579,200
10,295,000
12,010,900
- 956 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
9,694,500
11,633,400
13,572,300
5,707,800
6,849,300
7,990,900
8,115,700
9,738,800
11,361,900
9,185,300
11,022,400
12,859,400
4,952,400
5,942,900
6,933,400
6,537,200
7,844,600
9,152,000
9,734,100
11,680,900
13,627,700
2,507,400
3,008,900
3,510,400
5,104,100
6,125,000
7,145,800
9,470,100
11,364,100
13,258,200
1,880,600
2,256,700
2,632,900
3,766,000
4,519,200
5,272,400
4,418,700
5,302,500
6,186,200
1,702,000
2,042,400
2,382,800
3,270,600
3,924,700
4,578,900
6,669,700
8,003,600
9,337,600
3,301,600
3,961,900
4,622,200
5,942,900
7,131,500
8,320,000
8,111,700
9,734,100
11,356,400
1,919,000
2,302,700
2,686,500
2,364,400
2,837,300
3,310,200
3,236,700
3,884,000
4,531,300
1,619,200
2,374,400
4,058,100
1,410,800
1,877,800
3,255,100
1,943,000
2,849,200
4,869,700
1,693,000
2,253,300
3,906,100
2,266,900
3,324,100
5,681,300
1,975,100
2,628,900
4,557,100
2,083,400
2,500,100
2,916,800
3,696,100
4,435,300
5,174,600
5,999,300
7,199,100
8,399,000
1,054,300
1,265,200
1,476,100
2,239,500
2,687,400
3,135,300
4,246,900
5,096,300
5,945,700
705,200
846,200
987,200
1,330,700
1,596,900
1,863,000
1,723,500
2,068,300
2,413,000
3,651,400
4,381,700
5,112,000
- 957 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
4,643,800
5,572,500
6,501,300
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
6,648,900
7,978,700
9,308,500
1,759,900
2,111,900
2,463,900
2,611,900
3,134,300
3,656,700
3,141,400
3,769,700
4,398,000
1,177,500
1,413,000
1,648,500
1,581,600
1,897,900
2,214,200
2,877,100
3,452,500
4,028,000
537,000
644,400
751,800
1,023,500
1,228,200
1,432,900
1,487,900
1,785,500
2,083,000
636,000
763,100
890,300
1,000,800
1,201,000
1,401,100
1,611,900
1,934,300
2,256,600
1,112,200
1,334,700
1,557,100
1,681,500
2,017,800
2,354,000
2,624,300
3,149,100
3,674,000
3,848,000
4,617,600
5,387,200

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
5,973,700
15,778,000
7,168,400
18,933,600
8,363,100
22,089,200
5,953,100
7,143,700
8,334,300
7,546,400
9,055,700
10,565,000
10,858,100
13,029,700
15,201,300
4,651,700
7,133,100
10,477,000
4,409,900
5,138,200
8,517,500
5,582,000
8,559,700
12,572,400
5,291,900
6,165,800
10,221,000
6,512,300
9,986,300
14,667,900
6,173,800
7,193,500
11,924,600
2,797,200
3,356,700
3,916,100
3,432,900
4,119,500
4,806,100
4,068,000
4,881,600
5,695,200
3,100,100
4,407,400
5,681,000
3,720,100
5,288,900
6,817,200
4,340,100
6,170,400
7,953,400
4,246,700
5,096,000
5,945,300
6,320,200
7,584,200
8,848,300
16,225,200
19,470,200
22,715,300
3,642,000
4,938,400
9,657,200
4,370,400
5,926,000
11,588,600
5,098,800
6,913,700
13,520,000
2,620,900
3,145,100
3,669,300
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 958 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
1,592,900
1,911,500
2,230,100
697 U-4-12-I
698 U-4-12-II

2,499,500
2,907,500
2,999,500
3,489,000
3,499,400
4,070,500
699 U-4-12-III

3,771,800
4,526,200
5,280,500
1,894,300
2,273,200
2,652,000
2,233,200
2,679,800
3,126,500
2,671,000
3,205,200
3,739,400
2,608,700
3,123,800
3,130,400
3,748,600
3,652,200
4,373,400

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
5,245,900
6,295,000
7,344,200
2,094,700
2,513,600
2,932,600
2,609,700
3,131,700
3,653,600
3,652,400
4,382,800
5,113,300
3,416,600
4,100,000
4,783,300
7,038,100
8,445,800
9,853,400
8,631,300
10,357,600
12,083,800
6,500,000
7,422,200
11,623,500
7,800,000
8,906,700
13,948,200
9,100,000
10,391,100
16,272,900
6,111,200
7,333,500
8,555,700
8,345,400
10,014,500
11,683,600
10,577,900
12,693,500
14,809,000
3,187,700
3,825,200
4,462,800
6,090,700
7,308,800
8,526,900
9,555,500
11,466,600
13,377,700
6,251,100
7,501,300
8,751,500
9,082,600
10,899,100
12,715,700
11,341,300
13,609,600
15,877,800
1,006,700
1,110,900
1,228,900
1,208,100
1,333,100
1,474,700
1,409,400
1,555,300
1,720,500
3,022,900
3,627,500
4,232,100
5,021,200
6,025,500
7,029,700
8,278,200
9,933,900
11,589,500
2,612,000
3,134,400
3,656,800
3,504,600
4,205,500
4,906,400
4,694,500
5,633,300
6,572,200
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
723 V-1-14-III
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
6,000,100
7,200,100
8,400,100
9,212,000
11,054,300
12,896,700
1,249,400
1,514,200
1,499,300
1,817,000
1,749,100
2,119,900
- 959 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,119,300
8,543,200
9,967,100
8,533,000
10,239,600
11,946,200
12,176,400
14,611,600
17,046,900
1,510,100
1,812,100
2,114,200
1,666,400
1,843,400
1,999,700
2,212,000
2,333,000
2,580,700
1,578,400
1,894,100
2,209,800
1,741,800
2,090,100
2,438,500
1,926,700
2,312,100
2,697,400
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
1,698,000
2,037,600
2,377,300
743 W-1-12-II
744 W-1-12-III

2,119,400
3,753,100
2,543,300
4,503,700
2,967,200
5,254,300
745 W-1-13-I
1,745,400
2,094,500
2,443,600
746 W-1-13-II
747 W-1-13-III

1,895,000
2,545,400
2,273,900
3,054,500
2,652,900
3,563,600
748 W-1-20-I
749 W-1-20-II

5,845,300
7,303,800
7,014,400
8,764,500
8,183,400
10,225,300
750 W-1-20-III
8,467,000
10,160,300
11,853,700
751 W-1-30-I
3,299,800
3,959,700
4,619,700
752 W-1-30-II
5,263,100
6,315,700
7,368,400
753 W-1-30-III
12,913,300
15,496,000
18,078,700
754 W-4-10-I
2,458,700
2,950,400
3,442,100
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
3,644,900
7,203,000
2,236,000
3,394,600
4,131,800
4,373,800
8,643,600
2,683,200
4,073,500
4,958,200
5,102,800
10,084,200
3,130,400
4,752,400
5,784,500
2,770,700
3,324,800
3,879,000
3,804,000
4,564,800
5,325,600
4,146,500
4,975,800
5,805,100
879,700
1,201,700
1,494,400
1,175,700
1,399,300
1,790,300
1,559,000
1,731,400
2,397,200
2,074,300
2,773,800
3,759,400
1,530,600
2,763,500
4,085,800
2,065,500
2,741,700
3,894,800
1,769,800
2,125,600
2,921,700
1,055,700
1,442,100
1,793,300
1,410,800
1,679,200
2,148,300
1,870,800
2,077,700
2,876,600
2,489,100
3,328,600
4,511,300
1,836,700
3,316,200
4,903,000
2,478,600
3,290,000
4,673,700
2,123,700
2,550,700
3,506,100
1,231,600
1,682,400
2,092,200
1,645,900
1,959,100
2,506,400
2,182,600
2,423,900
3,356,100
2,904,000
3,883,400
5,263,200
2,142,800
3,868,900
5,720,100
2,891,700
3,838,400
5,452,700
2,477,700
2,975,800
4,090,400
737 W-1-10-II
738 W-1-10-III
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
- 960 -

REGIONAL 5
RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
823,000
987,600
1,152,200
2,005,300
2,406,400
2,807,400
2,543,100
3,051,800
3,560,400
- 961 -

REGIONAL 5
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
957,300
1,241,700
2,309,100
1,908,200
2,479,800
456,100
810,800
356,700
652,100
675,800
767,200
1,153,400
1,573,300
1,442,000
467,100
1,078,200
391,100
671,400
2,045,200
732,500
1,729,700
422,000
984,500
1,541,000
1,292,400
317,000
960,600
534,100
274,600
296,900
262,100
313,400
436,400
375,000
353,000
317,200
470,700
205,600
242,200
277,800
5,635,900
2,252,400
2,259,900
581,300
951,900
596,000
1,211,400
776,200
444,500
335,700
541,400
298,800
255,800
1,996,400
931,700
532,400
2,078,200
1,385,500
269,800
2,251,400
1,558,600
3,506,000
809,700
498,100
267,900
223,200
251,600
3,836,100
1,867,300
- 962 -

REGIONAL 5
RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
2,373,200
4,200,100
3,482,400
2,652,900
874,600
2,952,700
1,928,000
473,900
4,433,000
4,013,200
2,690,800
2,549,200
315,100
302,800
1,218,200
332,900
296,600
327,800
1,125,200
1,537,000
1,342,500
1,185,600
718,000
298,400
525,900
361,000
326,000
317,600
403,200
459,900
269,600
773,700
1,410,000
1,082,400
2,544,500
331,300
331,300
2,351,300
1,367,200
262,300
1,213,300
3,151,900
723,700
570,000
279,200
241,000
302,500
421,800
1,009,900
890,200
623,100
464,800
255,800
1,082,000
867,000
370,400
422,700
1,385,200
306,300
1,415,200
1,082,700
330,200
366,000
357,500
216,400
1,179,700
1,620,800
321,200
- 963 -

REGIONAL 5
RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
984,500
367,500
397,300
367,900
583,700
449,000
1,124,400
331,700
923,000
1,233,400
270,100
1,644,100
890,900
1,925,400
971,900
429,200
330,200
69,600
427,900
967,000
376,800
509,000
291,100
113,200
294,000
4,377,500
2,488,300
4,152,900
1,020,200
570,000
388,400
878,400
464,600
935,000
541,400
322,300
539,500
242,900
370,700
355,200
782,000
1,694,700
1,363,500
1,202,200
848,400
312,100
312,100
312,100
254,900
161,700
254,200
310,800
336,200
247,600
218,400
97,500
107,200
79,300
93,000
88,700
135,500
121,500
173,500
190,600
107,800
130,900
89,500
139,700
198,200
- 964 -

REGIONAL 5
RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
141,100
194,800
550,700
638,400
133,400
265,000
162,300
231,700
445,800
381,600
274,300
259,800
132,600
130,300
305,900
193,000
276,900
196,100
150,000
1,923,900
1,979,000
314,400
325,700
622,800
782,200
797,200
411,800
1,283,400
277,400
334,700
335,800
268,900
339,600
321,400
150,600
330,800
293,200
265,200
300,000
2,483,100
322,400
893,600
320,500
456,000
478,700
381,900
776,000
794,700
847,300
741,200
1,287,400
220,800
1,533,200
291,100
777,200
1,766,200
2,042,200
892,200
323,300
630,600
628,100
291,100
2,281,700
1,794,700
144,900
158,700
206,200
277,600
- 965 -

REGIONAL 5
RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
969,200
458,800
945,700
1,140,900
546,700
760,500
525,700
565,600
612,100
313,300
740,600
189,400
701,500
1,043,400
76,900
- 966 -

RUMAH SAKIT UMUM PUSAT DR. CIPTO MANGUNKUSUMO
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
5,569,500
6,683,400
7,797,300
A-4-10-II
SEPTIKEMIA (SEDANG)
9,515,000
11,418,000
13,321,000
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
12,829,200
4,263,700
15,395,000
5,116,500
17,960,900
5,969,200
5
6
A-4-11-II
A-4-11-III

6,068,500
8,399,400
7,282,200
10,079,200
8,495,900
11,759,100
A-4-12-I
2,780,700
3,336,800
3,893,000
8
9
A-4-12-II
A-4-12-III

4,800,000
6,915,900
5,760,000
8,299,000
6,719,900
9,682,200
10 A-4-13-I
11 A-4-13-II

2,483,500
4,389,000
2,980,200
5,266,900
3,477,000
6,144,700
12 A-4-13-III
5,266,900
6,320,200
7,373,600
2,782,300
3,338,700
3,895,200
4,681,300
5,617,600
6,553,800
5,617,600
6,741,100
7,864,600
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,100,900
22,541,700
21,721,100
27,050,000
25,341,300
31,558,300
18 A-4-15-III
INFEKSI HIV (BERAT)
25,465,800
30,558,900
35,652,100
19 B-1-01-I
20 B-1-01-II

79,045,000
87,207,400
94,854,000
104,648,900
110,662,900
122,090,300
21 B-1-01-III
22 B-1-10-I

192,228,500
12,777,200
230,674,200
15,332,600
269,120,000
17,888,100
23 B-1-10-II
28,359,700
34,031,700
39,703,600
24 B-1-10-III
25 B-1-11-I

55,985,900
32,192,200
67,183,100
38,630,700
78,380,300
45,069,100
26 B-1-11-II
27 B-1-11-III

38,358,700
59,275,000
46,030,500
71,130,000
53,702,200
82,985,000
28 B-1-12-I
15,003,500
18,004,200
21,004,900
29 B-1-12-II
16,686,500
20,023,900
23,361,200
30 B-1-12-III
26,104,200
31,325,100
36,545,900
11,950,500
14,340,600
16,730,600
19,663,000
23,595,600
27,528,200
25,442,200
30,530,600
35,619,100
19,768,800
23,722,600
27,676,300
20,762,800
24,915,400
29,067,900
36,753,800
5,080,500
8,109,900
11,187,900
44,104,500
6,096,600
9,731,900
13,425,400
51,455,300
7,112,600
11,353,900
15,663,000
6,763,200
8,115,800
9,468,400
9,468,500
11,362,200
13,255,900
11,470,900
13,765,100
16,059,300
9,684,400
13,790,300
20,516,900
9,238,200
11,621,300
16,548,300
24,620,300
11,085,800
13,558,200
19,306,400
28,723,600
12,933,400
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 967 -

RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,762,100
12,914,500
15,066,900
48 B-4-13-III
49 B-4-14-I

14,825,700
9,228,300
17,790,800
11,074,000
20,755,900
12,919,600
50 B-4-14-II
10,766,000
12,919,200
15,072,400
51 B-4-14-III
52 C-4-10-I

14,421,300
11,801,200
17,305,500
14,161,500
20,189,800
16,521,700
53 C-4-10-II
54 C-4-10-III

18,979,600
35,561,700
22,775,600
42,674,000
26,571,500
49,786,300
55 C-4-11-I
9,729,200
11,675,100
13,620,900
56 C-4-11-II
57 C-4-11-III

13,019,100
20,017,100
15,622,900
24,020,500
18,226,800
28,023,900
58 C-4-12-I
59 C-4-12-II
6,478,000
12,759,200
7,773,600
15,311,000
9,069,200
17,862,900
60 C-4-12-III
RADIOTERAPI (BERAT)
32,769,200
39,323,000
45,876,800
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
4,870,200
9,165,700
5,844,200
10,998,800
6,818,200
12,832,000
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
12,407,200
8,092,000
14,888,700
9,710,400
17,370,100
11,328,800
65 C-4-14-II
11,351,400
13,621,700
15,892,000
66 C-4-14-III
67 D-1-10-I

16,913,400
45,981,400
20,296,100
55,177,700
23,678,700
64,374,000
68 D-1-10-II
69 D-1-10-III

70,033,300
106,712,200
84,039,900
128,054,600
98,046,600
149,397,100
70 D-1-11-I
13,089,700
15,707,600
18,325,600
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
33,424,100
43,435,900
40,108,900
52,123,100
46,793,700
60,810,300
11,347,200
13,616,700
15,886,100
31,271,300
37,525,600
43,779,800
49,605,500
59,526,600
69,447,700
2,831,200
4,646,300
7,309,700
8,883,300
15,963,000
21,929,300
7,658,700
10,622,700
16,311,700
3,397,400
5,575,600
8,771,700
10,660,000
19,155,600
26,315,100
9,190,400
12,747,300
19,574,000
3,963,700
6,504,800
10,233,600
12,436,700
22,348,200
30,701,000
10,722,100
14,871,800
22,836,400
6,563,300
7,876,000
9,188,600
9,289,300
11,147,100
13,005,000
11,881,300
14,257,500
16,633,800
7,039,400
8,447,300
9,855,200
11,525,300
13,830,400
16,135,400
14,096,600
16,915,900
19,735,300
14,032,300
16,838,700
19,645,200
19,156,100
22,987,300
26,818,600
93 E-1-01-III
46,187,400
55,424,900
64,662,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
14,589,000
20,251,300
38,261,300
17,506,800
24,301,500
45,913,600
20,424,600
28,351,800
53,565,800
16,515,900
19,819,100
23,122,200
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 968 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,099,400
4,919,300
5,739,200
104 E-4-11-II
105 E-4-11-III

6,249,900
8,469,100
7,499,900
10,162,900
8,749,900
11,856,700
106 E-4-12-I
107 E-4-12-II

4,710,200
8,156,900
5,652,200
9,788,300
6,594,200
11,419,600
108 E-4-12-III

(RINGAN)
(SEDANG)
9,668,900
11,602,700
13,536,400
8,123,700
9,748,400
11,373,200
11,899,800
14,279,700
16,659,700
15,555,400
18,666,400
21,777,500
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
22,229,900
26,675,900
31,121,900
30,637,400
36,764,900
42,892,400
3,690,400
4,428,500
5,166,600
7,147,700
8,577,200
10,006,800
11,976,800
14,372,200
16,767,500
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,460,700
6,276,000
6,552,800
7,531,100
7,645,000
8,786,300
114 F-4-10-III
115 F-4-11-I
7,531,100
5,281,400
9,037,400
6,337,600
10,543,600
7,393,900
116 F-4-11-II
6,153,300
7,384,000
8,614,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,890,800
9,469,000
11,047,200
2,895,000
3,474,000
4,053,100
4,115,800
4,939,000
5,762,200
8,941,400
10,729,700
12,518,000
4,254,300
5,613,600
7,267,500
2,427,300
3,113,300
4,189,200
5,105,100
6,736,300
8,721,000
2,912,700
3,736,000
5,027,000
5,956,000
7,859,000
10,174,500
3,398,200
4,358,600
5,864,900
127 F-4-15-I
3,865,600
4,638,700
5,411,800
128 F-4-15-II
5,760,200
6,912,200
8,064,300
129 F-4-15-III
7,605,300
9,126,300
10,647,400
7,605,700
9,126,800
10,648,000
8,842,900
10,611,500
12,380,000
11,803,700
14,164,500
16,525,200
133 F-4-17-I

1,796,200
2,155,400
2,514,600
134 F-4-17-II
5,264,400
6,317,200
7,370,100
135
136
137
138
139
140
141

(RINGAN)
5,616,600
6,608,800
7,271,600
11,209,600
5,050,700
6,467,600
8,052,100
6,739,900
7,930,600
8,725,900
13,451,600
6,060,800
7,761,100
9,662,500
7,863,200
9,252,300
10,180,200
15,693,500
7,070,900
9,054,700
11,273,000
33,933,900
40,720,700
47,507,500
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 969 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,137,500
60,165,000
70,192,500
148 G-1-11-I
149 G-1-11-II

25,969,600
47,478,500
31,163,500
56,974,200
36,357,500
66,469,900
150 G-1-11-III
68,666,300
82,399,600
96,132,900
10,843,200
13,011,900
15,180,500
20,326,100
24,391,400
28,456,600
27,700,600
33,240,700
38,780,800
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
3,271,100
8,784,500
3,925,300
10,541,400
4,579,500
12,298,300
156 G-1-13-III
157 G-1-20-I

12,515,200
17,069,000
15,018,200
20,482,800
17,521,300
23,896,600
158 G-1-20-II
27,787,100
33,344,500
38,902,000
159 G-1-20-III
42,643,800
51,172,600
59,701,300
160 G-1-30-I
28,885,100
34,662,100
40,439,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
38,944,200
58,481,500
46,733,000
70,177,800
54,521,900
81,874,100
9,307,700
11,169,300
13,030,800
11,377,200
13,652,700
15,928,100
15,611,500
18,733,800
21,856,100
9,743,700
11,692,500
13,641,200
12,943,300
15,532,000
18,120,700
19,018,100
22,821,800
26,625,400
10,809,600
12,971,500
15,133,400
13,653,200
16,383,900
19,114,500
19,829,600
23,795,500
27,761,400
6,493,400
7,792,100
9,090,800
11,323,300
13,588,000
15,852,600
13,429,700
16,115,600
18,801,500
11,015,400
13,218,400
15,421,500
14,726,700
17,672,100
20,617,400
18,483,800
22,180,600
25,877,300
9,000,500
10,800,600
12,600,700
10,741,700
12,890,000
15,038,300
15,161,000
18,193,100
21,225,300
7,419,700
8,903,700
10,387,600
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
48,669,400
58,403,300
68,137,200
71,664,500
85,997,400
100,330,300
33,312,800
40,799,900
39,975,400
48,959,900
46,637,900
57,119,800
- 970 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
9,850,700
11,820,800
13,790,900
183 G-4-16-III
14,028,200
16,833,800
19,639,400
9,882,600
11,859,100
13,835,600
12,958,200
15,549,800
18,141,500
16,282,600
19,539,100
22,795,600
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
9,732,800
11,679,400
13,625,900
188 G-4-18-II
13,009,800
15,611,800
18,213,700
189 G-4-18-III
14,556,900
17,468,300
20,379,700
8,120,300
9,744,300
11,368,400
13,725,200
16,470,300
19,215,300
18,020,600
21,624,700
25,228,900
193 G-4-20-I

5,680,500
6,816,700
7,952,800
194 G-4-20-II
8,030,500
9,636,600
11,242,800
195 G-4-20-III
196 G-4-21-I

13,264,500
5,915,400
15,917,400
7,098,500
18,570,300
8,281,500
197 G-4-21-II
198 G-4-21-III

10,011,900
11,766,300
12,014,300
14,119,500
14,016,600
16,472,800
199 G-4-22-I
2,798,200
3,357,800
3,917,400
200 G-4-22-II
201 G-4-22-III

4,955,600
7,817,000
5,946,700
9,380,400
6,937,800
10,943,800
202 G-4-23-I
203 G-4-23-II

3,676,700
4,612,900
4,412,000
5,535,500
5,147,300
6,458,100
204 G-4-23-III
6,567,700
7,881,200
9,194,800
205 G-4-24-I
206 G-4-24-II

6,486,100
8,103,400
7,783,300
9,724,100
9,080,500
11,344,800
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
13,500,100
5,542,300
7,008,800
9,288,000
16,200,100
6,650,700
8,410,500
11,145,600
18,900,100
7,759,200
9,812,300
13,003,200
5,529,800
6,635,800
7,741,800
6,432,900
7,719,500
9,006,100
9,619,200
11,543,000
13,466,900
13,883,500
15,343,500
20,866,100
9,983,400
12,403,300
17,372,600
6,752,900
9,162,200
18,008,800
6,475,300
7,386,400
10,576,900
7,634,500
9,121,800
15,286,500
16,660,200
18,412,100
25,039,400
11,980,000
14,884,000
20,847,200
8,103,400
10,994,700
21,610,600
7,770,400
8,863,700
12,692,200
9,161,400
10,946,200
18,343,800
19,436,900
21,480,800
29,212,600
13,976,700
17,364,600
24,321,700
9,454,000
12,827,100
25,212,400
9,065,500
10,340,900
14,807,600
10,688,300
12,770,500
21,401,100
229 I-1-01-I
102,544,600
123,053,500
143,562,400
230 I-1-01-II
104,800,500
125,760,600
146,720,800
231 I-1-01-III

(RINGAN)
165,426,200
198,511,500
231,596,700
56,891,300
68,269,600
79,647,900
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 971 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,292,200
57,950,600
245 I-1-06-II
69,955,200
83,946,200
97,937,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
83,469,500
100,163,400
116,857,300
75,168,000
90,201,600
105,235,200
93,960,000
112,752,000
131,544,000
140,940,000
169,128,000
197,316,000
8,915,100
10,698,100
12,481,100
9,912,700
11,895,200
13,877,700
13,190,700
15,828,900
18,467,000
25,661,800
30,794,100
35,926,500
41,910,900
50,293,000
58,675,200
55,140,000
66,168,100
77,196,100
24,891,600
29,869,900
34,848,200
33,148,200
39,777,900
46,407,500
40,880,900
49,057,100
57,233,300
50,946,900
61,136,300
71,325,700
63,319,500
75,983,500
88,647,400
82,970,400
99,564,500
116,158,600
9,678,400
13,515,800
26,026,000
11,614,100
16,218,900
31,231,200
13,549,800
18,922,100
36,436,400
25,090,100
30,108,100
35,126,100
56,768,700
68,122,500
79,476,200
65,481,800
78,578,200
91,674,600
29,051,900
34,862,300
40,672,700
36,375,700
43,650,900
50,926,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
73,389,100
88,066,900
102,744,700
90,456,600
108,548,000
126,639,300
33,876,900
40,652,300
47,427,600
46,960,400
56,352,500
65,744,500
59,596,300
71,515,600
83,434,900
51,050,600
61,260,700
71,470,900
80,571,700
96,686,000
112,800,300
128,712,700
154,455,200
180,197,800
84,564,000
101,476,800
118,389,600
103,356,000
124,027,200
144,698,400
140,940,000
169,128,000
197,316,000
67,609,100
- 972 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,754,000
44,104,800
51,455,600
279 I-1-40-III
49,090,900
58,909,100
68,727,200
280 I-4-10-I
281 I-4-10-II

8,617,200
15,387,000
10,340,600
18,464,400
12,064,100
21,541,800
282 I-4-10-III
22,170,500
26,604,600
31,038,700
283 I-4-11-I
284 I-4-11-II

13,257,500
16,406,300
15,909,000
19,687,500
18,560,500
22,968,800
285 I-4-11-III
286 I-4-12-I

30,349,900
5,774,300
36,419,800
6,929,100
42,489,800
8,084,000
287 I-4-12-II
6,693,200
8,031,900
9,370,500
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
8,031,900
9,638,300
11,244,600
7,755,500
9,306,600
10,857,700
13,848,300
16,618,000
19,387,600
19,953,500
23,944,200
27,934,900
7,323,700
7,575,700
13,280,300
8,788,400
9,090,900
15,936,300
10,253,200
10,606,000
18,592,400
4,722,500
5,667,000
6,611,500
8,905,200
10,686,300
12,467,300
10,686,300
12,823,500
14,960,800
4,622,300
7,422,300
8,906,800
1,948,600
3,144,400
4,402,200
5,546,800
8,906,800
10,688,200
2,338,300
3,773,300
5,282,600
6,471,300
10,391,300
12,469,500
2,728,000
4,402,200
6,163,000
8,916,000
10,699,200
12,482,400
13,574,900
16,289,900
19,004,900
18,430,200
22,116,300
25,802,300
8,602,100
10,322,600
12,043,000
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
44,996,200
53,995,400
62,994,700
32,746,500
39,295,800
45,845,100
40,909,400
49,091,200
57,273,100
43,004,200
51,605,000
60,205,900
24,770,900
29,725,100
34,679,200
51,528,900
61,834,700
72,140,500
79,851,300
95,821,500
111,791,800
22,860,800
27,433,000
32,005,200
307 I-4-19-I
308 I-4-19-II

(SEDANG)
13,428,400
16,114,100
18,799,800
309 I-4-19-III
16,031,000
19,237,200
22,443,400
310
311
312
313
314

8,957,400
10,345,800
15,469,100
5,170,700
6,551,300
10,748,800
12,414,900
18,562,900
6,204,800
7,861,600
12,540,300
14,484,100
21,656,700
7,239,000
9,171,800
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 973 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
9,456,100
11,347,300
13,238,600
316 I-4-22-I
317 I-4-22-II
3,422,100
4,260,000
4,106,500
5,112,000
4,791,000
5,964,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,226,800
7,472,200
8,717,500
7,352,700
8,823,300
10,293,800
9,027,000
10,832,400
12,637,900
17,638,300
21,166,000
24,693,600
3,317,600
3,981,100
4,644,700
7,639,600
9,167,500
10,695,400
9,658,900
11,590,700
13,522,500
119,451,400
143,341,700
167,232,000
135,181,500
162,217,800
189,254,100
185,424,700
222,509,700
259,594,600
77,927,600
93,513,100
109,098,600
98,329,500
117,995,400
137,661,300
145,750,700
174,900,900
204,051,000
19,249,400
23,099,300
26,949,200
38,951,300
46,741,500
54,531,800
40,480,000
48,576,000
56,672,000
33,481,700
40,178,000
46,874,300
35,059,800
42,071,800
49,083,700
41,352,000
49,622,500
57,892,900
16,064,100
19,277,000
22,489,800
29,100,000
34,920,000
40,740,000
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
83,996,000
100,795,200
117,594,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,989,800
6,174,800
9,341,500
5,858,600
8,159,900
10,937,500
9,950,800
11,327,600
15,816,400
8,798,200
12,246,800
22,848,600
6,737,100
10,963,100
12,970,500
4,431,800
7,339,100
13,329,900
3,587,800
7,409,700
11,209,800
7,030,300
9,791,800
13,125,000
11,941,000
13,593,100
18,979,700
10,557,800
14,696,200
27,418,300
8,084,500
13,155,800
15,564,600
5,318,100
8,806,900
15,995,900
4,185,700
8,644,700
13,078,100
8,202,000
11,423,800
15,312,500
13,931,100
15,858,600
22,142,900
12,317,500
17,145,500
31,988,000
9,431,900
15,348,400
18,158,700
6,204,500
10,274,700
18,661,900
3,692,600
4,431,100
5,169,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 974 -

RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,192,600
8,631,100
10,069,600
12,276,800
14,732,200
17,187,500
5,117,700
6,128,500
6,141,200
7,354,300
7,164,700
8,580,000

8,042,500
2,274,800
9,651,000
2,729,800
11,259,500
3,184,700
365 J-4-18-II
4,336,800
5,204,200
6,071,500
366 J-4-18-III
367 J-4-19-I

6,162,800
6,487,500
7,395,400
7,785,000
8,628,000
9,082,600
368 J-4-19-II
369 J-4-19-III

7,357,300
8,125,200
8,828,700
9,750,300
10,300,200
11,375,300
370 J-4-20-I
7,153,300
8,584,000
10,014,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
9,911,700
11,619,600
11,894,000
13,943,500
13,876,400
16,267,400
2,948,500
3,538,200
4,127,800
6,583,800
7,900,600
9,217,400
12,402,800
14,883,300
17,363,900
17,450,800
20,940,900
24,431,100
21,930,600
26,316,700
30,702,800
25,703,400
30,844,100
35,984,800
13,556,100
16,267,400
18,978,600

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
17,797,600
31,269,800
21,357,100
37,523,700
24,916,600
43,777,700
7,322,100
8,786,500
10,250,900
9,523,200
11,427,900
13,332,500
18,867,000
22,640,400
26,413,700
5,213,900
5,735,300
9,166,200
6,256,700
6,882,400
10,999,500
7,299,500
8,029,400
12,832,700
12,060,900
14,473,100
16,885,300
14,135,100
16,962,100
19,789,200
390 K-1-14-III
24,675,800
29,610,900
34,546,100
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

25,948,700
36,244,500
52,920,800
31,138,400
43,493,400
63,504,900
36,328,100
50,742,200
74,089,100
15,345,900
18,415,000
21,484,200
27,253,900
32,704,600
38,155,400
37,501,700
45,002,100
52,502,400
397 K-1-40-I
17,122,400
20,546,900
23,971,400
398 K-1-40-II

(SEDANG)
18,878,100
22,653,700
26,429,300
399 K-1-40-III
31,991,500
38,389,800
44,788,100
400
401
402
403
404

12,483,100
16,210,900
22,908,900
8,640,700
12,415,400
14,979,700
19,453,100
27,490,700
10,368,900
14,898,500
17,476,400
22,695,200
32,072,500
12,097,000
17,381,600
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 975 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
14,898,500
17,878,200
20,857,900
406 K-4-11-I
407 K-4-11-II

2,844,800
5,603,400
3,413,700
6,724,100
3,982,700
7,844,700
408 K-4-11-III
409 K-4-12-I

6,724,100
6,492,700
8,068,900
7,791,300
9,413,700
9,089,800
410 K-4-12-II
8,737,200
10,484,600
12,232,100
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
14,454,200
17,345,000
20,235,900
8,752,600
10,503,100
12,253,600
11,322,100
13,586,500
15,850,900
17,439,600
20,927,500
24,415,400
4,994,300
5,993,100
6,992,000
6,704,000
8,044,700
9,385,500
10,757,200
12,908,600
15,060,100
418 K-4-15-I
6,695,500
8,034,600
9,373,700
419 K-4-15-II
10,731,700
12,878,000
15,024,400
420 K-4-15-III
15,189,600
18,227,500
21,265,400
421 K-4-16-I
5,428,100
6,513,700
7,599,300
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,709,000
8,421,100
8,050,800
10,105,300
9,392,700
11,789,600
2,396,000
2,875,200
3,354,400
2,950,600
3,540,800
4,130,900
3,540,800
4,248,900
4,957,100
2,111,400
2,533,700
2,956,000
3,563,000
4,275,600
4,988,200
429 K-4-18-III
4,275,600
5,130,800
5,985,900
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
28,733,900
43,373,100
57,953,500
19,519,700
33,494,500
41,583,900
34,480,700
52,047,700
69,544,200
23,423,600
40,193,400
49,900,700
40,227,500
60,722,300
81,134,900
27,327,500
46,892,300
58,217,500
10,939,200
13,127,100
15,314,900
21,941,700
26,330,100
30,718,400
36,932,800
44,319,300
51,705,900
14,361,100
23,112,600
33,060,300
3,756,200
4,359,900
5,060,700
7,866,100
10,811,200
24,566,500
3,735,700
4,940,900
13,070,100
17,233,300
27,735,100
39,672,300
4,507,400
5,231,900
6,072,800
9,439,300
12,973,500
29,479,800
4,482,800
5,929,100
15,684,100
20,105,500
32,357,600
46,284,400
5,258,700
6,103,900
7,085,000
11,012,500
15,135,700
34,393,100
5,229,900
6,917,300
18,298,200
2,511,500
3,013,800
3,516,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 976 -

RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,091,400
4,909,700
5,727,900
8,127,700
9,753,300
11,378,800
5,822,000
6,986,400
8,150,800
8,744,900
10,493,800
12,242,800
12,326,900
14,792,300
17,257,700
22,866,900
27,440,300
32,013,700
32,502,100
39,002,500
45,502,900
45,655,700
54,786,900
63,918,000
20,267,200
24,320,700
28,374,100
33,247,600
56,486,900
39,897,200
67,784,300
46,546,700
79,081,700
51,152,200
61,382,600
71,613,100
59,830,000
71,795,900
83,761,900
74,049,500
88,859,500
103,669,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,197,900
31,437,500
36,677,100
467 M-1-04-II
33,656,700
40,388,100
47,119,400
468 M-1-04-III
40,271,100
48,325,300
56,379,500
469 M-1-05-I
470 M-1-05-II

16,133,900
26,097,100
19,360,600
31,316,500
22,587,400
36,536,000
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
33,335,800
40,002,900
46,670,100
18,618,600
22,342,300
26,066,000
24,942,400
29,930,900
34,919,400
50,810,100
60,972,100
71,134,100
29,729,800
35,675,700
41,621,700
65,238,400
78,286,100
91,333,700
140,713,100
168,855,800
196,998,400
27,154,600
32,585,500
38,016,400
34,692,700
41,631,300
48,569,800
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
77,736,900
93,284,200
108,831,600
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
13,040,100
21,130,300
30,214,400
15,648,100
25,356,400
36,257,300
18,256,100
29,582,400
42,300,200
9,482,700
11,379,300
13,275,800
16,817,200
20,180,700
23,544,100
24,011,800
28,814,100
33,616,500
11,363,600
18,857,800
30,972,700
13,636,300
22,629,300
37,167,200
15,909,000
26,400,900
43,361,700
17,550,200
21,060,200
24,570,200
22,064,600
26,477,500
30,890,400
33,331,200
39,997,500
46,663,700
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 977 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
6,511,000
7,813,200
9,115,400
500 M-4-10-II
501 M-4-10-III
9,710,100
18,371,500
11,652,100
22,045,800
13,594,100
25,720,100
8,113,300
9,736,000
11,358,600
17,788,100
21,345,700
24,903,300
25,718,500
30,862,200
36,005,900
5,828,600
6,994,300
8,160,100
9,694,600
11,633,500
13,572,400
15,849,200
19,019,000
22,188,900
10,783,600
12,940,300
15,097,000
16,201,900
19,442,300
22,682,600
31,609,500
37,931,400
44,253,300
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
12,298,300
14,758,000
17,217,600
512 M-4-14-II
15,168,100
18,201,700
21,235,400
513 M-4-14-III
514 M-4-15-I
22,793,300
6,563,300
27,352,000
7,875,900
31,910,600
9,188,600
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
8,748,400
19,301,200
6,243,500
9,998,300
16,796,400
10,498,100
23,161,500
7,492,300
11,997,900
20,155,700
12,247,800
27,021,700
8,741,000
13,997,600
23,515,000
4,604,700
5,525,600
6,446,500
6,440,200
7,728,200
9,016,200
8,993,200
10,791,900
12,590,500
3,867,100
5,827,900
7,017,100
4,640,500
6,993,500
8,420,500
5,414,000
8,159,100
9,823,900
6,387,200
7,664,700
8,942,100
10,758,500
12,910,200
15,061,900
21,012,000
25,214,400
29,416,800
5,798,600
6,958,400
8,118,100
8,491,100
10,189,300
11,887,500
9,489,800
11,387,800
13,285,800
5,838,800
7,006,500
8,174,300
7,302,600
8,763,100
10,223,700
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
32,514,800
39,017,800
45,520,800
35,766,300
42,919,600
50,072,900
40,947,700
49,137,200
57,326,800
18,483,300
22,180,000
25,876,600
21,950,700
49,406,200
26,340,800
59,287,500
30,730,900
69,168,700
- 978 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
16,372,300
19,646,800
22,921,200
535 N-1-01-I

283,523,900
340,228,700
396,933,400
536 N-1-01-II
283,523,900
340,228,700
396,933,400
537 N-1-01-III
538 N-1-11-I

283,523,900
18,713,100
340,228,700
22,455,700
396,933,400
26,198,400
539 N-1-11-II
540 N-1-11-III

29,590,000
46,130,800
35,508,000
55,357,000
41,426,000
64,583,100
9,100,000
10,920,000
12,740,000
18,117,100
21,740,500
25,363,900
39,314,700
47,177,600
55,040,600
18,767,200
22,520,700
26,274,100

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
29,181,900
36,753,000
35,018,300
44,103,500
40,854,700
51,454,100
19,083,700
22,900,400
26,717,200
28,869,900
34,643,900
40,417,800
33,226,500
39,871,800
46,517,100
17,138,500
20,566,300
23,994,000
23,273,700
27,928,500
32,583,200
27,087,600
32,505,100
37,922,600
7,281,500
8,737,800
10,194,100
8,807,100
10,568,500
12,329,900
12,953,900
15,544,700
18,135,500
3,529,300
6,166,100
7,671,900
2,661,000
5,528,100
8,982,800
3,600,700
6,019,700
12,453,400
4,235,100
7,399,300
9,206,300
3,193,100
6,633,700
10,779,400
4,320,900
7,223,600
14,944,100
4,941,000
8,632,500
10,740,700
3,725,300
7,739,400
12,576,000
5,041,000
8,427,500
17,434,800
5,613,900
6,736,700
7,859,500
7,965,900
9,559,000
11,152,200
12,769,200
15,323,100
17,876,900
6,632,100
7,958,500
9,285,000
8,229,300
9,875,100
11,521,000
9,391,000
11,269,200
13,147,400
8,121,000
9,745,200
11,369,400
11,591,300
13,909,500
16,227,800
15,428,800
18,514,600
21,600,300
5,649,400
7,514,000
6,779,300
9,016,800
7,909,200
10,519,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 979 -

RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
13,465,400
16,158,500
18,851,600
7,548,900
9,058,600
10,568,400
8,389,700
10,067,600
11,745,600
10,436,900
12,524,300
14,611,600
5,348,300
6,417,900
7,487,600
6,423,200
7,707,900
8,992,500
8,071,000
9,685,200
11,299,400
2,054,100
2,464,900
2,875,800
3,369,900
4,043,900
4,043,900
4,852,600
4,717,800
5,661,400
119,427,400
143,312,900
167,198,400
147,773,500
177,328,200
206,882,900
173,444,500
208,133,400
242,822,400
192,691,200
231,229,400
269,767,700
221,036,600
265,244,000
309,451,300
252,550,200
303,060,300
353,570,300
18,880,300
22,656,400
26,432,500
32,674,800
39,209,800
45,744,800
35,626,900
42,752,300
49,877,700
77,470,600
92,964,700
108,458,800
100,323,200
120,387,800
140,452,500
143,838,100
172,605,700
201,373,300
42,075,900
50,491,100
58,906,200
66,099,200
79,319,100
92,538,900
87,945,700
105,534,800
123,123,900
11,567,400
13,880,800
16,194,300
32,432,300
38,918,700
45,405,200
42,964,800
51,557,700
60,150,700
11,204,200
13,445,000
15,685,800
31,413,900
37,696,700
43,979,500
41,615,700
49,938,900
58,262,000
8,828,800
10,594,600
12,360,300
12,516,900
15,020,300
17,523,700
17,122,400
20,546,900
23,971,300
16,417,700
19,701,200
22,984,700
29,704,400
35,645,300
41,586,200
- 980 -

RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
30,980,000
37,175,900
43,371,900
14,276,200
17,131,500
19,986,700
21,687,800
26,025,400
30,362,900
26,939,100
32,326,900
37,714,700
7,723,600
9,268,300
10,813,000
12,048,800
14,458,500
16,868,300
22,449,200
26,939,100
31,428,900
7,789,600
9,347,500
10,905,500
15,856,500
19,027,800
22,199,100
39,146,200
46,975,400
54,804,700
5,842,300
7,010,800
8,179,200
11,699,500
14,039,400
16,379,200
13,727,200
16,472,600
19,218,100
5,287,400
6,344,800
7,402,300
10,160,500
12,192,600
14,224,700
20,720,000
24,864,000
29,008,000
5,149,100
6,178,900
7,208,700
9,268,300
11,121,900
12,975,600
18,707,700
22,449,200
26,190,800
5,961,400
7,153,700
8,346,000
7,345,400
8,814,400
10,283,500
10,055,100
12,066,100
14,077,100
1,729,700
3,515,800
8,112,200
4,382,800
5,833,400
10,112,300
2,075,700
4,219,000
9,734,600
5,259,400
7,000,100
12,134,800
2,421,600
4,922,200
11,357,000
6,136,000
8,166,800
14,157,200
6,472,300
7,766,800
9,061,200
11,482,400
13,778,800
16,075,300
18,637,300
22,364,700
26,092,200
3,275,400
3,930,500
4,585,600
6,957,300
8,348,700
9,740,200
13,193,500
15,832,100
18,470,800
2,190,600
2,628,800
3,066,900
4,134,100
4,960,900
5,787,700
5,354,400
6,425,200
7,496,100
11,343,500
13,612,200
15,880,900
- 981 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
14,426,300
17,311,600
20,196,900
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
20,655,500
24,786,600
28,917,800
5,467,400
6,560,900
7,654,300
8,114,200
9,737,000
11,359,900
9,759,100
11,710,900
13,662,800
3,658,100
4,389,700
5,121,300
4,913,300
5,896,000
6,878,600
8,938,100
10,725,700
12,513,300
1,883,500
2,260,200
2,636,900
3,589,500
4,307,400
5,025,300
5,218,200
6,261,800
7,305,500
2,155,300
2,586,400
3,017,400
3,391,800
4,070,200
4,748,600
5,463,200
6,555,800
7,648,500
4,403,200
5,283,800
6,164,400
6,644,300
7,973,200
9,302,100
10,352,800
12,423,300
14,493,900
11,954,300
14,345,200
16,736,000

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
18,557,800
49,016,000
22,269,400
58,819,200
25,980,900
68,622,400
18,493,900
22,192,600
25,891,400
23,443,700
28,132,500
32,821,200
33,731,800
40,478,100
47,224,500
14,450,900
22,159,700
32,548,000
14,460,800
16,849,100
27,930,600
17,341,100
26,591,600
39,057,500
17,353,000
20,219,000
33,516,700
20,231,200
31,023,500
45,567,100
20,245,200
23,588,800
39,102,900
8,689,900
10,427,900
12,165,900
10,664,600
12,797,600
14,930,500
12,637,600
15,165,100
17,692,600
4,294,600
6,105,700
9,300,900
5,153,600
7,326,900
11,161,100
6,012,500
8,548,000
13,021,300
13,192,700
15,831,200
18,469,800
19,634,400
23,561,200
27,488,100
50,405,100
60,486,200
70,567,200
11,314,200
15,341,500
30,000,900
13,577,000
18,409,800
36,001,100
15,839,800
21,478,100
42,001,300
8,142,100
9,770,600
11,399,000
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 982 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
4,367,000
5,240,400
6,113,800
697 U-4-12-I
698 U-4-12-II

2,670,200
4,305,300
3,204,300
5,166,300
3,738,300
6,027,400
699 U-4-12-III

7,539,900
9,047,900
10,555,800
2,023,700
2,428,400
2,833,100
3,306,800
3,968,200
4,629,500
5,339,400
6,407,300
7,475,200
8,104,200
9,704,500
9,725,000
11,645,400
11,345,800
13,586,300

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
16,296,800
19,556,200
22,815,500
6,507,400
7,808,900
9,110,400
8,107,400
9,728,900
11,350,300
11,346,400
13,615,700
15,885,000
10,614,100
12,736,900
14,859,800
21,864,700
26,237,600
30,610,600
26,814,000
32,176,800
37,539,600
20,192,900
23,057,900
36,109,600
24,231,400
27,669,400
43,331,500
28,270,000
32,281,000
50,553,400
18,985,200
22,782,200
26,579,300
25,925,800
31,111,000
36,296,100
32,861,200
39,433,500
46,005,700
9,902,900
11,883,500
13,864,100
18,921,200
22,705,500
26,489,700
29,685,100
35,622,100
41,559,100
19,419,600
23,303,500
27,187,400
28,216,100
33,859,300
39,502,500
723 V-1-14-III
35,232,900
42,279,400
49,326,000
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
3,127,500
3,451,200
3,817,700
3,753,000
4,141,500
4,581,300
4,378,600
4,831,700
5,344,800
8,451,900
10,142,200
11,832,600
14,039,000
16,846,800
19,654,600
23,145,400
27,774,500
32,403,500
8,114,400
9,737,200
11,360,100
10,887,400
13,064,900
15,242,300
14,583,800
17,500,500
20,417,300
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
16,775,800
20,131,000
23,486,200
25,756,100
30,907,300
36,058,500
2,509,000
3,520,400
3,010,800
4,224,500
3,512,600
4,928,600
- 983 -

RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I
737 W-1-10-II
738 W-1-10-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
22,116,900
26,540,300
30,963,700
26,508,600
31,810,300
37,112,100
37,827,100
45,392,500
52,957,900
4,691,300
5,629,600
6,567,800
5,176,800
5,726,600
6,212,200
6,871,900
7,247,600
8,017,200
4,903,500
5,884,100
6,864,800
5,410,900
6,493,100
7,575,300
5,985,600
7,182,700
8,379,800
5,275,100
6,330,100
7,385,200
6,584,300
11,659,300
7,901,100
13,991,100
9,218,000
16,323,000
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
743 W-1-12-II
744 W-1-12-III

745 W-1-13-I
5,422,400
6,506,900
7,591,300
746 W-1-13-II
747 W-1-13-III

5,886,900
7,907,600
7,064,200
9,489,100
8,241,600
11,070,600
748 W-1-20-I
749 W-1-20-II

18,159,000
22,689,900
21,790,800
27,227,900
25,422,700
31,765,900
750 W-1-20-III
26,303,400
31,564,100
36,824,800
751 W-1-30-I
10,251,000
12,301,200
14,351,400
752 W-1-30-II
16,350,400
19,620,400
22,890,500
753 W-1-30-III
40,116,500
48,139,800
56,163,100
754 W-4-10-I
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
7,638,100
9,165,700
10,693,300
11,323,100
22,376,700
6,251,600
9,491,000
11,552,300
13,587,700
26,852,100
7,502,000
11,389,200
13,862,700
15,852,400
31,327,400
8,752,300
13,287,300
16,173,200
2,959,900
3,551,900
4,143,800
5,632,700
6,759,300
7,885,800
8,289,000
9,946,800
11,604,500
2,733,000
3,733,300
4,642,600
3,652,300
4,347,200
5,561,700
1,665,400
2,563,800
4,792,000
2,215,900
4,107,300
7,515,200
1,635,100
4,092,100
8,167,600
7,244,000
9,615,400
13,659,600
3,165,900
3,802,500
5,226,700
3,279,600
4,480,000
5,571,100
4,382,800
5,216,600
6,674,000
1,998,500
3,076,500
5,750,400
2,659,100
4,928,800
9,018,200
1,962,100
4,910,500
9,801,100
8,692,800
11,538,400
16,391,500
3,799,100
4,562,900
6,272,000
3,826,100
5,226,700
6,499,700
5,113,200
6,086,100
7,786,400
2,331,600
3,589,300
6,708,800
3,102,300
5,750,300
10,521,200
2,289,100
5,728,900
11,434,600
10,141,700
13,461,500
19,123,400
4,432,300
5,323,400
7,317,400
- 984 -

RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,092,500
2,511,000
2,929,500
4,201,500
5,041,800
5,882,100
8,864,100
10,636,900
12,409,700
- 985 -

RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
2,482,800
3,220,500
5,988,900
4,949,200
6,431,700
1,183,100
2,628,600
925,100
1,606,100
1,794,000
2,036,700
3,062,000
4,176,600
3,827,900
1,240,100
2,862,200
1,038,200
1,782,400
5,429,400
1,944,400
4,591,900
1,120,300
3,191,800
3,996,700
3,352,100
822,100
2,491,600
1,385,300
890,300
770,100
679,800
812,900
1,131,900
588,100
915,500
497,400
1,220,800
446,600
628,300
451,700
14,617,400
5,841,900
5,861,500
1,507,800
3,086,200
1,932,300
3,927,500
2,013,300
1,152,900
870,600
1,404,200
702,900
663,600
6,472,400
1,521,900
1,014,600
6,737,600
4,491,700
699,800
7,299,100
5,053,200
4,512,400
2,625,100
1,614,700
694,700
484,900
652,500
9,949,600
4,843,200
- 986 -

RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
6,155,300
10,893,600
9,032,100
6,880,600
2,268,400
7,658,200
5,000,500
1,229,200
11,497,600
10,408,700
6,979,100
6,611,800
817,200
785,200
3,159,500
863,500
769,300
850,300
3,648,100
3,986,400
3,482,000
3,843,900
2,327,900
773,900
1,364,000
936,400
845,500
823,800
1,045,800
1,192,700
699,200
2,006,600
3,657,000
2,807,200
6,599,500
859,400
859,400
7,623,000
3,546,100
680,200
3,147,000
8,175,000
1,876,900
1,478,400
724,200
273,600
980,600
1,367,400
3,274,300
2,886,000
2,020,200
1,205,600
663,600
3,507,900
2,248,600
1,201,000
1,096,300
3,592,700
665,400
4,588,200
3,510,200
856,400
949,300
927,300
470,100
3,824,600
4,203,900
833,100
- 987 -

RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
2,553,400
953,100
1,030,500
954,200
1,513,800
1,164,500
2,916,300
860,400
2,394,000
3,998,700
700,600
4,264,200
2,310,700
4,993,700
2,520,800
1,113,300
856,400
79,000
1,109,900
2,508,000
977,400
1,320,200
754,900
211,000
762,400
11,353,800
6,453,700
6,030,300
3,307,500
1,478,400
1,007,300
2,278,300
1,205,000
2,425,100
1,404,200
835,900
1,399,200
787,400
1,201,800
921,300
1,188,900
4,395,300
3,536,300
3,118,000
2,200,500
809,500
809,500
809,500
661,200
419,400
659,400
806,100
871,900
642,200
566,500
110,700
121,700
90,000
105,600
100,700
153,800
206,400
450,100
494,400
122,400
148,600
101,600
158,500
224,900
- 988 -

RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
160,100
505,200
1,428,300
1,655,700
151,400
687,300
184,300
263,100
1,156,100
989,800
711,500
673,700
150,600
147,900
793,300
419,400
527,700
395,900
389,100
6,237,500
5,132,800
815,500
844,600
1,615,300
888,000
2,067,700
1,068,100
3,328,600
314,900
868,100
870,900
697,400
880,800
833,500
390,500
858,000
760,500
687,900
778,000
6,440,200
1,045,200
2,317,700
831,300
1,478,400
543,500
433,500
2,012,700
2,061,200
2,197,700
1,922,400
1,670,200
572,700
4,970,600
754,900
2,519,600
5,726,100
5,296,800
2,313,900
838,600
1,635,500
1,629,100
754,900
5,917,800
4,654,800
253,200
180,100
234,000
900,000
- 989 -

RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
2,221,900
1,487,500
2,452,700
2,959,000
1,418,000
1,972,600
1,363,400
642,100
1,403,200
454,900
1,920,800
215,000
796,400
1,488,600
87,300
- 990 -

RUMAH SAKIT JANTUNG DAN PEMBULUH DARAH HARAPAN KITA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
5,314,000
6,376,800
7,439,600
A-4-10-II
SEPTIKEMIA (SEDANG)
9,078,500
10,894,200
12,709,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
12,240,700
4,263,700
14,688,900
5,116,500
17,137,000
5,969,200
5
6
A-4-11-II
A-4-11-III

6,068,500
8,399,400
7,282,200
10,079,200
8,495,900
11,759,100
A-4-12-I
2,780,700
3,336,800
3,893,000
8
9
A-4-12-II
A-4-12-III

4,800,000
6,915,900
5,760,000
8,299,000
6,719,900
9,682,200
10 A-4-13-I
11 A-4-13-II

2,276,600
4,023,300
2,731,900
4,827,900
3,187,200
5,632,600
12 A-4-13-III
4,827,900
5,793,500
6,759,100
2,550,400
3,060,500
3,570,600
4,291,200
5,149,400
6,007,700
5,149,400
6,179,300
7,209,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,100,900
22,541,700
21,721,100
27,050,000
25,341,300
31,558,300
18 A-4-15-III
INFEKSI HIV (BERAT)
25,465,800
30,558,900
35,652,100
19 B-1-01-I
20 B-1-01-II

75,419,200
83,207,200
90,503,000
99,848,600
105,586,800
116,490,100
21 B-1-01-III
22 B-1-10-I

183,411,000
12,191,100
220,093,200
14,629,300
256,775,400
17,067,500
23 B-1-10-II
27,058,900
32,470,600
37,882,400
24 B-1-10-III
25 B-1-11-I

53,417,900
32,192,200
64,101,400
38,630,700
74,785,000
45,069,100
26 B-1-11-II
27 B-1-11-III

38,358,700
59,275,000
46,030,500
71,130,000
53,702,200
82,985,000
28 B-1-12-I
14,315,300
17,178,400
20,041,400
29 B-1-12-II
15,921,100
19,105,400
22,289,600
30 B-1-12-III
24,906,800
29,888,200
34,869,600
11,402,300
13,682,700
15,963,200
18,761,100
22,513,300
26,265,500
24,275,200
29,130,200
33,985,200
19,768,800
23,722,600
27,676,300
20,762,800
24,915,400
29,067,900
36,753,800
4,847,400
7,737,900
10,674,700
44,104,500
5,816,900
9,285,500
12,809,600
51,455,300
6,786,400
10,833,100
14,944,600
6,763,200
8,115,800
9,468,400
9,468,500
11,362,200
13,255,900
11,470,900
13,765,100
16,059,300
9,240,200
13,157,700
19,575,800
8,814,400
11,088,300
15,789,200
23,490,900
10,577,300
12,936,300
18,420,800
27,406,100
12,340,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 991 -

RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,268,400
12,322,100
14,375,800
48 B-4-13-III
49 B-4-14-I

14,145,600
8,805,000
16,974,700
10,566,000
19,803,900
12,327,000
50 B-4-14-II
10,272,100
12,326,600
14,381,000
51 B-4-14-III
52 C-4-10-I

13,759,800
11,801,200
16,511,700
14,161,500
19,263,700
16,521,700
53 C-4-10-II
54 C-4-10-III

18,979,600
35,561,700
22,775,600
42,674,000
26,571,500
49,786,300
55 C-4-11-I
9,282,900
11,139,500
12,996,100
56 C-4-11-II
57 C-4-11-III

12,421,900
19,098,900
14,906,300
22,918,700
17,390,700
26,738,500
58 C-4-12-I
59 C-4-12-II
6,180,900
12,173,900
7,417,100
14,608,700
8,653,200
17,043,500
60 C-4-12-III
RADIOTERAPI (BERAT)
31,266,100
37,519,300
43,772,500
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
4,646,800
8,745,300
5,576,100
10,494,300
6,505,500
12,243,400
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
11,838,100
7,720,800
14,205,700
9,265,000
16,573,400
10,809,100
65 C-4-14-II
10,830,700
12,996,900
15,163,000
66 C-4-14-III
67 D-1-10-I

16,137,600
41,982,200
19,365,100
50,378,600
22,592,600
58,775,100
68 D-1-10-II
69 D-1-10-III

63,941,900
101,817,300
76,730,200
122,180,800
89,518,600
142,544,300
70 D-1-11-I
12,489,300
14,987,100
17,485,000
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
31,890,900
41,443,500
38,269,100
49,732,200
44,647,300
58,020,900
10,826,700
12,992,100
15,157,400
29,836,900
35,804,300
41,771,700
47,330,100
56,796,100
66,262,100
2,831,200
4,646,300
7,309,700
8,475,900
15,230,800
20,923,400
7,307,400
10,135,500
15,563,500
3,397,400
5,575,600
8,771,700
10,171,000
18,276,900
25,108,000
8,768,800
12,162,500
18,676,200
3,963,700
6,504,800
10,233,600
11,866,200
21,323,100
29,292,700
10,230,300
14,189,600
21,788,900
6,262,200
7,514,700
8,767,100
8,863,200
10,635,800
12,408,500
11,336,300
13,603,500
15,870,800
6,716,500
8,059,800
9,403,100
10,996,600
13,196,000
15,395,300
13,450,000
16,140,000
18,830,000
13,388,600
16,066,300
18,744,000
18,277,400
21,932,900
25,588,400
93 E-1-01-III
44,068,800
52,882,500
61,696,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
13,919,800
19,322,400
36,506,300
16,703,800
23,186,800
43,807,500
19,487,700
27,051,300
51,108,800
15,758,300
18,910,000
22,061,600
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 992 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,099,400
4,919,300
5,739,200
104 E-4-11-II
105 E-4-11-III

6,249,900
8,469,100
7,499,900
10,162,900
8,749,900
11,856,700
106 E-4-12-I
107 E-4-12-II

4,710,200
8,156,900
5,652,200
9,788,300
6,594,200
11,419,600
108 E-4-12-III

(RINGAN)
(SEDANG)
9,668,900
11,602,700
13,536,400
7,751,100
9,301,300
10,851,500
11,353,900
13,624,700
15,895,500
14,841,800
17,810,200
20,778,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
21,210,200
25,452,300
29,694,300
29,232,100
35,078,500
40,924,900
3,690,400
4,428,500
5,166,600
7,147,700
8,577,200
10,006,800
11,976,800
14,372,200
16,767,500
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,460,700
6,276,000
6,552,800
7,531,100
7,645,000
8,786,300
114 F-4-10-III
115 F-4-11-I
7,531,100
5,281,400
9,037,400
6,337,600
10,543,600
7,393,900
116 F-4-11-II
6,153,300
7,384,000
8,614,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,890,800
9,469,000
11,047,200
2,895,000
3,474,000
4,053,100
4,115,800
4,939,000
5,762,200
8,941,400
10,729,700
12,518,000
4,254,300
5,613,600
7,267,500
2,427,300
3,113,300
4,189,200
5,105,100
6,736,300
8,721,000
2,912,700
3,736,000
5,027,000
5,956,000
7,859,000
10,174,500
3,398,200
4,358,600
5,864,900
127 F-4-15-I
3,865,600
4,638,700
5,411,800
128 F-4-15-II
5,760,200
6,912,200
8,064,300
129 F-4-15-III
7,605,300
9,126,300
10,647,400
7,605,700
9,126,800
10,648,000
8,842,900
10,611,500
12,380,000
11,803,700
14,164,500
16,525,200
133 F-4-17-I

1,796,200
2,155,400
2,514,600
134 F-4-17-II
5,264,400
6,317,200
7,370,100
135
136
137
138
139
140
141

(RINGAN)
5,616,600
6,608,800
7,271,600
11,209,600
5,050,700
6,467,600
8,052,100
6,739,900
7,930,600
8,725,900
13,451,600
6,060,800
7,761,100
9,662,500
7,863,200
9,252,300
10,180,200
15,693,500
7,070,900
9,054,700
11,273,000
32,377,300
38,852,800
45,328,300
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 993 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,137,500
60,165,000
70,192,500
148 G-1-11-I
149 G-1-11-II

24,778,400
45,300,700
29,734,100
54,360,800
34,689,700
63,421,000
150 G-1-11-III
65,516,600
78,619,900
91,723,300
10,345,800
12,415,000
14,484,200
19,393,800
23,272,500
27,151,300
26,429,900
31,715,900
37,001,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
3,121,000
8,381,600
3,745,200
10,057,900
4,369,400
11,734,200
156 G-1-13-III
157 G-1-20-I

12,515,200
16,286,100
15,018,200
19,543,300
17,521,300
22,800,500
158 G-1-20-II
26,512,500
31,815,000
37,117,500
159 G-1-20-III
40,687,700
48,825,300
56,962,800
160 G-1-30-I
28,885,100
34,662,100
40,439,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
38,944,200
58,481,500
46,733,000
70,177,800
54,521,900
81,874,100
8,880,800
10,656,900
12,433,100
10,855,300
13,026,400
15,197,500
14,895,400
17,874,400
20,853,500
9,296,800
11,156,100
13,015,500
12,349,600
14,819,600
17,289,500
18,145,800
21,774,900
25,404,100
10,313,700
12,376,500
14,439,200
13,027,000
15,632,300
18,237,700
18,920,000
22,704,000
26,488,000
6,195,600
7,434,700
8,673,800
10,803,900
12,964,700
15,125,500
12,813,700
15,376,400
17,939,100
10,510,100
12,612,100
14,714,100
14,051,200
16,861,500
19,671,700
17,636,000
21,163,100
24,690,300
8,587,700
10,305,200
12,022,700
10,248,900
12,298,700
14,348,500
14,465,500
17,358,600
20,251,700
7,079,400
8,495,200
9,911,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
46,437,000
55,724,300
65,011,700
68,377,200
82,052,700
95,728,100
33,312,800
40,799,900
39,975,400
48,959,900
46,637,900
57,119,800
- 994 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
9,398,800
11,278,600
13,158,400
183 G-4-16-III
13,384,700
16,061,600
18,738,600
9,429,200
11,315,100
13,200,900
12,363,800
14,836,600
17,309,300
15,535,700
18,642,800
21,750,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
9,286,400
11,143,600
13,000,900
188 G-4-18-II
12,413,000
14,895,600
17,378,200
189 G-4-18-III
13,889,200
16,667,000
19,444,900
7,747,800
9,297,400
10,846,900
13,095,700
15,714,800
18,333,900
17,194,000
20,632,800
24,071,600
193 G-4-20-I

5,420,000
6,504,000
7,588,000
194 G-4-20-II
7,662,200
9,194,600
10,727,100
195 G-4-20-III
196 G-4-21-I

12,656,100
5,644,000
15,187,300
6,772,900
17,718,500
7,901,700
197 G-4-21-II
198 G-4-21-III

9,552,600
11,226,600
11,463,200
13,471,900
13,373,700
15,717,200
199 G-4-22-I
2,798,200
3,357,800
3,917,400
200 G-4-22-II
201 G-4-22-III

4,955,600
7,817,000
5,946,700
9,380,400
6,937,800
10,943,800
202 G-4-23-I
203 G-4-23-II

3,676,700
4,612,900
4,412,000
5,535,500
5,147,300
6,458,100
204 G-4-23-III
6,567,700
7,881,200
9,194,800
205 G-4-24-I
206 G-4-24-II

6,188,600
7,731,700
7,426,300
9,278,100
8,664,000
10,824,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
12,880,800
5,288,000
6,687,300
8,862,000
15,457,000
6,345,600
8,024,800
10,634,400
18,033,200
7,403,200
9,362,200
12,406,800
5,529,800
6,635,800
7,741,800
6,432,900
7,719,500
9,006,100
9,619,200
11,543,000
13,466,900
11,801,000
13,561,900
18,443,300
6,771,000
8,689,000
13,844,900
6,443,100
8,742,000
17,182,800
6,178,300
7,047,600
10,091,700
7,284,300
8,703,400
14,585,300
14,161,200
16,274,300
22,132,000
8,125,200
10,426,800
16,613,800
7,731,700
10,490,400
20,619,300
7,414,000
8,457,100
12,110,000
8,741,200
10,444,100
17,502,400
16,521,400
18,986,700
25,820,700
9,479,300
12,164,600
19,382,800
9,020,400
12,238,800
24,055,900
8,649,600
9,866,600
14,128,400
10,198,000
12,184,700
20,419,500
229 I-1-01-I
97,840,900
117,409,100
136,977,200
230 I-1-01-II
99,993,300
119,992,000
139,990,700
231 I-1-01-III

(RINGAN)
157,838,100
189,405,800
220,973,400
54,281,700
65,138,100
75,994,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 995 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,292,200
57,950,600
245 I-1-06-II
69,955,200
83,946,200
97,937,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
83,469,500
100,163,400
116,857,300
75,168,000
90,201,600
105,235,200
93,960,000
112,752,000
131,544,000
140,940,000
169,128,000
197,316,000
8,506,100
10,207,400
11,908,600
9,458,000
11,349,500
13,241,100
12,585,700
15,102,800
17,619,900
24,484,700
29,381,600
34,278,600
39,988,400
47,986,100
55,983,800
52,610,800
63,132,900
73,655,100
23,749,800
28,499,800
33,249,700
31,627,700
37,953,200
44,278,800
39,005,700
46,806,800
54,608,000
48,610,000
58,332,000
68,054,000
60,415,100
72,498,100
84,581,100
79,164,600
94,997,500
110,830,400
9,234,500
12,895,800
24,832,200
11,081,400
15,474,900
29,798,600
12,928,300
18,054,100
34,765,100
23,939,200
28,727,000
33,514,900
54,164,700
64,997,700
75,830,600
62,478,200
74,973,800
87,469,500
27,719,300
33,263,200
38,807,000
34,707,200
41,648,600
48,590,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
70,022,700
84,027,300
98,031,800
86,307,400
103,568,900
120,830,400
33,876,900
40,652,300
47,427,600
46,960,400
56,352,500
65,744,500
59,596,300
71,515,600
83,434,900
51,050,600
61,260,700
71,470,900
80,571,700
96,686,000
112,800,300
128,712,700
154,455,200
180,197,800
84,564,000
101,476,800
118,389,600
103,356,000
124,027,200
144,698,400
140,940,000
169,128,000
197,316,000
67,609,100
- 996 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,754,000
44,104,800
51,455,600
279 I-1-40-III
49,090,900
58,909,100
68,727,200
280 I-4-10-I
281 I-4-10-II

8,221,900
14,681,200
9,866,300
17,617,500
11,510,700
20,553,700
282 I-4-10-III
21,153,600
25,384,300
29,615,000
283 I-4-11-I
284 I-4-11-II

12,649,400
15,653,700
15,179,300
18,784,400
17,709,200
21,915,200
285 I-4-11-III
286 I-4-12-I

28,957,700
5,293,100
34,749,300
6,351,700
40,540,800
7,410,300
287 I-4-12-II
6,135,500
7,362,600
8,589,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,362,600
8,835,100
10,307,600
7,399,700
8,879,700
10,359,600
13,213,100
15,855,700
18,498,300
19,038,200
22,845,900
26,653,500
6,987,800
7,228,200
12,671,100
8,385,300
8,673,900
15,205,300
9,782,900
10,119,500
17,739,600
4,722,500
5,667,000
6,611,500
8,905,200
10,686,300
12,467,300
10,686,300
12,823,500
14,960,800
4,410,300
7,081,900
8,498,300
1,948,600
3,144,400
4,402,200
5,292,400
8,498,300
10,197,900
2,338,300
3,773,300
5,282,600
6,174,400
9,914,600
11,897,600
2,728,000
4,402,200
6,163,000
8,507,000
10,208,400
11,909,800
12,952,300
15,542,700
18,133,200
17,584,800
21,101,800
24,618,800
8,207,600
9,849,100
11,490,600
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
42,932,200
51,518,700
60,105,100
31,244,400
37,493,300
43,742,200
39,032,900
46,839,400
54,646,000
41,031,600
49,237,900
57,444,200
23,634,600
28,361,600
33,088,500
49,165,300
58,998,400
68,831,400
76,188,500
91,426,200
106,663,900
21,812,200
26,174,700
30,537,100
307 I-4-19-I
308 I-4-19-II

(SEDANG)
12,812,500
15,374,900
17,937,400
309 I-4-19-III
15,295,600
18,354,800
21,413,900
310
311
312
313
314

8,546,500
9,871,200
14,759,500
4,933,500
6,250,800
10,255,800
11,845,500
17,711,400
5,920,200
7,501,000
11,965,100
13,819,700
20,663,300
6,906,900
8,751,100
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 997 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
9,022,400
10,826,800
12,631,300
316 I-4-22-I
317 I-4-22-II
3,422,100
4,260,000
4,106,500
5,112,000
4,791,000
5,964,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,226,800
7,472,200
8,717,500
7,015,400
8,418,500
9,821,600
8,613,000
10,335,600
12,058,200
16,829,200
20,195,100
23,560,900
3,317,600
3,981,100
4,644,700
7,639,600
9,167,500
10,695,400
9,658,900
11,590,700
13,522,500
113,972,200
136,766,600
159,561,100
128,980,700
154,776,900
180,573,000
166,882,300
200,258,700
233,635,200
70,134,800
84,161,800
98,188,800
88,496,500
106,195,800
123,895,100
139,065,100
166,878,200
194,691,200
18,366,400
22,039,700
25,713,000
37,164,600
44,597,500
52,030,400
38,623,200
46,347,800
54,072,400
33,481,700
40,178,000
46,874,300
35,059,800
42,071,800
49,083,700
39,455,200
47,346,300
55,237,300
15,327,300
18,392,700
21,458,200
27,765,200
33,318,200
38,871,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
80,143,100
96,171,800
112,200,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,989,800
6,174,800
9,341,500
5,589,900
7,785,600
10,435,800
9,494,400
10,808,000
15,090,900
8,394,600
11,685,100
21,800,500
6,737,100
10,963,100
12,970,500
4,431,800
7,339,100
13,329,900
3,587,800
7,409,700
11,209,800
6,707,800
9,342,700
12,522,900
11,393,200
12,969,600
18,109,100
10,073,500
14,022,100
26,160,600
8,084,500
13,155,800
15,564,600
5,318,100
8,806,900
15,995,900
4,185,700
8,644,700
13,078,100
7,825,800
10,899,800
14,610,100
13,292,100
15,131,100
21,127,300
11,752,500
16,359,100
30,520,700
9,431,900
15,348,400
18,158,700
6,204,500
10,274,700
18,661,900
3,692,600
4,431,100
5,169,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 998 -

RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,192,600
8,631,100
10,069,600
12,276,800
14,732,200
17,187,500
5,117,700
6,128,500
6,141,200
7,354,300
7,164,700
8,580,000

8,042,500
2,274,800
9,651,000
2,729,800
11,259,500
3,184,700
365 J-4-18-II
4,336,800
5,204,200
6,071,500
366 J-4-18-III
367 J-4-19-I

6,162,800
6,487,500
7,395,400
7,785,000
8,628,000
9,082,600
368 J-4-19-II
369 J-4-19-III

7,357,300
8,125,200
8,828,700
9,750,300
10,300,200
11,375,300
370 J-4-20-I
7,153,300
8,584,000
10,014,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
9,911,700
11,619,600
11,894,000
13,943,500
13,876,400
16,267,400
2,948,500
3,538,200
4,127,800
6,583,800
7,900,600
9,217,400
12,402,800
14,883,300
17,363,900
16,650,300
19,980,400
23,310,400
20,924,700
25,109,600
29,294,500
24,524,400
29,429,300
34,334,200
12,934,300
15,521,200
18,108,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
16,981,200
29,835,400
20,377,400
35,802,500
23,773,700
41,769,600
6,986,200
8,383,500
9,780,700
9,086,400
10,903,700
12,721,000
18,001,500
21,601,800
25,202,100
5,213,900
5,735,300
9,166,200
6,256,700
6,882,400
10,999,500
7,299,500
8,029,400
12,832,700
11,507,700
13,809,200
16,110,700
13,486,700
16,184,100
18,881,400
390 K-1-14-III
23,543,900
28,252,700
32,961,400
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

24,758,400
34,581,900
50,493,300
29,710,100
41,498,300
60,591,900
34,661,700
48,414,700
70,690,600
13,828,500
16,594,200
19,359,900
24,559,100
29,470,900
34,382,700
33,793,700
40,552,400
47,311,100
397 K-1-40-I
16,337,000
19,604,400
22,871,800
398 K-1-40-II

(SEDANG)
18,012,100
21,614,600
25,217,000
399 K-1-40-III
30,524,100
36,628,900
42,733,700
400
401
402
403
404

12,483,100
16,210,900
22,908,900
8,244,400
11,845,900
14,979,700
19,453,100
27,490,700
9,893,200
14,215,100
17,476,400
22,695,200
32,072,500
11,542,100
16,584,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 999 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
14,215,100
17,058,100
19,901,200
406 K-4-11-I
407 K-4-11-II

2,607,700
5,136,400
3,129,200
6,163,700
3,650,800
7,191,000
408 K-4-11-III
409 K-4-12-I

6,163,700
6,194,900
7,396,500
7,433,900
8,629,200
8,672,900
410 K-4-12-II
8,336,400
10,003,700
11,671,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
13,791,200
16,549,400
19,307,600
8,351,100
10,021,300
11,691,600
10,802,700
12,963,300
15,123,800
16,639,600
19,967,500
23,295,500
4,169,500
5,003,400
5,837,400
5,596,900
6,716,300
7,835,600
8,980,800
10,777,000
12,573,100
418 K-4-15-I
5,289,600
6,347,500
7,405,400
419 K-4-15-II
8,714,400
10,457,300
12,200,200
420 K-4-15-III
12,230,300
14,676,400
17,122,400
421 K-4-16-I
4,236,500
5,083,800
5,931,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,543,400
7,449,700
6,652,100
8,939,600
7,760,800
10,429,600
2,196,300
2,635,600
3,074,800
2,704,800
3,245,700
3,786,700
3,245,700
3,894,800
4,544,000
1,935,500
2,322,600
2,709,700
3,266,100
3,919,300
4,572,600
429 K-4-18-III
3,919,300
4,703,200
5,487,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
28,733,900
43,373,100
57,953,500
18,624,300
31,958,100
39,676,500
34,480,700
52,047,700
69,544,200
22,349,200
38,349,700
47,611,800
40,227,500
60,722,300
81,134,900
26,074,000
44,741,400
55,547,100
10,437,500
12,524,900
14,612,400
20,935,200
25,122,300
29,309,300
35,238,700
42,286,400
49,334,200
13,702,300
22,052,400
31,543,800
3,583,900
4,159,900
4,828,600
7,505,200
10,315,300
23,439,600
3,564,300
4,714,300
12,470,600
16,442,800
26,462,900
37,852,600
4,300,700
4,991,900
5,794,300
9,006,300
12,378,400
28,127,500
4,277,200
5,657,200
14,964,700
19,183,200
30,873,400
44,161,300
5,017,500
5,823,900
6,760,000
10,507,300
14,441,500
32,815,500
4,990,000
6,600,000
17,458,800
2,511,500
3,013,800
3,516,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 1000 -

RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,091,400
4,909,700
5,727,900
8,127,700
9,753,300
11,378,800
4,937,700
5,925,300
6,912,800
7,416,600
8,900,000
10,383,300
10,454,700
12,545,600
14,636,500
21,818,000
26,181,600
30,545,200
31,011,200
37,213,500
43,415,700
43,561,500
52,273,800
60,986,100
19,337,600
23,205,100
27,072,600
31,722,600
53,895,900
38,067,100
64,675,100
44,411,600
75,454,200
51,152,200
61,382,600
71,613,100
59,830,000
71,795,900
83,761,900
74,049,500
88,859,500
103,669,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,197,900
31,437,500
36,677,100
467 M-1-04-II
33,656,700
40,388,100
47,119,400
468 M-1-04-III
40,271,100
48,325,300
56,379,500
469 M-1-05-I
470 M-1-05-II

15,393,800
24,900,100
18,472,600
29,880,100
21,551,300
34,860,100
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
31,806,700
38,168,000
44,529,300
18,618,600
22,342,300
26,066,000
24,942,400
29,930,900
34,919,400
50,810,100
60,972,100
71,134,100
25,529,500
30,635,400
35,741,300
56,021,300
67,225,600
78,429,800
120,832,800
144,999,300
169,165,900
25,909,000
31,090,800
36,272,600
33,101,400
39,721,600
46,341,900
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
74,171,100
89,005,300
103,839,500
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,442,000
20,161,100
28,828,500
14,930,300
24,193,300
34,594,200
17,418,700
28,225,500
40,359,900
9,047,800
10,857,300
12,666,900
16,045,800
19,255,000
22,464,100
22,910,300
27,492,400
32,074,500
10,842,300
17,992,800
29,552,000
13,010,800
21,591,300
35,462,300
15,179,300
25,189,900
41,372,700
16,745,100
20,094,200
23,443,200
21,052,500
25,263,000
29,473,500
31,802,300
38,162,800
44,523,300
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 1001 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
6,212,300
7,454,800
8,697,300
500 M-4-10-II
501 M-4-10-III
9,264,700
17,528,800
11,117,600
21,034,500
12,970,500
24,540,300
7,741,100
9,289,400
10,837,600
16,972,100
20,366,600
23,761,000
24,538,800
29,446,500
34,354,300
4,943,300
5,932,000
6,920,700
8,222,100
9,866,500
11,511,000
12,372,700
14,847,200
17,321,800
10,288,900
12,346,700
14,404,500
15,458,700
18,550,400
21,642,200
30,159,600
36,191,500
42,223,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
11,734,200
14,081,000
16,427,800
512 M-4-14-II
14,472,400
17,366,800
20,261,300
513 M-4-14-III
514 M-4-15-I
21,747,800
5,566,400
26,097,300
6,679,700
30,446,900
7,793,000
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,419,700
15,785,000
5,957,200
9,539,700
16,026,000
8,903,600
18,942,000
7,148,600
11,447,600
19,231,100
10,387,500
22,099,100
8,340,000
13,355,500
22,436,300
4,604,700
5,525,600
6,446,500
6,440,200
7,728,200
9,016,200
8,993,200
10,791,900
12,590,500
3,867,100
5,827,900
7,017,100
4,640,500
6,993,500
8,420,500
5,414,000
8,159,100
9,823,900
6,094,200
7,313,100
8,531,900
10,265,000
12,318,000
14,371,000
20,048,200
24,057,900
28,067,500
5,532,600
6,639,200
7,745,700
8,101,600
9,721,900
11,342,300
9,054,500
10,865,400
12,676,400
4,952,000
5,942,300
6,932,700
6,193,500
7,432,200
8,670,800
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
31,023,400
37,228,100
43,432,700
34,125,700
40,950,900
47,776,000
39,069,400
46,883,300
54,697,200
17,635,500
21,162,600
24,689,700
20,943,800
47,140,000
25,132,500
56,567,900
29,321,300
65,995,900
- 1002 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
13,885,600
16,662,700
19,439,900
535 N-1-01-I

