PMK No. 69 TTG Tarif Pelayanan Kesehatan Program JKN

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 69 TAHUN 2013

TENTANG
STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN
TINGKAT PERTAMA DAN FASILITAS KESEHATAN TINGKAT LANJ UTAN DALAM
PENYELENGGARAAN PROGRAM J AMINAN KESEHATAN
DENGAN RAHMAT TUHAN YANG MAHA ESA
MENTERI KESEHATAN REPUBLIK INDONESIA,
Menimbang : bahwa untuk melaksanakan ketentuan Pasal 37 ayat (1)
Peraturan Presiden Nomor 12 Tahun 2013 tentang J aminan
Kesehatan, perlu menetapkan Peraturan Menteri Kesehatan
tentang Standar Tarif Pelayanan Kesehatan bagi Fasilitas
Kesehatan Tingkat Pertama dan Fasilitas Kesehatan Tingkat
Lanjutan Dalam Penyelenggaraan Program J aminan Kesehatan;
Mengingat : 1. Undang-Undang Nomor 40 Tahun 2004 tentang Sistem
J aminan Sosial Nasional (Lembaran Negara Republik
Indonesia Tahun 2004 Nomor 150, Tambahan Lembaran
Negara Republik Indonesia Nomor 4456);
2. Undang-Undang Nomor 36 Tahun 2009 tentang Kesehatan
(Lembaran Negara Republik Indonesia Tahun 2009 Nomor 144,
Tambahan Lembaran Negara Republik Indonesia Nomor 5063);
3. Undang-Undang Nomor 24 Tahun 2011 tentang Badan
Penyelenggara J aminan Sosial (Lembaran Negara Republik
Indonesia Tahun 2011 Nomor 116, Tambahan Lembaran
Negara Republik Indonesia Nomor 5256);
4. Peraturan Presiden Nomor 12 Tahun 2013 tentang J aminan
Kesehatan (Lembaran Negara Republik Indonesia Tahun 2013
Nomor 29);
MEMUTUSKAN :
Menetapkan : PERATURAN MENTERI KESEHATAN TENTANG STANDAR
TARIF PELAYANAN KESEHATAN PADA FASILITAS
KESEHATAN TINGKAT PERTAMA DAN FASILITAS
KESEHATAN TINGKAT LANJ UTAN DALAM
PENYELENGGARAAN PROGRAM J AMINAN KESEHATAN.
- 2 -
Pasal 1
Dalam Peraturan Menteri ini yang dimaksud dengan :
1. Tarif Kapitasi adalah besaran pembayaran per-bulan yang dibayar dimuka oleh
BPJ S Kesehatan kepada Fasilitas Kesehatan Tingkat Pertama berdasarkan
jumlah peserta yang terdaftar tanpa memperhitungkan jenis dan jumlah
pelayanan kesehatan yang diberikan.
2. Tarif Non Kapitasi adalah besaran pembayaran klaim oleh BPJ S Kesehatan
kepada Fasilitas Kesehatan Tingkat Pertama berdasarkan jenis dan jumlah
pelayanan kesehatan yang diberikan.
3. Tarif Indonesian - Case Based Groups yang selanjutnya disebut Tarif INA-CBGs
adalah besaran pembayaran klaim oleh BPJ S Kesehatan kepada Fasilitas
Kesehatan Tingkat Lanjutan atas paket layanan yang didasarkan kepada
pengelompokan diagnosis penyakit.
Pasal 2
(1) Tarif pelayanan kesehatan pada Fasilitas Kesehatan Tingkat Pertama meliputi:
a. Tarif Kapitasi
b. Tarif Non Kapitasi
(2) Tarif pelayanan kesehatan sebagaimana dimaksud pada ayat (1) tercantum
dalam Lampiran I yang merupakan bagian tidak terpisahkan dari Peraturan
Menteri ini.
Pasal 3
(1) Tarif Kapitasi sebagaimana dimaksud dalam Pasal 2 ayat (1) huruf a merupakan
rentang nilai yang besarannya untuk setiap Fasilitas Kesehatan Tingkat Pertama
ditetapkan berdasarkan seleksi dan kredensial yang dilakukan oleh BPJ S
Kesehatan sesuai dengan ketentuan peraturan perundang-undangan.
(2) Tarif Kapitasi sebagaimana dimaksud pada ayat (1) diberlakukan bagi Fasilitas
Kesehatan Tingkat Pertama yang melaksanakan pelayanan kesehatan
komprehensif kepada Peserta Program J aminan Kesehatan berupa Rawat J alan
Tingkat Pertama.
(3) Tarif Non Kapitasi sebagaimana dimaksud Pasal 2 ayat (1) huruf b merupakan
nilai besaran yang sama bagi seluruh Fasilitas Kesehatan Tingkat Pertama yang
melaksanakan pelayanan kesehatan kepada Peserta Program J aminan
Kesehatan berupa Rawat Inap Tingkat Pertama dan pelayanan Kebidanan dan
Neonatal.
- 3 -
(4) Pembiayaan untuk pelayanan ambulans, pelayanan obat rujuk balik, pelayanan
skrining kesehatan tertentu, dan/atau pelayanan kesehatan pada daerah
terpencil dan kepulauan dibayar oleh BPJ S Kesehatan yang diatur lebih lanjut
dengan Peraturan BPJ S Kesehatan.
Pasal 4
(1) Tarif INA-CBGs meliputi:
a. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit kelas A, kelas B,
kelas C dan kelas D dalam regional 1;
b. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit kelas A, kelas B,
c. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit kelas A, kelas B,
d. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit kelas A, kelas B,
e. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit kelas A, kelas B,
f. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit umum rujukan
nasional; dan
g. tarif pelayanan kesehatan yang dilakukan oleh rumah sakit khusus rujukan
nasional.
(2) Penetapan regional sebagaimana dimaksud pada ayat (1) huruf a sampai
dengan huruf e, bagi setiap Fasilitas Kesehatan Tingkat Lanjutan merupakan
hasil kesepakatan bersama antara BPJ S Kesehatan dengan Asosiasi Fasilitas
Kesehatan Tingkat Lanjutan.
(3) Tarif rawat jalan di Fasilitas Kesehatan Tingkat Lanjutan berupa Klinik Utama
atau yang setara diberlakukan tarif sebesar 50% (lima puluh persen) dari standar
Tarif INA-CBGs untuk kelompok rumah sakit kelas D.
(4) Tarif rawat inap di Fasilitas Kesehatan Tingkat Lanjutan berupa Klinik Utama
atau yang setara diberlakukan tarif sebesar 35% (tiga puluh lima persen) dari
standar Tarif INA-CBGs untuk kelompok rumah sakit kelas D dengan perawatan
kelas III.
(5) Tarif INA-CBGs sebagaimana dimaksud pada ayat (1) tercantum dalam
Lampiran II yang merupakan bagian tidak terpisahkan dari Peraturan Menteri ini.
Pasal 5
Pedoman Teknis Pelaksanaan Peraturan Menteri ini ditetapkan oleh BPJ S
Kesehatan setelah berkoordinasi dengan Menteri.
- 4 -
Pasal 6
Peraturan Menteri ini mulai berlaku pada tanggal 1 J anuari 2014.
Agar setiap orang mengetahuinya, memerintahkan pengundangan Peraturan Menteri
ini dengan penempatannya dalam Berita Negara Republik Indonesia.
Ditetapkan di J akarta
pada tanggal 1 November 2013
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NAFSIAH MBOI
Diundangkan di J akarta
pada tanggal
MENTERI HUKUM DAN HAK ASASI MANUSIA
REPUBLIK INDONESIA,
ttd
AMIR SYAMSUDIN
BERITA NEGARA REPUBLIK INDONESIA TAHUN 2013 NOMOR

- 5 -

LAMPIRAN I
PERATURAN MENTERI KESEHATAN
NOMOR 69 TAHUN 2013
TENTANG STANDAR TARIF PELAYANAN
KESEHATAN PADA FASILITAS
KESEHATAN TINGKAT PERTAMA DAN
FASILITAS KESEHATAN TINGKAT
LANJ UTAN DALAM PENYELENGGARAAN
PROGRAM J AMINAN KESEHATAN

STANDAR TARIF PELAYANAN KESEHATAN PADA
FASILITAS KESEHATAN TINGKAT PERTAMA

I. TARIF KAPITASI UNTUK PELAYANAN KESEHATAN RAWAT J ALAN TINGKAT
PERTAMA

A. TARIF KAPITASI DI PUSKESMAS
NO PUSKESMAS TARIF (Rp)
1 Puskesmas atau Fasilitas Kesehatan yang setara 3.000 - 6.000

B. TARIF KAPITASI DI RS PRATAMA, KLINIK PRATAMA, DOKTER PRAKTEK,
DOKTER GIGI PRAKTEK

NO J ENIS FASILITAS KESEHATAN PRIMER MILIK SWASTA TARIF (Rp)
1 RS. Pratama, Klinik Pratama, Praktek Dokter, atau
Fasilitas Kesehatan yang setara
8.000 - 10.000
2 Praktik Dokter Gigi di luar Fasilitas Kesehatan A1 atau
B1
2.000

II. TARIF NON KAPITASI UNTUK PELAYANAN KESEHATAN RAWAT INAP TINGKAT
PERTAMA DAN PELAYANAN MATERNAL DAN NEONATAL

A. TARIF NON KAPITASI

NO J ENIS PELAYANAN TARIF (Rp)
1 Paket Rawat Inap per hari untuk Fasilitas Kesehatan
berupa Puskesmas dengan perawatan, Rumah Sakit
Kelas D Pratama, dan Klinik Pratama
100.000

- 6 -

B. TARIF NON KAPITASI PELAYANAN KESEHATAN KEBIDANAN DAN NEONATAL

NO J ENIS PELAYANAN TARIF (Rp)
1 Pemeriksaan ANC 25.000
2 Persalinan pervaginam normal 600.000
3 Penanganan perdarahan paska keguguran, persalinan
pervaginam dengan tindakan emergensi dasar
750.000
4 Pemeriksaan PNC/neonates 25.000
5 Pelayanan tindakan paska persalinan (mis. placenta
manual)
175.000
6 Pelayanan pra rujukan pada komplikasi kebidanan dan
neonatal
125.000
7 Pelayanan KB pemasangan:
- IUD/Implant
- Suntik

100.000
15.000
8 Penanganan komplikasi KB paska persalinan 125.000

MENTERI KESEHATAN
REPUBLIK INDONESIA,

ttd

NAFSIAH MBOI

- 7 -

LAMPIRAN II
PERATURAN MENTERI KESEHATAN
NOMOR 69 TAHUN 2013
TENTANG STANDAR TARIF
PELAYANAN KESEHATAN PADA
FASILITAS KESEHATAN TINGKAT
PERTAMA DAN FASILITAS
KESEHATAN TINGKAT LANJ UTAN
DALAM PENYELENGGARAAN
PROGRAM J AMINAN KESEHATAN

STANDAR TARIF PELAYANAN KESEHATAN PADA
FASILITAS KESEHATAN TINGKAT LANJ UTAN
(INA-CBGs)

No
Kode INA-
CBG
Deskripsi Kode INA-CBG Tarif Kelas 3 Tarif Kelas 2 Tarif Kelas 1
1 A-4-10-I SEPTIKEMIA RINGAN 3.255.749 3.906.899 4.558.049
2 A-4-10-II SEPTIKEMIA SEDANG 5.562.095 6.674.514 7.786.933
3 A-4-10-III SEPTIKEMIA BERAT 7.855.880 9.427.056 10.998.232
4 A-4-11-I INFEKSI SESUDAH OPERASI & TRAUMA RINGAN 7.088.577 8.506.292 9.924.007
5 A-4-11-II INFEKSI SESUDAH OPERASI & TRAUMA SEDANG 12.485.416 14.982.500 17.479.583
6 A-4-11-III INFEKSI SESUDAH OPERASI & TRAUMA BERAT 20.422.950 24.507.540 28.592.130
7 A-4-12-I DEMAM RINGAN 3.568.515 4.282.218 4.995.921
8 A-4-12-II DEMAM SEDANG 4.443.939 5.332.727 6.221.514
9 A-4-12-III DEMAM BERAT 4.742.946 5.691.536 6.640.125
10 A-4-13-I INFEKSI NON BAKTERI RINGAN 4.546.533 5.455.839 6.365.146
11 A-4-13-II INFEKSI NON BAKTERI SEDANG 5.369.563 6.443.476 7.517.389
12 A-4-13-III INFEKSI NON BAKTERI BERAT 6.750.986 8.101.183 9.451.380
13 A-4-14-I PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN RINGAN 3.783.365 4.540.038 5.296.710
14 A-4-14-II PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN SEDANG 4.866.364 5.839.637 6.812.910
15 A-4-14-III PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN BERAT 5.575.708 6.690.850 7.805.992
16 A-4-15-I INFEKSI HIV RINGAN 5.682.628 6.819.154 7.955.679
17 A-4-15-II INFEKSI HIV SEDANG 8.506.218 10.207.462 11.908.705
18 A-4-15-III INFEKSI HIV BERAT 10.674.537 12.809.444 14.944.352
19 B-1-01-I PROSEDUR PENCANGKOKAN HATI RINGAN 58.061.438 69.673.726 81.286.013
20 B-1-01-II PROSEDUR PENCANGKOKAN HATI SEDANG 64.057.111 76.868.533 89.679.955
21 B-1-01-III PROSEDUR PENCANGKOKAN HATI BERAT 112.369.422 134.843.306 157.317.191
22 B-1-10-I PROSEDUR HATI DAN PANKREAS RINGAN 7.527.158 9.032.589 10.538.021
23 B-1-10-II PROSEDUR HATI DAN PANKREAS SEDANG 19.183.723 23.020.467 26.857.212
24 B-1-10-III PROSEDUR HATI DAN PANKREAS BERAT 32.727.261 39.272.713 45.818.165
25 B-1-11-I PROSEDUR SALURAN EMPEDU KOMPLEK (RINGAN) 5.050.813 6.060.975 7.071.138
26 B-1-11-II PROSEDUR SALURAN EMPEDU KOMPLEK (SEDANG) 12.624.649 15.149.579 17.674.509
27 B-1-11-III PROSEDUR SALURAN EMPEDU KOMPLEK (BERAT) 15.858.679 19.030.415 22.202.151
28 B-1-12-I PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK RINGAN 8.770.435 10.524.522 12.278.608
29 B-1-12-II PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK SEDANG 18.796.970 22.556.365 26.315.759
30 B-1-12-III PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK BERAT 22.877.106 27.452.527 32.027.948
31 B-1-13-I PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (RINGAN) 7.056.673 8.468.007 9.879.342
32 B-1-13-II PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (SEDANG) 11.494.221 13.793.065 16.091.909
33 B-1-13-III PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (BERAT) 16.945.678 20.334.814 23.723.950
34 B-1-14-I PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK RINGAN 9.598.716 11.518.460 13.438.203
35 B-1-14-II PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK SEDANG 10.675.509 12.810.611 14.945.712
36 B-1-14-III PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK BERAT 16.700.671 20.040.805 23.380.939
37 B-4-10-I SIROSIS DAN HEPATITIS ALKOHOLIK RINGAN 2.969.822 3.563.787 4.157.751
38 B-4-10-II SIROSIS DAN HEPATITIS ALKOHOLIK SEDANG 4.740.768 5.688.921 6.637.075
39 B-4-10-III SIROSIS DAN HEPATITIS ALKOHOLIK BERAT 6.539.988 7.847.985 9.155.983
40 B-4-11-I TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS RINGAN 6.261.607 7.513.928 8.766.250
41 B-4-11-II TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS SEDANG 9.385.998 11.263.198 13.140.398
42 B-4-11-III TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS BERAT 10.620.246 12.744.295 14.868.344
43 B-4-12-I GANGGUAN PANKREAS SELAIN TUMOR (RINGAN) 5.661.174 6.793.409 7.925.644
44 B-4-12-II GANGGUAN PANKREAS SELAIN TUMOR (SEDANG) 8.061.242 9.673.490 11.285.738
45 B-4-12-III GANGGUAN PANKREAS SELAIN TUMOR (BERAT) 17.323.768 20.788.522 24.253.276
46 B-4-13-I
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU HEPATITIS
ALKOHOLIK RINGAN
5.684.451 6.821.341 7.958.232
47 B-4-13-II
ALKOHOLIK SEDANG
6.622.215 7.946.658 9.271.102
48 B-4-13-III
ALKOHOLIK BERAT
9.812.573 11.775.088 13.737.603
49 B-4-14-I GANGGUAN SALURAN EMPEDU LAIN-LAIN RINGAN 5.678.410 6.814.092 7.949.773
50 B-4-14-II GANGGUAN SALURAN EMPEDU LAIN-LAIN SEDANG 6.624.572 7.949.487 9.274.401
51 B-4-14-III GANGGUAN SALURAN EMPEDU LAIN-LAIN BERAT 8.873.791 10.648.550 12.423.308
52 C-4-10-I LEUKEMIA AKUT RINGAN 4.990.840 5.989.008 6.987.176
53 C-4-10-II LEUKEMIA AKUT SEDANG 10.422.665 12.507.198 14.591.730
54 C-4-10-III LEUKEMIA AKUT BERAT 18.079.332 21.695.199 25.311.065
55 C-4-11-I LIMFOMA & LEUKEMIA NON AKUT RINGAN 5.687.324 6.824.789 7.962.253
56 C-4-11-II LIMFOMA & LEUKEMIA NON AKUT SEDANG 7.610.507 9.132.609 10.654.710
57 C-4-11-III LIMFOMA & LEUKEMIA NON AKUT BERAT 11.843.707 14.212.449 16.581.190
58 C-4-12-I RADIOTERAPI RINGAN 3.786.769 4.544.123 5.301.477
59 C-4-12-II RADIOTERAPI SEDANG 9.453.587 11.344.305 13.235.022
60 C-4-12-III RADIOTERAPI BERAT 19.155.589 22.986.707 26.817.825
Tarif INA-CBG 2013 Regional 1
Rumah Sakit Kelas A
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
61 C-4-13-I KEMOTERAPI RINGAN 3.687.683 4.425.220 5.162.756
62 C-4-13-II KEMOTERAPI SEDANG 6.940.277 8.328.332 9.716.388
63 C-4-13-III KEMOTERAPI BERAT 9.582.621 11.499.145 13.415.670
64 C-4-14-I TUMOR MYELOPROLIFERATIF LAIN-LAIN RINGAN 4.730.302 5.676.363 6.622.423
65 C-4-14-II TUMOR MYELOPROLIFERATIF LAIN-LAIN SEDANG 6.635.581 7.962.697 9.289.813
66 C-4-14-III TUMOR MYELOPROLIFERATIF LAIN-LAIN BERAT 9.886.903 11.864.284 13.841.665
67 D-1-10-I PROSEDUR PENCANGKOKAN SUMSUM TULANG RINGAN 37.152.517 44.583.020 52.013.524
68 D-1-10-II PROSEDUR PENCANGKOKAN SUMSUM TULANG SEDANG 56.585.975 67.903.170 79.220.365
69 D-1-10-III PROSEDUR PENCANGKOKAN SUMSUM TULANG BERAT 76.689.669 92.027.602 107.365.536
70 D-1-11-I PROSEDUR LIMPA RINGAN 7.651.752 9.182.102 10.712.453
71 D-1-11-II PROSEDUR LIMPA SEDANG 19.538.385 23.446.062 27.353.739
72 D-1-11-III PROSEDUR LIMPA BERAT 30.617.128 36.740.554 42.863.980
73 D-1-20-I
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK DARAH LAIN-
LAIN (RINGAN)
8.334.933 10.001.920 11.668.907
74 D-1-20-II
LAIN (SEDANG)
22.969.906 27.563.887 32.157.868
75 D-1-20-III
LAIN (BERAT)
36.437.059 43.724.471 51.011.882
76 D-4-10-I AGRANULOSITOSIS RINGAN 3.633.342 4.360.010 5.086.679
77 D-4-10-II AGRANULOSITOSIS SEDANG 5.962.600 7.155.120 8.347.639
78 D-4-10-III AGRANULOSITOSIS BERAT 9.380.599 11.256.719 13.132.838
79 D-4-11-I GANGGUAN PEMBEKUAN DARAH RINGAN 6.605.385 7.926.462 9.247.538
80 D-4-11-II GANGGUAN PEMBEKUAN DARAH SEDANG 13.478.590 16.174.308 18.870.026
81 D-4-11-III GANGGUAN PEMBEKUAN DARAH BERAT 18.516.307 22.219.569 25.922.830
82 D-4-12-I KRISIS ANEMIA SEL SICKLE RINGAN 4.477.012 5.372.414 6.267.817
83 D-4-12-II KRISIS ANEMIA SEL SICKLE SEDANG 6.209.635 7.451.562 8.693.489
84 D-4-12-III KRISIS ANEMIA SEL SICKLE BERAT 9.535.165 11.442.198 13.349.231
85 D-4-13-I
GANGGUAN SEL DARAH MERAH SELAIN KRISIS ANEMIA SEL SICKLE
RINGAN
3.663.961 4.396.754 5.129.546
86 D-4-13-II
SEDANG
5.185.827 6.222.992 7.260.158
87 D-4-13-III
BERAT
6.632.822 7.959.387 9.285.951
88 D-4-14-I
GANGGUAN PADA DARAH & ORGAN PEMBENTUK DARAH LAIN-
LAIN (RINGAN)
4.114.952 4.937.943 5.760.933
89 D-4-14-II
LAIN (SEDANG)
8.680.331 10.416.397 12.152.463
90 D-4-14-III
LAIN (BERAT)
11.217.841 13.461.409 15.704.977
91 E-1-01-I PROSEDUR KELENJAR PITUITARI DAN PINEAL RINGAN 8.202.680 9.843.216 11.483.751
92 E-1-01-II PROSEDUR KELENJAR PITUITARI DAN PINEAL SEDANG 11.416.725 13.700.070 15.983.414
93 E-1-01-III PROSEDUR KELENJAR PITUITARI DAN PINEAL BERAT 26.999.387 32.399.264 37.799.142
94 E-1-10-I PROSEDUR KELENJAR ADRENAL RINGAN 8.528.124 10.233.749 11.939.373
95 E-1-10-II PROSEDUR KELENJAR ADRENAL SEDANG 10.350.517 12.420.620 14.490.723
96 E-1-10-III PROSEDUR KELENJAR ADRENAL BERAT 21.816.068 26.179.282 30.542.495
97 E-1-20-I
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN TIROGLOSAL
RINGAN
9.654.576 11.585.491 13.516.406
98 E-1-20-II
SEDANG
12.994.791 15.593.750 18.192.708
99 E-1-20-III
BERAT
25.869.205 31.043.046 36.216.887
100 E-4-10-I
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK
RINGAN
4.735.965 5.683.157 6.630.350
101 E-4-10-II
SEDANG
6.617.569 7.941.083 9.264.597
102 E-4-10-III
BERAT
11.864.316 14.237.179 16.610.042
103 E-4-11-I HIPOVOLEMIA & GANGGUAN ELEKROLIT RINGAN 3.795.353 4.554.423 5.313.494
104 E-4-11-II HIPOVOLEMIA & GANGGUAN ELEKROLIT SEDANG 5.786.435 6.943.722 8.101.009
105 E-4-11-III HIPOVOLEMIA & GANGGUAN ELEKROLIT BERAT 11.325.819 13.590.983 15.856.147
106 E-4-12-I GANGGUAN METABOLIK BAWAAN RINGAN 4.360.859 5.233.030 6.105.202
107 E-4-12-II GANGGUAN METABOLIK BAWAAN SEDANG 7.551.897 9.062.276 10.572.656
108 E-4-12-III GANGGUAN METABOLIK BAWAAN BERAT 11.337.984 13.605.581 15.873.177
109 E-4-13-I GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN RINGAN 4.748.818 5.698.582 6.648.346
110 E-4-13-II GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN SEDANG 7.880.031 9.456.037 11.032.043
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
111 E-4-13-III GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN BERAT 11.119.624 13.343.549 15.567.474
112 F-4-10-I SCHIZOFRENIA RINGAN 5.635.386 6.762.463 7.889.540
113 F-4-10-II SCHIZOFRENIA SEDANG 6.236.892 7.484.270 8.731.649
114 F-4-10-III SCHIZOFRENIA BERAT 9.233.857 11.080.629 12.927.400
115 F-4-11-I DEPRESI MAYOR RINGAN 5.201.744 6.242.093 7.282.441
116 F-4-11-II DEPRESI MAYOR SEDANG 6.060.604 7.272.725 8.484.845
117 F-4-11-III DEPRESI MAYOR BERAT 7.771.942 9.326.331 10.880.719
118 F-4-12-I GANGGUAN PERSONALITI & KONTROL IMPULSE RINGAN 2.851.427 3.421.712 3.991.997
119 F-4-12-II GANGGUAN PERSONALITI & KONTROL IMPULSE SEDANG 4.053.868 4.864.642 5.675.416
120 F-4-12-III GANGGUAN PERSONALITI & KONTROL IMPULSE BERAT 8.806.706 10.568.047 12.329.388
121 F-4-13-I GANGGUAN BIPOLAR RINGAN 4.190.128 5.028.154 5.866.180
122 F-4-13-II GANGGUAN BIPOLAR SEDANG 5.528.988 6.634.786 7.740.584
123 F-4-13-III GANGGUAN BIPOLAR BERAT 7.157.995 8.589.594 10.021.193
124 F-4-14-I DEPRESI RINGAN 2.390.710 2.868.851 3.346.993
125 F-4-14-II DEPRESI SEDANG 3.066.345 3.679.614 4.292.883
126 F-4-14-III DEPRESI BERAT 4.126.033 4.951.239 5.776.446
127 F-4-15-I NEUROSA SELAIN DEPRESI RINGAN 3.807.295 4.568.754 5.330.213
128 F-4-15-II NEUROSA SELAIN DEPRESI SEDANG 5.673.403 6.808.084 7.942.765
129 F-4-15-III NEUROSA SELAIN DEPRESI BERAT 7.490.725 8.988.870 10.487.015
130 F-4-16-I GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL RINGAN 7.491.055 8.989.266 10.487.478
131 F-4-16-II GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL SEDANG 8.709.650 10.451.580 12.193.511
132 F-4-16-III GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL BERAT 11.625.895 13.951.074 16.276.253
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK RINGAN 1.769.071 2.122.885 2.476.699
134 F-4-17-II GANGGUAN MENTAL PADA KANAK-KANAK SEDANG 5.185.045 6.222.054 7.259.063
135 F-4-17-III GANGGUAN MENTAL PADA KANAK-KANAK BERAT 5.531.975 6.638.370 7.744.765
136 F-4-18-I GANGGUAN NUTRISI KOMPULSIF RINGAN 6.509.188 7.811.025 9.112.863
137 F-4-18-II GANGGUAN NUTRISI KOMPULSIF SEDANG 7.161.945 8.594.334 10.026.723
138 F-4-18-III GANGGUAN NUTRISI KOMPULSIF BERAT 11.040.731 13.248.877 15.457.024
139 F-4-19-I GANGGUAN MENTAL LAIN-LAIN RINGAN 4.974.576 5.969.492 6.964.407
140 F-4-19-II GANGGUAN MENTAL LAIN-LAIN SEDANG 6.370.123 7.644.148 8.918.173
141 F-4-19-III GANGGUAN MENTAL LAIN-LAIN BERAT 7.930.815 9.516.978 11.103.141
142 G-1-01-I PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL RINGAN 16.192.299 19.430.758 22.669.218
143 G-1-01-II PROSEDUR PEMBULUH DARAH INTRA KRANIAL SEDANG 24.253.344 29.104.013 33.954.682
144 G-1-01-III PROSEDUR PEMBULUH DARAH INTRA KRANIAL BERAT 53.057.680 63.669.216 74.280.752
145 G-1-10-I PROSEDUR KRANIOTOMI RINGAN 18.240.128 21.888.154 25.536.179
146 G-1-10-II PROSEDUR KRANIOTOMI SEDANG 21.597.674 25.917.209 30.236.743
147 G-1-10-III PROSEDUR KRANIOTOMI BERAT 23.021.720 27.626.064 32.230.408
148 G-1-11-I PROSEDUR VENTRICULAR SHUNT RINGAN 9.155.994 10.987.192 12.818.391
149 G-1-11-II PROSEDUR VENTRICULAR SHUNT SEDANG 18.767.440 22.520.927 26.274.415
150 G-1-11-III PROSEDUR VENTRICULAR SHUNT BERAT 39.214.996 47.057.995 54.900.994
151 G-1-12-I PROSEDUR PEMBULUH DARAH EXTRA KRANIAL RINGAN 6.338.553 7.606.263 8.873.974
152 G-1-12-II PROSEDUR PEMBULUH DARAH EXTRA KRANIAL SEDANG 13.260.946 15.913.135 18.565.324
153 G-1-12-III PROSEDUR PEMBULUH DARAH EXTRA KRANIAL BERAT 23.389.401 28.067.281 32.745.161
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE RINGAN 1.912.163 2.294.595 2.677.028
155 G-1-13-II PROSEDUR CARPAL TUNNEL RELEASE SEDANG 5.135.098 6.162.118 7.189.138
156 G-1-13-III PROSEDUR CARPAL TUNNEL RELEASE BERAT 11.587.044 13.904.453 16.221.862
157 G-1-20-I PROSEDUR SARAF KRANIAL DAN PERIFER RINGAN 13.955.069 16.746.083 19.537.097
158 G-1-20-II PROSEDUR SARAF KRANIAL DAN PERIFER SEDANG 18.120.413 21.744.496 25.368.579
159 G-1-20-III PROSEDUR SARAF KRANIAL DAN PERIFER BERAT 36.007.009 43.208.411 50.409.812
160 G-1-30-I PROSEDUR TULANG BELAKANG RINGAN 11.422.467 13.706.961 15.991.454
161 G-1-30-II PROSEDUR TULANG BELAKANG SEDANG 29.837.071 35.804.486 41.771.900
162 G-1-30-III PROSEDUR TULANG BELAKANG BERAT 38.427.115 46.112.538 53.797.960
163 G-4-10-I KECEDERAAN & GANGGUAN TULANG BELAKANG RINGAN 5.440.985 6.529.182 7.617.379
164 G-4-10-II KECEDERAAN & GANGGUAN TULANG BELAKANG SEDANG 6.650.692 7.980.830 9.310.969
165 G-4-10-III KECEDERAAN & GANGGUAN TULANG BELAKANG BERAT 9.125.908 10.951.089 12.776.271
166 G-4-11-I
TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF
RINGAN
7.377.991 8.853.590 10.329.188
167 G-4-11-II
TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF
SEDANG
9.800.699 11.760.839 13.720.979
168 G-4-11-III TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF BERAT 14.400.618 17.280.741 20.160.865
169 G-4-12-I SKLEROSIS MULTIPLE & ATAXIA CEREBELAR RINGAN 6.318.844 7.582.612 8.846.381
170 G-4-12-II SKLEROSIS MULTIPLE & ATAXIA CEREBELAR SEDANG 7.981.120 9.577.344 11.173.568
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
171 G-4-12-III SKLEROSIS MULTIPLE & ATAXIA CEREBELAR BERAT 11.591.650 13.909.980 16.228.310
172 G-4-13-I PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK RINGAN 3.795.862 4.555.035 5.314.207
173 G-4-13-II PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK SEDANG 6.619.132 7.942.959 9.266.785
174 G-4-13-III PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK BERAT 7.850.426 9.420.511 10.990.596
175 G-4-14-I KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK RINGAN 6.439.122 7.726.946 9.014.770
176 G-4-14-II KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK SEDANG 8.608.741 10.330.489 12.052.238
177 G-4-14-III KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK BERAT 10.804.951 12.965.941 15.126.931
178 G-4-15-I
KECEDERAAN PEMBULUH DARAH OTAK NON SPESIFIK &
PENYUMBATAN PRE-CEREBRAL TANPA INFARK RINGAN
5.261.316 6.313.579 7.365.842
179 G-4-15-II
PENYUMBATAN PRE-CEREBRAL TANPA INFARK SEDANG
6.279.156 7.534.987 8.790.818
180 G-4-15-III
PENYUMBATAN PRE-CEREBRAL TANPA INFARK BERAT
8.862.478 10.634.973 12.407.469
181 G-4-16-I ISKEMIK TRANSIENT RINGAN 4.337.295 5.204.754 6.072.213
182 G-4-16-II ISKEMIK TRANSIENT SEDANG 5.758.286 6.909.943 8.061.600
183 G-4-16-III ISKEMIK TRANSIENT BERAT 11.844.914 14.213.897 16.582.879
184 G-4-17-I GANGUAN PERSARAFAN KRANIAL DAN PERIFER RINGAN 5.776.986 6.932.383 8.087.780
185 G-4-17-II GANGUAN PERSARAFAN KRANIAL DAN PERIFER SEDANG 7.574.845 9.089.814 10.604.783
186 G-4-17-III GANGUAN PERSARAFAN KRANIAL DAN PERIFER BERAT 12.695.951 15.235.142 17.774.332
187 G-4-18-I INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN RINGAN 5.689.372 6.827.247 7.965.121
188 G-4-18-II INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN SEDANG 7.605.064 9.126.077 10.647.090
189 G-4-18-III INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN BERAT 8.509.440 10.211.328 11.913.215
190 G-4-19-I
INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK TERMASUK
MENINGITIS VIRUS) RINGAN
4.746.844 5.696.212 6.645.581
191 G-4-19-II
MENINGITIS VIRUS) SEDANG
8.023.254 9.627.904 11.232.555
192 G-4-19-III
MENINGITIS VIRUS) BERAT
11.649.252 13.979.102 16.308.953
193 G-4-20-I MENINGITIS VIRUS RINGAN 3.320.610 3.984.733 4.648.855
194 G-4-20-II MENINGITIS VIRUS SEDANG 4.694.349 5.633.219 6.572.089
195 G-4-20-III MENINGITIS VIRUS BERAT 7.753.944 9.304.733 10.855.522
196 G-4-21-I KOMA & STUPOR NON TRAUMA (RINGAN) 3.457.901 4.149.482 4.841.062
197 G-4-21-II KOMA & STUPOR NON TRAUMA (SEDANG) 5.852.537 7.023.045 8.193.552
198 G-4-21-III KOMA & STUPOR NON TRAUMA (BERAT) 6.878.085 8.253.702 9.629.319
199 G-4-22-I SERANGAN KEJANG RINGAN 3.590.852 4.309.023 5.027.193
200 G-4-22-II SERANGAN KEJANG SEDANG 4.588.096 5.505.715 6.423.334
201 G-4-22-III SERANGAN KEJANG BERAT 5.360.973 6.433.168 7.505.362
202 G-4-23-I MIGREN DAN SAKIT KEPALA LAIN (RINGAN) 3.782.154 4.538.585 5.295.015
203 G-4-23-II MIGREN DAN SAKIT KEPALA LAIN (SEDANG 4.745.390 5.694.468 6.643.546
204 G-4-23-III MIGREN DAN SAKIT KEPALA LAIN (BERAT) 6.756.206 8.107.447 9.458.688
205 G-4-24-I TRAUMA KEPALA RINGAN 3.791.557 4.549.868 5.308.179
206 G-4-24-II TRAUMA KEPALA SEDANG 4.736.971 5.684.365 6.631.759
207 G-4-24-III TRAUMA KEPALA BERAT 9.170.986 11.005.183 12.839.380
208 G-4-25-I GEGAR OTAK RINGAN 3.239.838 3.887.806 4.535.773
209 G-4-25-II GEGAR OTAK SEDANG 4.097.070 4.916.484 5.735.898
210 G-4-25-III GEGAR OTAK BERAT 5.429.432 6.515.318 7.601.204
211 G-4-26-I GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (RINGAN) 5.688.612 6.826.335 7.964.057
212 G-4-26-II GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (SEDANG) 6.617.628 7.941.154 9.264.680
213 G-4-26-III GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (BERAT) 10.351.232 12.421.479 14.491.725
214 H-1-20-I PROSEDUR EKTRAOKULER DAN MATA RINGAN 12.114.759 14.537.711 16.960.663
215 H-1-20-II PROSEDUR EKTRAOKULER DAN MATA SEDANG 13.388.711 16.066.453 18.744.195
216 H-1-20-III PROSEDUR EKTRAOKULER DAN MATA BERAT 18.207.810 21.849.372 25.490.934
217 H-1-30-I PROSEDUR LENSA DAN INTRA OKULER RINGAN 4.670.726 5.604.871 6.539.016
218 H-1-30-II PROSEDUR LENSA DAN INTRA OKULER SEDANG 8.217.817 9.861.380 11.504.943
219 H-1-30-III PROSEDUR LENSA DAN INTRA OKULER BERAT 9.141.020 10.969.223 12.797.427
220 H-4-10-I INFEKSI MATA AKUT MAYOR (RINGAN) 5.681.479 6.817.774 7.954.070
221 H-4-10-II INFEKSI MATA AKUT MAYOR (SEDANG) 7.708.511 9.250.214 10.791.916
222 H-4-10-III INFEKSI MATA AKUT MAYOR (BERAT) 15.151.510 18.181.812 21.212.114
223 H-4-11-I GANGGUAN PERSARAFAN MATA RINGAN 3.785.205 4.542.245 5.299.286
224 H-4-11-II GANGGUAN PERSARAFAN MATA SEDANG 4.317.852 5.181.422 6.044.992
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
225 H-4-11-III GANGGUAN PERSARAFAN MATA BERAT 6.182.809 7.419.371 8.655.933
226 H-4-12-I GANGGUAN MATA LAIN-LAIN (RINGAN) 4.462.786 5.355.343 6.247.901
227 H-4-12-II GANGGUAN MATA LAIN-LAIN (SEDANG) 5.332.281 6.398.737 7.465.194
228 H-4-12-III GANGGUAN MATA LAIN-LAIN (BERAT) 8.935.915 10.723.098 12.510.281
229 I-1-01-I PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG RINGAN 75.322.874 90.387.449 105.452.023
230 I-1-01-II PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG SEDANG 76.979.901 92.375.882 107.771.862
231 I-1-01-III PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG BERAT 121.511.760 145.814.112 170.116.464
232 I-1-02-I PROSEDUR KATUP JANTUNG DENGAN KATETERISASI RINGAN 41.788.819 50.146.583 58.504.347
233 I-1-02-II PROSEDUR KATUP JANTUNG DENGAN KATETERISASI SEDANG 53.907.057 64.688.469 75.469.880
234 I-1-02-III PROSEDUR KATUP JANTUNG DENGAN KATETERISASI BERAT 66.443.771 79.732.525 93.021.279
235 I-1-03-I
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG
ANOMALI RINGAN
25.695.740 30.834.888 35.974.036
236 I-1-03-II
ANOMALI SEDANG
31.204.530 37.445.436 43.686.342
237 I-1-03-III
ANOMALI BERAT
48.469.577 58.163.492 67.857.408
238 I-1-04-I
PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG
RINGAN
43.105.487 51.726.584 60.347.682
239 I-1-04-II
SEDANG
68.032.035 81.638.442 95.244.849
240 I-1-04-III
BERAT
108.680.778 130.416.934 152.153.089
241 I-1-05-I
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH KORONER DENGAN
KATETERISASI JANTUNG RINGAN
55.308.275 66.369.930 77.431.585
242 I-1-05-II
KATETERISASI JANTUNG SEDANG
66.370.200 79.644.240 92.918.280
243 I-1-05-III
KATETERISASI JANTUNG BERAT
91.324.834 109.589.800 127.854.767
244 I-1-06-I PROSEDUR KARDIOTORASIK LAIN RINGAN 40.776.323 48.931.588 57.086.853
245 I-1-06-II PROSEDUR KARDIOTORASIK LAIN SEDANG 59.067.813 70.881.375 82.694.938
246 I-1-06-III PROSEDUR KARDIOTORASIK LAIN BERAT 70.478.800 84.574.560 98.670.319
247 I-1-07-I
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH KORONER TANPA
33.604.061 40.324.874 47.045.686
248 I-1-07-II
41.457.511 49.749.013 58.040.515
249 I-1-07-III
45.229.989 54.275.986 63.321.984
250 I-1-11-I
PROSEDUR DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM
BANTUAN JANTUNG RINGAN
5.211.369 6.253.643 7.295.916
251 I-1-11-II
BANTUAN JANTUNG SEDANG
5.794.534 6.953.441 8.112.348
252 I-1-11-III
BANTUAN JANTUNG BERAT
7.710.747 9.252.896 10.795.046
253 I-1-12-I PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS RINGAN 21.667.976 26.001.572 30.335.167
254 I-1-12-II PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS SEDANG 24.499.434 29.399.320 34.299.207
255 I-1-12-III PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS BERAT 40.895.847 49.075.016 57.254.186
256 I-1-13-I PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK RINGAN 15.969.257 19.163.108 22.356.959
257 I-1-13-II PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK SEDANG 19.377.143 23.252.572 27.128.000
258 I-1-13-III PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK BERAT 24.441.621 29.329.945 34.218.269
259 I-1-14-I
PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN
RINGAN
43.017.922 51.621.507 60.225.091
260 I-1-14-II
SEDANG
53.464.958 64.157.950 74.850.942
261 I-1-14-III
BERAT
70.057.508 84.069.010 98.080.512
262 I-1-15-I PROSEDUR KATETERISASI JANTUNG RINGAN 10.016.906 12.020.288 14.023.669
263 I-1-15-II PROSEDUR KATETERISASI JANTUNG SEDANG 13.305.503 15.966.603 18.627.704
264 I-1-15-III PROSEDUR KATETERISASI JANTUNG BERAT 28.465.727 34.158.873 39.852.018
265 I-1-16-I
PROSEDUR REVISI DEFIBRILATOR & PACEMAKER JANTUNG TIDAK
TERMASUK PENGGANTIAN ALAT (RINGAN)
18.435.867 22.123.040 25.810.213
266 I-1-16-II
TERMASUK PENGGANTIAN ALAT (SEDANG)
47.933.658 57.520.390 67.107.122
267 I-1-16-III
TERMASUK PENGGANTIAN ALAT (BERAT)
55.290.726 66.348.871 77.407.016
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
268 I-1-17-I
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA
RINGAN
31.775.235 38.130.282 44.485.329
269 I-1-17-II
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA
SEDANG
39.785.575 47.742.690 55.699.805
270 I-1-17-III PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA BERAT 49.214.152 59.056.982 68.899.812
271 I-1-20-I PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN RINGAN 27.650.073 33.180.088 38.710.102
272 I-1-20-II PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN SEDANG 34.542.464 41.450.957 48.359.450
273 I-1-20-III PROSEDUR SISTIM PEREDARAN DARAH LAIN BERAT 36.311.356 43.573.627 50.835.898
274 I-1-30-I
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER
JANTUNG RINGAN
20.915.671 25.098.805 29.281.939
275 I-1-30-II
JANTUNG SEDANG
43.509.293 52.211.152 60.913.011
276 I-1-30-III
JANTUNG BERAT
67.423.813 80.908.576 94.393.338
277 I-1-40-I PROSEDUR KARDIOVASKULAR PERKUTAN RINGAN 19.302.954 23.163.545 27.024.136
278 I-1-40-II PROSEDUR KARDIOVASKULAR PERKUTAN SEDANG 47.720.195 57.264.234 66.808.273
279 I-1-40-III PROSEDUR KARDIOVASKULAR PERKUTAN BERAT 63.737.961 76.485.554 89.233.146
280 I-4-10-I INFARK MYOKARD AKUT RINGAN 6.524.956 7.829.948 9.134.939
281 I-4-10-II INFARK MYOKARD AKUT SEDANG 11.651.158 13.981.390 16.311.622
282 I-4-10-III INFARK MYOKARD AKUT BERAT 16.807.813 20.169.375 23.530.938
283 I-4-11-I ENDOKARDITIS AKUT DAN SUBAKUT RINGAN 7.749.895 9.299.874 10.849.852
284 I-4-11-II ENDOKARDITIS AKUT DAN SUBAKUT SEDANG 9.590.511 11.508.614 13.426.716
285 I-4-11-III ENDOKARDITIS AKUT DAN SUBAKUT BERAT 17.741.332 21.289.599 24.837.865
286 I-4-12-I KEGAGALAN JANTUNG RINGAN 6.757.511 8.109.013 9.460.516
287 I-4-12-II KEGAGALAN JANTUNG SEDANG 10.935.701 13.122.842 15.309.982
288 I-4-12-III KEGAGALAN JANTUNG BERAT 13.509.186 16.211.023 18.912.860
289 I-4-13-I THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA RINGAN 7.492.893 8.991.471 10.490.050
290 I-4-13-II THROMBOPHLEBITIS DALAM PEMBULUH DARAH VENA SEDANG 10.853.034 13.023.641 15.194.248
291 I-4-13-III THROMBOPHLEBITIS DALAM PEMBULUH DARAH VENA BERAT 24.298.572 29.158.287 34.018.001
292 I-4-14-I CARDIAC ARREST, TIDAK DIKETAHUI RINGAN 4.281.133 5.137.359 5.993.586
293 I-4-14-II CARDIAC ARREST, TIDAK DIKETAHUI SEDANG 4.428.435 5.314.122 6.199.809
294 I-4-14-III CARDIAC ARREST, TIDAK DIKETAHUI BERAT 7.763.149 9.315.778 10.868.408
295 I-4-15-I GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (RINGAN) 7.575.542 9.090.650 10.605.758
296 I-4-15-II GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (SEDANG) 9.777.162 11.732.595 13.688.027
297 I-4-15-III GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (BERAT) 11.143.428 13.372.114 15.600.800
298 I-4-16-I ATHEROSKLEROSIS RINGAN 5.289.664 6.347.597 7.405.530
299 I-4-16-II ATHEROSKLEROSIS SEDANG 7.515.904 9.019.085 10.522.266
300 I-4-16-III ATHEROSKLEROSIS BERAT 10.692.772 12.831.326 14.969.880
301 I-4-17-I HIPERTENSI RINGAN 4.341.345 5.209.614 6.077.883
302 I-4-17-II HIPERTENSI SEDANG 5.885.294 7.062.352 8.239.411
303 I-4-17-III HIPERTENSI BERAT 7.142.857 8.571.428 10.000.000
304 I-4-18-I GANGUAN KATUP JANTUNG KONGENITAL RINGAN 6.751.266 8.101.520 9.451.773
305 I-4-18-II GANGUAN KATUP JANTUNG KONGENITAL SEDANG 10.278.971 12.334.765 14.390.559
306 I-4-18-III GANGUAN-PENYAKIT KATUP JANTUNG KONGENITAL BERAT 13.955.503 16.746.603 19.537.704
307 I-4-19-I GANGGUAN KONDUKSI & ARITMIA JANTUNG RINGAN 5.028.455 6.034.145 7.039.836
308 I-4-19-II GANGGUAN KONDUKSI & ARITMIA JANTUNG SEDANG 7.849.732 9.419.678 10.989.625
309 I-4-19-III GANGGUAN KONDUKSI & ARITMIA JANTUNG BERAT 9.371.141 11.245.369 13.119.598
310 I-4-20-I ANGINA PEKTORIS DAN NYERI DADA RINGAN 5.236.170 6.283.403 7.330.637
311 I-4-20-II ANGINA PEKTORIS DAN NYERI DADA SEDANG 6.047.744 7.257.293 8.466.841
312 I-4-20-III ANGINA PEKTORIS DAN NYERI DADA BERAT 9.042.597 10.851.116 12.659.636
313 I-4-21-I SYNCOPE & COLLAPSE RINGAN 7.864.768 9.437.722 11.010.676
314 I-4-21-II SYNCOPE & COLLAPSE SEDANG 9.810.788 11.772.946 13.735.104
315 I-4-21-III SYNCOPE & COLLAPSE BERAT 13.383.996 16.060.795 18.737.594
316 I-4-22-I KARDIOMIOPATHI RINGAN 5.688.566 6.826.279 7.963.992
317 I-4-22-II KARDIOMIOPATHI SEDANG 7.081.511 8.497.813 9.914.116
318 I-4-22-III KARDIOMIOPATHI BERAT 10.350.892 12.421.070 14.491.249
319 I-4-23-I
KOMPLIKASI, REAKSI, MALFUNGSI DARI PROSEDUR ATAU
PEMASANGAN ALAT KARDIOVASKULAR RINGAN
4.298.147 5.157.777 6.017.406
320 I-4-23-II
PEMASANGAN ALAT KARDIOVASKULAR SEDANG
5.276.840 6.332.208 7.387.576
321 I-4-23-III
PEMASANGAN ALAT KARDIOVASKULAR BERAT
10.310.694 12.372.833 14.434.972
322 I-4-24-I DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (RINGAN) 5.013.503 6.016.203 7.018.904
323 I-4-24-II DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (SEDANG) 11.544.932 13.853.918 16.162.904
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
324 I-4-24-III DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (BERAT) 14.596.481 17.515.777 20.435.073
325 J-1-01-I
PROSEDUR VENTILASI MEKANIKAL LONG TERM DENGAN
TRAKEOSTOMI RINGAN
73.124.051 87.748.861 102.373.671
326 J-1-01-II
TRAKEOSTOMI SEDANG
81.248.945 97.498.734 113.748.524
327 J-1-01-III
TRAKEOSTOMI BERAT
90.276.606 108.331.927 126.387.248
328 J-1-02-I
PROSEDUR VENTILASI MEKANIKAL LONG TERM TANPA
TRAKEOSTOMI RINGAN
38.804.333 46.565.200 54.326.067
329 J-1-02-II
TRAKEOSTOMI SEDANG
53.048.614 63.658.336 74.268.059
330 J-1-02-III
TRAKEOSTOMI BERAT
86.037.044 103.244.452 120.451.861
331 J-1-10-I PROSEDUR SISTEM PERNAFASAN KOMPLEKS RINGAN 12.125.411 14.550.493 16.975.575
332 J-1-10-II PROSEDUR SISTEM PERNAFASAN KOMPLEKS SEDANG 19.874.207 23.849.049 27.823.890
333 J-1-10-III PROSEDUR SISTEM PERNAFASAN KOMPLEKS BERAT 28.151.246 33.781.495 39.411.744
334 J-1-20-I PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS RINGAN 15.618.731 18.742.478 21.866.224
335 J-1-20-II PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS SEDANG 19.672.242 23.606.690 27.541.138
336 J-1-20-III PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS BERAT 30.377.180 36.452.616 42.528.052
337 J-1-30-I PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS RINGAN 9.390.426 11.268.511 13.146.597
338 J-1-30-II PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS SEDANG 21.221.428 25.465.714 29.709.999
339 J-1-30-III PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS BERAT 70.923.428 85.108.114 99.292.799
340 J-4-10-I KISTA FIBROSIS RINGAN 5.542.099 6.650.519 7.758.939
341 J-4-10-II KISTA FIBROSIS SEDANG 7.924.034 9.508.841 11.093.648
342 J-4-10-III KISTA FIBROSIS BERAT 11.987.971 14.385.565 16.783.159
343 J-4-11-I KEGAGALAN PERNAFASAN RINGAN 3.424.671 4.109.605 4.794.540
344 J-4-11-II KEGAGALAN PERNAFASAN SEDANG 4.769.993 5.723.992 6.677.991
345 J-4-11-III KEGAGALAN PERNAFASAN BERAT 6.835.566 8.202.680 9.569.793
346 J-4-12-I EMBOLI PARU RINGAN 5.816.860 6.980.232 8.143.604
347 J-4-12-II EMBOLI PARU SEDANG 6.923.743 8.308.492 9.693.240
348 J-4-12-III EMBOLI PARU BERAT 9.245.607 11.094.728 12.943.849
349 J-4-13-I TRAUMA DADA MAYOR TRAUMA RINGAN 7.428.913 8.914.695 10.400.478
350 J-4-13-II TRAUMA DADA MAYOR TRAUMA SEDANG 9.662.071 11.594.485 13.526.899
351 J-4-13-III TRAUMA DADA MAYOR TRAUMA BERAT 19.292.591 23.151.109 27.009.628
352 J-4-14-I TUMOR PARU RINGAN 5.670.400 6.804.480 7.938.560
353 J-4-14-II TUMOR PARU SEDANG 9.227.322 11.072.786 12.918.251
354 J-4-14-III TUMOR PARU BERAT 10.916.856 13.100.228 15.283.599
355 J-4-15-I PERADANGAN DAN INFEKSI PERNAFASAN RINGAN 5.687.331 6.824.797 7.962.264
356 J-4-15-II PERADANGAN DAN INFEKSI PERNAFASAN SEDANG 6.794.768 8.153.721 9.512.675
357 J-4-15-III PERADANGAN DAN INFEKSI PERNAFASAN BERAT 10.502.835 12.603.401 14.703.968
358 J-4-16-I SIMPLE PNEUMONIA & WHOOPING COUGH RINGAN 4.738.728 5.686.473 6.634.219
359 J-4-16-II SIMPLE PNEUMONIA & WHOOPING COUGH SEDANG 6.659.159 7.990.990 9.322.822
360 J-4-16-III SIMPLE PNEUMONIA & WHOOPING COUGH BERAT 11.021.691 13.226.029 15.430.367
361 J-4-17-I PENYAKIT PARU OBSTRUKTIF KRONIS RINGAN 4.738.116 5.685.740 6.633.363
362 J-4-17-II PENYAKIT PARU OBSTRUKTIF KRONIS SEDANG 5.674.019 6.808.823 7.943.627
363 J-4-17-III PENYAKIT PARU OBSTRUKTIF KRONIS BERAT 8.537.819 10.245.383 11.952.947
364 J-4-18-I ASTHMA & BRONKIOLITIS RINGAN 3.781.373 4.537.647 5.293.922
365 J-4-18-II ASTHMA & BRONKIOLITIS SEDANG 5.201.028 6.241.234 7.281.440
366 J-4-18-III ASTHMA & BRONKIOLITIS BERAT 5.474.668 6.569.602 7.664.535
367 J-4-19-I PENYAKIT PARU INTERSTITIAL RINGAN 6.623.577 7.948.293 9.273.008
368 J-4-19-II PENYAKIT PARU INTERSTITIAL SEDANG 7.568.533 9.082.239 10.595.946
369 J-4-19-III PENYAKIT PARU INTERSTITIAL BERAT 10.518.582 12.622.298 14.726.015
370 J-4-20-I PLEURAL EFUSI DAN PNEUMOTORAK RINGAN 6.622.782 7.947.338 9.271.894
371 J-4-20-II PLEURAL EFUSI DAN PNEUMOTORAK SEDANG 9.485.484 11.382.581 13.279.678
372 J-4-20-III PLEURAL EFUSI DAN PNEUMOTORAK BERAT 14.962.052 17.954.463 20.946.873
373 J-4-21-I
GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN LAIN-LAIN
(RINGAN)
3.783.780 4.540.536 5.297.293
374 J-4-21-II
(SEDANG)
8.613.908 10.336.690 12.059.472
375 J-4-21-III
(BERAT)
12.286.251 14.743.501 17.200.752
376 K-1-10-I PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (RINGAN) 10.201.072 12.241.287 14.281.501
377 K-1-10-II PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (SEDANG) 12.819.835 15.383.802 17.947.769
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
378 K-1-10-III PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (BERAT) 15.025.283 18.030.340 21.035.397
379 K-1-11-I PROSEDUR ADHESIOLISIS PERITONEAL RINGAN 7.924.415 9.509.298 11.094.181
380 K-1-11-II PROSEDUR ADHESIOLISIS PERITONEAL SEDANG 10.403.793 12.484.551 14.565.310
381 K-1-11-III PROSEDUR ADHESIOLISIS PERITONEAL BERAT 26.403.128 31.683.754 36.964.379
382 K-1-12-I
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL
(RINGAN)
4.280.244 5.136.293 5.992.342
383 K-1-12-II
(SEDANG)
5.566.961 6.680.353 7.793.745
384 K-1-12-III
(BERAT)
11.028.892 13.234.671 15.440.449
385 K-1-13-I PROSEDUR APPENDIK RINGAN 4.827.235 5.792.682 6.758.129
386 K-1-13-II PROSEDUR APPENDIK SEDANG 8.430.201 10.116.241 11.802.281
387 K-1-13-III PROSEDUR APPENDIK BERAT 9.022.799 10.827.359 12.631.918
388 K-1-14-I PROSEDUR HERNIA INGUINAL DAN FEMORAL RINGAN 7.833.764 9.400.517 10.967.269
389 K-1-14-II PROSEDUR HERNIA INGUINAL DAN FEMORAL SEDANG 9.180.967 11.017.161 12.853.354
390 K-1-14-III PROSEDUR HERNIA INGUINAL DAN FEMORAL BERAT 20.835.388 25.002.465 29.169.543
391 K-1-20-I PROSEDUR INTESTINAL KOMPLEKS (RINGAN) 15.168.576 18.202.291 21.236.006
392 K-1-20-II PROSEDUR INTESTINAL KOMPLEKS (SEDANG) 21.187.089 25.424.507 29.661.925
393 K-1-20-III PROSEDUR INTESTINAL KOMPLEKS (BERAT) 37.048.273 44.457.927 51.867.582
394 K-1-30-I
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG NON KOMPLEKS
(RINGAN)
9.967.325 11.960.790 13.954.255
395 K-1-30-II
(SEDANG)
19.516.277 23.419.532 27.322.788
396 K-1-30-III
(BERAT)
28.684.983 34.421.979 40.158.976
397 K-1-40-I PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (RINGAN) 10.009.159 12.010.991 14.012.823
398 K-1-40-II PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (SEDANG) 11.035.440 13.242.527 15.449.615
399 K-1-40-III PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (BERAT) 22.902.116 27.482.539 32.062.963
400 K-1-50-I PROSEDUR ANAL RINGAN 7.647.959 9.177.551 10.707.143
401 K-1-50-II PROSEDUR ANAL SEDANG 9.931.830 11.918.196 13.904.562
402 K-1-50-III PROSEDUR ANAL BERAT 14.035.465 16.842.558 19.649.651
403 K-4-10-I TUMOR PENCERNAAN RINGAN 9.807.488 11.768.985 13.730.483
404 K-4-10-II TUMOR PENCERNAAN SEDANG 15.590.223 18.708.268 21.826.313
405 K-4-10-III TUMOR PENCERNAAN BERAT 25.876.036 31.051.243 36.226.451
406 K-4-11-I GASTRITIS & ULKUS PEPTIKUM RINGAN 3.802.870 4.563.444 5.324.018
407 K-4-11-II GASTRITIS & ULKUS PEPTIKUM SEDANG 5.676.314 6.811.577 7.946.839
408 K-4-11-III GASTRITIS & ULKUS PEPTIKUM BERAT 9.517.684 11.421.220 13.324.757
409 K-4-12-I GANGGUAN ESOFAGUS RINGAN 3.795.403 4.554.483 5.313.564
410 K-4-12-II GANGGUAN ESOFAGUS SEDANG 5.107.408 6.128.890 7.150.371
411 K-4-12-III GANGGUAN ESOFAGUS BERAT 11.561.396 13.873.675 16.185.954
412 K-4-13-I
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT PERADANGAN
USUS BESAR (RINGAN)
5.684.938 6.821.926 7.958.914
413 K-4-13-II
USUS BESAR (SEDANG)
7.353.793 8.824.551 10.295.310
414 K-4-13-III
USUS BESAR (BERAT)
11.327.184 13.592.621 15.858.058
415 K-4-14-I INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL RINGAN 4.505.360 5.406.432 6.307.504
416 K-4-14-II INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL SEDANG 6.047.645 7.257.174 8.466.702
417 K-4-14-III INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL BERAT 9.704.053 11.644.864 13.585.675
418 K-4-15-I OBSTRUKSI SALURAN GASTROINTESTINAL RINGAN 4.706.498 5.647.798 6.589.098
419 K-4-15-II OBSTRUKSI SALURAN GASTROINTESTINAL SEDANG 7.248.431 8.698.118 10.147.804
420 K-4-15-III OBSTRUKSI SALURAN GASTROINTESTINAL BERAT 10.317.275 12.380.730 14.444.185
421 K-4-16-I INFEKSI-INFEKSI GASTROINTESTINAL RINGAN 4.735.885 5.683.062 6.630.239
422 K-4-16-II INFEKSI-INFEKSI GASTROINTESTINAL SEDANG 5.679.645 6.815.574 7.951.503
423 K-4-16-III INFEKSI-INFEKSI GASTROINTESTINAL BERAT 6.627.290 7.952.748 9.278.206
424 K-4-17-I NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (RINGAN) 3.435.440 4.122.528 4.809.616
425 K-4-17-II NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (SEDANG) 4.861.739 5.834.087 6.806.435
426 K-4-17-III NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (BERAT) 5.484.053 6.580.863 7.677.674
427 K-4-18-I DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (RINGAN) 3.790.358 4.548.429 5.306.501
428 K-4-18-II DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (SEDANG) 5.685.429 6.822.514 7.959.600
429 K-4-18-III DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (BERAT) 6.974.371 8.369.245 9.764.119
430 L-1-20-I PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR RINGAN 34.933.074 41.919.689 48.906.304
431 L-1-20-II PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR SEDANG 36.505.787 43.806.944 51.108.101
432 L-1-20-III PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR BERAT 55.693.494 66.832.192 77.970.891
433 L-1-30-I PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR RINGAN 15.392.471 18.470.965 21.549.459
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
434 L-1-30-II PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR SEDANG 22.991.394 27.589.673 32.187.952
435 L-1-30-III PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR BERAT 24.308.398 29.170.078 34.031.758
436 L-1-40-I
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA
RINGAN
6.394.682 7.673.619 8.952.555
437 L-1-40-II
SEDANG
12.826.271 15.391.526 17.956.780
438 L-1-40-III
BERAT
31.184.803 37.421.763 43.658.724
439 L-1-50-I PROSEDUR PADA PAYUDARA RINGAN 11.758.034 14.109.641 16.461.248
440 L-1-50-II PROSEDUR PADA PAYUDARA SEDANG 18.099.372 21.719.246 25.339.121
441 L-1-50-III PROSEDUR PADA PAYUDARA BERAT 22.472.291 26.966.750 31.461.208
442 L-4-10-I PENYAKIT KULIT MAYOR RINGAN 5.708.914 6.850.697 7.992.480
443 L-4-10-II PENYAKIT KULIT MAYOR SEDANG 6.626.478 7.951.774 9.277.070
444 L-4-10-III PENYAKIT KULIT MAYOR BERAT 12.095.283 14.514.339 16.933.396
445 L-4-11-I TUMOR PAYUDARA RINGAN 4.840.255 5.808.306 6.776.357
446 L-4-11-II TUMOR PAYUDARA SEDANG 6.652.504 7.983.004 9.313.505
447 L-4-11-III TUMOR PAYUDARA BERAT 15.116.412 18.139.694 21.162.976
448 L-4-12-I PERADANGAN KULIT/CELLULITIS RINGAN 5.677.691 6.813.230 7.948.768
449 L-4-12-II PERADANGAN KULIT/CELLULITIS SEDANG 7.509.494 9.011.393 10.513.292