283,523,900
340,228,700
396,933,400
536 N-1-01-II
283,523,900
340,228,700
396,933,400
537 N-1-01-III
538 N-1-11-I

283,523,900
17,854,800
340,228,700
21,425,700
396,933,400
24,996,700
539 N-1-11-II
540 N-1-11-III

28,232,700
44,014,800
33,879,200
52,817,700
39,525,800
61,620,700
9,100,000
10,920,000
12,740,000
18,117,100
21,740,500
25,363,900
39,314,700
47,177,600
55,040,600
15,916,800
19,100,100
22,283,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
27,843,400
31,170,800
33,412,000
37,404,900
38,980,700
43,639,100
18,208,300
21,850,000
25,491,700
27,545,600
33,054,800
38,563,900
31,702,400
38,042,900
44,383,400
16,352,400
19,622,900
22,893,400
22,206,200
26,647,400
31,088,600
25,845,100
31,014,100
36,183,100
6,947,500
8,337,000
9,726,500
8,403,100
10,083,700
11,764,300
12,359,700
14,831,700
17,303,600
3,529,300
6,166,100
7,671,900
2,661,000
5,528,100
8,982,800
3,600,700
6,019,700
12,453,400
4,235,100
7,399,300
9,206,300
3,193,100
6,633,700
10,779,400
4,320,900
7,223,600
14,944,100
4,941,000
8,632,500
10,740,700
3,725,300
7,739,400
12,576,000
5,041,000
8,427,500
17,434,800
5,356,400
6,427,700
7,499,000
7,600,500
9,120,600
10,640,700
12,183,500
14,620,200
17,056,900
6,327,900
7,593,500
8,859,100
7,851,800
9,422,200
10,992,500
8,960,200
10,752,300
12,544,300
7,748,500
9,298,200
10,847,900
11,059,600
13,271,500
15,483,400
14,721,100
17,665,300
20,609,500
5,649,400
7,514,000
6,779,300
9,016,800
7,909,200
10,519,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 1003 -

RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,221,200
13,465,400
15,709,600
4,766,300
5,719,500
6,672,800
5,297,200
6,356,600
7,416,000
6,589,700
7,907,700
9,225,600
3,376,800
4,052,200
4,727,600
4,055,500
4,866,600
5,677,800
5,095,900
6,115,100
7,134,300
1,882,900
2,259,500
2,636,100
3,089,100
3,706,900
3,706,900
4,448,300
4,324,700
5,189,600
75,405,000
90,486,000
105,567,000
93,302,400
111,962,900
130,623,400
109,510,800
131,412,900
153,315,100
170,327,600
204,393,200
238,458,700
195,383,400
234,460,100
273,536,800
223,239,500
267,887,400
312,535,300
15,438,500
18,526,200
21,613,900
20,435,000
24,522,000
28,609,000
28,732,600
34,479,100
40,225,600
68,544,600
82,253,600
95,962,500
89,194,800
107,033,800
124,872,700
127,883,000
153,459,600
179,036,200
37,226,100
44,671,300
52,116,500
52,868,100
63,441,700
74,015,300
77,894,100
93,472,900
109,051,700
7,303,500
8,764,200
10,224,900
20,477,300
24,572,800
28,668,300
27,127,400
32,552,900
37,978,400
9,925,600
11,910,800
13,895,900
24,983,800
29,980,500
34,977,300
33,279,700
39,935,700
46,591,600
7,751,300
9,301,500
10,851,800
11,011,700
13,214,000
15,416,300
16,337,000
19,604,400
22,871,800
12,865,400
15,438,500
18,011,600
17,029,200
20,435,000
23,840,800
- 1004 -

RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
23,943,800
28,732,600
33,521,300
11,695,900
14,035,000
16,374,200
14,191,000
17,029,200
19,867,400
20,820,700
24,984,800
29,149,000
6,497,700
7,797,200
9,096,800
10,136,400
12,163,700
14,191,000
16,015,900
19,219,100
22,422,300
4,918,300
5,901,900
6,885,600
10,011,600
12,013,900
14,016,300
39,146,200
46,975,400
54,804,700
3,688,800
4,426,500
5,164,300
7,386,900
8,864,300
10,341,700
8,667,200
10,400,600
12,134,100
3,338,400
4,006,000
4,673,700
6,415,200
7,698,300
8,981,300
15,044,700
18,053,700
21,062,600
4,331,800
5,198,200
6,064,500
8,230,400
9,876,500
11,522,600
16,529,900
19,835,900
23,141,900
3,764,000
4,516,800
5,269,600
4,637,800
5,565,300
6,492,900
6,348,600
7,618,400
8,888,100
1,729,700
3,515,800
8,112,200
4,181,800
5,565,900
9,648,500
2,075,700
4,219,000
9,734,600
5,018,100
6,679,000
11,578,100
2,421,600
4,922,200
11,357,000
5,854,500
7,792,200
13,507,800
6,175,400
7,410,500
8,645,600
10,955,700
13,146,800
15,337,900
17,782,400
21,338,900
24,895,400
3,125,200
3,750,200
4,375,300
6,638,200
7,965,800
9,293,400
12,588,300
15,105,900
17,623,600
2,090,200
2,508,200
2,926,200
3,944,500
4,733,400
5,522,300
5,108,800
6,130,500
7,152,300
10,823,200
12,987,800
15,152,500
- 1005 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
13,764,600
16,517,500
19,270,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
19,708,100
23,649,700
27,591,300
5,216,600
6,259,900
7,303,200
7,742,000
9,290,400
10,838,800
9,311,500
11,173,800
13,036,100
3,490,300
4,188,400
4,886,400
4,687,900
5,625,500
6,563,100
8,528,100
10,233,700
11,939,300
1,603,000
1,923,600
2,244,200
3,055,000
3,666,000
4,276,900
4,441,100
5,329,400
6,217,600
1,901,500
2,281,800
2,662,100
2,992,500
3,591,000
4,189,500
4,820,000
5,784,000
6,748,100
3,318,100
3,981,700
4,645,400
5,023,800
6,028,600
7,033,300
7,795,500
9,354,600
10,913,700
11,406,000
13,687,100
15,968,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
17,706,600
46,767,700
21,247,900
56,121,200
24,789,200
65,474,700
17,645,500
21,174,600
24,703,800
22,368,400
26,842,000
31,315,700
32,184,500
38,621,400
45,058,300
13,788,000
21,143,200
31,055,000
13,071,300
15,230,200
25,246,800
16,545,600
25,371,900
37,266,000
15,685,600
18,276,200
30,296,200
19,303,200
29,600,500
43,477,000
18,299,900
21,322,200
35,345,600
8,291,300
9,949,600
11,607,800
10,175,400
12,210,500
14,245,600
12,057,900
14,469,500
16,881,000
4,294,600
6,105,700
9,300,900
5,153,600
7,326,900
11,161,100
6,012,500
8,548,000
13,021,300
12,587,500
15,105,000
17,622,600
18,733,700
22,480,500
26,227,200
48,093,100
57,711,700
67,330,300
10,795,200
14,637,800
28,624,800
12,954,200
17,565,400
34,349,700
15,113,200
20,492,900
40,074,700
7,768,700
9,322,400
10,876,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 1006 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
3,516,200
4,219,400
4,922,600
697 U-4-12-I
698 U-4-12-II

2,670,200
4,305,300
3,204,300
5,166,300
3,738,300
6,027,400
699 U-4-12-III

7,539,900
9,047,900
10,555,800
2,023,700
2,428,400
2,833,100
3,306,800
3,968,200
4,629,500
5,339,400
6,407,300
7,475,200
7,732,400
9,259,400
9,278,900
11,111,200
10,825,400
12,963,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
15,549,300
18,659,100
21,769,000
6,208,900
7,450,700
8,692,500
7,735,500
9,282,600
10,829,700
10,825,900
12,991,100
15,156,300
10,127,300
12,152,700
14,178,200
20,861,800
25,034,100
29,206,500
25,584,000
30,700,800
35,817,600
19,266,600
22,000,200
34,453,200
23,120,000
26,400,200
41,343,900
26,973,300
30,800,300
48,234,500
18,114,300
21,737,200
25,360,100
24,736,600
29,683,900
34,631,200
31,353,900
37,624,700
43,895,500
9,448,700
11,338,400
13,228,100
18,053,300
21,664,000
25,274,600
28,323,400
33,988,100
39,652,800
18,528,800
22,234,600
25,940,300
26,921,800
32,306,200
37,690,500
723 V-1-14-III
33,616,700
40,340,100
47,063,400
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,984,100
3,292,900
3,642,600
3,580,900
3,951,500
4,371,100
4,177,700
4,610,100
5,099,700
8,064,200
9,677,000
11,289,900
13,395,000
16,074,000
18,753,000
22,083,700
26,500,500
30,917,200
7,742,200
9,290,600
10,839,000
10,388,000
12,465,600
14,543,200
13,914,800
16,697,800
19,480,700
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
16,006,300
19,207,600
22,408,900
24,574,600
29,489,600
34,404,500
1,915,100
2,858,400
2,298,100
3,430,100
2,681,200
4,001,800
- 1007 -

RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I
737 W-1-10-II
738 W-1-10-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
21,102,400
25,322,900
29,543,400
25,292,700
30,351,200
35,409,700
36,092,000
43,310,400
50,528,700
4,476,100
5,371,300
6,266,600
4,939,400
5,463,900
5,927,200
6,556,700
6,915,100
7,649,500
4,678,500
5,614,200
6,549,900
5,162,700
6,195,300
7,227,800
5,711,000
6,853,200
7,995,400
5,033,200
6,039,800
7,046,400
6,282,200
11,124,400
7,538,700
13,349,300
8,795,100
15,574,200
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
743 W-1-12-II
744 W-1-12-III

745 W-1-13-I
5,173,700
6,208,400
7,243,100
746 W-1-13-II
747 W-1-13-III

5,616,800
7,544,900
6,740,200
9,053,800
7,863,600
10,562,800
748 W-1-20-I
749 W-1-20-II

17,326,100
21,649,100
20,791,300
25,978,900
24,256,500
30,308,800
750 W-1-20-III
25,096,900
30,116,300
35,135,600
751 W-1-30-I
9,780,800
11,737,000
13,693,100
752 W-1-30-II
15,600,400
18,720,500
21,840,500
753 W-1-30-III
38,276,400
45,931,600
53,586,900
754 W-4-10-I
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
7,287,700
8,745,300
10,202,800
10,803,700
21,350,300
5,964,900
9,055,600
11,022,400
12,964,500
25,620,400
7,157,900
10,866,700
13,226,800
15,125,200
29,890,400
8,350,800
12,677,900
15,431,300
2,959,900
3,551,900
4,143,800
5,632,700
6,759,300
7,885,800
8,289,000
9,946,800
11,604,500
2,607,600
3,562,100
4,429,700
3,484,800
4,147,800
5,306,600
1,665,400
2,563,800
4,792,000
2,215,900
4,107,300
7,515,200
1,635,100
4,092,100
8,167,600
6,165,300
8,183,500
11,625,500
3,165,900
3,802,500
5,226,700
3,129,100
4,274,500
5,315,600
4,181,700
4,977,300
6,367,900
1,998,500
3,076,500
5,750,400
2,659,100
4,928,800
9,018,200
1,962,100
4,910,500
9,801,100
7,398,400
9,820,300
13,950,500
3,799,100
4,562,900
6,272,000
3,650,600
4,986,900
6,201,500
4,878,700
5,806,900
7,429,200
2,331,600
3,589,300
6,708,800
3,102,300
5,750,300
10,521,200
2,289,100
5,728,900
11,434,600
8,631,400
11,457,000
16,275,600
4,432,300
5,323,400
7,317,400
- 1008 -

RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,092,500
2,511,000
2,929,500
4,201,500
5,041,800
5,882,100
8,864,100
10,636,900
12,409,700
- 1009 -

RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
2,358,600
3,059,500
5,689,400
4,701,700
6,110,100
1,123,900
2,497,200
878,800
1,525,800
1,861,000
2,112,700
3,176,400
4,332,600
3,970,900
1,286,400
2,969,100
1,077,000
1,849,000
5,632,200
2,017,100
4,763,400
1,162,100
3,032,300
3,796,900
3,184,500
781,000
2,367,000
1,316,000
845,800
731,600
645,800
772,300
1,075,300
539,100
869,800
456,000
1,159,800
409,400
596,900
414,000
13,886,600
5,549,900
5,568,400
1,432,400
2,931,900
1,835,700
3,731,100
1,912,600
1,095,300
827,100
1,334,000
644,300
630,400
6,148,800
1,521,900
1,014,600
6,400,700
4,267,200
664,800
6,934,100
4,800,600
3,344,400
2,493,900
1,534,000
660,000
444,500
619,900
9,452,100
4,601,000
- 1010 -

RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
5,847,500
10,348,900
8,580,500
6,536,600
2,154,900
7,275,300
4,750,400
1,167,700
10,922,800
9,888,300
6,630,100
6,281,200
776,300
746,000
3,001,600
820,300
730,900
807,800
3,465,700
3,787,100
3,307,900
3,651,700
2,211,500
735,200
1,295,800
889,500
803,200
782,600
993,600
1,133,100
664,200
1,906,300
3,474,200
2,666,900
6,269,500
816,400
816,400
7,241,800
3,368,800
646,200
2,989,600
7,766,300
1,783,100
1,404,400
688,000
273,600
931,600
1,299,000
3,110,600
2,741,700
1,919,200
1,145,400
630,400
3,332,500
2,136,200
1,140,900
1,041,500
3,413,000
610,000
4,358,800
3,334,700
813,500
901,800
880,900
430,900
3,633,300
3,993,700
791,500
- 1011 -

RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
2,425,700
905,500
979,000
906,500
1,438,100
1,106,200
2,770,500
817,400
2,274,300
3,798,800
665,600
4,051,000
2,195,200
4,744,000
2,394,800
1,057,600
813,500
79,000
1,054,400
2,382,600
928,500
1,254,200
717,200
211,000
724,300
10,786,100
6,131,000
6,030,300
3,142,100
1,404,400
957,000
2,164,400
1,144,800
2,303,800
1,334,000
794,100
1,329,200
748,000
1,141,700
875,300
1,085,600
4,175,600
3,359,500
2,962,100
2,090,500
769,000
769,000
769,000
628,100
398,400
626,400
765,700
828,300
610,100
538,100
110,700
121,700
90,000
105,600
100,700
153,800
189,200
427,600
469,700
122,400
148,600
101,600
158,500
224,900
- 1012 -

RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
160,100
480,000
1,356,900
1,573,000
151,400
652,900
184,300
263,100
1,098,300
940,300
675,900
640,000
150,600
147,900
753,700
384,500
527,700
395,900
369,600
5,925,600
4,876,200
774,800
802,400
1,534,600
888,000
1,964,300
1,014,700
3,162,200
314,900
824,700
827,400
662,500
836,800
791,800
371,000
815,100
722,500
653,500
739,100
6,118,200
993,000
2,201,800
789,800
1,404,400
543,500
433,500
1,912,100
1,958,100
2,087,800
1,826,300
1,670,200
544,100
4,722,000
717,200
2,393,600
5,439,800
5,032,000
2,198,200
796,600
1,553,700
1,547,600
717,200
5,621,900
4,422,000
253,200
180,100
234,000
855,000
- 1013 -

RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
2,110,800
1,487,500
2,330,100
2,811,100
1,347,100
1,873,900
1,295,200
642,100
1,333,100
454,900
1,824,800
215,000
796,400
1,546,800
87,300
- 1014 -

RUMAH SAKIT KANKER DHARMAIS
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
5,314,000
6,376,800
7,439,600
A-4-10-II
SEPTIKEMIA (SEDANG)
9,078,500
10,894,200
12,709,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
12,240,700
4,263,700
14,688,900
5,116,500
17,137,000
5,969,200
5
6
A-4-11-II
A-4-11-III

6,068,500
8,399,400
7,282,200
10,079,200
8,495,900
11,759,100
A-4-12-I
2,780,700
3,336,800
3,893,000
8
9
A-4-12-II
A-4-12-III

4,800,000
6,915,900
5,760,000
8,299,000
6,719,900
9,682,200
10 A-4-13-I
11 A-4-13-II

2,276,600
4,023,300
2,731,900
4,827,900
3,187,200
5,632,600
12 A-4-13-III
4,827,900
5,793,500
6,759,100
2,550,400
3,060,500
3,570,600
4,291,200
5,149,400
6,007,700
5,149,400
6,179,300
7,209,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,100,900
22,541,700
21,721,100
27,050,000
25,341,300
31,558,300
18 A-4-15-III
INFEKSI HIV (BERAT)
25,465,800
30,558,900
35,652,100
19 B-1-01-I
20 B-1-01-II

75,419,200
83,207,200
90,503,000
99,848,600
105,586,800
116,490,100
21 B-1-01-III
22 B-1-10-I

183,411,000
12,191,100
220,093,200
14,629,300
256,775,400
17,067,500
23 B-1-10-II
27,058,900
32,470,600
37,882,400
24 B-1-10-III
25 B-1-11-I

53,417,900
32,192,200
64,101,400
38,630,700
74,785,000
45,069,100
26 B-1-11-II
27 B-1-11-III

38,358,700
59,275,000
46,030,500
71,130,000
53,702,200
82,985,000
28 B-1-12-I
14,315,300
17,178,400
20,041,400
29 B-1-12-II
15,921,100
19,105,400
22,289,600
30 B-1-12-III
24,906,800
29,888,200
34,869,600
11,402,300
13,682,700
15,963,200
18,761,100
22,513,300
26,265,500
24,275,200
29,130,200
33,985,200
19,768,800
23,722,600
27,676,300
20,762,800
24,915,400
29,067,900
36,753,800
4,847,400
7,737,900
10,674,700
44,104,500
5,816,900
9,285,500
12,809,600
51,455,300
6,786,400
10,833,100
14,944,600
6,763,200
8,115,800
9,468,400
9,468,500
11,362,200
13,255,900
11,470,900
13,765,100
16,059,300
9,240,200
13,157,700
19,575,800
8,814,400
11,088,300
15,789,200
23,490,900
10,577,300
12,936,300
18,420,800
27,406,100
12,340,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 1015 -

RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,268,400
12,322,100
14,375,800
48 B-4-13-III
49 B-4-14-I

14,145,600
8,805,000
16,974,700
10,566,000
19,803,900
12,327,000
50 B-4-14-II
10,272,100
12,326,600
14,381,000
51 B-4-14-III
52 C-4-10-I

13,759,800
11,801,200
16,511,700
14,161,500
19,263,700
16,521,700
53 C-4-10-II
54 C-4-10-III

18,979,600
35,561,700
22,775,600
42,674,000
26,571,500
49,786,300
55 C-4-11-I
9,282,900
11,139,500
12,996,100
56 C-4-11-II
57 C-4-11-III

12,421,900
19,098,900
14,906,300
22,918,700
17,390,700
26,738,500
58 C-4-12-I
59 C-4-12-II
6,180,900
12,173,900
7,417,100
14,608,700
8,653,200
17,043,500
60 C-4-12-III
RADIOTERAPI (BERAT)
31,266,100
37,519,300
43,772,500
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
4,646,800
8,745,300
5,576,100
10,494,300
6,505,500
12,243,400
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
11,838,100
7,720,800
14,205,700
9,265,000
16,573,400
10,809,100
65 C-4-14-II
10,830,700
12,996,900
15,163,000
66 C-4-14-III
67 D-1-10-I

16,137,600
41,982,200
19,365,100
50,378,600
22,592,600
58,775,100
68 D-1-10-II
69 D-1-10-III

63,941,900
101,817,300
76,730,200
122,180,800
89,518,600
142,544,300
70 D-1-11-I
12,489,300
14,987,100
17,485,000
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
31,890,900
41,443,500
38,269,100
49,732,200
44,647,300
58,020,900
10,826,700
12,992,100
15,157,400
29,836,900
35,804,300
41,771,700
47,330,100
56,796,100
66,262,100
2,831,200
4,646,300
7,309,700
8,475,900
15,230,800
20,923,400
7,307,400
10,135,500
15,563,500
3,397,400
5,575,600
8,771,700
10,171,000
18,276,900
25,108,000
8,768,800
12,162,500
18,676,200
3,963,700
6,504,800
10,233,600
11,866,200
21,323,100
29,292,700
10,230,300
14,189,600
21,788,900
6,262,200
7,514,700
8,767,100
8,863,200
10,635,800
12,408,500
11,336,300
13,603,500
15,870,800
6,716,500
8,059,800
9,403,100
10,996,600
13,196,000
15,395,300
13,450,000
16,140,000
18,830,000
13,388,600
16,066,300
18,744,000
18,277,400
21,932,900
25,588,400
93 E-1-01-III
44,068,800
52,882,500
61,696,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
13,919,800
19,322,400
36,506,300
16,703,800
23,186,800
43,807,500
19,487,700
27,051,300
51,108,800
15,758,300
18,910,000
22,061,600
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 1016 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,099,400
4,919,300
5,739,200
104 E-4-11-II
105 E-4-11-III

6,249,900
8,469,100
7,499,900
10,162,900
8,749,900
11,856,700
106 E-4-12-I
107 E-4-12-II

4,710,200
8,156,900
5,652,200
9,788,300
6,594,200
11,419,600
108 E-4-12-III

(RINGAN)
(SEDANG)
9,668,900
11,602,700
13,536,400
7,751,100
9,301,300
10,851,500
11,353,900
13,624,700
15,895,500
14,841,800
17,810,200
20,778,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
21,210,200
25,452,300
29,694,300
29,232,100
35,078,500
40,924,900
3,690,400
4,428,500
5,166,600
7,147,700
8,577,200
10,006,800
11,976,800
14,372,200
16,767,500
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,460,700
6,276,000
6,552,800
7,531,100
7,645,000
8,786,300
114 F-4-10-III
115 F-4-11-I
7,531,100
5,281,400
9,037,400
6,337,600
10,543,600
7,393,900
116 F-4-11-II
6,153,300
7,384,000
8,614,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,890,800
9,469,000
11,047,200
2,895,000
3,474,000
4,053,100
4,115,800
4,939,000
5,762,200
8,941,400
10,729,700
12,518,000
4,254,300
5,613,600
7,267,500
2,427,300
3,113,300
4,189,200
5,105,100
6,736,300
8,721,000
2,912,700
3,736,000
5,027,000
5,956,000
7,859,000
10,174,500
3,398,200
4,358,600
5,864,900
127 F-4-15-I
3,865,600
4,638,700
5,411,800
128 F-4-15-II
5,760,200
6,912,200
8,064,300
129 F-4-15-III
7,605,300
9,126,300
10,647,400
7,605,700
9,126,800
10,648,000
8,842,900
10,611,500
12,380,000
11,803,700
14,164,500
16,525,200
133 F-4-17-I

1,796,200
2,155,400
2,514,600
134 F-4-17-II
5,264,400
6,317,200
7,370,100
135
136
137
138
139
140
141

(RINGAN)
5,616,600
6,608,800
7,271,600
11,209,600
5,050,700
6,467,600
8,052,100
6,739,900
7,930,600
8,725,900
13,451,600
6,060,800
7,761,100
9,662,500
7,863,200
9,252,300
10,180,200
15,693,500
7,070,900
9,054,700
11,273,000
32,377,300
38,852,800
45,328,300
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 1017 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,137,500
60,165,000
70,192,500
148 G-1-11-I
149 G-1-11-II

24,778,400
45,300,700
29,734,100
54,360,800
34,689,700
63,421,000
150 G-1-11-III
65,516,600
78,619,900
91,723,300
10,345,800
12,415,000
14,484,200
19,393,800
23,272,500
27,151,300
26,429,900
31,715,900
37,001,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
3,121,000
8,381,600
3,745,200
10,057,900
4,369,400
11,734,200
156 G-1-13-III
157 G-1-20-I

12,515,200
16,286,100
15,018,200
19,543,300
17,521,300
22,800,500
158 G-1-20-II
26,512,500
31,815,000
37,117,500
159 G-1-20-III
40,687,700
48,825,300
56,962,800
160 G-1-30-I
28,885,100
34,662,100
40,439,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
38,944,200
58,481,500
46,733,000
70,177,800
54,521,900
81,874,100
8,880,800
10,656,900
12,433,100
10,855,300
13,026,400
15,197,500
14,895,400
17,874,400
20,853,500
9,296,800
11,156,100
13,015,500
12,349,600
14,819,600
17,289,500
18,145,800
21,774,900
25,404,100
10,313,700
12,376,500
14,439,200
13,027,000
15,632,300
18,237,700
18,920,000
22,704,000
26,488,000
6,195,600
7,434,700
8,673,800
10,803,900
12,964,700
15,125,500
12,813,700
15,376,400
17,939,100
10,510,100
12,612,100
14,714,100
14,051,200
16,861,500
19,671,700
17,636,000
21,163,100
24,690,300
8,587,700
10,305,200
12,022,700
10,248,900
12,298,700
14,348,500
14,465,500
17,358,600
20,251,700
7,079,400
8,495,200
9,911,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
46,437,000
55,724,300
65,011,700
68,377,200
82,052,700
95,728,100
33,312,800
40,799,900
39,975,400
48,959,900
46,637,900
57,119,800
- 1018 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
9,398,800
11,278,600
13,158,400
183 G-4-16-III
13,384,700
16,061,600
18,738,600
9,429,200
11,315,100
13,200,900
12,363,800
14,836,600
17,309,300
15,535,700
18,642,800
21,750,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
9,286,400
11,143,600
13,000,900
188 G-4-18-II
12,413,000
14,895,600
17,378,200
189 G-4-18-III
13,889,200
16,667,000
19,444,900
7,747,800
9,297,400
10,846,900
13,095,700
15,714,800
18,333,900
17,194,000
20,632,800
24,071,600
193 G-4-20-I

5,420,000
6,504,000
7,588,000
194 G-4-20-II
7,662,200
9,194,600
10,727,100
195 G-4-20-III
196 G-4-21-I

12,656,100
5,644,000
15,187,300
6,772,900
17,718,500
7,901,700
197 G-4-21-II
198 G-4-21-III

9,552,600
11,226,600
11,463,200
13,471,900
13,373,700
15,717,200
199 G-4-22-I
2,798,200
3,357,800
3,917,400
200 G-4-22-II
201 G-4-22-III

4,955,600
7,817,000
5,946,700
9,380,400
6,937,800
10,943,800
202 G-4-23-I
203 G-4-23-II

3,676,700
4,612,900
4,412,000
5,535,500
5,147,300
6,458,100
204 G-4-23-III
6,567,700
7,881,200
9,194,800
205 G-4-24-I
206 G-4-24-II

6,188,600
7,731,700
7,426,300
9,278,100
8,664,000
10,824,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
12,880,800
5,288,000
6,687,300
8,862,000
15,457,000
6,345,600
8,024,800
10,634,400
18,033,200
7,403,200
9,362,200
12,406,800
5,529,800
6,635,800
7,741,800
6,432,900
7,719,500
9,006,100
9,619,200
11,543,000
13,466,900
11,801,000
13,561,900
18,443,300
6,771,000
8,689,000
13,844,900
6,443,100
8,742,000
17,182,800
6,178,300
7,047,600
10,091,700
7,284,300
8,703,400
14,585,300
14,161,200
16,274,300
22,132,000
8,125,200
10,426,800
16,613,800
7,731,700
10,490,400
20,619,300
7,414,000
8,457,100
12,110,000
8,741,200
10,444,100
17,502,400
16,521,400
18,986,700
25,820,700
9,479,300
12,164,600
19,382,800
9,020,400
12,238,800
24,055,900
8,649,600
9,866,600
14,128,400
10,198,000
12,184,700
20,419,500
229 I-1-01-I
97,840,900
117,409,100
136,977,200
230 I-1-01-II
99,993,300
119,992,000
139,990,700
231 I-1-01-III

(RINGAN)
157,838,100
189,405,800
220,973,400
54,281,700
65,138,100
75,994,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 1019 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,292,200
57,950,600
245 I-1-06-II
69,955,200
83,946,200
97,937,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
83,469,500
100,163,400
116,857,300
75,168,000
90,201,600
105,235,200
93,960,000
112,752,000
131,544,000
140,940,000
169,128,000
197,316,000
8,506,100
10,207,400
11,908,600
9,458,000
11,349,500
13,241,100
12,585,700
15,102,800
17,619,900
24,484,700
29,381,600
34,278,600
39,988,400
47,986,100
55,983,800
52,610,800
63,132,900
73,655,100
23,749,800
28,499,800
33,249,700
31,627,700
37,953,200
44,278,800
39,005,700
46,806,800
54,608,000
48,610,000
58,332,000
68,054,000
60,415,100
72,498,100
84,581,100
79,164,600
94,997,500
110,830,400
9,234,500
12,895,800
24,832,200
11,081,400
15,474,900
29,798,600
12,928,300
18,054,100
34,765,100
23,939,200
28,727,000
33,514,900
54,164,700
64,997,700
75,830,600
62,478,200
74,973,800
87,469,500
27,719,300
33,263,200
38,807,000
34,707,200
41,648,600
48,590,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
70,022,700
84,027,300
98,031,800
86,307,400
103,568,900
120,830,400
33,876,900
40,652,300
47,427,600
46,960,400
56,352,500
65,744,500
59,596,300
71,515,600
83,434,900
51,050,600
61,260,700
71,470,900
80,571,700
96,686,000
112,800,300
128,712,700
154,455,200
180,197,800
84,564,000
101,476,800
118,389,600
103,356,000
124,027,200
144,698,400
140,940,000
169,128,000
197,316,000
67,609,100
- 1020 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,754,000
44,104,800
51,455,600
279 I-1-40-III
49,090,900
58,909,100
68,727,200
280 I-4-10-I
281 I-4-10-II

8,221,900
14,681,200
9,866,300
17,617,500
11,510,700
20,553,700
282 I-4-10-III
21,153,600
25,384,300
29,615,000
283 I-4-11-I
284 I-4-11-II

12,649,400
15,653,700
15,179,300
18,784,400
17,709,200
21,915,200
285 I-4-11-III
286 I-4-12-I

28,957,700
5,293,100
34,749,300
6,351,700
40,540,800
7,410,300
287 I-4-12-II
6,135,500
7,362,600
8,589,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,362,600
8,835,100
10,307,600
7,399,700
8,879,700
10,359,600
13,213,100
15,855,700
18,498,300
19,038,200
22,845,900
26,653,500
6,987,800
7,228,200
12,671,100
8,385,300
8,673,900
15,205,300
9,782,900
10,119,500
17,739,600
4,722,500
5,667,000
6,611,500
8,905,200
10,686,300
12,467,300
10,686,300
12,823,500
14,960,800
4,410,300
7,081,900
8,498,300
1,948,600
3,144,400
4,402,200
5,292,400
8,498,300
10,197,900
2,338,300
3,773,300
5,282,600
6,174,400
9,914,600
11,897,600
2,728,000
4,402,200
6,163,000
8,507,000
10,208,400
11,909,800
12,952,300
15,542,700
18,133,200
17,584,800
21,101,800
24,618,800
8,207,600
9,849,100
11,490,600
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
42,932,200
51,518,700
60,105,100
31,244,400
37,493,300
43,742,200
39,032,900
46,839,400
54,646,000
41,031,600
49,237,900
57,444,200
23,634,600
28,361,600
33,088,500
49,165,300
58,998,400
68,831,400
76,188,500
91,426,200
106,663,900
21,812,200
26,174,700
30,537,100
307 I-4-19-I
308 I-4-19-II

(SEDANG)
12,812,500
15,374,900
17,937,400
309 I-4-19-III
15,295,600
18,354,800
21,413,900
310
311
312
313
314

8,546,500
9,871,200
14,759,500
4,933,500
6,250,800
10,255,800
11,845,500
17,711,400
5,920,200
7,501,000
11,965,100
13,819,700
20,663,300
6,906,900
8,751,100
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 1021 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
9,022,400
10,826,800
12,631,300
316 I-4-22-I
317 I-4-22-II
3,422,100
4,260,000
4,106,500
5,112,000
4,791,000
5,964,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,226,800
7,472,200
8,717,500
7,015,400
8,418,500
9,821,600
8,613,000
10,335,600
12,058,200
16,829,200
20,195,100
23,560,900
3,317,600
3,981,100
4,644,700
7,639,600
9,167,500
10,695,400
9,658,900
11,590,700
13,522,500
113,972,200
136,766,600
159,561,100
128,980,700
154,776,900
180,573,000
166,882,300
200,258,700
233,635,200
70,134,800
84,161,800
98,188,800
88,496,500
106,195,800
123,895,100
139,065,100
166,878,200
194,691,200
18,366,400
22,039,700
25,713,000
37,164,600
44,597,500
52,030,400
38,623,200
46,347,800
54,072,400
33,481,700
40,178,000
46,874,300
35,059,800
42,071,800
49,083,700
39,455,200
47,346,300
55,237,300
15,327,300
18,392,700
21,458,200
27,765,200
33,318,200
38,871,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
80,143,100
96,171,800
112,200,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,989,800
6,174,800
9,341,500
5,589,900
7,785,600
10,435,800
9,494,400
10,808,000
15,090,900
8,394,600
11,685,100
21,800,500
6,737,100
10,963,100
12,970,500
4,431,800
7,339,100
13,329,900
3,587,800
7,409,700
11,209,800
6,707,800
9,342,700
12,522,900
11,393,200
12,969,600
18,109,100
10,073,500
14,022,100
26,160,600
8,084,500
13,155,800
15,564,600
5,318,100
8,806,900
15,995,900
4,185,700
8,644,700
13,078,100
7,825,800
10,899,800
14,610,100
13,292,100
15,131,100
21,127,300
11,752,500
16,359,100
30,520,700
9,431,900
15,348,400
18,158,700
6,204,500
10,274,700
18,661,900
3,692,600
4,431,100
5,169,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 1022 -

RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,192,600
8,631,100
10,069,600
12,276,800
14,732,200
17,187,500
5,117,700
6,128,500
6,141,200
7,354,300
7,164,700
8,580,000

8,042,500
2,274,800
9,651,000
2,729,800
11,259,500
3,184,700
365 J-4-18-II
4,336,800
5,204,200
6,071,500
366 J-4-18-III
367 J-4-19-I

6,162,800
6,487,500
7,395,400
7,785,000
8,628,000
9,082,600
368 J-4-19-II
369 J-4-19-III

7,357,300
8,125,200
8,828,700
9,750,300
10,300,200
11,375,300
370 J-4-20-I
7,153,300
8,584,000
10,014,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
9,911,700
11,619,600
11,894,000
13,943,500
13,876,400
16,267,400
2,948,500
3,538,200
4,127,800
6,583,800
7,900,600
9,217,400
12,402,800
14,883,300
17,363,900
16,650,300
19,980,400
23,310,400
20,924,700
25,109,600
29,294,500
24,524,400
29,429,300
34,334,200
12,934,300
15,521,200
18,108,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
16,981,200
29,835,400
20,377,400
35,802,500
23,773,700
41,769,600
6,986,200
8,383,500
9,780,700
9,086,400
10,903,700
12,721,000
18,001,500
21,601,800
25,202,100
5,213,900
5,735,300
9,166,200
6,256,700
6,882,400
10,999,500
7,299,500
8,029,400
12,832,700
11,507,700
13,809,200
16,110,700
13,486,700
16,184,100
18,881,400
390 K-1-14-III
23,543,900
28,252,700
32,961,400
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

24,758,400
34,581,900
50,493,300
29,710,100
41,498,300
60,591,900
34,661,700
48,414,700
70,690,600
13,828,500
16,594,200
19,359,900
24,559,100
29,470,900
34,382,700
33,793,700
40,552,400
47,311,100
397 K-1-40-I
16,337,000
19,604,400
22,871,800
398 K-1-40-II

(SEDANG)
18,012,100
21,614,600
25,217,000
399 K-1-40-III
30,524,100
36,628,900
42,733,700
400
401
402
403
404

12,483,100
16,210,900
22,908,900
8,244,400
11,845,900
14,979,700
19,453,100
27,490,700
9,893,200
14,215,100
17,476,400
22,695,200
32,072,500
11,542,100
16,584,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 1023 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
14,215,100
17,058,100
19,901,200
406 K-4-11-I
407 K-4-11-II

2,607,700
5,136,400
3,129,200
6,163,700
3,650,800
7,191,000
408 K-4-11-III
409 K-4-12-I

6,163,700
6,194,900
7,396,500
7,433,900
8,629,200
8,672,900
410 K-4-12-II
8,336,400
10,003,700
11,671,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
13,791,200
16,549,400
19,307,600
8,351,100
10,021,300
11,691,600
10,802,700
12,963,300
15,123,800
16,639,600
19,967,500
23,295,500
4,169,500
5,003,400
5,837,400
5,596,900
6,716,300
7,835,600
8,980,800
10,777,000
12,573,100
418 K-4-15-I
5,289,600
6,347,500
7,405,400
419 K-4-15-II
8,714,400
10,457,300
12,200,200
420 K-4-15-III
12,230,300
14,676,400
17,122,400
421 K-4-16-I
4,236,500
5,083,800
5,931,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,543,400
7,449,700
6,652,100
8,939,600
7,760,800
10,429,600
2,196,300
2,635,600
3,074,800
2,704,800
3,245,700
3,786,700
3,245,700
3,894,800
4,544,000
1,935,500
2,322,600
2,709,700
3,266,100
3,919,300
4,572,600
429 K-4-18-III
3,919,300
4,703,200
5,487,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
28,733,900
43,373,100
57,953,500
18,624,300
31,958,100
39,676,500
34,480,700
52,047,700
69,544,200
22,349,200
38,349,700
47,611,800
40,227,500
60,722,300
81,134,900
26,074,000
44,741,400
55,547,100
10,437,500
12,524,900
14,612,400
20,935,200
25,122,300
29,309,300
35,238,700
42,286,400
49,334,200
13,702,300
22,052,400
31,543,800
3,583,900
4,159,900
4,828,600
7,505,200
10,315,300
23,439,600
3,564,300
4,714,300
12,470,600
16,442,800
26,462,900
37,852,600
4,300,700
4,991,900
5,794,300
9,006,300
12,378,400
28,127,500
4,277,200
5,657,200
14,964,700
19,183,200
30,873,400
44,161,300
5,017,500
5,823,900
6,760,000
10,507,300
14,441,500
32,815,500
4,990,000
6,600,000
17,458,800
2,511,500
3,013,800
3,516,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 1024 -

RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,091,400
4,909,700
5,727,900
8,127,700
9,753,300
11,378,800
4,937,700
5,925,300
6,912,800
7,416,600
8,900,000
10,383,300
10,454,700
12,545,600
14,636,500
21,818,000
26,181,600
30,545,200
31,011,200
37,213,500
43,415,700
43,561,500
52,273,800
60,986,100
19,337,600
23,205,100
27,072,600
31,722,600
53,895,900
38,067,100
64,675,100
44,411,600
75,454,200
51,152,200
61,382,600
71,613,100
59,830,000
71,795,900
83,761,900
74,049,500
88,859,500
103,669,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,197,900
31,437,500
36,677,100
467 M-1-04-II
33,656,700
40,388,100
47,119,400
468 M-1-04-III
40,271,100
48,325,300
56,379,500
469 M-1-05-I
470 M-1-05-II

15,393,800
24,900,100
18,472,600
29,880,100
21,551,300
34,860,100
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
31,806,700
38,168,000
44,529,300
18,618,600
22,342,300
26,066,000
24,942,400
29,930,900
34,919,400
50,810,100
60,972,100
71,134,100
25,529,500
30,635,400
35,741,300
56,021,300
67,225,600
78,429,800
120,832,800
144,999,300
169,165,900
25,909,000
31,090,800
36,272,600
33,101,400
39,721,600
46,341,900
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
74,171,100
89,005,300
103,839,500
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,442,000
20,161,100
28,828,500
14,930,300
24,193,300
34,594,200
17,418,700
28,225,500
40,359,900
9,047,800
10,857,300
12,666,900
16,045,800
19,255,000
22,464,100
22,910,300
27,492,400
32,074,500
10,842,300
17,992,800
29,552,000
13,010,800
21,591,300
35,462,300
15,179,300
25,189,900
41,372,700
16,745,100
20,094,200
23,443,200
21,052,500
25,263,000
29,473,500
31,802,300
38,162,800
44,523,300
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 1025 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
6,212,300
7,454,800
8,697,300
500 M-4-10-II
501 M-4-10-III
9,264,700
17,528,800
11,117,600
21,034,500
12,970,500
24,540,300
7,741,100
9,289,400
10,837,600
16,972,100
20,366,600
23,761,000
24,538,800
29,446,500
34,354,300
4,943,300
5,932,000
6,920,700
8,222,100
9,866,500
11,511,000
12,372,700
14,847,200
17,321,800
10,288,900
12,346,700
14,404,500
15,458,700
18,550,400
21,642,200
30,159,600
36,191,500
42,223,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
11,734,200
14,081,000
16,427,800
512 M-4-14-II
14,472,400
17,366,800
20,261,300
513 M-4-14-III
514 M-4-15-I
21,747,800
5,566,400
26,097,300
6,679,700
30,446,900
7,793,000
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,419,700
15,785,000
5,957,200
9,539,700
16,026,000
8,903,600
18,942,000
7,148,600
11,447,600
19,231,100
10,387,500
22,099,100
8,340,000
13,355,500
22,436,300
4,604,700
5,525,600
6,446,500
6,440,200
7,728,200
9,016,200
8,993,200
10,791,900
12,590,500
3,867,100
5,827,900
7,017,100
4,640,500
6,993,500
8,420,500
5,414,000
8,159,100
9,823,900
6,094,200
7,313,100
8,531,900
10,265,000
12,318,000
14,371,000
20,048,200
24,057,900
28,067,500
5,532,600
6,639,200
7,745,700
8,101,600
9,721,900
11,342,300
9,054,500
10,865,400
12,676,400
4,952,000
5,942,300
6,932,700
6,193,500
7,432,200
8,670,800
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
31,023,400
37,228,100
43,432,700
34,125,700
40,950,900
47,776,000
39,069,400
46,883,300
54,697,200
17,635,500
21,162,600
24,689,700
20,943,800
47,140,000
25,132,500
56,567,900
29,321,300
65,995,900
- 1026 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
13,885,600
16,662,700
19,439,900
535 N-1-01-I

283,523,900
340,228,700
396,933,400
536 N-1-01-II
283,523,900
340,228,700
396,933,400
537 N-1-01-III
538 N-1-11-I

283,523,900
17,854,800
340,228,700
21,425,700
396,933,400
24,996,700
539 N-1-11-II
540 N-1-11-III

28,232,700
44,014,800
33,879,200
52,817,700
39,525,800
61,620,700
9,100,000
10,920,000
12,740,000
18,117,100
21,740,500
25,363,900
39,314,700
47,177,600
55,040,600
15,916,800
19,100,100
22,283,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
27,843,400
31,170,800
33,412,000
37,404,900
38,980,700
43,639,100
18,208,300
21,850,000
25,491,700
27,545,600
33,054,800
38,563,900
31,702,400
38,042,900
44,383,400
16,352,400
19,622,900
22,893,400
22,206,200
26,647,400
31,088,600
25,845,100
31,014,100
36,183,100
6,947,500
8,337,000
9,726,500
8,403,100
10,083,700
11,764,300
12,359,700
14,831,700
17,303,600
3,529,300
6,166,100
7,671,900
2,661,000
5,528,100
8,982,800
3,600,700
6,019,700
12,453,400
4,235,100
7,399,300
9,206,300
3,193,100
6,633,700
10,779,400
4,320,900
7,223,600
14,944,100
4,941,000
8,632,500
10,740,700
3,725,300
7,739,400
12,576,000
5,041,000
8,427,500
17,434,800
5,356,400
6,427,700
7,499,000
7,600,500
9,120,600
10,640,700
12,183,500
14,620,200
17,056,900
6,327,900
7,593,500
8,859,100
7,851,800
9,422,200
10,992,500
8,960,200
10,752,300
12,544,300
7,748,500
9,298,200
10,847,900
11,059,600
13,271,500
15,483,400
14,721,100
17,665,300
20,609,500
5,649,400
7,514,000
6,779,300
9,016,800
7,909,200
10,519,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 1027 -

RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,221,200
13,465,400
15,709,600
4,766,300
5,719,500
6,672,800
5,297,200
6,356,600
7,416,000
6,589,700
7,907,700
9,225,600
3,376,800
4,052,200
4,727,600
4,055,500
4,866,600
5,677,800
5,095,900
6,115,100
7,134,300
1,882,900
2,259,500
2,636,100
3,089,100
3,706,900
3,706,900
4,448,300
4,324,700
5,189,600
75,405,000
90,486,000
105,567,000
93,302,400
111,962,900
130,623,400
109,510,800
131,412,900
153,315,100
170,327,600
204,393,200
238,458,700
195,383,400
234,460,100
273,536,800
223,239,500
267,887,400
312,535,300
15,438,500
18,526,200
21,613,900
20,435,000
24,522,000
28,609,000
28,732,600
34,479,100
40,225,600
68,544,600
82,253,600
95,962,500
89,194,800
107,033,800
124,872,700
127,883,000
153,459,600
179,036,200
37,226,100
44,671,300
52,116,500
52,868,100
63,441,700
74,015,300
77,894,100
93,472,900
109,051,700
7,303,500
8,764,200
10,224,900
20,477,300
24,572,800
28,668,300
27,127,400
32,552,900
37,978,400
9,925,600
11,910,800
13,895,900
24,983,800
29,980,500
34,977,300
33,279,700
39,935,700
46,591,600
7,751,300
9,301,500
10,851,800
11,011,700
13,214,000
15,416,300
16,337,000
19,604,400
22,871,800
12,865,400
15,438,500
18,011,600
17,029,200
20,435,000
23,840,800
- 1028 -

RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
23,943,800
28,732,600
33,521,300
11,695,900
14,035,000
16,374,200
14,191,000
17,029,200
19,867,400
20,820,700
24,984,800
29,149,000
6,497,700
7,797,200
9,096,800
10,136,400
12,163,700
14,191,000
16,015,900
19,219,100
22,422,300
4,918,300
5,901,900
6,885,600
10,011,600
12,013,900
14,016,300
39,146,200
46,975,400
54,804,700
3,688,800
4,426,500
5,164,300
7,386,900
8,864,300
10,341,700
8,667,200
10,400,600
12,134,100
3,338,400
4,006,000
4,673,700
6,415,200
7,698,300
8,981,300
15,044,700
18,053,700
21,062,600
4,331,800
5,198,200
6,064,500
8,230,400
9,876,500
11,522,600
16,529,900
19,835,900
23,141,900
3,764,000
4,516,800
5,269,600
4,637,800
5,565,300
6,492,900
6,348,600
7,618,400
8,888,100
1,729,700
3,515,800
8,112,200
4,181,800
5,565,900
9,648,500
2,075,700
4,219,000
9,734,600
5,018,100
6,679,000
11,578,100
2,421,600
4,922,200
11,357,000
5,854,500
7,792,200
13,507,800
6,175,400
7,410,500
8,645,600
10,955,700
13,146,800
15,337,900
17,782,400
21,338,900
24,895,400
3,125,200
3,750,200
4,375,300
6,638,200
7,965,800
9,293,400
12,588,300
15,105,900
17,623,600
2,090,200
2,508,200
2,926,200
3,944,500
4,733,400
5,522,300
5,108,800
6,130,500
7,152,300
10,823,200
12,987,800
15,152,500
- 1029 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
13,764,600
16,517,500
19,270,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
19,708,100
23,649,700
27,591,300
5,216,600
6,259,900
7,303,200
7,742,000
9,290,400
10,838,800
9,311,500
11,173,800
13,036,100
3,490,300
4,188,400
4,886,400
4,687,900
5,625,500
6,563,100
8,528,100
10,233,700
11,939,300
1,603,000
1,923,600
2,244,200
3,055,000
3,666,000
4,276,900
4,441,100
5,329,400
6,217,600
1,901,500
2,281,800
2,662,100
2,992,500
3,591,000
4,189,500
4,820,000
5,784,000
6,748,100
3,318,100
3,981,700
4,645,400
5,023,800
6,028,600
7,033,300
7,795,500
9,354,600
10,913,700
11,406,000
13,687,100
15,968,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
17,706,600
46,767,700
21,247,900
56,121,200
24,789,200
65,474,700
17,645,500
21,174,600
24,703,800
22,368,400
26,842,000
31,315,700
32,184,500
38,621,400
45,058,300
13,788,000
21,143,200
31,055,000
13,071,300
15,230,200
25,246,800
16,545,600
25,371,900
37,266,000
15,685,600
18,276,200
30,296,200
19,303,200
29,600,500
43,477,000
18,299,900
21,322,200
35,345,600
8,291,300
9,949,600
11,607,800
10,175,400
12,210,500
14,245,600
12,057,900
14,469,500
16,881,000
4,294,600
6,105,700
9,300,900
5,153,600
7,326,900
11,161,100
6,012,500
8,548,000
13,021,300
12,587,500
15,105,000
17,622,600
18,733,700
22,480,500
26,227,200
48,093,100
57,711,700
67,330,300
10,795,200
14,637,800
28,624,800
12,954,200
17,565,400
34,349,700
15,113,200
20,492,900
40,074,700
7,768,700
9,322,400
10,876,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 1030 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
3,516,200
4,219,400
4,922,600
697 U-4-12-I
698 U-4-12-II

2,670,200
4,305,300
3,204,300
5,166,300
3,738,300
6,027,400
699 U-4-12-III

7,539,900
9,047,900
10,555,800
2,023,700
2,428,400
2,833,100
3,306,800
3,968,200
4,629,500
5,339,400
6,407,300
7,475,200
7,732,400
9,259,400
9,278,900
11,111,200
10,825,400
12,963,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
15,549,300
18,659,100
21,769,000
6,208,900
7,450,700
8,692,500
7,735,500
9,282,600
10,829,700
10,825,900
12,991,100
15,156,300
10,127,300
12,152,700
14,178,200
20,861,800
25,034,100
29,206,500
25,584,000
30,700,800
35,817,600
19,266,600
22,000,200
34,453,200
23,120,000
26,400,200
41,343,900
26,973,300
30,800,300
48,234,500
18,114,300
21,737,200
25,360,100
24,736,600
29,683,900
34,631,200
31,353,900
37,624,700
43,895,500
9,448,700
11,338,400
13,228,100
18,053,300
21,664,000
25,274,600
28,323,400
33,988,100
39,652,800
18,528,800
22,234,600
25,940,300
26,921,800
32,306,200
37,690,500
723 V-1-14-III
33,616,700
40,340,100
47,063,400
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,984,100
3,292,900
3,642,600
3,580,900
3,951,500
4,371,100
4,177,700
4,610,100
5,099,700
8,064,200
9,677,000
11,289,900
13,395,000
16,074,000
18,753,000
22,083,700
26,500,500
30,917,200
7,742,200
9,290,600
10,839,000
10,388,000
12,465,600
14,543,200
13,914,800
16,697,800
19,480,700
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
16,006,300
19,207,600
22,408,900
24,574,600
29,489,600
34,404,500
1,915,100
2,858,400
2,298,100
3,430,100
2,681,200
4,001,800
- 1031 -

RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I
737 W-1-10-II
738 W-1-10-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
21,102,400
25,322,900
29,543,400
25,292,700
30,351,200
35,409,700
36,092,000
43,310,400
50,528,700
4,476,100
5,371,300
6,266,600
4,939,400
5,463,900
5,927,200
6,556,700
6,915,100
7,649,500
4,678,500
5,614,200
6,549,900
5,162,700
6,195,300
7,227,800
5,711,000
6,853,200
7,995,400
5,033,200
6,039,800
7,046,400
6,282,200
11,124,400
7,538,700
13,349,300
8,795,100
15,574,200
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
743 W-1-12-II
744 W-1-12-III

745 W-1-13-I
5,173,700
6,208,400
7,243,100
746 W-1-13-II
747 W-1-13-III

5,616,800
7,544,900
6,740,200
9,053,800
7,863,600
10,562,800
748 W-1-20-I
749 W-1-20-II

17,326,100
21,649,100
20,791,300
25,978,900
24,256,500
30,308,800
750 W-1-20-III
25,096,900
30,116,300
35,135,600
751 W-1-30-I
9,780,800
11,737,000
13,693,100
752 W-1-30-II
15,600,400
18,720,500
21,840,500
753 W-1-30-III
38,276,400
45,931,600
53,586,900
754 W-4-10-I
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
7,287,700
8,745,300
10,202,800
10,803,700
21,350,300
5,964,900
9,055,600
11,022,400
12,964,500
25,620,400
7,157,900
10,866,700
13,226,800
15,125,200
29,890,400
8,350,800
12,677,900
15,431,300
2,959,900
3,551,900
4,143,800
5,632,700
6,759,300
7,885,800
8,289,000
9,946,800
11,604,500
2,607,600
3,562,100
4,429,700
3,484,800
4,147,800
5,306,600
1,665,400
2,563,800
4,792,000
2,215,900
4,107,300
7,515,200
1,635,100
4,092,100
8,167,600
6,165,300
8,183,500
11,625,500
3,165,900
3,802,500
5,226,700
3,129,100
4,274,500
5,315,600
4,181,700
4,977,300
6,367,900
1,998,500
3,076,500
5,750,400
2,659,100
4,928,800
9,018,200
1,962,100
4,910,500
9,801,100
7,398,400
9,820,300
13,950,500
3,799,100
4,562,900
6,272,000
3,650,600
4,986,900
6,201,500
4,878,700
5,806,900
7,429,200
2,331,600
3,589,300
6,708,800
3,102,300
5,750,300
10,521,200
2,289,100
5,728,900
11,434,600
8,631,400
11,457,000
16,275,600
4,432,300
5,323,400
7,317,400
- 1032 -

RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,092,500
2,511,000
2,929,500
4,201,500
5,041,800
5,882,100
8,864,100
10,636,900
12,409,700
- 1033 -

RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
2,358,600
3,059,500
5,689,400
4,701,700
6,110,100
1,123,900
2,497,200
878,800
1,525,800
1,861,000
2,112,700
3,176,400
4,332,600
3,970,900
1,286,400
2,969,100
1,077,000
1,849,000
5,632,200
2,017,100
4,763,400
1,162,100
3,032,300
3,796,900
3,184,500
781,000
2,367,000
1,316,000
845,800
731,600
645,800
772,300
1,075,300
539,100
869,800
456,000
1,159,800
409,400
596,900
414,000
13,886,600
5,549,900
5,568,400
1,432,400
2,931,900
1,835,700
3,731,100
1,912,600
1,095,300
827,100
1,334,000
644,300
630,400
6,148,800
1,521,900
1,014,600
6,400,700
4,267,200
664,800
6,934,100
4,800,600
3,344,400
2,493,900
1,534,000
660,000
444,500
619,900
9,452,100
4,601,000
- 1034 -

RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
5,847,500
10,348,900
8,580,500
6,536,600
2,154,900
7,275,300
4,750,400
1,167,700
10,922,800
9,888,300
6,630,100
6,281,200
776,300
746,000
3,001,600
820,300
730,900
807,800
3,465,700
3,787,100
3,307,900
3,651,700
2,211,500
735,200
1,295,800
889,500
803,200
782,600
993,600
1,133,100
664,200
1,906,300
3,474,200
2,666,900
6,269,500
816,400
816,400
7,241,800
3,368,800
646,200
2,989,600
7,766,300
1,783,100
1,404,400
688,000
273,600
931,600
1,299,000
3,110,600
2,741,700
1,919,200
1,145,400
630,400
3,332,500
2,136,200
1,140,900
1,041,500
3,413,000
610,000
4,358,800
3,334,700
813,500
901,800
880,900
430,900
3,633,300
3,993,700
791,500
- 1035 -

RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
2,425,700
905,500
979,000
906,500
1,438,100
1,106,200
2,770,500
817,400
2,274,300
3,798,800
665,600
4,051,000
2,195,200
4,744,000
2,394,800
1,057,600
813,500
79,000
1,054,400
2,382,600
928,500
1,254,200
717,200
211,000
724,300
10,786,100
6,131,000
6,030,300
3,142,100
1,404,400
957,000
2,164,400
1,144,800
2,303,800
1,334,000
794,100
1,329,200
748,000
1,141,700
875,300
1,085,600
4,175,600
3,359,500
2,962,100
2,090,500
769,000
769,000
769,000
628,100
398,400
626,400
765,700
828,300
610,100
538,100
110,700
121,700
90,000
105,600
100,700
153,800
189,200
427,600
469,700
122,400
148,600
101,600
158,500
224,900
- 1036 -

RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
160,100
480,000
1,356,900
1,573,000
151,400
652,900
184,300
263,100
1,098,300
940,300
675,900
640,000
150,600
147,900
753,700
384,500
527,700
395,900
369,600
5,925,600
4,876,200
774,800
802,400
1,534,600
888,000
1,964,300
1,014,700
3,162,200
314,900
824,700
827,400
662,500
836,800
791,800
371,000
815,100
722,500
653,500
739,100
6,118,200
993,000
2,201,800
789,800
1,404,400
543,500
433,500
1,912,100
1,958,100
2,087,800
1,826,300
1,670,200
544,100
4,722,000
717,200
2,393,600
5,439,800
5,032,000
2,198,200
796,600
1,553,700
1,547,600
717,200
5,621,900
4,422,000
253,200
180,100
234,000
855,000
- 1037 -

RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
2,110,800
1,487,500
2,330,100
2,811,100
1,347,100
1,873,900
1,295,200
642,100
1,333,100
454,900
1,824,800
215,000
796,400
1,546,800
87,300
- 1038 -

RUMAH SAKIT ANAK DAN BUNDA HARAPAN KITA
RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
A-4-10-I
SEPTIKEMIA (RINGAN)
5,314,000
6,376,800
7,439,600
A-4-10-II
SEPTIKEMIA (SEDANG)
9,078,500
10,894,200
12,709,900
3
4
A-4-10-III
A-4-11-I
SEPTIKEMIA (BERAT)
12,240,700
4,263,700
14,688,900
5,116,500
17,137,000
5,969,200
5
6
A-4-11-II
A-4-11-III

6,068,500
8,399,400
7,282,200
10,079,200
8,495,900
11,759,100
A-4-12-I
2,780,700
3,336,800
3,893,000
8
9
A-4-12-II
A-4-12-III

4,800,000
6,915,900
5,760,000
8,299,000
6,719,900
9,682,200
10 A-4-13-I
11 A-4-13-II

2,276,600
4,023,300
2,731,900
4,827,900
3,187,200
5,632,600
12 A-4-13-III
4,827,900
5,793,500
6,759,100
2,550,400
3,060,500
3,570,600
4,291,200
5,149,400
6,007,700
5,149,400
6,179,300
7,209,200
16 A-4-15-I
17 A-4-15-II

(RINGAN)
(SEDANG)
(BERAT)
18,100,900
22,541,700
21,721,100
27,050,000
25,341,300
31,558,300
18 A-4-15-III
INFEKSI HIV (BERAT)
25,465,800
30,558,900
35,652,100
19 B-1-01-I
20 B-1-01-II

75,419,200
83,207,200
90,503,000
99,848,600
105,586,800
116,490,100
21 B-1-01-III
22 B-1-10-I

183,411,000
12,191,100
220,093,200
14,629,300
256,775,400
17,067,500
23 B-1-10-II
27,058,900
32,470,600
37,882,400
24 B-1-10-III
25 B-1-11-I

53,417,900
32,192,200
64,101,400
38,630,700
74,785,000
45,069,100
26 B-1-11-II
27 B-1-11-III

38,358,700
59,275,000
46,030,500
71,130,000
53,702,200
82,985,000
28 B-1-12-I
14,315,300
17,178,400
20,041,400
29 B-1-12-II
15,921,100
19,105,400
22,289,600
30 B-1-12-III
24,906,800
29,888,200
34,869,600
11,402,300
13,682,700
15,963,200
18,761,100
22,513,300
26,265,500
24,275,200
29,130,200
33,985,200
19,768,800
23,722,600
27,676,300
20,762,800
24,915,400
29,067,900
36,753,800
4,847,400
7,737,900
10,674,700
44,104,500
5,816,900
9,285,500
12,809,600
51,455,300
6,786,400
10,833,100
14,944,600
6,763,200
8,115,800
9,468,400
9,468,500
11,362,200
13,255,900
11,470,900
13,765,100
16,059,300
9,240,200
13,157,700
19,575,800
8,814,400
11,088,300
15,789,200
23,490,900
10,577,300
12,936,300
18,420,800
27,406,100
12,340,200
13 A-4-14-I
14 A-4-14-II
15 A-4-14-III
31 B-1-13-I
32 B-1-13-II
33 B-1-13-III
34 B-1-14-I
35 B-1-14-II
36
37
38
39
B-1-14-III
B-4-10-I
B-4-10-II
B-4-10-III
40 B-4-11-I
41 B-4-11-II
42 B-4-11-III
43
44
45
46
B-4-12-I
B-4-12-II
B-4-12-III
B-4-13-I

(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
(BERAT)
- 1039 -

RAWAT INAP
NO
47
KODE
INA-CBG
B-4-13-II
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
10,268,400
12,322,100
14,375,800
48 B-4-13-III
49 B-4-14-I

14,145,600
8,805,000
16,974,700
10,566,000
19,803,900
12,327,000
50 B-4-14-II
10,272,100
12,326,600
14,381,000
51 B-4-14-III
52 C-4-10-I

13,759,800
11,801,200
16,511,700
14,161,500
19,263,700
16,521,700
53 C-4-10-II
54 C-4-10-III

18,979,600
35,561,700
22,775,600
42,674,000
26,571,500
49,786,300
55 C-4-11-I
9,282,900
11,139,500
12,996,100
56 C-4-11-II
57 C-4-11-III

12,421,900
19,098,900
14,906,300
22,918,700
17,390,700
26,738,500
58 C-4-12-I
59 C-4-12-II
6,180,900
12,173,900
7,417,100
14,608,700
8,653,200
17,043,500
60 C-4-12-III
RADIOTERAPI (BERAT)
31,266,100
37,519,300
43,772,500
61 C-4-13-I
62 C-4-13-II
KEMOTERAPI (RINGAN)
KEMOTERAPI (SEDANG)
4,646,800
8,745,300
5,576,100
10,494,300
6,505,500
12,243,400
63 C-4-13-III
64 C-4-14-I
KEMOTERAPI (BERAT)
11,838,100
7,720,800
14,205,700
9,265,000
16,573,400
10,809,100
65 C-4-14-II
10,830,700
12,996,900
15,163,000
66 C-4-14-III
67 D-1-10-I

16,137,600
41,982,200
19,365,100
50,378,600
22,592,600
58,775,100
68 D-1-10-II
69 D-1-10-III

63,941,900
101,817,300
76,730,200
122,180,800
89,518,600
142,544,300
70 D-1-11-I
12,489,300
14,987,100
17,485,000
71 D-1-11-II
72 D-1-11-III

(RINGAN)
(SEDANG)
31,890,900
41,443,500
38,269,100
49,732,200
44,647,300
58,020,900
10,826,700
12,992,100
15,157,400
29,836,900
35,804,300
41,771,700
47,330,100
56,796,100
66,262,100
2,831,200
4,646,300
7,309,700
8,475,900
15,230,800
20,923,400
7,307,400
10,135,500
15,563,500
3,397,400
5,575,600
8,771,700
10,171,000
18,276,900
25,108,000
8,768,800
12,162,500
18,676,200
3,963,700
6,504,800
10,233,600
11,866,200
21,323,100
29,292,700
10,230,300
14,189,600
21,788,900
6,262,200
7,514,700
8,767,100
8,863,200
10,635,800
12,408,500
11,336,300
13,603,500
15,870,800
6,716,500
8,059,800
9,403,100
10,996,600
13,196,000
15,395,300
13,450,000
16,140,000
18,830,000
13,388,600
16,066,300
18,744,000
18,277,400
21,932,900
25,588,400
93 E-1-01-III
44,068,800
52,882,500
61,696,300
94 E-1-10-I
95 E-1-10-II
96 E-1-10-III

TIROGLOSAL (RINGAN)
13,919,800
19,322,400
36,506,300
16,703,800
23,186,800
43,807,500
19,487,700
27,051,300
51,108,800
15,758,300
18,910,000
22,061,600
73 D-1-20-I
74 D-1-20-II
75 D-1-20-III
76
77
78
79
80
81
82
83
84
D-4-10-I
D-4-10-II
D-4-10-III
D-4-11-I
D-4-11-II
D-4-11-III
D-4-12-I
D-4-12-II
D-4-12-III
85 D-4-13-I
86 D-4-13-II
87 D-4-13-III
88 D-4-14-I
89 D-4-14-II
90 D-4-14-III
91 E-1-01-I
92 E-1-01-II
97 E-1-20-I
- 1040 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
103 E-4-11-I

TIROGLOSAL (SEDANG)
TIROGLOSAL (BERAT)
METABOLIK (RINGAN)
METABOLIK (SEDANG)
METABOLIK (BERAT)
4,099,400
4,919,300
5,739,200
104 E-4-11-II
105 E-4-11-III

6,249,900
8,469,100
7,499,900
10,162,900
8,749,900
11,856,700
106 E-4-12-I
107 E-4-12-II

4,710,200
8,156,900
5,652,200
9,788,300
6,594,200
11,419,600
108 E-4-12-III

(RINGAN)
(SEDANG)
9,668,900
11,602,700
13,536,400
7,751,100
9,301,300
10,851,500
11,353,900
13,624,700
15,895,500
14,841,800
17,810,200
20,778,600
98
E-1-20-II
99 E-1-20-III
100 E-4-10-I
101 E-4-10-II
102 E-4-10-III
109 E-4-13-I
110 E-4-13-II
21,210,200
25,452,300
29,694,300
29,232,100
35,078,500
40,924,900
3,690,400
4,428,500
5,166,600
7,147,700
8,577,200
10,006,800
11,976,800
14,372,200
16,767,500
111 E-4-13-III
112 F-4-10-I
113 F-4-10-II
5,460,700
6,276,000
6,552,800
7,531,100
7,645,000
8,786,300
114 F-4-10-III
115 F-4-11-I
7,531,100
5,281,400
9,037,400
6,337,600
10,543,600
7,393,900
116 F-4-11-II
6,153,300
7,384,000
8,614,700
117 F-4-11-III

(RINGAN)
(SEDANG)
(BERAT)
DEPRESI (RINGAN)
DEPRESI (SEDANG)
DEPRESI (BERAT)
7,890,800
9,469,000
11,047,200
2,895,000
3,474,000
4,053,100
4,115,800
4,939,000
5,762,200
8,941,400
10,729,700
12,518,000
4,254,300
5,613,600
7,267,500
2,427,300
3,113,300
4,189,200
5,105,100
6,736,300
8,721,000
2,912,700
3,736,000
5,027,000
5,956,000
7,859,000
10,174,500
3,398,200
4,358,600
5,864,900
127 F-4-15-I
3,865,600
4,638,700
5,411,800
128 F-4-15-II
5,760,200
6,912,200
8,064,300
129 F-4-15-III
7,605,300
9,126,300
10,647,400
7,605,700
9,126,800
10,648,000
8,842,900
10,611,500
12,380,000
11,803,700
14,164,500
16,525,200
133 F-4-17-I

1,796,200
2,155,400
2,514,600
134 F-4-17-II
5,264,400
6,317,200
7,370,100
135
136
137
138
139
140
141

(RINGAN)
5,616,600
6,608,800
7,271,600
11,209,600
5,050,700
6,467,600
8,052,100
6,739,900
7,930,600
8,725,900
13,451,600
6,060,800
7,761,100
9,662,500
7,863,200
9,252,300
10,180,200
15,693,500
7,070,900
9,054,700
11,273,000
32,377,300
38,852,800
45,328,300
118 F-4-12-I
119 F-4-12-II
120 F-4-12-III
121
122
123
124
125
126
F-4-13-I
F-4-13-II
F-4-13-III
F-4-14-I
F-4-14-II
F-4-14-III
130 F-4-16-I
131 F-4-16-II
132 F-4-16-III
F-4-17-III
F-4-18-I
F-4-18-II
F-4-18-III
F-4-19-I
F-4-19-II
F-4-19-III
142 G-1-01-I
- 1041 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
145 G-1-10-I
146 G-1-10-II

(SEDANG)
(BERAT)
KRANIOTOMI (RINGAN)
KRANIOTOMI (SEDANG)
147 G-1-10-III
KRANIOTOMI (BERAT)
50,137,500
60,165,000
70,192,500
148 G-1-11-I
149 G-1-11-II

24,778,400
45,300,700
29,734,100
54,360,800
34,689,700
63,421,000
150 G-1-11-III
65,516,600
78,619,900
91,723,300
10,345,800
12,415,000
14,484,200
19,393,800
23,272,500
27,151,300
26,429,900
31,715,900
37,001,900
154 G-1-13-I
155 G-1-13-II
PROSEDUR
PROSEDUR
(RINGAN)
PROSEDUR
(SEDANG)
PROSEDUR
(BERAT)
PROSEDUR
PROSEDUR
3,121,000
8,381,600
3,745,200
10,057,900
4,369,400
11,734,200
156 G-1-13-III
157 G-1-20-I

12,515,200
16,286,100
15,018,200
19,543,300
17,521,300
22,800,500
158 G-1-20-II
26,512,500
31,815,000
37,117,500
159 G-1-20-III
40,687,700
48,825,300
56,962,800
160 G-1-30-I
28,885,100
34,662,100
40,439,200
161 G-1-30-II
162 G-1-30-III

(RINGAN)
(SEDANG)
(BERAT)
DEGENERATIF (BERAT)
(RINGAN)
(SEDANG)
38,944,200
58,481,500
46,733,000
70,177,800
54,521,900
81,874,100
8,880,800
10,656,900
12,433,100
10,855,300
13,026,400
15,197,500
14,895,400
17,874,400
20,853,500
9,296,800
11,156,100
13,015,500
12,349,600
14,819,600
17,289,500
18,145,800
21,774,900
25,404,100
10,313,700
12,376,500
14,439,200
13,027,000
15,632,300
18,237,700
18,920,000
22,704,000
26,488,000
6,195,600
7,434,700
8,673,800
10,803,900
12,964,700
15,125,500
12,813,700
15,376,400
17,939,100
10,510,100
12,612,100
14,714,100
14,051,200
16,861,500
19,671,700
17,636,000
21,163,100
24,690,300
8,587,700
10,305,200
12,022,700
10,248,900
12,298,700
14,348,500
14,465,500
17,358,600
20,251,700
7,079,400
8,495,200
9,911,100
143 G-1-01-II
144 G-1-01-III
151 G-1-12-I
152 G-1-12-II
153 G-1-12-III
163 G-4-10-I
164 G-4-10-II
165 G-4-10-III
166 G-4-11-I
167 G-4-11-II
168 G-4-11-III
169 G-4-12-I
170 G-4-12-II
171 G-4-12-III
172 G-4-13-I
173 G-4-13-II
174 G-4-13-III
175 G-4-14-I
176 G-4-14-II
177 G-4-14-III
178 G-4-15-I
179 G-4-15-II
180 G-4-15-III
181 G-4-16-I


(RINGAN)
(SEDANG)
(BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
46,437,000
55,724,300
65,011,700
68,377,200
82,052,700
95,728,100
33,312,800
40,799,900
39,975,400
48,959,900
46,637,900
57,119,800
- 1042 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
182 G-4-16-II
9,398,800
11,278,600
13,158,400
183 G-4-16-III
13,384,700
16,061,600
18,738,600
9,429,200
11,315,100
13,200,900
12,363,800
14,836,600
17,309,300
15,535,700
18,642,800
21,750,000
187 G-4-18-I

(RINGAN)
(SEDANG)
(BERAT)
9,286,400
11,143,600
13,000,900
188 G-4-18-II
12,413,000
14,895,600
17,378,200
189 G-4-18-III
13,889,200
16,667,000
19,444,900
7,747,800
9,297,400
10,846,900
13,095,700
15,714,800
18,333,900
17,194,000
20,632,800
24,071,600
193 G-4-20-I

5,420,000
6,504,000
7,588,000
194 G-4-20-II
7,662,200
9,194,600
10,727,100
195 G-4-20-III
196 G-4-21-I

12,656,100
5,644,000
15,187,300
6,772,900
17,718,500
7,901,700
197 G-4-21-II
198 G-4-21-III

9,552,600
11,226,600
11,463,200
13,471,900
13,373,700
15,717,200
199 G-4-22-I
2,798,200
3,357,800
3,917,400
200 G-4-22-II
201 G-4-22-III

4,955,600
7,817,000
5,946,700
9,380,400
6,937,800
10,943,800
202 G-4-23-I
203 G-4-23-II

3,676,700
4,612,900
4,412,000
5,535,500
5,147,300
6,458,100
204 G-4-23-III
6,567,700
7,881,200
9,194,800
205 G-4-24-I
206 G-4-24-II

6,188,600
7,731,700
7,426,300
9,278,100
8,664,000
10,824,400
207
208
209
210

GEGAR OTAK (RINGAN)
GEGAR OTAK (SEDANG)
GEGAR OTAK (BERAT)
12,880,800
5,288,000
6,687,300
8,862,000
15,457,000
6,345,600
8,024,800
10,634,400
18,033,200
7,403,200
9,362,200
12,406,800
5,529,800
6,635,800
7,741,800
6,432,900
7,719,500
9,006,100
9,619,200
11,543,000
13,466,900
11,801,000
13,561,900
18,443,300
6,771,000
8,689,000
13,844,900
6,443,100
8,742,000
17,182,800
6,178,300
7,047,600
10,091,700
7,284,300
8,703,400
14,585,300
14,161,200
16,274,300
22,132,000
8,125,200
10,426,800
16,613,800
7,731,700
10,490,400
20,619,300
7,414,000
8,457,100
12,110,000
8,741,200
10,444,100
17,502,400
16,521,400
18,986,700
25,820,700
9,479,300
12,164,600
19,382,800
9,020,400
12,238,800
24,055,900
8,649,600
9,866,600
14,128,400
10,198,000
12,184,700
20,419,500
229 I-1-01-I
97,840,900
117,409,100
136,977,200
230 I-1-01-II
99,993,300
119,992,000
139,990,700
231 I-1-01-III

(RINGAN)
157,838,100
189,405,800
220,973,400
54,281,700
65,138,100
75,994,400
184 G-4-17-I
185 G-4-17-II
186 G-4-17-III
190 G-4-19-I
191 G-4-19-II
192 G-4-19-III
G-4-24-III
G-4-25-I
G-4-25-II
G-4-25-III
211 G-4-26-I
212 G-4-26-II
213 G-4-26-III
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
H-1-20-I
H-1-20-II
H-1-20-III
H-1-30-I
H-1-30-II
H-1-30-III
H-4-10-I
H-4-10-II
H-4-10-III
H-4-11-I
H-4-11-II
H-4-11-III
H-4-12-I
H-4-12-II
H-4-12-III
232 I-1-02-I
- 1043 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
244 I-1-06-I

(SEDANG)
(BERAT)
ANOMALI (RINGAN)
ANOMALI (SEDANG)
ANOMALI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
48,292,200
57,950,600
245 I-1-06-II
69,955,200
83,946,200
97,937,300
246 I-1-06-III

JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
83,469,500
100,163,400
116,857,300
75,168,000
90,201,600
105,235,200
93,960,000
112,752,000
131,544,000
140,940,000
169,128,000
197,316,000
8,506,100
10,207,400
11,908,600
9,458,000
11,349,500
13,241,100
12,585,700
15,102,800
17,619,900
24,484,700
29,381,600
34,278,600
39,988,400
47,986,100
55,983,800
52,610,800
63,132,900
73,655,100
23,749,800
28,499,800
33,249,700
31,627,700
37,953,200
44,278,800
39,005,700
46,806,800
54,608,000
48,610,000
58,332,000
68,054,000
60,415,100
72,498,100
84,581,100
79,164,600
94,997,500
110,830,400
9,234,500
12,895,800
24,832,200
11,081,400
15,474,900
29,798,600
12,928,300
18,054,100
34,765,100
23,939,200
28,727,000
33,514,900
54,164,700
64,997,700
75,830,600
62,478,200
74,973,800
87,469,500
27,719,300
33,263,200
38,807,000
34,707,200
41,648,600
48,590,000
233 I-1-02-II
234 I-1-02-III
235 I-1-03-I
236 I-1-03-II
237 I-1-03-III
238 I-1-04-I
239 I-1-04-II
240 I-1-04-III
241 I-1-05-I
242 I-1-05-II
243 I-1-05-III
247 I-1-07-I
248 I-1-07-II
249 I-1-07-III
250 I-1-11-I
251 I-1-11-II
252 I-1-11-III
253 I-1-12-I
254 I-1-12-II
255 I-1-12-III
256 I-1-13-I
257 I-1-13-II
258 I-1-13-III
259 I-1-14-I
260 I-1-14-II
261 I-1-14-III
262 I-1-15-I
263 I-1-15-II
264 I-1-15-III
265 I-1-16-I
266 I-1-16-II
267 I-1-16-III
268 I-1-17-I
269 I-1-17-II
70,022,700
84,027,300
98,031,800
86,307,400
103,568,900
120,830,400
33,876,900
40,652,300
47,427,600
46,960,400
56,352,500
65,744,500
59,596,300
71,515,600
83,434,900
51,050,600
61,260,700
71,470,900
80,571,700
96,686,000
112,800,300
128,712,700
154,455,200
180,197,800
84,564,000
101,476,800
118,389,600
103,356,000
124,027,200
144,698,400
140,940,000
169,128,000
197,316,000
67,609,100
- 1044 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
277 I-1-40-I

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
278 I-1-40-II
36,754,000
44,104,800
51,455,600
279 I-1-40-III
49,090,900
58,909,100
68,727,200
280 I-4-10-I
281 I-4-10-II

8,221,900
14,681,200
9,866,300
17,617,500
11,510,700
20,553,700
282 I-4-10-III
21,153,600
25,384,300
29,615,000
283 I-4-11-I
284 I-4-11-II

12,649,400
15,653,700
15,179,300
18,784,400
17,709,200
21,915,200
285 I-4-11-III
286 I-4-12-I

28,957,700
5,293,100
34,749,300
6,351,700
40,540,800
7,410,300
287 I-4-12-II
6,135,500
7,362,600
8,589,600
288 I-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
7,362,600
8,835,100
10,307,600
7,399,700
8,879,700
10,359,600
13,213,100
15,855,700
18,498,300
19,038,200
22,845,900
26,653,500
6,987,800
7,228,200
12,671,100
8,385,300
8,673,900
15,205,300
9,782,900
10,119,500
17,739,600
4,722,500
5,667,000
6,611,500
8,905,200
10,686,300
12,467,300
10,686,300
12,823,500
14,960,800
4,410,300
7,081,900
8,498,300
1,948,600
3,144,400
4,402,200
5,292,400
8,498,300
10,197,900
2,338,300
3,773,300
5,282,600
6,174,400
9,914,600
11,897,600
2,728,000
4,402,200
6,163,000
8,507,000
10,208,400
11,909,800
12,952,300
15,542,700
18,133,200
17,584,800
21,101,800
24,618,800
8,207,600
9,849,100
11,490,600
270 I-1-17-III
271 I-1-20-I
272 I-1-20-II
273 I-1-20-III
274 I-1-30-I
275 I-1-30-II
276 I-1-30-III
289 I-4-13-I
290 I-4-13-II
291 I-4-13-III
292 I-4-14-I
293 I-4-14-II
294 I-4-14-III
295 I-4-15-I
296 I-4-15-II
297 I-4-15-III
298
299
300
301
302
303
HIPERTENSI (RINGAN)
HIPERTENSI (SEDANG)
HIPERTENSI (BERAT)
JANTUNG (RINGAN)
JANTUNG (SEDANG)
JANTUNG (BERAT)
I-4-16-I
I-4-16-II
I-4-16-III
I-4-17-I
I-4-17-II
I-4-17-III
304 I-4-18-I
305 I-4-18-II
306 I-4-18-III
42,932,200
51,518,700
60,105,100
31,244,400
37,493,300
43,742,200
39,032,900
46,839,400
54,646,000
41,031,600
49,237,900
57,444,200
23,634,600
28,361,600
33,088,500
49,165,300
58,998,400
68,831,400
76,188,500
91,426,200
106,663,900
21,812,200
26,174,700
30,537,100
307 I-4-19-I
308 I-4-19-II