450 L-4-12-III PERADANGAN KULIT/CELLULITIS BERAT 13.956.457 16.747.749 19.539.040
451 L-4-13-I
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA
RINGAN
3.223.063 3.867.675 4.512.288
452 L-4-13-II
SEDANG
3.787.919 4.545.502 5.303.086
453 L-4-13-III
BERAT
5.574.044 6.688.853 7.803.661
454 L-4-14-I GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (RINGAN) 3.781.465 4.537.758 5.294.051
455 L-4-14-II GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (SEDANG) 5.679.844 6.815.813 7.951.781
456 L-4-14-III GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (BERAT) 8.006.455 9.607.746 11.209.037
457 M-1-01-I
PROSEDUR BILATERAL DAN MULTIPLE SENDI ANGGOTA TUBUH
BAWAH MAYOR (RINGAN)
17.021.825 20.426.190 23.830.555
458 M-1-01-II
BAWAH MAYOR (SEDANG)
18.999.459 22.799.350 26.599.242
459 M-1-01-III
BAWAH MAYOR (BERAT)
26.688.607 32.026.328 37.364.049
460 M-1-02-I PROSEDUR AMPUTASI RINGAN 11.847.425 14.216.910 16.586.395
461 M-1-02-II PROSEDUR AMPUTASI SEDANG 19.435.272 23.322.327 27.209.381
462 M-1-02-III PROSEDUR AMPUTASI BERAT 34.263.687 41.116.424 47.969.161
463 M-1-03-I
PROSEDUR FUSI TULANG BELAKANG PADA LENGKUNGAN TULANG
BELAKANG RINGAN
31.673.387 38.008.065 44.342.742
464 M-1-03-II
BELAKANG SEDANG
38.025.828 45.630.993 53.236.159
465 M-1-03-III
BELAKANG BERAT
39.550.146 47.460.175 55.370.204
466 M-1-04-I
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA TUBUH BAGIAN
7.807.062 9.368.475 10.929.887
467 M-1-04-II
9.981.510 11.977.812 13.974.114
468 M-1-04-III
BAWAH MAYOR (BERAT)
12.489.785 14.987.742 17.485.699
469 M-1-05-I
PROSEDUR PADA SENDI LENGAN/ANGGOTA TUBUH BAGIAN
11.175.243 13.410.292 15.645.340
470 M-1-05-II
11.440.578 13.728.693 16.016.809
471 M-1-05-III
BAWAH MAYOR (BERAT)
19.486.780 23.384.136 27.281.492
472 M-1-07-I
PROSEDUR FUSI TULANG BELAKANG SELAIN LENGKUNGAN TULANG
BELAKANG RINGAN
13.676.046 16.411.256 19.146.465
473 M-1-07-II
BELAKANG SEDANG
18.321.123 21.985.348 25.649.573
474 M-1-07-III
BELAKANG BERAT
37.321.932 44.786.318 52.250.705
475 M-1-10-I PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH RINGAN 23.038.911 27.646.694 32.254.476
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
476 M-1-10-II PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH SEDANG 55.085.140 66.102.168 77.119.195
477 M-1-10-III PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH BERAT 118.813.461 142.576.153 166.338.845
478 M-1-20-I
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR
RINGAN
8.264.291 9.917.149 11.570.007
479 M-1-20-II
SEDANG
11.791.298 14.149.557 16.507.817
480 M-1-20-III
BERAT
29.252.922 35.103.507 40.954.091
481 M-1-30-I PROSEDUR KAKI RINGAN 11.069.671 13.283.605 15.497.539
482 M-1-30-II PROSEDUR KAKI SEDANG 22.961.068 27.553.282 32.145.495
483 M-1-30-III PROSEDUR KAKI BERAT 34.253.072 41.103.687 47.954.301
484 M-1-40-I
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI
INTERNAL RINGAN
5.543.295 6.651.954 7.760.613
485 M-1-40-II
INTERNAL SEDANG
10.246.066 12.295.279 14.344.492
486 M-1-40-III
INTERNAL BERAT
17.839.800 21.407.760 24.975.721
487 M-1-50-I PROSEDUR JARINGAN LUNAK RINGAN 6.642.692 7.971.231 9.299.769
488 M-1-50-II PROSEDUR JARINGAN LUNAK SEDANG 13.326.279 15.991.535 18.656.791
489 M-1-50-III PROSEDUR JARINGAN LUNAK BERAT 20.415.164 24.498.196 28.581.229
490 M-1-60-I
PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN PENGHUBUNG
LAIN-LAIN (RINGAN)
4.988.382 5.986.059 6.983.735
491 M-1-60-II
LAIN-LAIN (SEDANG)
10.013.093 12.015.712 14.018.331
492 M-1-60-III
LAIN-LAIN (BERAT)
17.433.460 20.920.152 24.406.844
493 M-1-70-I PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (RINGAN) 27.454.428 32.945.314 38.436.199
494 M-1-70-II PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (SEDANG) 30.199.871 36.239.845 42.279.819
495 M-1-70-III PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (BERAT) 33.219.858 39.863.830 46.507.801
496 M-1-80-I PROSEDUR ANGGOTA TUBUH ATAS RINGAN 15.606.695 18.728.034 21.849.373
497 M-1-80-II PROSEDUR ANGGOTA TUBUH ATAS SEDANG 18.232.339 21.878.807 25.525.275
498 M-1-80-III PROSEDUR ANGGOTA TUBUH ATAS BERAT 41.717.007 50.060.409 58.403.810
499 M-4-10-I FRAKTUR FEMUR RINGAN 3.806.107 4.567.328 5.328.549
500 M-4-10-II FRAKTUR FEMUR SEDANG 5.676.076 6.811.292 7.946.507
501 M-4-10-III FRAKTUR FEMUR BERAT 10.739.294 12.887.153 15.035.012
502 M-4-11-I FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL RINGAN 4.742.764 5.691.317 6.639.870
503 M-4-11-II FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL SEDANG 10.398.180 12.477.816 14.557.452
504 M-4-11-III FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL BERAT 15.034.067 18.040.880 21.047.693
505 M-4-12-I FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS RINGAN 3.785.777 4.542.932 5.300.088
506 M-4-12-II FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS SEDANG 6.296.705 7.556.046 8.815.387
507 M-4-12-III FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS BERAT 10.115.344 12.138.412 14.161.481
508 M-4-13-I
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN FRAKTUR
PATOLOGIS RINGAN
6.303.625 7.564.350 8.825.075
509 M-4-13-II
PATOLOGIS SEDANG
9.470.968 11.365.161 13.259.355
510 M-4-13-III
PATOLOGIS BERAT
18.741.398 22.489.678 26.237.958
511 M-4-14-I OSTEOMIELITIS RINGAN 7.189.162 8.626.994 10.064.827
512 M-4-14-II OSTEOMIELITIS SEDANG 8.866.711 10.640.053 12.413.395
513 M-4-14-III OSTEOMIELITIS BERAT 13.324.125 15.988.950 18.653.775
514 M-4-15-I ARTRITIS SEPSIS RINGAN 4.262.919 5.115.502 5.968.086
515 M-4-15-II ARTRITIS SEPSIS SEDANG 5.682.171 6.818.605 7.955.040
516 M-4-15-III ARTRITIS SEPSIS BERAT 16.118.193 19.341.832 22.565.471
517 M-4-16-I GANGGUAN JARINGAN KONEKTIF RINGAN 4.727.675 5.673.210 6.618.744
518 M-4-16-II GANGGUAN JARINGAN KONEKTIF SEDANG 7.570.779 9.084.935 10.599.091
519 M-4-16-III GANGGUAN JARINGAN KONEKTIF BERAT 12.718.326 15.261.991 17.805.657
520 M-4-17-I MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG RINGAN 4.736.904 5.684.285 6.631.666
521 M-4-17-II MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG SEDANG 6.625.037 7.950.044 9.275.051
522 M-4-17-III MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG BERAT 9.251.372 11.101.646 12.951.920
523 M-4-18-I PENYAKIT TULANG DAN SENDI LAIN-LAIN RINGAN 4.637.652 5.565.183 6.492.713
524 M-4-18-II PENYAKIT TULANG DAN SENDI LAIN-LAIN SEDANG 6.989.214 8.387.057 9.784.900
525 M-4-18-III PENYAKIT TULANG DAN SENDI LAIN-LAIN BERAT 8.415.405 10.098.487 11.781.568
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
526 M-4-19-I
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PROSEDUR ATAU
PEMASANGAN ALAT ORTOPEDIK RINGAN
3.733.689 4.480.427 5.227.164
527 M-4-19-II
PEMASANGAN ALAT ORTOPEDIK SEDANG
6.289.025 7.546.830 8.804.635
528 M-4-19-III
PEMASANGAN ALAT ORTOPEDIK BERAT
12.282.827 14.739.392 17.195.958
529 M-4-20-I
TANDA-TANDA, GEJALA, MUSKULOSKLETAL , KESELEO DAN
PERADANGAN MINOR (RINGAN)
3.766.279 4.519.534 5.272.790
530 M-4-20-II
PERADANGAN MINOR (SEDANG)
5.515.101 6.618.121 7.721.141
531 M-4-20-III
PERADANGAN MINOR (BERAT)
6.163.738 7.396.485 8.629.233
532 M-4-21-I
DIAGNOSIS SISTEM MUSKULOSKLETAL & JARINGAN PENGHUBUNG
LAIN-LAIN (RINGAN)
3.792.350 4.550.820 5.309.290
533 M-4-21-II
LAIN-LAIN (SEDANG)
4.743.170 5.691.804 6.640.439
534 M-4-21-III
LAIN-LAIN (BERAT)
10.634.000 12.760.800 14.887.600
535 N-1-01-I PROSEDUR PENCANGKOKAN GINJAL RINGAN 250.000.000 250.000.000 250.000.000
536 N-1-01-II PROSEDUR PENCANGKOKAN GINJAL SEDANG 250.000.000 250.000.000 250.000.000
537 N-1-01-III PROSEDUR PENCANGKOKAN GINJAL BERAT 250.000.000 250.000.000 250.000.000
538 N-1-11-I PROSEDUR KANDUNG KEMIH KOMPLEK RINGAN 12.776.158 15.331.390 17.886.621
539 N-1-11-II PROSEDUR KANDUNG KEMIH KOMPLEK SEDANG 17.297.190 20.756.628 24.216.066
540 N-1-11-III PROSEDUR KANDUNG KEMIH KOMPLEK BERAT 30.639.825 36.767.789 42.895.754
541 N-1-12-I
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT
DIALISIS RINGAN
6.838.023 8.205.628 9.573.232
542 N-1-12-II
DIALISIS SEDANG
16.032.862 19.239.434 22.446.007
543 N-1-12-III
DIALISIS BERAT
29.216.085 35.059.302 40.902.519
544 N-1-20-I PROSEDUR SALURAN URIN ATAS RINGAN 14.014.650 16.817.580 19.620.510
545 N-1-20-II PROSEDUR SALURAN URIN ATAS SEDANG 18.572.377 22.286.853 26.001.328
546 N-1-20-III PROSEDUR SALURAN URIN ATAS BERAT 23.871.486 28.645.783 33.420.080
547 N-1-30-I PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH RINGAN 11.155.604 13.386.725 15.617.846
548 N-1-30-II PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH SEDANG 16.876.249 20.251.499 23.626.749
549 N-1-30-III PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH BERAT 19.422.912 23.307.495 27.192.077
550 N-1-40-I PROSEDUR PADA URETRA DAN TRANSURETRA RINGAN 10.018.484 12.022.180 14.025.877
551 N-1-40-II PROSEDUR PADA URETRA DAN TRANSURETRA SEDANG 13.604.933 16.325.919 19.046.906
552 N-1-40-III PROSEDUR PADA URETRA DAN TRANSURETRA BERAT 15.834.354 19.001.224 22.168.095
553 N-4-10-I TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL RINGAN 4.729.439 5.675.327 6.621.215
554 N-4-10-II TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL SEDANG 5.720.300 6.864.360 8.008.420
555 N-4-10-III TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL BERAT 11.367.193 13.640.631 15.914.070
556 N-4-11-I PERADANGAN GINJAL RINGAN 3.267.532 3.921.039 4.574.545
557 N-4-11-II PERADANGAN GINJAL SEDANG 5.708.828 6.850.594 7.992.359
558 N-4-11-III PERADANGAN GINJAL BERAT 7.102.959 8.523.550 9.944.142
559 N-4-12-I INFEKSI GINJAL DAN SALURAN URIN RINGAN 3.794.276 4.553.131 5.311.986
560 N-4-12-II INFEKSI GINJAL DAN SALURAN URIN SEDANG 5.686.784 6.824.141 7.961.497
561 N-4-12-III INFEKSI GINJAL DAN SALURAN URIN BERAT 7.727.969 9.273.562 10.819.156
562 N-4-13-I BATU URIN RINGAN 4.711.223 5.653.468 6.595.712
563 N-4-13-II BATU URIN SEDANG 5.677.441 6.812.929 7.948.417
564 N-4-13-III BATU URIN BERAT 12.336.479 14.803.774 17.271.070
565 N-4-14-I
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PEMASANGAN ALAT
SALURAN URIN, PEMINDAHAN KULIT ATAU PENCAKOKAN (RINGAN)
3.281.718 3.938.061 4.594.405
566 N-4-14-II
SALURAN URIN, PEMINDAHAN KULIT ATAU PENCAKOKAN (SEDANG)
4.656.551 5.587.862 6.519.172
567 N-4-14-III
SALURAN URIN, PEMINDAHAN KULIT ATAU PENCAKOKAN (BERAT)
7.552.131 9.062.557 10.572.984
568 N-4-15-I GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN RINGAN 4.307.597 5.169.116 6.030.636
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
569 N-4-15-II GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN SEDANG 5.345.011 6.414.013 7.483.015
570 N-4-15-III GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN BERAT 6.099.617 7.319.540 8.539.463
571 N-4-16-I DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (RINGAN) 4.747.204 5.696.645 6.646.086
572 N-4-16-II DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (SEDANG) 7.296.321 8.755.586 10.214.850
573 N-4-16-III DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (BERAT) 12.945.907 15.535.088 18.124.269
574 O-6-10-I PROSEDUR OPERASI PEMBEDAHAN CAESAR RINGAN 5.484.728 6.581.673 7.678.619
575 O-6-10-II PROSEDUR OPERASI PEMBEDAHAN CAESAR SEDANG 6.052.369 7.262.843 8.473.317
576 O-6-10-III PROSEDUR OPERASI PEMBEDAHAN CAESAR BERAT 8.288.235 9.945.882 11.603.529
577 O-6-11-I
PROSEDUR PERSALINAN VAGINAL DENGAN STERILISASI &/ DILATASI
& KURET RINGAN
4.412.788 5.295.346 6.177.903
578 O-6-11-II
& KURET SEDANG
4.904.262 5.885.114 6.865.967
579 O-6-11-III
& KURET BERAT
8.812.518 10.575.021 12.337.525
580 O-6-12-I
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN
STERILISASI &/ DILATASI &KURET RINGAN
3.126.416 3.751.700 4.376.983
581 O-6-12-II
STERILISASI &/ DILATASI & KURET SEDANG
3.754.804 4.505.765 5.256.726
582 O-6-12-III
STERILISASI &/ DILATASI & KURET BERAT
4.717.973 5.661.567 6.605.162
583 O-6-13-I PERSALINAN VAGINAL RINGAN 2.745.861 3.295.034 3.844.206
584 O-6-13-II PERSALINAN VAGINAL SEDANG 3.249.906 3.899.887 4.549.868
585 O-6-13-III PERSALINAN VAGINAL BERAT 4.074.061 4.888.873 5.703.685
586 P-8-01-I
PROSEDUR NEONATAL DENGAN PENCANGKOKAN ORGAN ATAU
OKSIGENASI SELAPUT EKSTRAKORPORAL RINGAN
87.723.920 105.268.704 122.813.488
587 P-8-01-II
OKSIGENASI SELAPUT EKSTRAKORPORAL SEDANG
108.545.097 130.254.116 151.963.135
588 P-8-01-III
OKSIGENASI SELAPUT EKSTRAKORPORAL BERAT
127.401.464 152.881.756 178.362.049
589 P-8-02-I
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-1 DENGAN
PROSEDUR MAYOR RINGAN
104.172.839 125.007.406 145.841.974
590 P-8-02-II
PROSEDUR MAYOR SEDANG
119.496.728 143.396.073 167.295.419
591 P-8-02-III
PROSEDUR MAYOR BERAT
136.533.483 163.840.179 191.146.876
592 P-8-03-I
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-1 TANPA
5.879.017 7.054.820 8.230.624
593 P-8-03-II
8.230.624 9.876.749 11.522.873
594 P-8-03-III
11.454.617 13.745.540 16.036.464
595 P-8-04-I
47.359.669 56.831.603 66.303.537
596 P-8-04-II
61.462.640 73.755.168 86.047.696
597 P-8-04-III
88.121.955 105.746.346 123.370.737
598 P-8-05-I
25.752.653 30.903.183 36.053.714
599 P-8-05-II
36.500.913 43.801.096 51.101.278
600 P-8-05-III
53.779.196 64.535.035 75.290.874
601 P-8-06-I
5.098.457 6.118.149 7.137.840
602 P-8-06-II
9.460.156 11.352.188 13.244.219
603 P-8-06-III
18.421.018 22.105.221 25.789.425
604 P-8-07-I
8.230.624 9.876.749 11.522.873
605 P-8-07-II
23.076.688 27.692.025 32.307.363
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
606 P-8-07-III
30.570.888 36.685.066 42.799.244
607 P-8-08-I
SINDROMA DISTRES PERNAFASAN RINGAN
4.762.273 5.714.728 6.667.183
608 P-8-08-II
SINDROMA DISTRES PERNAFASAN SEDANG
6.757.440 8.108.928 9.460.416
609 P-8-08-III
SINDROMA DISTRES PERNAFASAN BERAT
12.359.200 14.831.039 17.302.879
610 P-8-10-I
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS
PERAWATAN PASIEN AKUT LAIN RINGAN
3.337.870 4.005.444 4.673.018
611 P-8-10-II
PERAWATAN PASIEN AKUT LAIN SEDANG
5.253.848 6.304.618 7.355.387
612 P-8-10-III
PERAWATAN PASIEN AKUT LAIN BERAT
10.315.446 12.378.535 14.441.624
613 P-8-11-I NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR RINGAN 8.353.942 10.024.731 11.695.519
614 P-8-11-II NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR SEDANG 17.800.490 21.360.588 24.920.686
615 P-8-11-III NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR BERAT 21.334.953 25.601.943 29.868.934
622 P-8-14-I
NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU
KONDISI HEREDITER RINGAN
4.553.488 5.464.185 6.374.883
623 P-8-14-II
KONDISI HEREDITER SEDANG
9.269.139 11.122.966 12.976.794
624 P-8-14-III
KONDISI HEREDITER BERAT
10.169.924 12.203.909 14.237.894
625 P-8-15-I NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI RINGAN 3.415.166 4.098.199 4.781.232
626 P-8-15-II NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI SEDANG 6.839.036 8.206.843 9.574.650
627 P-8-15-III NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI BERAT 8.024.433 9.629.320 11.234.207
628 P-8-16-I
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI
PERINATAL RINGAN
3.090.809 3.708.971 4.327.132
629 P-8-16-II
PERINATAL SEDANG
6.390.351 7.668.421 8.946.491
630 P-8-16-III
PERINATAL BERAT
16.784.506 20.141.407 23.498.308
634 S-4-10-I
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK ATAU BANYAK
TEMPAT (RINGAN)
3.484.820 4.181.784 4.878.748
635 S-4-10-II
TEMPAT (SEDANG)
4.293.807 5.152.569 6.011.330
636 S-4-10-III
TEMPAT (BERAT)
5.877.827 7.053.392 8.228.957
637 S-4-11-I REAKSI ALLERGI RINGAN 2.219.804 2.663.765 3.107.726
638 S-4-11-II REAKSI ALLERGI SEDANG 3.255.130 3.906.156 4.557.182
639 S-4-11-III REAKSI ALLERGI BERAT 5.563.397 6.676.076 7.788.756
640 S-4-12-I EFEK TOKSIK DAN KERACUNAN OBAT RINGAN 2.846.679 3.416.015 3.985.351
641 S-4-12-II EFEK TOKSIK DAN KERACUNAN OBAT SEDANG 3.788.878 4.546.654 5.304.430
642 S-4-12-III EFEK TOKSIK DAN KERACUNAN OBAT BERAT 6.572.089 7.886.507 9.200.924
643 S-4-13-I KOMPLIKASI DARI PENATALAKSANAAN PASIEN RINGAN 3.783.469 4.540.162 5.296.856
644 S-4-13-II KOMPLIKASI DARI PENATALAKSANAAN PASIEN SEDANG 6.712.124 8.054.549 9.396.974
645 S-4-13-III KOMPLIKASI DARI PENATALAKSANAAN PASIEN BERAT 13.496.507 16.195.808 18.895.110
646 S-4-14-I
SINDROMA MALTREATMENT PADA DEWASA ATAU KANAK-KANAK
RINGAN
2.127.475 2.552.970 2.978.465
647 S-4-14-II
SEDANG
4.518.859 5.422.631 6.326.403
648 S-4-14-III
BERAT
8.569.296 10.283.156 11.997.015
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
649 S-4-15-I
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN AKUT YANG LAIN
(RINGAN)
1.609.105 1.930.927 2.252.748
650 S-4-15-II
(SEDANG)
3.036.647 3.643.976 4.251.305
651 S-4-15-III
(BERAT)
3.932.994 4.719.593 5.506.191
652 S-4-16-I LUKA BAKAR RINGAN 6.630.955 7.957.146 9.283.337
653 S-4-16-II LUKA BAKAR SEDANG 8.433.141 10.119.769 11.806.397
654 S-4-16-III LUKA BAKAR BERAT 14.071.573 16.885.888 19.700.202
655 S-4-17-I
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK TOKSIK LAIN-LAIN
RINGAN
3.196.054 3.835.265 4.474.476
656 S-4-17-II
SEDANG
4.743.200 5.691.840 6.640.480
657 S-4-17-III
BERAT
7.290.247 8.748.296 10.206.345
658 T-1-10-I TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT RINGAN 2.687.017 3.224.421 3.761.824
659 T-1-10-II TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT SEDANG 3.609.013 4.330.816 5.052.618
660 T-1-10-III TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT BERAT 6.565.339 7.878.407 9.191.475
661 T-4-10-I
PENYALAHGUNAAN & KETERGANTUNGAN OBAT DAN ALKOHOL,
MENOLAK NASEHAT DOKTER RINGAN
1.471.414 1.765.696 2.059.979
662 T-4-10-II
MENOLAK NASEHAT DOKTER SEDANG
2.803.785 3.364.542 3.925.299
663 T-4-10-III
MENOLAK NASEHAT DOKTER BERAT
4.075.411 4.890.493 5.705.575
664 T-4-11-I
PENYALAHGUNAAN & KETERGANTUNGAN ALKOHOL,OPIUM DAN
KOKAIN RINGAN
1.421.045 1.705.254 1.989.463
665 T-4-11-II
KOKAIN SEDANG
2.236.324 2.683.589 3.130.854
666 T-4-11-III
KOKAIN BERAT
3.602.064 4.322.476 5.042.889
667 T-4-12-I
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN
(RINGAN)
3.329.585 3.995.502 4.661.419
668 T-4-12-II
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN
(SEDANG)
5.026.415 6.031.698 7.036.981
669 T-4-12-III PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (BERAT) 7.780.156 9.336.188 10.892.219
670 U-1-10-I PROSEDUR KOMPLEKS LARING RINGAN 3.251.736 3.902.084 4.552.431
671 U-1-10-II PROSEDUR KOMPLEKS LARING SEDANG 6.635.368 7.962.441 9.289.515
672 U-1-10-III PROSEDUR KOMPLEKS LARING BERAT 28.652.858 34.383.430 40.114.001
673 U-1-11-I PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (RINGAN) 12.472.755 14.967.306 17.461.857
674 U-1-11-II PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (SEDANG) 18.812.854 22.575.425 26.337.996
675 U-1-11-III PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (BERAT) 28.481.976 34.178.372 39.874.767
676 U-1-12-I PROSEDUR MASTOID DAN SINUS RINGAN 8.447.484 10.136.980 11.826.477
677 U-1-12-II PROSEDUR MASTOID DAN SINUS SEDANG 18.710.873 22.453.047 26.195.222
678 U-1-12-III PROSEDUR MASTOID DAN SINUS BERAT 27.482.453 32.978.944 38.475.435
679 U-1-13-I PROSEDUR KELENJAR LUDAH RINGAN 9.493.317 11.391.981 13.290.644
680 U-1-13-II PROSEDUR KELENJAR LUDAH SEDANG 10.367.753 12.441.304 14.514.855
681 U-1-13-III PROSEDUR KELENJAR LUDAH BERAT 17.186.515 20.623.818 24.061.121
682 U-1-14-I
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT
(RINGAN)
5.079.812 6.095.775 7.111.737
683 U-1-14-II
(SEDANG)
6.234.148 7.480.978 8.727.808
684 U-1-14-III
(BERAT)
7.387.484 8.864.981 10.342.478
685 U-1-15-I PROSEDUR TONSIL & ADENOID RINGAN 2.987.331 3.584.798 4.182.264
686 U-1-15-II PROSEDUR TONSIL & ADENOID SEDANG 4.247.147 5.096.577 5.946.006
687 U-1-15-III PROSEDUR TONSIL & ADENOID BERAT 7.782.968 9.339.561 10.896.155
688 U-1-20-I
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN TELINGA LAIN-
LAIN (RINGAN)
7.711.886 9.254.263 10.796.640
689 U-1-20-II
LAIN (SEDANG)
13.772.412 16.526.894 19.281.377
690 U-1-20-III
LAIN (BERAT)
32.927.153 39.512.583 46.098.014
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
691 U-1-30-I PROSEDUR MULUT RINGAN 6.613.774 7.936.528 9.259.283
692 U-1-30-II PROSEDUR MULUT SEDANG 8.968.052 10.761.663 12.555.273
693 U-1-30-III PROSEDUR MULUT BERAT 17.537.361 21.044.834 24.552.306
694 U-4-10-I TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA RINGAN 6.165.293 7.398.351 8.631.410
695 U-4-10-II TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA SEDANG 14.114.096 16.936.915 19.759.734
696 U-4-10-III TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA BERAT 21.669.602 26.003.522 30.337.442
697 U-4-11-I DYSEQUILIBRIUM RINGAN 3.781.492 4.537.790 5.294.088
698 U-4-11-II DYSEQUILIBRIUM SEDANG 5.499.577 6.599.492 7.699.408
699 U-4-11-III DYSEQUILIBRIUM BERAT 5.785.520 6.942.624 8.099.729
700 U-4-12-I EPISTAKSIS/PERDARAHAN HIDUNG RINGAN 3.426.733 4.112.080 4.797.426
701 U-4-12-II EPISTAKSIS/PERDARAHAN HIDUNG SEDANG 3.986.015 4.783.218 5.580.421
702 U-4-12-III EPISTAKSIS/PERDARAHAN HIDUNG BERAT 5.170.871 6.205.045 7.239.220
703 U-4-13-I
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA DAN
LARINGOTRAKEITIS RINGAN
3.363.955 4.036.746 4.709.537
704 U-4-13-II
LARINGOTRAKEITIS SEDANG
3.965.724 4.758.869 5.552.014
705 U-4-13-III
LARINGOTRAKEITIS BERAT
4.743.241 5.691.889 6.640.537
706 U-4-14-I PENYAKIT MULUT DAN GIGI RINGAN 4.737.390 5.684.868 6.632.346
707 U-4-14-II PENYAKIT MULUT DAN GIGI SEDANG 5.672.845 6.807.413 7.941.982
708 U-4-14-III PENYAKIT MULUT DAN GIGI BERAT 9.526.528 11.431.833 13.337.139
709 U-4-15-I
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG & TELINGA LAIN-LAIN
(RINGAN)
3.803.991 4.564.790 5.325.588
710 U-4-15-II
(SEDANG)
4.739.248 5.687.097 6.634.947
711 U-4-15-III
(BERAT)
6.632.660 7.959.192 9.285.724
712 V-1-10-I PROSEDUR PENGANGKATAN PROSTAT KOMPLEK RINGAN 11.097.981 13.317.577 15.537.173
713 V-1-10-II PROSEDUR PENGANGKATAN PROSTAT KOMPLEK SEDANG 12.781.242 15.337.490 17.893.739
714 V-1-10-III PROSEDUR PENGANGKATAN PROSTAT KOMPLEK BERAT 19.209.409 23.051.291 26.893.172
715 V-1-11-I PROSEDUR PADA PENIS RINGAN 11.804.020 14.164.823 16.525.627
716 V-1-11-II PROSEDUR PADA PENIS SEDANG 13.478.758 16.174.510 18.870.261
717 V-1-11-III PROSEDUR PADA PENIS BERAT 21.108.224 25.329.869 29.551.514
718 V-1-12-I
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-MODERAT
(RINGAN)
6.204.570 7.445.483 8.686.397
719 V-1-12-II
(SEDANG)
21.890.939 26.269.127 30.647.314
720 V-1-12-III
(BERAT)
22.640.870 27.169.043 31.697.217
721 V-1-13-I
PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK
(RINGAN)
9.406.899 11.288.278 13.169.658
722 V-1-13-II
PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK
(SEDANG)
17.973.478 21.568.174 25.162.870
723 V-1-13-III PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (BERAT) 28.198.198 33.837.838 39.477.478
724 V-1-14-I PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA RINGAN 11.351.886 13.622.263 15.892.640
725 V-1-14-II PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA SEDANG 16.494.065 19.792.878 23.091.691
726 V-1-14-III PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA BERAT 20.586.290 24.703.548 28.820.806
727 V-1-15-I PROSEDUR SIRKUMSISI RINGAN 5.345.437 6.414.525 7.483.612
728 V-1-15-II PROSEDUR SIRKUMSISI SEDANG 9.491.292 11.389.551 13.287.809
729 V-1-15-III PROSEDUR SIRKUMSISI BERAT 15.633.431 18.760.118 21.886.804
730 V-4-10-I TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI RINGAN 7.929.434 9.515.321 11.101.208
731 V-4-10-II TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI SEDANG 9.707.280 11.648.735 13.590.191
732 V-4-10-III TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI BERAT 20.574.816 24.689.779 28.804.742
733 V-4-11-I
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR
(RINGAN)
4.743.319 5.691.983 6.640.646
734 V-4-11-II
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR
(SEDANG)
6.624.568 7.949.482 9.274.396
735 V-4-11-III DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (BERAT) 8.603.106 10.323.728 12.044.349
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
736 W-1-01-I
PROSEDUR OPERASI PENGANGKATAN RAHIM DAN VULVA RADIKAL
& EVISCERASI RINGAN
12.928.693 15.514.432 18.100.170
737 W-1-01-II
& EVISCERASI SEDANG
15.495.941 18.595.129 21.694.317
738 W-1-01-III
& EVISCERASI BERAT
27.998.705 33.598.446 39.198.187
739 W-1-10-I PROSEDUR ABORSI RINGAN 3.593.038 4.311.646 5.030.253
740 W-1-10-II PROSEDUR ABORSI SEDANG 5.544.124 6.652.949 7.761.774
741 W-1-10-III PROSEDUR ABORSI BERAT 8.967.589 10.761.107 12.554.625
742 W-1-11-I PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK RINGAN 3.726.247 4.471.496 5.216.746
743 W-1-11-II PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK SEDANG 6.551.165 7.861.398 9.171.631
744 W-1-11-III PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK BERAT 13.794.909 16.553.890 19.312.872
745 W-1-12-I
PROSEDUR OPERASI MEMBUKA TUBA YANG
TERHALANG/TERGANGGU RINGAN
3.394.673 4.073.607 4.752.542
746 W-1-12-II
TERHALANG/TERGANGGU SEDANG
3.848.894 4.618.673 5.388.451
747 W-1-12-III
TERHALANG/TERGANGGU BERAT
5.912.685 7.095.222 8.277.759
748 W-1-13-I PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP RINGAN 4.120.633 4.944.759 5.768.886
749 W-1-13-II PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP SEDANG 4.473.637 5.368.365 6.263.092
750 W-1-13-III PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP BERAT 6.009.172 7.211.006 8.412.841
751 W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA RINGAN 10.615.101 12.738.121 14.861.142
752 W-1-20-II PROSEDUR PADA RAHIM & ADNEKSA SEDANG 13.202.899 15.843.479 18.484.059
753 W-1-20-III PROSEDUR PADA RAHIM & ADNEKSA BERAT 22.209.763 26.651.716 31.093.668
754 W-1-30-I PROSEDUR PADA VAGINA, SERVIK & VULVA RINGAN 5.992.360 7.190.832 8.389.304
755 W-1-30-II PROSEDUR PADA VAGINA, SERVIK & VULVA SEDANG 9.557.808 11.469.370 13.380.932
756 W-1-30-III PROSEDUR PADA VAGINA, SERVIK & VULVA BERAT 23.450.563 28.140.676 32.830.789
757 W-4-10-I TUMOR SISTEM REPRODUKSI WANITA RINGAN 4.464.919 5.357.903 6.250.887
758 W-4-10-II TUMOR SISTEM REPRODUKSI WANITA SEDANG 6.619.093 7.942.912 9.266.730
759 W-4-10-III TUMOR SISTEM REPRODUKSI WANITA BERAT 15.195.636 18.234.763 21.273.890
760 W-4-11-I INFEKSI SISTEM REPRODUKSI WANITA RINGAN 4.060.561 4.872.674 5.684.786
761 W-4-11-II INFEKSI SISTEM REPRODUKSI WANITA SEDANG 6.164.458 7.397.349 8.630.241
762 W-4-11-III INFEKSI SISTEM REPRODUKSI WANITA BERAT 7.503.371 9.004.045 10.504.719
763 W-4-12-I
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI WANITA LAIN-
LAIN (RINGAN)
3.798.474 4.558.169 5.317.864
764 W-4-12-II
LAIN (SEDANG)
5.215.008 6.258.010 7.301.011
765 W-4-12-III
LAIN (BERAT)
5.684.567 6.821.480 7.958.393
766 W-4-13-I ABORTUS RINGAN 2.076.868 2.492.241 2.907.615
767 W-4-13-II ABORTUS SEDANG 2.837.058 3.404.470 3.971.881
768 W-4-13-III ABORTUS BERAT 3.528.102 4.233.722 4.939.343
769 W-4-14-I ABORTUS MENGANCAM RINGAN 2.775.541 3.330.649 3.885.757
770 W-4-14-II ABORTUS MENGANCAM SEDANG 3.303.583 3.964.299 4.625.016
771 W-4-14-III ABORTUS MENGANCAM BERAT 4.226.460 5.071.752 5.917.044
772 W-4-15-I PERSALINAN FALSE LABOR RINGAN 2.137.263 2.564.716 2.992.169
773 W-4-15-II PERSALINAN FALSE LABOR SEDANG 2.373.650 2.848.380 3.323.110
774 W-4-15-III PERSALINAN FALSE LABOR BERAT 3.286.413 3.943.696 4.600.978
775 W-4-16-I GANGGUAN ANTEPARTUM RINGAN 2.843.640 3.412.368 3.981.095
776 W-4-16-II GANGGUAN ANTEPARTUM SEDANG 3.802.731 4.563.277 5.323.823
777 W-4-16-III GANGGUAN ANTEPARTUM BERAT 5.153.958 6.184.750 7.215.541
778 W-4-17-I GANGGUAN POSTPARTUM RINGAN 2.098.301 2.517.961 2.937.622
779 W-4-17-II GANGGUAN POSTPARTUM SEDANG 3.788.565 4.546.277 5.303.990
780 W-4-17-III GANGGUAN POSTPARTUM BERAT 7.189.144 8.626.973 10.064.802
781 Z-4-10-I REHABILITASI RINGAN 5.990.948 7.189.138 8.387.327
782 Z-4-10-II REHABILITASI SEDANG 7.951.708 9.542.049 11.132.391
783 Z-4-10-III REHABILITASI BERAT 11.296.811 13.556.173 15.815.536
784 Z-4-11-I GEJALA-GEJALA DAN TANDA-TANDA RINGAN 4.187.356 5.024.827 5.862.298
785 Z-4-11-II GEJALA-GEJALA DAN TANDA-TANDA SEDANG 5.029.177 6.035.012 7.040.847
786 Z-4-11-III GEJALA-GEJALA DAN TANDA-TANDA BERAT 9.959.736 11.951.683 13.943.630
787 Z-4-12-I
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS KESEHATAN LAIN-
LAIN (RINGAN)
2.838.262 3.405.914 3.973.566
788 Z-4-12-II
LAIN (SEDANG)
5.698.833 6.838.600 7.978.367
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
789 Z-4-12-III
LAIN (BERAT)
12.023.061 14.427.673 16.832.285
No
Kode INA-
CBG
Deskripsi Kode INA-CBG Tarif INA - CBG
1 B-2-10-0 PROSEDUR PADA HATI DAN PANKREAS 1.858.798
2 B-2-11-0 PROSEDUR BESAR PADA SALURAN EMPEDU 2.411.152
3 B-2-12-0 PROSEDUR KOLESISTEKTOMI TANPA LAPAROSKOPI 4.483.854
4 B-2-13-0 PROSEDUR LAIN-LAIN PADA HEPATOBILIARI & PANKREAS 3.705.470
5 B-2-14-0 PROSEDUR KOLESISTEKTOMI DENGAN LAPAROSKOPI 3.095.601
6 B-3-10-0 PROSEDUR PADA PERKUTAN HATI & SALURAN EMPEDU 885.763
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 1.968.103
8 B-3-12-0 PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN PANKREAS 497.261
9 C-3-10-0 PROSEDUR RADIOTERAPI 1.101.213
10 C-3-11-0 KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH 1.726.889
11 C-3-12-0 KEMOTERAPI PADA TUMOR KOLON 1.960.530
12 C-3-13-0 KEMOTERAPI PADA TUMOR PAYUDARA ATAU OVARIUM 2.947.513
13 C-3-14-0 KEMOTERAPI PADA TUMOR GASTROINTESTINAL 4.020.373
14 C-3-15-0 KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU PROSTAT 3.684.832
15 C-3-16-0 KEMOTERAPI PADA TUMOR OTAK 835.631
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 2.755.136
17 C-3-18-0 KEMOTERAPI PADA LEUKEMIA AKUT 699.599
18 C-3-19-0 KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS 1.715.785
19 C-3-20-0 KEMOTERAPI PADA TUMOR KULIT 5.226.406
20 C-3-21-0 KEMOTERAPI PADA TUMOR GINEKOLOGI 1.871.723
21 C-3-22-0 KEMOTERAPI PADA TUMOR METASTASE 4.420.200
22 C-3-23-0 KEMOTERAPI PADA TUMOR LAIN-LAIN 754.844
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 2.389.773
24 D-2-11-0 PROSEDUR LIMPA 2.992.404
25 D-2-21-0 PROSEDUR BESAR PADA NODUL LIMPA DAN TYMUS 2.509.779
26 D-2-22-0 PROSEDUR KECIL PADA NODUL LIMPA DAN TYMUS 550.821
27 D-3-10-0 PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG 1.865.400
28 D-3-11-0 PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH 1.037.126
29 E-2-10-0 PROSEDUR PADA KELENJAR ADRENAL 614.458
30 E-2-21-0 PROSEDUR BESAR PADA KELENJAR TIROID DAN PARATIROID 445.461
31 E-2-22-0
PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN
THYROGLOSSAL
352.388
32 E-3-10-0 PROSEDUR DIAGNOSTIK PADA KELENJAR ENDOKRIN 421.315
33 F-3-10-0 TERAPI SHOCK 586.728
34 F-5-10-0 PELAYANAN KESEHATAN MENTAL EKSTENSIF 720.260
35 F-5-11-0 TERAPI KELOMPOK 474.504
36 F-5-12-0 PROSEDUR TES DIAGNOSTIK KESEHATAN JIWA 609.192
37 F-5-13-0 PSIKOTERAPI INDIVIDU DEWASA AKUT 632.822
38 F-5-14-0 PSIKOTHERAPI INDIVIDU DEWASA BUKAN AKUT 345.446
39 F-5-15-0 PENGOBATAN INDIVIDU KETERBELAKANGAN MENTAL 325.682
40 F-5-16-0
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN
MENTAL
414.839
41 G-2-10-0 PROSEDUR KRANIOTOMI 10.944.077
42 G-2-11-0 PROSEDUR SHUNT VENTRIKEL 3.028.107
43 G-2-12-0 PROSEDUR PADA PEMBULUH DARAH EKSTRAKRANIAL 4.388.472
44 G-2-13-0 PROSEDUR CARPAL TUNNEL RELEASE 1.076.590
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 1.599.726
46 G-2-22-0 PROSEDUR KECIL PADA SARAF PERIFER 1.446.728
47 G-2-31-0 PROSEDUR BESAR PADA TULANG BELAKANG 2.940.555
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
48 G-2-32-0 PROSEDUR KECIL PADA TULANG BELAKANG 1.507.326
49 G-3-10-0 PROSEDUR TAP & INJEKSI PADA SPINAL 597.607
50 G-3-11-0 PROSEDUR INJEKSI PADA SARAF PERIFER 651.781
51 G-3-12-0 PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN 1.051.281
52 G-3-13-0 PROSEDUR ELEKROENSEFALOGRAFI (EEG) 1.065.799
53 H-2-21-0 PROSEDUR BESAR PADA MATA 1.397.974
54 H-2-22-0 PROSEDUR SEDANG PADA MATA 562.546
55 H-2-23-0 PROSEDUR KECIL PADA MATA 445.461
56 H-2-31-0 PROSEDUR BESAR PADA SEGMEN ANTERIOR MATA 2.836.627
57 H-2-32-0 PROSEDUR SEDANG PADA SEGMEN ANTERIOR MATA 539.855
58 H-2-33-0 PROSEDUR KECIL PADA SEGMEN ANTERIOR MATA 362.739
59 H-2-34-0 PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA 1.271.086
60 H-2-35-0 PROSEDUR KECIL PADA SEGMEN POSTERIOR MATA 342.402
61 H-2-36-0 PROSEDUR OPERASI KATARAK 2.802.435
62 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 1.965.469
63 H-3-10-0 PROSEDUR LASER SEDANG PADA MATA 836.974
64 H-3-11-0 PROSEDUR KECIL PADA EKTRAOKULER 360.090
65 H-3-12-0 PROSEDUR LAIN-LAIN PADA MATA 375.041
66 H-3-13-0 PROSEDUR DIAGNOSTIK & IMAGING PADA MATA 338.173
67 I-2-11-0
PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU
JANTUNG
5.157.140
68 I-2-12-0 PROSEDUR BESAR PADA PEMBULUH DARAH TORASIK 3.626.032
69 I-2-13-0 PROSEDUR BESAR PADA PEMBULUH DARAH ABDOMEN 4.608.469
70 I-2-14-0
PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA
JANTUNG
8.156.009
71 I-2-15-0 PROSEDUR KATETERISASI JANTUNG 6.762.293
72 I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK
TERMASUK PENGGANTIAN ALAT
5.151.551
73 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA 1.698.319
74 I-2-21-0 ANGIOGRAFI ARTERI BUKAN JANTUNG 3.976.265
75 I-2-22-0 PROSEDUR SEDANG PADA PEMBULUH DARAH 3.063.114
76 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH 767.640
77 I-2-31-0 PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR JANTUNG 5.959.541
78 I-2-32-0 PEMASANGAN ATAU PENGGANTIAN ALAT PACU JANTUNG 7.792.975
79 I-2-41-0 PROSEDUR ELEKTROFISIOLOGIK 5.225.285
80 I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN
KARDIOVASKULAR PERKUTAN LAIN
4.950.217
81 I-3-10-0 PROSEDUR RESUSITASI 611.830
82 I-3-11-0 PROSEDUR KARDIOVERSI 407.038
83 I-3-12-0 PROSEDUR KECIL LAIN-LAIN PADA JANTUNG 2.365.549
84 I-3-13-0 PROSEDUR EKOKARDIOGRAFI 646.511
85 I-3-14-0 PROSEDUR STRESS TESTING 499.136
86 I-3-15-0 PROSEDUR PENGAWASAN FUNGSI KARDIOVASKULAR 440.689
87 J-2-10-0 PROSEDUR BESAR PADA SISTEM SALURAN PERNAFASAN 2.731.312
88 J-2-21-0 PROSEDUR VENTILASI MEKANIKAL JANGKA PENDEK 439.015
89 J-2-22-0 PROSEDUR PADA LARING DAN TRAKEA 1.804.821
90 J-2-31-0 PROSEDUR THORAKOSKOPI/MEDIASTINOSKOPI 2.877.944
91 J-2-32-0 PROSEDUR DADA INTERMEDIATE 1.742.926
92 J-3-10-0 PROSEDUR PADA DINDING DADA 445.461
93 J-3-11-0 PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA 1.021.302
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
94 J-3-12-0 PROSEDUR THORACENTESIS 485.364
95 J-3-13-0 PROSEDUR TERAPI SALURAN PERNAFASAN 582.462
96 J-3-14-0 PROSEDUR BIOPSI PERKUTAN DAN ASPIRASI 616.769
97 J-3-15-0 PROSEDUR BRONKOSKOPI 542.091
98 J-3-16-0 PROSEDUR UJI FUNGSI PARU 618.249
99 J-3-17-0 PROSEDUR LAIN-LAIN PADA SISTEM SALURAN PERNAFASAN 362.416
100 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL 1.040.137
101 K-2-11-0 PROSEDUR ADHESIOLYSIS PADA PERITONEUM 2.737.997
102 K-2-12-0
PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN
FEMORALIS
2.101.766
103 K-2-13-0 PROSEDUR PADA USUS BUNTU 3.420.738
104 K-2-14-0 PROSEDUR PADA HERNIA INGUINALIS DAN FEMORALIS 445.461
105 K-2-21-0 PROSEDUR BESAR PADA USUS HALUS DAN USUS BESAR 445.461
106 K-2-22-0 PROSEDUR BESAR PADA GASTROINTESTINAL ATAS 5.707.344
107 K-2-31-0 PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS 1.925.106
108 K-2-32-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL ATAS 445.461
109 K-2-41-0 PROSEDUR LAPAROSKOPI 2.120.544
110 K-2-42-0 PROSEDUR LAPAROTOMI & GASTROINTESTINAL LAINNYA 6.120.643
111 K-2-51-0 PROSEDUR UNTUK WASIR 1.405.200
112 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM 766.270
113 K-2-53-0 PROSEDUR KECIL PADA ANUS & REKTUM 375.443
114 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL 797.685
116 K-3-12-0 PROSEDUR SIGMOIDOSKOPI DAN ANOSKOPI 516.822
117 K-3-13-0 PROSEDUR KOLONOSKOPI 444.899
118 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 1.193.846
119 K-3-15-0 PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS 575.632
120 K-3-16-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL 624.959
121 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 2.626.425
122 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR 1.683.520
123 L-2-31-0 PROSEDUR BESAR PEMINDAHAN KULIT TANPA LUKA BAKAR 622.518
124 L-2-32-0 PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR 619.438
125 L-2-41-0 PROSEDUR BEDAH PLASTIK 1.862.153
126 L-2-42-0 PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH KULIT 514.621
127 L-2-51-0 PROSEDUR PENGANGKATAN PAYUDARA 3.435.233
128 L-2-52-0
PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN
PAYUDARA
2.628.067
129 L-2-53-0 PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 443.848
130 L-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA PAYUDARA 492.093
131 L-3-11-0 PROSEDUR BESAR PADA KULIT 480.625
132 L-3-12-0 PROSEDUR KECIL PADA KULIT 363.545
133 M-2-10-0 PROSEDUR REKONTRUKSI TULANG KRANIAL DAN WAJAH 2.863.442
134 M-2-21-0 PROSEDUR BESAR PADA SENDI PANGGUL DAN PAHA 3.147.472
135 M-2-22-0 PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA 623.766
136 M-2-31-0 PROSEDUR BUNION 1.911.773
137 M-2-32-0 PROSEDUR LAIN-LAIN PADA KAKI 493.988
138 M-2-41-0 PROSEDUR EKSISI, INSISI DAN ARTHROTOMI TULANG 534.174
139 M-2-42-0 PROSEDUR PEMINDAHAN ALAT IMPLAN 208.246
140 M-2-51-0 PROSEDUR BESAR PADA JARINGAN LUNAK 644.928
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
141 M-2-52-0 PROSEDUR KECIL PADA JARINGAN LUNAK 444.238
142 M-2-61-0 PROSEDUR ARTROSKOPI 2.183.438
143 M-2-62-0 PROSEDUR LAIN-LAIN PADA SENDI & TULANG 445.980
144 M-2-63-0 PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG 1.792.371
145 M-2-64-0 PROSEDUR BESAR PADA TULANG KEPALA & WAJAH 2.993.867
146 M-2-65-0 PROSEDUR KECIL PADA TULANG KEPALA & WAJAH 363.121
147 M-2-71-0 PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH 2.210.261
148 M-2-72-0 PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH 1.730.039
149 M-2-81-0 PROSEDUR BESAR PADA LENGAN, SIKU & BAHU 2.588.396
150 M-2-82-0 PROSEDUR KECIL PADA LENGAN, SIKU & BAHU 1.887.343
151 M-2-83-0 PROSEDUR BESAR PADA TANGAN & PERGELANGAN TANGAN 646.623
152 M-2-84-0 PROSEDUR KECIL PADA TANGAN & PERGELANGAN TANGAN 443.906
153 M-3-10-0 PROSEDUR MANIPULATIVE OSTEOPATHIC 1.036.139
154 M-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK MUSKULOSKELETAL 575.251
155 M-3-12-0 PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL 1.300.040
156 M-3-13-0 PROSEDUR REDUKSI FRAKTUR TERTUTUP 506.596
157 M-3-14-0 PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP 684.268
158 M-3-15-0 PROSEDUR APLIKASI CASTS DAN SPLINTS 391.357
159 M-3-16-0 PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL 361.730
160 M-3-17-0 PROSEDUR PEMASANGAN ALAT PROSTETIK 395.172
161 N-2-11-0 PROSEDUR BESAR PADA KANDUNG KEMIH 5.884.978