(SEDANG)
12,812,500
15,374,900
17,937,400
309 I-4-19-III
15,295,600
18,354,800
21,413,900
310
311
312
313
314

8,546,500
9,871,200
14,759,500
4,933,500
6,250,800
10,255,800
11,845,500
17,711,400
5,920,200
7,501,000
11,965,100
13,819,700
20,663,300
6,906,900
8,751,100
I-4-20-I
I-4-20-II
I-4-20-III
I-4-21-I
I-4-21-II
- 1045 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
315 I-4-21-III
9,022,400
10,826,800
12,631,300
316 I-4-22-I
317 I-4-22-II
3,422,100
4,260,000
4,106,500
5,112,000
4,791,000
5,964,000
318 I-4-22-III
(RINGAN)
(SEDANG)
(BERAT)
TRAKEOSTOMI (BERAT)
TRAKEOSTOMI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
6,226,800
7,472,200
8,717,500
7,015,400
8,418,500
9,821,600
8,613,000
10,335,600
12,058,200
16,829,200
20,195,100
23,560,900
3,317,600
3,981,100
4,644,700
7,639,600
9,167,500
10,695,400
9,658,900
11,590,700
13,522,500
113,972,200
136,766,600
159,561,100
128,980,700
154,776,900
180,573,000
166,882,300
200,258,700
233,635,200
70,134,800
84,161,800
98,188,800
88,496,500
106,195,800
123,895,100
139,065,100
166,878,200
194,691,200
18,366,400
22,039,700
25,713,000
37,164,600
44,597,500
52,030,400
38,623,200
46,347,800
54,072,400
33,481,700
40,178,000
46,874,300
35,059,800
42,071,800
49,083,700
39,455,200
47,346,300
55,237,300
15,327,300
18,392,700
21,458,200
27,765,200
33,318,200
38,871,200
319 I-4-23-I
320 I-4-23-II
321 I-4-23-III
322 I-4-24-I
323 I-4-24-II
324 I-4-24-III
325 J-1-01-I
326 J-1-01-II
327 J-1-01-III
328 J-1-02-I
329 J-1-02-II
330 J-1-02-III
331 J-1-10-I
332 J-1-10-II
333 J-1-10-III
334 J-1-20-I
335 J-1-20-II
336 J-1-20-III
337 J-1-30-I
338 J-1-30-II
339 J-1-30-III
80,143,100
96,171,800
112,200,400
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357

EMBOLI PARU (BERAT)
TRAUMA DADA (BERAT)
TUMOR PARU (RINGAN)
TUMOR PARU (SEDANG)
TUMOR PARU (BERAT)
2,989,800
6,174,800
9,341,500
5,589,900
7,785,600
10,435,800
9,494,400
10,808,000
15,090,900
8,394,600
11,685,100
21,800,500
6,737,100
10,963,100
12,970,500
4,431,800
7,339,100
13,329,900
3,587,800
7,409,700
11,209,800
6,707,800
9,342,700
12,522,900
11,393,200
12,969,600
18,109,100
10,073,500
14,022,100
26,160,600
8,084,500
13,155,800
15,564,600
5,318,100
8,806,900
15,995,900
4,185,700
8,644,700
13,078,100
7,825,800
10,899,800
14,610,100
13,292,100
15,131,100
21,127,300
11,752,500
16,359,100
30,520,700
9,431,900
15,348,400
18,158,700
6,204,500
10,274,700
18,661,900
3,692,600
4,431,100
5,169,700
J-4-10-I
J-4-10-II
J-4-10-III
J-4-11-I
J-4-11-II
J-4-11-III
J-4-12-I
J-4-12-II
J-4-12-III
J-4-13-I
J-4-13-II
J-4-13-III
J-4-14-I
J-4-14-II
J-4-14-III
J-4-15-I
J-4-15-II
J-4-15-III
358 J-4-16-I
- 1046 -

RAWAT INAP
NO
KODE
INA-CBG
359 J-4-16-II
360 J-4-16-III
361 J-4-17-I
362 J-4-17-II

363 J-4-17-III
364 J-4-18-I
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
7,192,600
8,631,100
10,069,600
12,276,800
14,732,200
17,187,500
5,117,700
6,128,500
6,141,200
7,354,300
7,164,700
8,580,000

8,042,500
2,274,800
9,651,000
2,729,800
11,259,500
3,184,700
365 J-4-18-II
4,336,800
5,204,200
6,071,500
366 J-4-18-III
367 J-4-19-I

6,162,800
6,487,500
7,395,400
7,785,000
8,628,000
9,082,600
368 J-4-19-II
369 J-4-19-III

7,357,300
8,125,200
8,828,700
9,750,300
10,300,200
11,375,300
370 J-4-20-I
7,153,300
8,584,000
10,014,700
371 J-4-20-II
372 J-4-20-III

BESAR (RINGAN)
BESAR (SEDANG)
BESAR (BERAT)
9,911,700
11,619,600
11,894,000
13,943,500
13,876,400
16,267,400
2,948,500
3,538,200
4,127,800
6,583,800
7,900,600
9,217,400
12,402,800
14,883,300
17,363,900
16,650,300
19,980,400
23,310,400
20,924,700
25,109,600
29,294,500
24,524,400
29,429,300
34,334,200
12,934,300
15,521,200
18,108,000

FEMORAL (RINGAN)
FEMORAL (SEDANG)
FEMORAL (BERAT)
(RINGAN)
(SEDANG)
16,981,200
29,835,400
20,377,400
35,802,500
23,773,700
41,769,600
6,986,200
8,383,500
9,780,700
9,086,400
10,903,700
12,721,000
18,001,500
21,601,800
25,202,100
5,213,900
5,735,300
9,166,200
6,256,700
6,882,400
10,999,500
7,299,500
8,029,400
12,832,700
11,507,700
13,809,200
16,110,700
13,486,700
16,184,100
18,881,400
390 K-1-14-III
23,543,900
28,252,700
32,961,400
391 K-1-20-I
392 K-1-20-II
393 K-1-20-III

24,758,400
34,581,900
50,493,300
29,710,100
41,498,300
60,591,900
34,661,700
48,414,700
70,690,600
13,828,500
16,594,200
19,359,900
24,559,100
29,470,900
34,382,700
33,793,700
40,552,400
47,311,100
397 K-1-40-I
16,337,000
19,604,400
22,871,800
398 K-1-40-II

(SEDANG)
18,012,100
21,614,600
25,217,000
399 K-1-40-III
30,524,100
36,628,900
42,733,700
400
401
402
403
404

12,483,100
16,210,900
22,908,900
8,244,400
11,845,900
14,979,700
19,453,100
27,490,700
9,893,200
14,215,100
17,476,400
22,695,200
32,072,500
11,542,100
16,584,300
373 J-4-21-I
374 J-4-21-II
375 J-4-21-III
376 K-1-10-I
377 K-1-10-II
378 K-1-10-III
379 K-1-11-I
380 K-1-11-II
381 K-1-11-III
382 K-1-12-I
383 K-1-12-II
384 K-1-12-III
385 K-1-13-I
386 K-1-13-II
387 K-1-13-III
388 K-1-14-I
389 K-1-14-II
394 K-1-30-I
395 K-1-30-II
396 K-1-30-III
K-1-50-I
K-1-50-II
K-1-50-III
K-4-10-I
K-4-10-II
- 1047 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
405 K-4-10-III
14,215,100
17,058,100
19,901,200
406 K-4-11-I
407 K-4-11-II

2,607,700
5,136,400
3,129,200
6,163,700
3,650,800
7,191,000
408 K-4-11-III
409 K-4-12-I

6,163,700
6,194,900
7,396,500
7,433,900
8,629,200
8,672,900
410 K-4-12-II
8,336,400
10,003,700
11,671,000
411 K-4-12-III

(RINGAN)
(SEDANG)
(BERAT)
13,791,200
16,549,400
19,307,600
8,351,100
10,021,300
11,691,600
10,802,700
12,963,300
15,123,800
16,639,600
19,967,500
23,295,500
4,169,500
5,003,400
5,837,400
5,596,900
6,716,300
7,835,600
8,980,800
10,777,000
12,573,100
418 K-4-15-I
5,289,600
6,347,500
7,405,400
419 K-4-15-II
8,714,400
10,457,300
12,200,200
420 K-4-15-III
12,230,300
14,676,400
17,122,400
421 K-4-16-I
4,236,500
5,083,800
5,931,100
422 K-4-16-II
423 K-4-16-III

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
5,543,400
7,449,700
6,652,100
8,939,600
7,760,800
10,429,600
2,196,300
2,635,600
3,074,800
2,704,800
3,245,700
3,786,700
3,245,700
3,894,800
4,544,000
1,935,500
2,322,600
2,709,700
3,266,100
3,919,300
4,572,600
429 K-4-18-III
3,919,300
4,703,200
5,487,100
430
431
432
433
434
435

(RINGAN)
(SEDANG)
(BERAT)
PAYUDARA (RINGAN)
28,733,900
43,373,100
57,953,500
18,624,300
31,958,100
39,676,500
34,480,700
52,047,700
69,544,200
22,349,200
38,349,700
47,611,800
40,227,500
60,722,300
81,134,900
26,074,000
44,741,400
55,547,100
10,437,500
12,524,900
14,612,400
20,935,200
25,122,300
29,309,300
35,238,700
42,286,400
49,334,200
13,702,300
22,052,400
31,543,800
3,583,900
4,159,900
4,828,600
7,505,200
10,315,300
23,439,600
3,564,300
4,714,300
12,470,600
16,442,800
26,462,900
37,852,600
4,300,700
4,991,900
5,794,300
9,006,300
12,378,400
28,127,500
4,277,200
5,657,200
14,964,700
19,183,200
30,873,400
44,161,300
5,017,500
5,823,900
6,760,000
10,507,300
14,441,500
32,815,500
4,990,000
6,600,000
17,458,800
2,511,500
3,013,800
3,516,100
412 K-4-13-I
413 K-4-13-II
414 K-4-13-III
415 K-4-14-I
416 K-4-14-II
417 K-4-14-III
424 K-4-17-I
425 K-4-17-II
426 K-4-17-III
427 K-4-18-I
428 K-4-18-II
L-1-20-I
L-1-20-II
L-1-20-III
L-1-30-I
L-1-30-II
L-1-30-III
436 L-1-40-I
437 L-1-40-II
438 L-1-40-III
439
440
441
442
443
444
445
446
447
448
449
450
L-1-50-I
L-1-50-II
L-1-50-III
L-4-10-I
L-4-10-II
L-4-10-III
L-4-11-I
L-4-11-II
L-4-11-III
L-4-12-I
L-4-12-II
L-4-12-III
451 L-4-13-I
- 1048 -

RAWAT INAP
NO
KODE
INA-CBG
452 L-4-13-II
453 L-4-13-III
454 L-4-14-I
455 L-4-14-II
456 L-4-14-III
457 M-1-01-I
458 M-1-01-II
459 M-1-01-III
460 M-1-02-I

PAYUDARA (SEDANG)
PAYUDARA (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
AMPUTASI (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
4,091,400
4,909,700
5,727,900
8,127,700
9,753,300
11,378,800
4,937,700
5,925,300
6,912,800
7,416,600
8,900,000
10,383,300
10,454,700
12,545,600
14,636,500
21,818,000
26,181,600
30,545,200
31,011,200
37,213,500
43,415,700
43,561,500
52,273,800
60,986,100
19,337,600
23,205,100
27,072,600
31,722,600
53,895,900
38,067,100
64,675,100
44,411,600
75,454,200
51,152,200
61,382,600
71,613,100
59,830,000
71,795,900
83,761,900
74,049,500
88,859,500
103,669,400
466 M-1-04-I
AMPUTASI (SEDANG)
AMPUTASI (BERAT)
26,197,900
31,437,500
36,677,100
467 M-1-04-II
33,656,700
40,388,100
47,119,400
468 M-1-04-III
40,271,100
48,325,300
56,379,500
469 M-1-05-I
470 M-1-05-II

15,393,800
24,900,100
18,472,600
29,880,100
21,551,300
34,860,100
471 M-1-05-III

WAJAH (RINGAN)
WAJAH (SEDANG)
WAJAH (BERAT)
(RINGAN)
(SEDANG)
31,806,700
38,168,000
44,529,300
18,618,600
22,342,300
26,066,000
24,942,400
29,930,900
34,919,400
50,810,100
60,972,100
71,134,100
25,529,500
30,635,400
35,741,300
56,021,300
67,225,600
78,429,800
120,832,800
144,999,300
169,165,900
25,909,000
31,090,800
36,272,600
33,101,400
39,721,600
46,341,900
461 M-1-02-II
462 M-1-02-III
463 M-1-03-I
464 M-1-03-II
465 M-1-03-III
472 M-1-07-I
473 M-1-07-II
474 M-1-07-III
475 M-1-10-I
476 M-1-10-II
477 M-1-10-III
478 M-1-20-I
479 M-1-20-II
480 M-1-20-III
74,171,100
89,005,300
103,839,500
481 M-1-30-I
482 M-1-30-II
483 M-1-30-III

INTERNAL (RINGAN)
INTERNAL (SEDANG)
INTERNAL (BERAT)
12,442,000
20,161,100
28,828,500
14,930,300
24,193,300
34,594,200
17,418,700
28,225,500
40,359,900
9,047,800
10,857,300
12,666,900
16,045,800
19,255,000
22,464,100
22,910,300
27,492,400
32,074,500
10,842,300
17,992,800
29,552,000
13,010,800
21,591,300
35,462,300
15,179,300
25,189,900
41,372,700
16,745,100
20,094,200
23,443,200
21,052,500
25,263,000
29,473,500
31,802,300
38,162,800
44,523,300
484 M-1-40-I
485 M-1-40-II
486 M-1-40-III
487 M-1-50-I
488 M-1-50-II
489 M-1-50-III
490 M-1-60-I
491 M-1-60-II
492 M-1-60-III
- 1049 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
496 M-1-80-I

KAKI (RINGAN)
KAKI (SEDANG)
KAKI (BERAT)
497 M-1-80-II
498 M-1-80-III

499 M-4-10-I
6,212,300
7,454,800
8,697,300
500 M-4-10-II
501 M-4-10-III
9,264,700
17,528,800
11,117,600
21,034,500
12,970,500
24,540,300
7,741,100
9,289,400
10,837,600
16,972,100
20,366,600
23,761,000
24,538,800
29,446,500
34,354,300
4,943,300
5,932,000
6,920,700
8,222,100
9,866,500
11,511,000
12,372,700
14,847,200
17,321,800
10,288,900
12,346,700
14,404,500
15,458,700
18,550,400
21,642,200
30,159,600
36,191,500
42,223,400
511 M-4-14-I

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
11,734,200
14,081,000
16,427,800
512 M-4-14-II
14,472,400
17,366,800
20,261,300
513 M-4-14-III
514 M-4-15-I
21,747,800
5,566,400
26,097,300
6,679,700
30,446,900
7,793,000
515
516
517
518
519

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7,419,700
15,785,000
5,957,200
9,539,700
16,026,000
8,903,600
18,942,000
7,148,600
11,447,600
19,231,100
10,387,500
22,099,100
8,340,000
13,355,500
22,436,300
4,604,700
5,525,600
6,446,500
6,440,200
7,728,200
9,016,200
8,993,200
10,791,900
12,590,500
3,867,100
5,827,900
7,017,100
4,640,500
6,993,500
8,420,500
5,414,000
8,159,100
9,823,900
6,094,200
7,313,100
8,531,900
10,265,000
12,318,000
14,371,000
20,048,200
24,057,900
28,067,500
5,532,600
6,639,200
7,745,700
8,101,600
9,721,900
11,342,300
9,054,500
10,865,400
12,676,400
4,952,000
5,942,300
6,932,700
6,193,500
7,432,200
8,670,800
493 M-1-70-I
494 M-1-70-II
495 M-1-70-III
502 M-4-11-I
503 M-4-11-II
504 M-4-11-III
505 M-4-12-I
506 M-4-12-II
507 M-4-12-III
508 M-4-13-I
509 M-4-13-II
510 M-4-13-III
M-4-15-II
M-4-15-III
M-4-16-I
M-4-16-II
M-4-16-III
520 M-4-17-I
521 M-4-17-II
522 M-4-17-III
523 M-4-18-I
524 M-4-18-II
525 M-4-18-III
526 M-4-19-I
527 M-4-19-II
528 M-4-19-III
529 M-4-20-I
530 M-4-20-II
531 M-4-20-III
532 M-4-21-I
533 M-4-21-II
31,023,400
37,228,100
43,432,700
34,125,700
40,950,900
47,776,000
39,069,400
46,883,300
54,697,200
17,635,500
21,162,600
24,689,700
20,943,800
47,140,000
25,132,500
56,567,900
29,321,300
65,995,900
- 1050 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
13,885,600
16,662,700
19,439,900
535 N-1-01-I

283,523,900
340,228,700
396,933,400
536 N-1-01-II
283,523,900
340,228,700
396,933,400
537 N-1-01-III
538 N-1-11-I

283,523,900
17,854,800
340,228,700
21,425,700
396,933,400
24,996,700
539 N-1-11-II
540 N-1-11-III

28,232,700
44,014,800
33,879,200
52,817,700
39,525,800
61,620,700
9,100,000
10,920,000
12,740,000
18,117,100
21,740,500
25,363,900
39,314,700
47,177,600
55,040,600
15,916,800
19,100,100
22,283,500

BAWAH (RINGAN)
BAWAH (SEDANG)
BAWAH (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
BATU URIN (RINGAN)
BATU URIN (SEDANG)
BATU URIN (BERAT)
URIN (RINGAN)
URIN (SEDANG)
URIN (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
27,843,400
31,170,800
33,412,000
37,404,900
38,980,700
43,639,100
18,208,300
21,850,000
25,491,700
27,545,600
33,054,800
38,563,900
31,702,400
38,042,900
44,383,400
16,352,400
19,622,900
22,893,400
22,206,200
26,647,400
31,088,600
25,845,100
31,014,100
36,183,100
6,947,500
8,337,000
9,726,500
8,403,100
10,083,700
11,764,300
12,359,700
14,831,700
17,303,600
3,529,300
6,166,100
7,671,900
2,661,000
5,528,100
8,982,800
3,600,700
6,019,700
12,453,400
4,235,100
7,399,300
9,206,300
3,193,100
6,633,700
10,779,400
4,320,900
7,223,600
14,944,100
4,941,000
8,632,500
10,740,700
3,725,300
7,739,400
12,576,000
5,041,000
8,427,500
17,434,800
5,356,400
6,427,700
7,499,000
7,600,500
9,120,600
10,640,700
12,183,500
14,620,200
17,056,900
6,327,900
7,593,500
8,859,100
7,851,800
9,422,200
10,992,500
8,960,200
10,752,300
12,544,300
7,748,500
9,298,200
10,847,900
11,059,600
13,271,500
15,483,400
14,721,100
17,665,300
20,609,500
5,649,400
7,514,000
6,779,300
9,016,800
7,909,200
10,519,600
534 M-4-21-III
541 N-1-12-I
542 N-1-12-II
543 N-1-12-III
544 N-1-20-I
545 N-1-20-II
546 N-1-20-III
547 N-1-30-I
548 N-1-30-II
549 N-1-30-III
550 N-1-40-I
551 N-1-40-II
552 N-1-40-III
553 N-4-10-I
554 N-4-10-II
555 N-4-10-III
556
557
558
559
560
561
562
563
564
N-4-11-I
N-4-11-II
N-4-11-III
N-4-12-I
N-4-12-II
N-4-12-III
N-4-13-I
N-4-13-II
N-4-13-III
565 N-4-14-I
566 N-4-14-II
567 N-4-14-III
568 N-4-15-I
569 N-4-15-II
570 N-4-15-III
571 N-4-16-I
572 N-4-16-II
573 N-4-16-III
574 O-6-10-I
575 O-6-10-II
- 1051 -

RAWAT INAP
NO
KODE
INA-CBG
576 O-6-10-III
577 O-6-11-I
578 O-6-11-II
579 O-6-11-III
580 O-6-12-I
581 O-6-12-II
582 O-6-12-III
583 O-6-13-I
584 O-6-13-II
585 O-6-13-III
586 P-8-01-I
587 P-8-01-II
588 P-8-01-III
589 P-8-02-I
590 P-8-02-II
591 P-8-02-III
592 P-8-03-I
593 P-8-03-II
594 P-8-03-III
595 P-8-04-I
596 P-8-04-II
597 P-8-04-III
598 P-8-05-I
599 P-8-05-II
600 P-8-05-III
601 P-8-06-I
602 P-8-06-II
603 P-8-06-III
604 P-8-07-I
605 P-8-07-II
606 P-8-07-III
607 P-8-08-I
608 P-8-08-II
609 P-8-08-III
610 P-8-11-I
611 P-8-11-II

MAYOR (RINGAN)
MAYOR (SEDANG)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
11,221,200
13,465,400
15,709,600
4,766,300
5,719,500
6,672,800
5,297,200
6,356,600
7,416,000
6,589,700
7,907,700
9,225,600
3,376,800
4,052,200
4,727,600
4,055,500
4,866,600
5,677,800
5,095,900
6,115,100
7,134,300
1,882,900
2,259,500
2,636,100
3,089,100
3,706,900
3,706,900
4,448,300
4,324,700
5,189,600
75,405,000
90,486,000
105,567,000
93,302,400
111,962,900
130,623,400
109,510,800
131,412,900
153,315,100
170,327,600
204,393,200
238,458,700
195,383,400
234,460,100
273,536,800
223,239,500
267,887,400
312,535,300
15,438,500
18,526,200
21,613,900
20,435,000
24,522,000
28,609,000
28,732,600
34,479,100
40,225,600
68,544,600
82,253,600
95,962,500
89,194,800
107,033,800
124,872,700
127,883,000
153,459,600
179,036,200
37,226,100
44,671,300
52,116,500
52,868,100
63,441,700
74,015,300
77,894,100
93,472,900
109,051,700
7,303,500
8,764,200
10,224,900
20,477,300
24,572,800
28,668,300
27,127,400
32,552,900
37,978,400
9,925,600
11,910,800
13,895,900
24,983,800
29,980,500
34,977,300
33,279,700
39,935,700
46,591,600
7,751,300
9,301,500
10,851,800
11,011,700
13,214,000
15,416,300
16,337,000
19,604,400
22,871,800
12,865,400
15,438,500
18,011,600
17,029,200
20,435,000
23,840,800
- 1052 -

RAWAT INAP
NO
KODE
INA-CBG
612 P-8-11-III
613 P-8-12-I
614 P-8-12-II
615 P-8-12-III
616 P-8-13-I
617 P-8-13-II
618 P-8-13-III
619 P-8-14-I
620 P-8-14-II
621 P-8-14-III
622 P-8-15-I
623 P-8-15-II
624 P-8-15-III
625 P-8-16-I
626 P-8-16-II
627 P-8-16-III
628 P-8-17-I
629 P-8-17-II
630 P-8-17-III
631 S-4-10-I
632 S-4-10-II
633 S-4-10-III
634
635
636
637
638
639
S-4-11-I
S-4-11-II
S-4-11-III
S-4-12-I
S-4-12-II
S-4-12-III
640 S-4-13-I
641 S-4-13-II
642 S-4-13-III
643 S-4-14-I
644 S-4-14-II
645 S-4-14-III
646 S-4-15-I
647 S-4-15-II
648 S-4-15-III
649 S-4-16-I

MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
MAYOR (RINGAN)
MAYOR (SEDANG)
MAYOR (BERAT)
ASPIRASI (RINGAN)
ASPIRASI (SEDANG)
ASPIRASI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
KANAK-KANAK (BERAT)
LUKA BAKAR (RINGAN)
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
23,943,800
28,732,600
33,521,300
11,695,900
14,035,000
16,374,200
14,191,000
17,029,200
19,867,400
20,820,700
24,984,800
29,149,000
6,497,700
7,797,200
9,096,800
10,136,400
12,163,700
14,191,000
16,015,900
19,219,100
22,422,300
4,918,300
5,901,900
6,885,600
10,011,600
12,013,900
14,016,300
39,146,200
46,975,400
54,804,700
3,688,800
4,426,500
5,164,300
7,386,900
8,864,300
10,341,700
8,667,200
10,400,600
12,134,100
3,338,400
4,006,000
4,673,700
6,415,200
7,698,300
8,981,300
15,044,700
18,053,700
21,062,600
4,331,800
5,198,200
6,064,500
8,230,400
9,876,500
11,522,600
16,529,900
19,835,900
23,141,900
3,764,000
4,516,800
5,269,600
4,637,800
5,565,300
6,492,900
6,348,600
7,618,400
8,888,100
1,729,700
3,515,800
8,112,200
4,181,800
5,565,900
9,648,500
2,075,700
4,219,000
9,734,600
5,018,100
6,679,000
11,578,100
2,421,600
4,922,200
11,357,000
5,854,500
7,792,200
13,507,800
6,175,400
7,410,500
8,645,600
10,955,700
13,146,800
15,337,900
17,782,400
21,338,900
24,895,400
3,125,200
3,750,200
4,375,300
6,638,200
7,965,800
9,293,400
12,588,300
15,105,900
17,623,600
2,090,200
2,508,200
2,926,200
3,944,500
4,733,400
5,522,300
5,108,800
6,130,500
7,152,300
10,823,200
12,987,800
15,152,500
- 1053 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
650 S-4-16-II
LUKA BAKAR (SEDANG)
13,764,600
16,517,500
19,270,500
651 S-4-16-III
LUKA BAKAR (BERAT)

OBAT (RINGAN)
OBAT (SEDANG)
OBAT (BERAT)
19,708,100
23,649,700
27,591,300
5,216,600
6,259,900
7,303,200
7,742,000
9,290,400
10,838,800
9,311,500
11,173,800
13,036,100
3,490,300
4,188,400
4,886,400
4,687,900
5,625,500
6,563,100
8,528,100
10,233,700
11,939,300
1,603,000
1,923,600
2,244,200
3,055,000
3,666,000
4,276,900
4,441,100
5,329,400
6,217,600
1,901,500
2,281,800
2,662,100
2,992,500
3,591,000
4,189,500
4,820,000
5,784,000
6,748,100
3,318,100
3,981,700
4,645,400
5,023,800
6,028,600
7,033,300
7,795,500
9,354,600
10,913,700
11,406,000
13,687,100
15,968,300

(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
17,706,600
46,767,700
21,247,900
56,121,200
24,789,200
65,474,700
17,645,500
21,174,600
24,703,800
22,368,400
26,842,000
31,315,700
32,184,500
38,621,400
45,058,300
13,788,000
21,143,200
31,055,000
13,071,300
15,230,200
25,246,800
16,545,600
25,371,900
37,266,000
15,685,600
18,276,200
30,296,200
19,303,200
29,600,500
43,477,000
18,299,900
21,322,200
35,345,600
8,291,300
9,949,600
11,607,800
10,175,400
12,210,500
14,245,600
12,057,900
14,469,500
16,881,000
4,294,600
6,105,700
9,300,900
5,153,600
7,326,900
11,161,100
6,012,500
8,548,000
13,021,300
12,587,500
15,105,000
17,622,600
18,733,700
22,480,500
26,227,200
48,093,100
57,711,700
67,330,300
10,795,200
14,637,800
28,624,800
12,954,200
17,565,400
34,349,700
15,113,200
20,492,900
40,074,700
7,768,700
9,322,400
10,876,100
652 S-4-17-I
653 S-4-17-II
654 S-4-17-III
655 T-1-10-I
656 T-1-10-II
657 T-1-10-III
658 T-4-10-I
659 T-4-10-II
660 T-4-10-III
661 T-4-11-I
662 T-4-11-II
663 T-4-11-III
664 T-4-12-I
665 T-4-12-II
666 T-4-12-III
667 U-1-10-I
668 U-1-10-II
669 U-1-10-III
670 U-1-11-I
671 U-1-11-II
672 U-1-11-III
673
674
675
676
677
678
U-1-12-I
U-1-12-II
U-1-12-III
U-1-13-I
U-1-13-II
U-1-13-III
679 U-1-14-I
680 U-1-14-II
681 U-1-14-III
682 U-1-15-I
683 U-1-15-II
684 U-1-15-III
685 U-1-20-I
686 U-1-20-II
687 U-1-20-III
688 U-1-30-I
689 U-1-30-II
690 U-1-30-III
691 U-4-10-I
- 1054 -

RAWAT INAP
NO
KODE
INA-CBG
TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
694 U-4-11-I
695 U-4-11-II

TENGGOROKAN (BERAT)
696 U-4-11-III
3,516,200
4,219,400
4,922,600
697 U-4-12-I
698 U-4-12-II

2,670,200
4,305,300
3,204,300
5,166,300
3,738,300
6,027,400
699 U-4-12-III

7,539,900
9,047,900
10,555,800
2,023,700
2,428,400
2,833,100
3,306,800
3,968,200
4,629,500
5,339,400
6,407,300
7,475,200
7,732,400
9,259,400
9,278,900
11,111,200
10,825,400
12,963,100

(RINGAN)
(SEDANG)
(BERAT)
KOMPLEK (RINGAN)
KOMPLEK (SEDANG)
KOMPLEK (BERAT)
(RINGAN)
(SEDANG)
15,549,300
18,659,100
21,769,000
6,208,900
7,450,700
8,692,500
7,735,500
9,282,600
10,829,700
10,825,900
12,991,100
15,156,300
10,127,300
12,152,700
14,178,200
20,861,800
25,034,100
29,206,500
25,584,000
30,700,800
35,817,600
19,266,600
22,000,200
34,453,200
23,120,000
26,400,200
41,343,900
26,973,300
30,800,300
48,234,500
18,114,300
21,737,200
25,360,100
24,736,600
29,683,900
34,631,200
31,353,900
37,624,700
43,895,500
9,448,700
11,338,400
13,228,100
18,053,300
21,664,000
25,274,600
28,323,400
33,988,100
39,652,800
18,528,800
22,234,600
25,940,300
26,921,800
32,306,200
37,690,500
723 V-1-14-III
33,616,700
40,340,100
47,063,400
724 V-1-15-I
725 V-1-15-II
726 V-1-15-III
SIRKUMSISI (RINGAN)
SIRKUMSISI (SEDANG)
SIRKUMSISI (BERAT)
(RINGAN)
(SEDANG)
(BERAT)
TUMOR (RINGAN)
TUMOR (SEDANG)
TUMOR (BERAT)
2,984,100
3,292,900
3,642,600
3,580,900
3,951,500
4,371,100
4,177,700
4,610,100
5,099,700
8,064,200
9,677,000
11,289,900
13,395,000
16,074,000
18,753,000
22,083,700
26,500,500
30,917,200
7,742,200
9,290,600
10,839,000
10,388,000
12,465,600
14,543,200
13,914,800
16,697,800
19,480,700
692 U-4-10-II
693 U-4-10-III
700 U-4-13-I
701 U-4-13-II
702 U-4-13-III
703 U-4-14-I
704 U-4-14-II
705 U-4-14-III
706 U-4-15-I
707 U-4-15-II
708 U-4-15-III
709 V-1-10-I
710 V-1-10-II
711 V-1-10-III
712 V-1-11-I
713 V-1-11-II
714 V-1-11-III
715 V-1-12-I
716 V-1-12-II
717 V-1-12-III
718 V-1-13-I
719 V-1-13-II
720 V-1-13-III
721 V-1-14-I
722 V-1-14-II
727 V-4-10-I
728 V-4-10-II
729 V-4-10-III
730 V-4-11-I
731 V-4-11-II
732 V-4-11-III
16,006,300
19,207,600
22,408,900
24,574,600
29,489,600
34,404,500
1,915,100
2,858,400
2,298,100
3,430,100
2,681,200
4,001,800
- 1055 -

RAWAT INAP
NO
KODE
INA-CBG
733 W-1-01-I
734 W-1-01-II
735 W-1-01-III
736 W-1-10-I
737 W-1-10-II
738 W-1-10-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
21,102,400
25,322,900
29,543,400
25,292,700
30,351,200
35,409,700
36,092,000
43,310,400
50,528,700
4,476,100
5,371,300
6,266,600
4,939,400
5,463,900
5,927,200
6,556,700
6,915,100
7,649,500
4,678,500
5,614,200
6,549,900
5,162,700
6,195,300
7,227,800
5,711,000
6,853,200
7,995,400
5,033,200
6,039,800
7,046,400
6,282,200
11,124,400
7,538,700
13,349,300
8,795,100
15,574,200
742 W-1-12-I

SERVIK (RINGAN)
SERVIK (SEDANG)
SERVIK (BERAT)
743 W-1-12-II
744 W-1-12-III

745 W-1-13-I
5,173,700
6,208,400
7,243,100
746 W-1-13-II
747 W-1-13-III

5,616,800
7,544,900
6,740,200
9,053,800
7,863,600
10,562,800
748 W-1-20-I
749 W-1-20-II

17,326,100
21,649,100
20,791,300
25,978,900
24,256,500
30,308,800
750 W-1-20-III
25,096,900
30,116,300
35,135,600
751 W-1-30-I
9,780,800
11,737,000
13,693,100
752 W-1-30-II
15,600,400
18,720,500
21,840,500
753 W-1-30-III
38,276,400
45,931,600
53,586,900
754 W-4-10-I
755
756
757
758
759

ABORTUS (RINGAN)
ABORTUS (SEDANG)
ABORTUS (BERAT)
739 W-1-11-I
740 W-1-11-II
741 W-1-11-III
W-4-10-II
W-4-10-III
W-4-11-I
W-4-11-II
W-4-11-III
760 W-4-12-I
761 W-4-12-II
762 W-4-12-III
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
W-4-13-I
W-4-13-II
W-4-13-III
W-4-14-I
W-4-14-II
W-4-14-III
W-4-15-I
W-4-15-II
W-4-15-III
W-4-16-I
W-4-16-II
W-4-16-III
W-4-17-I
W-4-17-II
W-4-17-III
Z-4-10-I
Z-4-10-II
Z-4-10-III
Z-4-11-I
Z-4-11-II
Z-4-11-III
7,287,700
8,745,300
10,202,800
10,803,700
21,350,300
5,964,900
9,055,600
11,022,400
12,964,500
25,620,400
7,157,900
10,866,700
13,226,800
15,125,200
29,890,400
8,350,800
12,677,900
15,431,300
2,959,900
3,551,900
4,143,800
5,632,700
6,759,300
7,885,800
8,289,000
9,946,800
11,604,500
2,607,600
3,562,100
4,429,700
3,484,800
4,147,800
5,306,600
1,665,400
2,563,800
4,792,000
2,215,900
4,107,300
7,515,200
1,635,100
4,092,100
8,167,600
6,165,300
8,183,500
11,625,500
3,165,900
3,802,500
5,226,700
3,129,100
4,274,500
5,315,600
4,181,700
4,977,300
6,367,900
1,998,500
3,076,500
5,750,400
2,659,100
4,928,800
9,018,200
1,962,100
4,910,500
9,801,100
7,398,400
9,820,300
13,950,500
3,799,100
4,562,900
6,272,000
3,650,600
4,986,900
6,201,500
4,878,700
5,806,900
7,429,200
2,331,600
3,589,300
6,708,800
3,102,300
5,750,300
10,521,200
2,289,100
5,728,900
11,434,600
8,631,400
11,457,000
16,275,600
4,432,300
5,323,400
7,317,400
- 1056 -

RAWAT INAP
NO
KODE
INA-CBG
784 Z-4-12-I
785 Z-4-12-II
786 Z-4-12-III

TARIF
KELAS 3
TARIF
KELAS 2
TARIF
KELAS 1
2,092,500
2,511,000
2,929,500
4,201,500
5,041,800
5,882,100
8,864,100
10,636,900
12,409,700
- 1057 -

RUMAH SAKIT IBU DAN ANAK HARAPAN KITA
RAWAT JALAN
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
KODE
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
C-3-11-0
C-3-12-0
C-3-13-0
C-3-14-0
C-3-15-0
C-3-16-0
C-3-17-0
C-3-18-0
C-3-19-0
C-3-20-0
C-3-21-0
C-3-22-0
C-3-23-0
D-2-10-0
D-2-11-0
D-2-21-0
D-2-22-0
D-3-10-0
D-3-11-0
E-2-10-0
E-2-21-0

PROSEDUR LIMPA
31 E-2-22-0
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69

TERAPI SHOCK
TERAPI KELOMPOK
PROSEDUR KRANIOTOMI
E-3-10-0
F-3-10-0
F-5-10-0
F-5-11-0
F-5-12-0
F-5-13-0
F-5-14-0
F-5-15-0
F-5-16-0
G-2-10-0
G-2-11-0
G-2-12-0
G-2-13-0
G-2-21-0
G-2-22-0
G-2-31-0
G-2-32-0
G-3-10-0
G-3-11-0
G-3-12-0
G-3-13-0
G-5-17-0
H-2-21-0
H-2-22-0
H-2-23-0
H-2-31-0
H-2-32-0
H-2-33-0
H-2-34-0
H-2-35-0
H-2-36-0
H-2-37-0
H-3-10-0
H-3-11-0
H-3-12-0
H-3-13-0
I-2-11-0
I-2-12-0
TARIF
INA-CBG
2,358,600
3,059,500
5,689,400
4,701,700
6,110,100
1,123,900
2,497,200
878,800
1,525,800
1,861,000
2,112,700
3,176,400
4,332,600
3,970,900
1,286,400
2,969,100
1,077,000
1,849,000
5,632,200
2,017,100
4,763,400
1,162,100
3,032,300
3,796,900
3,184,500
781,000
2,367,000
1,316,000
845,800
731,600
645,800
772,300
1,075,300
539,100
869,800
456,000
1,159,800
409,400
596,900
414,000
13,886,600
5,549,900
5,568,400
1,432,400
2,931,900
1,835,700
3,731,100
1,912,600
1,095,300
827,100
1,334,000
644,300
630,400
6,148,800
1,521,900
1,014,600
6,400,700
4,267,200
664,800
6,934,100
4,800,600
3,344,400
2,493,900
1,534,000
660,000
444,500
619,900
9,452,100
4,601,000
- 1058 -

RAWAT JALAN
KODE
INA-CBG
73 I-2-16-0
PENGGANTIAN ALAT
81 I-2-42-0
PERKUTAN LAIN
NO
TARIF
INA-CBG
5,847,500
10,348,900
8,580,500
6,536,600
2,154,900
7,275,300
4,750,400
1,167,700
10,922,800
9,888,300
6,630,100
6,281,200
776,300
746,000
3,001,600
820,300
730,900
807,800
3,465,700
3,787,100
3,307,900
3,651,700
2,211,500
735,200
1,295,800
889,500
803,200
782,600
993,600
1,133,100
664,200
1,906,300
3,474,200
2,666,900
6,269,500
816,400
816,400
7,241,800
3,368,800
646,200
2,989,600
7,766,300
1,783,100
1,404,400
688,000
273,600
931,600
1,299,000
3,110,600
2,741,700
1,919,200
1,145,400
630,400
3,332,500
2,136,200
1,140,900
1,041,500
3,413,000
610,000
4,358,800
3,334,700
813,500
901,800
880,900
430,900
3,633,300
3,993,700
791,500
- 1059 -

RAWAT JALAN
NO
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
KODE
INA-CBG
M-2-31-0
M-2-32-0
M-2-41-0
M-2-42-0
M-2-51-0
M-2-52-0
M-2-61-0
M-2-62-0
M-2-63-0
M-2-64-0
M-2-65-0
M-2-71-0
M-2-72-0
M-2-81-0
M-2-82-0
M-2-83-0
M-2-84-0
M-3-10-0
M-3-11-0
M-3-12-0
M-3-13-0
M-3-14-0
M-3-15-0
M-3-16-0
M-3-17-0
N-2-11-0
N-2-12-0
N-2-21-0
N-2-22-0
N-2-23-0
N-2-24-0
N-2-31-0
N-2-32-0
N-2-41-0
N-2-42-0
N-3-10-0
N-3-11-0
N-3-12-0
N-3-13-0
N-3-14-0
N-3-15-0
O-7-10-0
O-7-11-0
181 O-7-12-0
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
O-7-13-0
P-9-11-0
P-9-12-0
P-9-13-0
P-9-14-0
P-9-15-0
P-9-16-0
P-9-17-0
Q-5-10-0
Q-5-11-0
Q-5-12-0
Q-5-13-0
Q-5-14-0
Q-5-15-0
Q-5-16-0
Q-5-17-0
Q-5-18-0
Q-5-19-0
Q-5-20-0
Q-5-21-0
Q-5-22-0
Q-5-23-0
Q-5-24-0
Q-5-25-0
Q-5-26-0

PROSEDUR BUNION
PROSEDUR ARTROSKOPI
PROSEDUR DIALISIS
GIGI
MEDICAL CHECK-UP
VAKSINASI
ABORSI MENGANCAM
ABORSI
BRONKIAL AKUT
TARIF
INA-CBG
2,425,700
905,500
979,000
906,500
1,438,100
1,106,200
2,770,500
817,400
2,274,300
3,798,800
665,600
4,051,000
2,195,200
4,744,000
2,394,800
1,057,600
813,500
79,000
1,054,400
2,382,600
928,500
1,254,200
717,200
211,000
724,300
10,786,100
6,131,000
6,030,300
3,142,100
1,404,400
957,000
2,164,400
1,144,800
2,303,800
1,334,000
794,100
1,329,200
748,000
1,141,700
875,300
1,085,600
4,175,600
3,359,500
2,962,100
2,090,500
769,000
769,000
769,000
628,100
398,400
626,400
765,700
828,300
610,100
538,100
110,700
121,700
90,000
105,600
100,700
153,800
189,200
427,600
469,700
122,400
148,600
101,600
158,500
224,900
- 1060 -

RAWAT JALAN
NO
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
KODE
INA-CBG
Q-5-27-0
Q-5-28-0
Q-5-29-0
Q-5-30-0
Q-5-31-0
Q-5-32-0
Q-5-33-0
Q-5-34-0
Q-5-35-0
Q-5-36-0
Q-5-37-0
Q-5-38-0
Q-5-39-0
Q-5-40-0
Q-5-41-0
Q-5-42-0
Q-5-43-0
Q-5-44-0
T-2-10-0
U-2-10-0
U-2-11-0
U-2-12-0
U-2-13-0
U-2-14-0
U-2-15-0
U-2-21-0
U-2-22-0
U-2-23-0
U-2-24-0
U-2-25-0
U-2-31-0
U-2-32-0
U-3-10-0
U-3-11-0
U-3-12-0
242 U-3-13-0
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
U-3-14-0
U-3-15-0
U-3-16-0
V-2-10-0
V-2-11-0
V-2-12-0
V-2-13-0
V-2-14-0
V-2-15-0
V-3-10-0
V-3-11-0
V-3-12-0
W-2-10-0
W-2-11-0
W-2-12-0
W-2-13-0
W-2-21-0
W-2-22-0
W-2-23-0
W-2-31-0
W-2-32-0
W-2-33-0
W-2-34-0
W-3-10-0
W-3-11-0
W-3-12-0
Z-3-10-0
270 Z-3-11-0
271
272
273
274
Z-3-12-0
Z-3-13-0
Z-3-14-0
Z-3-15-0

FRAKTUR
SALURAN KEMIH AKUT
HEMATOLOGI AKUT
INFEKSI VIRUS HIV
INFEKSI AKUT
PARU AKUT
RHINOPLASTY
TENGGOROKAN
PROSEDUR PADA GIGI
PROSEDUR PADA PENIS
SIRKUMSISI/SUNAT
PROSEDUR ABORSI
EMPEDU
DIAGNOSTIK TIDUR
TARIF
INA-CBG
160,100
480,000
1,356,900
1,573,000
151,400
652,900
184,300
263,100
1,098,300
940,300
675,900
640,000
150,600
147,900
753,700
384,500
527,700
395,900
369,600
5,925,600
4,876,200
774,800
802,400
1,534,600
888,000
1,964,300
1,014,700
3,162,200
314,900
824,700
827,400
662,500
836,800
791,800
371,000
815,100
722,500
653,500
739,100
6,118,200
993,000
2,201,800
789,800
1,404,400
543,500
433,500
1,912,100
1,958,100
2,087,800
1,826,300
1,670,200
544,100
4,722,000
717,200
2,393,600
5,439,800
5,032,000
2,198,200
796,600
1,553,700
1,547,600
717,200
5,621,900
4,422,000
253,200
180,100
234,000
855,000
- 1061 -

RAWAT JALAN
NO
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
KODE
INA-CBG
Z-3-16-0
Z-3-17-0
Z-3-18-0
Z-3-19-0
Z-3-20-0
Z-3-21-0
Z-3-22-0
Z-3-23-0
Z-3-24-0
Z-3-25-0
Z-3-26-0
Z-3-27-0
Z-3-28-0
Z-3-29-0
Z-3-30-0

CT-SCAN KEPALA
CT SCAN LAIN-LAIN
PERAWATAN LUKA
IMAGING PAYUDARA
IMAGING LAIN-LAIN
FOTOTERAPI
TARIF
INA-CBG
2,110,800
1,487,500
2,330,100
2,811,100
1,347,100
1,873,900
1,295,200
642,100
1,333,100
454,900
1,824,800
215,000
796,400
1,546,800
87,300
- 1062 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II
Anti Hemofilia Factor

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
A
B
C
D
RAWAT PEMERINTAH PEMERINTAH PEMERINTAH PEMERINTAH
1
3,264,500
3,140,200
2,912,200
2,540,600
2
3,264,500
3,140,200
2,912,200
2,540,600
3
3,264,500
3,140,200
2,912,200
2,540,600
1
3,264,500
3,140,200
2,912,200
2,540,600
2
3,264,500
3,140,200
2,912,200
2,540,600
3
3,264,500
3,140,200
2,912,200
2,540,600
1
3,264,500
3,140,200
2,912,200
2,540,600
2
3,264,500
3,140,200
2,912,200
2,540,600
3
3,264,500
3,140,200
2,912,200
2,540,600
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
6,216,000
5,800,000
5,545,300
5,805,300
2
6,216,000
5,800,000
5,545,300
5,805,300
3
6,216,000
5,800,000
5,545,300
5,805,300
1
2,109,900
1,968,700
1,694,000
1,642,100
2
2,109,900
1,968,700
1,694,000
1,642,100
3
2,109,900
1,968,700
1,694,000
1,642,100
1
2,109,900
1,968,700
1,694,000
1,642,100
2
2,109,900
1,968,700
1,694,000
1,642,100
3
2,109,900
1,968,700
1,694,000
1,642,100
1
2,109,900
1,968,700
1,694,000
1,642,100
2
2,109,900
1,968,700
1,694,000
1,642,100
3
2,109,900
1,968,700
1,694,000
1,642,100
1
11,217,600
7,850,200
6,754,700
5,893,000
2
11,217,600
7,850,200
6,754,700
5,893,000
3
11,217,600
7,850,200
6,754,700
5,893,000
1
11,217,600
7,850,200
6,754,700
5,893,000
2
11,217,600
7,850,200
6,754,700
5,893,000
3
11,217,600
7,850,200
6,754,700
5,893,000
1
11,217,600
7,850,200
6,754,700
5,893,000
2
11,217,600
7,850,200
6,754,700
5,893,000
3
11,217,600
7,850,200
6,754,700
5,893,000
1
4,297,300
4,009,700
3,450,200
3,344,400
2
4,297,300
4,009,700
3,450,200
3,344,400
3
4,297,300
4,009,700
3,450,200
3,344,400
1
4,297,300
4,009,700
3,450,200
3,344,400
2
4,297,300
4,009,700
3,450,200
3,344,400
3
4,297,300
4,009,700
3,450,200
3,344,400
1
4,297,300
4,009,700
3,450,200
3,344,400
2
4,297,300
4,009,700
3,450,200
3,344,400
3
4,297,300
4,009,700
3,450,200
3,344,400
1
15,673,000
15,076,400
12,583,500
12,197,700
2
15,673,000
15,076,400
12,583,500
12,197,700
3
15,673,000
15,076,400
12,583,500
12,197,700
1
15,673,000
15,076,400
12,583,500
12,197,700
2
15,673,000
15,076,400
12,583,500
12,197,700
3
15,673,000
15,076,400
12,583,500
12,197,700
1
15,673,000
15,076,400
12,583,500
12,197,700
2
15,673,000
15,076,400
12,583,500
12,197,700
3
15,673,000
15,076,400
12,583,500
12,197,700
- 1063 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
A
B
C
D
1
16,656,400
8,443,500
5,283,900
1,565,200
2
16,656,400
8,443,500
5,283,900
1,565,200
3
16,656,400
8,443,500
5,283,900
1,565,200
1
16,656,400
8,443,500
5,283,900
1,565,200
2
16,656,400
8,443,500
5,283,900
1,565,200
3
16,656,400
8,443,500
5,283,900
1,565,200
1
16,656,400
8,443,500
5,283,900
1,565,200
2
16,656,400
8,443,500
5,283,900
1,565,200
3
16,656,400
8,443,500
5,283,900
1,565,200
1
16,938,500
7,259,700
5,552,700
4,844,200
2
16,938,500
7,259,700
5,552,700
4,844,200
3
16,938,500
7,259,700
5,552,700
4,844,200
1
16,938,500
7,259,700
5,552,700
4,844,200
2
16,938,500
7,259,700
5,552,700
4,844,200
3
16,938,500
7,259,700
5,552,700
4,844,200
1
16,938,500
7,259,700
5,552,700
4,844,200
2
16,938,500
7,259,700
5,552,700
4,844,200
3
16,938,500
7,259,700
5,552,700
4,844,200
1
11,081,000
7,754,500
5,931,100
5,174,300
2
11,081,000
7,754,500
5,931,100
5,174,300
3
11,081,000
7,754,500
5,931,100
5,174,300
1
11,081,000
7,754,500
5,931,100
5,174,300
2
11,081,000
7,754,500
5,931,100
5,174,300
3
11,081,000
7,754,500
5,931,100
5,174,300
1
11,081,000
7,754,500
5,931,100
5,174,300
2
11,081,000
7,754,500
5,931,100
5,174,300
3
11,081,000
7,754,500
5,931,100
5,174,300
1
26,197,900
11,228,200
8,588,000
7,492,200
2
26,197,900
11,228,200
8,588,000
7,492,200
3
26,197,900
11,228,200
8,588,000
7,492,200
1
26,197,900
11,228,200
8,588,000
7,492,200
2
26,197,900
11,228,200
8,588,000
7,492,200
3
26,197,900
11,228,200
8,588,000
7,492,200
1
26,197,900
11,228,200
8,588,000
7,492,200
2
26,197,900
11,228,200
8,588,000
7,492,200
3
26,197,900
11,228,200
8,588,000
7,492,200
1
103,378,500
96,957,300
55,333,500
48,273,500
2
103,378,500
96,957,300
55,333,500
48,273,500
3
103,378,500
96,957,300
55,333,500
48,273,500
1
103,378,500
96,957,300
55,333,500
48,273,500
2
103,378,500
96,957,300
55,333,500
48,273,500
3
103,378,500
96,957,300
55,333,500
48,273,500
1
103,378,500
96,957,300
55,333,500
48,273,500
2
103,378,500
96,957,300
55,333,500
48,273,500
3
103,378,500
96,957,300
55,333,500
48,273,500
1
13,099,000
5,614,100
4,294,000
3,746,100
2
13,099,000
5,614,100
4,294,000
3,746,100
3
13,099,000
5,614,100
4,294,000
3,746,100
1
13,099,000
5,614,100
4,294,000
3,746,100
2
13,099,000
5,614,100
4,294,000
3,746,100
3
13,099,000
5,614,100
4,294,000
3,746,100
1
13,099,000
5,614,100
4,294,000
3,746,100
2
13,099,000
5,614,100
4,294,000
3,746,100
3
13,099,000
5,614,100
4,294,000
3,746,100
1
14,434,100
10,413,400
7,725,900
6,740,100
2
14,434,100
10,413,400
7,725,900
6,740,100
3
14,434,100
10,413,400
7,725,900
6,740,100
1
14,434,100
10,413,400
7,725,900
6,740,100
2
14,434,100
10,413,400
7,725,900
6,740,100
3
14,434,100
10,413,400
7,725,900
6,740,100
1
14,434,100
10,413,400
7,725,900
6,740,100
2
14,434,100
10,413,400
7,725,900
6,740,100
3
14,434,100
10,413,400
7,725,900
6,740,100
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
- 1064 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
Stereotactic Surgery
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Defect of Heart with
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Imaging Procedure of
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
I-1-06-I
I-1-06-II
I-1-06-III
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
A
B
C
D
1
8,067,400
6,210,100
3,886,300
3,390,400
2
8,067,400
6,210,100
3,886,300
3,390,400
3
8,067,400
6,210,100
3,886,300
3,390,400
1
8,067,400
6,210,100
3,886,300
3,390,400
2
8,067,400
6,210,100
3,886,300
3,390,400
3
8,067,400
6,210,100
3,886,300
3,390,400
1
8,067,400
6,210,100
3,886,300
3,390,400
2
8,067,400
6,210,100
3,886,300
3,390,400
3
8,067,400
6,210,100
3,886,300
3,390,400
1
48,292,200
21,337,800
15,830,800
13,810,900
2
48,292,200
21,337,800
15,830,800
13,810,900
3
48,292,200
21,337,800
15,830,800
13,810,900
1
48,292,200
21,337,800
15,830,800
13,810,900
2
48,292,200
21,337,800
15,830,800
13,810,900
3
48,292,200
21,337,800
15,830,800
13,810,900
1
48,292,200
21,337,800
15,830,800
13,810,900
2
48,292,200
21,337,800
15,830,800
13,810,900
3
48,292,200
21,337,800
15,830,800
13,810,900
1
4,090,100
2,862,300
2,189,300
1,909,900
2
4,090,100
2,862,300
2,189,300
1,909,900
3
4,090,100
2,862,300
2,189,300
1,909,900
1
4,090,100
2,862,300
2,189,300
1,909,900
2
4,090,100
2,862,300
2,189,300
1,909,900
3
4,090,100
2,862,300
2,189,300
1,909,900
1
4,090,100
2,862,300
2,189,300
1,909,900
2
4,090,100
2,862,300
2,189,300
1,909,900
3
4,090,100
2,862,300
2,189,300
1,909,900
1
10,142,700
7,097,900
5,428,900
4,736,200
2
10,142,700
7,097,900
5,428,900
4,736,200
3
10,142,700
7,097,900
5,428,900
4,736,200
1
10,142,700
7,097,900
5,428,900
4,736,200
2
10,142,700
7,097,900
5,428,900
4,736,200
3
10,142,700
7,097,900
5,428,900
4,736,200
1
10,142,700
7,097,900
5,428,900
4,736,200
2
10,142,700
7,097,900
5,428,900
4,736,200
3
10,142,700
7,097,900
5,428,900
4,736,200
1
12,153,800
8,505,300
6,505,400
5,675,300
2
12,153,800
8,505,300
6,505,400
5,675,300
3
12,153,800
8,505,300
6,505,400
5,675,300
1
12,153,800
8,505,300
6,505,400
5,675,300
2
12,153,800
8,505,300
6,505,400
5,675,300
3
12,153,800
8,505,300
6,505,400
5,675,300
1
12,153,800
8,505,300
6,505,400
5,675,300
2
12,153,800
8,505,300
6,505,400
5,675,300
3
12,153,800
8,505,300
6,505,400
5,675,300
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
1
8,041,400
7,237,200
6,433,000
5,629,000
2
8,041,400
7,237,200
6,433,000
5,629,000
3
8,041,400
7,237,200
6,433,000
5,629,000
6,033,600
4,032,600
3,990,800
3,876,400
6,033,600
4,032,600
3,990,800
3,876,400
6,033,600
4,032,600
3,990,800
3,876,400
Q-5-44-0
10,181,700
5,499,000
5,442,000
5,286,000
Z-3-17-0
Z-3-16-0
2,231,300
1,865,900
905,000
1,679,300
651,200
1,492,700
618,300
1,306,200
H-3-13-0
548,000
360,900
357,200
339,000
H-2-36-0
J-3-15-0
B-3-11-0
4,410,000
1,171,000
2,943,200
3,780,000
771,200
2,132,200
3,465,000
763,200
1,534,400
3,150,000
724,600
1,457,000
- 1065 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
3,362,400
3,362,400
3,362,400
3,362,400
3,362,400
3,362,400
3,362,400
3,362,400
3,362,400
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
6,402,500
2,173,200
2,173,200
2,173,200
2,173,200
2,173,200
2,173,200
2,173,200
2,173,200
2,173,200
11,554,200
11,554,200
11,554,200
11,554,200
11,554,200
11,554,200
11,554,200
11,554,200
11,554,200
4,426,200
4,426,200
4,426,200
4,426,200
4,426,200
4,426,200
4,426,200
4,426,200
4,426,200
16,143,200
16,143,200
16,143,200
16,143,200
16,143,200
16,143,200
16,143,200
16,143,200
16,143,200
B
SWASTA
3,234,400
3,234,400
3,234,400
3,234,400
3,234,400
3,234,400
3,234,400
3,234,400
3,234,400
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
5,974,000
2,027,800
2,027,800
2,027,800
2,027,800
2,027,800
2,027,800
2,027,800
2,027,800
2,027,800
8,085,600
8,085,600
8,085,600
8,085,600
8,085,600
8,085,600
8,085,600
8,085,600
8,085,600
4,130,000
4,130,000
4,130,000
4,130,000
4,130,000
4,130,000
4,130,000
4,130,000
4,130,000
15,528,600
15,528,600
15,528,600
15,528,600
15,528,600
15,528,600
15,528,600
15,528,600
15,528,600
C
SWASTA
2,999,600
2,999,600
2,999,600
2,999,600
2,999,600
2,999,600
2,999,600
2,999,600
2,999,600
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
5,711,500
1,744,800
1,744,800
1,744,800
1,744,800
1,744,800
1,744,800
1,744,800
1,744,800
1,744,800
6,957,500
6,957,500
6,957,500
6,957,500
6,957,500
6,957,500
6,957,500
6,957,500
6,957,500
3,553,700
3,553,700
3,553,700
3,553,700
3,553,700
3,553,700
3,553,700
3,553,700
3,553,700
12,961,100
12,961,100
12,961,100
12,961,100
12,961,100
12,961,100
12,961,100
12,961,100
12,961,100
D
SWASTA
2,616,800
2,616,800
2,616,800
2,616,800
2,616,800
2,616,800
2,616,800
2,616,800
2,616,800
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
5,979,300
1,691,300
1,691,300
1,691,300
1,691,300
1,691,300
1,691,300
1,691,300
1,691,300
1,691,300
6,069,600
6,069,600
6,069,600
6,069,600
6,069,600
6,069,600
6,069,600
6,069,600
6,069,600
3,444,700
3,444,700
3,444,700
3,444,700
3,444,700
3,444,700
3,444,700
3,444,700
3,444,700
12,563,600
12,563,600
12,563,600
12,563,600
12,563,600
12,563,600
12,563,600
12,563,600
12,563,600
- 1066 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
17,156,100
17,156,100
17,156,100
17,156,100
17,156,100
17,156,100
17,156,100
17,156,100
17,156,100
17,446,600
17,446,600
17,446,600
17,446,600
17,446,600
17,446,600
17,446,600
17,446,600
17,446,600
11,413,400
11,413,400
11,413,400
11,413,400
11,413,400
11,413,400
11,413,400
11,413,400
11,413,400
26,983,900
26,983,900
26,983,900
26,983,900
26,983,900
26,983,900
26,983,900
26,983,900
26,983,900
106,480,000
106,480,000
106,480,000
106,480,000
106,480,000
106,480,000
106,480,000
106,480,000
106,480,000
13,492,000
13,492,000
13,492,000
13,492,000
13,492,000
13,492,000
13,492,000
13,492,000
13,492,000
14,867,100
14,867,100
14,867,100
14,867,100
14,867,100
14,867,100
14,867,100
14,867,100
14,867,100
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
B
SWASTA
8,696,800
8,696,800
8,696,800
8,696,800
8,696,800
8,696,800
8,696,800
8,696,800
8,696,800
7,477,500
7,477,500
7,477,500
7,477,500
7,477,500
7,477,500
7,477,500
7,477,500
7,477,500
7,987,100
7,987,100
7,987,100
7,987,100
7,987,100
7,987,100
7,987,100
7,987,100
7,987,100
11,565,100
11,565,100
11,565,100
11,565,100
11,565,100
11,565,100
11,565,100
11,565,100
11,565,100
99,865,400
99,865,400
99,865,400
99,865,400
99,865,400
99,865,400
99,865,400
99,865,400
99,865,400
5,782,600
5,782,600
5,782,600
5,782,600
5,782,600
5,782,600
5,782,600
5,782,600
5,782,600
10,725,800
10,725,800
10,725,800
10,725,800
10,725,800
10,725,800
10,725,800
10,725,800
10,725,800
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
C
SWASTA
5,442,400
5,442,400
5,442,400
5,442,400
5,442,400
5,442,400
5,442,400
5,442,400
5,442,400
5,719,200
5,719,200
5,719,200
5,719,200
5,719,200
5,719,200
5,719,200
5,719,200
5,719,200
6,109,000
6,109,000
6,109,000
6,109,000
6,109,000
6,109,000
6,109,000
6,109,000
6,109,000
8,845,700
8,845,700
8,845,700
8,845,700
8,845,700
8,845,700
8,845,700
8,845,700
8,845,700
56,993,500
56,993,500
56,993,500
56,993,500
56,993,500
56,993,500
56,993,500
56,993,500
56,993,500
4,422,900
4,422,900
4,422,900
4,422,900
4,422,900
4,422,900
4,422,900
4,422,900
4,422,900
7,957,600
7,957,600
7,957,600
7,957,600
7,957,600
7,957,600
7,957,600
7,957,600
7,957,600
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
D
SWASTA
1,612,100
1,612,100
1,612,100
1,612,100
1,612,100
1,612,100
1,612,100
1,612,100
1,612,100
4,989,500
4,989,500
4,989,500
4,989,500
4,989,500
4,989,500
4,989,500
4,989,500
4,989,500
5,329,500
5,329,500
5,329,500
5,329,500
5,329,500
5,329,500
5,329,500
5,329,500
5,329,500
7,717,000
7,717,000
7,717,000
7,717,000
7,717,000
7,717,000
7,717,000
7,717,000
7,717,000
49,721,500
49,721,500
49,721,500
49,721,500
49,721,500
49,721,500
49,721,500
49,721,500
49,721,500
3,858,500
3,858,500
3,858,500
3,858,500
3,858,500
3,858,500
3,858,500
3,858,500
3,858,500
6,942,300
6,942,300
6,942,300
6,942,300
6,942,300
6,942,300
6,942,300
6,942,300
6,942,300
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
- 1067 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
A
SWASTA
8,309,400
8,309,400
8,309,400
8,309,400
8,309,400
8,309,400
8,309,400
8,309,400
8,309,400
49,741,000
49,741,000
49,741,000
49,741,000
49,741,000
49,741,000
49,741,000
49,741,000
49,741,000
4,212,900
4,212,900
4,212,900
4,212,900
4,212,900
4,212,900
4,212,900
4,212,900
4,212,900
10,447,000
10,447,000
10,447,000
10,447,000
10,447,000
10,447,000
10,447,000
10,447,000
10,447,000
12,518,500
12,518,500
12,518,500
12,518,500
12,518,500
12,518,500
12,518,500
12,518,500
12,518,500
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
8,282,600
6,334,400
6,334,400
6,334,400
B
SWASTA
6,396,400
6,396,400
6,396,400
6,396,400
6,396,400
6,396,400
6,396,400
6,396,400
6,396,400
21,977,900
21,977,900
21,977,900
21,977,900
21,977,900
21,977,900
21,977,900
21,977,900
21,977,900
2,948,200
2,948,200
2,948,200
2,948,200
2,948,200
2,948,200
2,948,200
2,948,200
2,948,200
7,310,800
7,310,800
7,310,800
7,310,800
7,310,800
7,310,800
7,310,800
7,310,800
7,310,800
8,760,500
8,760,500
8,760,500
8,760,500
8,760,500
8,760,500
8,760,500
8,760,500
8,760,500
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
7,454,300
4,232,800
4,232,800
4,232,800
C
SWASTA
4,002,800
4,002,800
4,002,800
4,002,800
4,002,800
4,002,800
4,002,800
4,002,800
4,002,800
16,305,700
16,305,700
16,305,700
16,305,700
16,305,700
16,305,700
16,305,700
16,305,700
16,305,700
2,254,900
2,254,900
2,254,900
2,254,900
2,254,900
2,254,900
2,254,900
2,254,900
2,254,900
5,591,800
5,591,800
5,591,800
5,591,800
5,591,800
5,591,800
5,591,800
5,591,800
5,591,800
6,700,500
6,700,500
6,700,500
6,700,500
6,700,500
6,700,500
6,700,500
6,700,500
6,700,500
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
6,626,000
4,188,800
4,188,800
4,188,800
D
SWASTA
3,492,100
3,492,100
3,492,100
3,492,100
3,492,100
3,492,100
3,492,100
3,492,100
3,492,100
14,225,200
14,225,200
14,225,200
14,225,200
14,225,200
14,225,200
14,225,200
14,225,200
14,225,200
1,967,200
1,967,200
1,967,200
1,967,200
1,967,200
1,967,200
1,967,200
1,967,200
1,967,200
4,878,300
4,878,300
4,878,300
4,878,300
4,878,300
4,878,300
4,878,300
4,878,300
4,878,300
5,845,600
5,845,600
5,845,600
5,845,600
5,845,600
5,845,600
5,845,600
5,845,600
5,845,600
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
5,797,800
4,070,000
4,070,000
4,070,000
Q-5-44-0
10,689,300
5,772,000
5,712,000
5,550,000
Z-3-17-0
Z-3-16-0
2,342,700
1,959,200
950,100
1,763,300
683,900
1,567,400
649,200
1,371,500
H-3-13-0
575,400
378,900
375,000
356,000
H-2-36-0
J-3-15-0
B-3-11-0
4,630,500
1,229,600
3,090,400
3,969,000
809,800
2,238,800
3,638,300
801,200
1,611,200
3,307,500
760,800
1,529,800
I-1-06-I
I-1-06-II
I-1-06-III
- 1068 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
A
B
C
D
1
3,293,900
3,168,500
2,938,400
2,563,500
2
3,293,900
3,168,500
2,938,400
2,563,500
3
3,293,900
3,168,500
2,938,400
2,563,500
1
3,293,900
3,168,500
2,938,400
2,563,500
2
3,293,900
3,168,500
2,938,400
2,563,500
3
3,293,900
3,168,500
2,938,400
2,563,500
1
3,293,900
3,168,500
2,938,400
2,563,500
2
3,293,900
3,168,500
2,938,400
2,563,500
3
3,293,900
3,168,500
2,938,400
2,563,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
6,272,000
5,852,200
5,595,000
5,857,500
2
6,272,000
5,852,200
5,595,000
5,857,500
3
6,272,000
5,852,200
5,595,000
5,857,500
1
2,128,900
1,986,400
1,709,300
1,656,800
2
2,128,900
1,986,400
1,709,300
1,656,800
3
2,128,900
1,986,400
1,709,300
1,656,800
1
2,128,900
1,986,400
1,709,300
1,656,800
2
2,128,900
1,986,400
1,709,300
1,656,800
3
2,128,900
1,986,400
1,709,300
1,656,800
1
2,128,900
1,986,400
1,709,300
1,656,800
2
2,128,900
1,986,400
1,709,300
1,656,800
3
2,128,900
1,986,400
1,709,300
1,656,800
1
11,318,600
7,920,800
6,815,700
5,945,900
2
11,318,600
7,920,800
6,815,700
5,945,900
3
11,318,600
7,920,800
6,815,700
5,945,900
1
11,318,600
7,920,800
6,815,700
5,945,900
2
11,318,600
7,920,800
6,815,700
5,945,900
3
11,318,600
7,920,800
6,815,700
5,945,900
1
11,318,600
7,920,800
6,815,700
5,945,900
2
11,318,600
7,920,800
6,815,700
5,945,900
3
11,318,600
7,920,800
6,815,700
5,945,900
1
4,336,000
4,045,800
3,481,300
3,374,500
2
4,336,000
4,045,800
3,481,300
3,374,500
3
4,336,000
4,045,800
3,481,300
3,374,500
1
4,336,000
4,045,800
3,481,300
3,374,500
2
4,336,000
4,045,800
3,481,300
3,374,500
3
4,336,000
4,045,800
3,481,300
3,374,500
1
4,336,000
4,045,800
3,481,300
3,374,500
2
4,336,000
4,045,800
3,481,300
3,374,500
3
4,336,000
4,045,800
3,481,300
3,374,500
1
15,814,100
15,212,100
12,696,800
12,307,500
2
15,814,100
15,212,100
12,696,800
12,307,500
3
15,814,100
15,212,100
12,696,800
12,307,500
1
15,814,100
15,212,100
12,696,800
12,307,500
2
15,814,100
15,212,100
12,696,800
12,307,500
3
15,814,100
15,212,100
12,696,800
12,307,500
1
15,814,100
15,212,100
12,696,800
12,307,500
2
15,814,100
15,212,100
12,696,800
12,307,500
3
15,814,100
15,212,100
12,696,800
12,307,500
- 1069 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
A
B
C
D
1
16,806,300
8,519,500
5,331,500
1,579,200
2
16,806,300
8,519,500
5,331,500
1,579,200
3
16,806,300
8,519,500
5,331,500
1,579,200
1
16,806,300
8,519,500
5,331,500
1,579,200
2
16,806,300
8,519,500
5,331,500
1,579,200
3
16,806,300
8,519,500
5,331,500
1,579,200
1
16,806,300
8,519,500
5,331,500
1,579,200
2
16,806,300
8,519,500
5,331,500
1,579,200
3
16,806,300
8,519,500
5,331,500
1,579,200
1
17,090,900
7,325,000
5,602,600
4,887,800
2
17,090,900
7,325,000
5,602,600
4,887,800
3
17,090,900
7,325,000
5,602,600
4,887,800
1
17,090,900
7,325,000
5,602,600
4,887,800
2
17,090,900
7,325,000
5,602,600
4,887,800
3
17,090,900
7,325,000
5,602,600
4,887,800
1
17,090,900
7,325,000
5,602,600
4,887,800
2
17,090,900
7,325,000
5,602,600
4,887,800
3
17,090,900
7,325,000
5,602,600
4,887,800
1
11,180,700
7,824,300
5,984,500
5,220,900
2
11,180,700
7,824,300
5,984,500
5,220,900
3
11,180,700
7,824,300
5,984,500
5,220,900
1
11,180,700
7,824,300
5,984,500
5,220,900
2
11,180,700
7,824,300
5,984,500
5,220,900
3
11,180,700
7,824,300
5,984,500
5,220,900
1
11,180,700
7,824,300
5,984,500
5,220,900
2
11,180,700
7,824,300
5,984,500
5,220,900
3
11,180,700
7,824,300
5,984,500
5,220,900
1
26,433,700
11,329,300
8,665,300
7,559,700
2
26,433,700
11,329,300
8,665,300
7,559,700
3
26,433,700
11,329,300
8,665,300
7,559,700
1
26,433,700
11,329,300
8,665,300
7,559,700
2
26,433,700
11,329,300
8,665,300
7,559,700
3
26,433,700
11,329,300
8,665,300
7,559,700
1
26,433,700
11,329,300
8,665,300
7,559,700
2
26,433,700
11,329,300
8,665,300
7,559,700
3
26,433,700
11,329,300
8,665,300
7,559,700
1
104,309,000
97,829,600
55,831,500
48,707,500
2
104,309,000
97,829,600
55,831,500
48,707,500
3
104,309,000
97,829,600
55,831,500
48,707,500
1
104,309,000
97,829,600
55,831,500
48,707,500
2
104,309,000
97,829,600
55,831,500
48,707,500
3
104,309,000
97,829,600
55,831,500
48,707,500
1
104,309,000
97,829,600
55,831,500
48,707,500
2
104,309,000
97,829,600
55,831,500
48,707,500
3
104,309,000
97,829,600
55,831,500
48,707,500
1
13,216,900
5,664,700
4,332,700
3,779,900
2
13,216,900
5,664,700
4,332,700
3,779,900
3
13,216,900
5,664,700
4,332,700
3,779,900
1
13,216,900
5,664,700
4,332,700
3,779,900
2
13,216,900
5,664,700
4,332,700
3,779,900
3
13,216,900
5,664,700
4,332,700
3,779,900
1
13,216,900
5,664,700
4,332,700
3,779,900
2
13,216,900
5,664,700
4,332,700
3,779,900
3
13,216,900
5,664,700
4,332,700
3,779,900
1
14,564,000
10,507,100
7,795,400
6,800,700
2
14,564,000
10,507,100
7,795,400
6,800,700
3
14,564,000
10,507,100
7,795,400
6,800,700
1
14,564,000
10,507,100
7,795,400
6,800,700
2
14,564,000
10,507,100
7,795,400
6,800,700
3
14,564,000
10,507,100
7,795,400
6,800,700
1
14,564,000
10,507,100
7,795,400
6,800,700
2
14,564,000
10,507,100
7,795,400
6,800,700
3
14,564,000
10,507,100
7,795,400
6,800,700
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
- 1070 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
I-1-06-I
I-1-06-II
I-1-06-III
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
A
B
C
D
1
8,140,000
6,266,000
3,921,200
3,420,900
2
8,140,000
6,266,000
3,921,200
3,420,900
3
8,140,000
6,266,000
3,921,200
3,420,900
1
8,140,000
6,266,000
3,921,200
3,420,900
2
8,140,000
6,266,000
3,921,200
3,420,900
3
8,140,000
6,266,000
3,921,200
3,420,900
1
8,140,000
6,266,000
3,921,200
3,420,900
2
8,140,000
6,266,000
3,921,200
3,420,900
3
8,140,000
6,266,000
3,921,200
3,420,900
1
48,726,800
21,529,800
15,973,300
13,935,200
2
48,726,800
21,529,800
15,973,300
13,935,200
3
48,726,800
21,529,800
15,973,300
13,935,200
1
48,726,800
21,529,800
15,973,300
13,935,200
2
48,726,800
21,529,800
15,973,300
13,935,200
3
48,726,800
21,529,800
15,973,300
13,935,200
1
48,726,800
21,529,800
15,973,300
13,935,200
2
48,726,800
21,529,800
15,973,300
13,935,200
3
48,726,800
21,529,800
15,973,300
13,935,200
1
4,127,000
2,888,100
2,209,000
1,927,100
2
4,127,000
2,888,100
2,209,000
1,927,100
3
4,127,000
2,888,100
2,209,000
1,927,100
1
4,127,000
2,888,100
2,209,000
1,927,100
2
4,127,000
2,888,100
2,209,000
1,927,100
3
4,127,000
2,888,100
2,209,000
1,927,100
1
4,127,000
2,888,100
2,209,000
1,927,100
2
4,127,000
2,888,100
2,209,000
1,927,100
3
4,127,000
2,888,100
2,209,000
1,927,100
1
10,234,000
7,161,800
5,477,800
4,778,800
2
10,234,000
7,161,800
5,477,800
4,778,800
3
10,234,000
7,161,800
5,477,800
4,778,800
1
10,234,000
7,161,800
5,477,800
4,778,800
2
10,234,000
7,161,800
5,477,800
4,778,800
3
10,234,000
7,161,800
5,477,800
4,778,800
1
10,234,000
7,161,800
5,477,800
4,778,800
2
10,234,000
7,161,800
5,477,800
4,778,800
3
10,234,000
7,161,800
5,477,800
4,778,800
1
12,263,200
8,581,900
6,563,900
5,726,400
2
12,263,200
8,581,900
6,563,900
5,726,400
3
12,263,200
8,581,900
6,563,900
5,726,400
1
12,263,200
8,581,900
6,563,900
5,726,400
2
12,263,200
8,581,900
6,563,900
5,726,400
3
12,263,200
8,581,900
6,563,900
5,726,400
1
12,263,200
8,581,900
6,563,900
5,726,400
2
12,263,200
8,581,900
6,563,900
5,726,400
3
12,263,200
8,581,900
6,563,900
5,726,400
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
1
8,113,700
7,302,300
6,490,900
5,679,600
2
8,113,700
7,302,300
6,490,900
5,679,600
3
8,113,700
7,302,300
6,490,900
5,679,600
6,088,000
4,067,800
4,026,000
3,911,600
6,088,000
4,067,800
4,026,000
3,911,600
6,088,000
4,067,800
4,026,000
3,911,600
Q-5-44-0
10,273,500
5,547,000
5,490,000
5,334,000
Z-3-17-0
Z-3-16-0
2,251,200
1,882,700
913,100
1,694,400
657,200
1,506,200
623,900
1,317,900
H-3-13-0
552,900
364,100
360,300
342,200
H-2-36-0
J-3-15-0
B-3-11-0
4,449,700
1,181,600
2,969,800
3,814,000
778,200
2,151,400
3,496,200
770,000
1,548,200
3,178,400
731,200
1,470,000
- 1071 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
3,392,600
3,392,600
3,392,600
3,392,600
3,392,600
3,392,600
3,392,600
3,392,600
3,392,600
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
6,460,100
2,192,800
2,192,800
2,192,800
2,192,800
2,192,800
2,192,800
2,192,800
2,192,800
2,192,800
11,658,200
11,658,200
11,658,200
11,658,200
11,658,200
11,658,200
11,658,200
11,658,200
11,658,200
4,466,000
4,466,000
4,466,000
4,466,000
4,466,000
4,466,000
4,466,000
4,466,000
4,466,000
16,288,500
16,288,500
16,288,500
16,288,500
16,288,500
16,288,500
16,288,500
16,288,500
16,288,500
B
SWASTA
3,263,500
3,263,500
3,263,500
3,263,500
3,263,500
3,263,500
3,263,500
3,263,500
3,263,500
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
6,027,800
2,046,000
2,046,000
2,046,000
2,046,000
2,046,000
2,046,000
2,046,000
2,046,000
2,046,000
8,158,400
8,158,400
8,158,400
8,158,400
8,158,400
8,158,400
8,158,400
8,158,400
8,158,400
4,167,100
4,167,100
4,167,100
4,167,100
4,167,100
4,167,100
4,167,100
4,167,100
4,167,100
15,668,400
15,668,400
15,668,400
15,668,400
15,668,400
15,668,400
15,668,400
15,668,400
15,668,400
C
SWASTA
3,026,600
3,026,600
3,026,600
3,026,600
3,026,600
3,026,600
3,026,600
3,026,600
3,026,600
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
5,763,000
1,760,500
1,760,500
1,760,500
1,760,500
1,760,500
1,760,500
1,760,500
1,760,500
1,760,500
7,020,000
7,020,000
7,020,000
7,020,000
7,020,000
7,020,000
7,020,000
7,020,000
7,020,000
3,585,700
3,585,700
3,585,700
3,585,700
3,585,700
3,585,700
3,585,700
3,585,700
3,585,700
13,077,700
13,077,700
13,077,700
13,077,700
13,077,700
13,077,700
13,077,700
13,077,700
13,077,700
D
SWASTA
2,640,400
2,640,400
2,640,400
2,640,400
2,640,400
2,640,400
2,640,400
2,640,400
2,640,400
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
6,033,000
1,706,500
1,706,500
1,706,500
1,706,500
1,706,500
1,706,500
1,706,500
1,706,500
1,706,500
6,124,300
6,124,300
6,124,300
6,124,300
6,124,300
6,124,300
6,124,300
6,124,300
6,124,300
3,475,700
3,475,700
3,475,700
3,475,700
3,475,700
3,475,700
3,475,700
3,475,700
3,475,700
12,676,700
12,676,700
12,676,700
12,676,700
12,676,700
12,676,700
12,676,700
12,676,700
12,676,700
- 1072 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
17,310,500
17,310,500
17,310,500
17,310,500
17,310,500
17,310,500
17,310,500
17,310,500
17,310,500
17,603,600
17,603,600
17,603,600
17,603,600
17,603,600
17,603,600
17,603,600
17,603,600
17,603,600
11,516,100
11,516,100
11,516,100
11,516,100
11,516,100
11,516,100
11,516,100
11,516,100
11,516,100
27,226,700
27,226,700
27,226,700
27,226,700
27,226,700
27,226,700
27,226,700
27,226,700
27,226,700
107,438,500
107,438,500
107,438,500
107,438,500
107,438,500
107,438,500
107,438,500
107,438,500
107,438,500
13,613,400
13,613,400
13,613,400
13,613,400
13,613,400
13,613,400
13,613,400
13,613,400
13,613,400
15,000,900
15,000,900
15,000,900
15,000,900
15,000,900
15,000,900
15,000,900
15,000,900
15,000,900
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
B
SWASTA
8,775,100
8,775,100
8,775,100
8,775,100
8,775,100
8,775,100
8,775,100
8,775,100
8,775,100
7,544,800
7,544,800
7,544,800
7,544,800
7,544,800
7,544,800
7,544,800
7,544,800
7,544,800
8,059,000
8,059,000
8,059,000
8,059,000
8,059,000
8,059,000
8,059,000
8,059,000
8,059,000
11,669,200
11,669,200
11,669,200
11,669,200
11,669,200
11,669,200
11,669,200
11,669,200
11,669,200
100,764,300
100,764,300
100,764,300
100,764,300
100,764,300
100,764,300
100,764,300
100,764,300
100,764,300
5,834,600
5,834,600
5,834,600
5,834,600
5,834,600
5,834,600
5,834,600
5,834,600
5,834,600
10,822,300
10,822,300
10,822,300
10,822,300
10,822,300
10,822,300
10,822,300
10,822,300
10,822,300
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
C
SWASTA
5,491,400
5,491,400
5,491,400
5,491,400
5,491,400
5,491,400
5,491,400
5,491,400
5,491,400
5,770,700
5,770,700
5,770,700
5,770,700
5,770,700
5,770,700
5,770,700
5,770,700
5,770,700
6,164,000
6,164,000
6,164,000
6,164,000
6,164,000
6,164,000
6,164,000
6,164,000
6,164,000
8,925,300
8,925,300
8,925,300
8,925,300
8,925,300
8,925,300
8,925,300
8,925,300
8,925,300
57,506,500
57,506,500
57,506,500
57,506,500
57,506,500
57,506,500
57,506,500
57,506,500
57,506,500
4,462,700
4,462,700
4,462,700
4,462,700
4,462,700
4,462,700
4,462,700
4,462,700
4,462,700
8,029,200
8,029,200
8,029,200
8,029,200
8,029,200
8,029,200
8,029,200
8,029,200
8,029,200
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
D
SWASTA
1,626,600
1,626,600
1,626,600
1,626,600
1,626,600
1,626,600
1,626,600
1,626,600
1,626,600
5,034,400
5,034,400
5,034,400
5,034,400
5,034,400
5,034,400
5,034,400
5,034,400
5,034,400
5,377,500
5,377,500
5,377,500
5,377,500
5,377,500
5,377,500
5,377,500
5,377,500
5,377,500
7,786,400
7,786,400
7,786,400
7,786,400
7,786,400
7,786,400
7,786,400
7,786,400
7,786,400
50,169,000
50,169,000
50,169,000
50,169,000
50,169,000
50,169,000
50,169,000
50,169,000
50,169,000
3,893,200
3,893,200
3,893,200
3,893,200
3,893,200
3,893,200
3,893,200
3,893,200
3,893,200
7,004,700
7,004,700
7,004,700
7,004,700
7,004,700
7,004,700
7,004,700
7,004,700
7,004,700
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
- 1073 -