162 N-2-12-0
DIALISIS
3.410.717
163 N-2-21-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN
KEMIH
3.380.648
164 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 2.476.327
165 N-2-23-0 PROSEDUR SEDANG PADA GINJAL DAN URETER 1.566.270
166 N-2-24-0 PROSEDUR KECIL PADA GINJAL DAN URETER 621.702
167 N-2-31-0 PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA 1.705.732
168 N-2-32-0 PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA 624.563
169 N-2-41-0 PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA 1.051.301
170 N-2-42-0 PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA 622.112
171 N-3-10-0 PROSEDUR PADA GINJAL DAN URETER 625.854
172 N-3-11-0 PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH 725.244
173 N-3-12-0
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN
KEMIH
538.089
174 N-3-13-0 PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH 766.270
175 N-3-14-0 PROSEDUR KECIL ENDOSKOPI PADA SALURAN KEMIH 539.159
176 N-3-15-0 PROSEDUR DIALISIS 1.380.582
177 O-7-10-0 PROSEDUR PERSALINAN DENGAN BEDAH CAESAR 3.290.837
178 O-7-11-0
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN
DAN KURETASE
2.647.673
179 O-7-12-0
STERILISASI DAN ATAU PELEBARAN DAN KURETASE
1.875.850
180 O-7-13-0 PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR 1.647.517
181 P-9-10-0
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN
PASIEN AKUT LAIN
419.590
182 P-9-11-0 NEONATAL, BBL GROUP-2 419.590
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
185 P-9-14-0
NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI
HEREDITER
342.754
186 P-9-15-0 NEONATAL, BBL GROUP-5 DENGAN SINDROM ASPIRASI 217.343
187 P-9-16-0 NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL 341.781
189 Q-5-10-0 PENYALAHGUNAAN ZAT KIMIA AKUT 451.987
190 Q-5-11-0 PENYALAHGUNAAN ZAT KIMIA BUKAN AKUT 332.862
191 Q-5-12-0 GIGI 293.578
192 Q-5-13-0 MEDICAL CHECK-UP 223.434
193 Q-5-14-0 RONGENT (PLAIN FILM) 245.656
194 Q-5-15-0 ELEKTROKARDIOGRAM (ECG) 181.660
195 Q-5-16-0 VAKSINASI 213.159
196 Q-5-17-0 PASANG INFUS 203.343
197 Q-5-18-0 KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN 310.382
198 Q-5-19-0 KONTAK PELAYANAN KESEHATAN LAIN-LAIN 347.907
199 Q-5-20-0 ABORSI MENGANCAM 233.273
200 Q-5-21-0 ABORSI 282.536
201 Q-5-22-0 PERSALINAN YANG SUKAR (FALSE LABOR) 247.125
202 Q-5-23-0 PEMERIKSAAN ANTEPARTUM 299.962
203 Q-5-24-0 PEMERIKSAAN POSTPARTUM 205.038
204 Q-5-25-0 GASTROINTESTINAL AKUT 319.971
205 Q-5-26-0 BRONKIAL AKUT 453.991
206 Q-5-27-0 SISTEM PERSARAFAN PUSAT AKUT 323.242
207 Q-5-28-0 KECEDERAAN SISTEM PERSARAFAN PUSAT 261.874
208 Q-5-29-0 GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN 740.308
209 Q-5-30-0 INFARK MIOKARD AKUT DAN ARITMIA 858.238
210 Q-5-31-0 FRAKTUR 305.661
211 Q-5-32-0 SALURAN KEMIH AKUT 356.280
212 Q-5-33-0 HEMATOLOGI AKUT 371.929
213 Q-5-34-0 INFEKSI VIRUS HIV 530.998
214 Q-5-35-0 INFEKSI AKUT 599.265
215 Q-5-36-0 KEKACAUAN METABOLIK AKUT 701.636
216 Q-5-37-0 CARDIAC ARREST, RESPIRATORY ARREST & SHOCK 368.792
217 Q-5-38-0 PARU AKUT 476.524
218 Q-5-39-0 KECEDERAAN BESAR PADA JARINGAN LUNAK 303.824
219 Q-5-40-0 INFEKSI SALURAN KEMIH AKUT 298.585
220 Q-5-41-0 PENYAKIT AKUT BESAR LAIN-LAIN 411.222
221 Q-5-42-0 PENYAKIT AKUT KECIL LAIN-LAIN 324.445
222 Q-5-43-0 PENYAKIT KRONIS BESAR LAIN-LAIN 465.329
223 Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN 378.878
224 T-2-10-0 PEMULIHAN ALKOHOL, OBAT DAN ATAU TERAPI DETOKSIKASI 201.687
225 U-2-10-0 PROSEDUR BESAR PADA LARING 3.233.139
226 U-2-11-0 PROSEDUR BESAR LAIN-LAIN PADA KEPALA & LEHER 3.842.945
227 U-2-12-0 PROSEDUR PADA SINUS & MASTOID 422.706
228 U-2-13-0 PROSEDUR KELENJAR LUDAH 437.782
229 U-2-14-0 PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT 837.290
230 U-2-15-0 PROSEDUR OPERASI TONSIL & AMANDEL 474.634
231 U-2-21-0
PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
1.071.744
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
232 U-2-22-0
PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
553.647
233 U-2-23-0 PROSEDUR PERBAIKAN HIDUNG (RHINOPLASTY) 1.725.307
234 U-2-24-0 PROSEDUR KECIL PADA HIDUNG 1.180.492
235 U-2-25-0 PROSEDUR PADA TELINGA TENGAH 449.976
236 U-2-31-0 PROSEDUR BESAR PADA MULUT DAN LIDAH 451.427
237 U-2-32-0 PROSEDUR KECIL PADA MULUT DAN LIDAH 361.458
238 U-3-10-0
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
456.531
239 U-3-11-0
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
432.079
240 U-3-12-0 PROSEDUR KAUTERISASI & PACKING PADA RONGGA HIDUNG 202.451
241 U-3-13-0
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT
DAN TENGGOROKAN
444.679
242 U-3-14-0
PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
408.480
243 U-3-15-0
PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
356.516
244 U-3-16-0 PROSEDUR PADA GIGI 403.236
245 V-2-10-0 PROSEDUR BESAR PADA PENGANGKATAN PROSTAT 4.821.776
246 V-2-11-0 PROSEDUR PADA PENIS 541.764
247 V-2-12-0 PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM 1.735.259
248 V-2-13-0 PROSEDUR KECIL PADA PROSTAT DAN SKROTUM 622.405
249 V-2-14-0 PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL 766.270
250 V-2-15-0 SIRKUMSISI/SUNAT 364.404
251 V-3-10-0 PROSEDUR STERILISASI PADA LAKI-LAKI 875.084
252 V-3-11-0
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-
LAKI
1.506.929
253 V-3-12-0 PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI 1.068.329
254 W-2-10-0 PROSEDUR ABORSI 390.689
255 W-2-11-0 PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM 996.414
256 W-2-12-0 PROSEDUR MEMBUKA TUBA YANG TERHALANG/TERGANGGU 1.851.256
257 W-2-13-0 PROSEDUR ENDOSKOPI TUBA YANG TERHALANG/TERGANGGU 296.908
258 W-2-21-0 PROSEDUR BESAR PADA FRAKTUR RONGGA PANGGUL TERBUKA 3.721.518
259 W-2-22-0 PROSEDUR KECIL PADA FRAKTUR RONGGA PANGGUL TERBUKA 391.357
260 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 1.305.979
261 W-2-31-0 PROSEDUR PEMBUANGAN RAHIM MELALUI JALAN LAHIR 4.287.130
262 W-2-32-0
PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL
INTERMEDIATE
3.006.759
263 W-2-33-0 PROSEDUR KECIL VULVOVAGINAL 1.277.912
264 W-2-34-0 PROSEDUR GINEKOLOGI LAIN-LAIN 434.640
265 W-3-10-0 PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI 1.056.345
266 W-3-11-0 PROSEDUR SEDANG GINEKOLOGI 844.411
267 W-3-12-0 PROSEDUR KECIL GINEKOLOGI 391.357
268 Z-3-10-0 PROSEDUR RADIOSURGICAL 4.430.687
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI
DAN SALURAN EMPEDU
3.386.457
270 Z-3-12-0 PROSEDUR REHABILITASI 565.456
271 Z-3-13-0 PROSEDUR KECIL PELAYANAN PENUNJANG LAIN-LAIN 3.450.569
272 Z-3-14-0 DIAGNOSTIK TIDUR 682.285
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
273 Z-3-15-0 IMAGING NUKLIR JANTUNG 445.461
274 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 1.429.795
275 Z-3-17-0 PENGOBATAN NUKLIR 600.259
276 Z-3-18-0 CT-SCAN KEPALA 578.338
277 Z-3-19-0 CT SCAN LAIN-LAIN 601.937
278 Z-3-20-0 IMAGING KONTRAS SALURAN URINARI 409.392
279 Z-3-21-0 IMAGING KONTRAS PEMBULUH DARAH 391.357
280 Z-3-22-0 IMAGING KONTRAS LAIN-LAIN 441.220
281 Z-3-23-0 PROSEDUR ULTRASOUND LAIN-LAIN 459.569
282 Z-3-24-0 PROSEDUR ULTRASOUND PEMBULUH DARAH 902.962
283 Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK 402.178
284 Z-3-26-0 PROSEDUR BESAR RADIOGRAFI 454.541
285 Z-3-27-0 PERAWATAN LUKA 433.963
286 Z-3-28-0 IMAGING PAYUDARA 445.461
287 Z-3-29-0 IMAGING LAIN-LAIN 1.283.899
288 Z-3-30-0 FOTOTERAPI 176.200
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.948.069 2.337.682 2.727.296
8 A-4-12-II DEMAM SEDANG 3.081.176 3.697.411 4.313.646
9 A-4-12-III DEMAM BERAT 3.521.744 4.226.093 4.930.442
13 A-4-14-I
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN
RINGAN
3.051.914 3.662.297 4.272.680
14 A-4-14-II
SEDANG
3.925.534 4.710.640 5.495.747
15 A-4-14-III
BERAT
4.497.738 5.397.286 6.296.833
28 B-1-12-I
PROSEDUR CHOLESISTEKTOMI TANPA
LAPAROSKOPIK RINGAN
6.751.263 8.101.515 9.451.768
29 B-1-12-II
LAPAROSKOPIK SEDANG
14.469.608 17.363.529 20.257.451
30 B-1-12-III
LAPAROSKOPIK BERAT
17.110.482 20.532.578 23.954.674
31 B-1-13-I
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-
LAIN (RINGAN)
5.428.994 6.514.793 7.600.592
32 B-1-13-II
LAIN (SEDANG)
8.843.044 10.611.653 12.380.261
33 B-1-13-III
LAIN (BERAT)
13.037.128 15.644.553 18.251.979
34 B-1-14-I
PROSEDUR CHOLESISTEKTOMI DENGAN
LAPAROSKOPIK RINGAN
7.343.392 8.812.070 10.280.749
35 B-1-14-II
LAPAROSKOPIK SEDANG
8.167.334 9.800.800 11.434.267
36 B-1-14-III
LAPAROSKOPIK BERAT
12.776.823 15.332.187 17.887.552
Rumah Sakit Kelas B
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
40 B-4-11-I
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS
RINGAN
4.033.956 4.840.747 5.647.539
41 B-4-11-II
SEDANG
6.149.104 7.378.925 8.608.745
42 B-4-11-III
BERAT
6.633.765 7.960.518 9.287.270
46 B-4-13-I
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU
HEPATITIS ALKOHOLIK RINGAN
2.941.039 3.529.247 4.117.455
47 B-4-13-II
HEPATITIS ALKOHOLIK SEDANG
4.278.816 5.134.579 5.990.342
48 B-4-13-III
HEPATITIS ALKOHOLIK BERAT
5.357.092 6.428.511 7.499.929
67 D-1-10-I
PROSEDUR PENCANGKOKAN SUMSUM TULANG
RINGAN
20.282.946 24.339.535 28.396.124
68 D-1-10-II
SEDANG
30.892.482 37.070.978 43.249.475
69 D-1-10-III
BERAT
41.867.754 50.241.305 58.614.856
73 D-1-20-I
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK
DARAH LAIN-LAIN (RINGAN)
4.313.098 5.175.717 6.038.337
74 D-1-20-II
DARAH LAIN-LAIN (SEDANG)
12.679.606 15.215.528 17.751.449
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
75 D-1-20-III
DARAH LAIN-LAIN (BERAT)
19.892.387 23.870.864 27.849.342
85 D-4-13-I
GANGGUAN SEL DARAH MERAH SELAIN KRISIS
ANEMIA SEL SICKLE RINGAN
1.960.306 2.352.367 2.744.428
86 D-4-13-II
ANEMIA SEL SICKLE SEDANG
2.939.953 3.527.944 4.115.934
87 D-4-13-III
ANEMIA SEL SICKLE BERAT
4.057.471 4.868.965 5.680.460
88 D-4-14-I
GANGGUAN PADA DARAH & ORGAN PEMBENTUK
2.436.190 2.923.429 3.410.667
89 D-4-14-II
4.367.655 5.241.185 6.114.716
90 D-4-14-III
6.124.405 7.349.286 8.574.167
91 E-1-01-I
PROSEDUR KELENJAR PITUITARI DAN PINEAL
RINGAN
6.084.613 7.301.535 8.518.458
92 E-1-01-II
SEDANG
7.970.264 9.564.316 11.158.369
97 E-1-20-I
PROSEDUR PADA TIROID, PARATIROID DAN
SALURAN TIROGLOSAL RINGAN
5.843.413 7.012.095 8.180.778
98 E-1-20-II
SALURAN TIROGLOSAL SEDANG
9.561.003 11.473.203 13.385.404
99 E-1-20-III
SALURAN TIROGLOSAL BERAT
17.936.193 21.523.432 25.110.671
100 E-4-10-I
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/
METABOLIK RINGAN
3.059.460 3.671.353 4.283.245
101 E-4-10-II
METABOLIK SEDANG
4.235.205 5.082.246 5.929.287
102 E-4-10-III
METABOLIK BERAT
6.461.474 7.753.768 9.046.063
109 E-4-13-I
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN
RINGAN
2.966.249 3.559.499 4.152.749
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
110 E-4-13-II
SEDANG
5.013.858 6.016.630 7.019.402
118 F-4-12-I
GANGGUAN PERSONALITI & KONTROL IMPULSE
RINGAN
1.877.806 2.253.368 2.628.929
119 F-4-12-II
SEDANG
2.489.455 2.987.346 3.485.237
120 F-4-12-III
BERAT
4.876.306 5.851.567 6.826.828
130 F-4-16-I
GANGGUAN ORGANIK DAN KETERBELAKANGAN
MENTAL RINGAN
5.767.718 6.921.262 8.074.805
131 F-4-16-II
MENTAL SEDANG
6.702.373 8.042.847 9.383.322
132 F-4-16-III
MENTAL BERAT
8.946.548 10.735.858 12.525.168
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK RINGAN 965.803 1.158.963 1.352.124
142 G-1-01-I
PROSEDUR PADA PEMBULUH DARAH INTRA
KRANIAL RINGAN
8.839.961 10.607.954 12.375.946
143 G-1-01-II
PROSEDUR PEMBULUH DARAH INTRA KRANIAL
SEDANG
12.640.865 15.169.038 17.697.212
144 G-1-01-III
BERAT
24.516.105 29.419.327 34.322.548
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
151 G-1-12-I
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL
RINGAN
4.463.864 5.356.637 6.249.410
152 G-1-12-II
SEDANG
9.628.711 11.554.453 13.480.196
153 G-1-12-III
BERAT
14.301.419 17.161.703 20.021.987
163 G-4-10-I
KECEDERAAN & GANGGUAN TULANG BELAKANG
RINGAN
2.927.168 3.512.602 4.098.035
164 G-4-10-II
SEDANG
4.007.482 4.808.978 5.610.474
165 G-4-10-III
BERAT
6.939.080 8.326.896 9.714.712
166 G-4-11-I
TUMOR SISTEM PERSARAFAN & GANGGUAN
DEGENERATIF RINGAN
5.316.990 6.380.388 7.443.786
167 G-4-11-II
DEGENERATIF SEDANG
6.704.874 8.045.849 9.386.823
168 G-4-11-III
DEGENERATIF BERAT
8.601.400 10.321.680 12.041.959
172 G-4-13-I
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK
RINGAN
2.705.048 3.246.057 3.787.067
173 G-4-13-II
SEDANG
3.752.059 4.502.470 5.252.882
174 G-4-13-III
BERAT
4.398.569 5.278.283 6.157.997
175 G-4-14-I
KECEDERAAN PEMBULUH DARAH OTAK DENGAN
INFARK RINGAN
3.684.854 4.421.824 5.158.795
176 G-4-14-II
INFARK SEDANG
6.663.579 7.996.295 9.329.011
177 G-4-14-III
INFARK BERAT
8.332.363 9.998.836 11.665.308
178 G-4-15-I
KECEDERAAN PEMBULUH DARAH OTAK NON
SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA
INFARK RINGAN
2.872.210 3.446.652 4.021.094
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
179 G-4-15-II
INFARK SEDANG
3.427.996 4.113.595 4.799.194
180 G-4-15-III
INFARK BERAT
4.893.903 5.872.684 6.851.464
184 G-4-17-I
GANGUAN PERSARAFAN KRANIAL DAN PERIFER
RINGAN
3.815.992 4.579.190 5.342.389
185 G-4-17-II
SEDANG
4.739.533 5.687.440 6.635.346
186 G-4-17-III
BERAT
7.943.497 9.532.196 11.120.895
187 G-4-18-I
INFEKSI TUBERKULOSA DAN BAKTERI SISTEM
PERSARAFAN RINGAN
2.962.410 3.554.892 4.147.374
188 G-4-18-II
PERSARAFAN SEDANG
5.665.649 6.798.778 7.931.908
189 G-4-18-III
PERSARAFAN BERAT
5.997.435 7.196.922 8.396.409
190 G-4-19-I
INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK
TERMASUK MENINGITIS VIRUS) RINGAN
3.247.507 3.897.009 4.546.510
191 G-4-19-II
TERMASUK MENINGITIS VIRUS) SEDANG
4.380.269 5.256.323 6.132.377
192 G-4-19-III
TERMASUK MENINGITIS VIRUS) BERAT
6.717.790 8.061.348 9.404.906
211 G-4-26-I
GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-
LAIN (RINGAN)
3.272.379 3.926.854 4.581.330
212 G-4-26-II
LAIN (SEDANG)
4.483.260 5.379.912 6.276.564
213 G-4-26-III
LAIN (BERAT)
5.384.213 6.461.055 7.537.898
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
229 I-1-01-I
PROSEDUR TRANPLANTASI PARU ATAU/DAN
JANTUNG RINGAN
41.121.380 49.345.656 57.569.932
230 I-1-01-II
JANTUNG SEDANG
42.026.265 50.431.517 58.836.770
231 I-1-01-III
JANTUNG BERAT
66.337.652 79.605.183 92.872.713
232 I-1-02-I
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI
RINGAN
22.813.905 27.376.686 31.939.466
233 I-1-02-II
SEDANG
29.429.937 35.315.924 41.201.912
234 I-1-02-III
BERAT
36.274.108 43.528.930 50.783.752
235 I-1-03-I
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS
PADA JANTUNG ANOMALI RINGAN
14.028.081 16.833.697 19.639.313
236 I-1-03-II
PADA JANTUNG ANOMALI SEDANG
15.995.821 19.194.985 22.394.149
237 I-1-03-III
PADA JANTUNG ANOMALI BERAT
26.461.463 31.753.756 37.046.048
238 I-1-04-I
PROSEDUR KATUP JANTUNG TANPA KATETERISASI
JANTUNG RINGAN
22.825.408 27.390.489 31.955.571
239 I-1-04-II
JANTUNG SEDANG
54.425.628 65.310.754 76.195.879
240 I-1-04-III
JANTUNG BERAT
86.944.622 104.333.547 121.722.471
241 I-1-05-I
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH
KORONER DENGAN KATETERISASI JANTUNG
RINGAN
30.194.874 36.233.849 42.272.823
242 I-1-05-II
SEDANG
36.233.849 43.480.618 50.727.388
243 I-1-05-III
KORONER DENGAN KATETERISASI JANTUNG BERAT
49.857.547 59.829.056 69.800.566
247 I-1-07-I
KORONER TANPA KATETERISASI JANTUNG RINGAN
24.926.303 29.911.564 34.896.824
248 I-1-07-II
KORONER TANPA KATETERISASI JANTUNG SEDANG
30.751.659 36.901.990 43.052.322
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
249 I-1-07-III
KORONER TANPA KATETERISASI JANTUNG BERAT
33.549.860 40.259.832 46.969.804
250 I-1-11-I
PROSEDUR DEFIBRILATOR JANTUNG DAN
PEMASANGAN SISTEM BANTUAN JANTUNG RINGAN
4.011.386 4.813.663 5.615.940
251 I-1-11-II
PEMASANGAN SISTEM BANTUAN JANTUNG SEDANG
4.460.260 5.352.312 6.244.364
252 I-1-11-III
PEMASANGAN SISTEM BANTUAN JANTUNG BERAT
5.935.246 7.122.296 8.309.345
253 I-1-12-I
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS
RINGAN
12.120.213 14.544.255 16.968.298
254 I-1-12-II
SEDANG
13.806.465 16.567.758 19.329.051
255 I-1-12-III
BERAT
22.326.707 26.792.049 31.257.390
256 I-1-13-I
PROSEDUR PEMBULUH DARAH ABDOMINAL
KOMPLEK RINGAN
12.775.405 15.330.486 17.885.568
257 I-1-13-II
KOMPLEK SEDANG
15.501.714 18.602.057 21.702.400
258 I-1-13-III
KOMPLEK BERAT
18.129.913 21.755.896 25.381.879
259 I-1-14-I
PROSEDUR PEMASANGAN PACEMAKER JANTUNG
PERMANEN RINGAN
23.484.902 28.181.882 32.878.863
260 I-1-14-II
PERMANEN SEDANG
29.188.378 35.026.054 40.863.729
261 I-1-14-III
PERMANEN BERAT
38.246.840 45.896.208 53.545.576
265 I-1-16-I
PROSEDUR REVISI DEFIBRILATOR & PACEMAKER
JANTUNG TIDAK TERMASUK PENGGANTIAN ALAT
(RINGAN)
10.064.958 12.077.950 14.090.941
266 I-1-16-II
(SEDANG)
26.168.891 31.402.669 36.636.447
267 I-1-16-III
(BERAT)
30.185.173 36.222.208 42.259.242
268 I-1-17-I
PROSEDUR LIGASI DAN STRIPPING PEMBULUH
DARAH VENA RINGAN
25.420.188 30.504.225 35.588.263
269 I-1-17-II
DARAH VENA SEDANG
31.828.460 38.194.152 44.559.844
270 I-1-17-III
DARAH VENA BERAT
39.371.321 47.245.586 55.119.850
271 I-1-20-I
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN
RINGAN
22.120.059 26.544.070 30.968.082
272 I-1-20-II
SEDANG
27.633.971 33.160.766 38.687.560
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
274 I-1-30-I
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN
PACEMAKER JANTUNG RINGAN
11.418.747 13.702.496 15.986.246
275 I-1-30-II
PACEMAKER JANTUNG SEDANG
23.753.301 28.503.961 33.254.621
276 I-1-30-III
PACEMAKER JANTUNG BERAT
36.808.989 44.170.787 51.532.585
289 I-4-13-I
THROMBOPHLEBITIS PADA PEMBULUH DARAH
VENA RINGAN
5.747.229 6.896.675 8.046.120
290 I-4-13-II
THROMBOPHLEBITIS DALAM PEMBULUH DARAH
VENA SEDANG
7.287.903 8.745.484 10.203.064
291 I-4-13-III
VENA BERAT
13.265.631 15.918.757 18.571.883
295 I-4-15-I
GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN
(RINGAN)
3.918.919 4.702.703 5.486.487
296 I-4-15-II
(SEDANG)
5.624.511 6.749.413 7.874.315
297 I-4-15-III
(BERAT)
6.410.589 7.692.707 8.974.825
306 I-4-18-III
GANGUAN-PENYAKIT KATUP JANTUNG
KONGENITAL BERAT
8.782.082 10.538.498 12.294.915
307 I-4-19-I
GANGGUAN KONDUKSI & ARITMIA JANTUNG
RINGAN
3.321.853 3.986.224 4.650.595
308 I-4-19-II
SEDANG
5.384.164 6.460.997 7.537.829
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
319 I-4-23-I
KOMPLIKASI, REAKSI, MALFUNGSI DARI PROSEDUR
ATAU PEMASANGAN ALAT KARDIOVASKULAR
RINGAN
2.346.439 2.815.727 3.285.015
320 I-4-23-II
SEDANG
2.880.887 3.457.064 4.033.241
321 I-4-23-III
ATAU PEMASANGAN ALAT KARDIOVASKULAR BERAT
5.628.990 6.754.788 7.880.586
322 I-4-24-I
DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN
(RINGAN)
3.149.403 3.779.283 4.409.164
323 I-4-24-II
(SEDANG)
7.866.011 9.439.213 11.012.415
324 I-4-24-III
(BERAT)
9.898.856 11.878.627 13.858.399
325 J-1-01-I
PROSEDUR VENTILASI MEKANIKAL LONG TERM
DENGAN TRAKEOSTOMI RINGAN
30.026.602 36.031.923 42.037.243
326 J-1-01-II
DENGAN TRAKEOSTOMI SEDANG
32.077.310 38.492.772 44.908.234
327 J-1-01-III
DENGAN TRAKEOSTOMI BERAT
46.132.541 55.359.050 64.585.558
328 J-1-02-I
TANPA TRAKEOSTOMI RINGAN
12.946.192 15.535.430 18.124.668
329 J-1-02-II
TANPA TRAKEOSTOMI SEDANG
13.092.383 15.710.860 18.329.337
330 J-1-02-III
TANPA TRAKEOSTOMI BERAT
20.580.091 24.696.109 28.812.127
331 J-1-10-I
PROSEDUR SISTEM PERNAFASAN KOMPLEKS
RINGAN
6.209.543 7.451.452 8.693.360
332 J-1-10-II
SEDANG
12.238.731 14.686.477 17.134.223
334 J-1-20-I
PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS
RINGAN
12.494.985 14.993.982 17.492.979
335 J-1-20-II
SEDANG
15.737.793 18.885.352 22.032.911
336 J-1-20-III
BERAT
24.301.744 29.162.093 34.022.442
337 J-1-30-I
PROSEDUR SISTEM PERNAFASAN MODERAT
KOMPLEKS RINGAN
3.618.147 4.341.777 5.065.406
338 J-1-30-II
KOMPLEKS SEDANG
11.585.531 13.902.637 16.219.743
339 J-1-30-III
KOMPLEKS BERAT
34.590.152 41.508.182 48.426.212
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
358 J-4-16-I
SIMPLE PNEUMONIA & WHOOPING COUGH
RINGAN
3.822.574 4.587.089 5.351.603
359 J-4-16-II
SEDANG
5.371.721 6.446.066 7.520.410
373 J-4-21-I
GEJALA, TANDA DAN DIAGNOSIS SISTEM
PERNAFASAN LAIN-LAIN (RINGAN)
2.290.291 2.748.350 3.206.408
374 J-4-21-II
PERNAFASAN LAIN-LAIN (SEDANG)
4.275.427 5.130.512 5.985.597
375 J-4-21-III
PERNAFASAN LAIN-LAIN (BERAT)
5.981.852 7.178.223 8.374.593
376 K-1-10-I
PROSEDUR NON KOMPLEKS USUS HALUS & USUS
BESAR (RINGAN)
5.265.532 6.318.639 7.371.745
377 K-1-10-II
BESAR (SEDANG)
9.892.978 11.871.574 13.850.169
378 K-1-10-III
BESAR (BERAT)
11.576.235 13.891.482 16.206.729
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
382 K-1-12-I
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL &
FEMORAL (RINGAN)
3.280.387 3.936.464 4.592.541
383 K-1-12-II
FEMORAL (SEDANG)
4.264.008 5.116.809 5.969.611
384 K-1-12-III
FEMORAL (BERAT)
8.504.468 10.205.361 11.906.255
388 K-1-14-I
PROSEDUR HERNIA INGUINAL DAN FEMORAL
RINGAN
4.877.741 5.853.289 6.828.838
389 K-1-14-II
SEDANG
6.046.075 7.255.289 8.464.504
390 K-1-14-III
BERAT
13.628.662 16.354.394 19.080.127
394 K-1-30-I
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG
NON KOMPLEKS (RINGAN)
7.526.478 9.031.774 10.537.069
395 K-1-30-II
NON KOMPLEKS (SEDANG)
10.559.650 12.671.580 14.783.510
396 K-1-30-III
NON KOMPLEKS (BERAT)
19.429.386 23.315.263 27.201.140
397 K-1-40-I
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN
(RINGAN)
6.925.578 8.310.693 9.695.809
398 K-1-40-II
(SEDANG)
8.493.097 10.191.716 11.890.336
399 K-1-40-III
(BERAT)
14.084.983 16.901.980 19.718.977
412 K-4-13-I
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT
PERADANGAN USUS BESAR (RINGAN)
3.100.612 3.720.734 4.340.856
413 K-4-13-II
PERADANGAN USUS BESAR (SEDANG)
3.973.435 4.768.122 5.562.808
414 K-4-13-III
PERADANGAN USUS BESAR (BERAT)
6.183.978 7.420.774 8.657.570
415 K-4-14-I
INSUFISIENSI PEMBULUH DARAH
GASTROINTESTINAL RINGAN
2.459.542 2.951.451 3.443.359
416 K-4-14-II
GASTROINTESTINAL SEDANG
3.301.543 3.961.851 4.622.160
417 K-4-14-III
GASTROINTESTINAL BERAT
5.796.458 6.955.749 8.115.041
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
424 K-4-17-I
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN
(RINGAN)
2.771.255 3.325.506 3.879.757
425 K-4-17-II
(SEDANG)
3.921.803 4.706.164 5.490.524
426 K-4-17-III
(BERAT)
4.423.803 5.308.563 6.193.324
427 K-4-18-I
DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN
(RINGAN)
3.057.555 3.669.066 4.280.578
428 K-4-18-II
(SEDANG)
4.586.246 5.503.495 6.420.744
429 K-4-18-III
(BERAT)
5.625.992 6.751.191 7.876.389
430 L-1-20-I
PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR
RINGAN
26.856.614 32.227.936 37.599.259
431 L-1-20-II
SEDANG
27.678.229 33.213.875 38.749.521
432 L-1-20-III
BERAT
38.927.655 46.713.186 54.498.717
433 L-1-30-I
PROSEDUR PEMINDAHAN KULIT TANPA LUKA
BAKAR RINGAN
8.403.236 10.083.883 11.764.530
434 L-1-30-II
BAKAR SEDANG
15.670.382 18.804.459 21.938.535
435 L-1-30-III
BAKAR BERAT
18.612.218 22.334.662 26.057.106
436 L-1-40-I
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT
DAN PAYUDARA RINGAN
3.994.358 4.793.230 5.592.101
437 L-1-40-II
DAN PAYUDARA SEDANG
8.613.085 10.335.702 12.058.319
438 L-1-40-III
DAN PAYUDARA BERAT
14.733.630 17.680.356 20.627.082
451 L-4-13-I
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT
DAN PAYUDARA RINGAN
1.950.644 2.340.773 2.730.901
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
452 L-4-13-II
DAN PAYUDARA SEDANG
2.607.701 3.129.241 3.650.781
453 L-4-13-III
DAN PAYUDARA BERAT
3.442.218 4.130.662 4.819.105
454 L-4-14-I
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN
(RINGAN)
2.257.810 2.709.372 3.160.934
455 L-4-14-II
(SEDANG)
3.355.248 4.026.297 4.697.347
456 L-4-14-III
(BERAT)
5.938.717 7.126.460 8.314.204
457 M-1-01-I
PROSEDUR BILATERAL DAN MULTIPLE SENDI
ANGGOTA TUBUH BAWAH MAYOR (RINGAN)
9.292.880 11.151.456 13.010.032
458 M-1-01-II
ANGGOTA TUBUH BAWAH MAYOR (SEDANG)
10.372.357 12.446.829 14.521.300
459 M-1-01-III
ANGGOTA TUBUH BAWAH MAYOR (BERAT)
14.570.352 17.484.422 20.398.492
463 M-1-03-I
PROSEDUR FUSI TULANG BELAKANG PADA
LENGKUNGAN TULANG BELAKANG RINGAN
17.134.418 20.561.302 23.988.186
464 M-1-03-II
LENGKUNGAN TULANG BELAKANG SEDANG
19.950.056 23.940.067 27.930.078
465 M-1-03-III
LENGKUNGAN TULANG BELAKANG BERAT
25.165.279 30.198.334 35.231.390
466 M-1-04-I
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA
TUBUH BAGIAN BAWAH MAYOR (RINGAN)
5.978.542 7.174.251 8.369.959
467 M-1-04-II
TUBUH BAGIAN BAWAH MAYOR (SEDANG)
7.656.960 9.188.352 10.719.744
468 M-1-04-III
TUBUH BAGIAN BAWAH MAYOR (BERAT)
9.581.242 11.497.490 13.413.739
469 M-1-05-I
PROSEDUR PADA SENDI LENGAN/ANGGOTA TUBUH
BAGIAN BAWAH MAYOR (RINGAN)
7.583.330 9.099.996 10.616.661
470 M-1-05-II
BAGIAN BAWAH MAYOR (SEDANG)
8.806.695 10.568.034 12.329.372
471 M-1-05-III
BAGIAN BAWAH MAYOR (BERAT)
15.589.424 18.707.309 21.825.193
472 M-1-07-I
PROSEDUR FUSI TULANG BELAKANG SELAIN
7.466.115 8.959.338 10.452.561
473 M-1-07-II
10.002.261 12.002.713 14.003.165
474 M-1-07-III
20.375.554 24.450.665 28.525.776
475 M-1-10-I
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG
WAJAH RINGAN
18.431.129 22.117.355 25.803.581
476 M-1-10-II
WAJAH SEDANG
44.068.112 52.881.734 61.695.356
477 M-1-10-III
WAJAH BERAT
95.050.768 114.060.922 133.071.076
478 M-1-20-I
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN
SENDI MAYOR RINGAN
6.356.183 7.627.420 8.898.657
479 M-1-20-II
SENDI MAYOR SEDANG
7.215.922 8.659.107 10.102.291
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
480 M-1-20-III
SENDI MAYOR BERAT
17.706.360 21.247.631 24.788.903
484 M-1-40-I
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN
ALAT FIKSASI INTERNAL RINGAN
3.765.792 4.518.950 5.272.109
485 M-1-40-II
ALAT FIKSASI INTERNAL SEDANG
6.198.558 7.438.270 8.677.981
486 M-1-40-III
ALAT FIKSASI INTERNAL BERAT
9.181.066 11.017.279 12.853.493
490 M-1-60-I
PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN
PENGHUBUNG LAIN-LAIN (RINGAN)
3.835.377 4.602.452 5.369.528
491 M-1-60-II
PENGHUBUNG LAIN-LAIN (SEDANG)
7.691.543 9.229.852 10.768.161
492 M-1-60-III
PENGHUBUNG LAIN-LAIN (BERAT)
11.926.796 14.312.155 16.697.514
493 M-1-70-I
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN
KAKI (RINGAN)
21.963.543 26.356.251 30.748.960
494 M-1-70-II
KAKI (SEDANG)
24.159.897 28.991.876 33.823.855
495 M-1-70-III
KAKI (BERAT)
26.575.886 31.891.064 37.206.241
502 M-4-11-I
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL
RINGAN
3.481.352 4.177.623 4.873.893
503 M-4-11-II
SEDANG
6.474.617 7.769.541 9.064.464
504 M-4-11-III
BERAT
11.572.777 13.887.333 16.201.888
505 M-4-12-I
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS
RINGAN
1.948.318 2.337.982 2.727.645
506 M-4-12-II
SEDANG
3.437.546 4.125.055 4.812.564
507 M-4-12-III
BERAT
6.369.796 7.643.755 8.917.714
508 M-4-13-I
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF
DAN FRAKTUR PATOLOGIS RINGAN
4.378.310 5.253.972 6.129.634
509 M-4-13-II
DAN FRAKTUR PATOLOGIS SEDANG
5.447.722 6.537.267 7.626.811
510 M-4-13-III
DAN FRAKTUR PATOLOGIS BERAT
11.133.511 13.360.213 15.586.915
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
520 M-4-17-I
MASALAH BAGIAN PUNGGUNG/PINGGANG
BELAKANG RINGAN
2.808.754 3.370.505 3.932.256
521 M-4-17-II
BELAKANG SEDANG
3.676.124 4.411.348 5.146.573
522 M-4-17-III
BELAKANG BERAT
5.065.983 6.079.179 7.092.376
526 M-4-19-I
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI
PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK
RINGAN
2.868.195 3.441.834 4.015.473
527 M-4-19-II
SEDANG
4.582.072 5.498.486 6.414.900
528 M-4-19-III
BERAT
7.316.346 8.779.615 10.242.884
529 M-4-20-I
TANDA-TANDA, GEJALA, MUSKULOSKLETAL ,
KESELEO DAN PERADANGAN MINOR (RINGAN)
2.056.119 2.467.343 2.878.567
530 M-4-20-II
KESELEO DAN PERADANGAN MINOR (SEDANG)
2.938.545 3.526.254 4.113.963
531 M-4-20-III
KESELEO DAN PERADANGAN MINOR (BERAT)
3.253.890 3.904.668 4.555.446
532 M-4-21-I
DIAGNOSIS SISTEM MUSKULOSKLETAL & JARINGAN
2.049.738 2.459.685 2.869.633
533 M-4-21-II
3.432.558 4.119.070 4.805.581
534 M-4-21-III
5.805.430 6.966.516 8.127.602
541 N-1-12-I
PROSEDUR MEMBUAT BARU, MEREVISI DAN
MEMINDAHKAN ALAT DIALISIS RINGAN
3.733.007 4.479.608 5.226.210
542 N-1-12-II
MEMINDAHKAN ALAT DIALISIS SEDANG
12.387.359 14.864.831 17.342.303
543 N-1-12-III
MEMINDAHKAN ALAT DIALISIS BERAT
22.502.437 27.002.925 31.503.412
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
547 N-1-30-I
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN
BAWAH RINGAN
7.391.091 8.869.309 10.347.527
548 N-1-30-II
BAWAH SEDANG
11.047.334 13.256.800 15.466.267
549 N-1-30-III
BAWAH BERAT
11.601.282 13.921.538 16.241.795
550 N-1-40-I
PROSEDUR PADA URETRA DAN TRANSURETRA
RINGAN
7.715.506 9.258.608 10.801.709
551 N-1-40-II
SEDANG
10.466.961 12.560.353 14.653.745
552 N-1-40-III
BERAT
12.156.410 14.587.692 17.018.974
553 N-4-10-I
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL
RINGAN
3.001.693 3.602.032 4.202.370
554 N-4-10-II
SEDANG
4.045.357 4.854.428 5.663.500
555 N-4-10-III
BERAT
7.077.431 8.492.917 9.908.403
565 N-4-14-I
PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN
KULIT ATAU PENCAKOKAN (RINGAN)
1.709.688 2.051.626 2.393.564
566 N-4-14-II
KULIT ATAU PENCAKOKAN (SEDANG)
2.542.360 3.050.832 3.559.304
567 N-4-14-III
KULIT ATAU PENCAKOKAN (BERAT)
4.122.898 4.947.477 5.772.057
568 N-4-15-I
GEJALA, TANDA-TANDA PADA GINJAL DAN
SALURAN URIN RINGAN
2.751.616 3.301.939 3.852.263
569 N-4-15-II
SALURAN URIN SEDANG
3.764.194 4.517.032 5.269.871
570 N-4-15-III
SALURAN URIN BERAT
4.295.624 5.154.749 6.013.874
571 N-4-16-I
DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN
(RINGAN)
3.314.203 3.977.044 4.639.885
572 N-4-16-II
(SEDANG)
3.983.156 4.779.787 5.576.418
573 N-4-16-III
(BERAT)
7.090.567 8.508.681 9.926.794
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
575 O-6-10-II
PROSEDUR OPERASI PEMBEDAHAN CAESAR
SEDANG
4.882.245 5.858.694 6.835.142
577 O-6-11-I
PROSEDUR PERSALINAN VAGINAL DENGAN
STERILISASI &/ DILATASI & KURET RINGAN
2.498.906 2.998.688 3.498.469
578 O-6-11-II
3.534.047 4.240.856 4.947.666
579 O-6-11-III
6.001.501 7.201.801 8.402.101
580 O-6-12-I
PROSEDUR SELAIN STERILISASI &/ DILATASI &KURET
RINGAN
2.406.765 2.888.117 3.369.470
581 O-6-12-II
PROSEDUR SELAIN STERILISASI &/ DILATASI & KURET
SEDANG
2.890.518 3.468.622 4.046.726
582 O-6-12-III
BERAT
3.774.378 4.529.254 5.284.129
586 P-8-01-I
PROSEDUR NEONATAL DENGAN PENCANGKOKAN
ORGAN ATAU OKSIGENASI SELAPUT
EKSTRAKORPORAL RINGAN
47.891.844 57.470.212 67.048.581
587 P-8-01-II
EKSTRAKORPORAL SEDANG
59.258.665 71.110.398 82.962.131
588 P-8-01-III
EKSTRAKORPORAL BERAT
69.553.061 83.463.673 97.374.285
589 P-8-02-I
PROSEDUR NEONATAL, BERAT BADAN LAHIR
GROUP-1 DENGAN PROSEDUR MAYOR RINGAN
77.271.208 92.725.450 108.179.692
590 P-8-02-II
GROUP-1 DENGAN PROSEDUR MAYOR SEDANG
88.638.030 106.365.636 124.093.242
591 P-8-02-III
GROUP-1 DENGAN PROSEDUR MAYOR BERAT
101.275.287 121.530.344 141.785.401
592 P-8-03-I
GROUP-1 TANPA PROSEDUR MAYOR RINGAN
2.677.726 3.213.271 3.748.816
593 P-8-03-II
GROUP-1 TANPA PROSEDUR MAYOR SEDANG
3.990.952 4.789.143 5.587.333
594 P-8-03-III
GROUP-1 TANPA PROSEDUR MAYOR BERAT
7.253.065 8.703.677 10.154.290
595 P-8-04-I
32.243.798 38.692.558 45.141.318
596 P-8-04-II
41.682.600 50.019.120 58.355.640
597 P-8-04-III
59.762.357 71.714.828 83.667.300
598 P-8-05-I
17.508.505 21.010.205 24.511.906
599 P-8-05-II
24.807.132 29.768.559 34.729.985
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
600 P-8-05-III
36.427.739 43.713.286 50.998.834
601 P-8-06-I
2.967.422 3.560.906 4.154.390
602 P-8-06-II
6.443.085 7.731.702 9.020.319
603 P-8-06-III
11.766.310 14.119.572 16.472.834
604 P-8-07-I
4.640.035 5.568.042 6.496.049
605 P-8-07-II
11.482.374 13.778.849 16.075.324
606 P-8-07-III
15.435.868 18.523.041 21.610.215
607 P-8-08-I
GROUP-5 DENGAN SINDROMA DISTRES
PERNAFASAN RINGAN
3.841.567 4.609.881 5.378.194
608 P-8-08-II
PERNAFASAN SEDANG
5.451.001 6.541.202 7.631.402
609 P-8-08-III
PERNAFASAN BERAT
8.826.371 10.591.645 12.356.919
610 P-8-10-I
NEONATAL, MENINGGAL DAN DITRANSFER KE
FASILITAS PERAWATAN PASIEN AKUT LAIN RINGAN
2.272.660 2.727.192 3.181.724
611 P-8-10-II
FASILITAS PERAWATAN PASIEN AKUT LAIN SEDANG
3.897.265 4.676.718 5.456.172
612 P-8-10-III
FASILITAS PERAWATAN PASIEN AKUT LAIN BERAT
7.651.481 9.181.777 10.712.073
613 P-8-11-I
NEONATAL, BBL GROUP-2 TANPA PROSEDUR
MAYOR RINGAN
2.743.154 3.291.785 3.840.415
614 P-8-11-II
MAYOR SEDANG
13.610.157 16.332.189 19.054.220
615 P-8-11-III
MAYOR BERAT
13.895.292 16.674.351 19.453.409
616 P-8-12-I
MAYOR RINGAN
3.700.643 4.440.771 5.180.900
617 P-8-12-II
MAYOR SEDANG
5.761.949 6.914.339 8.066.729
618 P-8-12-III
MAYOR BERAT
6.790.973 8.149.167 9.507.362
619 P-8-13-I
MAYOR RINGAN
2.155.562 2.586.675 3.017.787
620 P-8-13-II
MAYOR SEDANG
5.296.393 6.355.672 7.414.951
621 P-8-13-III
MAYOR BERAT
12.902.425 15.482.909 18.063.394
622 P-8-14-I
NEONATAL, BBL GROUP-5 DENGAN ANOMALI
MAYOR ATAU KONDISI HEREDITER RINGAN
3.486.282 4.183.539 4.880.795
623 P-8-14-II
MAYOR ATAU KONDISI HEREDITER SEDANG
7.135.789 8.562.947 9.990.105
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
624 P-8-14-III
MAYOR ATAU KONDISI HEREDITER BERAT
7.838.284 9.405.940 10.973.597
625 P-8-15-I
NEONATAL, BBL GROUP-5 DENGAN SINDROMA
ASPIRASI RINGAN
2.628.200 3.153.840 3.679.480
626 P-8-15-II
ASPIRASI SEDANG
5.257.139 6.308.567 7.359.995
627 P-8-15-III
ASPIRASI BERAT
6.163.012 7.395.614 8.628.217
628 P-8-16-I
NEONATAL, BBL GROUP-5 DENGAN
KONGENITAL/INFEKSI PERINATAL RINGAN
2.384.582 2.861.498 3.338.415
629 P-8-16-II
KONGENITAL/INFEKSI PERINATAL SEDANG
5.112.281 6.134.737 7.157.193
630 P-8-16-III
KONGENITAL/INFEKSI PERINATAL BERAT
13.427.605 16.113.126 18.798.647
631 P-8-17-I
MAYOR RINGAN
1.829.473 2.195.368 2.561.263
632 P-8-17-II
MAYOR SEDANG
4.756.472 5.707.767 6.659.061
633 P-8-17-III
MAYOR BERAT
8.989.939 10.787.927 12.585.914
634 S-4-10-I
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK
ATAU BANYAK TEMPAT (RINGAN)
1.902.444 2.282.933 2.663.422
635 S-4-10-II
ATAU BANYAK TEMPAT (SEDANG)
2.449.126 2.938.951 3.428.776
636 S-4-10-III
ATAU BANYAK TEMPAT (BERAT)
3.185.854 3.823.024 4.460.195
643 S-4-13-I
KOMPLIKASI DARI PENATALAKSANAAN PASIEN
RINGAN
2.337.377 2.804.852 3.272.327
644 S-4-13-II
SEDANG
3.869.376 4.643.251 5.417.127
645 S-4-13-III
BERAT
7.368.268 8.841.922 10.315.576
646 S-4-14-I
SINDROMA MALTREATMENT PADA DEWASA ATAU
KANAK-KANAK RINGAN
1.161.339 1.393.607 1.625.875
647 S-4-14-II
KANAK-KANAK SEDANG
2.467.074 2.960.489 3.453.903
648 S-4-14-III
KANAK-KANAK BERAT
4.678.451 5.614.141 6.549.831
649 S-4-15-I
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN
AKUT YANG LAIN (RINGAN)
878.331 1.053.998 1.229.664
650 S-4-15-II
AKUT YANG LAIN (SEDANG)
1.657.711 1.989.253 2.320.795
651 S-4-15-III
AKUT YANG LAIN (BERAT)
2.147.121 2.576.545 3.005.969
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
655 S-4-17-I
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK
TOKSIK LAIN-LAIN RINGAN
1.984.946 2.381.935 2.778.924
656 S-4-17-II
TOKSIK LAIN-LAIN SEDANG
2.861.116 3.433.339 4.005.562
657 S-4-17-III
TOKSIK LAIN-LAIN BERAT
3.979.917 4.775.900 5.571.884
658 T-1-10-I
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL &
OBAT RINGAN
2.068.503 2.482.203 2.895.904
659 T-1-10-II
OBAT SEDANG
2.777.859 3.333.431 3.889.002
660 T-1-10-III
OBAT BERAT
5.053.831 6.064.597 7.075.363
661 T-4-10-I
PENYALAHGUNAAN & KETERGANTUNGAN OBAT
DAN ALKOHOL, MENOLAK NASEHAT DOKTER
RINGAN
803.134 963.761 1.124.388
662 T-4-10-II
SEDANG
1.530.596 1.836.715 2.142.834
663 T-4-10-III
DAN ALKOHOL, MENOLAK NASEHAT DOKTER BERAT
2.225.070 2.670.085 3.115.099
664 T-4-11-I
PENYALAHGUNAAN & KETERGANTUNGAN
ALKOHOL,OPIUM DAN KOKAIN RINGAN
1.096.074 1.315.288 1.534.503
665 T-4-11-II
ALKOHOL,OPIUM DAN KOKAIN SEDANG
1.724.908 2.069.889 2.414.871
666 T-4-11-III
ALKOHOL,OPIUM DAN KOKAIN BERAT
2.778.319 3.333.982 3.889.646
667 T-4-12-I
LAIN-LAIN (RINGAN)
1.805.777 2.166.932 2.528.087
668 T-4-12-II
LAIN-LAIN (SEDANG)
2.690.654 3.228.785 3.766.916
669 T-4-12-III
LAIN-LAIN (BERAT)
4.128.160 4.953.792 5.779.424
673 U-1-11-I
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN
(RINGAN)
6.252.993 7.503.592 8.754.190
674 U-1-11-II
(SEDANG)
8.555.452 10.266.542 11.977.632
675 U-1-11-III
(BERAT)
19.436.895 23.324.275 27.211.654
682 U-1-14-I
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-
LANGIT MULUT (RINGAN)
3.918.512 4.702.214 5.485.916
683 U-1-14-II
LANGIT MULUT (SEDANG)
4.808.802 5.770.562 6.732.323
684 U-1-14-III
LANGIT MULUT (BERAT)
5.698.565 6.838.279 7.977.992
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
688 U-1-20-I
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN
TELINGA LAIN-LAIN (RINGAN)
5.951.802 7.142.162 8.332.523
689 U-1-20-II
TELINGA LAIN-LAIN (SEDANG)
8.712.586 10.455.103 12.197.620
690 U-1-20-III
TELINGA LAIN-LAIN (BERAT)
15.761.973 18.914.367 22.066.762
694 U-4-10-I
TUMOR KERONGKONGAN, MULUT, HIDUNG DAN
TELINGA RINGAN
4.753.878 5.704.654 6.655.429
695 U-4-10-II
TELINGA SEDANG
11.291.276 13.549.532 15.807.787
696 U-4-10-III
TELINGA BERAT
14.077.849 16.893.419 19.708.989
703 U-4-13-I
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA
DAN LARINGOTRAKEITIS RINGAN
1.957.556 2.349.067 2.740.578
704 U-4-13-II
DAN LARINGOTRAKEITIS SEDANG
2.232.388 2.678.865 3.125.343
705 U-4-13-III
DAN LARINGOTRAKEITIS BERAT
2.854.968 3.425.962 3.996.956
709 U-4-15-I
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG &
2.111.223 2.533.468 2.955.712
710 U-4-15-II
2.767.344 3.320.813 3.874.282
711 U-4-15-III
3.763.912 4.516.694 5.269.477
712 V-1-10-I
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK
RINGAN
6.511.795 7.814.154 9.116.513
713 V-1-10-II
SEDANG
7.342.123 8.810.548 10.278.972
714 V-1-10-III
BERAT
9.448.837 11.338.605 13.228.372
718 V-1-12-I
PROSEDUR PADA SKROTUM DAN PROSTAT
KOMPLEK-MODERAT (RINGAN)
4.787.114 5.744.537 6.701.960
719 V-1-12-II
KOMPLEK-MODERAT (SEDANG)
11.938.243 14.325.892 16.713.540
720 V-1-12-III
KOMPLEK-MODERAT (BERAT)
12.360.466 14.832.560 17.304.653
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
721 V-1-13-I
PROSEDUR PADA SKROTUM DAN PROSTAT NON
KOMPLEK (RINGAN)
7.268.899 8.722.679 10.176.459
722 V-1-13-II
KOMPLEK (SEDANG)
10.339.664 12.407.597 14.475.529
723 V-1-13-III
KOMPLEK (BERAT)
12.819.224 15.383.069 17.946.914
724 V-1-14-I
PROSEDUR PENGANGKATAN PROSTAT MELALUI
URETRA RINGAN
7.736.907 9.284.288 10.831.669
725 V-1-14-II
URETRA SEDANG
10.333.126 12.399.752 14.466.377
726 V-1-14-III
URETRA BERAT
14.048.577 16.858.292 19.668.008
730 V-4-10-I
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI
RINGAN
5.411.055 6.493.265 7.575.476
731 V-4-10-II
SEDANG
6.995.555 8.394.667 9.793.778
732 V-4-10-III
BERAT
13.366.935 16.040.322 18.713.709
733 V-4-11-I
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN
TUMOR (RINGAN)
2.700.282 3.240.339 3.780.395
734 V-4-11-II
TUMOR (SEDANG)
3.791.128 4.549.354 5.307.580
735 V-4-11-III
TUMOR (BERAT)
6.643.546 7.972.255 9.300.965
736 W-1-01-I
PROSEDUR OPERASI PENGANGKATAN RAHIM DAN
VULVA RADIKAL & EVISCERASI RINGAN
9.899.422 11.879.307 13.859.191
737 W-1-01-II
VULVA RADIKAL & EVISCERASI SEDANG
11.102.122 13.322.547 15.542.971
738 W-1-01-III
VULVA RADIKAL & EVISCERASI BERAT
17.578.430 21.094.116 24.609.802
742 W-1-11-I
PROSEDUR DILATASI, KURET, INTRAUTERIN &
SERVIK RINGAN
3.005.839 3.607.007 4.208.175
743 W-1-11-II
SERVIK SEDANG
5.284.606 6.341.528 7.398.449
744 W-1-11-III
SERVIK BERAT
11.127.893 13.353.472 15.579.050
745 W-1-12-I
2.615.364 3.138.437 3.661.510
746 W-1-12-II
2.956.973 3.548.368 4.139.762
747 W-1-12-III
4.542.283 5.450.740 6.359.197
748 W-1-13-I
PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP
RINGAN
2.249.623 2.699.547 3.149.472
749 W-1-13-II
SEDANG
2.442.442 2.930.930 3.419.419
750 W-1-13-III
BERAT
3.280.650 3.936.780 4.592.910
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
755 W-1-30-II
PROSEDUR PADA VAGINA, SERVIK & VULVA
SEDANG
5.970.174 7.164.209 8.358.244
763 W-4-12-I
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI
WANITA LAIN-LAIN (RINGAN)
1.959.465 2.351.358 2.743.251
764 W-4-12-II
WANITA LAIN-LAIN (SEDANG)
3.170.431 3.804.517 4.438.603
765 W-4-12-III
WANITA LAIN-LAIN (BERAT)
4.032.150 4.838.580 5.645.010
787 Z-4-12-I
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS
KESEHATAN LAIN-LAIN (RINGAN)
1.523.757 1.828.509 2.133.260
788 Z-4-12-II
KESEHATAN LAIN-LAIN (SEDANG)
3.958.152 4.749.782 5.541.412
789 Z-4-12-III
KESEHATAN LAIN-LAIN (BERAT)
5.115.855 6.139.026 7.162.197
No
Kode INA-
CBG
1 B-2-10-0 PROSEDUR PADA HATI DAN PANKREAS 812.276
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 855.784
9 C-3-10-0 PROSEDUR RADIOTERAPI 888.312
24 D-2-11-0 PROSEDUR LIMPA 1.307.651
28 D-3-11-0 PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH 452.210
31 E-2-22-0
THYROGLOSSAL
181.307
33 F-3-10-0 TERAPI SHOCK 256.138
40 F-5-16-0 PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN MENTAL 143.717
44 G-2-13-0 PROSEDUR CARPAL TUNNEL RELEASE 470.459
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 700.315
46 G-2-22-0 PROSEDUR KECIL PADA SARAF PERIFER 630.621
48 G-2-32-0 PROSEDUR KECIL PADA TULANG BELAKANG 658.686
51 G-3-12-0 PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN 465.570
Rumah Sakit Kelas B
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
52 G-3-13-0 PROSEDUR ELEKROENSEFALOGRAFI (EEG) 462.729
53 H-2-21-0 PROSEDUR BESAR PADA MATA 609.207
59 H-2-34-0 PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA 556.557
62 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 858.787
67 I-2-11-0
JANTUNG
2.253.619
70 I-2-14-0
JANTUNG
3.564.095
72 I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK
PENGGANTIAN ALAT
2.251.177
73 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA 605.297
80 I-2-42-0
2.147.836
89 J-2-22-0 PROSEDUR PADA LARING DAN TRAKEA 786.258
91 J-2-32-0 PROSEDUR DADA INTERMEDIATE 763.974
93 J-3-11-0 PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA 448.497
100 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL 468.265
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
102 K-2-12-0
FEMORALIS
918.451
107 K-2-31-0 PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS 841.252
109 K-2-41-0 PROSEDUR LAPAROSKOPI 926.656
111 K-2-51-0 PROSEDUR UNTUK WASIR 614.059
118 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 521.699
122 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR 735.681
125 L-2-41-0 PROSEDUR BEDAH PLASTIK 811.563
128 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 1.148.439
136 M-2-31-0 PROSEDUR BUNION 835.426
142 M-2-61-0 PROSEDUR ARTROSKOPI 954.141
144 M-2-63-0 PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG 777.752
147 M-2-71-0 PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH 965.862
148 M-2-72-0 PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH 760.386
150 M-2-82-0 PROSEDUR KECIL PADA LENGAN, SIKU & BAHU 822.273
153 M-3-10-0 PROSEDUR MANIPULATIVE OSTEOPATHIC 452.091
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
155 M-3-12-0 PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL 564.743
162 N-2-12-0 PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS 1.487.533
163 N-2-21-0 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN KEMIH 1.479.975
165 N-2-23-0 PROSEDUR SEDANG PADA GINJAL DAN URETER 734.852
167 N-2-31-0 PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA 741.073
169 N-2-41-0 PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA 459.969
173 N-3-12-0 PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN KEMIH 299.222
176 N-3-15-0 PROSEDUR DIALISIS 982.650
178 O-7-11-0
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN
KURETASE
2.135.789
179 O-7-12-0
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN
ATAU PELEBARAN DAN KURETASE
1.444.059
181 P-9-10-0
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN
AKUT LAIN
183.357
185 P-9-14-0
HEREDITER
149.422
191 Q-5-12-0 GIGI 128.507
195 Q-5-16-0 VAKSINASI 102.443
196 Q-5-17-0 PASANG INFUS 88.435
200 Q-5-21-0 ABORSI 100.582
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
205 Q-5-26-0 BRONKIAL AKUT 198.414
210 Q-5-31-0 FRAKTUR 134.443
214 Q-5-35-0 INFEKSI AKUT 260.778
217 Q-5-38-0 PARU AKUT 207.366
231 U-2-21-0 PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 468.045
232 U-2-22-0 PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 242.565
233 U-2-23-0 PROSEDUR PERBAIKAN HIDUNG (RHINOPLASTY) 753.942
234 U-2-24-0 PROSEDUR KECIL PADA HIDUNG 518.155
238 U-3-10-0
TENGGOROKAN
199.213
239 U-3-11-0
TENGGOROKAN
188.283
241 U-3-13-0
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
193.710
242 U-3-14-0 PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 179.239
243 U-3-15-0 PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 155.826
247 V-2-12-0 PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM 758.291
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
252 V-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI 656.624
253 V-3-12-0 PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI 465.608
256 W-2-12-0 PROSEDUR MEMBUKA TUBA YANG TERHALANG/TERGANGGU 808.980
260 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 570.700
262 W-2-32-0 PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL INTERMEDIATE 1.313.924
263 W-2-33-0 PROSEDUR KECIL VULVOVAGINAL 558.435
265 W-3-10-0 PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI 461.612
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN
SALURAN EMPEDU
1.479.848
274 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 624.806
276 Z-3-18-0 CT-SCAN KEPALA 252.728
287 Z-3-29-0 IMAGING LAIN-LAIN 561.051
288 Z-3-30-0 FOTOTERAPI 76.895
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.556.927 1.868.312 2.179.698
8 A-4-12-II DEMAM SEDANG 1.988.713 2.386.456 2.784.198
9 A-4-12-III DEMAM BERAT 2.122.649 2.547.179 2.971.709
13 A-4-14-I
RINGAN
2.774.467 3.329.361 3.884.254
14 A-4-14-II
SEDANG
3.568.667 4.282.400 4.996.134
15 A-4-14-III
BERAT
4.088.853 4.906.623 5.724.394
28 B-1-12-I
PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK
RINGAN
5.401.010 6.481.212 7.561.414
29 B-1-12-II
SEDANG
11.575.686 13.890.823 16.205.960
30 B-1-12-III
BERAT
13.688.385 16.426.062 19.163.739
31 B-1-13-I
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN
(RINGAN)
4.343.195 5.211.834 6.080.474
32 B-1-13-II
(SEDANG)
7.074.435 8.489.322 9.904.209
33 B-1-13-III
(BERAT)
10.429.702 12.515.643 14.601.583
34 B-1-14-I
PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK
RINGAN
5.874.714 7.049.656 8.224.599
35 B-1-14-II
SEDANG
6.533.867 7.840.640 9.147.414
36 B-1-14-III
BERAT
10.221.458 12.265.750 14.310.041
40 B-4-11-I
RINGAN
2.802.260 3.362.713 3.923.165
41 B-4-11-II
SEDANG
4.200.393 5.040.472 5.880.550
Rumah Sakit Kelas C
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
46 B-4-13-I
2.332.606 2.799.128 3.265.649
47 B-4-13-II
3.532.105 4.238.527 4.944.948
48 B-4-13-III
4.391.253 5.269.504 6.147.754
73 D-1-20-I
3.535.482 4.242.579 4.949.675
74 D-1-20-II
9.406.189 11.287.427 13.168.664
75 D-1-20-III
16.305.955 19.567.146 22.828.337
85 D-4-13-I
GANGGUAN SEL DARAH MERAH SELAIN KRISIS ANEMIA
SEL SICKLE RINGAN
1.552.099 1.862.519 2.172.939
86 D-4-13-II
SEL SICKLE SEDANG
2.325.780 2.790.936 3.256.092
87 D-4-13-III
SEL SICKLE BERAT
2.717.161 3.260.593 3.804.026
88 D-4-14-I
1.873.583 2.248.300 2.623.017
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
89 D-4-14-II
3.580.203 4.296.243 5.012.284
90 D-4-14-III
5.020.226 6.024.271 7.028.316
97 E-1-20-I
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN
TIROGLOSAL RINGAN
4.789.894 5.747.873 6.705.852
98 E-1-20-II
TIROGLOSAL SEDANG
7.641.303 9.169.563 10.697.824
99 E-1-20-III
TIROGLOSAL BERAT
13.776.309 16.531.570 19.286.832
100 E-4-10-I
METABOLIK RINGAN
1.942.893 2.331.471 2.720.050
101 E-4-10-II
METABOLIK SEDANG
3.388.164 4.065.797 4.743.430
102 E-4-10-III
METABOLIK BERAT
4.294.479 5.153.374 6.012.270
130 F-4-16-I
MENTAL RINGAN
4.614.175 5.537.009 6.459.844
131 F-4-16-II
MENTAL SEDANG
5.361.898 6.434.278 7.506.657
132 F-4-16-III
MENTAL BERAT
7.157.239 8.588.687 10.020.134
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK RINGAN 787.718 945.262 1.102.805
142 G-1-01-I
PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL
RINGAN
7.209.959 8.651.951 10.093.943
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE RINGAN 851.300 1.021.560 1.191.820
163 G-4-10-I
RINGAN
2.334.415 2.801.298 3.268.181
164 G-4-10-II
SEDANG
2.711.086 3.253.304 3.795.521
166 G-4-11-I
DEGENERATIF RINGAN
3.301.804 3.962.165 4.622.526
167 G-4-11-II
DEGENERATIF SEDANG
5.363.899 6.436.679 7.509.459
168 G-4-11-III
DEGENERATIF BERAT
6.521.841 7.826.209 9.130.577
172 G-4-13-I
RINGAN
2.164.038 2.596.846 3.029.654
173 G-4-13-II
SEDANG
2.709.452 3.251.342 3.793.232
174 G-4-13-III
BERAT
3.220.558 3.864.669 4.508.781
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
175 G-4-14-I
INFARK RINGAN
2.929.890 3.515.868 4.101.846
176 G-4-14-II
INFARK SEDANG
5.330.863 6.397.036 7.463.209
177 G-4-14-III
INFARK BERAT
6.665.890 7.999.069 9.332.247
178 G-4-15-I
2.354.374 2.825.249 3.296.124
179 G-4-15-II
2.809.957 3.371.948 3.933.939
180 G-4-15-III
3.652.814 4.383.377 5.113.940
187 G-4-18-I
PERSARAFAN RINGAN
2.327.413 2.792.896 3.258.378
188 G-4-18-II
PERSARAFAN SEDANG
4.532.519 5.439.023 6.345.527
189 G-4-18-III
PERSARAFAN BERAT
4.797.948 5.757.538 6.717.127
190 G-4-19-I
2.598.006 3.117.607 3.637.208
191 G-4-19-II
3.590.543 4.308.652 5.026.760
192 G-4-19-III
4.513.630 5.416.356 6.319.082
211 G-4-26-I
GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN
(RINGAN)
2.333.685 2.800.421 3.267.158
212 G-4-26-II
(SEDANG)
2.707.870 3.249.443 3.791.017
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
213 G-4-26-III
(BERAT)
3.976.112 4.771.334 5.566.556
229 I-1-01-I
PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG
RINGAN
33.539.000 40.246.800 46.954.599
230 I-1-01-II
SEDANG
34.277.032 41.132.439 47.987.845
231 I-1-01-III
BERAT
54.105.638 64.926.766 75.747.894
232 I-1-02-I
RINGAN
18.607.244 22.328.693 26.050.141
233 I-1-02-II
SEDANG
24.003.344 28.804.013 33.604.682
234 I-1-02-III
BERAT
29.585.518 35.502.621 41.419.725
235 I-1-03-I
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA
JANTUNG ANOMALI RINGAN
11.441.440 13.729.728 16.018.016
236 I-1-03-II
JANTUNG ANOMALI SEDANG
13.111.907 15.734.289 18.356.670
237 I-1-03-III
JANTUNG ANOMALI BERAT
21.690.681 26.028.818 30.366.954
238 I-1-04-I
JANTUNG RINGAN
17.818.511 21.382.213 24.945.916
239 I-1-04-II
JANTUNG SEDANG
18.260.326 21.912.392 25.564.457
240 I-1-04-III
JANTUNG BERAT
42.364.804 50.837.765 59.310.725
241 I-1-05-I
KORONER DENGAN KATETERISASI JANTUNG RINGAN
24.627.234 29.552.681 34.478.128
242 I-1-05-II
KORONER DENGAN KATETERISASI JANTUNG SEDANG
29.552.681 35.463.218 41.373.754
243 I-1-05-III
40.664.303 48.797.164 56.930.024
247 I-1-07-I
19.941.043 23.929.251 27.917.460
248 I-1-07-II
24.601.327 29.521.592 34.441.858
249 I-1-07-III
26.839.888 32.207.865 37.575.843
250 I-1-11-I
PROSEDUR DEFIBRILATOR JANTUNG DAN PEMASANGAN
SISTEM BANTUAN JANTUNG RINGAN
3.209.109 3.850.930 4.492.752
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
251 I-1-11-II
SISTEM BANTUAN JANTUNG SEDANG
3.568.208 4.281.849 4.995.491
252 I-1-11-III
SISTEM BANTUAN JANTUNG BERAT
4.748.197 5.697.836 6.647.476
253 I-1-12-I
RINGAN
8.891.860 10.670.232 12.448.604
254 I-1-12-II
SEDANG
10.104.709 12.125.651 14.146.593
255 I-1-12-III
BERAT
17.203.305 20.643.966 24.084.626
256 I-1-13-I
PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK
RINGAN
4.243.783 5.092.540 5.941.296
257 I-1-13-II
SEDANG
6.078.876 7.294.651 8.510.426
258 I-1-13-III
BERAT
14.503.931 17.404.717 20.305.503
259 I-1-14-I
PERMANEN RINGAN
19.154.516 22.985.419 26.816.322
260 I-1-14-II
PERMANEN SEDANG
23.806.327 28.567.592 33.328.857
261 I-1-14-III
PERMANEN BERAT
31.194.497 37.433.396 43.672.296
265 I-1-16-I
(RINGAN)
8.209.078 9.850.894 11.492.709
266 I-1-16-II
(SEDANG)
21.343.603 25.612.324 29.881.044
267 I-1-16-III
(BERAT)
24.619.322 29.543.187 34.467.051
268 I-1-17-I
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH
VENA RINGAN
11.572.881 13.887.457 16.202.033
269 I-1-17-II
VENA SEDANG
15.026.193 18.031.432 21.036.670
270 I-1-17-III
VENA BERAT
31.497.057 37.796.469 44.095.880
271 I-1-20-I
RINGAN
10.268.663 12.322.396 14.376.128
272 I-1-20-II
SEDANG
12.984.373 15.581.248 18.178.123
274 I-1-30-I
9.313.242 11.175.890 13.038.539
275 I-1-30-II
19.373.424 23.248.109 27.122.794
276 I-1-30-III
30.021.771 36.026.126 42.030.480
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
289 I-4-13-I
THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA
RINGAN
4.597.783 5.517.340 6.436.896
290 I-4-13-II
THROMBOPHLEBITIS DALAM PEMBULUH DARAH VENA
SEDANG
5.830.322 6.996.387 8.162.451
291 I-4-13-III
BERAT
10.112.772 12.135.326 14.157.880
295 I-4-15-I
(RINGAN)
3.104.245 3.725.095 4.345.944
296 I-4-15-II
(SEDANG)
4.449.092 5.338.911 6.228.729
297 I-4-15-III
(BERAT)
5.070.895 6.085.074 7.099.253
306 I-4-18-III
GANGUAN-PENYAKIT KATUP JANTUNG KONGENITAL
BERAT
6.314.689 7.577.627 8.840.565
319 I-4-23-I
ATAU PEMASANGAN ALAT KARDIOVASKULAR RINGAN
1.913.779 2.296.535 2.679.290
320 I-4-23-II
ATAU PEMASANGAN ALAT KARDIOVASKULAR SEDANG
2.349.679 2.819.615 3.289.551
321 I-4-23-III
4.591.059 5.509.271 6.427.483
322 I-4-24-I
(RINGAN)
2.284.594 2.741.513 3.198.432
323 I-4-24-II
(SEDANG)
6.292.808 7.551.370 8.809.932
324 I-4-24-III
(BERAT)
7.919.085 9.502.902 11.086.719
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.705.922 22.447.107 26.188.291
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.377.880 24.453.455 28.529.031
327 J-1-01-III
TRAKEOSTOMI BERAT
36.906.033 44.287.240 51.668.446
328 J-1-02-I
TRAKEOSTOMI RINGAN
8.770.331 10.524.398 12.278.464
329 J-1-02-II
TRAKEOSTOMI SEDANG
10.088.019 12.105.623 14.123.227
330 J-1-02-III
TRAKEOSTOMI BERAT
16.464.073 19.756.887 23.049.702
334 J-1-20-I
RINGAN
5.760.913 6.913.096 8.065.278
335 J-1-20-II
SEDANG
7.612.084 9.134.501 10.656.918
337 J-1-30-I
PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS
RINGAN
2.894.518 3.473.421 4.052.325
338 J-1-30-II
SEDANG
9.496.756 11.396.107 13.295.459
339 J-1-30-III
BERAT
25.597.212 30.716.655 35.836.097
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
373 J-4-21-I
GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN
LAIN-LAIN (RINGAN)
1.548.831 1.858.597 2.168.363
374 J-4-21-II
LAIN-LAIN (SEDANG)
3.134.398 3.761.278 4.388.158
375 J-4-21-III
LAIN-LAIN (BERAT)
4.447.246 5.336.696 6.226.145
376 K-1-10-I
PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR
(RINGAN)
4.187.487 5.024.984 5.862.482
377 K-1-10-II
(SEDANG)
7.914.382 9.497.259 11.080.135
378 K-1-10-III
(BERAT)
9.260.988 11.113.186 12.965.383
382 K-1-12-I
FEMORAL (RINGAN)
2.624.309 3.149.171 3.674.033
383 K-1-12-II
FEMORAL (SEDANG)
3.411.206 4.093.448 4.775.689
384 K-1-12-III
FEMORAL (BERAT)
6.803.574 8.164.289 9.525.004
394 K-1-30-I
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG NON
KOMPLEKS (RINGAN)
6.021.182 7.225.419 8.429.655
395 K-1-30-II
KOMPLEKS (SEDANG)
8.364.063 10.036.876 11.709.689
396 K-1-30-III
KOMPLEKS (BERAT)
15.543.508 18.652.210 21.760.912
412 K-4-13-I
2.331.505 2.797.807 3.264.108
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
413 K-4-13-II
3.013.286 3.615.943 4.218.600
414 K-4-13-III
4.942.332 5.930.798 6.919.265
415 K-4-14-I
INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL
RINGAN
1.945.544 2.334.652 2.723.761
416 K-4-14-II
SEDANG
2.633.232 3.159.878 3.686.524
417 K-4-14-III
BERAT
3.967.423 4.760.907 5.554.392
424 K-4-17-I
(RINGAN)
2.519.323 3.023.187 3.527.052
425 K-4-17-II
(SEDANG)
3.565.275 4.278.331 4.991.386
426 K-4-17-III
(BERAT)
4.021.639 4.825.966 5.630.294
430 L-1-20-I
RINGAN
21.485.291 25.782.349 30.079.407
431 L-1-20-II
SEDANG
22.142.583 26.571.100 30.999.617
432 L-1-20-III
BERAT
33.278.214 39.933.856 46.589.499
433 L-1-30-I
PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR
RINGAN
6.888.202 8.265.843 9.643.483
434 L-1-30-II
SEDANG
12.536.306 15.043.567 17.550.828
435 L-1-30-III
BERAT
14.889.775 17.867.730 20.845.685
436 L-1-40-I
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT DAN
PAYUDARA RINGAN
3.274.209 3.929.050 4.583.892
437 L-1-40-II
PAYUDARA SEDANG
6.945.417 8.334.501 9.723.584
438 L-1-40-III
PAYUDARA BERAT
11.792.088 14.150.505 16.508.923
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
451 L-4-13-I
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN
PAYUDARA RINGAN
1.463.047 1.755.657 2.048.266
452 L-4-13-II
PAYUDARA SEDANG
2.086.161 2.503.393 2.920.625
453 L-4-13-III
PAYUDARA BERAT
2.525.345 3.030.414 3.535.483
454 L-4-14-I
(RINGAN)
1.551.727 1.862.072 2.172.417
455 L-4-14-II
(SEDANG)
2.328.904 2.794.684 3.260.465
456 L-4-14-III
(BERAT)
4.750.974 5.701.168 6.651.363
457 M-1-01-I
PROSEDUR BILATERAL DAN MULTIPLE SENDI ANGGOTA
TUBUH BAWAH MAYOR (RINGAN)
7.579.364 9.095.236 10.611.109
458 M-1-01-II
TUBUH BAWAH MAYOR (SEDANG)
8.459.796 10.151.755 11.843.714
459 M-1-01-III
TUBUH BAWAH MAYOR (BERAT)
11.883.721 14.260.466 16.637.210
463 M-1-03-I
13.625.965 16.351.158 19.076.351
464 M-1-03-II
15.855.520 19.026.624 22.197.728
465 M-1-03-III
16.193.128 19.431.753 22.670.379
466 M-1-04-I
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA TUBUH
4.782.834 5.739.400 6.695.967
467 M-1-04-II
6.125.568 7.350.682 8.575.795
468 M-1-04-III
7.664.994 9.197.992 10.730.991
469 M-1-05-I
6.066.664 7.279.996 8.493.329
470 M-1-05-II
7.045.356 8.454.427 9.863.498
471 M-1-05-III
12.471.539 14.965.847 17.460.155
472 M-1-07-I
6.089.436 7.307.324 8.525.211
473 M-1-07-II
8.157.942 9.789.530 11.421.119
474 M-1-07-III
16.618.501 19.942.201 23.265.902
475 M-1-10-I
WAJAH RINGAN
5.155.363 6.186.435 7.217.508
476 M-1-10-II
WAJAH SEDANG
12.685.517 15.222.621 17.759.724
477 M-1-10-III
WAJAH BERAT
17.289.826 20.747.791 24.205.756
478 M-1-20-I
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI
MAYOR RINGAN
5.084.947 6.101.936 7.118.925
479 M-1-20-II
MAYOR SEDANG
5.372.393 6.446.872 7.521.350
480 M-1-20-III
MAYOR BERAT
14.165.088 16.998.105 19.831.123
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
484 M-1-40-I
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT
FIKSASI INTERNAL RINGAN
2.956.682 3.548.019 4.139.355
485 M-1-40-II
FIKSASI INTERNAL SEDANG
5.429.186 6.515.023 7.600.860
486 M-1-40-III
FIKSASI INTERNAL BERAT
8.802.101 10.562.521 12.322.941
490 M-1-60-I
2.947.397 3.536.877 4.126.356
491 M-1-60-II
5.925.237 7.110.284 8.295.331
492 M-1-60-III
9.776.494 11.731.792 13.687.091
493 M-1-70-I
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI
(RINGAN)
9.119.304 10.943.165 12.767.026
494 M-1-70-II
(SEDANG)
11.436.680 13.724.015 16.011.351
495 M-1-70-III
(BERAT)
12.035.900 14.443.080 16.850.260
502 M-4-11-I
RINGAN
2.060.484 2.472.581 2.884.678
503 M-4-11-II
SEDANG
4.714.965 5.657.958 6.600.951
504 M-4-11-III
BERAT
9.258.222 11.109.866 12.961.511
505 M-4-12-I
RINGAN
1.550.355 1.860.426 2.170.497
506 M-4-12-II
SEDANG
2.817.785 3.381.342 3.944.899
508 M-4-13-I
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN
FRAKTUR PATOLOGIS RINGAN
3.502.648 4.203.178 4.903.708
509 M-4-13-II
FRAKTUR PATOLOGIS SEDANG
3.869.191 4.643.029 5.416.867
510 M-4-13-III
FRAKTUR PATOLOGIS BERAT
8.533.027 10.239.632 11.946.237
520 M-4-17-I
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG
RINGAN
1.937.381 2.324.858 2.712.334
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
521 M-4-17-II
SEDANG
2.724.664 3.269.597 3.814.530
522 M-4-17-III
BERAT
3.807.099 4.568.519 5.329.939
526 M-4-19-I
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PROSEDUR
ATAU PEMASANGAN ALAT ORTOPEDIK RINGAN
2.294.556 2.753.467 3.212.378
527 M-4-19-II
ATAU PEMASANGAN ALAT ORTOPEDIK SEDANG
3.665.657 4.398.789 5.131.920
528 M-4-19-III
ATAU PEMASANGAN ALAT ORTOPEDIK BERAT
5.568.163 6.681.796 7.795.429
529 M-4-20-I
TANDA-TANDA, GEJALA, MUSKULOSKLETAL , KESELEO
DAN PERADANGAN MINOR (RINGAN)
1.550.585 1.860.702 2.170.819
530 M-4-20-II
DAN PERADANGAN MINOR (SEDANG)
2.332.242 2.798.691 3.265.139
531 M-4-20-III
DAN PERADANGAN MINOR (BERAT)
2.578.976 3.094.771 3.610.567
532 M-4-21-I
1.547.541 1.857.049 2.166.557
533 M-4-21-II
2.033.400 2.440.080 2.846.760
534 M-4-21-III
4.758.759 5.710.511 6.662.263
541 N-1-12-I
3.059.977 3.671.972 4.283.967
542 N-1-12-II
9.909.887 11.891.865 13.873.842
543 N-1-12-III
18.001.950 21.602.340 25.202.730
547 N-1-30-I
BAWAH RINGAN
5.912.873 7.095.447 8.278.022
548 N-1-30-II
BAWAH SEDANG
7.697.253 9.236.703 10.776.154
549 N-1-30-III
BAWAH BERAT
8.843.991 10.612.789 12.381.587
553 N-4-10-I
RINGAN
1.940.468 2.328.561 2.716.655
554 N-4-10-II
SEDANG
3.236.286 3.883.543 4.530.800
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
555 N-4-10-III
BERAT
4.329.425 5.195.310 6.061.195
565 N-4-14-I
1.343.355 1.612.026 1.880.697
566 N-4-14-II
2.073.574 2.488.289 2.903.003
567 N-4-14-III
3.362.676 4.035.211 4.707.746
568 N-4-15-I
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN
URIN RINGAN
1.927.797 2.313.357 2.698.916
569 N-4-15-II
URIN SEDANG
2.391.892 2.870.271 3.348.649
570 N-4-15-III
URIN BERAT
2.729.581 3.275.497 3.821.413
571 N-4-16-I
(RINGAN)
2.594.429 3.113.315 3.632.201
572 N-4-16-II
(SEDANG)
3.101.775 3.722.130 4.342.484
573 N-4-16-III
(BERAT)
5.296.599 6.355.919 7.415.239
577 O-6-11-I
PROSEDUR PERSALINAN VAGINAL DENGAN STERILISASI
&/ DILATASI & KURET RINGAN
2.048.374 2.458.049 2.867.724
578 O-6-11-II
&/ DILATASI & KURET SEDANG
2.721.319 3.265.583 3.809.846
579 O-6-11-III
&/ DILATASI & KURET BERAT
4.621.330 5.545.596 6.469.862
580 O-6-12-I
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR
SELAIN STERILISASI &/ DILATASI &KURET RINGAN
1.925.412 2.310.494 2.695.576
581 O-6-12-II
SELAIN STERILISASI &/ DILATASI & KURET SEDANG
2.312.415 2.774.898 3.237.380
582 O-6-12-III
SELAIN STERILISASI &/ DILATASI & KURET BERAT
3.019.503 3.623.403 4.227.304
586 P-8-01-I
ORGAN ATAU OKSIGENASI SELAPUT EKSTRAKORPORAL
RINGAN
39.061.056 46.873.267 54.685.479
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
587 P-8-01-II
SEDANG
48.331.947 57.998.336 67.664.726
588 P-8-01-III
BERAT
56.728.157 68.073.788 79.419.420
589 P-8-02-I
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-1
DENGAN PROSEDUR MAYOR RINGAN
61.816.967 74.180.360 86.543.753
590 P-8-02-II
DENGAN PROSEDUR MAYOR SEDANG
70.910.424 85.092.509 99.274.593
591 P-8-02-III
DENGAN PROSEDUR MAYOR BERAT
81.020.229 97.224.275 113.428.321
592 P-8-03-I
TANPA PROSEDUR MAYOR RINGAN
2.126.788 2.552.145 2.977.503
593 P-8-03-II
TANPA PROSEDUR MAYOR SEDANG
2.984.063 3.580.875 4.177.688
594 P-8-03-III
TANPA PROSEDUR MAYOR BERAT
4.700.078 5.640.093 6.580.109
595 P-8-04-I
19.101.041 22.921.249 26.741.457
596 P-8-04-II
33.346.080 40.015.296 46.684.512
597 P-8-04-III
47.809.886 57.371.863 66.933.840
598 P-8-05-I
14.006.804 16.808.164 19.609.525
599 P-8-05-II
19.845.706 23.814.847 27.783.988
600 P-8-05-III
29.142.191 34.970.629 40.799.067
601 P-8-06-I
2.091.881 2.510.258 2.928.634
602 P-8-06-II
5.154.468 6.185.362 7.216.255
603 P-8-06-III
8.243.540 9.892.248 11.540.956
604 P-8-07-I
2.993.825 3.592.590 4.191.355
605 P-8-07-II
8.376.264 10.051.517 11.726.769
606 P-8-07-III
11.061.592 13.273.911 15.486.229
607 P-8-08-I
DENGAN SINDROMA DISTRES PERNAFASAN RINGAN
3.492.334 4.190.801 4.889.267
608 P-8-08-II
DENGAN SINDROMA DISTRES PERNAFASAN SEDANG
4.955.456 5.946.547 6.937.638
609 P-8-08-III
DENGAN SINDROMA DISTRES PERNAFASAN BERAT
8.023.973 9.628.768 11.233.563
610 P-8-10-I
1.818.128 2.181.753 2.545.379
611 P-8-10-II
3.117.812 3.741.375 4.364.937
612 P-8-10-III
6.121.184 7.345.421 8.569.658
613 P-8-11-I
NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR
RINGAN
2.177.148 2.612.578 3.048.008
614 P-8-11-II
SEDANG
10.888.126 13.065.751 15.243.376
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
615 P-8-11-III
BERAT
11.116.234 13.339.481 15.562.727
616 P-8-12-I
RINGAN
2.960.514 3.552.617 4.144.720
617 P-8-12-II
SEDANG
4.609.559 5.531.471 6.453.383
618 P-8-12-III
BERAT
5.432.778 6.519.334 7.605.890
619 P-8-13-I
RINGAN
1.959.602 2.351.523 2.743.443
620 P-8-13-II
SEDANG
3.388.361 4.066.033 4.743.705
621 P-8-13-III
BERAT
5.043.991 6.052.789 7.061.588
622 P-8-14-I
NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR
ATAU KONDISI HEREDITER RINGAN
2.070.822 2.484.987 2.899.151
623 P-8-14-II
ATAU KONDISI HEREDITER SEDANG
5.708.631 6.850.358 7.992.084
624 P-8-14-III
ATAU KONDISI HEREDITER BERAT
6.270.627 7.524.752 8.778.878
625 P-8-15-I
NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI
RINGAN
2.102.560 2.523.072 2.943.584
626 P-8-15-II
SEDANG
4.205.711 5.046.853 5.887.996
627 P-8-15-III
BERAT
4.930.409 5.916.491 6.902.573
628 P-8-16-I
1.907.665 2.289.199 2.670.732
629 P-8-16-II
2.593.426 3.112.112 3.630.797
630 P-8-16-III
2.697.496 3.236.995 3.776.494
631 P-8-17-I
RINGAN
1.663.158 1.995.789 2.328.421
632 P-8-17-II
SEDANG
4.324.066 5.188.879 6.053.692
633 P-8-17-III
BERAT
8.172.672 9.807.206 11.441.740
634 S-4-10-I
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK ATAU
BANYAK TEMPAT (RINGAN)
1.551.652 1.861.983 2.172.313
635 S-4-10-II
BANYAK TEMPAT (SEDANG)
1.941.223 2.329.468 2.717.712
636 S-4-10-III
BANYAK TEMPAT (BERAT)
2.524.603 3.029.523 3.534.444
637 S-4-11-I REAKSI ALLERGI RINGAN 971.206 1.165.448 1.359.689
646 S-4-14-I
KANAK-KANAK RINGAN
947.200 1.136.639 1.326.079
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
647 S-4-14-II
KANAK-KANAK SEDANG
2.012.170 2.414.603 2.817.037
648 S-4-14-III
KANAK-KANAK BERAT
3.815.790 4.578.949 5.342.107
649 S-4-15-I
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN AKUT
YANG LAIN (RINGAN)
716.376 859.651 1.002.926
650 S-4-15-II
YANG LAIN (SEDANG)
1.352.045 1.622.454 1.892.863
651 S-4-15-III
YANG LAIN (BERAT)
1.751.213 2.101.455 2.451.698
655 S-4-17-I
1.448.098 1.737.718 2.027.338
656 S-4-17-II
1.939.800 2.327.760 2.715.720
657 S-4-17-III
3.171.025 3.805.230 4.439.435
658 T-1-10-I
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT
RINGAN
1.654.802 1.985.763 2.316.723
659 T-1-10-II
SEDANG
2.222.287 2.666.744 3.111.202
660 T-1-10-III
BERAT
4.043.065 4.851.677 5.660.290
661 T-4-10-I
PENYALAHGUNAAN & KETERGANTUNGAN OBAT DAN
ALKOHOL, MENOLAK NASEHAT DOKTER RINGAN
655.044 786.053 917.062
662 T-4-10-II
ALKOHOL, MENOLAK NASEHAT DOKTER SEDANG
1.248.369 1.498.042 1.747.716
663 T-4-10-III
ALKOHOL, MENOLAK NASEHAT DOKTER BERAT
1.814.789 2.177.747 2.540.705
664 T-4-11-I
876.859 1.052.231 1.227.602
665 T-4-11-II
1.379.926 1.655.912 1.931.897
666 T-4-11-III
2.222.655 2.667.186 3.111.717
667 T-4-12-I
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-
LAIN (RINGAN)
1.362.578 1.635.093 1.907.609
668 T-4-12-II
LAIN (SEDANG)
2.059.489 2.471.386 2.883.284
669 T-4-12-III
LAIN (BERAT)
3.188.287 3.825.944 4.463.602
673 U-1-11-I
(RINGAN)
5.125.630 6.150.757 7.175.883
674 U-1-11-II
(SEDANG)
6.797.191 8.156.629 9.516.067
675 U-1-11-III
(BERAT)
12.746.068 15.295.282 17.844.495
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
682 U-1-14-I
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT
MULUT (RINGAN)
3.134.809 3.761.771 4.388.733
683 U-1-14-II
MULUT (SEDANG)
3.847.041 4.616.450 5.385.858
684 U-1-14-III
MULUT (BERAT)
4.558.852 5.470.623 6.382.393
688 U-1-20-I
4.761.441 5.713.730 6.666.018
689 U-1-20-II
6.249.057 7.498.868 8.748.680
690 U-1-20-III
12.553.689 15.064.427 17.575.165
694 U-4-10-I
TELINGA RINGAN
3.803.103 4.563.723 5.324.344
695 U-4-10-II
TELINGA SEDANG
6.316.077 7.579.293 8.842.508
696 U-4-10-III
TELINGA BERAT
9.697.252 11.636.703 13.576.153
703 U-4-13-I
1.524.137 1.828.964 2.133.791
704 U-4-13-II
1.778.792 2.134.551 2.490.309
705 U-4-13-III
2.012.608 2.415.129 2.817.651
709 U-4-15-I
1.556.440 1.867.728 2.179.016
710 U-4-15-II
1.946.273 2.335.528 2.724.783
711 U-4-15-III
2.721.101 3.265.321 3.809.541
712 V-1-10-I
RINGAN
4.553.218 5.463.862 6.374.505
713 V-1-10-II
SEDANG
5.226.898 6.272.277 7.317.657
718 V-1-12-I
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-
MODERAT (RINGAN)
3.829.692 4.595.630 5.361.568
719 V-1-12-II
MODERAT (SEDANG)
8.813.770 10.576.524 12.339.278
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
720 V-1-12-III
MODERAT (BERAT)
10.131.977 12.158.373 14.184.768
721 V-1-13-I
KOMPLEK (RINGAN)
5.570.554 6.684.664 7.798.775
722 V-1-13-II
KOMPLEK (SEDANG)
8.475.509 10.170.610 11.865.712
723 V-1-13-III
KOMPLEK (BERAT)
11.754.740 14.105.688 16.456.635
724 V-1-14-I
PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA
RINGAN
6.189.525 7.427.430 8.665.335
725 V-1-14-II
SEDANG
7.524.820 9.029.785 10.534.749
726 V-1-14-III
BERAT
9.212.588 11.055.106 12.897.624
733 V-4-11-I
TUMOR (RINGAN)
1.992.100 2.390.519 2.788.939
734 V-4-11-II
TUMOR (SEDANG)
2.905.624 3.486.749 4.067.874
735 V-4-11-III
TUMOR (BERAT)
5.314.837 6.377.804 7.440.772
736 W-1-01-I
7.919.538 9.503.445 11.087.353
737 W-1-01-II
8.881.698 10.658.038 12.434.377
738 W-1-01-III
12.529.726 15.035.671 17.541.617
742 W-1-11-I
PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK
RINGAN
2.732.581 3.279.097 3.825.613
743 W-1-11-II
SEDANG
4.804.188 5.765.025 6.725.863
744 W-1-11-III
BERAT
10.116.266 12.139.520 14.162.773
745 W-1-12-I
2.092.291 2.510.750 2.929.208
746 W-1-12-II
2.365.578 2.838.694 3.311.810
747 W-1-12-III
3.633.827 4.360.592 5.087.357
748 W-1-13-I
RINGAN
1.834.814 2.201.777 2.568.740
749 W-1-13-II
SEDANG
1.992.080 2.390.495 2.788.911
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
763 W-4-12-I
1.552.895 1.863.474 2.174.053
764 W-4-12-II
2.131.039 2.557.247 2.983.455
765 W-4-12-III
3.225.720 3.870.864 4.516.008
766 W-4-13-I ABORTUS RINGAN 849.415 1.019.297 1.189.180
772 W-4-15-I PERSALINAN FALSE LABOR RINGAN 974.030 1.168.836 1.363.642
787 Z-4-12-I
1.166.153 1.399.384 1.632.614
788 Z-4-12-II
3.166.521 3.799.826 4.433.130
789 Z-4-12-III
4.092.684 4.911.221 5.729.757
No Kode INA-CBG Deskripsi Kode INA-CBG Tarif INA - CBG
24 D-2-11-0 PROSEDUR LIMPA 1.264.833
31 E-2-22-0 PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL 178.559
33 F-3-10-0 TERAPI SHOCK 248.220
Rumah Sakit Kelas C
Rawat Jalan
Rumah Sakit Kelas C
Rawat Jalan
67 I-2-11-0 PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTUNG 2.179.826
70 I-2-14-0 PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUNG 3.447.391
72 I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK PENGGANTIAN
ALAT 2.177.464
80 I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN
LAIN 2.098.711
83 I-3-12-0 PROSEDUR KECIL LAIN-LAIN PADA JANTUNG 999.873
102 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 888.377
Rumah Sakit Kelas C
Rawat Jalan
178 O-7-11-0 PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN KURETASE 1.941.627
179 O-7-12-0
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU
PELEBARAN DAN KURETASE 1.155.247
181 P-9-10-0 NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN AKUT LAIN 177.353
Rumah Sakit Kelas C
Rawat Jalan
185 P-9-14-0 NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDITER 143.775
191 Q-5-12-0 GIGI 124.157
195 Q-5-16-0 VAKSINASI 99.196
196 Q-5-17-0 PASANG INFUS 85.539
200 Q-5-21-0 ABORSI 80.465
205 Q-5-26-0 BRONKIAL AKUT 191.788
210 Q-5-31-0 FRAKTUR 129.891
214 Q-5-35-0 INFEKSI AKUT 252.812
217 Q-5-38-0 PARU AKUT 201.031
238 U-3-10-0 PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 194.316
239 U-3-11-0 PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 182.389
241 U-3-13-0 PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
187.770
Rumah Sakit Kelas C
Rawat Jalan
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN
EMPEDU 1.431.392
276 Z-3-18-0 CT-SCAN KEPALA 244.452
288 Z-3-30-0 FOTOTERAPI 74.474
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.298.769 1.558.523 1.818.277
8 A-4-12-II DEMAM SEDANG 1.676.151 2.011.382 2.346.612
9 A-4-12-III DEMAM BERAT 2.075.283 2.490.340 2.905.396
13 A-4-14-I
RINGAN
2.522.243 3.026.692 3.531.140
14 A-4-14-II
SEDANG
3.244.243 3.893.091 4.541.940
15 A-4-14-III
BERAT
3.717.139 4.460.567 5.203.994
28 B-1-12-I
LAPAROSKOPIK RINGAN
3.969.608 4.763.529 5.557.451
29 B-1-12-II
LAPAROSKOPIK SEDANG
8.507.840 10.209.408 11.910.977
30 B-1-12-III
LAPAROSKOPIK BERAT
10.354.362 12.425.235 14.496.107
31 B-1-13-I
LAIN (RINGAN)
3.199.805 3.839.766 4.479.727
32 B-1-13-II
LAIN (SEDANG)
5.212.018 6.254.422 7.296.825
33 B-1-13-III
LAIN (BERAT)
7.683.977 9.220.772 10.757.568
34 B-1-14-I
LAPAROSKOPIK RINGAN
4.342.811 5.211.373 6.079.935
35 B-1-14-II
LAPAROSKOPIK SEDANG
4.830.082 5.796.099 6.762.115
36 B-1-14-III
LAPAROSKOPIK BERAT
7.556.089 9.067.307 10.578.525
40 B-4-11-I
RINGAN
2.361.835 2.834.202 3.306.569
Rumah Sakit Kelas D
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
41 B-4-11-II
SEDANG
3.540.226 4.248.272 4.956.317
42 B-4-11-III
BERAT
4.583.112 5.499.735 6.416.357
46 B-4-13-I
1.944.029 2.332.835 2.721.641
47 B-4-13-II
2.515.541 3.018.650 3.521.758
48 B-4-13-III
3.701.089 4.441.307 5.181.525
67 D-1-10-I
RINGAN
13.802.816 16.563.379 19.323.943
68 D-1-10-II
SEDANG
21.022.748 25.227.297 29.431.847
69 D-1-10-III
BERAT
28.491.568 34.189.881 39.888.195
73 D-1-20-I
2.979.818 3.575.782 4.171.745
74 D-1-20-II
8.584.842 10.301.810 12.018.779
75 D-1-20-III
13.743.184 16.491.820 19.240.457
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
85 D-4-13-I
ANEMIA SEL SICKLE RINGAN
1.300.464 1.560.557 1.820.650
86 D-4-13-II
ANEMIA SEL SICKLE SEDANG
1.949.815 2.339.779 2.729.742
87 D-4-13-III
ANEMIA SEL SICKLE BERAT
2.391.571 2.869.886 3.348.200
88 D-4-14-I
1.627.260 1.952.712 2.278.164
89 D-4-14-II
3.017.510 3.621.012 4.224.514
90 D-4-14-III
4.231.208 5.077.449 5.923.691
91 E-1-01-I
RINGAN
3.720.289 4.464.347 5.208.404
92 E-1-01-II
SEDANG
4.873.224 5.847.869 6.822.514
97 E-1-20-I
SALURAN TIROGLOSAL RINGAN
4.037.077 4.844.492 5.651.908
98 E-1-20-II
SALURAN TIROGLOSAL SEDANG
5.878.871 7.054.645 8.230.419
99 E-1-20-III
SALURAN TIROGLOSAL BERAT
9.757.240 11.708.688 13.660.136
100 E-4-10-I
METABOLIK RINGAN
1.799.131 2.158.957 2.518.783
101 E-4-10-II
METABOLIK SEDANG
2.765.074 3.318.088 3.871.103
102 E-4-10-III
METABOLIK BERAT
3.830.664 4.596.796 5.362.929
109 E-4-13-I
RINGAN
2.049.312 2.459.174 2.869.037
110 E-4-13-II
SEDANG
3.463.957 4.156.749 4.849.540
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
118 F-4-12-I
RINGAN
1.148.139 1.377.767 1.607.395
119 F-4-12-II
SEDANG
1.522.117 1.826.540 2.130.964
120 F-4-12-III
BERAT
3.015.188 3.618.226 4.221.263
130 F-4-16-I
MENTAL RINGAN
3.416.624 4.099.948 4.783.273
131 F-4-16-II
MENTAL SEDANG
3.957.777 4.749.333 5.540.888
132 F-4-16-III
MENTAL BERAT
5.282.972 6.339.566 7.396.161
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK RINGAN 657.242 788.690 920.138
142 G-1-01-I
PROSEDUR PADA PEMBULUH DARAH INTRA
KRANIAL RINGAN
6.015.712 7.218.855 8.421.997
143 G-1-01-II
SEDANG
8.289.212 9.947.055 11.604.897
144 G-1-01-III
BERAT
16.114.247 19.337.096 22.559.945
151 G-1-12-I
RINGAN
2.390.681 2.868.818 3.346.954
152 G-1-12-II
SEDANG
6.002.031 7.202.437 8.402.843
153 G-1-12-III
BERAT
8.821.888 10.586.266 12.350.644
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE RINGAN 710.292 852.351 994.409
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
163 G-4-10-I
RINGAN
1.942.615 2.331.138 2.719.661
164 G-4-10-II
SEDANG
2.368.385 2.842.062 3.315.739
165 G-4-10-III
BERAT
4.146.851 4.976.221 5.805.592
166 G-4-11-I
DEGENERATIF RINGAN
3.116.811 3.740.173 4.363.535
167 G-4-11-II
DEGENERATIF SEDANG
4.470.112 5.364.134 6.258.156
168 G-4-11-III
DEGENERATIF BERAT
5.942.505 7.131.006 8.319.507
170 G-4-12-II
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR
SEDANG
3.619.652 4.343.583 5.067.513
172 G-4-13-I
RINGAN
1.595.630 1.914.756 2.233.882
173 G-4-13-II
SEDANG
2.268.183 2.721.820 3.175.456
174 G-4-13-III
BERAT
2.683.190 3.219.828 3.756.466
175 G-4-14-I
INFARK RINGAN
2.545.779 3.054.935 3.564.091
176 G-4-14-II
INFARK SEDANG
3.932.971 4.719.566 5.506.160
177 G-4-14-III
INFARK BERAT
4.917.919 5.901.503 6.885.087
178 G-4-15-I
INFARK RINGAN
1.944.656 2.333.587 2.722.518
179 G-4-15-II
INFARK SEDANG
2.368.322 2.841.986 3.315.650
180 G-4-15-III
INFARK BERAT
3.051.221 3.661.465 4.271.709
184 G-4-17-I
RINGAN
2.178.826 2.614.591 3.050.356
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
185 G-4-17-II
SEDANG
2.897.728 3.477.273 4.056.819
186 G-4-17-III
BERAT
4.856.615 5.827.939 6.799.262
187 G-4-18-I
PERSARAFAN RINGAN
1.941.776 2.330.131 2.718.486
188 G-4-18-II
PERSARAFAN SEDANG
3.329.472 3.995.366 4.661.261
189 G-4-18-III
PERSARAFAN BERAT
3.534.606 4.241.528 4.948.449
190 G-4-19-I
1.940.737 2.328.885 2.717.032
191 G-4-19-II
3.026.225 3.631.470 4.236.715
192 G-4-19-III
3.804.232 4.565.079 5.325.925
211 G-4-26-I
LAIN (RINGAN)
2.260.810 2.712.972 3.165.134
212 G-4-26-II
LAIN (SEDANG)
2.644.546 3.173.455 3.702.365
213 G-4-26-III
LAIN (BERAT)
3.351.195 4.021.434 4.691.673
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
229 I-1-01-I
JANTUNG RINGAN
27.983.650 33.580.380 39.177.110
230 I-1-01-II
JANTUNG SEDANG
28.599.436 34.319.323 40.039.210
231 I-1-01-III
JANTUNG BERAT
45.143.661 54.172.393 63.201.126
232 I-1-02-I
PROSEDUR KATUP JANTUNG DENGAN
KATETERISASI RINGAN
15.525.168 18.630.201 21.735.235
233 I-1-02-II
KATETERISASI SEDANG
20.027.466 24.032.960 28.038.453
234 I-1-02-III
KATETERISASI BERAT
24.685.017 29.622.020 34.559.023
235 I-1-03-I
PADA JANTUNG ANOMALI RINGAN
9.594.755 11.513.706 13.432.657
236 I-1-03-II
PADA JANTUNG ANOMALI SEDANG
11.051.137 13.261.365 15.471.592
237 I-1-03-III
PADA JANTUNG ANOMALI BERAT
18.281.604 21.937.925 25.594.246
238 I-1-04-I
JANTUNG RINGAN
13.956.042 16.747.250 19.538.459
239 I-1-04-II
JANTUNG SEDANG
15.018.015 18.021.617 21.025.220
240 I-1-04-III
JANTUNG BERAT
31.145.058 37.374.069 43.603.081
241 I-1-05-I
RINGAN
20.548.016 24.657.619 28.767.223
242 I-1-05-II
SEDANG
24.657.619 29.589.143 34.520.667
243 I-1-05-III
33.928.729 40.714.474 47.500.220
247 I-1-07-I
15.240.583 18.288.700 21.336.817
248 I-1-07-II
18.802.356 22.562.827 26.323.298
249 I-1-07-III
20.513.248 24.615.898 28.718.547
250 I-1-11-I
PEMASANGAN SISTEM BANTUAN JANTUNG RINGAN
2.358.615 2.830.338 3.302.061
251 I-1-11-II
PEMASANGAN SISTEM BANTUAN JANTUNG SEDANG
2.622.544 3.147.052 3.671.561
252 I-1-11-III
PEMASANGAN SISTEM BANTUAN JANTUNG BERAT
3.489.806 4.187.768 4.885.729
253 I-1-12-I
RINGAN
7.452.478 8.942.973 10.433.469
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
254 I-1-12-II
SEDANG
8.516.574 10.219.889 11.923.203
255 I-1-12-III
BERAT
14.422.374 17.306.848 20.191.323
256 I-1-13-I
KOMPLEK RINGAN
3.697.025 4.436.430 5.175.835
257 I-1-13-II
KOMPLEK SEDANG
5.090.418 6.108.501 7.126.585
258 I-1-13-III
KOMPLEK BERAT
11.085.096 13.302.115 15.519.134
259 I-1-14-I
PERMANEN RINGAN
15.981.790 19.178.148 22.374.506
260 I-1-14-II
PERMANEN SEDANG
19.863.082 23.835.699 27.808.315
261 I-1-14-III
PERMANEN BERAT
26.027.487 31.232.985 36.438.482
265 I-1-16-I
(RINGAN)
6.849.339 8.219.206 9.589.074
266 I-1-16-II
(SEDANG)
17.808.281 21.369.937 24.931.593
267 I-1-16-III
(BERAT)
20.541.415 24.649.698 28.757.981
268 I-1-17-I
DARAH VENA RINGAN
2.625.648 3.150.777 3.675.907
269 I-1-17-II
DARAH VENA SEDANG
4.429.101 5.314.922 6.200.742
270 I-1-17-III
DARAH VENA BERAT
25.794.484 30.953.380 36.112.277
271 I-1-20-I
RINGAN
3.183.864 3.820.637 4.457.410
272 I-1-20-II
SEDANG
5.269.505 6.323.406 7.377.307
274 I-1-30-I
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR
DAN PACEMAKER JANTUNG RINGAN
7.770.610 9.324.732 10.878.854
275 I-1-30-II
16.164.439 19.397.327 22.630.215
276 I-1-30-III
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR
DAN PACEMAKER JANTUNG BERAT
25.049.010 30.058.812 35.068.614
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
289 I-4-13-I
THROMBOPHLEBITIS PADA PEMBULUH DARAH
VENA RINGAN
3.388.334 4.066.001 4.743.668
290 I-4-13-II
VENA SEDANG
4.934.340 5.921.208 6.908.077
291 I-4-13-III
VENA BERAT
8.431.720 10.118.064 11.804.408
295 I-4-15-I
(RINGAN)
2.601.659 3.121.991 3.642.323
296 I-4-15-II
(SEDANG)
3.885.843 4.663.011 5.440.180
297 I-4-15-III
(BERAT)
4.428.926 5.314.711 6.200.496
306 I-4-18-III
GANGUAN-PENYAKIT KATUP JANTUNG
KONGENITAL BERAT
5.322.223 6.386.668 7.451.112
307 I-4-19-I
RINGAN
1.896.687 2.276.024 2.655.361
308 I-4-19-II
SEDANG
3.170.561 3.804.674 4.438.786
309 I-4-19-III
BERAT
3.631.777 4.358.133 5.084.488
319 I-4-23-I
RINGAN
1.596.783 1.916.140 2.235.497
320 I-4-23-II
SEDANG
1.960.482 2.352.578 2.744.675
321 I-4-23-III
3.830.603 4.596.724 5.362.844
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
322 I-4-24-I
(RINGAN)
1.925.530 2.310.635 2.695.741
323 I-4-24-II
(SEDANG)
4.624.043 5.548.852 6.473.660
324 I-4-24-III
(BERAT)
5.868.833 7.042.599 8.216.366
325 J-1-01-I
DENGAN TRAKEOSTOMI RINGAN
18.359.038 22.030.845 25.702.653
326 J-1-01-II
DENGAN TRAKEOSTOMI SEDANG
19.612.893 23.535.472 27.458.050
327 J-1-01-III
DENGAN TRAKEOSTOMI BERAT
27.286.007 32.743.209 38.200.410
328 J-1-02-I
TANPA TRAKEOSTOMI RINGAN
7.391.917 8.870.301 10.348.684
329 J-1-02-II
TANPA TRAKEOSTOMI SEDANG
9.045.221 10.854.265 12.663.309
330 J-1-02-III
TANPA TRAKEOSTOMI BERAT
12.159.100 14.590.920 17.022.740
331 J-1-10-I
RINGAN
3.655.308 4.386.369 5.117.431
332 J-1-10-II
SEDANG
7.196.130 8.635.355 10.074.581
334 J-1-20-I
RINGAN
3.166.711 3.800.053 4.433.395
335 J-1-20-II
SEDANG
3.906.747 4.688.096 5.469.445
336 J-1-20-III
BERAT
5.534.250 6.641.100 7.747.950
337 J-1-30-I
KOMPLEKS RINGAN
2.135.318 2.562.381 2.989.445
338 J-1-30-II
KOMPLEKS SEDANG
8.004.172 9.605.006 11.205.840
339 J-1-30-III
KOMPLEKS BERAT
21.463.517 25.756.221 30.048.924
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
358 J-4-16-I
RINGAN
3.159.152 3.790.982 4.422.813
359 J-4-16-II
SEDANG
4.439.439 5.327.327 6.215.215
373 J-4-21-I
PERNAFASAN LAIN-LAIN (RINGAN)
1.392.432 1.670.918 1.949.404
374 J-4-21-II
PERNAFASAN LAIN-LAIN (SEDANG)
2.600.169 3.120.203 3.640.237
375 J-4-21-III
PERNAFASAN LAIN-LAIN (BERAT)
3.724.255 4.469.106 5.213.957
376 K-1-10-I
BESAR (RINGAN)
3.507.652 4.209.182 4.910.713
377 K-1-10-II
BESAR (SEDANG)
5.816.874 6.980.248 8.143.623
378 K-1-10-III
BESAR (BERAT)
6.822.489 8.186.986 9.551.484
382 K-1-12-I
FEMORAL (RINGAN)
1.937.307 2.324.769 2.712.230
383 K-1-12-II
FEMORAL (SEDANG)
2.522.821 3.027.385 3.531.950
384 K-1-12-III
FEMORAL (BERAT)
5.017.676 6.021.212 7.024.747
388 K-1-14-I
RINGAN
3.008.854 3.610.625 4.212.396
389 K-1-14-II
SEDANG
4.177.091 5.012.509 5.847.927
390 K-1-14-III
BERAT
8.400.302 10.080.362 11.760.423
394 K-1-30-I
NON KOMPLEKS (RINGAN)
4.549.884 5.459.860 6.369.837
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
395 K-1-30-II
NON KOMPLEKS (SEDANG)
7.008.516 8.410.219 9.811.923
396 K-1-30-III
NON KOMPLEKS (BERAT)
13.020.608 15.624.729 18.228.851
397 K-1-40-I
(RINGAN)
4.569.407 5.483.288 6.397.169
398 K-1-40-II
(SEDANG)
5.022.215 6.026.658 7.031.101
399 K-1-40-III
(BERAT)
8.328.860 9.994.632 11.660.404
412 K-4-13-I
1.943.474 2.332.168 2.720.863
413 K-4-13-II
2.525.426 3.030.512 3.535.597
414 K-4-13-III
4.122.833 4.947.399 5.771.966
415 K-4-14-I
GASTROINTESTINAL RINGAN
1.622.774 1.947.329 2.271.884
416 K-4-14-II
GASTROINTESTINAL SEDANG
2.201.125 2.641.350 3.081.575
417 K-4-14-III
GASTROINTESTINAL BERAT
3.544.103 4.252.924 4.961.745
424 K-4-17-I
(RINGAN)
2.290.293 2.748.352 3.206.411
425 K-4-17-II
(SEDANG)
3.241.160 3.889.391 4.537.623
426 K-4-17-III
(BERAT)
3.656.035 4.387.242 5.118.449
427 K-4-18-I
(RINGAN)
2.526.905 3.032.286 3.537.667
428 K-4-18-II
(SEDANG)
3.790.286 4.548.343 5.306.400
429 K-4-18-III
(BERAT)
4.649.580 5.579.496 6.509.413
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
430 L-1-20-I
RINGAN
15.844.381 19.013.258 22.182.134
431 L-1-20-II
SEDANG
16.471.377 19.765.653 23.059.928
432 L-1-20-III
BERAT
27.849.027 33.418.833 38.988.638
433 L-1-30-I
BAKAR RINGAN
5.805.599 6.966.718 8.127.838
434 L-1-30-II
BAKAR SEDANG
10.447.379 12.536.855 14.626.331
435 L-1-30-III
BAKAR BERAT
11.032.651 13.239.181 15.445.712
436 L-1-40-I
DAN PAYUDARA RINGAN
2.759.608 3.311.530 3.863.452
437 L-1-40-II
DAN PAYUDARA SEDANG
4.837.869 5.805.442 6.773.016
438 L-1-40-III
DAN PAYUDARA BERAT
8.188.531 9.826.237 11.463.943
451 L-4-13-I
DAN PAYUDARA RINGAN
1.347.654 1.617.185 1.886.716
452 L-4-13-II
DAN PAYUDARA SEDANG
1.684.496 2.021.395 2.358.294
453 L-4-13-III
DAN PAYUDARA BERAT
2.378.148 2.853.777 3.329.407
454 L-4-14-I
(RINGAN)
1.336.484 1.603.781 1.871.078
455 L-4-14-II
(SEDANG)
1.981.569 2.377.883 2.774.197
456 L-4-14-III
(BERAT)
3.651.599 4.381.919 5.112.239
457 M-1-01-I
ANGGOTA TUBUH BAWAH MAYOR (RINGAN)
6.323.929 7.588.715 8.853.501
458 M-1-01-II
ANGGOTA TUBUH BAWAH MAYOR (SEDANG)
7.058.528 8.470.234 9.881.939
459 M-1-01-III
ANGGOTA TUBUH BAWAH MAYOR (BERAT)
9.915.319 11.898.383 13.881.447
463 M-1-03-I
11.348.492 13.618.190 15.887.888
464 M-1-03-II
13.283.640 15.940.369 18.597.097
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
465 M-1-03-III
15.386.699 18.464.039 21.541.379
466 M-1-04-I
TUBUH BAGIAN BAWAH MAYOR (RINGAN)
3.530.855 4.237.026 4.943.198
467 M-1-04-II
TUBUH BAGIAN BAWAH MAYOR (SEDANG)
4.540.595 5.448.714 6.356.834
468 M-1-04-III
TUBUH BAGIAN BAWAH MAYOR (BERAT)
5.681.699 6.818.039 7.954.379
469 M-1-05-I
4.486.990 5.384.388 6.281.786
470 M-1-05-II
5.178.161 6.213.793 7.249.425
471 M-1-05-III
8.819.818 10.583.781 12.347.745
472 M-1-07-I
5.080.791 6.096.950 7.113.108
473 M-1-07-II
6.806.673 8.168.007 9.529.342
474 M-1-07-III
13.865.837 16.639.005 19.412.172
475 M-1-10-I
WAJAH RINGAN
3.808.127 4.569.753 5.331.378
476 M-1-10-II
WAJAH SEDANG
10.691.762 12.830.114 14.968.467
477 M-1-10-III
WAJAH BERAT
15.753.969 18.904.763 22.055.557
478 M-1-20-I
SENDI MAYOR RINGAN
3.757.469 4.508.963 5.260.457
479 M-1-20-II
SENDI MAYOR SEDANG
4.268.001 5.121.601 5.975.201
480 M-1-20-III
SENDI MAYOR BERAT
10.412.313 12.494.775 14.577.238
484 M-1-40-I
ALAT FIKSASI INTERNAL RINGAN
2.225.548 2.670.658 3.115.768
485 M-1-40-II
ALAT FIKSASI INTERNAL SEDANG
3.655.740 4.386.888 5.118.036
486 M-1-40-III
ALAT FIKSASI INTERNAL BERAT
6.120.422 7.344.507 8.568.591
490 M-1-60-I
2.277.148 2.732.577 3.188.007
491 M-1-60-II
4.557.007 5.468.408 6.379.810
492 M-1-60-III
7.910.346 9.492.415 11.074.484
493 M-1-70-I
KAKI (RINGAN)
3.045.555 3.654.666 4.263.777
494 M-1-70-II
KAKI (SEDANG)
6.209.557 7.451.468 8.693.380
495 M-1-70-III
KAKI (BERAT)
8.684.373 10.421.247 12.158.122
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
502 M-4-11-I
RINGAN
2.050.022 2.460.026 2.870.030
503 M-4-11-II
SEDANG
3.993.894 4.792.673 5.591.452
504 M-4-11-III
BERAT
6.804.562 8.165.475 9.526.387
505 M-4-12-I
RINGAN
1.298.818 1.558.581 1.818.345
506 M-4-12-II
SEDANG
2.363.045 2.835.654 3.308.263
507 M-4-12-III
BERAT
4.223.293 5.067.952 5.912.611
508 M-4-13-I
DAN FRAKTUR PATOLOGIS RINGAN
2.873.628 3.448.354 4.023.080
509 M-4-13-II
DAN FRAKTUR PATOLOGIS SEDANG
3.249.111 3.898.934 4.548.756
510 M-4-13-III
DAN FRAKTUR PATOLOGIS BERAT
7.691.882 9.230.258 10.768.634
520 M-4-17-I
BELAKANG RINGAN
1.653.957 1.984.748 2.315.540
521 M-4-17-II
BELAKANG SEDANG
2.269.096 2.722.916 3.176.735
522 M-4-17-III
BELAKANG BERAT
3.182.271 3.818.725 4.455.180
526 M-4-19-I
RINGAN
1.688.391 2.026.069 2.363.747
527 M-4-19-II
SEDANG
2.843.790 3.412.549 3.981.307
528 M-4-19-III
BERAT
4.865.248 5.838.298 6.811.348
529 M-4-20-I
KESELEO DAN PERADANGAN MINOR (RINGAN)
1.299.780 1.559.736 1.819.692
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
530 M-4-20-II
KESELEO DAN PERADANGAN MINOR (SEDANG)
1.944.888 2.333.865 2.722.843
531 M-4-20-III
KESELEO DAN PERADANGAN MINOR (BERAT)
2.162.020 2.594.424 3.026.828
532 M-4-21-I
1.295.444 1.554.533 1.813.622
533 M-4-21-II
2.020.351 2.424.421 2.828.491
534 M-4-21-III
4.010.836 4.813.003 5.615.170
541 N-1-12-I
2.579.047 3.094.856 3.610.666
542 N-1-12-II
7.298.309 8.757.971 10.217.632
543 N-1-12-III
13.299.529 15.959.435 18.619.341
547 N-1-30-I
BAWAH RINGAN
5.055.268 6.066.322 7.077.375
548 N-1-30-II
BAWAH SEDANG
7.632.344 9.158.812 10.685.281
549 N-1-30-III
BAWAH BERAT
8.015.054 9.618.064 11.221.075
550 N-1-40-I
RINGAN
4.560.507 5.472.608 6.384.709
551 N-1-40-II
SEDANG
6.185.233 7.422.280 8.659.327
552 N-1-40-III
BERAT
7.170.716 8.604.859 10.039.003
553 N-4-10-I
RINGAN
1.777.231 2.132.677 2.488.123
554 N-4-10-II
SEDANG
2.599.203 3.119.044 3.638.885
555 N-4-10-III
BERAT
4.159.835 4.991.802 5.823.770
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
565 N-4-14-I
1.124.572 1.349.487 1.574.401
566 N-4-14-II
1.730.110 2.076.132 2.422.154
567 N-4-14-III
2.805.687 3.366.825 3.927.962
568 N-4-15-I
SALURAN URIN RINGAN
1.624.809 1.949.771 2.274.733
569 N-4-15-II
SALURAN URIN SEDANG
2.237.720 2.685.264 3.132.807
570 N-4-15-III
SALURAN URIN BERAT
2.553.642 3.064.370 3.575.099
571 N-4-16-I
(RINGAN)
2.003.492 2.404.191 2.804.889
572 N-4-16-II
(SEDANG)
2.600.516 3.120.619 3.640.723
573 N-4-16-III
(BERAT)
4.464.144 5.356.973 6.249.802
574 O-6-10-I
RINGAN
3.656.485 4.387.782 5.119.079
575 O-6-10-II
SEDANG
4.034.913 4.841.895 5.648.878
577 O-6-11-I
STERILISASI &/ DILATASI & KURET RINGAN
1.726.436 2.071.723 2.417.010
578 O-6-11-II
2.090.149 2.508.179 2.926.209
579 O-6-11-III
3.539.010 4.246.813 4.954.615
580 O-6-12-I
PROSEDUR SELAIN STERILISASI &/ DILATASI &KURET
RINGAN
1.415.130 1.698.155 1.981.181
581 O-6-12-II
SEDANG
1.699.567 2.039.480 2.379.394
582 O-6-12-III
BERAT
2.135.262 2.562.315 2.989.367
586 P-8-01-I
EKSTRAKORPORAL RINGAN
32.591.041 39.109.250 45.627.458
587 P-8-01-II
EKSTRAKORPORAL SEDANG
40.326.316 48.391.579 56.456.842
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
588 P-8-01-III
EKSTRAKORPORAL BERAT
47.331.790 56.798.148 66.264.506
589 P-8-02-I
47.245.606 56.694.727 66.143.848
590 P-8-02-II
54.195.573 65.034.688 75.873.803
591 P-8-02-III
61.922.317 74.306.781 86.691.244
592 P-8-03-I
GROUP-1 TANPA PROSEDUR MAYOR RINGAN
1.781.035 2.137.242 2.493.448
593 P-8-03-II
GROUP-1 TANPA PROSEDUR MAYOR SEDANG
2.496.434 2.995.721 3.495.008
594 P-8-03-III
GROUP-1 TANPA PROSEDUR MAYOR BERAT
4.299.956 5.159.947 6.019.938
595 P-8-04-I
18.953.731 22.744.477 26.535.224
596 P-8-04-II
24.730.704 29.676.845 34.622.986
597 P-8-04-III
35.457.605 42.549.126 49.640.647
598 P-8-05-I
10.326.037 12.391.245 14.456.452
599 P-8-05-II
14.673.908 17.608.690 20.543.471
600 P-8-05-III
21.620.033 25.944.040 30.268.047
601 P-8-06-I
1.783.606 2.140.327 2.497.049
602 P-8-06-II
4.278.842 5.134.611 5.990.379
603 P-8-06-III
7.851.151 9.421.381 10.991.611
604 P-8-07-I
2.745.468 3.294.562 3.843.656
605 P-8-07-II
6.984.946 8.381.935 9.778.924
606 P-8-07-III
9.257.641 11.109.169 12.960.697
607 P-8-08-I
PERNAFASAN RINGAN
3.174.849 3.809.819 4.444.788
608 P-8-08-II
PERNAFASAN SEDANG
4.504.960 5.405.952 6.306.944
609 P-8-08-III
PERNAFASAN BERAT
7.294.521 8.753.426 10.212.330
610 P-8-10-I
FASILITAS PERAWATAN PASIEN AKUT LAIN RINGAN
1.345.109 1.614.131 1.883.153
611 P-8-10-II
FASILITAS PERAWATAN PASIEN AKUT LAIN SEDANG
2.382.888 2.859.466 3.336.044
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
612 P-8-10-III
FASILITAS PERAWATAN PASIEN AKUT LAIN BERAT
4.678.312 5.613.975 6.549.637
613 P-8-11-I
MAYOR RINGAN
1.820.635 2.184.762 2.548.889
614 P-8-11-II
MAYOR SEDANG
8.025.438 9.630.525 11.235.613
615 P-8-11-III
MAYOR BERAT
8.193.572 9.832.287 11.471.001
616 P-8-12-I
MAYOR RINGAN
2.185.056 2.622.067 3.059.078
617 P-8-12-II
MAYOR SEDANG
3.397.622 4.077.146 4.756.670
618 P-8-12-III
MAYOR BERAT
4.016.361 4.819.633 5.622.906
619 P-8-13-I
MAYOR RINGAN
1.781.457 2.137.748 2.494.039
620 P-8-13-II
MAYOR SEDANG
3.080.328 3.696.393 4.312.459
621 P-8-13-III
MAYOR BERAT
4.585.447 5.502.536 6.419.625
622 P-8-14-I
MAYOR ATAU KONDISI HEREDITER RINGAN
2.059.519 2.471.423 2.883.327
623 P-8-14-II
MAYOR ATAU KONDISI HEREDITER SEDANG
4.199.334 5.039.200 5.879.067
624 P-8-14-III
MAYOR ATAU KONDISI HEREDITER BERAT
4.606.754 5.528.105 6.449.456
625 P-8-15-I
ASPIRASI RINGAN
1.553.854 1.864.625 2.175.396
626 P-8-15-II
ASPIRASI SEDANG
3.095.484 3.714.580 4.333.677
627 P-8-15-III
ASPIRASI BERAT
3.634.114 4.360.937 5.087.760
628 P-8-16-I
1.406.596 1.687.915 1.969.235
629 P-8-16-II
1.988.275 2.385.930 2.783.585
630 P-8-16-III
2.579.543 3.095.451 3.611.360
631 P-8-17-I
MAYOR RINGAN
1.511.962 1.814.354 2.116.746
632 P-8-17-II
MAYOR SEDANG
3.930.969 4.717.163 5.503.357
633 P-8-17-III
MAYOR BERAT
7.429.702 8.915.642 10.401.582
634 S-4-10-I
ATAU BANYAK TEMPAT (RINGAN)
1.301.211 1.561.453 1.821.695
635 S-4-10-II
ATAU BANYAK TEMPAT (SEDANG)
1.625.770 1.950.924 2.276.078
636 S-4-10-III
ATAU BANYAK TEMPAT (BERAT)
2.104.937 2.525.924 2.946.911
637 S-4-11-I REAKSI ALLERGI RINGAN 813.070 975.684 1.138.298
640 S-4-12-I EFEK TOKSIK DAN KERACUNAN OBAT RINGAN 970.805 1.164.966 1.359.127
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
643 S-4-13-I
RINGAN
1.386.704 1.664.044 1.941.385
644 S-4-13-II
SEDANG
2.286.766 2.744.119 3.201.472
645 S-4-13-III
BERAT
4.683.319 5.619.982 6.556.646
646 S-4-14-I
KANAK-KANAK RINGAN
790.307 948.368 1.106.430
647 S-4-14-II
KANAK-KANAK SEDANG
1.678.877 2.014.652 2.350.428
648 S-4-14-III
KANAK-KANAK BERAT
3.183.749 3.820.498 4.457.248
649 S-4-15-I
AKUT YANG LAIN (RINGAN)
597.716 717.260 836.803
650 S-4-15-II
AKUT YANG LAIN (SEDANG)
1.128.094 1.353.713 1.579.332
651 S-4-15-III
AKUT YANG LAIN (BERAT)
1.461.144 1.753.373 2.045.602
655 S-4-17-I
1.371.353 1.645.623 1.919.894
656 S-4-17-II
1.687.665 2.025.198 2.362.731
657 S-4-17-III
2.653.394 3.184.073 3.714.752
658 T-1-10-I
OBAT RINGAN
1.216.238 1.459.486 1.702.734
659 T-1-10-II
OBAT SEDANG
1.633.326 1.959.991 2.286.656
660 T-1-10-III
OBAT BERAT
2.971.552 3.565.862 4.160.172
661 T-4-10-I
RINGAN
546.544 655.852 765.161
662 T-4-10-II
SEDANG
1.041.591 1.249.909 1.458.227
663 T-4-10-III
DAN ALKOHOL, MENOLAK NASEHAT DOKTER BERAT
1.514.190 1.817.028 2.119.866
664 T-4-11-I
647.167 776.600 906.033
665 T-4-11-II
1.018.456 1.222.147 1.425.838
666 T-4-11-III
1.640.432 1.968.519 2.296.605
667 T-4-12-I
LAIN-LAIN (RINGAN)
1.131.900 1.358.280 1.584.660
668 T-4-12-II
LAIN-LAIN (SEDANG)
1.711.182 2.053.418 2.395.655
669 T-4-12-III
LAIN-LAIN (BERAT)
2.670.705 3.204.846 3.738.987
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
673 U-1-11-I
(RINGAN)
4.320.046 5.184.055 6.048.065
674 U-1-11-II
(SEDANG)
5.683.424 6.820.109 7.956.793
675 U-1-11-III
(BERAT)
10.742.796 12.891.355 15.039.915
682 U-1-14-I
LANGIT MULUT (RINGAN)
2.307.720 2.769.264 3.230.808
683 U-1-14-II
LANGIT MULUT (SEDANG)
2.832.037 3.398.444 3.964.851
684 U-1-14-III
LANGIT MULUT (BERAT)
3.356.043 4.027.252 4.698.460
688 U-1-20-I
3.504.032 4.204.838 4.905.645
689 U-1-20-II
6.019.321 7.223.186 8.427.050
690 U-1-20-III
10.503.422 12.604.106 14.704.791
694 U-4-10-I
TELINGA RINGAN
2.806.560 3.367.871 3.929.183
695 U-4-10-II
TELINGA SEDANG
5.323.393 6.388.072 7.452.751
696 U-4-10-III
TELINGA BERAT
8.173.156 9.807.787 11.442.419
703 U-4-13-I
DAN LARINGOTRAKEITIS RINGAN
1.299.025 1.558.830 1.818.635
704 U-4-13-II
DAN LARINGOTRAKEITIS SEDANG
1.481.991 1.778.389 2.074.787
705 U-4-13-III
DAN LARINGOTRAKEITIS BERAT
1.972.431 2.366.917 2.761.403
709 U-4-15-I
1.293.471 1.552.165 1.810.859
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
710 U-4-15-II
1.640.382 1.968.458 2.296.534
711 U-4-15-III
2.275.790 2.730.948 3.186.106
712 V-1-10-I
RINGAN
3.837.599 4.605.118 5.372.638
713 V-1-10-II
SEDANG
4.373.930 5.248.717 6.123.503
714 V-1-10-III
BERAT
6.527.980 7.833.576 9.139.172
718 V-1-12-I
KOMPLEK-MODERAT (RINGAN)
2.823.740 3.388.488 3.953.236
719 V-1-12-II
KOMPLEK-MODERAT (SEDANG)
7.920.123 9.504.147 11.088.172
720 V-1-12-III
KOMPLEK-MODERAT (BERAT)
8.539.556 10.247.468 11.955.379
721 V-1-13-I
KOMPLEK (RINGAN)
4.279.025 5.134.831 5.990.636
722 V-1-13-II
KOMPLEK (SEDANG)
7.143.431 8.572.118 10.000.804
723 V-1-13-III
KOMPLEK (BERAT)
8.556.281 10.267.537 11.978.793
724 V-1-14-I
URETRA RINGAN
5.158.164 6.189.796 7.221.429
725 V-1-14-II
URETRA SEDANG
6.374.031 7.648.837 8.923.643
726 V-1-14-III
URETRA BERAT
7.764.666 9.317.599 10.870.532
730 V-4-10-I
RINGAN
2.990.697 3.588.836 4.186.975
731 V-4-10-II
SEDANG
4.137.397 4.964.876 5.792.355
732 V-4-10-III
BERAT
7.760.422 9.312.506 10.864.590
733 V-4-11-I
TUMOR (RINGAN)
1.865.562 2.238.674 2.611.786
734 V-4-11-II
TUMOR (SEDANG)
2.619.202 3.143.042 3.666.882
735 V-4-11-III
TUMOR (BERAT)
3.917.469 4.700.963 5.484.456
736 W-1-01-I
5.847.583 7.017.100 8.186.616
737 W-1-01-II
7.056.580 8.467.896 9.879.212
738 W-1-01-III
11.722.107 14.066.528 16.410.949
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
742 W-1-11-I
SERVIK RINGAN
2.484.165 2.980.997 3.477.830
743 W-1-11-II
SERVIK SEDANG
4.367.443 5.240.932 6.114.421
744 W-1-11-III
SERVIK BERAT
9.196.606 11.035.927 12.875.248
745 W-1-12-I
1.543.625 1.852.350 2.161.075
746 W-1-12-II
1.745.954 2.095.144 2.444.335
747 W-1-12-III
2.682.005 3.218.406 3.754.807
748 W-1-13-I
RINGAN
1.530.898 1.837.078 2.143.258
749 W-1-13-II
SEDANG
1.662.114 1.994.537 2.326.960
750 W-1-13-III
BERAT
2.232.526 2.679.032 3.125.537
754 W-1-30-I
RINGAN
2.585.906 3.103.087 3.620.268
755 W-1-30-II
SEDANG
4.124.653 4.949.584 5.774.515
763 W-4-12-I
1.301.086 1.561.303 1.821.520
764 W-4-12-II
1.971.339 2.365.606 2.759.874
765 W-4-12-III
2.378.815 2.854.578 3.330.341
766 W-4-13-I ABORTUS RINGAN 710.800 852.960 995.120
767 W-4-13-II ABORTUS SEDANG 974.170 1.169.004 1.363.838
769 W-4-14-I ABORTUS MENGANCAM RINGAN 972.136 1.166.563 1.360.990
778 W-4-17-I GANGGUAN POSTPARTUM RINGAN 952.451 1.142.941 1.333.432
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
787 Z-4-12-I
976.373 1.171.647 1.366.922
788 Z-4-12-II
2.379.097 2.854.916 3.330.736
789 Z-4-12-III
3.017.191 3.620.630 4.224.068
2 B-2-11-0 PROSEDUR BESAR PADA SALURAN EMPEDU 982.567
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 973.855
24 D-2-11-0 PROSEDUR LIMPA 1.219.433
31
E-2-22-0 PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL 169.541
33 F-3-10-0 TERAPI SHOCK 239.517
Rumah Sakit Kelas D
Rawat Jalan
Rumah Sakit Kelas D
Rawat Jalan
72
I-2-16-0
PENGGANTIAN ALAT
2.099.306
80
I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR
PERKUTAN LAIN
2.027.683
Rumah Sakit Kelas D
Rawat Jalan
179
O-7-12-0
PELEBARAN DAN KURETASE
849.078
181
P-9-10-0 NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN AKUT LAIN 170.987
Rumah Sakit Kelas D
Rawat Jalan
191 Q-5-12-0 GIGI 120.168
195 Q-5-16-0 VAKSINASI 96.024
196 Q-5-17-0 PASANG INFUS 82.667
200 Q-5-21-0 ABORSI 64.372
205 Q-5-26-0 BRONKIAL AKUT 185.538
210 Q-5-31-0 FRAKTUR 125.719
214 Q-5-35-0 INFEKSI AKUT 245.760
217 Q-5-38-0 PARU AKUT 193.909
238
U-3-10-0 PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 188.068
241
U-3-13-0 PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 182.566
Rumah Sakit Kelas D
Rawat Jalan
269
Z-3-11-0
EMPEDU
1.380.013
276 Z-3-18-0 CT-SCAN KEPALA 235.678
288 Z-3-30-0 FOTOTERAPI 72.302
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 3.600.632 4.320.758 5.040.885
8 A-4-12-II DEMAM SEDANG 4.483.934 5.380.721 6.277.508
9 A-4-12-III DEMAM BERAT 4.785.633 5.742.759 6.699.886
13 A-4-14-I
RINGAN
3.817.415 4.580.898 5.344.381
14 A-4-14-II
SEDANG
4.910.161 5.892.194 6.874.226
15 A-4-14-III
BERAT
5.625.890 6.751.068 7.876.246
28 B-1-12-I
RINGAN
8.849.369 10.619.242 12.389.116
29 B-1-12-II
SEDANG
18.966.143 22.759.372 26.552.600
30 B-1-12-III
BERAT
23.083.000 27.699.600 32.316.199
31 B-1-13-I
(RINGAN)
7.120.183 8.544.219 9.968.256
32 B-1-13-II
(SEDANG)
11.597.669 13.917.203 16.236.736
33 B-1-13-III
(BERAT)
17.098.190 20.517.827 23.937.465
34 B-1-14-I
RINGAN
9.685.105 11.622.126 13.559.147
35 B-1-14-II
SEDANG
10.771.588 12.925.906 15.080.224
36 B-1-14-III
BERAT
16.850.977 20.221.172 23.591.367
40 B-4-11-I
RINGAN
6.317.962 7.581.554 8.845.146
41 B-4-11-II
SEDANG
9.470.472 11.364.567 13.258.661
Rumah Sakit Kelas A
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
46 B-4-13-I
5.735.611 6.882.733 8.029.856
47 B-4-13-II
6.681.815 8.018.178 9.354.541
48 B-4-13-III
9.900.887 11.881.064 13.861.241
73 D-1-20-I
8.409.948 10.091.937 11.773.927
74 D-1-20-II
23.176.635 27.811.962 32.447.289
75 D-1-20-III
36.764.992 44.117.991 51.470.989
85 D-4-13-I
SEL SICKLE RINGAN
3.696.937 4.436.325 5.175.712
86 D-4-13-II
SEL SICKLE SEDANG
5.232.499 6.278.999 7.325.499
87 D-4-13-III
SEL SICKLE BERAT
6.692.518 8.031.021 9.369.525
88 D-4-14-I
4.151.987 4.982.384 5.812.782
89 D-4-14-II
8.758.454 10.510.145 12.261.835
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
90 D-4-14-III
11.318.801 13.582.562 15.846.322
97 E-1-20-I
TIROGLOSAL RINGAN
9.741.467 11.689.761 13.638.054
98 E-1-20-II
TIROGLOSAL SEDANG
13.111.744 15.734.093 18.356.442
99 E-1-20-III
TIROGLOSAL BERAT
26.102.028 31.322.433 36.542.839
100 E-4-10-I
METABOLIK RINGAN
4.778.588 5.734.306 6.690.023
101 E-4-10-II
METABOLIK SEDANG
6.677.127 8.012.553 9.347.978
102 E-4-10-III
METABOLIK BERAT
11.971.094 14.365.313 16.759.532
130 F-4-16-I
MENTAL RINGAN
7.558.475 9.070.170 10.581.865
131 F-4-16-II
MENTAL SEDANG
8.788.037 10.545.645 12.303.252
132 F-4-16-III
MENTAL BERAT
11.730.528 14.076.633 16.422.739
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
142 G-1-01-I
RINGAN
16.338.029 19.605.635 22.873.241
163 G-4-10-I
RINGAN
5.489.954 6.587.944 7.685.935
164 G-4-10-II
SEDANG
6.710.548 8.052.658 9.394.768
166 G-4-11-I
DEGENERATIF RINGAN
7.444.393 8.933.272 10.422.151
167 G-4-11-II
DEGENERATIF SEDANG
9.888.906 11.866.687 13.844.468
168 G-4-11-III
DEGENERATIF BERAT
14.530.223 17.436.268 20.342.312
172 G-4-13-I
RINGAN
3.830.025 4.596.030 5.362.035
173 G-4-13-II
SEDANG
6.678.704 8.014.445 9.350.186
174 G-4-13-III
BERAT
7.921.080 9.505.296 11.089.512
175 G-4-14-I
INFARK RINGAN
6.497.074 7.796.488 9.095.903
176 G-4-14-II
INFARK SEDANG
8.686.220 10.423.464 12.160.708
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
177 G-4-14-III
INFARK BERAT
10.902.195 13.082.634 15.263.073
178 G-4-15-I
5.308.668 6.370.401 7.432.135
179 G-4-15-II
6.335.668 7.602.802 8.869.936
180 G-4-15-III
8.942.240 10.730.688 12.519.136
185 G-4-17-II
SEDANG
7.643.019 9.171.622 10.700.226
187 G-4-18-I
PERSARAFAN RINGAN
5.740.577 6.888.692 8.036.807
188 G-4-18-II
PERSARAFAN SEDANG
7.673.510 9.208.212 10.742.914
189 G-4-18-III
PERSARAFAN BERAT
8.586.025 10.303.229 12.020.434
190 G-4-19-I
4.789.565 5.747.478 6.705.391
191 G-4-19-II
8.095.463 9.714.555 11.333.648
192 G-4-19-III
11.754.095 14.104.914 16.455.733
211 G-4-26-I
(RINGAN)
5.739.810 6.887.772 8.035.734
212 G-4-26-II
(SEDANG)
6.677.187 8.012.624 9.348.062
213 G-4-26-III
(BERAT)
10.444.393 12.533.272 14.622.151
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
229 I-1-01-I
RINGAN
76.000.780 91.200.936 106.401.092
230 I-1-01-II
SEDANG
77.672.721 93.207.265 108.741.809
231 I-1-01-III
BERAT
122.605.366 147.126.439 171.647.512
232 I-1-02-I
RINGAN
42.164.919 50.597.903 59.030.886
233 I-1-02-II
SEDANG
54.392.221 65.270.665 76.149.109
234 I-1-02-III
BERAT
67.041.765 80.450.117 93.858.470
235 I-1-03-I
25.927.002 31.112.402 36.297.802
236 I-1-03-II
31.485.371 37.782.445 44.079.519
237 I-1-03-III
48.905.803 58.686.964 68.468.124
238 I-1-04-I
JANTUNG RINGAN
43.493.436 52.192.123 60.890.811
239 I-1-04-II
JANTUNG SEDANG
68.644.323 82.373.188 96.102.053
240 I-1-04-III
JANTUNG BERAT
109.658.905 131.590.686 153.522.467
241 I-1-05-I
55.806.049 66.967.259 78.128.469
242 I-1-05-II
66.967.532 80.361.038 93.754.544
243 I-1-05-III
92.146.757 110.576.108 129.005.460
247 I-1-07-I
33.906.498 40.687.797 47.469.097
248 I-1-07-II
41.830.629 50.196.754 58.562.880
249 I-1-07-III
45.637.058 54.764.470 63.891.882
250 I-1-11-I
5.258.271 6.309.925 7.361.580
251 I-1-11-II
5.846.685 7.016.022 8.185.359
252 I-1-11-III
7.780.144 9.336.172 10.892.201
253 I-1-12-I
RINGAN
21.862.988 26.235.586 30.608.183
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
254 I-1-12-II
SEDANG
24.719.929 29.663.914 34.607.900
255 I-1-12-III
BERAT
41.263.909 49.516.691 57.769.473
256 I-1-13-I
RINGAN
16.112.980 19.335.576 22.558.172
257 I-1-13-II
SEDANG
19.551.537 23.461.845 27.372.152
258 I-1-13-III
BERAT
24.661.595 29.593.914 34.526.233
259 I-1-14-I
PERMANEN RINGAN
43.405.083 52.086.100 60.767.117
260 I-1-14-II
PERMANEN SEDANG
53.946.143 64.735.371 75.524.600
261 I-1-14-III
PERMANEN BERAT
70.688.026 84.825.631 98.963.236
265 I-1-16-I
(RINGAN)
18.601.789 22.322.147 26.042.505
266 I-1-16-II
(SEDANG)
48.365.061 58.038.073 67.711.086
267 I-1-16-III
(BERAT)
55.788.343 66.946.011 78.103.680
268 I-1-17-I
VENA RINGAN
32.061.212 38.473.454 44.885.697
269 I-1-17-II
VENA SEDANG
40.143.645 48.172.374 56.201.103
270 I-1-17-III
VENA BERAT
49.657.079 59.588.495 69.519.911
271 I-1-20-I
RINGAN
27.898.924 33.478.709 39.058.493
272 I-1-20-II
SEDANG
34.853.347 41.824.016 48.794.685
274 I-1-30-I
21.103.912 25.324.694 29.545.477
275 I-1-30-II
43.900.877 52.681.052 61.461.228
276 I-1-30-III
68.030.627 81.636.753 95.242.878
289 I-4-13-I
RINGAN
7.560.329 9.072.394 10.584.460
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
290 I-4-13-II
SEDANG
10.950.712 13.140.854 15.330.996
291 I-4-13-III
BERAT
24.517.259 29.420.711 34.324.163
295 I-4-15-I
(RINGAN)
7.643.721 9.172.466 10.701.210
296 I-4-15-II
(SEDANG)
9.865.157 11.838.188 13.811.219
297 I-4-15-III
(BERAT)
11.243.719 13.492.463 15.741.207
306 I-4-18-III
BERAT
14.081.102 16.897.323 19.713.543
319 I-4-23-I
4.336.831 5.204.197 6.071.563
320 I-4-23-II
5.324.331 6.389.198 7.454.064
321 I-4-23-III
10.403.490 12.484.188 14.564.887
322 I-4-24-I
(RINGAN)
5.058.624 6.070.349 7.082.074
323 I-4-24-II
(SEDANG)
11.648.836 13.978.603 16.308.371
324 I-4-24-III
(BERAT)
14.727.849 17.673.419 20.618.989
325 J-1-01-I
TRAKEOSTOMI RINGAN
73.782.167 88.538.600 103.295.034
326 J-1-01-II
TRAKEOSTOMI SEDANG
81.980.186 98.376.223 114.772.260
327 J-1-01-III
TRAKEOSTOMI BERAT
91.089.095 109.306.915 127.524.734
328 J-1-02-I
TRAKEOSTOMI RINGAN
39.153.572 46.984.287 54.815.001
329 J-1-02-II
TRAKEOSTOMI SEDANG
53.526.051 64.231.261 74.936.472
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
330 J-1-02-III
TRAKEOSTOMI BERAT
86.811.377 104.173.652 121.535.928
334 J-1-20-I
RINGAN
15.759.300 18.911.160 22.063.020
335 J-1-20-II
SEDANG
19.849.292 23.819.150 27.789.009
336 J-1-20-III
BERAT
30.650.575 36.780.689 42.910.804
337 J-1-30-I
RINGAN
9.474.940 11.369.928 13.264.916
338 J-1-30-II
SEDANG
21.412.421 25.694.905 29.977.389
339 J-1-30-III
BERAT
71.561.739 85.874.087 100.186.435
373 J-4-21-I
LAIN-LAIN (RINGAN)
3.817.834 4.581.401 5.344.968
374 J-4-21-II
LAIN-LAIN (SEDANG)
8.691.434 10.429.720 12.168.007
375 J-4-21-III
LAIN-LAIN (BERAT)
12.396.827 14.876.193 17.355.558
376 K-1-10-I
(RINGAN)
10.292.882 12.351.459 14.410.035
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
377 K-1-10-II
(SEDANG)
12.935.213 15.522.256 18.109.299
378 K-1-10-III
(BERAT)
15.160.511 18.192.613 21.224.715
382 K-1-12-I
FEMORAL (RINGAN)
4.318.766 5.182.520 6.046.273
383 K-1-12-II
FEMORAL (SEDANG)
5.617.063 6.740.476 7.863.889
384 K-1-12-III
FEMORAL (BERAT)
11.128.152 13.353.783 15.579.413
394 K-1-30-I
KOMPLEKS (RINGAN)
10.057.031 12.068.437 14.079.843
395 K-1-30-II
KOMPLEKS (SEDANG)
19.691.924 23.630.308 27.568.693
396 K-1-30-III
KOMPLEKS (BERAT)
28.943.148 34.731.777 40.520.407
412 K-4-13-I
5.736.103 6.883.324 8.030.544
413 K-4-13-II
7.419.977 8.903.972 10.387.968
414 K-4-13-III
11.429.129 13.714.955 16.000.781
415 K-4-14-I
RINGAN
4.545.908 5.455.090 6.364.272
416 K-4-14-II
SEDANG
6.102.073 7.322.488 8.542.903
417 K-4-14-III
BERAT
9.791.390 11.749.668 13.707.946
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
424 K-4-17-I
(RINGAN)
3.466.359 4.159.631 4.852.903
425 K-4-17-II
(SEDANG)
4.905.495 5.886.594 6.867.693
426 K-4-17-III
(BERAT)
5.533.409 6.640.091 7.746.773
430 L-1-20-I
RINGAN
35.247.472 42.296.967 49.346.461
431 L-1-20-II
SEDANG
36.834.339 44.201.207 51.568.074
432 L-1-20-III
BERAT
56.194.735 67.433.682 78.672.629
433 L-1-30-I
RINGAN
15.531.003 18.637.203 21.743.404
434 L-1-30-II
SEDANG
23.198.317 27.837.980 32.477.643
435 L-1-30-III
BERAT
24.527.174 29.432.609 34.338.043
436 L-1-40-I
PAYUDARA RINGAN
6.452.234 7.742.681 9.033.128
437 L-1-40-II
PAYUDARA SEDANG
12.941.708 15.530.049 18.118.391
438 L-1-40-III
PAYUDARA BERAT
31.465.466 37.758.559 44.051.652
451 L-4-13-I
PAYUDARA RINGAN
3.252.070 3.902.484 4.552.898
452 L-4-13-II
PAYUDARA SEDANG
3.822.010 4.586.412 5.350.814
453 L-4-13-III
PAYUDARA BERAT
5.624.210 6.749.052 7.873.894
454 L-4-14-I
(RINGAN)
3.815.498 4.578.598 5.341.698
455 L-4-14-II
(SEDANG)
5.730.962 6.877.155 8.023.347
456 L-4-14-III
(BERAT)
8.078.513 9.694.216 11.309.919
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
457 M-1-01-I
17.175.021 20.610.025 24.045.030
458 M-1-01-II
19.170.454 23.004.544 26.838.635
459 M-1-01-III
26.928.804 32.314.565 37.700.326
463 M-1-03-I
31.958.448 38.350.137 44.741.827
464 M-1-03-II
38.368.060 46.041.672 53.715.284
465 M-1-03-III
39.906.097 47.887.317 55.868.536
466 M-1-04-I
7.877.326 9.452.791 11.028.256
467 M-1-04-II
10.071.343 12.085.612 14.099.881
468 M-1-04-III
12.602.193 15.122.631 17.643.070
469 M-1-05-I
11.275.820 13.530.984 15.786.149
470 M-1-05-II
11.543.543 13.852.252 16.160.960
471 M-1-05-III
19.662.161 23.594.593 27.527.025
472 M-1-07-I
13.799.131 16.558.957 19.318.783
473 M-1-07-II
18.486.014 22.183.216 25.880.419
474 M-1-07-III
37.657.829 45.189.395 52.720.961
475 M-1-10-I
WAJAH RINGAN
23.246.261 27.895.514 32.544.766
476 M-1-10-II
WAJAH SEDANG
55.580.906 66.697.087 77.813.268
477 M-1-10-III
WAJAH BERAT
119.882.782 143.859.338 167.835.894
478 M-1-20-I
MAYOR RINGAN
8.338.669 10.006.403 11.674.137
479 M-1-20-II
MAYOR SEDANG
11.897.420 14.276.904 16.656.387
480 M-1-20-III
MAYOR BERAT
29.516.198 35.419.438 41.322.678
484 M-1-40-I
5.593.184 6.711.821 7.830.458
485 M-1-40-II
10.338.281 12.405.937 14.473.593
486 M-1-40-III
18.000.359 21.600.430 25.200.502
490 M-1-60-I
5.033.278 6.039.933 7.046.589
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
491 M-1-60-II
10.103.211 12.123.853 14.144.496
492 M-1-60-III
17.590.361 21.108.434 24.626.506
493 M-1-70-I
(RINGAN)
27.701.518 33.241.822 38.782.125
494 M-1-70-II
(SEDANG)
30.471.670 36.566.004 42.660.338
495 M-1-70-III
(BERAT)
33.518.837 40.222.604 46.926.371
502 M-4-11-I
RINGAN
4.785.449 5.742.539 6.699.629
503 M-4-11-II
SEDANG
10.491.763 12.590.116 14.688.469
504 M-4-11-III
BERAT
15.169.373 18.203.248 21.237.122
505 M-4-12-I
RINGAN
3.819.849 4.583.819 5.347.789
506 M-4-12-II
SEDANG
6.353.375 7.624.050 8.894.725
508 M-4-13-I
6.360.357 7.632.429 8.904.500
509 M-4-13-II
9.556.207 11.467.448 13.378.689
510 M-4-13-III
18.910.071 22.692.085 26.474.099
520 M-4-17-I
RINGAN
4.779.536 5.735.443 6.691.351
521 M-4-17-II
SEDANG
6.684.662 8.021.594 9.358.527
522 M-4-17-III
BERAT
9.334.634 11.201.561 13.068.487
526 M-4-19-I
3.767.292 4.520.751 5.274.209
527 M-4-19-II
6.345.627 7.614.752 8.883.877
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
528 M-4-19-III
12.393.372 14.872.047 17.350.721
529 M-4-20-I
3.800.175 4.560.210 5.320.245
530 M-4-20-II
5.564.737 6.677.684 7.790.632
531 M-4-20-III
6.219.211 7.463.054 8.706.896
532 M-4-21-I
3.826.481 4.591.777 5.357.073
533 M-4-21-II
4.785.859 5.743.031 6.700.202
534 M-4-21-III
10.729.706 12.875.647 15.021.589
541 N-1-12-I
6.899.565 8.279.478 9.659.392
542 N-1-12-II
16.177.158 19.412.589 22.648.021
543 N-1-12-III
29.479.030 35.374.835 41.270.641
547 N-1-30-I
BAWAH RINGAN
11.256.005 13.507.205 15.758.406
548 N-1-30-II
BAWAH SEDANG
17.028.136 20.433.763 23.839.390
549 N-1-30-III
BAWAH BERAT
19.597.719 23.517.262 27.436.806
553 N-4-10-I
RINGAN
4.772.004 5.726.405 6.680.806
554 N-4-10-II
SEDANG
5.771.782 6.926.139 8.080.495
555 N-4-10-III
BERAT
11.469.497 13.763.397 16.057.296
565 N-4-14-I
3.311.253 3.973.504 4.635.755
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
566 N-4-14-II
4.698.460 5.638.152 6.577.844
567 N-4-14-III
7.620.100 9.144.120 10.668.141
568 N-4-15-I
URIN RINGAN
4.346.365 5.215.638 6.084.911
569 N-4-15-II
URIN SEDANG
5.393.116 6.471.739 7.550.362
570 N-4-15-III
URIN BERAT
6.154.513 7.385.416 8.616.318
571 N-4-16-I
(RINGAN)
4.789.929 5.747.915 6.705.900
572 N-4-16-II
(SEDANG)
7.361.988 8.834.386 10.306.783
573 N-4-16-III
(BERAT)
13.062.420 15.674.904 18.287.388
577 O-6-11-I
4.452.503 5.343.004 6.233.504
578 O-6-11-II
4.948.400 5.938.080 6.927.760
579 O-6-11-III
8.891.830 10.670.196 12.448.562
580 O-6-12-I
3.154.554 3.785.465 4.416.376
581 O-6-12-II
3.788.598 4.546.317 5.304.037
582 O-6-12-III
4.760.435 5.712.521 6.664.608
586 P-8-01-I
RINGAN
88.513.435 106.216.122 123.918.810
587 P-8-01-II
SEDANG
109.522.003 131.426.403 153.330.804
588 P-8-01-III
BERAT
128.548.077 154.257.692 179.967.307
589 P-8-02-I
105.110.394 126.132.473 147.154.552
590 P-8-02-II
120.572.198 144.686.638 168.801.078
591 P-8-02-III
137.762.284 165.314.741 192.867.197
592 P-8-03-I
5.931.928 7.118.314 8.304.699
593 P-8-03-II
8.304.699 9.965.639 11.626.579
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
594 P-8-03-III
11.557.708 13.869.250 16.180.792
595 P-8-04-I
47.785.906 57.343.087 66.900.269
596 P-8-04-II
62.015.803 74.418.964 86.822.125
597 P-8-04-III
88.915.052 106.698.063 124.481.073
598 P-8-05-I
25.984.426 31.181.312 36.378.197
599 P-8-05-II
36.829.421 44.195.306 51.561.190
600 P-8-05-III
54.263.208 65.115.850 75.968.492
601 P-8-06-I
5.144.343 6.173.212 7.202.081
602 P-8-06-II
9.545.298 11.454.357 13.363.417
603 P-8-06-III
18.586.807 22.304.168 26.021.529
604 P-8-07-I
8.304.699 9.965.639 11.626.579
605 P-8-07-II
23.284.378 27.941.254 32.598.129
606 P-8-07-III
30.846.026 37.015.232 43.184.437
607 P-8-08-I
4.805.134 5.766.161 6.727.187
608 P-8-08-II
6.818.257 8.181.908 9.545.559
609 P-8-08-III
12.470.432 14.964.519 17.458.605
610 P-8-10-I
3.367.911 4.041.493 4.715.075
611 P-8-10-II
5.301.133 6.361.359 7.421.586
612 P-8-10-III
10.408.285 12.489.942 14.571.599
613 P-8-11-I
RINGAN
8.429.128 10.114.953 11.800.779
614 P-8-11-II
SEDANG
17.960.694 21.552.833 25.144.972
615 P-8-11-III
BERAT
21.526.967 25.832.361 30.137.754
616 P-8-12-I
RINGAN
10.724.466 12.869.359 15.014.252
617 P-8-12-II
SEDANG
13.566.217 16.279.460 18.992.704
618 P-8-12-III
BERAT
14.358.126 17.229.751 20.101.376
619 P-8-13-I
RINGAN
2.696.235 3.235.481 3.774.728
620 P-8-13-II
SEDANG
6.680.076 8.016.091 9.352.106
621 P-8-13-III
BERAT
16.273.183 19.527.819 22.782.456
622 P-8-14-I
4.594.469 5.513.363 6.432.257
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
623 P-8-14-II
9.352.561 11.223.073 13.093.585
624 P-8-14-III
10.261.454 12.313.744 14.366.035
625 P-8-15-I
RINGAN
3.445.902 4.135.083 4.824.263
626 P-8-15-II
SEDANG
6.900.587 8.280.704 9.660.822
627 P-8-15-III
BERAT
8.096.653 9.715.984 11.335.315
628 P-8-16-I
3.118.626 3.742.351 4.366.076
629 P-8-16-II
6.447.864 7.737.437 9.027.010
630 P-8-16-III
16.935.567 20.322.680 23.709.793
631 P-8-17-I
RINGAN
2.288.354 2.746.025 3.203.695
632 P-8-17-II
SEDANG
5.949.522 7.139.426 8.329.330
633 P-8-17-III
BERAT
14.101.225 16.921.470 19.741.715
634 S-4-10-I
3.516.184 4.219.420 4.922.657
635 S-4-10-II
4.332.452 5.198.942 6.065.432
636 S-4-10-III
5.930.727 7.116.872 8.303.018
646 S-4-14-I
KANAK-KANAK RINGAN
2.146.622 2.575.947 3.005.271
647 S-4-14-II
KANAK-KANAK SEDANG
4.559.529 5.471.435 6.383.341
648 S-4-14-III
KANAK-KANAK BERAT
8.646.420 10.375.704 12.104.988
649 S-4-15-I
YANG LAIN (RINGAN)
1.623.587 1.948.305 2.273.022
650 S-4-15-II
YANG LAIN (SEDANG)
3.063.976 3.676.772 4.289.567
651 S-4-15-III
YANG LAIN (BERAT)
3.968.391 4.762.069 5.555.747
655 S-4-17-I
3.224.818 3.869.782 4.514.746
656 S-4-17-II
4.785.889 5.743.067 6.700.244
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
657 S-4-17-III
7.355.859 8.827.031 10.298.202
658 T-1-10-I
RINGAN
2.711.200 3.253.440 3.795.680
659 T-1-10-II
SEDANG
3.641.494 4.369.793 5.098.092
660 T-1-10-III
BERAT
6.624.427 7.949.313 9.274.198
661 T-4-10-I
1.484.656 1.781.588 2.078.519
662 T-4-10-II
2.829.019 3.394.823 3.960.627
663 T-4-10-III
4.112.089 4.934.507 5.756.925
664 T-4-11-I
1.433.835 1.720.602 2.007.369
665 T-4-11-II
2.256.451 2.707.742 3.159.032
666 T-4-11-III
3.634.482 4.361.379 5.088.275
667 T-4-12-I
LAIN (RINGAN)
3.359.551 4.031.461 4.703.371
668 T-4-12-II
LAIN (SEDANG)
5.071.653 6.085.983 7.100.314
669 T-4-12-III
LAIN (BERAT)
7.850.178 9.420.213 10.990.249
673 U-1-11-I
(RINGAN)
12.585.010 15.102.011 17.619.013
674 U-1-11-II
(SEDANG)
18.982.170 22.778.604 26.575.038
675 U-1-11-III
(BERAT)
28.738.314 34.485.977 40.233.640
682 U-1-14-I
MULUT (RINGAN)
5.125.531 6.150.637 7.175.743
683 U-1-14-II
MULUT (SEDANG)
6.290.256 7.548.307 8.806.358
684 U-1-14-III
MULUT (BERAT)
7.453.971 8.944.766 10.435.560
688 U-1-20-I
7.781.293 9.337.551 10.893.810
689 U-1-20-II
13.896.364 16.675.636 19.454.909
690 U-1-20-III
33.223.497 39.868.197 46.512.896
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
694 U-4-10-I
TELINGA RINGAN
6.220.781 7.464.937 8.709.093
695 U-4-10-II
TELINGA SEDANG
14.241.122 17.089.347 19.937.571
696 U-4-10-III
TELINGA BERAT
21.864.628 26.237.554 30.610.479
703 U-4-13-I
3.394.231 4.073.077 4.751.923
704 U-4-13-II
4.001.416 4.801.699 5.601.982
705 U-4-13-III
4.785.930 5.743.116 6.700.302
709 U-4-15-I
3.838.227 4.605.873 5.373.518
710 U-4-15-II
4.781.901 5.738.281 6.694.661
711 U-4-15-III
6.692.354 8.030.824 9.369.295
712 V-1-10-I
RINGAN
11.197.863 13.437.435 15.677.008
713 V-1-10-II
SEDANG
12.896.273 15.475.528 18.054.782
718 V-1-12-I
MODERAT (RINGAN)
6.260.411 7.512.493 8.764.575
719 V-1-12-II
MODERAT (SEDANG)
22.087.957 26.505.549 30.923.140
720 V-1-12-III
MODERAT (BERAT)
22.844.637 27.413.565 31.982.492
721 V-1-13-I
KOMPLEK (RINGAN)
9.491.561 11.389.873 13.288.185
722 V-1-13-II
KOMPLEK (SEDANG)
18.135.240 21.762.288 25.389.335
723 V-1-13-III
KOMPLEK (BERAT)
28.451.982 34.142.379 39.832.775
724 V-1-14-I
RINGAN
11.454.053 13.744.863 16.035.674
725 V-1-14-II
SEDANG
16.642.512 19.971.014 23.299.516
726 V-1-14-III
BERAT
20.771.567 24.925.880 29.080.194
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
4.786.009 5.743.210 6.700.412
734 V-4-11-II
TUMOR (SEDANG)
6.684.189 8.021.027 9.357.865
735 V-4-11-III
TUMOR (BERAT)
8.680.534 10.416.641 12.152.748
736 W-1-01-I
13.045.051 15.654.062 18.263.072
737 W-1-01-II
15.635.404 18.762.485 21.889.566
738 W-1-01-III
28.250.693 33.900.832 39.550.970
742 W-1-11-I
RINGAN
3.759.783 4.511.740 5.263.696
743 W-1-11-II
SEDANG
6.610.126 7.932.151 9.254.176
744 W-1-11-III
BERAT
13.919.063 16.702.875 19.486.688
745 W-1-12-I
3.425.225 4.110.269 4.795.314
746 W-1-12-II
3.883.534 4.660.241 5.436.947
747 W-1-12-III
5.965.899 7.159.079 8.352.259
748 W-1-13-I
RINGAN
4.157.719 4.989.262 5.820.806
749 W-1-13-II
SEDANG
4.513.900 5.416.680 6.319.460
763 W-4-12-I
3.832.661 4.599.193 5.365.725
764 W-4-12-II
5.261.943 6.314.332 7.366.721
765 W-4-12-III
5.735.728 6.882.873 8.030.019
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
787 Z-4-12-I
2.863.806 3.436.567 4.009.328
788 Z-4-12-II
5.750.123 6.900.147 8.050.172
789 Z-4-12-III
12.131.268 14.557.522 16.983.776
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 3.019.335
33 F-3-10-0 TERAPI SHOCK 592.009
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT 5.197.915
80 I-2-42-0
PERKUTAN LAIN 4.994.769
102 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 2.120.682
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
179 O-7-12-0
181 P-9-10-0
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN AKUT
LAIN 423.367
191 Q-5-12-0 GIGI 296.220
195 Q-5-16-0 VAKSINASI 215.077
196 Q-5-17-0 PASANG INFUS 205.173
200 Q-5-21-0 ABORSI 285.079
205 Q-5-26-0 BRONKIAL AKUT 458.077
210 Q-5-31-0 FRAKTUR 308.412
214 Q-5-35-0 INFEKSI AKUT 604.659
217 Q-5-38-0 PARU AKUT 480.813
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
231 U-2-21-0 PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 1.081.390
241 U-3-13-0
TENGGOROKAN 448.681
252 V-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI 1.520.491
255 W-2-11-0 PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM 1.005.381
269 Z-3-11-0
EMPEDU 3.416.935
276 Z-3-18-0 CT-SCAN KEPALA 583.543
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 177.786
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.965.601 2.358.722 2.751.842
8 A-4-12-II DEMAM SEDANG 3.108.907 3.730.688 4.352.469
9 A-4-12-III DEMAM BERAT 3.553.440 4.264.128 4.974.816
13 A-4-14-I
RINGAN
3.079.381 3.695.258 4.311.134
14 A-4-14-II
SEDANG
3.960.864 4.753.036 5.545.209
15 A-4-14-III
BERAT
4.538.218 5.445.861 6.353.505
28 B-1-12-I
RINGAN
6.812.024 8.174.429 9.536.834
29 B-1-12-II
SEDANG
14.599.834 17.519.801 20.439.768
30 B-1-12-III
BERAT
17.264.476 20.717.371 24.170.266
31 B-1-13-I
(RINGAN)
5.477.855 6.573.426 7.668.997
32 B-1-13-II
(SEDANG)
8.922.631 10.707.157 12.491.684
33 B-1-13-III
(BERAT)
13.154.462 15.785.354 18.416.247
34 B-1-14-I
RINGAN
7.409.482 8.891.379 10.373.275
35 B-1-14-II
SEDANG
8.240.840 9.889.008 11.537.176
36 B-1-14-III
BERAT
12.891.814 15.470.177 18.048.540
40 B-4-11-I
RINGAN
4.070.262 4.884.314 5.698.366
41 B-4-11-II
SEDANG
6.204.446 7.445.335 8.686.224
46 B-4-13-I
2.967.509 3.561.010 4.154.512
Rumah Sakit Kelas B
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
47 B-4-13-II
4.317.325 5.180.790 6.044.255
48 B-4-13-III
5.405.306 6.486.367 7.567.428
73 D-1-20-I
4.351.916 5.222.299 6.092.682
74 D-1-20-II
12.793.723 15.352.467 17.911.212
75 D-1-20-III
20.071.418 24.085.702 28.099.986
85 D-4-13-I
SEL SICKLE RINGAN
1.977.949 2.373.538 2.769.128
86 D-4-13-II
SEL SICKLE SEDANG
2.966.413 3.559.695 4.152.978
87 D-4-13-III
SEL SICKLE BERAT
4.093.988 4.912.786 5.731.584
88 D-4-14-I
2.458.116 2.949.739 3.441.363
89 D-4-14-II
4.406.963 5.288.356 6.169.749
90 D-4-14-III
6.179.524 7.415.429 8.651.334
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
5.896.004 7.075.204 8.254.405
98 E-1-20-II
TIROGLOSAL SEDANG
9.647.052 11.576.462 13.505.873
99 E-1-20-III
TIROGLOSAL BERAT
18.097.619 21.717.143 25.336.667
100 E-4-10-I
METABOLIK RINGAN
3.086.996 3.704.395 4.321.794
101 E-4-10-II
METABOLIK SEDANG
4.273.322 5.127.986 5.982.651
102 E-4-10-III
METABOLIK BERAT
6.519.627 7.823.552 9.127.478
130 F-4-16-I
GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL
RINGAN
5.819.628 6.983.553 8.147.479
131 F-4-16-II
SEDANG
6.762.694 8.115.233 9.467.771
132 F-4-16-III
BERAT
9.027.067 10.832.481 12.637.894
142 G-1-01-I
RINGAN
8.919.521 10.703.425 12.487.330
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
163 G-4-10-I
RINGAN
2.953.513 3.544.215 4.134.918
164 G-4-10-II
SEDANG
4.043.549 4.852.259 5.660.969
166 G-4-11-I
DEGENERATIF RINGAN
5.364.843 6.437.812 7.510.781
167 G-4-11-II
DEGENERATIF SEDANG
6.765.218 8.118.261 9.471.305
168 G-4-11-III
DEGENERATIF BERAT
8.678.812 10.414.575 12.150.337
172 G-4-13-I
RINGAN
2.729.393 3.275.272 3.821.151
173 G-4-13-II
SEDANG
3.785.827 4.542.993 5.300.158
174 G-4-13-III
BERAT
4.438.157 5.325.788 6.213.419
175 G-4-14-I
INFARK RINGAN
3.718.017 4.461.621 5.205.224
176 G-4-14-II
INFARK SEDANG
6.723.551 8.068.262 9.412.972
177 G-4-14-III
INFARK BERAT
8.407.354 10.088.825 11.770.296
178 G-4-15-I
2.898.060 3.477.672 4.057.284
179 G-4-15-II
3.458.848 4.150.617 4.842.387
180 G-4-15-III
4.937.948 5.925.538 6.913.127
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
2.989.072 3.586.886 4.184.701
188 G-4-18-II
PERSARAFAN SEDANG
5.716.640 6.859.967 8.003.295
189 G-4-18-III
PERSARAFAN BERAT
6.051.412 7.261.695 8.471.977
190 G-4-19-I
3.276.735 3.932.082 4.587.429
191 G-4-19-II
4.419.691 5.303.630 6.187.568
192 G-4-19-III
6.778.250 8.133.900 9.489.550
211 G-4-26-I
(RINGAN)
3.301.830 3.962.196 4.622.562
212 G-4-26-II
(SEDANG)
4.523.610 5.428.332 6.333.053
213 G-4-26-III
(BERAT)
5.432.671 6.519.205 7.605.739
229 I-1-01-I
RINGAN
41.491.472 49.789.767 58.088.061
230 I-1-01-II
SEDANG
42.404.501 50.885.401 59.366.301
231 I-1-01-III
BERAT
66.934.691 80.321.630 93.708.568
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
232 I-1-02-I
RINGAN
23.019.230 27.623.076 32.226.922
233 I-1-02-II
SEDANG
29.694.806 35.633.768 41.572.729
234 I-1-02-III
BERAT
36.600.575 43.920.690 51.240.805
235 I-1-03-I
14.154.333 16.985.200 19.816.067
236 I-1-03-II
16.139.783 19.367.740 22.595.696
237 I-1-03-III
26.699.616 32.039.539 37.379.463
238 I-1-04-I
JANTUNG RINGAN
23.030.837 27.637.004 32.243.171
239 I-1-04-II
JANTUNG SEDANG
54.915.459 65.898.550 76.881.642
240 I-1-04-III
JANTUNG BERAT
87.727.124 105.272.549 122.817.974
241 I-1-05-I
30.466.628 36.559.953 42.653.279
242 I-1-05-II
36.559.953 43.871.944 51.183.934
243 I-1-05-III
50.306.265 60.367.518 70.428.771
247 I-1-07-I
25.150.640 30.180.768 35.210.896
248 I-1-07-II
31.028.424 37.234.108 43.439.793
249 I-1-07-III
33.851.808 40.622.170 47.392.532
250 I-1-11-I
4.047.488 4.856.986 5.666.483
251 I-1-11-II
4.500.402 5.400.483 6.300.563
252 I-1-11-III
5.988.664 7.186.396 8.384.129
253 I-1-12-I
RINGAN
12.229.294 14.675.153 17.121.012
254 I-1-12-II
SEDANG
13.930.723 16.716.868 19.503.012
255 I-1-12-III
BERAT
22.527.648 27.033.177 31.538.707
256 I-1-13-I
RINGAN
12.890.384 15.468.461 18.046.538
257 I-1-13-II
SEDANG
15.641.230 18.769.476 21.897.722
258 I-1-13-III
BERAT
18.293.083 21.951.699 25.610.316
259 I-1-14-I
PERMANEN RINGAN
23.696.266 28.435.519 33.174.772
260 I-1-14-II
PERMANEN SEDANG
29.451.073 35.341.288 41.231.503
261 I-1-14-III
PERMANEN BERAT
38.591.062 46.309.274 54.027.486
265 I-1-16-I
(RINGAN)
10.155.543 12.186.651 14.217.760
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
266 I-1-16-II
(SEDANG)
26.404.411 31.685.293 36.966.175
267 I-1-16-III
(BERAT)
30.456.840 36.548.208 42.639.576
268 I-1-17-I
VENA RINGAN
25.648.969 30.778.763 35.908.557
269 I-1-17-II
VENA SEDANG
32.114.916 38.537.899 44.960.883
270 I-1-17-III
VENA BERAT
39.725.663 47.670.796 55.615.929
271 I-1-20-I
RINGAN
22.319.139 26.782.967 31.246.795
272 I-1-20-II
SEDANG
27.882.677 33.459.213 39.035.748
274 I-1-30-I
11.521.516 13.825.819 16.130.122
275 I-1-30-II
23.967.080 28.760.496 33.553.913
276 I-1-30-III
37.140.270 44.568.324 51.996.378
289 I-4-13-I
RINGAN
5.798.954 6.958.745 8.118.535
290 I-4-13-II
SEDANG
7.353.494 8.824.193 10.294.892
291 I-4-13-III
BERAT
13.385.021 16.062.026 18.739.030
295 I-4-15-I
(RINGAN)
3.954.190 4.745.028 5.535.866
296 I-4-15-II
(SEDANG)
5.675.131 6.810.158 7.945.184
297 I-4-15-III
(BERAT)
6.468.284 7.761.941 9.055.598
306 I-4-18-III
BERAT
8.861.121 10.633.345 12.405.569
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
319 I-4-23-I
2.367.557 2.841.069 3.314.580
320 I-4-23-II
2.906.815 3.488.178 4.069.541
321 I-4-23-III
5.679.651 6.815.581 7.951.511
322 I-4-24-I
(RINGAN)
3.177.747 3.813.297 4.448.846
323 I-4-24-II
(SEDANG)
7.936.805 9.524.166 11.111.527
324 I-4-24-III
(BERAT)
9.987.946 11.985.535 13.983.124
325 J-1-01-I
TRAKEOSTOMI RINGAN
30.296.842 36.356.210 42.415.578
326 J-1-01-II
TRAKEOSTOMI SEDANG
32.366.006 38.839.207 45.312.408
327 J-1-01-III
TRAKEOSTOMI BERAT
46.547.734 55.857.281 65.166.828
328 J-1-02-I
TRAKEOSTOMI RINGAN
13.062.707 15.675.249 18.287.790
329 J-1-02-II
TRAKEOSTOMI SEDANG
13.210.215 15.852.258 18.494.301
330 J-1-02-III
TRAKEOSTOMI BERAT
20.765.312 24.918.374 29.071.437
334 J-1-20-I
RINGAN
12.607.440 15.128.928 17.650.416
335 J-1-20-II
SEDANG
15.879.433 19.055.320 22.231.207
337 J-1-30-I
RINGAN
3.650.710 4.380.853 5.110.995
338 J-1-30-II
SEDANG
11.689.801 14.027.761 16.365.721
339 J-1-30-III
BERAT
34.901.463 41.881.755 48.862.048
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
2.310.904 2.773.085 3.235.266
374 J-4-21-II
LAIN-LAIN (SEDANG)
4.313.905 5.176.686 6.039.468
375 J-4-21-III
LAIN-LAIN (BERAT)
6.035.689 7.242.827 8.449.965
376 K-1-10-I
(RINGAN)
5.312.922 6.375.506 7.438.091
377 K-1-10-II
(SEDANG)
9.982.015 11.978.418 13.974.821
378 K-1-10-III
(BERAT)
11.680.421 14.016.506 16.352.590
382 K-1-12-I
FEMORAL (RINGAN)
3.309.910 3.971.892 4.633.874
383 K-1-12-II
FEMORAL (SEDANG)
4.302.384 5.162.861 6.023.337
384 K-1-12-III
FEMORAL (BERAT)
8.581.008 10.297.209 12.013.411
394 K-1-30-I
KOMPLEKS (RINGAN)
7.594.216 9.113.060 10.631.903
395 K-1-30-II
KOMPLEKS (SEDANG)
10.654.687 12.785.624 14.916.561
396 K-1-30-III
KOMPLEKS (BERAT)
19.604.250 23.525.100 27.445.950
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
412 K-4-13-I
3.128.517 3.754.221 4.379.924
413 K-4-13-II
4.009.196 4.811.035 5.612.874
414 K-4-13-III
6.239.634 7.487.561 8.735.488
415 K-4-14-I
RINGAN
2.481.678 2.978.014 3.474.350
416 K-4-14-II
SEDANG
3.331.256 3.997.508 4.663.759
417 K-4-14-III
BERAT
5.848.626 7.018.351 8.188.076
424 K-4-17-I
(RINGAN)
2.796.196 3.355.436 3.914.675
425 K-4-17-II
(SEDANG)
3.957.099 4.748.519 5.539.939
426 K-4-17-III
(BERAT)
4.463.617 5.356.340 6.249.063
430 L-1-20-I
RINGAN
27.098.323 32.517.988 37.937.652
431 L-1-20-II
SEDANG
27.927.333 33.512.800 39.098.267
432 L-1-20-III
BERAT
39.278.004 47.133.604 54.989.205
433 L-1-30-I
RINGAN
8.478.865 10.174.638 11.870.411
434 L-1-30-II
SEDANG
15.811.416 18.973.699 22.135.982
435 L-1-30-III
BERAT
18.779.728 22.535.674 26.291.620
436 L-1-40-I
PAYUDARA RINGAN
4.030.307 4.836.369 5.642.430
437 L-1-40-II
PAYUDARA SEDANG
8.690.603 10.428.723 12.166.844
438 L-1-40-III
PAYUDARA BERAT
14.866.233 17.839.479 20.812.726
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
451 L-4-13-I
PAYUDARA RINGAN
1.968.200 2.361.840 2.755.479
452 L-4-13-II
PAYUDARA SEDANG
2.631.170 3.157.404 3.683.638
453 L-4-13-III
PAYUDARA BERAT
3.473.198 4.167.837 4.862.477
454 L-4-14-I
(RINGAN)
2.278.130 2.733.756 3.189.382
455 L-4-14-II
(SEDANG)
3.385.445 4.062.534 4.739.623
456 L-4-14-III
(BERAT)
5.992.165 7.190.598 8.389.031
457 M-1-01-I
9.376.516 11.251.819 13.127.122
458 M-1-01-II
10.465.708 12.558.850 14.651.992
459 M-1-01-III
14.701.485 17.641.782 20.582.079
463 M-1-03-I
17.288.628 20.746.354 24.204.079
464 M-1-03-II
20.129.606 24.155.527 28.181.448
465 M-1-03-III
25.391.766 30.470.119 35.548.473
466 M-1-04-I
6.032.349 7.238.819 8.445.289
467 M-1-04-II
7.725.873 9.271.047 10.816.222
468 M-1-04-III
9.667.473 11.600.968 13.534.462
469 M-1-05-I
7.651.580 9.181.895 10.712.211
470 M-1-05-II
8.885.955 10.663.146 12.440.337
471 M-1-05-III
15.729.729 18.875.674 22.021.620
472 M-1-07-I
7.533.310 9.039.972 10.546.634
473 M-1-07-II
10.092.281 12.110.738 14.129.194
474 M-1-07-III
20.558.934 24.670.721 28.782.508
475 M-1-10-I
WAJAH RINGAN
18.597.009 22.316.411 26.035.813
476 M-1-10-II
WAJAH SEDANG
44.464.725 53.357.670 62.250.615
477 M-1-10-III
WAJAH BERAT
95.906.225 115.087.470 134.268.716
478 M-1-20-I
MAYOR RINGAN
6.413.389 7.696.067 8.978.745
479 M-1-20-II
MAYOR SEDANG
7.280.866 8.737.039 10.193.212
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
480 M-1-20-III
MAYOR BERAT
17.865.717 21.438.860 25.012.004
484 M-1-40-I
3.799.684 4.559.621 5.319.558
485 M-1-40-II
6.254.345 7.505.214 8.756.083
486 M-1-40-III
9.263.696 11.116.435 12.969.174
490 M-1-60-I
3.869.895 4.643.874 5.417.853
491 M-1-60-II
7.760.767 9.312.921 10.865.074
492 M-1-60-III
12.034.137 14.440.964 16.847.791
493 M-1-70-I
(RINGAN)
22.161.214 26.593.457 31.025.700
494 M-1-70-II
(SEDANG)
24.377.336 29.252.803 34.128.270
495 M-1-70-III
(BERAT)
26.815.069 32.178.083 37.541.097
502 M-4-11-I
RINGAN
3.512.685 4.215.221 4.917.758
503 M-4-11-II
SEDANG
6.532.889 7.839.467 9.146.044
504 M-4-11-III
BERAT
11.676.932 14.012.319 16.347.705
506 M-4-12-II
SEDANG
3.468.484 4.162.181 4.855.877
508 M-4-13-I
4.417.715 5.301.258 6.184.801
509 M-4-13-II
5.496.752 6.596.102 7.695.452
510 M-4-13-III
11.233.713 13.480.455 15.727.198
520 M-4-17-I
RINGAN
2.834.033 3.400.839 3.967.646
521 M-4-17-II
SEDANG
3.709.209 4.451.050 5.192.892
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
522 M-4-17-III
BERAT
5.111.577 6.133.892 7.156.207
526 M-4-19-I
2.894.009 3.472.810 4.051.612
527 M-4-19-II
4.623.310 5.547.972 6.472.634
528 M-4-19-III
7.382.193 8.858.632 10.335.070
529 M-4-20-I
2.074.625 2.489.549 2.904.474
530 M-4-20-II
2.964.992 3.557.990 4.150.988
531 M-4-20-III
3.283.175 3.939.810 4.596.445
532 M-4-21-I
2.068.185 2.481.822 2.895.459
533 M-4-21-II
3.463.451 4.156.141 4.848.832
534 M-4-21-III
5.857.679 7.029.215 8.200.751
541 N-1-12-I
3.766.604 4.519.925 5.273.245
542 N-1-12-II
12.498.846 14.998.615 17.498.384
543 N-1-12-III
22.704.959 27.245.951 31.786.943
547 N-1-30-I
BAWAH RINGAN
7.457.611 8.949.133 10.440.655
548 N-1-30-II
BAWAH SEDANG
11.146.760 13.376.112 15.605.463
549 N-1-30-III
BAWAH BERAT
11.705.693 14.046.832 16.387.971
553 N-4-10-I
RINGAN
3.028.708 3.634.450 4.240.192
554 N-4-10-II
SEDANG
4.081.765 4.898.118 5.714.471
555 N-4-10-III
BERAT
7.141.128 8.569.353 9.997.579
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
565 N-4-14-I
1.725.075 2.070.091 2.415.106
566 N-4-14-II
2.565.241 3.078.290 3.591.338
567 N-4-14-III
4.160.004 4.992.005 5.824.005
568 N-4-15-I
URIN RINGAN
2.776.381 3.331.657 3.886.933
569 N-4-15-II
URIN SEDANG
3.798.071 4.557.686 5.317.300
570 N-4-15-III
URIN BERAT
4.334.285 5.201.142 6.067.999
571 N-4-16-I
(RINGAN)
3.344.031 4.012.837 4.681.644
572 N-4-16-II
(SEDANG)
4.019.004 4.822.805 5.626.606
573 N-4-16-III
(BERAT)
7.154.383 8.585.259 10.016.136
577 O-6-11-I
2.521.397 3.025.676 3.529.955
578 O-6-11-II
3.565.853 4.279.024 4.992.195
579 O-6-11-III
6.055.515 7.266.617 8.477.720
580 O-6-12-I
2.428.425 2.914.111 3.399.796
581 O-6-12-II
2.916.533 3.499.840 4.083.146
582 O-6-12-III
3.808.348 4.570.017 5.331.687
586 P-8-01-I
RINGAN
48.322.870 57.987.444 67.652.018
587 P-8-01-II
SEDANG
59.791.993 71.750.392 83.708.790
588 P-8-01-III
BERAT
70.179.038 84.214.846 98.250.654
589 P-8-02-I
77.966.649 93.559.979 109.153.309
590 P-8-02-II
89.435.772 107.322.926 125.210.081
591 P-8-02-III
102.186.764 122.624.117 143.061.470
592 P-8-03-I
2.701.825 3.242.190 3.782.555
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
593 P-8-03-II
4.026.871 4.832.245 5.637.619
594 P-8-03-III
7.318.342 8.782.011 10.245.679
595 P-8-04-I
32.533.993 39.040.791 45.547.590
596 P-8-04-II
42.057.744 50.469.292 58.880.841
597 P-8-04-III
60.300.218 72.360.262 84.420.306
598 P-8-05-I
17.666.081 21.199.297 24.732.513
599 P-8-05-II
25.030.397 30.036.476 35.042.555
600 P-8-05-III
36.755.588 44.106.706 51.457.824
601 P-8-06-I
2.994.129 3.592.954 4.191.780
602 P-8-06-II
6.501.073 7.801.287 9.101.502
603 P-8-06-III
11.872.207 14.246.648 16.621.089
604 P-8-07-I
4.681.795 5.618.155 6.554.514
605 P-8-07-II
11.585.715 13.902.858 16.220.001
606 P-8-07-III
15.574.790 18.689.749 21.804.707
607 P-8-08-I
3.876.141 4.651.369 5.426.598
608 P-8-08-II
5.500.060 6.600.072 7.700.084
609 P-8-08-III
8.905.808 10.686.970 12.468.131
610 P-8-10-I
2.293.114 2.751.736 3.210.359
611 P-8-10-II
3.932.341 4.718.809 5.505.277
612 P-8-10-III
7.720.344 9.264.413 10.808.481
613 P-8-11-I
RINGAN
2.767.842 3.321.411 3.874.979
614 P-8-11-II
SEDANG
13.732.649 16.479.178 19.225.708
615 P-8-11-III
BERAT
14.020.350 16.824.420 19.628.490
616 P-8-12-I
RINGAN
3.733.948 4.480.738 5.227.528
617 P-8-12-II
SEDANG
5.813.807 6.976.568 8.139.329
618 P-8-12-III
BERAT
6.852.092 8.222.510 9.592.928
619 P-8-13-I
RINGAN
2.174.963 2.609.955 3.044.948
620 P-8-13-II
SEDANG
5.344.061 6.412.873 7.481.685
621 P-8-13-III
BERAT
13.018.546 15.622.256 18.225.965
622 P-8-14-I
3.517.659 4.221.190 4.924.722
623 P-8-14-II
7.200.011 8.640.014 10.080.016
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
624 P-8-14-III
7.908.828 9.490.594 11.072.360
625 P-8-15-I
RINGAN
2.651.854 3.182.225 3.712.596
626 P-8-15-II
SEDANG
5.304.453 6.365.344 7.426.235
627 P-8-15-III
BERAT
6.218.479 7.462.175 8.705.871
628 P-8-16-I
2.406.043 2.887.252 3.368.460
629 P-8-16-II
5.158.291 6.189.950 7.221.608
630 P-8-16-III
13.548.453 16.258.144 18.967.835
631 P-8-17-I
RINGAN
1.845.939 2.215.126 2.584.314
632 P-8-17-II
SEDANG
4.799.281 5.759.137 6.718.993
633 P-8-17-III
BERAT
9.070.848 10.885.018 12.699.188
634 S-4-10-I
1.919.566 2.303.480 2.687.393
635 S-4-10-II
2.471.168 2.965.401 3.459.635
636 S-4-10-III
3.214.526 3.857.432 4.500.337
646 S-4-14-I
KANAK-KANAK RINGAN
1.171.791 1.406.149 1.640.508
647 S-4-14-II
KANAK-KANAK SEDANG
2.489.278 2.987.133 3.484.989
648 S-4-14-III
KANAK-KANAK BERAT
4.720.557 5.664.669 6.608.780
649 S-4-15-I
YANG LAIN (RINGAN)
886.236 1.063.484 1.240.731
650 S-4-15-II
YANG LAIN (SEDANG)
1.672.630 2.007.156 2.341.682
651 S-4-15-III
YANG LAIN (BERAT)
2.166.445 2.599.734 3.033.023
655 S-4-17-I
2.002.811 2.403.373 2.803.935
656 S-4-17-II
2.886.866 3.464.239 4.041.612
657 S-4-17-III
4.015.736 4.818.884 5.622.031
658 T-1-10-I
RINGAN
2.087.119 2.504.543 2.921.967
659 T-1-10-II
SEDANG
2.802.860 3.363.431 3.924.003
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
660 T-1-10-III
BERAT
5.099.315 6.119.178 7.139.041
661 T-4-10-I
810.362 972.435 1.134.507
662 T-4-10-II
1.544.371 1.853.245 2.162.119
663 T-4-10-III
2.245.096 2.694.115 3.143.135
664 T-4-11-I
1.105.938 1.327.126 1.548.314
665 T-4-11-II
1.740.432 2.088.518 2.436.605
666 T-4-11-III
2.803.323 3.363.988 3.924.653
667 T-4-12-I
LAIN (RINGAN)
1.822.029 2.186.434 2.550.840
668 T-4-12-II
LAIN (SEDANG)
2.714.870 3.257.844 3.800.818
669 T-4-12-III
LAIN (BERAT)
4.165.314 4.998.376 5.831.439
673 U-1-11-I
(RINGAN)
6.309.270 7.571.124 8.832.978
674 U-1-11-II
(SEDANG)
8.632.451 10.358.941 12.085.431
675 U-1-11-III
(BERAT)
19.611.827 23.534.193 27.456.558
682 U-1-14-I
MULUT (RINGAN)
3.953.778 4.744.534 5.535.289
683 U-1-14-II
MULUT (SEDANG)
4.852.081 5.822.497 6.792.913
684 U-1-14-III
MULUT (BERAT)
5.749.853 6.899.823 8.049.794
688 U-1-20-I
6.005.368 7.206.442 8.407.515
689 U-1-20-II
8.790.999 10.549.199 12.307.399
690 U-1-20-III
15.903.830 19.084.596 22.265.363
694 U-4-10-I
TELINGA RINGAN
4.796.663 5.755.996 6.715.328
695 U-4-10-II
TELINGA SEDANG
11.392.898 13.671.478 15.950.057
696 U-4-10-III
TELINGA BERAT
14.204.550 17.045.460 19.886.370
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
703 U-4-13-I
1.975.174 2.370.209 2.765.243
704 U-4-13-II
2.252.479 2.702.975 3.153.471
705 U-4-13-III
2.880.663 3.456.796 4.032.928
709 U-4-15-I
2.130.224 2.556.269 2.982.314
710 U-4-15-II
2.792.250 3.350.700 3.909.150
711 U-4-15-III
3.797.787 4.557.344 5.316.902
712 V-1-10-I
RINGAN
6.570.401 7.884.481 9.198.562
713 V-1-10-II
SEDANG
7.408.202 8.889.843 10.371.483
718 V-1-12-I
MODERAT (RINGAN)
4.830.199 5.796.238 6.762.278
719 V-1-12-II
MODERAT (SEDANG)
12.045.687 14.454.825 16.863.962
720 V-1-12-III
MODERAT (BERAT)
12.471.711 14.966.053 17.460.395
721 V-1-13-I
KOMPLEK (RINGAN)
7.334.319 8.801.183 10.268.047
722 V-1-13-II
KOMPLEK (SEDANG)
10.432.721 12.519.265 14.605.809
723 V-1-13-III
KOMPLEK (BERAT)
12.934.597 15.521.517 18.108.436
724 V-1-14-I
RINGAN
7.806.539 9.367.847 10.929.154
725 V-1-14-II
SEDANG
10.426.125 12.511.349 14.596.574
726 V-1-14-III
BERAT
14.175.014 17.010.017 19.845.020
733 V-4-11-I
TUMOR (RINGAN)
2.724.585 3.269.502 3.814.419
734 V-4-11-II
TUMOR (SEDANG)
3.825.248 4.590.298 5.355.348
735 V-4-11-III
TUMOR (BERAT)
6.703.338 8.044.006 9.384.673
736 W-1-01-I
9.988.517 11.986.220 13.983.924
737 W-1-01-II
11.202.042 13.442.450 15.682.858
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
738 W-1-01-III
17.736.636 21.283.963 24.831.290
742 W-1-11-I
RINGAN
3.032.892 3.639.470 4.246.048
743 W-1-11-II
SEDANG
5.332.168 6.398.602 7.465.035
744 W-1-11-III
BERAT
11.228.044 13.473.653 15.719.262
745 W-1-12-I
2.638.903 3.166.683 3.694.464
746 W-1-12-II
2.983.586 3.580.303 4.177.020
747 W-1-12-III
4.583.164 5.499.797 6.416.430
748 W-1-13-I
RINGAN
2.269.869 2.723.843 3.177.817
749 W-1-13-II
SEDANG
2.464.424 2.957.309 3.450.194
763 W-4-12-I
1.977.100 2.372.520 2.767.941
764 W-4-12-II
3.198.965 3.838.758 4.478.550
765 W-4-12-III
4.068.439 4.882.127 5.695.815
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
787 Z-4-12-I
1.537.471 1.844.965 2.152.460
788 Z-4-12-II
3.993.775 4.792.530 5.591.285
789 Z-4-12-III
5.161.898 6.194.277 7.226.657
24 D-2-11-0 PROSEDUR LIMPA 1.319.419
33 F-3-10-0 TERAPI SHOCK 258.444
Rumah Sakit Kelas B
Rawat Jalan
Rumah Sakit Kelas B
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT
2.271.437
80 I-2-42-0
PERKUTAN LAIN
2.167.167
Rumah Sakit Kelas B
Rawat Jalan
Rumah Sakit Kelas B
Rawat Jalan
179 O-7-12-0
1.457.055
191 Q-5-12-0 GIGI 129.664
195 Q-5-16-0 VAKSINASI 103.365
196 Q-5-17-0 PASANG INFUS 89.231
200 Q-5-21-0 ABORSI 101.487
205 Q-5-26-0 BRONKIAL AKUT 200.200
210 Q-5-31-0 FRAKTUR 135.653
214 Q-5-35-0 INFEKSI AKUT 263.125
217 Q-5-38-0 PARU AKUT 209.232
Rumah Sakit Kelas B
Rawat Jalan
241 U-3-13-0
TENGGOROKAN
195.454
269 Z-3-11-0
EMPEDU
1.493.166
276 Z-3-18-0 CT-SCAN KEPALA 255.002
Rumah Sakit Kelas B
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 77.587
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.570.939 1.885.127 2.199.315
8 A-4-12-II DEMAM SEDANG 2.006.611 2.407.934 2.809.256
9 A-4-12-III DEMAM BERAT 2.141.753 2.570.104 2.998.454
13 A-4-14-I
RINGAN
2.799.438 3.359.325 3.919.213
14 A-4-14-II
SEDANG
3.600.785 4.320.942 5.041.099
15 A-4-14-III
BERAT
4.125.652 4.950.783 5.775.913
28 B-1-12-I
RINGAN
5.449.619 6.539.543 7.629.467
29 B-1-12-II
SEDANG
11.679.867 14.015.841 16.351.814
30 B-1-12-III
BERAT
13.811.581 16.573.897 19.336.213
31 B-1-13-I
(RINGAN)
4.382.284 5.258.741 6.135.198
32 B-1-13-II
(SEDANG)
7.138.105 8.565.726 9.993.347
33 B-1-13-III
(BERAT)
10.523.570 12.628.284 14.732.997
34 B-1-14-I
RINGAN
5.927.586 7.113.103 8.298.620
35 B-1-14-II
SEDANG
6.592.672 7.911.206 9.229.741
36 B-1-14-III
BERAT
10.313.451 12.376.142 14.438.832
40 B-4-11-I
RINGAN
2.827.481 3.392.977 3.958.473
41 B-4-11-II
SEDANG
4.238.197 5.085.836 5.933.475
46 B-4-13-I
2.353.600 2.824.320 3.295.040
Rumah Sakit Kelas C
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
47 B-4-13-II
3.563.894 4.276.673 4.989.452
48 B-4-13-III
4.430.774 5.316.929 6.203.084
73 D-1-20-I
3.567.302 4.280.762 4.994.222
74 D-1-20-II
9.490.845 11.389.014 13.287.182
75 D-1-20-III
16.452.709 19.743.250 23.033.792
85 D-4-13-I
SEL SICKLE RINGAN
1.566.068 1.879.282 2.192.495
86 D-4-13-II
SEL SICKLE SEDANG
2.346.712 2.816.055 3.285.397
87 D-4-13-III
SEL SICKLE BERAT
2.741.616 3.289.939 3.838.262
88 D-4-14-I
1.890.446 2.268.535 2.646.624
89 D-4-14-II
3.612.425 4.334.910 5.057.394
90 D-4-14-III
5.065.408 6.078.489 7.091.571
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.833.003 5.799.604 6.766.205
98 E-1-20-II
TIROGLOSAL SEDANG
7.710.074 9.252.089 10.794.104
99 E-1-20-III
TIROGLOSAL BERAT
13.900.295 16.680.354 19.460.413
100 E-4-10-I
METABOLIK RINGAN
1.960.379 2.352.454 2.744.530
101 E-4-10-II
METABOLIK SEDANG
3.418.658 4.102.389 4.786.121
102 E-4-10-III
METABOLIK BERAT
4.333.129 5.199.755 6.066.381
130 F-4-16-I
RINGAN
4.655.702 5.586.843 6.517.983
131 F-4-16-II
SEDANG
5.410.155 6.492.186 7.574.217
132 F-4-16-III
BERAT
7.221.654 8.665.985 10.110.316
142 G-1-01-I
RINGAN
7.274.849 8.729.818 10.184.788
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
163 G-4-10-I
RINGAN
2.355.425 2.826.510 3.297.595
164 G-4-10-II
SEDANG
2.735.486 3.282.584 3.829.681
166 G-4-11-I
DEGENERATIF RINGAN
3.331.520 3.997.824 4.664.128
167 G-4-11-II
DEGENERATIF SEDANG
5.412.174 6.494.609 7.577.044
168 G-4-11-III
DEGENERATIF BERAT
6.580.538 7.896.645 9.212.753
172 G-4-13-I
RINGAN
2.183.515 2.620.218 3.056.920
173 G-4-13-II
SEDANG
2.733.837 3.280.604 3.827.371
174 G-4-13-III
BERAT
3.249.543 3.899.451 4.549.360
175 G-4-14-I
INFARK RINGAN
2.956.259 3.547.511 4.138.763
176 G-4-14-II
INFARK SEDANG
5.378.841 6.454.609 7.530.378
177 G-4-14-III
INFARK BERAT
6.725.884 8.071.060 9.416.237
178 G-4-15-I
2.375.564 2.850.677 3.325.789
179 G-4-15-II
2.835.246 3.402.295 3.969.345
180 G-4-15-III
3.685.690 4.422.828 5.159.966
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
2.348.360 2.818.032 3.287.704
188 G-4-18-II
PERSARAFAN SEDANG
4.573.312 5.487.974 6.402.636
189 G-4-18-III
PERSARAFAN BERAT
4.841.130 5.809.356 6.777.582
190 G-4-19-I
2.621.388 3.145.666 3.669.943
191 G-4-19-II
3.622.858 4.347.429 5.072.001
192 G-4-19-III
4.554.252 5.465.103 6.375.953
211 G-4-26-I
(RINGAN)
2.354.688 2.825.625 3.296.563
212 G-4-26-II
(SEDANG)
2.732.240 3.278.688 3.825.136
213 G-4-26-III
(BERAT)
4.011.897 4.814.276 5.616.655
229 I-1-01-I
RINGAN
33.840.851 40.609.021 47.377.191
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
230 I-1-01-II
SEDANG
34.585.526 41.502.631 48.419.736
231 I-1-01-III
BERAT
54.592.589 65.511.107 76.429.625
232 I-1-02-I
RINGAN
18.774.709 22.529.651 26.284.593
233 I-1-02-II
SEDANG
24.219.375 29.063.249 33.907.124
234 I-1-02-III
BERAT
29.851.787 35.822.145 41.792.502
235 I-1-03-I
11.544.413 13.853.295 16.162.178
236 I-1-03-II
13.229.914 15.875.897 18.521.880
237 I-1-03-III
21.885.898 26.263.077 30.640.257
238 I-1-04-I
JANTUNG RINGAN
17.978.878 21.574.653 25.170.429
239 I-1-04-II
JANTUNG SEDANG
18.424.669 22.109.603 25.794.537
240 I-1-04-III
JANTUNG BERAT
42.746.087 51.295.304 59.844.522
241 I-1-05-I
24.848.880 29.818.655 34.788.431
242 I-1-05-II
29.818.655 35.782.387 41.746.118
243 I-1-05-III
41.030.282 49.236.338 57.442.394
247 I-1-07-I
20.120.512 24.144.614 28.168.717
248 I-1-07-II
24.822.739 29.787.287 34.751.834
249 I-1-07-III
27.081.447 32.497.736 37.914.025
250 I-1-11-I
3.237.991 3.885.589 4.533.187
251 I-1-11-II
3.600.322 4.320.386 5.040.450
252 I-1-11-III
4.790.931 5.749.117 6.707.303
253 I-1-12-I
RINGAN
8.971.887 10.766.264 12.560.641
254 I-1-12-II
SEDANG
10.195.651 12.234.782 14.273.912
255 I-1-12-III
BERAT
17.358.134 20.829.761 24.301.388
256 I-1-13-I
RINGAN
4.281.977 5.138.373 5.994.768
257 I-1-13-II
SEDANG
6.133.586 7.360.303 8.587.020
258 I-1-13-III
BERAT
14.634.466 17.561.359 20.488.253
259 I-1-14-I
PERMANEN RINGAN
19.326.906 23.192.288 27.057.669
260 I-1-14-II
PERMANEN SEDANG
24.020.584 28.824.700 33.628.817
261 I-1-14-III
PERMANEN BERAT
31.475.247 37.770.297 44.065.346
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
265 I-1-16-I
(RINGAN)
8.282.960 9.939.552 11.596.144
266 I-1-16-II
(SEDANG)
21.535.696 25.842.835 30.149.974
267 I-1-16-III
(BERAT)
24.840.896 29.809.076 34.777.255
268 I-1-17-I
VENA RINGAN
11.677.037 14.012.444 16.347.851
269 I-1-17-II
VENA SEDANG
15.161.429 18.193.714 21.226.000
270 I-1-17-III
VENA BERAT
31.780.531 38.136.637 44.492.743
271 I-1-20-I
RINGAN
10.361.081 12.433.297 14.505.513
272 I-1-20-II
SEDANG
13.101.233 15.721.479 18.341.726
274 I-1-30-I
9.397.061 11.276.473 13.155.885
275 I-1-30-II
19.547.785 23.457.342 27.366.899
276 I-1-30-III
30.291.967 36.350.361 42.408.754
289 I-4-13-I
RINGAN
4.639.163 5.566.996 6.494.828
290 I-4-13-II
SEDANG
5.882.795 7.059.354 8.235.913
291 I-4-13-III
BERAT
10.203.787 12.244.544 14.285.301
295 I-4-15-I
(RINGAN)
3.132.184 3.758.620 4.385.057
296 I-4-15-II
(SEDANG)
4.489.134 5.386.961 6.284.788
297 I-4-15-III
(BERAT)
5.116.533 6.139.839 7.163.146
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
306 I-4-18-III
BERAT
6.371.521 7.645.826 8.920.130
319 I-4-23-I
1.931.003 2.317.204 2.703.404
320 I-4-23-II
2.370.827 2.844.992 3.319.157
321 I-4-23-III
4.632.379 5.558.855 6.485.331
322 I-4-24-I
(RINGAN)
2.305.156 2.766.187 3.227.218
323 I-4-24-II
(SEDANG)
6.349.444 7.619.333 8.889.221
324 I-4-24-III
(BERAT)
7.990.357 9.588.428 11.186.499
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.874.276 22.649.131 26.423.986
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.561.280 24.673.537 28.785.793
327 J-1-01-III
TRAKEOSTOMI BERAT
37.238.187 44.685.825 52.133.462
328 J-1-02-I
TRAKEOSTOMI RINGAN
8.849.264 10.619.117 12.388.970
329 J-1-02-II
TRAKEOSTOMI SEDANG
10.178.812 12.214.574 14.250.336
330 J-1-02-III
TRAKEOSTOMI BERAT
16.612.249 19.934.699 23.257.149
334 J-1-20-I
RINGAN
5.812.761 6.975.314 8.137.866
335 J-1-20-II
SEDANG
7.680.593 9.216.711 10.752.830
337 J-1-30-I
RINGAN
2.920.568 3.504.682 4.088.796
338 J-1-30-II
SEDANG
9.582.227 11.498.672 13.415.118
339 J-1-30-III
BERAT
25.827.587 30.993.105 36.158.622
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.562.770 1.875.325 2.187.879
374 J-4-21-II
LAIN-LAIN (SEDANG)
3.162.608 3.795.129 4.427.651
375 J-4-21-III
LAIN-LAIN (BERAT)
4.487.272 5.384.726 6.282.180
376 K-1-10-I
(RINGAN)
4.225.174 5.070.209 5.915.244
377 K-1-10-II
(SEDANG)
7.985.612 9.582.734 11.179.857
378 K-1-10-III
(BERAT)
9.344.337 11.213.204 13.082.072
382 K-1-12-I
FEMORAL (RINGAN)
2.647.928 3.177.514 3.707.099
383 K-1-12-II
FEMORAL (SEDANG)
3.441.907 4.130.289 4.818.670
384 K-1-12-III
FEMORAL (BERAT)
6.864.806 8.237.768 9.610.729
394 K-1-30-I
KOMPLEKS (RINGAN)
6.075.373 7.290.448 8.505.522
395 K-1-30-II
KOMPLEKS (SEDANG)
8.439.340 10.127.208 11.815.076
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
15.683.400 18.820.080 21.956.760
412 K-4-13-I
2.352.489 2.822.987 3.293.485
413 K-4-13-II
3.040.406 3.648.487 4.256.568
414 K-4-13-III
4.986.813 5.984.176 6.981.538
415 K-4-14-I
RINGAN
1.963.054 2.355.664 2.748.275
416 K-4-14-II
SEDANG
2.656.931 3.188.317 3.719.703
417 K-4-14-III
BERAT
4.003.130 4.803.755 5.604.381
424 K-4-17-I
(RINGAN)
2.541.997 3.050.396 3.558.795
425 K-4-17-II
(SEDANG)
3.597.363 4.316.836 5.036.308
426 K-4-17-III
(BERAT)
4.057.833 4.869.400 5.680.967
430 L-1-20-I
RINGAN
21.678.658 26.014.390 30.350.122
431 L-1-20-II
SEDANG
22.341.867 26.810.240 31.278.613
432 L-1-20-III
BERAT
33.577.718 40.293.261 47.008.805
433 L-1-30-I
RINGAN
6.950.196 8.340.236 9.730.275
434 L-1-30-II
SEDANG
12.649.133 15.178.959 17.708.786
435 L-1-30-III
BERAT
15.023.783 18.028.539 21.033.296
436 L-1-40-I
PAYUDARA RINGAN
3.303.676 3.964.412 4.625.147
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
437 L-1-40-II
PAYUDARA SEDANG
7.007.926 8.409.511 9.811.096
438 L-1-40-III
PAYUDARA BERAT
11.898.216 14.277.860 16.657.503
451 L-4-13-I
PAYUDARA RINGAN
1.476.215 1.771.458 2.066.701
452 L-4-13-II
PAYUDARA SEDANG
2.104.936 2.525.924 2.946.911
453 L-4-13-III
PAYUDARA BERAT
2.548.073 3.057.688 3.567.303
454 L-4-14-I
(RINGAN)
1.565.692 1.878.831 2.191.969
455 L-4-14-II
(SEDANG)
2.349.864 2.819.837 3.289.809
456 L-4-14-III
(BERAT)
4.793.732 5.752.479 6.711.225
457 M-1-01-I
7.647.578 9.177.093 10.706.609
458 M-1-01-II
8.535.934 10.243.121 11.950.308
459 M-1-01-III
11.990.675 14.388.810 16.786.945
463 M-1-03-I
13.748.599 16.498.318 19.248.038
464 M-1-03-II
15.998.219 19.197.863 22.397.507
465 M-1-03-III
16.338.866 19.606.639 22.874.412
466 M-1-04-I
4.825.879 5.791.055 6.756.231
467 M-1-04-II
6.180.698 7.416.838 8.652.977
468 M-1-04-III
7.733.979 9.280.774 10.827.570
469 M-1-05-I
6.121.264 7.345.516 8.569.769
470 M-1-05-II
7.108.764 8.530.517 9.952.269
471 M-1-05-III
12.583.783 15.100.540 17.617.296
472 M-1-07-I
6.144.241 7.373.090 8.601.938
473 M-1-07-II
8.231.363 9.877.636 11.523.909
474 M-1-07-III
16.768.068 20.121.681 23.475.295
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
475 M-1-10-I
WAJAH RINGAN
5.201.761 6.242.113 7.282.465
476 M-1-10-II
WAJAH SEDANG
12.799.687 15.359.624 17.919.562
477 M-1-10-III
WAJAH BERAT
17.445.434 20.934.521 24.423.608
478 M-1-20-I
MAYOR RINGAN
5.130.711 6.156.853 7.182.996
479 M-1-20-II
MAYOR SEDANG
5.420.745 6.504.894 7.589.043
480 M-1-20-III
MAYOR BERAT
14.292.573 17.151.088 20.009.603
484 M-1-40-I
2.983.293 3.579.951 4.176.610
485 M-1-40-II
5.478.048 6.573.658 7.669.268
486 M-1-40-III
8.881.320 10.657.584 12.433.848
490 M-1-60-I
2.973.924 3.568.709 4.163.493
491 M-1-60-II
5.978.564 7.174.277 8.369.989
492 M-1-60-III
9.864.482 11.837.378 13.810.275
493 M-1-70-I
(RINGAN)
9.201.378 11.041.653 12.881.929
494 M-1-70-II
(SEDANG)
11.539.610 13.847.532 16.155.454
495 M-1-70-III
(BERAT)
12.144.223 14.573.067 17.001.912
502 M-4-11-I
RINGAN
2.079.029 2.494.835 2.910.640
503 M-4-11-II
SEDANG
4.757.400 5.708.880 6.660.360
504 M-4-11-III
BERAT
9.341.546 11.209.855 13.078.164
506 M-4-12-II
SEDANG
2.843.145 3.411.774 3.980.403
508 M-4-13-I
3.534.172 4.241.007 4.947.841
509 M-4-13-II
3.904.014 4.684.816 5.465.619
510 M-4-13-III
8.609.824 10.331.789 12.053.753
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
520 M-4-17-I
RINGAN
1.954.818 2.345.781 2.736.745
521 M-4-17-II
SEDANG
2.749.186 3.299.024 3.848.861
522 M-4-17-III
BERAT
3.841.363 4.609.636 5.377.909
526 M-4-19-I
2.315.207 2.778.248 3.241.290
527 M-4-19-II
3.698.648 4.438.378 5.178.108
528 M-4-19-III
5.618.277 6.741.932 7.865.588
529 M-4-20-I
1.564.540 1.877.448 2.190.356
530 M-4-20-II
2.353.232 2.823.879 3.294.525
531 M-4-20-III
2.602.187 3.122.624 3.643.062
532 M-4-21-I
1.561.468 1.873.762 2.186.056
533 M-4-21-II
2.051.701 2.462.041 2.872.381
534 M-4-21-III
4.801.588 5.761.906 6.722.224
541 N-1-12-I
3.087.517 3.705.020 4.322.523
542 N-1-12-II
9.999.076 11.998.892 13.998.707
543 N-1-12-III
18.163.967 21.796.761 25.429.554
547 N-1-30-I
BAWAH RINGAN
5.966.088 7.159.306 8.352.524
548 N-1-30-II
BAWAH SEDANG
7.766.528 9.319.833 10.873.139
549 N-1-30-III
BAWAH BERAT
8.923.587 10.708.304 12.493.021
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
553 N-4-10-I
RINGAN
1.957.932 2.349.518 2.741.104
554 N-4-10-II
SEDANG
3.265.412 3.918.495 4.571.577
555 N-4-10-III
BERAT
4.368.390 5.242.067 6.115.745
565 N-4-14-I
1.355.445 1.626.534 1.897.623
566 N-4-14-II
2.092.236 2.510.683 2.929.130
567 N-4-14-III
3.392.940 4.071.528 4.750.116
568 N-4-15-I
URIN RINGAN
1.945.147 2.334.177 2.723.206
569 N-4-15-II
URIN SEDANG
2.413.419 2.896.103 3.378.787
570 N-4-15-III
URIN BERAT
2.754.147 3.304.976 3.855.806
571 N-4-16-I
(RINGAN)
2.617.779 3.141.335 3.664.891
572 N-4-16-II
(SEDANG)
3.129.691 3.755.629 4.381.567
573 N-4-16-III
(BERAT)
5.344.268 6.413.122 7.481.976
577 O-6-11-I
2.066.810 2.480.172 2.893.534
578 O-6-11-II
2.745.811 3.294.973 3.844.135
579 O-6-11-III
4.662.922 5.595.506 6.528.091
580 O-6-12-I
1.942.740 2.331.288 2.719.837
581 O-6-12-II
2.333.226 2.799.872 3.266.517
582 O-6-12-III
3.046.678 3.656.014 4.265.349
586 P-8-01-I
RINGAN
39.412.606 47.295.127 55.177.648
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
587 P-8-01-II
SEDANG
48.766.934 58.520.321 68.273.708
588 P-8-01-III
BERAT
57.238.710 68.686.452 80.134.194
589 P-8-02-I
62.373.319 74.847.983 87.322.647
590 P-8-02-II
71.548.618 85.858.341 100.168.065
591 P-8-02-III
81.749.411 98.099.294 114.449.176
592 P-8-03-I
2.145.929 2.575.115 3.004.300
593 P-8-03-II
3.010.919 3.613.103 4.215.287
594 P-8-03-III
4.742.378 5.690.854 6.639.330
595 P-8-04-I
19.272.950 23.127.540 26.982.130
596 P-8-04-II
33.646.195 40.375.434 47.104.673
597 P-8-04-III
48.240.175 57.888.210 67.536.244
598 P-8-05-I
14.132.865 16.959.438 19.786.011
599 P-8-05-II
20.024.317 24.029.181 28.034.044
600 P-8-05-III
29.404.471 35.285.365 41.166.259
601 P-8-06-I
2.110.708 2.532.850 2.954.992
602 P-8-06-II
5.200.858 6.241.030 7.281.201
603 P-8-06-III
8.317.732 9.981.279 11.644.825
604 P-8-07-I
3.020.769 3.624.923 4.229.077
605 P-8-07-II
8.451.650 10.141.980 11.832.310
606 P-8-07-III
11.161.147 13.393.376 15.625.605
607 P-8-08-I
3.523.765 4.228.518 4.933.271
608 P-8-08-II
5.000.055 6.000.066 7.000.077
609 P-8-08-III
8.096.189 9.715.427 11.334.665
610 P-8-10-I
1.834.491 2.201.389 2.568.287
611 P-8-10-II
3.145.873 3.775.047 4.404.222
612 P-8-10-III
6.176.275 7.411.530 8.646.785
613 P-8-11-I
RINGAN
2.196.743 2.636.091 3.075.440
614 P-8-11-II
SEDANG
10.986.119 13.183.343 15.380.566
615 P-8-11-III
BERAT
11.216.280 13.459.536 15.702.792
616 P-8-12-I
RINGAN
2.987.159 3.584.591 4.182.022
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
617 P-8-12-II
SEDANG
4.651.045 5.581.254 6.511.463
618 P-8-12-III
BERAT
5.481.673 6.578.008 7.674.343
619 P-8-13-I
RINGAN
1.977.239 2.372.686 2.768.134
620 P-8-13-II
SEDANG
3.418.856 4.102.627 4.786.398
621 P-8-13-III
BERAT
5.089.387 6.107.265 7.125.142
622 P-8-14-I
2.089.460 2.507.351 2.925.243
623 P-8-14-II
5.760.009 6.912.011 8.064.013
624 P-8-14-III
6.327.063 7.592.475 8.857.888
625 P-8-15-I
RINGAN
2.121.483 2.545.780 2.970.077
626 P-8-15-II
SEDANG
4.243.563 5.092.275 5.940.988
627 P-8-15-III
BERAT
4.974.783 5.969.740 6.964.696
628 P-8-16-I
1.924.834 2.309.801 2.694.768
629 P-8-16-II
2.616.767 3.140.121 3.663.474
630 P-8-16-III
2.721.773 3.266.128 3.810.483
631 P-8-17-I
RINGAN
1.678.126 2.013.751 2.349.377
632 P-8-17-II
SEDANG
4.362.983 5.235.579 6.108.176
633 P-8-17-III
BERAT
8.246.226 9.895.471 11.544.716
634 S-4-10-I
1.565.617 1.878.740 2.191.864
635 S-4-10-II
1.958.694 2.350.433 2.742.172
636 S-4-10-III
2.547.324 3.056.789 3.566.254
646 S-4-14-I
KANAK-KANAK RINGAN
955.724 1.146.869 1.338.014
647 S-4-14-II
KANAK-KANAK SEDANG
2.030.279 2.436.335 2.842.391
648 S-4-14-III
KANAK-KANAK BERAT
3.850.133 4.620.159 5.390.186
649 S-4-15-I
YANG LAIN (RINGAN)
722.823 867.388 1.011.952
650 S-4-15-II
YANG LAIN (SEDANG)
1.364.213 1.637.056 1.909.899
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
651 S-4-15-III
YANG LAIN (BERAT)
1.766.973 2.120.368 2.473.763
655 S-4-17-I
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK TOKSIK
LAIN-LAIN RINGAN
1.461.131 1.753.357 2.045.584
656 S-4-17-II
LAIN-LAIN SEDANG
1.957.258 2.348.709 2.740.161
657 S-4-17-III
LAIN-LAIN BERAT
3.199.564 3.839.477 4.479.390
658 T-1-10-I
RINGAN
1.669.695 2.003.634 2.337.574
659 T-1-10-II
SEDANG
2.242.288 2.690.745 3.139.203
660 T-1-10-III
BERAT
4.079.452 4.895.343 5.711.233
661 T-4-10-I
660.939 793.127 925.315
662 T-4-10-II
1.259.604 1.511.525 1.763.446
663 T-4-10-III
1.831.122 2.197.347 2.563.571
664 T-4-11-I
884.751 1.061.701 1.238.651
665 T-4-11-II
1.392.346 1.670.815 1.949.284
666 T-4-11-III
2.242.659 2.691.190 3.139.722
667 T-4-12-I
LAIN (RINGAN)
1.374.841 1.649.809 1.924.777
668 T-4-12-II
LAIN (SEDANG)
2.078.024 2.493.629 2.909.234
669 T-4-12-III
LAIN (BERAT)
3.216.982 3.860.378 4.503.774
673 U-1-11-I
(RINGAN)
5.171.761 6.206.113 7.240.466
674 U-1-11-II
(SEDANG)
6.858.366 8.230.039 9.601.712
675 U-1-11-III
(BERAT)
12.860.783 15.432.939 18.005.096
682 U-1-14-I
MULUT (RINGAN)
3.163.023 3.795.627 4.428.232
683 U-1-14-II
MULUT (SEDANG)
3.881.665 4.657.998 5.434.331
684 U-1-14-III
MULUT (BERAT)
4.599.882 5.519.858 6.439.835
688 U-1-20-I
4.804.294 5.765.153 6.726.012
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
689 U-1-20-II
6.305.298 7.566.358 8.827.418
690 U-1-20-III
12.666.672 15.200.007 17.733.341
694 U-4-10-I
TELINGA RINGAN
3.837.330 4.604.797 5.372.263
695 U-4-10-II
TELINGA SEDANG
6.372.922 7.647.507 8.922.091
696 U-4-10-III
TELINGA BERAT
9.784.527 11.741.433 13.698.338
703 U-4-13-I
1.537.854 1.845.425 2.152.996
704 U-4-13-II
1.794.801 2.153.761 2.512.722
705 U-4-13-III
2.030.721 2.436.865 2.843.009
709 U-4-15-I
1.570.448 1.884.538 2.198.627
710 U-4-15-II
1.963.790 2.356.548 2.749.306
711 U-4-15-III
2.745.591 3.294.709 3.843.827
712 V-1-10-I
RINGAN
4.594.197 5.513.036 6.431.876
713 V-1-10-II
SEDANG
5.273.940 6.328.728 7.383.516
718 V-1-12-I
MODERAT (RINGAN)
3.864.159 4.636.991 5.409.822
719 V-1-12-II
MODERAT (SEDANG)
8.893.094 10.671.713 12.450.332
720 V-1-12-III
MODERAT (BERAT)
10.223.165 12.267.798 14.312.431
721 V-1-13-I
KOMPLEK (RINGAN)
5.620.689 6.744.826 7.868.964
722 V-1-13-II
KOMPLEK (SEDANG)
8.551.788 10.262.146 11.972.503
723 V-1-13-III
KOMPLEK (BERAT)
11.860.532 14.232.639 16.604.745
724 V-1-14-I
RINGAN
6.245.231 7.494.277 8.743.324
725 V-1-14-II
SEDANG
7.592.544 9.111.053 10.629.561
726 V-1-14-III
BERAT
9.295.502 11.154.602 13.013.702
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
2.010.028 2.412.034 2.814.040
734 V-4-11-II
TUMOR (SEDANG)
2.931.775 3.518.130 4.104.485
735 V-4-11-III
TUMOR (BERAT)
5.362.670 6.435.205 7.507.739
736 W-1-01-I
7.990.814 9.588.976 11.187.139
737 W-1-01-II
8.961.633 10.753.960 12.546.287
738 W-1-01-III
12.642.494 15.170.993 17.699.491
742 W-1-11-I
RINGAN
2.757.174 3.308.609 3.860.044
743 W-1-11-II
SEDANG
4.847.425 5.816.910 6.786.396
744 W-1-11-III
BERAT
10.207.313 12.248.775 14.290.238
745 W-1-12-I
2.111.122 2.533.346 2.955.571
746 W-1-12-II
2.386.869 2.864.242 3.341.616
747 W-1-12-III
3.666.531 4.399.837 5.133.144
748 W-1-13-I
RINGAN
1.851.328 2.221.593 2.591.859
749 W-1-13-II
SEDANG
2.010.008 2.412.010 2.814.012
763 W-4-12-I
1.566.871 1.880.246 2.193.620
764 W-4-12-II
2.150.219 2.580.262 3.010.306
765 W-4-12-III
3.254.751 3.905.701 4.556.652
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
787 Z-4-12-I
1.176.648 1.411.978 1.647.308
788 Z-4-12-II
3.195.020 3.834.024 4.473.028
789 Z-4-12-III
4.129.518 4.955.422 5.781.325
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.276.216
31 E-2-22-0
PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL
180.166
33 F-3-10-0 TERAPI SHOCK 250.454
Rumah Sakit Kelas C
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT
2.197.061
80 I-2-42-0
PERKUTAN LAIN
2.117.600
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
179 O-7-12-0
1.165.644
181 P-9-10-0
LAIN
178.949
191 Q-5-12-0 GIGI 125.274
195 Q-5-16-0 VAKSINASI 100.089
196 Q-5-17-0 PASANG INFUS 86.309
200 Q-5-21-0 ABORSI 81.190
205 Q-5-26-0 BRONKIAL AKUT 193.514
210 Q-5-31-0 FRAKTUR 131.060
214 Q-5-35-0 INFEKSI AKUT 255.087
217 Q-5-38-0 PARU AKUT 202.841
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
238 U-3-10-0
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
196.065
241 U-3-13-0
TENGGOROKAN
189.460
269 Z-3-11-0
EMPEDU
1.444.274
276 Z-3-18-0 CT-SCAN KEPALA 246.653
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 75.145
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.310.458 1.572.550 1.834.642
8 A-4-12-II DEMAM SEDANG 1.691.237 2.029.484 2.367.731
9 A-4-12-III DEMAM BERAT 2.093.961 2.512.753 2.931.545
13 A-4-14-I
RINGAN
2.544.943 3.053.932 3.562.921
14 A-4-14-II
SEDANG
3.273.441 3.928.129 4.582.817
15 A-4-14-III
BERAT
3.750.593 4.500.712 5.250.830
28 B-1-12-I
RINGAN
4.005.334 4.806.401 5.607.468
29 B-1-12-II
SEDANG
8.584.411 10.301.293 12.018.175
30 B-1-12-III
BERAT
10.447.552 12.537.062 14.626.572
31 B-1-13-I
(RINGAN)
3.228.603 3.874.324 4.520.045
32 B-1-13-II
(SEDANG)
5.258.926 6.310.711 7.362.497
33 B-1-13-III
(BERAT)
7.753.133 9.303.759 10.854.386
34 B-1-14-I
RINGAN
4.381.896 5.258.275 6.134.655
35 B-1-14-II
SEDANG
4.873.553 5.848.263 6.822.974
36 B-1-14-III
BERAT
7.624.094 9.148.913 10.673.732
40 B-4-11-I
RINGAN
2.383.092 2.859.710 3.336.329
41 B-4-11-II
SEDANG
3.572.088 4.286.506 5.000.924
46 B-4-13-I
1.961.526 2.353.831 2.746.136
Rumah Sakit Kelas D
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
47 B-4-13-II
2.538.181 3.045.818 3.553.454
48 B-4-13-III
3.734.399 4.481.279 5.228.159
73 D-1-20-I
3.006.636 3.607.964 4.209.291
74 D-1-20-II
8.662.105 10.394.526 12.126.948
75 D-1-20-III
13.866.872 16.640.247 19.413.621
85 D-4-13-I
SEL SICKLE RINGAN
1.312.168 1.574.602 1.837.035
86 D-4-13-II
SEL SICKLE SEDANG
1.967.364 2.360.837 2.754.309
87 D-4-13-III
SEL SICKLE BERAT
2.413.096 2.895.715 3.378.334
88 D-4-14-I
1.641.905 1.970.286 2.298.668
89 D-4-14-II
3.044.668 3.653.601 4.262.535
90 D-4-14-III
4.269.288 5.123.146 5.977.004
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.073.411 4.888.093 5.702.775
98 E-1-20-II
TIROGLOSAL SEDANG
5.931.780 7.118.137 8.304.493
99 E-1-20-III
TIROGLOSAL BERAT
9.845.056 11.814.067 13.783.078
100 E-4-10-I
METABOLIK RINGAN
1.815.323 2.178.388 2.541.452
101 E-4-10-II
METABOLIK SEDANG
2.789.959 3.347.951 3.905.943
102 E-4-10-III
METABOLIK BERAT
3.865.140 4.638.168 5.411.196
130 F-4-16-I
RINGAN
3.447.373 4.136.848 4.826.322
131 F-4-16-II
SEDANG
3.993.397 4.792.077 5.590.756
132 F-4-16-III
BERAT
5.330.519 6.396.622 7.462.726
142 G-1-01-I
RINGAN
6.069.854 7.283.824 8.497.795
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE RINGAN 716.685 860.022 1.003.359
163 G-4-10-I
RINGAN
1.960.098 2.352.118 2.744.138
164 G-4-10-II
SEDANG
2.389.700 2.867.640 3.345.580
166 G-4-11-I
DEGENERATIF RINGAN
3.144.862 3.773.834 4.402.807
167 G-4-11-II
DEGENERATIF SEDANG
4.510.343 5.412.411 6.314.480
168 G-4-11-III
DEGENERATIF BERAT
5.995.988 7.195.185 8.394.383
172 G-4-13-I
RINGAN
1.609.990 1.931.989 2.253.987
173 G-4-13-II
SEDANG
2.288.597 2.746.316 3.204.035
174 G-4-13-III
BERAT
2.707.339 3.248.806 3.790.274
175 G-4-14-I
INFARK RINGAN
2.568.691 3.082.429 3.596.167
176 G-4-14-II
INFARK SEDANG
3.968.368 4.762.042 5.555.715
177 G-4-14-III
INFARK BERAT
4.962.181 5.954.617 6.947.053
178 G-4-15-I
1.962.158 2.354.589 2.747.021
179 G-4-15-II
2.389.637 2.867.564 3.345.491
180 G-4-15-III
3.078.682 3.694.418 4.310.155
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
1.959.252 2.351.102 2.742.952
188 G-4-18-II
PERSARAFAN SEDANG
3.359.437 4.031.325 4.703.212
189 G-4-18-III
PERSARAFAN BERAT
3.566.418 4.279.701 4.992.985
190 G-4-19-I
1.958.204 2.349.845 2.741.485
191 G-4-19-II
3.053.461 3.664.153 4.274.846
192 G-4-19-III
3.838.470 4.606.165 5.373.859
211 G-4-26-I
(RINGAN)
2.281.157 2.737.388 3.193.620
212 G-4-26-II
(SEDANG)
2.668.347 3.202.016 3.735.686
213 G-4-26-III
(BERAT)
3.381.356 4.057.627 4.733.898
229 I-1-01-I
RINGAN
28.235.503 33.882.603 39.529.704
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
230 I-1-01-II
SEDANG
28.856.831 34.628.197 40.399.563
231 I-1-01-III
BERAT
45.549.954 54.659.945 63.769.936
232 I-1-02-I
RINGAN
15.664.894 18.797.873 21.930.852
233 I-1-02-II
SEDANG
20.207.714 24.249.256 28.290.799
234 I-1-02-III
BERAT
24.907.182 29.888.618 34.870.055
235 I-1-03-I
9.681.108 11.617.330 13.553.551
236 I-1-03-II
11.150.597 13.380.717 15.610.836
237 I-1-03-III
18.446.139 22.135.366 25.824.594
238 I-1-04-I
JANTUNG RINGAN
14.081.646 16.897.976 19.714.305
239 I-1-04-II
JANTUNG SEDANG
15.153.177 18.183.812 21.214.447
240 I-1-04-III
JANTUNG BERAT
31.425.363 37.710.436 43.995.508
241 I-1-05-I
20.732.948 24.879.538 29.026.128
242 I-1-05-II
24.879.538 29.855.446 34.831.353
243 I-1-05-III
34.234.087 41.080.905 47.927.722
247 I-1-07-I
15.377.749 18.453.298 21.528.848
248 I-1-07-II
18.971.577 22.765.892 26.560.208
249 I-1-07-III
20.697.867 24.837.441 28.977.014
250 I-1-11-I
2.379.842 2.855.811 3.331.779
251 I-1-11-II
2.646.147 3.175.376 3.704.605
252 I-1-11-III
3.521.215 4.225.458 4.929.700
253 I-1-12-I
RINGAN
7.519.550 9.023.460 10.527.370
254 I-1-12-II
SEDANG
8.593.223 10.311.868 12.030.512
255 I-1-12-III
BERAT
14.552.175 17.462.610 20.373.045
256 I-1-13-I
RINGAN
3.730.299 4.476.358 5.222.418
257 I-1-13-II
SEDANG
5.136.231 6.163.478 7.190.724
258 I-1-13-III
BERAT
11.184.862 13.421.834 15.658.806
259 I-1-14-I
PERMANEN RINGAN
16.125.626 19.350.752 22.575.877
260 I-1-14-II
PERMANEN SEDANG
20.041.850 24.050.220 28.058.590
261 I-1-14-III
PERMANEN BERAT
26.261.734 31.514.081 36.766.428
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
265 I-1-16-I
(RINGAN)
6.910.983 8.293.179 9.675.376
266 I-1-16-II
(SEDANG)
17.968.555 21.562.266 25.155.977
267 I-1-16-III
(BERAT)
20.726.287 24.871.545 29.016.802
268 I-1-17-I
VENA RINGAN
2.649.278 3.179.134 3.708.990
269 I-1-17-II
VENA SEDANG
4.468.963 5.362.756 6.256.549
270 I-1-17-III
VENA BERAT
26.026.634 31.231.961 36.437.288
271 I-1-20-I
RINGAN
3.212.519 3.855.023 4.497.526
272 I-1-20-II
SEDANG
5.316.931 6.380.317 7.443.703
274 I-1-30-I
7.840.546 9.408.655 10.976.764
275 I-1-30-II
16.309.919 19.571.903 22.833.887
276 I-1-30-III
25.274.451 30.329.341 35.384.232
289 I-4-13-I
RINGAN
3.418.829 4.102.595 4.786.361
290 I-4-13-II
SEDANG
4.978.749 5.974.499 6.970.249
291 I-4-13-III
BERAT
8.507.606 10.209.127 11.910.648
295 I-4-15-I
(RINGAN)
2.625.074 3.150.089 3.675.104
296 I-4-15-II
(SEDANG)
3.920.815 4.704.978 5.489.141
297 I-4-15-III
(BERAT)
4.468.786 5.362.543 6.256.300
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
306 I-4-18-III
BERAT
5.370.123 6.444.148 7.518.173
319 I-4-23-I
1.611.154 1.933.385 2.255.616
320 I-4-23-II
1.978.126 2.373.752 2.769.377
321 I-4-23-III
3.865.079 4.638.094 5.411.110
322 I-4-24-I
(RINGAN)
1.942.859 2.331.431 2.720.003
323 I-4-24-II
(SEDANG)
4.665.659 5.598.791 6.531.923
324 I-4-24-III
(BERAT)
5.921.652 7.105.982 8.290.313
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.524.269 22.229.123 25.933.976
326 J-1-01-II
TRAKEOSTOMI SEDANG
19.789.409 23.747.291 27.705.173
327 J-1-01-III
TRAKEOSTOMI BERAT
27.531.581 33.037.898 38.544.214
328 J-1-02-I
TRAKEOSTOMI RINGAN
7.458.445 8.950.134 10.441.823
329 J-1-02-II
TRAKEOSTOMI SEDANG
9.126.628 10.951.953 12.777.279
330 J-1-02-III
TRAKEOSTOMI BERAT
12.268.532 14.722.238 17.175.944
334 J-1-20-I
RINGAN
3.195.211 3.834.253 4.473.295
335 J-1-20-II
SEDANG
3.941.907 4.730.289 5.518.670
337 J-1-30-I
RINGAN
2.154.536 2.585.443 3.016.350
338 J-1-30-II
SEDANG
8.076.209 9.691.451 11.306.693
339 J-1-30-III
BERAT
21.656.689 25.988.027 30.319.365
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.404.963 1.685.956 1.966.949
374 J-4-21-II
LAIN-LAIN (SEDANG)
2.623.570 3.148.285 3.672.999
375 J-4-21-III
LAIN-LAIN (BERAT)
3.757.773 4.509.328 5.260.882
376 K-1-10-I
(RINGAN)
3.539.221 4.247.065 4.954.909
377 K-1-10-II
(SEDANG)
5.869.226 7.043.071 8.216.916
378 K-1-10-III
(BERAT)
6.883.891 8.260.669 9.637.447
382 K-1-12-I
FEMORAL (RINGAN)
1.954.743 2.345.692 2.736.640
383 K-1-12-II
FEMORAL (SEDANG)
2.545.527 3.054.632 3.563.737
384 K-1-12-III
FEMORAL (BERAT)
5.062.836 6.075.403 7.087.970
394 K-1-30-I
KOMPLEKS (RINGAN)
4.590.833 5.508.999 6.427.166
395 K-1-30-II
KOMPLEKS (SEDANG)
7.071.593 8.485.911 9.900.230
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
13.137.793 15.765.352 18.392.910
412 K-4-13-I
1.960.965 2.353.158 2.745.351
413 K-4-13-II
2.548.155 3.057.786 3.567.417
414 K-4-13-III
4.159.938 4.991.926 5.823.914
415 K-4-14-I
RINGAN
1.637.379 1.964.855 2.292.331
416 K-4-14-II
SEDANG
2.220.935 2.665.122 3.109.309
417 K-4-14-III
BERAT
3.576.000 4.291.200 5.006.400
424 K-4-17-I
(RINGAN)
2.310.906 2.773.087 3.235.268
425 K-4-17-II
(SEDANG)
3.270.330 3.924.396 4.578.462
426 K-4-17-III
(BERAT)
3.688.939 4.426.727 5.164.515
430 L-1-20-I
RINGAN
15.986.981 19.184.377 22.381.773
431 L-1-20-II
SEDANG
16.619.620 19.943.544 23.267.467
432 L-1-20-III
BERAT
28.099.669 33.719.602 39.339.536
433 L-1-30-I
RINGAN
5.857.849 7.029.419 8.200.989
434 L-1-30-II
SEDANG
10.541.406 12.649.687 14.757.968
435 L-1-30-III
BERAT
11.131.945 13.358.334 15.584.723
436 L-1-40-I
PAYUDARA RINGAN
2.784.445 3.341.334 3.898.223
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
437 L-1-40-II
PAYUDARA SEDANG
4.881.409 5.857.691 6.833.973
438 L-1-40-III
PAYUDARA BERAT
8.262.227 9.914.673 11.567.118
451 L-4-13-I
PAYUDARA RINGAN
1.359.783 1.631.740 1.903.696
452 L-4-13-II
PAYUDARA SEDANG
1.699.656 2.039.587 2.379.518
453 L-4-13-III
PAYUDARA BERAT
2.399.551 2.879.461 3.359.371
454 L-4-14-I
(RINGAN)
1.348.512 1.618.215 1.887.917
455 L-4-14-II
(SEDANG)
1.999.403 2.399.284 2.799.164
456 L-4-14-III
(BERAT)
3.684.463 4.421.356 5.158.249
457 M-1-01-I
6.380.845 7.657.013 8.933.182
458 M-1-01-II
7.122.055 8.546.466 9.970.877
459 M-1-01-III
10.004.557 12.005.469 14.006.380
463 M-1-03-I
11.450.628 13.740.754 16.030.879
464 M-1-03-II
13.403.193 16.083.832 18.764.471
465 M-1-03-III
15.525.179 18.630.215 21.735.251
466 M-1-04-I
3.562.633 4.275.160 4.987.686
467 M-1-04-II
4.581.461 5.497.753 6.414.045
468 M-1-04-III
5.732.834 6.879.401 8.025.968
469 M-1-05-I
4.527.373 5.432.848 6.338.322
470 M-1-05-II
5.224.764 6.269.717 7.314.670
471 M-1-05-III
8.899.196 10.679.035 12.458.875
472 M-1-07-I
5.126.518 6.151.822 7.177.126
473 M-1-07-II
6.867.933 8.241.519 9.615.106
474 M-1-07-III
13.990.630 16.788.756 19.586.882
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
475 M-1-10-I
WAJAH RINGAN
3.842.401 4.610.881 5.379.361
476 M-1-10-II
WAJAH SEDANG
10.787.988 12.945.585 15.103.183
477 M-1-10-III
WAJAH BERAT
15.895.755 19.074.906 22.254.057
478 M-1-20-I
MAYOR RINGAN
3.791.287 4.549.544 5.307.801
479 M-1-20-II
MAYOR SEDANG
4.306.413 5.167.695 6.028.978
480 M-1-20-III
MAYOR BERAT
10.506.023 12.607.228 14.708.433
484 M-1-40-I
2.245.578 2.694.694 3.143.809
485 M-1-40-II
3.688.642 4.426.370 5.164.098
486 M-1-40-III
6.175.506 7.410.608 8.645.709
490 M-1-60-I
2.297.642 2.757.171 3.216.699
491 M-1-60-II
4.598.020 5.517.624 6.437.228
492 M-1-60-III
7.981.539 9.577.846 11.174.154
493 M-1-70-I
(RINGAN)
3.072.965 3.687.558 4.302.151
494 M-1-70-II
(SEDANG)
6.265.443 7.518.531 8.771.620
495 M-1-70-III
(BERAT)
8.762.532 10.515.039 12.267.545
502 M-4-11-I
RINGAN
2.068.472 2.482.166 2.895.861
503 M-4-11-II
SEDANG
4.029.839 4.835.807 5.641.775
504 M-4-11-III
BERAT
6.865.803 8.238.964 9.612.124
506 M-4-12-II
SEDANG
2.384.313 2.861.175 3.338.038
508 M-4-13-I
2.899.491 3.479.389 4.059.287
509 M-4-13-II
3.278.353 3.934.024 4.589.695
510 M-4-13-III
7.761.109 9.313.330 10.865.552
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
520 M-4-17-I
RINGAN
1.668.843 2.002.611 2.336.380
521 M-4-17-II
SEDANG
2.289.518 2.747.422 3.205.325
522 M-4-17-III
BERAT
3.210.912 3.853.094 4.495.276
526 M-4-19-I
1.703.586 2.044.303 2.385.021
527 M-4-19-II
2.869.385 3.443.262 4.017.138
528 M-4-19-III
4.909.036 5.890.843 6.872.650
529 M-4-20-I
1.311.478 1.573.774 1.836.069
530 M-4-20-II
1.962.392 2.354.870 2.747.348
531 M-4-20-III
2.181.478 2.617.774 3.054.070
532 M-4-21-I
1.307.103 1.568.524 1.829.944
533 M-4-21-II
2.038.534 2.446.241 2.853.948
534 M-4-21-III
4.046.933 4.856.320 5.665.706
541 N-1-12-I
2.602.258 3.122.710 3.643.162
542 N-1-12-II
7.363.994 8.836.792 10.309.591
543 N-1-12-III
13.419.225 16.103.070 18.786.915
547 N-1-30-I
BAWAH RINGAN
5.100.765 6.120.918 7.141.071
548 N-1-30-II
BAWAH SEDANG
7.701.035 9.241.242 10.781.449
549 N-1-30-III
BAWAH BERAT
8.087.189 9.704.627 11.322.065
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
553 N-4-10-I
RINGAN
1.793.226 2.151.871 2.510.516
554 N-4-10-II
SEDANG
2.622.596 3.147.115 3.671.635
555 N-4-10-III
BERAT
4.197.274 5.036.729 5.876.184
565 N-4-14-I
1.134.694 1.361.632 1.588.571
566 N-4-14-II
1.745.681 2.094.817 2.443.954
567 N-4-14-III
2.830.938 3.397.126 3.963.314
568 N-4-15-I
URIN RINGAN
1.639.433 1.967.319 2.295.206
569 N-4-15-II
URIN SEDANG
2.257.859 2.709.431 3.161.003
570 N-4-15-III
URIN BERAT
2.576.625 3.091.950 3.607.275
571 N-4-16-I
(RINGAN)
2.021.524 2.425.828 2.830.133
572 N-4-16-II
(SEDANG)
2.623.921 3.148.705 3.673.489
573 N-4-16-III
(BERAT)
4.504.321 5.405.186 6.306.050
577 O-6-11-I
1.741.974 2.090.369 2.438.763
578 O-6-11-II
2.108.960 2.530.753 2.952.545
579 O-6-11-III
3.570.862 4.285.034 4.999.206
580 O-6-12-I
1.427.866 1.713.439 1.999.012
581 O-6-12-II
1.714.863 2.057.836 2.400.808
582 O-6-12-III
2.154.480 2.585.376 3.016.272
586 P-8-01-I
RINGAN
32.884.361 39.461.233 46.038.105
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
587 P-8-01-II
SEDANG
40.689.252 48.827.103 56.964.953
588 P-8-01-III
BERAT
47.757.776 57.309.331 66.860.886
589 P-8-02-I
47.670.817 57.204.980 66.739.143
590 P-8-02-II
54.683.333 65.620.000 76.556.667
591 P-8-02-III
62.479.618 74.975.542 87.471.466
592 P-8-03-I
1.797.064 2.156.477 2.515.889
593 P-8-03-II
2.518.902 3.022.682 3.526.463
594 P-8-03-III
4.338.655 5.206.387 6.074.118
595 P-8-04-I
19.124.315 22.949.178 26.774.041
596 P-8-04-II
24.953.280 29.943.936 34.934.593
597 P-8-04-III
35.776.723 42.932.068 50.087.412
598 P-8-05-I
10.418.972 12.502.766 14.586.560
599 P-8-05-II
14.805.973 17.767.168 20.728.362
600 P-8-05-III
21.814.614 26.177.537 30.540.459
601 P-8-06-I
1.799.659 2.159.590 2.519.522
602 P-8-06-II
4.317.352 5.180.822 6.044.293
603 P-8-06-III
7.921.811 9.506.173 11.090.535
604 P-8-07-I
2.770.178 3.324.213 3.878.249
605 P-8-07-II
7.047.810 8.457.373 9.866.935
606 P-8-07-III
9.340.960 11.209.152 13.077.344
607 P-8-08-I
3.203.423 3.844.107 4.484.792
608 P-8-08-II
4.545.504 5.454.605 6.363.706
609 P-8-08-III
7.360.172 8.832.206 10.304.241
610 P-8-10-I
1.357.215 1.628.658 1.900.101
611 P-8-10-II
2.404.334 2.885.201 3.366.068
612 P-8-10-III
4.720.417 5.664.500 6.608.584
613 P-8-11-I
RINGAN
1.837.021 2.204.425 2.571.829
614 P-8-11-II
SEDANG
8.097.667 9.717.200 11.336.734
615 P-8-11-III
BERAT
8.267.314 9.920.777 11.574.240
616 P-8-12-I
RINGAN
2.204.721 2.645.665 3.086.610
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
617 P-8-12-II
SEDANG
3.428.200 4.113.840 4.799.480
618 P-8-12-III
BERAT
4.052.508 4.863.010 5.673.512
619 P-8-13-I
RINGAN
1.797.490 2.156.988 2.516.486
620 P-8-13-II
SEDANG
3.108.051 3.729.661 4.351.271
621 P-8-13-III
BERAT
4.626.716 5.552.059 6.477.402
622 P-8-14-I
2.078.055 2.493.666 2.909.277
623 P-8-14-II
4.237.128 5.084.553 5.931.979
624 P-8-14-III
4.648.215 5.577.858 6.507.501
625 P-8-15-I
RINGAN
1.567.839 1.881.407 2.194.975
626 P-8-15-II
SEDANG
3.123.343 3.748.011 4.372.680
627 P-8-15-III
BERAT
3.666.821 4.400.186 5.133.550
628 P-8-16-I
1.419.256 1.703.107 1.986.958
629 P-8-16-II
2.006.169 2.407.403 2.808.637
630 P-8-16-III
2.602.759 3.123.310 3.643.862
631 P-8-17-I
RINGAN
1.525.569 1.830.683 2.135.797
632 P-8-17-II
SEDANG
3.966.348 4.759.617 5.552.887
633 P-8-17-III
BERAT
7.496.569 8.995.883 10.495.196
634 S-4-10-I
1.312.921 1.575.506 1.838.090
635 S-4-10-II
1.640.402 1.968.482 2.296.563
636 S-4-10-III
2.123.881 2.548.657 2.973.434
646 S-4-14-I
KANAK-KANAK RINGAN
797.420 956.904 1.116.387
647 S-4-14-II
KANAK-KANAK SEDANG
1.693.987 2.032.784 2.371.581
648 S-4-14-III
KANAK-KANAK BERAT
3.212.402 3.854.883 4.497.363
649 S-4-15-I
YANG LAIN (RINGAN)
603.096 723.715 844.334
650 S-4-15-II
YANG LAIN (SEDANG)
1.138.247 1.365.897 1.593.546
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
651 S-4-15-III
YANG LAIN (BERAT)
1.474.295 1.769.154 2.064.012
655 S-4-17-I
LAIN-LAIN RINGAN
1.383.695 1.660.434 1.937.173
656 S-4-17-II
LAIN-LAIN SEDANG
1.702.854 2.043.425 2.383.996
657 S-4-17-III
LAIN-LAIN BERAT
2.677.275 3.212.730 3.748.185
658 T-1-10-I
RINGAN
1.227.184 1.472.621 1.718.058
659 T-1-10-II
SEDANG
1.648.025 1.977.631 2.307.236
660 T-1-10-III
BERAT
2.998.296 3.597.955 4.197.614
661 T-4-10-I
551.462 661.755 772.047
662 T-4-10-II
1.050.965 1.261.158 1.471.351
663 T-4-10-III
1.527.818 1.833.382 2.138.945
664 T-4-11-I
652.991 783.589 914.187
665 T-4-11-II
1.027.622 1.233.146 1.438.671
666 T-4-11-III
1.655.196 1.986.236 2.317.275
667 T-4-12-I
LAIN (RINGAN)
1.142.087 1.370.505 1.598.922
668 T-4-12-II
LAIN (SEDANG)
1.726.583 2.071.899 2.417.216
669 T-4-12-III
LAIN (BERAT)
2.694.741 3.233.690 3.772.638
673 U-1-11-I
(RINGAN)
4.358.927 5.230.712 6.102.497
674 U-1-11-II
(SEDANG)
5.734.575 6.881.490 8.028.405
675 U-1-11-III
(BERAT)
10.839.481 13.007.378 15.175.274
682 U-1-14-I
MULUT (RINGAN)
2.328.490 2.794.187 3.259.885
683 U-1-14-II
MULUT (SEDANG)
2.857.525 3.429.030 4.000.535
684 U-1-14-III
MULUT (BERAT)
3.386.248 4.063.497 4.740.747
688 U-1-20-I
3.535.568 4.242.682 4.949.795
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
689 U-1-20-II
6.073.495 7.288.194 8.502.893
690 U-1-20-III
10.597.953 12.717.543 14.837.134
694 U-4-10-I
TELINGA RINGAN
2.831.819 3.398.182 3.964.546
695 U-4-10-II
TELINGA SEDANG
5.371.304 6.445.565 7.519.825
696 U-4-10-III
TELINGA BERAT
8.246.714 9.896.057 11.545.400
703 U-4-13-I
1.310.716 1.572.860 1.835.003
704 U-4-13-II
1.495.329 1.794.394 2.093.460
705 U-4-13-III
1.990.183 2.388.219 2.786.256
709 U-4-15-I
1.305.112 1.566.134 1.827.157
710 U-4-15-II
1.655.145 1.986.174 2.317.203
711 U-4-15-III
2.296.272 2.755.526 3.214.780
712 V-1-10-I
RINGAN
3.872.137 4.646.564 5.420.992
713 V-1-10-II
SEDANG
4.413.296 5.295.955 6.178.614
718 V-1-12-I
MODERAT (RINGAN)
2.849.153 3.418.984 3.988.815
719 V-1-12-II
MODERAT (SEDANG)
7.991.404 9.589.685 11.187.966
720 V-1-12-III
MODERAT (BERAT)
8.616.412 10.339.695 12.062.977
721 V-1-13-I
KOMPLEK (RINGAN)
4.317.537 5.181.044 6.044.551
722 V-1-13-II
KOMPLEK (SEDANG)
7.207.722 8.649.267 10.090.811
723 V-1-13-III
KOMPLEK (BERAT)
8.633.287 10.359.945 12.086.602
724 V-1-14-I
RINGAN
5.204.587 6.245.505 7.286.422
725 V-1-14-II
SEDANG
6.431.397 7.717.677 9.003.956
726 V-1-14-III
BERAT
7.834.548 9.401.457 10.968.367
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
1.882.352 2.258.822 2.635.293
734 V-4-11-II
TUMOR (SEDANG)
2.642.774 3.171.329 3.699.884
735 V-4-11-III
TUMOR (BERAT)
3.952.726 4.743.271 5.533.816
736 W-1-01-I
5.900.211 7.080.254 8.260.296
737 W-1-01-II
7.120.090 8.544.107 9.968.125
738 W-1-01-III
11.827.606 14.193.127 16.558.648
742 W-1-11-I
RINGAN
2.506.522 3.007.826 3.509.131
743 W-1-11-II
SEDANG
4.406.750 5.288.100 6.169.450
744 W-1-11-III
BERAT
9.279.375 11.135.250 12.991.125
745 W-1-12-I
1.557.518 1.869.021 2.180.525
746 W-1-12-II
1.761.667 2.114.001 2.466.334
747 W-1-12-III
2.706.143 3.247.372 3.788.600
748 W-1-13-I
RINGAN
1.544.677 1.853.612 2.162.547
749 W-1-13-II
SEDANG
1.677.074 2.012.488 2.347.903
763 W-4-12-I
1.312.795 1.575.354 1.837.913
764 W-4-12-II
1.989.081 2.386.897 2.784.713
765 W-4-12-III
2.400.224 2.880.269 3.360.314
766 W-4-13-I ABORTUS RINGAN 717.197 860.637 1.004.076
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
787 Z-4-12-I
985.160 1.182.192 1.379.224
788 Z-4-12-II
2.400.509 2.880.611 3.360.712
789 Z-4-12-III
3.044.346 3.653.215 4.262.084
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.230.408
33 F-3-10-0 TERAPI SHOCK 241.672
Rumah Sakit Kelas D
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
72 I-2-16-0 PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK PENGGANTIAN ALAT 2.118.200
80 I-2-42-0 PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN LAIN 2.045.932
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
179 O-7-12-0 PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU PELEBARAN 856.719
191 Q-5-12-0 GIGI 121.250
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
195 Q-5-16-0 VAKSINASI 96.889
196 Q-5-17-0 PASANG INFUS 83.411
200 Q-5-21-0 ABORSI 64.952
205 Q-5-26-0 BRONKIAL AKUT 187.208
210 Q-5-31-0 FRAKTUR 126.850
214 Q-5-35-0 INFEKSI AKUT 247.972
217 Q-5-38-0 PARU AKUT 195.654
241 U-3-13-0 PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 184.209
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
269 Z-3-11-0 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN EMPEDU 1.392.433
276 Z-3-18-0 CT-SCAN KEPALA 237.799
288 Z-3-30-0 FOTOTERAPI 72.953
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 3.611.337 4.333.605 5.055.872
8 A-4-12-II DEMAM SEDANG 4.497.266 5.396.719 6.296.173
9 A-4-12-III DEMAM BERAT 4.799.862 5.759.834 6.719.806
13 A-4-14-I
RINGAN
3.828.765 4.594.518 5.360.271
14 A-4-14-II
SEDANG
4.924.761 5.909.713 6.894.665
15 A-4-14-III
BERAT
5.642.617 6.771.140 7.899.664
28 B-1-12-I
RINGAN
8.875.680 10.650.816 12.425.952
29 B-1-12-II
SEDANG
19.022.534 22.827.041 26.631.548
30 B-1-12-III
BERAT
23.151.631 27.781.957 32.412.283
31 B-1-13-I
(RINGAN)
7.141.353 8.569.623 9.997.894
32 B-1-13-II
(SEDANG)
11.632.152 13.958.582 16.285.012
33 B-1-13-III
(BERAT)
17.149.027 20.578.832 24.008.637
34 B-1-14-I
RINGAN
9.713.901 11.656.681 13.599.461
35 B-1-14-II
SEDANG
10.803.615 12.964.338 15.125.061
36 B-1-14-III
BERAT
16.901.079 20.281.294 23.661.510
40 B-4-11-I
RINGAN
6.336.746 7.604.096 8.871.445
41 B-4-11-II
SEDANG
9.498.630 11.398.357 13.298.083
Rumah Sakit Kelas A
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
46 B-4-13-I
5.752.665 6.903.197 8.053.730
47 B-4-13-II
6.701.682 8.042.018 9.382.355
48 B-4-13-III
9.930.324 11.916.389 13.902.454
73 D-1-20-I
8.434.953 10.121.943 11.808.934
74 D-1-20-II
23.245.545 27.894.654 32.543.763
75 D-1-20-III
36.874.304 44.249.164 51.624.025
85 D-4-13-I
SEL SICKLE RINGAN
3.707.929 4.449.515 5.191.101
86 D-4-13-II
SEL SICKLE SEDANG
5.248.057 6.297.668 7.347.280
87 D-4-13-III
SEL SICKLE BERAT
6.712.416 8.054.900 9.397.383
88 D-4-14-I
4.164.332 4.997.198 5.830.065
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
89 D-4-14-II
8.784.495 10.541.394 12.298.293
90 D-4-14-III
11.352.455 13.622.946 15.893.437
97 E-1-20-I
TIROGLOSAL RINGAN
9.770.431 11.724.517 13.678.603
98 E-1-20-II
TIROGLOSAL SEDANG
13.150.729 15.780.875 18.411.020
99 E-1-20-III
TIROGLOSAL BERAT
26.179.635 31.415.562 36.651.489
100 E-4-10-I
METABOLIK RINGAN
4.792.796 5.751.355 6.709.915
101 E-4-10-II
METABOLIK SEDANG
6.696.980 8.036.376 9.375.772
102 E-4-10-III
METABOLIK BERAT
12.006.687 14.408.025 16.809.362
130 F-4-16-I
MENTAL RINGAN
7.580.948 9.097.138 10.613.327
131 F-4-16-II
MENTAL SEDANG
8.814.166 10.576.999 12.339.833
132 F-4-16-III
MENTAL BERAT
11.765.406 14.118.487 16.471.568
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
142 G-1-01-I
RINGAN
16.386.606 19.663.927 22.941.249
163 G-4-10-I
RINGAN
5.506.277 6.607.532 7.708.787
164 G-4-10-II
SEDANG
6.730.500 8.076.600 9.422.700
166 G-4-11-I
DEGENERATIF RINGAN
7.466.527 8.959.833 10.453.138
167 G-4-11-II
DEGENERATIF SEDANG
9.918.308 11.901.969 13.885.631
168 G-4-11-III
DEGENERATIF BERAT
14.573.425 17.488.110 20.402.795
172 G-4-13-I
RINGAN
3.841.413 4.609.695 5.377.978
173 G-4-13-II
SEDANG
6.698.562 8.038.274 9.377.986
174 G-4-13-III
BERAT
7.944.631 9.533.557 11.122.483
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
175 G-4-14-I
INFARK RINGAN
6.516.391 7.819.669 9.122.948
176 G-4-14-II
INFARK SEDANG
8.712.046 10.454.455 12.196.864
177 G-4-14-III
INFARK BERAT
10.934.610 13.121.532 15.308.454
178 G-4-15-I
5.324.452 6.389.342 7.454.232
179 G-4-15-II
6.354.506 7.625.407 8.896.308
180 G-4-15-III
8.968.827 10.762.593 12.556.358
187 G-4-18-I
PERSARAFAN RINGAN
5.757.645 6.909.174 8.060.703
188 G-4-18-II
PERSARAFAN SEDANG
7.696.325 9.235.590 10.774.855
189 G-4-18-III
PERSARAFAN BERAT
8.611.553 10.333.863 12.056.174
190 G-4-19-I
4.803.806 5.764.567 6.725.328
191 G-4-19-II
8.119.533 9.743.439 11.367.346
192 G-4-19-III
11.789.043 14.146.851 16.504.660
211 G-4-26-I
(RINGAN)
5.756.876 6.908.251 8.059.626
212 G-4-26-II
(SEDANG)
6.697.040 8.036.448 9.375.856
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
213 G-4-26-III
(BERAT)
10.475.447 12.570.536 14.665.626
229 I-1-01-I
RINGAN
76.226.748 91.472.098 106.717.448
230 I-1-01-II
SEDANG
77.903.660 93.484.392 109.065.124
231 I-1-01-III
BERAT
122.969.901 147.563.881 172.157.861
232 I-1-02-I
RINGAN
42.290.285 50.748.342 59.206.399
233 I-1-02-II
SEDANG
54.553.942 65.464.730 76.375.519
234 I-1-02-III
BERAT
67.241.096 80.689.315 94.137.534
235 I-1-03-I
26.004.089 31.204.907 36.405.725
236 I-1-03-II
31.578.984 37.894.781 44.210.578
237 I-1-03-III
49.051.212 58.861.454 68.671.696
238 I-1-04-I
JANTUNG RINGAN
43.622.753 52.347.303 61.071.854
239 I-1-04-II
JANTUNG SEDANG
68.848.419 82.618.103 96.387.787
240 I-1-04-III
JANTUNG BERAT
109.984.947 131.981.937 153.978.926
241 I-1-05-I
55.971.974 67.166.369 78.360.764
242 I-1-05-II
67.166.642 80.599.971 94.033.299
243 I-1-05-III
92.420.732 110.904.878 129.389.024
247 I-1-07-I
34.007.310 40.808.772 47.610.234
248 I-1-07-II
41.955.001 50.346.001 58.737.002
249 I-1-07-III
45.772.748 54.927.298 64.081.848
250 I-1-11-I
5.273.905 6.328.686 7.383.467
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
251 I-1-11-II
5.864.069 7.036.883 8.209.696
252 I-1-11-III
7.803.276 9.363.931 10.924.586
253 I-1-12-I
RINGAN
21.927.992 26.313.590 30.699.189
254 I-1-12-II
SEDANG
24.793.427 29.752.112 34.710.798
255 I-1-12-III
BERAT
41.386.597 49.663.916 57.941.236
256 I-1-13-I
RINGAN
16.160.888 19.393.065 22.625.243
257 I-1-13-II
SEDANG
19.609.669 23.531.602 27.453.536
258 I-1-13-III
BERAT
24.734.920 29.681.904 34.628.888
259 I-1-14-I
PERMANEN RINGAN
43.534.137 52.240.965 60.947.792
260 I-1-14-II
PERMANEN SEDANG
54.106.538 64.927.845 75.749.153
261 I-1-14-III
PERMANEN BERAT
70.898.198 85.077.838 99.257.478
265 I-1-16-I
(RINGAN)
18.657.097 22.388.516 26.119.936
266 I-1-16-II
(SEDANG)
48.508.862 58.210.635 67.912.407
267 I-1-16-III
(BERAT)
55.954.215 67.145.058 78.335.901
268 I-1-17-I
VENA RINGAN
32.156.537 38.587.845 45.019.152
269 I-1-17-II
VENA SEDANG
40.263.002 48.315.602 56.368.203
270 I-1-17-III
VENA BERAT
49.804.722 59.765.666 69.726.610
271 I-1-20-I
RINGAN
27.981.874 33.578.249 39.174.624
272 I-1-20-II
SEDANG
34.956.974 41.948.369 48.939.763
274 I-1-30-I
21.166.659 25.399.991 29.633.323
275 I-1-30-II
44.031.405 52.837.686 61.643.967
276 I-1-30-III
68.232.899 81.879.479 95.526.058
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
289 I-4-13-I
RINGAN
7.582.807 9.099.369 10.615.930
290 I-4-13-II
SEDANG
10.983.271 13.179.925 15.376.579
291 I-4-13-III
BERAT
24.590.155 29.508.186 34.426.217
295 I-4-15-I
(RINGAN)
7.666.448 9.199.738 10.733.027
296 I-4-15-II
(SEDANG)
9.894.488 11.873.386 13.852.284
297 I-4-15-III
(BERAT)
11.277.150 13.532.580 15.788.009
306 I-4-18-III
BERAT
14.122.969 16.947.563 19.772.156
319 I-4-23-I
4.349.725 5.219.670 6.089.615
320 I-4-23-II
5.340.162 6.408.194 7.476.227
321 I-4-23-III
10.434.422 12.521.307 14.608.191
322 I-4-24-I
(RINGAN)
5.073.665 6.088.398 7.103.131
323 I-4-24-II
(SEDANG)
11.683.471 14.020.165 16.356.859
324 I-4-24-III
(BERAT)
14.771.638 17.725.966 20.680.294
325 J-1-01-I
TRAKEOSTOMI RINGAN
74.001.539 88.801.847 103.602.155
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
326 J-1-01-II
TRAKEOSTOMI SEDANG
82.223.933 98.668.719 115.113.506
327 J-1-01-III
TRAKEOSTOMI BERAT
91.359.925 109.631.910 127.903.895
328 J-1-02-I
TRAKEOSTOMI RINGAN
39.269.985 47.123.982 54.977.980
329 J-1-02-II
TRAKEOSTOMI SEDANG
53.685.197 64.422.236 75.159.276
330 J-1-02-III
TRAKEOSTOMI BERAT
87.069.488 104.483.386 121.897.283
334 J-1-20-I
RINGAN
15.806.156 18.967.387 22.128.619
335 J-1-20-II
SEDANG
19.908.309 23.889.970 27.871.632
337 J-1-30-I
RINGAN
9.503.111 11.403.734 13.304.356
338 J-1-30-II
SEDANG
21.476.085 25.771.302 30.066.519
339 J-1-30-III
BERAT
71.774.509 86.129.411 100.484.313
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
3.829.186 4.595.023 5.360.860
374 J-4-21-II
LAIN-LAIN (SEDANG)
8.717.275 10.460.730 12.204.186
375 J-4-21-III
LAIN-LAIN (BERAT)
12.433.686 14.920.423 17.407.161
376 K-1-10-I
(RINGAN)
10.323.485 12.388.182 14.452.879
377 K-1-10-II
(SEDANG)
12.973.673 15.568.407 18.163.142
378 K-1-10-III
(BERAT)
15.205.587 18.246.704 21.287.821
382 K-1-12-I
FEMORAL (RINGAN)
4.331.607 5.197.928 6.064.250
383 K-1-12-II
FEMORAL (SEDANG)
5.633.764 6.760.517 7.887.270
384 K-1-12-III
FEMORAL (BERAT)
11.161.239 13.393.487 15.625.735
394 K-1-30-I
KOMPLEKS (RINGAN)
10.086.933 12.104.319 14.121.706
395 K-1-30-II
KOMPLEKS (SEDANG)
19.750.472 23.700.567 27.650.661
396 K-1-30-III
KOMPLEKS (BERAT)
29.029.203 34.835.043 40.640.884
412 K-4-13-I
5.753.158 6.903.789 8.054.421
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
413 K-4-13-II
7.442.038 8.930.446 10.418.854
414 K-4-13-III
11.463.111 13.755.733 16.048.355
415 K-4-14-I
RINGAN
4.559.425 5.471.309 6.383.194
416 K-4-14-II
SEDANG
6.120.216 7.344.260 8.568.303
417 K-4-14-III
BERAT
9.820.502 11.784.602 13.748.703
424 K-4-17-I
(RINGAN)
3.476.665 4.171.998 4.867.332
425 K-4-17-II
(SEDANG)
4.920.080 5.904.096 6.888.112
426 K-4-17-III
(BERAT)
5.549.861 6.659.834 7.769.806
430 L-1-20-I
RINGAN
35.352.271 42.422.726 49.493.180
431 L-1-20-II
SEDANG
36.943.856 44.332.627 51.721.399
432 L-1-20-III
BERAT
56.361.816 67.634.179 78.906.542
433 L-1-30-I
RINGAN
15.577.180 18.692.616 21.808.052
434 L-1-30-II
SEDANG
23.267.291 27.920.749 32.574.207
435 L-1-30-III
BERAT
24.600.099 29.520.119 34.440.139
436 L-1-40-I
PAYUDARA RINGAN
6.471.418 7.765.702 9.059.986
437 L-1-40-II
PAYUDARA SEDANG
12.980.187 15.576.224 18.172.261
438 L-1-40-III
PAYUDARA BERAT
31.559.020 37.870.824 44.182.628
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
451 L-4-13-I
PAYUDARA RINGAN
3.261.739 3.914.087 4.566.435
452 L-4-13-II
PAYUDARA SEDANG
3.833.374 4.600.048 5.366.723
453 L-4-13-III
PAYUDARA BERAT
5.640.932 6.769.119 7.897.305
454 L-4-14-I
(RINGAN)
3.826.843 4.592.211 5.357.580
455 L-4-14-II
(SEDANG)
5.748.002 6.897.602 8.047.203
456 L-4-14-III
(BERAT)
8.102.533 9.723.039 11.343.546
457 M-1-01-I
17.226.087 20.671.304 24.116.521
458 M-1-01-II
19.227.452 23.072.942 26.918.433
459 M-1-01-III
27.008.870 32.410.644 37.812.418
463 M-1-03-I
32.053.468 38.464.161 44.874.855
464 M-1-03-II
38.482.138 46.178.565 53.874.993
465 M-1-03-III
40.024.748 48.029.697 56.034.647
466 M-1-04-I
7.900.747 9.480.897 11.061.046
467 M-1-04-II
10.101.288 12.121.546 14.141.803
468 M-1-04-III
12.639.662 15.167.595 17.695.527
469 M-1-05-I
11.309.346 13.571.215 15.833.085
470 M-1-05-II
11.577.865 13.893.438 16.209.011
471 M-1-05-III
19.720.621 23.664.746 27.608.870
472 M-1-07-I
13.840.159 16.608.191 19.376.222
473 M-1-07-II
18.540.977 22.249.172 25.957.368
474 M-1-07-III
37.769.795 45.323.754 52.877.713
475 M-1-10-I
WAJAH RINGAN
23.315.378 27.978.454 32.641.529
476 M-1-10-II
WAJAH SEDANG
55.746.161 66.895.394 78.044.626
477 M-1-10-III
WAJAH BERAT
120.239.222 144.287.067 168.334.911
478 M-1-20-I
MAYOR RINGAN
8.363.462 10.036.155 11.708.847
479 M-1-20-II
MAYOR SEDANG
11.932.793 14.319.352 16.705.911
480 M-1-20-III
MAYOR BERAT
29.603.957 35.524.749 41.445.540
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
484 M-1-40-I
5.609.814 6.731.777 7.853.740
485 M-1-40-II
10.369.019 12.442.823 14.516.626
486 M-1-40-III
18.053.878 21.664.654 25.275.429
490 M-1-60-I
5.048.243 6.057.891 7.067.540
491 M-1-60-II
10.133.250 12.159.901 14.186.551
492 M-1-60-III
17.642.662 21.171.194 24.699.726
493 M-1-70-I
(RINGAN)
27.783.881 33.340.658 38.897.434
494 M-1-70-II
(SEDANG)
30.562.269 36.674.723 42.787.177
495 M-1-70-III
(BERAT)
33.618.496 40.342.196 47.065.895
502 M-4-11-I
RINGAN
4.799.677 5.759.613 6.719.548
503 M-4-11-II
SEDANG
10.522.958 12.627.550 14.732.141
504 M-4-11-III
BERAT
15.214.475 18.257.370 21.300.266
505 M-4-12-I
RINGAN
3.831.206 4.597.448 5.363.689
506 M-4-12-II
SEDANG
6.372.265 7.646.719 8.921.172
508 M-4-13-I
6.379.268 7.655.122 8.930.975
509 M-4-13-II
9.584.619 11.501.543 13.418.467
510 M-4-13-III
18.966.295 22.759.554 26.552.813
520 M-4-17-I
RINGAN
4.793.747 5.752.496 6.711.246
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
521 M-4-17-II
SEDANG
6.704.537 8.045.445 9.386.352
522 M-4-17-III
BERAT
9.362.388 11.234.866 13.107.343
526 M-4-19-I
3.778.493 4.534.192 5.289.890
527 M-4-19-II
6.364.494 7.637.392 8.910.291
528 M-4-19-III
12.430.221 14.916.265 17.402.309
529 M-4-20-I
3.811.474 4.573.769 5.336.064
530 M-4-20-II
5.581.282 6.697.539 7.813.795
531 M-4-20-III
6.237.703 7.485.243 8.732.784
532 M-4-21-I
3.837.858 4.605.429 5.373.001
533 M-4-21-II
4.800.088 5.760.106 6.720.124
534 M-4-21-III
10.761