REGIONAL 2
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
A
SWASTA
8,384,200
8,384,200
8,384,200
8,384,200
8,384,200
8,384,200
8,384,200
8,384,200
8,384,200
50,188,600
50,188,600
50,188,600
50,188,600
50,188,600
50,188,600
50,188,600
50,188,600
50,188,600
4,250,800
4,250,800
4,250,800
4,250,800
4,250,800
4,250,800
4,250,800
4,250,800
4,250,800
10,541,000
10,541,000
10,541,000
10,541,000
10,541,000
10,541,000
10,541,000
10,541,000
10,541,000
12,631,100
12,631,100
12,631,100
12,631,100
12,631,100
12,631,100
12,631,100
12,631,100
12,631,100
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
8,357,200
6,392,000
6,392,000
6,392,000
B
SWASTA
6,454,000
6,454,000
6,454,000
6,454,000
6,454,000
6,454,000
6,454,000
6,454,000
6,454,000
22,175,700
22,175,700
22,175,700
22,175,700
22,175,700
22,175,700
22,175,700
22,175,700
22,175,700
2,974,700
2,974,700
2,974,700
2,974,700
2,974,700
2,974,700
2,974,700
2,974,700
2,974,700
7,376,600
7,376,600
7,376,600
7,376,600
7,376,600
7,376,600
7,376,600
7,376,600
7,376,600
8,839,300
8,839,300
8,839,300
8,839,300
8,839,300
8,839,300
8,839,300
8,839,300
8,839,300
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
7,521,400
4,272,400
4,272,400
4,272,400
C
SWASTA
4,038,900
4,038,900
4,038,900
4,038,900
4,038,900
4,038,900
4,038,900
4,038,900
4,038,900
16,452,500
16,452,500
16,452,500
16,452,500
16,452,500
16,452,500
16,452,500
16,452,500
16,452,500
2,275,200
2,275,200
2,275,200
2,275,200
2,275,200
2,275,200
2,275,200
2,275,200
2,275,200
5,642,100
5,642,100
5,642,100
5,642,100
5,642,100
5,642,100
5,642,100
5,642,100
5,642,100
6,760,800
6,760,800
6,760,800
6,760,800
6,760,800
6,760,800
6,760,800
6,760,800
6,760,800
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
6,685,700
4,226,200
4,226,200
4,226,200
D
SWASTA
3,523,500
3,523,500
3,523,500
3,523,500
3,523,500
3,523,500
3,523,500
3,523,500
3,523,500
14,353,200
14,353,200
14,353,200
14,353,200
14,353,200
14,353,200
14,353,200
14,353,200
14,353,200
1,984,900
1,984,900
1,984,900
1,984,900
1,984,900
1,984,900
1,984,900
1,984,900
1,984,900
4,922,200
4,922,200
4,922,200
4,922,200
4,922,200
4,922,200
4,922,200
4,922,200
4,922,200
5,898,200
5,898,200
5,898,200
5,898,200
5,898,200
5,898,200
5,898,200
5,898,200
5,898,200
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
5,850,000
4,107,400
4,107,400
4,107,400
Q-5-44-0
10,786,500
5,826,000
5,763,000
5,601,000
Z-3-17-0
Z-3-16-0
2,363,900
1,976,900
958,700
1,779,200
690,000
1,581,500
655,100
1,383,900
H-3-13-0
580,500
382,400
378,300
359,300
H-2-36-0
J-3-15-0
B-3-11-0
4,672,200
1,240,600
3,118,200
4,004,700
817,000
2,258,800
3,671,000
808,400
1,625,600
3,337,300
767,600
1,543,600
I-1-06-I
I-1-06-II
I-1-06-III
- 1074 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
A
B
C
D
1
3,303,700
3,177,800
2,947,100
2,571,100
2
3,303,700
3,177,800
2,947,100
2,571,100
3
3,303,700
3,177,800
2,947,100
2,571,100
1
3,303,700
3,177,800
2,947,100
2,571,100
2
3,303,700
3,177,800
2,947,100
2,571,100
3
3,303,700
3,177,800
2,947,100
2,571,100
1
3,303,700
3,177,800
2,947,100
2,571,100
2
3,303,700
3,177,800
2,947,100
2,571,100
3
3,303,700
3,177,800
2,947,100
2,571,100
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
6,290,600
5,869,600
5,611,800
5,874,900
2
6,290,600
5,869,600
5,611,800
5,874,900
3
6,290,600
5,869,600
5,611,800
5,874,900
1
2,135,200
1,992,300
1,714,300
1,661,800
2
2,135,200
1,992,300
1,714,300
1,661,800
3
2,135,200
1,992,300
1,714,300
1,661,800
1
2,135,200
1,992,300
1,714,300
1,661,800
2
2,135,200
1,992,300
1,714,300
1,661,800
3
2,135,200
1,992,300
1,714,300
1,661,800
1
2,135,200
1,992,300
1,714,300
1,661,800
2
2,135,200
1,992,300
1,714,300
1,661,800
3
2,135,200
1,992,300
1,714,300
1,661,800
1
11,352,200
7,944,400
6,836,000
5,963,600
2
11,352,200
7,944,400
6,836,000
5,963,600
3
11,352,200
7,944,400
6,836,000
5,963,600
1
11,352,200
7,944,400
6,836,000
5,963,600
2
11,352,200
7,944,400
6,836,000
5,963,600
3
11,352,200
7,944,400
6,836,000
5,963,600
1
11,352,200
7,944,400
6,836,000
5,963,600
2
11,352,200
7,944,400
6,836,000
5,963,600
3
11,352,200
7,944,400
6,836,000
5,963,600
1
4,348,900
4,057,800
3,491,600
3,384,500
2
4,348,900
4,057,800
3,491,600
3,384,500
3
4,348,900
4,057,800
3,491,600
3,384,500
1
4,348,900
4,057,800
3,491,600
3,384,500
2
4,348,900
4,057,800
3,491,600
3,384,500
3
4,348,900
4,057,800
3,491,600
3,384,500
1
4,348,900
4,057,800
3,491,600
3,384,500
2
4,348,900
4,057,800
3,491,600
3,384,500
3
4,348,900
4,057,800
3,491,600
3,384,500
1
15,861,100
15,257,300
12,734,600
12,344,100
2
15,861,100
15,257,300
12,734,600
12,344,100
3
15,861,100
15,257,300
12,734,600
12,344,100
1
15,861,100
15,257,300
12,734,600
12,344,100
2
15,861,100
15,257,300
12,734,600
12,344,100
3
15,861,100
15,257,300
12,734,600
12,344,100
1
15,861,100
15,257,300
12,734,600
12,344,100
2
15,861,100
15,257,300
12,734,600
12,344,100
3
15,861,100
15,257,300
12,734,600
12,344,100
- 1075 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
A
B
C
D
1
16,856,300
8,544,800
5,347,300
1,583,900
2
16,856,300
8,544,800
5,347,300
1,583,900
3
16,856,300
8,544,800
5,347,300
1,583,900
1
16,856,300
8,544,800
5,347,300
1,583,900
2
16,856,300
8,544,800
5,347,300
1,583,900
3
16,856,300
8,544,800
5,347,300
1,583,900
1
16,856,300
8,544,800
5,347,300
1,583,900
2
16,856,300
8,544,800
5,347,300
1,583,900
3
16,856,300
8,544,800
5,347,300
1,583,900
1
17,141,700
7,346,800
5,619,300
4,902,300
2
17,141,700
7,346,800
5,619,300
4,902,300
3
17,141,700
7,346,800
5,619,300
4,902,300
1
17,141,700
7,346,800
5,619,300
4,902,300
2
17,141,700
7,346,800
5,619,300
4,902,300
3
17,141,700
7,346,800
5,619,300
4,902,300
1
17,141,700
7,346,800
5,619,300
4,902,300
2
17,141,700
7,346,800
5,619,300
4,902,300
3
17,141,700
7,346,800
5,619,300
4,902,300
1
11,213,900
7,847,500
6,002,300
5,236,400
2
11,213,900
7,847,500
6,002,300
5,236,400
3
11,213,900
7,847,500
6,002,300
5,236,400
1
11,213,900
7,847,500
6,002,300
5,236,400
2
11,213,900
7,847,500
6,002,300
5,236,400
3
11,213,900
7,847,500
6,002,300
5,236,400
1
11,213,900
7,847,500
6,002,300
5,236,400
2
11,213,900
7,847,500
6,002,300
5,236,400
3
11,213,900
7,847,500
6,002,300
5,236,400
1
26,512,300
11,363,000
8,691,100
7,582,100
2
26,512,300
11,363,000
8,691,100
7,582,100
3
26,512,300
11,363,000
8,691,100
7,582,100
1
26,512,300
11,363,000
8,691,100
7,582,100
2
26,512,300
11,363,000
8,691,100
7,582,100
3
26,512,300
11,363,000
8,691,100
7,582,100
1
26,512,300
11,363,000
8,691,100
7,582,100
2
26,512,300
11,363,000
8,691,100
7,582,100
3
26,512,300
11,363,000
8,691,100
7,582,100
1
104,619,500
98,120,800
55,997,500
48,852,500
2
104,619,500
98,120,800
55,997,500
48,852,500
3
104,619,500
98,120,800
55,997,500
48,852,500
1
104,619,500
98,120,800
55,997,500
48,852,500
2
104,619,500
98,120,800
55,997,500
48,852,500
3
104,619,500
98,120,800
55,997,500
48,852,500
1
104,619,500
98,120,800
55,997,500
48,852,500
2
104,619,500
98,120,800
55,997,500
48,852,500
3
104,619,500
98,120,800
55,997,500
48,852,500
1
13,256,200
5,681,500
4,345,600
3,791,100
2
13,256,200
5,681,500
4,345,600
3,791,100
3
13,256,200
5,681,500
4,345,600
3,791,100
1
13,256,200
5,681,500
4,345,600
3,791,100
2
13,256,200
5,681,500
4,345,600
3,791,100
3
13,256,200
5,681,500
4,345,600
3,791,100
1
13,256,200
5,681,500
4,345,600
3,791,100
2
13,256,200
5,681,500
4,345,600
3,791,100
3
13,256,200
5,681,500
4,345,600
3,791,100
1
14,607,300
10,538,400
7,818,600
6,820,900
2
14,607,300
10,538,400
7,818,600
6,820,900
3
14,607,300
10,538,400
7,818,600
6,820,900
1
14,607,300
10,538,400
7,818,600
6,820,900
2
14,607,300
10,538,400
7,818,600
6,820,900
3
14,607,300
10,538,400
7,818,600
6,820,900
1
14,607,300
10,538,400
7,818,600
6,820,900
2
14,607,300
10,538,400
7,818,600
6,820,900
3
14,607,300
10,538,400
7,818,600
6,820,900
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
- 1076 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
I-1-06-I
I-1-06-II
I-1-06-III
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
A
B
C
D
1
8,164,200
6,284,600
3,932,900
3,431,100
2
8,164,200
6,284,600
3,932,900
3,431,100
3
8,164,200
6,284,600
3,932,900
3,431,100
1
8,164,200
6,284,600
3,932,900
3,431,100
2
8,164,200
6,284,600
3,932,900
3,431,100
3
8,164,200
6,284,600
3,932,900
3,431,100
1
8,164,200
6,284,600
3,932,900
3,431,100
2
8,164,200
6,284,600
3,932,900
3,431,100
3
8,164,200
6,284,600
3,932,900
3,431,100
1
48,871,700
21,593,800
16,020,800
13,976,600
2
48,871,700
21,593,800
16,020,800
13,976,600
3
48,871,700
21,593,800
16,020,800
13,976,600
1
48,871,700
21,593,800
16,020,800
13,976,600
2
48,871,700
21,593,800
16,020,800
13,976,600
3
48,871,700
21,593,800
16,020,800
13,976,600
1
48,871,700
21,593,800
16,020,800
13,976,600
2
48,871,700
21,593,800
16,020,800
13,976,600
3
48,871,700
21,593,800
16,020,800
13,976,600
1
4,139,200
2,896,600
2,215,500
1,932,800
2
4,139,200
2,896,600
2,215,500
1,932,800
3
4,139,200
2,896,600
2,215,500
1,932,800
1
4,139,200
2,896,600
2,215,500
1,932,800
2
4,139,200
2,896,600
2,215,500
1,932,800
3
4,139,200
2,896,600
2,215,500
1,932,800
1
4,139,200
2,896,600
2,215,500
1,932,800
2
4,139,200
2,896,600
2,215,500
1,932,800
3
4,139,200
2,896,600
2,215,500
1,932,800
1
10,264,400
7,183,100
5,494,000
4,793,000
2
10,264,400
7,183,100
5,494,000
4,793,000
3
10,264,400
7,183,100
5,494,000
4,793,000
1
10,264,400
7,183,100
5,494,000
4,793,000
2
10,264,400
7,183,100
5,494,000
4,793,000
3
10,264,400
7,183,100
5,494,000
4,793,000
1
10,264,400
7,183,100
5,494,000
4,793,000
2
10,264,400
7,183,100
5,494,000
4,793,000
3
10,264,400
7,183,100
5,494,000
4,793,000
1
12,299,700
8,607,400
6,583,400
5,743,400
2
12,299,700
8,607,400
6,583,400
5,743,400
3
12,299,700
8,607,400
6,583,400
5,743,400
1
12,299,700
8,607,400
6,583,400
5,743,400
2
12,299,700
8,607,400
6,583,400
5,743,400
3
12,299,700
8,607,400
6,583,400
5,743,400
1
12,299,700
8,607,400
6,583,400
5,743,400
2
12,299,700
8,607,400
6,583,400
5,743,400
3
12,299,700
8,607,400
6,583,400
5,743,400
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
1
8,137,900
7,324,100
6,510,200
5,696,500
2
8,137,900
7,324,100
6,510,200
5,696,500
3
8,137,900
7,324,100
6,510,200
5,696,500
6,105,600
4,081,000
4,037,000
3,922,600
6,105,600
4,081,000
4,037,000
3,922,600
6,105,600
4,081,000
4,037,000
3,922,600
Q-5-44-0
10,303,200
5,565,000
5,505,000
5,349,000
Z-3-17-0
Z-3-16-0
2,258,000
1,888,400
915,800
1,699,500
659,100
1,510,500
625,800
1,321,800
H-3-13-0
554,600
365,300
361,400
343,200
H-2-36-0
J-3-15-0
B-3-11-0
4,462,900
1,185,000
2,978,600
3,825,400
780,400
2,157,800
3,506,600
772,200
1,552,800
3,187,800
733,200
1,474,400
- 1077 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
3,402,800
3,402,800
3,402,800
3,402,800
3,402,800
3,402,800
3,402,800
3,402,800
3,402,800
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
6,479,300
2,199,300
2,199,300
2,199,300
2,199,300
2,199,300
2,199,300
2,199,300
2,199,300
2,199,300
11,692,800
11,692,800
11,692,800
11,692,800
11,692,800
11,692,800
11,692,800
11,692,800
11,692,800
4,479,400
4,479,400
4,479,400
4,479,400
4,479,400
4,479,400
4,479,400
4,479,400
4,479,400
16,337,000
16,337,000
16,337,000
16,337,000
16,337,000
16,337,000
16,337,000
16,337,000
16,337,000
B
SWASTA
3,273,200
3,273,200
3,273,200
3,273,200
3,273,200
3,273,200
3,273,200
3,273,200
3,273,200
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
6,045,600
2,052,100
2,052,100
2,052,100
2,052,100
2,052,100
2,052,100
2,052,100
2,052,100
2,052,100
8,182,600
8,182,600
8,182,600
8,182,600
8,182,600
8,182,600
8,182,600
8,182,600
8,182,600
4,179,500
4,179,500
4,179,500
4,179,500
4,179,500
4,179,500
4,179,500
4,179,500
4,179,500
15,715,000
15,715,000
15,715,000
15,715,000
15,715,000
15,715,000
15,715,000
15,715,000
15,715,000
C
SWASTA
3,035,600
3,035,600
3,035,600
3,035,600
3,035,600
3,035,600
3,035,600
3,035,600
3,035,600
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
5,780,000
1,765,700
1,765,700
1,765,700
1,765,700
1,765,700
1,765,700
1,765,700
1,765,700
1,765,700
7,040,900
7,040,900
7,040,900
7,040,900
7,040,900
7,040,900
7,040,900
7,040,900
7,040,900
3,596,400
3,596,400
3,596,400
3,596,400
3,596,400
3,596,400
3,596,400
3,596,400
3,596,400
13,116,600
13,116,600
13,116,600
13,116,600
13,116,600
13,116,600
13,116,600
13,116,600
13,116,600
D
SWASTA
2,648,200
2,648,200
2,648,200
2,648,200
2,648,200
2,648,200
2,648,200
2,648,200
2,648,200
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
6,051,000
1,711,600
1,711,600
1,711,600
1,711,600
1,711,600
1,711,600
1,711,600
1,711,600
1,711,600
6,142,500
6,142,500
6,142,500
6,142,500
6,142,500
6,142,500
6,142,500
6,142,500
6,142,500
3,486,100
3,486,100
3,486,100
3,486,100
3,486,100
3,486,100
3,486,100
3,486,100
3,486,100
12,714,400
12,714,400
12,714,400
12,714,400
12,714,400
12,714,400
12,714,400
12,714,400
12,714,400
- 1078 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
17,362,000
17,362,000
17,362,000
17,362,000
17,362,000
17,362,000
17,362,000
17,362,000
17,362,000
17,656,000
17,656,000
17,656,000
17,656,000
17,656,000
17,656,000
17,656,000
17,656,000
17,656,000
11,550,300
11,550,300
11,550,300
11,550,300
11,550,300
11,550,300
11,550,300
11,550,300
11,550,300
27,307,700
27,307,700
27,307,700
27,307,700
27,307,700
27,307,700
27,307,700
27,307,700
27,307,700
107,758,000
107,758,000
107,758,000
107,758,000
107,758,000
107,758,000
107,758,000
107,758,000
107,758,000
13,653,900
13,653,900
13,653,900
13,653,900
13,653,900
13,653,900
13,653,900
13,653,900
13,653,900
15,045,500
15,045,500
15,045,500
15,045,500
15,045,500
15,045,500
15,045,500
15,045,500
15,045,500
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
B
SWASTA
8,801,200
8,801,200
8,801,200
8,801,200
8,801,200
8,801,200
8,801,200
8,801,200
8,801,200
7,567,200
7,567,200
7,567,200
7,567,200
7,567,200
7,567,200
7,567,200
7,567,200
7,567,200
8,083,000
8,083,000
8,083,000
8,083,000
8,083,000
8,083,000
8,083,000
8,083,000
8,083,000
11,703,900
11,703,900
11,703,900
11,703,900
11,703,900
11,703,900
11,703,900
11,703,900
11,703,900
101,064,000
101,064,000
101,064,000
101,064,000
101,064,000
101,064,000
101,064,000
101,064,000
101,064,000
5,852,000
5,852,000
5,852,000
5,852,000
5,852,000
5,852,000
5,852,000
5,852,000
5,852,000
10,854,500
10,854,500
10,854,500
10,854,500
10,854,500
10,854,500
10,854,500
10,854,500
10,854,500
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
C
SWASTA
5,507,700
5,507,700
5,507,700
5,507,700
5,507,700
5,507,700
5,507,700
5,507,700
5,507,700
5,787,900
5,787,900
5,787,900
5,787,900
5,787,900
5,787,900
5,787,900
5,787,900
5,787,900
6,182,300
6,182,300
6,182,300
6,182,300
6,182,300
6,182,300
6,182,300
6,182,300
6,182,300
8,951,800
8,951,800
8,951,800
8,951,800
8,951,800
8,951,800
8,951,800
8,951,800
8,951,800
57,677,500
57,677,500
57,677,500
57,677,500
57,677,500
57,677,500
57,677,500
57,677,500
57,677,500
4,475,900
4,475,900
4,475,900
4,475,900
4,475,900
4,475,900
4,475,900
4,475,900
4,475,900
8,053,100
8,053,100
8,053,100
8,053,100
8,053,100
8,053,100
8,053,100
8,053,100
8,053,100
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
D
SWASTA
1,631,500
1,631,500
1,631,500
1,631,500
1,631,500
1,631,500
1,631,500
1,631,500
1,631,500
5,049,400
5,049,400
5,049,400
5,049,400
5,049,400
5,049,400
5,049,400
5,049,400
5,049,400
5,393,500
5,393,500
5,393,500
5,393,500
5,393,500
5,393,500
5,393,500
5,393,500
5,393,500
7,809,600
7,809,600
7,809,600
7,809,600
7,809,600
7,809,600
7,809,600
7,809,600
7,809,600
50,318,000
50,318,000
50,318,000
50,318,000
50,318,000
50,318,000
50,318,000
50,318,000
50,318,000
3,904,800
3,904,800
3,904,800
3,904,800
3,904,800
3,904,800
3,904,800
3,904,800
3,904,800
7,025,600
7,025,600
7,025,600
7,025,600
7,025,600
7,025,600
7,025,600
7,025,600
7,025,600
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
- 1079 -

REGIONAL 3
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
A
SWASTA
8,409,100
8,409,100
8,409,100
8,409,100
8,409,100
8,409,100
8,409,100
8,409,100
8,409,100
50,337,900
50,337,900
50,337,900
50,337,900
50,337,900
50,337,900
50,337,900
50,337,900
50,337,900
4,263,400
4,263,400
4,263,400
4,263,400
4,263,400
4,263,400
4,263,400
4,263,400
4,263,400
10,572,300
10,572,300
10,572,300
10,572,300
10,572,300
10,572,300
10,572,300
10,572,300
10,572,300
12,668,700
12,668,700
12,668,700
12,668,700
12,668,700
12,668,700
12,668,700
12,668,700
12,668,700
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
8,382,000
6,411,200
6,411,200
6,411,200
B
SWASTA
6,473,200
6,473,200
6,473,200
6,473,200
6,473,200
6,473,200
6,473,200
6,473,200
6,473,200
22,241,700
22,241,700
22,241,700
22,241,700
22,241,700
22,241,700
22,241,700
22,241,700
22,241,700
2,983,500
2,983,500
2,983,500
2,983,500
2,983,500
2,983,500
2,983,500
2,983,500
2,983,500
7,398,600
7,398,600
7,398,600
7,398,600
7,398,600
7,398,600
7,398,600
7,398,600
7,398,600
8,865,600
8,865,600
8,865,600
8,865,600
8,865,600
8,865,600
8,865,600
8,865,600
8,865,600
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
7,543,800
4,283,400
4,283,400
4,283,400
C
SWASTA
4,050,900
4,050,900
4,050,900
4,050,900
4,050,900
4,050,900
4,050,900
4,050,900
4,050,900
16,501,400
16,501,400
16,501,400
16,501,400
16,501,400
16,501,400
16,501,400
16,501,400
16,501,400
2,282,000
2,282,000
2,282,000
2,282,000
2,282,000
2,282,000
2,282,000
2,282,000
2,282,000
5,658,900
5,658,900
5,658,900
5,658,900
5,658,900
5,658,900
5,658,900
5,658,900
5,658,900
6,780,900
6,780,900
6,780,900
6,780,900
6,780,900
6,780,900
6,780,900
6,780,900
6,780,900
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
6,705,500
4,239,400
4,239,400
4,239,400
D
SWASTA
3,534,000
3,534,000
3,534,000
3,534,000
3,534,000
3,534,000
3,534,000
3,534,000
3,534,000
14,395,900
14,395,900
14,395,900
14,395,900
14,395,900
14,395,900
14,395,900
14,395,900
14,395,900
1,990,800
1,990,800
1,990,800
1,990,800
1,990,800
1,990,800
1,990,800
1,990,800
1,990,800
4,936,800
4,936,800
4,936,800
4,936,800
4,936,800
4,936,800
4,936,800
4,936,800
4,936,800
5,915,700
5,915,700
5,915,700
5,915,700
5,915,700
5,915,700
5,915,700
5,915,700
5,915,700
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
5,867,400
4,120,600
4,120,600
4,120,600
Q-5-44-0
10,818,900
5,841,000
5,781,000
5,619,000
Z-3-17-0
Z-3-16-0
2,370,900
1,982,700
961,500
1,784,400
692,000
1,586,100
657,000
1,388,000
H-3-13-0
582,300
383,400
379,500
360,300
H-2-36-0
J-3-15-0
B-3-11-0
4,686,100
1,244,400
3,127,600
4,016,600
819,400
2,265,600
3,681,900
811,000
1,630,600
3,347,200
770,000
1,548,200
I-1-06-I
I-1-06-II
I-1-06-III
- 1080 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
A
B
C
D
1
3,352,600
3,225,000
2,990,800
2,609,200
2
3,352,600
3,225,000
2,990,800
2,609,200
3
3,352,600
3,225,000
2,990,800
2,609,200
1
3,352,600
3,225,000
2,990,800
2,609,200
2
3,352,600
3,225,000
2,990,800
2,609,200
3
3,352,600
3,225,000
2,990,800
2,609,200
1
3,352,600
3,225,000
2,990,800
2,609,200
2
3,352,600
3,225,000
2,990,800
2,609,200
3
3,352,600
3,225,000
2,990,800
2,609,200
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
6,383,900
5,956,600
5,695,000
5,961,900
2
6,383,900
5,956,600
5,695,000
5,961,900
3
6,383,900
5,956,600
5,695,000
5,961,900
1
2,166,900
2,021,800
1,739,700
1,686,400
2
2,166,900
2,021,800
1,739,700
1,686,400
3
2,166,900
2,021,800
1,739,700
1,686,400
1
2,166,900
2,021,800
1,739,700
1,686,400
2
2,166,900
2,021,800
1,739,700
1,686,400
3
2,166,900
2,021,800
1,739,700
1,686,400
1
2,166,900
2,021,800
1,739,700
1,686,400
2
2,166,900
2,021,800
1,739,700
1,686,400
3
2,166,900
2,021,800
1,739,700
1,686,400
1
11,520,600
8,062,200
6,937,200
6,052,100
2
11,520,600
8,062,200
6,937,200
6,052,100
3
11,520,600
8,062,200
6,937,200
6,052,100
1
11,520,600
8,062,200
6,937,200
6,052,100
2
11,520,600
8,062,200
6,937,200
6,052,100
3
11,520,600
8,062,200
6,937,200
6,052,100
1
11,520,600
8,062,200
6,937,200
6,052,100
2
11,520,600
8,062,200
6,937,200
6,052,100
3
11,520,600
8,062,200
6,937,200
6,052,100
1
4,413,300
4,117,900
3,543,400
3,434,700
2
4,413,300
4,117,900
3,543,400
3,434,700
3
4,413,300
4,117,900
3,543,400
3,434,700
1
4,413,300
4,117,900
3,543,400
3,434,700
2
4,413,300
4,117,900
3,543,400
3,434,700
3
4,413,300
4,117,900
3,543,400
3,434,700
1
4,413,300
4,117,900
3,543,400
3,434,700
2
4,413,300
4,117,900
3,543,400
3,434,700
3
4,413,300
4,117,900
3,543,400
3,434,700
1
16,096,200
15,483,400
12,923,300
12,527,000
2
16,096,200
15,483,400
12,923,300
12,527,000
3
16,096,200
15,483,400
12,923,300
12,527,000
1
16,096,200
15,483,400
12,923,300
12,527,000
2
16,096,200
15,483,400
12,923,300
12,527,000
3
16,096,200
15,483,400
12,923,300
12,527,000
1
16,096,200
15,483,400
12,923,300
12,527,000
2
16,096,200
15,483,400
12,923,300
12,527,000
3
16,096,200
15,483,400
12,923,300
12,527,000
- 1081 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
A
B
C
D
1
17,106,200
8,671,500
5,426,600
1,607,400
2
17,106,200
8,671,500
5,426,600
1,607,400
3
17,106,200
8,671,500
5,426,600
1,607,400
1
17,106,200
8,671,500
5,426,600
1,607,400
2
17,106,200
8,671,500
5,426,600
1,607,400
3
17,106,200
8,671,500
5,426,600
1,607,400
1
17,106,200
8,671,500
5,426,600
1,607,400
2
17,106,200
8,671,500
5,426,600
1,607,400
3
17,106,200
8,671,500
5,426,600
1,607,400
1
17,395,800
7,455,700
5,702,600
4,975,000
2
17,395,800
7,455,700
5,702,600
4,975,000
3
17,395,800
7,455,700
5,702,600
4,975,000
1
17,395,800
7,455,700
5,702,600
4,975,000
2
17,395,800
7,455,700
5,702,600
4,975,000
3
17,395,800
7,455,700
5,702,600
4,975,000
1
17,395,800
7,455,700
5,702,600
4,975,000
2
17,395,800
7,455,700
5,702,600
4,975,000
3
17,395,800
7,455,700
5,702,600
4,975,000
1
11,380,100
7,963,900
6,091,200
5,314,000
2
11,380,100
7,963,900
6,091,200
5,314,000
3
11,380,100
7,963,900
6,091,200
5,314,000
1
11,380,100
7,963,900
6,091,200
5,314,000
2
11,380,100
7,963,900
6,091,200
5,314,000
3
11,380,100
7,963,900
6,091,200
5,314,000
1
11,380,100
7,963,900
6,091,200
5,314,000
2
11,380,100
7,963,900
6,091,200
5,314,000
3
11,380,100
7,963,900
6,091,200
5,314,000
1
26,905,300
11,531,400
8,819,900
7,694,500
2
26,905,300
11,531,400
8,819,900
7,694,500
3
26,905,300
11,531,400
8,819,900
7,694,500
1
26,905,300
11,531,400
8,819,900
7,694,500
2
26,905,300
11,531,400
8,819,900
7,694,500
3
26,905,300
11,531,400
8,819,900
7,694,500
1
26,905,300
11,531,400
8,819,900
7,694,500
2
26,905,300
11,531,400
8,819,900
7,694,500
3
26,905,300
11,531,400
8,819,900
7,694,500
1
106,170,000
99,574,800
56,827,500
49,576,500
2
106,170,000
99,574,800
56,827,500
49,576,500
3
106,170,000
99,574,800
56,827,500
49,576,500
1
106,170,000
99,574,800
56,827,500
49,576,500
2
106,170,000
99,574,800
56,827,500
49,576,500
3
106,170,000
99,574,800
56,827,500
49,576,500
1
106,170,000
99,574,800
56,827,500
49,576,500
2
106,170,000
99,574,800
56,827,500
49,576,500
3
106,170,000
99,574,800
56,827,500
49,576,500
1
13,452,700
5,765,700
4,410,000
3,847,300
2
13,452,700
5,765,700
4,410,000
3,847,300
3
13,452,700
5,765,700
4,410,000
3,847,300
1
13,452,700
5,765,700
4,410,000
3,847,300
2
13,452,700
5,765,700
4,410,000
3,847,300
3
13,452,700
5,765,700
4,410,000
3,847,300
1
13,452,700
5,765,700
4,410,000
3,847,300
2
13,452,700
5,765,700
4,410,000
3,847,300
3
13,452,700
5,765,700
4,410,000
3,847,300
1
14,823,800
10,694,600
7,934,500
6,922,000
2
14,823,800
10,694,600
7,934,500
6,922,000
3
14,823,800
10,694,600
7,934,500
6,922,000
1
14,823,800
10,694,600
7,934,500
6,922,000
2
14,823,800
10,694,600
7,934,500
6,922,000
3
14,823,800
10,694,600
7,934,500
6,922,000
1
14,823,800
10,694,600
7,934,500
6,922,000
2
14,823,800
10,694,600
7,934,500
6,922,000
3
14,823,800
10,694,600
7,934,500
6,922,000
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
- 1082 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
I-1-06-I
I-1-06-II
I-1-06-III
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
A
B
C
D
1
8,285,200
6,377,800
3,991,200
3,481,900
2
8,285,200
6,377,800
3,991,200
3,481,900
3
8,285,200
6,377,800
3,991,200
3,481,900
1
8,285,200
6,377,800
3,991,200
3,481,900
2
8,285,200
6,377,800
3,991,200
3,481,900
3
8,285,200
6,377,800
3,991,200
3,481,900
1
8,285,200
6,377,800
3,991,200
3,481,900
2
8,285,200
6,377,800
3,991,200
3,481,900
3
8,285,200
6,377,800
3,991,200
3,481,900
1
49,596,100
21,913,900
16,258,200
14,183,700
2
49,596,100
21,913,900
16,258,200
14,183,700
3
49,596,100
21,913,900
16,258,200
14,183,700
1
49,596,100
21,913,900
16,258,200
14,183,700
2
49,596,100
21,913,900
16,258,200
14,183,700
3
49,596,100
21,913,900
16,258,200
14,183,700
1
49,596,100
21,913,900
16,258,200
14,183,700
2
49,596,100
21,913,900
16,258,200
14,183,700
3
49,596,100
21,913,900
16,258,200
14,183,700
1
4,200,600
2,939,600
2,248,400
1,961,500
2
4,200,600
2,939,600
2,248,400
1,961,500
3
4,200,600
2,939,600
2,248,400
1,961,500
1
4,200,600
2,939,600
2,248,400
1,961,500
2
4,200,600
2,939,600
2,248,400
1,961,500
3
4,200,600
2,939,600
2,248,400
1,961,500
1
4,200,600
2,939,600
2,248,400
1,961,500
2
4,200,600
2,939,600
2,248,400
1,961,500
3
4,200,600
2,939,600
2,248,400
1,961,500
1
10,416,500
7,289,500
5,575,500
4,864,100
2
10,416,500
7,289,500
5,575,500
4,864,100
3
10,416,500
7,289,500
5,575,500
4,864,100
1
10,416,500
7,289,500
5,575,500
4,864,100
2
10,416,500
7,289,500
5,575,500
4,864,100
3
10,416,500
7,289,500
5,575,500
4,864,100
1
10,416,500
7,289,500
5,575,500
4,864,100
2
10,416,500
7,289,500
5,575,500
4,864,100
3
10,416,500
7,289,500
5,575,500
4,864,100
1
12,482,000
8,734,900
6,681,000
5,828,500
2
12,482,000
8,734,900
6,681,000
5,828,500
3
12,482,000
8,734,900
6,681,000
5,828,500
1
12,482,000
8,734,900
6,681,000
5,828,500
2
12,482,000
8,734,900
6,681,000
5,828,500
3
12,482,000
8,734,900
6,681,000
5,828,500
1
12,482,000
8,734,900
6,681,000
5,828,500
2
12,482,000
8,734,900
6,681,000
5,828,500
3
12,482,000
8,734,900
6,681,000
5,828,500
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
1
8,258,500
7,432,600
6,606,700
5,781,000
2
8,258,500
7,432,600
6,606,700
5,781,000
3
8,258,500
7,432,600
6,606,700
5,781,000
6,196,800
4,140,400
4,098,600
3,982,000
6,196,800
4,140,400
4,098,600
3,982,000
6,196,800
4,140,400
4,098,600
3,982,000
Q-5-44-0
10,457,100
5,646,000
5,589,000
5,430,000
Z-3-17-0
Z-3-16-0
2,291,400
1,916,300
929,300
1,724,600
668,900
1,533,000
635,000
1,341,500
H-3-13-0
562,800
370,700
366,800
348,200
H-2-36-0
J-3-15-0
B-3-11-0
4,529,100
1,202,600
3,022,800
3,882,100
792,000
2,189,800
3,558,600
783,800
1,575,800
3,235,100
744,200
1,496,200
- 1083 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
3,453,200
3,453,200
3,453,200
3,453,200
3,453,200
3,453,200
3,453,200
3,453,200
3,453,200
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
6,575,300
2,231,900
2,231,900
2,231,900
2,231,900
2,231,900
2,231,900
2,231,900
2,231,900
2,231,900
11,866,200
11,866,200
11,866,200
11,866,200
11,866,200
11,866,200
11,866,200
11,866,200
11,866,200
4,545,700
4,545,700
4,545,700
4,545,700
4,545,700
4,545,700
4,545,700
4,545,700
4,545,700
16,579,100
16,579,100
16,579,100
16,579,100
16,579,100
16,579,100
16,579,100
16,579,100
16,579,100
B
SWASTA
3,321,800
3,321,800
3,321,800
3,321,800
3,321,800
3,321,800
3,321,800
3,321,800
3,321,800
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
6,135,200
2,082,500
2,082,500
2,082,500
2,082,500
2,082,500
2,082,500
2,082,500
2,082,500
2,082,500
8,304,000
8,304,000
8,304,000
8,304,000
8,304,000
8,304,000
8,304,000
8,304,000
8,304,000
4,241,500
4,241,500
4,241,500
4,241,500
4,241,500
4,241,500
4,241,500
4,241,500
4,241,500
15,947,900
15,947,900
15,947,900
15,947,900
15,947,900
15,947,900
15,947,900
15,947,900
15,947,900
C
SWASTA
3,080,500
3,080,500
3,080,500
3,080,500
3,080,500
3,080,500
3,080,500
3,080,500
3,080,500
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
5,865,800
1,791,900
1,791,900
1,791,900
1,791,900
1,791,900
1,791,900
1,791,900
1,791,900
1,791,900
7,145,300
7,145,300
7,145,300
7,145,300
7,145,300
7,145,300
7,145,300
7,145,300
7,145,300
3,649,700
3,649,700
3,649,700
3,649,700
3,649,700
3,649,700
3,649,700
3,649,700
3,649,700
13,311,000
13,311,000
13,311,000
13,311,000
13,311,000
13,311,000
13,311,000
13,311,000
13,311,000
D
SWASTA
2,687,500
2,687,500
2,687,500
2,687,500
2,687,500
2,687,500
2,687,500
2,687,500
2,687,500
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
6,140,700
1,737,000
1,737,000
1,737,000
1,737,000
1,737,000
1,737,000
1,737,000
1,737,000
1,737,000
6,233,600
6,233,600
6,233,600
6,233,600
6,233,600
6,233,600
6,233,600
6,233,600
6,233,600
3,537,800
3,537,800
3,537,800
3,537,800
3,537,800
3,537,800
3,537,800
3,537,800
3,537,800
12,902,800
12,902,800
12,902,800
12,902,800
12,902,800
12,902,800
12,902,800
12,902,800
12,902,800
- 1084 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
17,619,300
17,619,300
17,619,300
17,619,300
17,619,300
17,619,300
17,619,300
17,619,300
17,619,300
17,917,700
17,917,700
17,917,700
17,917,700
17,917,700
17,917,700
17,917,700
17,917,700
17,917,700
11,721,500
11,721,500
11,721,500
11,721,500
11,721,500
11,721,500
11,721,500
11,721,500
11,721,500
27,712,400
27,712,400
27,712,400
27,712,400
27,712,400
27,712,400
27,712,400
27,712,400
27,712,400
109,355,000
109,355,000
109,355,000
109,355,000
109,355,000
109,355,000
109,355,000
109,355,000
109,355,000
13,856,200
13,856,200
13,856,200
13,856,200
13,856,200
13,856,200
13,856,200
13,856,200
13,856,200
15,268,500
15,268,500
15,268,500
15,268,500
15,268,500
15,268,500
15,268,500
15,268,500
15,268,500
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
B
SWASTA
8,931,600
8,931,600
8,931,600
8,931,600
8,931,600
8,931,600
8,931,600
8,931,600
8,931,600
7,679,400
7,679,400
7,679,400
7,679,400
7,679,400
7,679,400
7,679,400
7,679,400
7,679,400
8,202,800
8,202,800
8,202,800
8,202,800
8,202,800
8,202,800
8,202,800
8,202,800
8,202,800
11,877,300
11,877,300
11,877,300
11,877,300
11,877,300
11,877,300
11,877,300
11,877,300
11,877,300
102,562,200
102,562,200
102,562,200
102,562,200
102,562,200
102,562,200
102,562,200
102,562,200
102,562,200
5,938,700
5,938,700
5,938,700
5,938,700
5,938,700
5,938,700
5,938,700
5,938,700
5,938,700
11,015,400
11,015,400
11,015,400
11,015,400
11,015,400
11,015,400
11,015,400
11,015,400
11,015,400
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
C
SWASTA
5,589,400
5,589,400
5,589,400
5,589,400
5,589,400
5,589,400
5,589,400
5,589,400
5,589,400
5,873,700
5,873,700
5,873,700
5,873,700
5,873,700
5,873,700
5,873,700
5,873,700
5,873,700
6,274,000
6,274,000
6,274,000
6,274,000
6,274,000
6,274,000
6,274,000
6,274,000
6,274,000
9,084,500
9,084,500
9,084,500
9,084,500
9,084,500
9,084,500
9,084,500
9,084,500
9,084,500
58,532,500
58,532,500
58,532,500
58,532,500
58,532,500
58,532,500
58,532,500
58,532,500
58,532,500
4,542,300
4,542,300
4,542,300
4,542,300
4,542,300
4,542,300
4,542,300
4,542,300
4,542,300
8,172,500
8,172,500
8,172,500
8,172,500
8,172,500
8,172,500
8,172,500
8,172,500
8,172,500
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
D
SWASTA
1,655,600
1,655,600
1,655,600
1,655,600
1,655,600
1,655,600
1,655,600
1,655,600
1,655,600
5,124,200
5,124,200
5,124,200
5,124,200
5,124,200
5,124,200
5,124,200
5,124,200
5,124,200
5,473,400
5,473,400
5,473,400
5,473,400
5,473,400
5,473,400
5,473,400
5,473,400
5,473,400
7,925,300
7,925,300
7,925,300
7,925,300
7,925,300
7,925,300
7,925,300
7,925,300
7,925,300
51,064,000
51,064,000
51,064,000
51,064,000
51,064,000
51,064,000
51,064,000
51,064,000
51,064,000
3,962,700
3,962,700
3,962,700
3,962,700
3,962,700
3,962,700
3,962,700
3,962,700
3,962,700
7,129,700
7,129,700
7,129,700
7,129,700
7,129,700
7,129,700
7,129,700
7,129,700
7,129,700
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
- 1085 -

REGIONAL 4
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
A
SWASTA
8,533,700
8,533,700
8,533,700
8,533,700
8,533,700
8,533,700
8,533,700
8,533,700
8,533,700
51,084,000
51,084,000
51,084,000
51,084,000
51,084,000
51,084,000
51,084,000
51,084,000
51,084,000
4,326,600
4,326,600
4,326,600
4,326,600
4,326,600
4,326,600
4,326,600
4,326,600
4,326,600
10,729,000
10,729,000
10,729,000
10,729,000
10,729,000
10,729,000
10,729,000
10,729,000
10,729,000
12,856,500
12,856,500
12,856,500
12,856,500
12,856,500
12,856,500
12,856,500
12,856,500
12,856,500
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
8,506,200
6,505,600
6,505,600
6,505,600
B
SWASTA
6,569,100
6,569,100
6,569,100
6,569,100
6,569,100
6,569,100
6,569,100
6,569,100
6,569,100
22,571,300
22,571,300
22,571,300
22,571,300
22,571,300
22,571,300
22,571,300
22,571,300
22,571,300
3,027,800
3,027,800
3,027,800
3,027,800
3,027,800
3,027,800
3,027,800
3,027,800
3,027,800
7,508,200
7,508,200
7,508,200
7,508,200
7,508,200
7,508,200
7,508,200
7,508,200
7,508,200
8,997,000
8,997,000
8,997,000
8,997,000
8,997,000
8,997,000
8,997,000
8,997,000
8,997,000
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
7,655,600
4,347,200
4,347,200
4,347,200
C
SWASTA
4,110,900
4,110,900
4,110,900
4,110,900
4,110,900
4,110,900
4,110,900
4,110,900
4,110,900
16,746,000
16,746,000
16,746,000
16,746,000
16,746,000
16,746,000
16,746,000
16,746,000
16,746,000
2,315,800
2,315,800
2,315,800
2,315,800
2,315,800
2,315,800
2,315,800
2,315,800
2,315,800
5,742,700
5,742,700
5,742,700
5,742,700
5,742,700
5,742,700
5,742,700
5,742,700
5,742,700
6,881,400
6,881,400
6,881,400
6,881,400
6,881,400
6,881,400
6,881,400
6,881,400
6,881,400
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
6,804,900
4,303,200
4,303,200
4,303,200
D
SWASTA
3,586,400
3,586,400
3,586,400
3,586,400
3,586,400
3,586,400
3,586,400
3,586,400
3,586,400
14,609,300
14,609,300
14,609,300
14,609,300
14,609,300
14,609,300
14,609,300
14,609,300
14,609,300
2,020,300
2,020,300
2,020,300
2,020,300
2,020,300
2,020,300
2,020,300
2,020,300
2,020,300
5,010,000
5,010,000
5,010,000
5,010,000
5,010,000
5,010,000
5,010,000
5,010,000
5,010,000
6,003,400
6,003,400
6,003,400
6,003,400
6,003,400
6,003,400
6,003,400
6,003,400
6,003,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
5,954,400
4,180,000
4,180,000
4,180,000
Q-5-44-0
10,978,200
5,928,000
5,868,000
5,700,000
Z-3-17-0
Z-3-16-0
2,406,000
2,012,100
975,800
1,810,800
702,300
1,609,700
666,800
1,408,500
H-3-13-0
590,900
389,100
385,100
365,700
H-2-36-0
J-3-15-0
B-3-11-0
4,755,500
1,262,800
3,174,000
4,076,200
831,600
2,299,200
3,736,500
823,000
1,654,600
3,396,800
781,400
1,571,200
I-1-06-I
I-1-06-II
I-1-06-III
- 1086 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
A
B
C
D
1
3,460,300
3,328,600
3,086,900
2,693,000
2
3,460,300
3,328,600
3,086,900
2,693,000
3
3,460,300
3,328,600
3,086,900
2,693,000
1
3,460,300
3,328,600
3,086,900
2,693,000
2
3,460,300
3,328,600
3,086,900
2,693,000
3
3,460,300
3,328,600
3,086,900
2,693,000
1
3,460,300
3,328,600
3,086,900
2,693,000
2
3,460,300
3,328,600
3,086,900
2,693,000
3
3,460,300
3,328,600
3,086,900
2,693,000
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
6,588,900
6,148,000
5,878,000
6,153,600
2
6,588,900
6,148,000
5,878,000
6,153,600
3
6,588,900
6,148,000
5,878,000
6,153,600
1
2,236,500
2,086,800
1,795,600
1,740,600
2
2,236,500
2,086,800
1,795,600
1,740,600
3
2,236,500
2,086,800
1,795,600
1,740,600
1
2,236,500
2,086,800
1,795,600
1,740,600
2
2,236,500
2,086,800
1,795,600
1,740,600
3
2,236,500
2,086,800
1,795,600
1,740,600
1
2,236,500
2,086,800
1,795,600
1,740,600
2
2,236,500
2,086,800
1,795,600
1,740,600
3
2,236,500
2,086,800
1,795,600
1,740,600
1
11,890,800
8,321,200
7,160,200
6,246,500
2
11,890,800
8,321,200
7,160,200
6,246,500
3
11,890,800
8,321,200
7,160,200
6,246,500
1
11,890,800
8,321,200
7,160,200
6,246,500
2
11,890,800
8,321,200
7,160,200
6,246,500
3
11,890,800
8,321,200
7,160,200
6,246,500
1
11,890,800
8,321,200
7,160,200
6,246,500
2
11,890,800
8,321,200
7,160,200
6,246,500
3
11,890,800
8,321,200
7,160,200
6,246,500
1
4,555,100
4,250,200
3,657,200
3,545,100
2
4,555,100
4,250,200
3,657,200
3,545,100
3
4,555,100
4,250,200
3,657,200
3,545,100
1
4,555,100
4,250,200
3,657,200
3,545,100
2
4,555,100
4,250,200
3,657,200
3,545,100
3
4,555,100
4,250,200
3,657,200
3,545,100
1
4,555,100
4,250,200
3,657,200
3,545,100
2
4,555,100
4,250,200
3,657,200
3,545,100
3
4,555,100
4,250,200
3,657,200
3,545,100
1
16,613,400
15,981,000
13,338,500
12,929,600
2
16,613,400
15,981,000
13,338,500
12,929,600
3
16,613,400
15,981,000
13,338,500
12,929,600
1
16,613,400
15,981,000
13,338,500
12,929,600
2
16,613,400
15,981,000
13,338,500
12,929,600
3
16,613,400
15,981,000
13,338,500
12,929,600
1
16,613,400
15,981,000
13,338,500
12,929,600
2
16,613,400
15,981,000
13,338,500
12,929,600
3
16,613,400
15,981,000
13,338,500
12,929,600
- 1087 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
A
B
C
D
1
17,655,800
8,950,100
5,600,900
1,659,100
2
17,655,800
8,950,100
5,600,900
1,659,100
3
17,655,800
8,950,100
5,600,900
1,659,100
1
17,655,800
8,950,100
5,600,900
1,659,100
2
17,655,800
8,950,100
5,600,900
1,659,100
3
17,655,800
8,950,100
5,600,900
1,659,100
1
17,655,800
8,950,100
5,600,900
1,659,100
2
17,655,800
8,950,100
5,600,900
1,659,100
3
17,655,800
8,950,100
5,600,900
1,659,100
1
17,954,800
7,695,300
5,885,800
5,134,800
2
17,954,800
7,695,300
5,885,800
5,134,800
3
17,954,800
7,695,300
5,885,800
5,134,800
1
17,954,800
7,695,300
5,885,800
5,134,800
2
17,954,800
7,695,300
5,885,800
5,134,800
3
17,954,800
7,695,300
5,885,800
5,134,800
1
17,954,800
7,695,300
5,885,800
5,134,800
2
17,954,800
7,695,300
5,885,800
5,134,800
3
17,954,800
7,695,300
5,885,800
5,134,800
1
11,745,800
8,219,800
6,287,000
5,484,800
2
11,745,800
8,219,800
6,287,000
5,484,800
3
11,745,800
8,219,800
6,287,000
5,484,800
1
11,745,800
8,219,800
6,287,000
5,484,800
2
11,745,800
8,219,800
6,287,000
5,484,800
3
11,745,800
8,219,800
6,287,000
5,484,800
1
11,745,800
8,219,800
6,287,000
5,484,800
2
11,745,800
8,219,800
6,287,000
5,484,800
3
11,745,800
8,219,800
6,287,000
5,484,800
1
27,769,800
11,901,900
9,103,300
7,941,800
2
27,769,800
11,901,900
9,103,300
7,941,800
3
27,769,800
11,901,900
9,103,300
7,941,800
1
27,769,800
11,901,900
9,103,300
7,941,800
2
27,769,800
11,901,900
9,103,300
7,941,800
3
27,769,800
11,901,900
9,103,300
7,941,800
1
27,769,800
11,901,900
9,103,300
7,941,800
2
27,769,800
11,901,900
9,103,300
7,941,800
3
27,769,800
11,901,900
9,103,300
7,941,800
1
109,581,500
102,774,100
58,653,500
51,169,500
2
109,581,500
102,774,100
58,653,500
51,169,500
3
109,581,500
102,774,100
58,653,500
51,169,500
1
109,581,500
102,774,100
58,653,500
51,169,500
2
109,581,500
102,774,100
58,653,500
51,169,500
3
109,581,500
102,774,100
58,653,500
51,169,500
1
109,581,500
102,774,100
58,653,500
51,169,500
2
109,581,500
102,774,100
58,653,500
51,169,500
3
109,581,500
102,774,100
58,653,500
51,169,500
1
13,884,900
5,951,000
4,551,700
3,970,900
2
13,884,900
5,951,000
4,551,700
3,970,900
3
13,884,900
5,951,000
4,551,700
3,970,900
1
13,884,900
5,951,000
4,551,700
3,970,900
2
13,884,900
5,951,000
4,551,700
3,970,900
3
13,884,900
5,951,000
4,551,700
3,970,900
1
13,884,900
5,951,000
4,551,700
3,970,900
2
13,884,900
5,951,000
4,551,700
3,970,900
3
13,884,900
5,951,000
4,551,700
3,970,900
1
15,300,100
11,038,200
8,189,400
7,144,500
2
15,300,100
11,038,200
8,189,400
7,144,500
3
15,300,100
11,038,200
8,189,400
7,144,500
1
15,300,100
11,038,200
8,189,400
7,144,500
2
15,300,100
11,038,200
8,189,400
7,144,500
3
15,300,100
11,038,200
8,189,400
7,144,500
1
15,300,100
11,038,200
8,189,400
7,144,500
2
15,300,100
11,038,200
8,189,400
7,144,500
3
15,300,100
11,038,200
8,189,400
7,144,500
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
- 1088 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
I-1-06-I
I-1-06-II
I-1-06-III
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
A
B
C
D
1
8,551,400
6,582,700
4,119,400
3,593,800
2
8,551,400
6,582,700
4,119,400
3,593,800
3
8,551,400
6,582,700
4,119,400
3,593,800
1
8,551,400
6,582,700
4,119,400
3,593,800
2
8,551,400
6,582,700
4,119,400
3,593,800
3
8,551,400
6,582,700
4,119,400
3,593,800
1
8,551,400
6,582,700
4,119,400
3,593,800
2
8,551,400
6,582,700
4,119,400
3,593,800
3
8,551,400
6,582,700
4,119,400
3,593,800
1
51,189,700
22,618,100
16,780,700
14,639,500
2
51,189,700
22,618,100
16,780,700
14,639,500
3
51,189,700
22,618,100
16,780,700
14,639,500
1
51,189,700
22,618,100
16,780,700
14,639,500
2
51,189,700
22,618,100
16,780,700
14,639,500
3
51,189,700
22,618,100
16,780,700
14,639,500
1
51,189,700
22,618,100
16,780,700
14,639,500
2
51,189,700
22,618,100
16,780,700
14,639,500
3
51,189,700
22,618,100
16,780,700
14,639,500
1
4,335,600
3,034,000
2,320,600
2,024,500
2
4,335,600
3,034,000
2,320,600
2,024,500
3
4,335,600
3,034,000
2,320,600
2,024,500
1
4,335,600
3,034,000
2,320,600
2,024,500
2
4,335,600
3,034,000
2,320,600
2,024,500
3
4,335,600
3,034,000
2,320,600
2,024,500
1
4,335,600
3,034,000
2,320,600
2,024,500
2
4,335,600
3,034,000
2,320,600
2,024,500
3
4,335,600
3,034,000
2,320,600
2,024,500
1
10,751,300
7,523,800
5,754,600
5,020,400
2
10,751,300
7,523,800
5,754,600
5,020,400
3
10,751,300
7,523,800
5,754,600
5,020,400
1
10,751,300
7,523,800
5,754,600
5,020,400
2
10,751,300
7,523,800
5,754,600
5,020,400
3
10,751,300
7,523,800
5,754,600
5,020,400
1
10,751,300
7,523,800
5,754,600
5,020,400
2
10,751,300
7,523,800
5,754,600
5,020,400
3
10,751,300
7,523,800
5,754,600
5,020,400
1
12,883,100
9,015,600
6,895,700
6,015,800
2
12,883,100
9,015,600
6,895,700
6,015,800
3
12,883,100
9,015,600
6,895,700
6,015,800
1
12,883,100
9,015,600
6,895,700
6,015,800
2
12,883,100
9,015,600
6,895,700
6,015,800
3
12,883,100
9,015,600
6,895,700
6,015,800
1
12,883,100
9,015,600
6,895,700
6,015,800
2
12,883,100
9,015,600
6,895,700
6,015,800
3
12,883,100
9,015,600
6,895,700
6,015,800
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
1
8,523,900
7,671,400
6,819,000
5,966,700
2
8,523,900
7,671,400
6,819,000
5,966,700
3
8,523,900
7,671,400
6,819,000
5,966,700
6,395,200
4,274,600
4,228,400
4,109,600
6,395,200
4,274,600
4,228,400
4,109,600
6,395,200
4,274,600
4,228,400
4,109,600
Q-5-44-0
10,791,900
5,829,000
5,766,000
5,604,000
Z-3-17-0
Z-3-16-0
2,365,100
1,977,900
959,100
1,780,100
690,300
1,582,200
655,500
1,384,500
H-3-13-0
580,800
382,500
378,500
359,400
H-2-36-0
J-3-15-0
B-3-11-0
4,674,600
1,241,200
3,119,800
4,006,800
817,400
2,260,000
3,672,900
809,000
1,626,600
3,339,000
768,000
1,544,400
- 1089 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
3,564,200
3,564,200
3,564,200
3,564,200
3,564,200
3,564,200
3,564,200
3,564,200
3,564,200
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
6,786,600
2,303,600
2,303,600
2,303,600
2,303,600
2,303,600
2,303,600
2,303,600
2,303,600
2,303,600
12,247,400
12,247,400
12,247,400
12,247,400
12,247,400
12,247,400
12,247,400
12,247,400
12,247,400
4,691,800
4,691,800
4,691,800
4,691,800
4,691,800
4,691,800
4,691,800
4,691,800
4,691,800
17,111,800
17,111,800
17,111,800
17,111,800
17,111,800
17,111,800
17,111,800
17,111,800
17,111,800
B
SWASTA
3,428,500
3,428,500
3,428,500
3,428,500
3,428,500
3,428,500
3,428,500
3,428,500
3,428,500
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
6,332,400
2,149,400
2,149,400
2,149,400
2,149,400
2,149,400
2,149,400
2,149,400
2,149,400
2,149,400
8,570,800
8,570,800
8,570,800
8,570,800
8,570,800
8,570,800
8,570,800
8,570,800
8,570,800
4,377,800
4,377,800
4,377,800
4,377,800
4,377,800
4,377,800
4,377,800
4,377,800
4,377,800
16,460,400
16,460,400
16,460,400
16,460,400
16,460,400
16,460,400
16,460,400
16,460,400
16,460,400
C
SWASTA
3,179,500
3,179,500
3,179,500
3,179,500
3,179,500
3,179,500
3,179,500
3,179,500
3,179,500
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
6,054,300
1,849,500
1,849,500
1,849,500
1,849,500
1,849,500
1,849,500
1,849,500
1,849,500
1,849,500
7,374,800
7,374,800
7,374,800
7,374,800
7,374,800
7,374,800
7,374,800
7,374,800
7,374,800
3,767,000
3,767,000
3,767,000
3,767,000
3,767,000
3,767,000
3,767,000
3,767,000
3,767,000
13,738,700
13,738,700
13,738,700
13,738,700
13,738,700
13,738,700
13,738,700
13,738,700
13,738,700
D
SWASTA
2,773,800
2,773,800
2,773,800
2,773,800
2,773,800
2,773,800
2,773,800
2,773,800
2,773,800
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
6,338,100
1,792,800
1,792,800
1,792,800
1,792,800
1,792,800
1,792,800
1,792,800
1,792,800
1,792,800
6,433,900
6,433,900
6,433,900
6,433,900
6,433,900
6,433,900
6,433,900
6,433,900
6,433,900
3,651,400
3,651,400
3,651,400
3,651,400
3,651,400
3,651,400
3,651,400
3,651,400
3,651,400
13,317,400
13,317,400
13,317,400
13,317,400
13,317,400
13,317,400
13,317,400
13,317,400
13,317,400
- 1090 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
A
SWASTA
18,185,500
18,185,500
18,185,500
18,185,500
18,185,500
18,185,500
18,185,500
18,185,500
18,185,500
18,493,400
18,493,400
18,493,400
18,493,400
18,493,400
18,493,400
18,493,400
18,493,400
18,493,400
12,098,200
12,098,200
12,098,200
12,098,200
12,098,200
12,098,200
12,098,200
12,098,200
12,098,200
28,602,900
28,602,900
28,602,900
28,602,900
28,602,900
28,602,900
28,602,900
28,602,900
28,602,900
112,869,000
112,869,000
112,869,000
112,869,000
112,869,000
112,869,000
112,869,000
112,869,000
112,869,000
14,301,500
14,301,500
14,301,500
14,301,500
14,301,500
14,301,500
14,301,500
14,301,500
14,301,500
15,759,100
15,759,100
15,759,100
15,759,100
15,759,100
15,759,100
15,759,100
15,759,100
15,759,100
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
B
SWASTA
9,218,600
9,218,600
9,218,600
9,218,600
9,218,600
9,218,600
9,218,600
9,218,600
9,218,600
7,926,100
7,926,100
7,926,100
7,926,100
7,926,100
7,926,100
7,926,100
7,926,100
7,926,100
8,466,400
8,466,400
8,466,400
8,466,400
8,466,400
8,466,400
8,466,400
8,466,400
8,466,400
12,259,000
12,259,000
12,259,000
12,259,000
12,259,000
12,259,000
12,259,000
12,259,000
12,259,000
105,857,700
105,857,700
105,857,700
105,857,700
105,857,700
105,857,700
105,857,700
105,857,700
105,857,700
6,129,500
6,129,500
6,129,500
6,129,500
6,129,500
6,129,500
6,129,500
6,129,500
6,129,500
11,369,400
11,369,400
11,369,400
11,369,400
11,369,400
11,369,400
11,369,400
11,369,400
11,369,400
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
C
SWASTA
5,769,000
5,769,000
5,769,000
5,769,000
5,769,000
5,769,000
5,769,000
5,769,000
5,769,000
6,062,400
6,062,400
6,062,400
6,062,400
6,062,400
6,062,400
6,062,400
6,062,400
6,062,400
6,475,600
6,475,600
6,475,600
6,475,600
6,475,600
6,475,600
6,475,600
6,475,600
6,475,600
9,376,400
9,376,400
9,376,400
9,376,400
9,376,400
9,376,400
9,376,400
9,376,400
9,376,400
60,413,000
60,413,000
60,413,000
60,413,000
60,413,000
60,413,000
60,413,000
60,413,000
60,413,000
4,688,200
4,688,200
4,688,200
4,688,200
4,688,200
4,688,200
4,688,200
4,688,200
4,688,200
8,435,100
8,435,100
8,435,100
8,435,100
8,435,100
8,435,100
8,435,100
8,435,100
8,435,100
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
D
SWASTA
1,708,800
1,708,800
1,708,800
1,708,800
1,708,800
1,708,800
1,708,800
1,708,800
1,708,800
5,288,900
5,288,900
5,288,900
5,288,900
5,288,900
5,288,900
5,288,900
5,288,900
5,288,900
5,649,300
5,649,300
5,649,300
5,649,300
5,649,300
5,649,300
5,649,300
5,649,300
5,649,300
8,180,000
8,180,000
8,180,000
8,180,000
8,180,000
8,180,000
8,180,000
8,180,000
8,180,000
52,704,500
52,704,500
52,704,500
52,704,500
52,704,500
52,704,500
52,704,500
52,704,500
52,704,500
4,090,000
4,090,000
4,090,000
4,090,000
4,090,000
4,090,000
4,090,000
4,090,000
4,090,000
7,358,800
7,358,800
7,358,800
7,358,800
7,358,800
7,358,800
7,358,800
7,358,800
7,358,800
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
- 1091 -

REGIONAL 5
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
A
SWASTA
8,807,900
8,807,900
8,807,900
8,807,900
8,807,900
8,807,900
8,807,900
8,807,900
8,807,900
52,725,400
52,725,400
52,725,400
52,725,400
52,725,400
52,725,400
52,725,400
52,725,400
52,725,400
4,465,600
4,465,600
4,465,600
4,465,600
4,465,600
4,465,600
4,465,600
4,465,600
4,465,600
11,073,800
11,073,800
11,073,800
11,073,800
11,073,800
11,073,800
11,073,800
11,073,800
11,073,800
13,269,600
13,269,600
13,269,600
13,269,600
13,269,600
13,269,600
13,269,600
13,269,600
13,269,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
8,779,600
6,715,200
6,715,200
6,715,200
B
SWASTA
6,780,200
6,780,200
6,780,200
6,780,200
6,780,200
6,780,200
6,780,200
6,780,200
6,780,200
23,296,600
23,296,600
23,296,600
23,296,600
23,296,600
23,296,600
23,296,600
23,296,600
23,296,600
3,125,100
3,125,100
3,125,100
3,125,100
3,125,100
3,125,100
3,125,100
3,125,100
3,125,100
7,749,500
7,749,500
7,749,500
7,749,500
7,749,500
7,749,500
7,749,500
7,749,500
7,749,500
9,286,100
9,286,100
9,286,100
9,286,100
9,286,100
9,286,100
9,286,100
9,286,100
9,286,100
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
7,901,600
4,488,000
4,488,000
4,488,000
C
SWASTA
4,243,000
4,243,000
4,243,000
4,243,000
4,243,000
4,243,000
4,243,000
4,243,000
4,243,000
17,284,100
17,284,100
17,284,100
17,284,100
17,284,100
17,284,100
17,284,100
17,284,100
17,284,100
2,390,200
2,390,200
2,390,200
2,390,200
2,390,200
2,390,200
2,390,200
2,390,200
2,390,200
5,927,300
5,927,300
5,927,300
5,927,300
5,927,300
5,927,300
5,927,300
5,927,300
5,927,300
7,102,600
7,102,600
7,102,600
7,102,600
7,102,600
7,102,600
7,102,600
7,102,600
7,102,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
7,023,600
4,439,600
4,439,600
4,439,600
D
SWASTA
3,701,600
3,701,600
3,701,600
3,701,600
3,701,600
3,701,600
3,701,600
3,701,600
3,701,600
15,078,700
15,078,700
15,078,700
15,078,700
15,078,700
15,078,700
15,078,700
15,078,700
15,078,700
2,085,200
2,085,200
2,085,200
2,085,200
2,085,200
2,085,200
2,085,200
2,085,200
2,085,200
5,171,000
5,171,000
5,171,000
5,171,000
5,171,000
5,171,000
5,171,000
5,171,000
5,171,000
6,196,300
6,196,300
6,196,300
6,196,300
6,196,300
6,196,300
6,196,300
6,196,300
6,196,300
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
6,145,700
4,314,200
4,314,200
4,314,200
Q-5-44-0
11,331,900
6,120,000
6,054,000
5,883,000
Z-3-17-0
Z-3-16-0
2,483,300
2,076,800
1,007,100
1,869,000
724,800
1,661,400
688,200
1,453,800
H-3-13-0
609,900
401,700
397,500
377,400
H-2-36-0
J-3-15-0
B-3-11-0
4,908,300
1,303,400
3,275,800
4,207,100
858,400
2,373,000
3,856,500
849,400
1,707,800
3,506,000
806,400
1,621,600
I-1-06-I
I-1-06-II
I-1-06-III
- 1092 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
DD-01-I
Streptokinase
I-4-10-I
DD-01-I
Streptokinase
I-4-10-II
DD-01-I
Streptokinase
I-4-10-III
DD-02-II
Deferiprone (IP)
D-4-13-I
DD-02-II
Deferiprone (IP)
D-4-13-II
DD-02-II
Deferiprone (IP)
D-4-13-III
DD-03-II
Deferoksamin (IP)
D-4-13-I
DD-03-II
Deferoksamin (IP)
D-4-13-II
DD-03-II
Deferoksamin (IP)
D-4-13-III
10
DD-04-II
Deferasirox (IP)
D-4-13-I
11
DD-04-II
Deferasirox (IP)
D-4-13-II
12
DD-04-II
Deferasirox (IP)
D-4-13-III
13
DD-05-II
Human Albumin for

Septicaemia
A-4-10-I
14
DD-05-II
Human Albumin for

Septicaemia
A-4-10-II
15
DD-05-II
Human Albumin for

Septicaemia
A-4-10-III
16
DD-06-II

(IP)
D-4-11-I
17
DD-06-II

(IP)
D-4-11-II
18
DD-06-II

D-4-11-III
(IP)
19
DD-11-II
Human Albumin for

Burn
S-4-16-I
20
DD-11-II
Human Albumin for

Burn
S-4-16-II
21
DD-11-II
Human Albumin for

Burn
S-4-16-III
22
DD-11-II
Human Albumin for

Burn
L-1-20-I
23
DD-11-II
Human Albumin for

Burn
L-1-20-II
24
DD-11-II
Human Albumin for

Burn
L-1-20-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
RSCM
RSJP-HK
RSAB-HK
3,446,900
3,446,900
3,446,900
3,446,900
3,446,900
3,446,900
3,446,900
3,446,900
3,446,900
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
6,563,300
2,227,800
2,227,800
2,227,800
2,227,800
2,227,800
2,227,800
2,227,800
2,227,800
2,227,800
11,104,100
11,104,100
11,104,100
11,104,100
11,104,100
11,104,100
11,104,100
11,104,100
11,104,100
4,537,400
4,537,400
4,537,400
4,537,400
4,537,400
4,537,400
4,537,400
4,537,400
4,537,400
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
RSK
DHARMAIS
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
3,288,800
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
6,262,200
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
2,125,600
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
10,594,900
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
4,329,300
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
11,493,600
- 1093 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
25
RR-01-II
Subdural Grid
Electrode
G-1-10-I
26
RR-01-II
Subdural Grid
Electrode
G-1-10-II
27
RR-01-II
Subdural Grid
Electrode
G-1-10-III
28
RR-02-II
Cote Graft
I-1-03-I
29
RR-02-II
Cote Graft
I-1-03-II
30
RR-02-II
Cote Graft
I-1-03-III
31 RR-03-III
TMJ Prothesis
M-1-60-I
32 RR-03-III
TMJ Prothesis
M-1-60-II
33 RR-03-III
TMJ Prothesis
M-1-60-III
34 RR-04-III
Hip Implant/Knee
Implant
M-1-04-I
35 RR-04-III
Hip Implant/Knee
Implant
M-1-04-II
36 RR-04-III
Hip Implant/Knee
Implant
M-1-04-III
37 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-I
38 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-II
39 RR-05-III
Prostesis
Evar/Tevar/Hevar
I-1-20-III
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
Hip
Replacement/Knee
Replacement
40
YY-01-II
M-1-04-I
41
YY-01-II
42
YY-01-II
43
YY-02-III
PCI
I-1-40-I
44
YY-02-III
PCI
I-1-40-II
45
YY-02-III
PCI
I-1-40-III
46
YY-03-III
Keratoplasty
H-1-30-I
47
YY-03-III
Keratoplasty
H-1-30-II
48
YY-03-III
Keratoplasty
H-1-30-III
M-1-04-II
M-1-04-III
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
RSCM
RSJP-HK
RSAB-HK
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
17,550,200
17,550,200
17,550,200
17,550,200
17,550,200
17,550,200
17,550,200
17,550,200
17,550,200
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
106,426,100
106,426,100
106,426,100
106,426,100
106,426,100
106,426,100
106,426,100
106,426,100
106,426,100
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
22,860,800
22,860,800
22,860,800
22,860,800
22,860,800
22,860,800
22,860,800
22,860,800
22,860,800
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
RSK
DHARMAIS
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,656,400
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,938,500
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
16,745,100
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
26,197,900
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
109,355,400
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
13,099,000
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
21,812,200
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
- 1094 -

REGIONAL 1
TOP UP SPESIAL CMG
NO
KODE
SPECIAL
DESKRIPSI
SPECIAL CMG
KODE CBG
49
YY-04-III
Pancreatectomy
B-1-10-I
50
YY-04-III
Pancreatectomy
B-1-10-II
51
YY-04-III
Pancreatectomy
B-1-10-III
52
YY-05-III
53
YY-05-III
54
YY-05-III
55
YY-06-III
& Radiotheraphy
C-4-12-I
56
YY-06-III
& Radiotheraphy
C-4-12-II
57
YY-06-III
& Radiotheraphy
C-4-12-III
58
YY-07-III
Torakotomi
J-1-30-I
59
YY-07-III
Torakotomi
J-1-30-II
60
YY-07-III
Torakotomi
J-1-30-III
61
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-I
62
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-II
63
YY-08-III
Lobektomi/Bilobekto
mi
J-1-10-III
64
YY-09-III
Vitrectomy
H-1-30-I
65
YY-09-III
Vitrectomy
H-1-30-II
66
YY-09-III
Vitrectomy
H-1-30-III
67 DD-07-II
68 DD-08-II
69 DD-09-II
70 DD-10-II
71 II-01-III
72 II-02-III
73 II-03-III
74 YY-10-III
75 YY-11-III
76 YY-12-III
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Repair of Septal
Prosthesis
Deferiprone (OP)
Deferoksamin (OP)
Deferasirox (OP)
(OP)
Nuclear Medicine
MRI
Diagnostic and
Eye
Phacoemulsification
Microlaringoscopy
Cholangiograph
RSCM
RSJP-HK
RSAB-HK
Q-5-44-0
Q-5-44-0
Q-5-44-0
KELAS
RAWAT
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
-
12,777,200
12,777,200
12,777,200
12,777,200
12,777,200
12,777,200
12,777,200
12,777,200
12,777,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
6,478,000
6,478,000
6,478,000
6,478,000
6,478,000
6,478,000
6,478,000
6,478,000
6,478,000
16,064,100
16,064,100
16,064,100
16,064,100
16,064,100
16,064,100
16,064,100
16,064,100
16,064,100
19,249,400
19,249,400
19,249,400
19,249,400
19,249,400
19,249,400
19,249,400
19,249,400
19,249,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
9,983,400
6,334,400
6,334,400
6,334,400
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,334,400
6,334,400
6,334,400
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,334,400
6,334,400
6,334,400
RSK
DHARMAIS
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
12,191,100
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
48,292,200
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
6,180,900
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
15,327,300
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
18,366,400
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,771,000
6,334,400
6,334,400
6,334,400
Q-5-44-0
10,293,400
10,293,400
10,293,400
10,293,400
Z-3-17-0
Z-3-16-0
2,231,300
3,332,900
2,231,300
3,166,200
2,231,300
3,166,200
2,231,300
3,166,200
H-3-13-0
978,800
929,900
929,900
929,900
H-2-36-0
J-3-15-0
B-3-11-0
4,512,400
2,091,600
5,257,200
3,344,400
1,987,200
4,994,400
3,344,400
1,987,200
4,994,400
3,344,400
1,987,200
4,994,400
I-1-06-I
I-1-06-II
I-1-06-III
- 1095 -
PERHITUNGAN TARIF
SPECIAL GROUPS UNTUK KASUS SUB-AKUT DAN KRONIS
1. Kasus Sub-Akut
LOS = 43 sampai dengan 103
Total tarif = Tarif Fase Akut + Top up payment Fase Sub Akut.
2. Kasus Kronis
LOS = 104 sampai dengan 180
Total tarif = Tarif Fase Akut + Top up payment Fase Sub Akut + Top up payment
Fase Kronis.
Keterangan
Tarif Fase Akut
= Tarif hasil grouping SW INA-CBG versi 4.0.
Top up payment Fase Sub Akut
= 0,375 x RIW fase sub akut x UC x LOS.
Top up payment Fase Kronis
= 0,25 x RIW fase kronis x UC x LOS.
Resource Intensity Weight (RIW)
= ADL Score : 60.
UC (Unit Cost)
= Rp. 879.103,00
LOS (Length Of Stay) rawatan
= Lama rawat pasien dalam 1 episode.
Rumus LOS :
Fase Akut
: Hari 1 sampai dengan 42.
Fase Sub Akut
: Rumus : LOS (LOS-103) - 42.

Bila (LOS-103) hasilnya 0 atau negatif maka, rumus LOS
Fase Akut = LOS-42.
Fase Kronis
: Rumus : LOS 103

Bila hasilnya 0 atau negatif maka LOS Fase Kronis = 0
Karena pasien tersebut dirawat 103 hari (tidak melalui fase
kronis).
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NILA FARID MOELOEK

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PERATURAN MENTERl KESEHATAN REPUBLIK INDONESIA

NOMOR 64 TAHUN 2016

DENGAN RAHMAT TUHAN YANG MAHA ESA

penyelenggaraan program jaminan kesehatan disusun

pemerintahan di bidang keuangan, dengan

memperhatikan kecukupan anggaran;

ditetapkan melalui Peraturan Menteri Kesehatan Nomor

Kesehatan dalam Penyelenggaraan Program Jaminan

sebagaimana dimaksud dalam huruf a;

dimaksud dalam huruf a dan huruf b, perlu menetapkan

Penyelenggaraan Program Jaminan Kesehatan;

: 1. Undang-Undang Nomor 40 Tahun 2004 tentang Sistem

Kesehatan (Lembaran Negara Republik Indonesia 2009

Indonesi Nomor 5063);

Indonesia Tahun 2013 Nomor 29) sebagaimana telah

Peraturan Menteri Kesehatan Nomor 52 Tahun 2016

Penyelenggaraan Program Jaminan Kesehatan (Berita

: PERATURAN MENTERI KESEHATAN TENTANG PERUBAHAN

Kesehatan (Berita Negara Republik Indonesia Tahun 2016

Ketentuan Pasal 25 diubah, sehingga berbunyi sebagai

Besaran tambahan pembayaran pelayanan rawat

Peserta yang menginginkan kelas pelayanan rawat

untuk kenaikan kelas pelayanan rawat inap ke

terhadap tarif INA CBG pada kelas rawat inap

untuk kenaikan kelas pelayanan rawat inap ke

sebesar selisih antara tarif kamar rawat inap

Pembayaran besaran selisih biaya sebagaimana

pemberi kerja; dan/atau

asuransi kesehatan tambahan.

Diantara Pasal 26 dan Pasal 27 disisipkan satu pasal,

Pembayaran atas pasien yang mendapat pelayanan

Pembayaran atas pasien yang mendapat pelayanan

Pembayaran atas pasien yang mendapat pelayanan

Program Jaminan Kesehatan;

Pembayaran atas selisih tarif pelayanan rawat inap

berlaku, menggunakan tarif

Program Jaminan Kesehatan.

Ketentuan dalam Lampiran diubah, sehingga berbunyi

merupakan bagian tidak terpisahkan dari Peraturan

pengundangan Peraturan Menteri ini dengan penempatannya

BERITA NEGARA REPUBLIK INDONESIA TAHUN 2016 NOMOR 1790

Telah diperiksa dan disetujui:

Kepala Pusat Jaminan

DESKRIPSI KODE INA-CBG

INFEKSI SESUDAH OPERASI & TRAUMA (RINGAN)

INFEKSI SESUDAH OPERASI & TRAUMA (BERAT)

DEMAM YANG TIDAK DITENTUKAN (SEDANG)

DEMAM YANG TIDAK DITENTUKAN (BERAT)

INFEKSI VIRAL & NON-BAKTERIAL LAIN (SEDANG)

INFEKSI HIV (SEDANG)

CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN)

CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG)

CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT)

PROSEDUR PANKREAS DAN HEPATOBILLIARI LAINLAIN (RINGAN)

TARIF INA-CBG TAHUN 2016

DESKRIPSI KODE INA-CBG

TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS

GANGGUAN PANKREAS SELAIN TUMOR (SEDANG)

GANGGUAN HATI LAIN-LAIN (RINGAN)

GANGGUAN HATI LAIN-LAIN (SEDANG)

GANGGUAN SALURAN EMPEDU LAIN-LAIN (RINGAN)

GANGGUAN SALURAN EMPEDU LAIN-LAIN (SEDANG)

GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT)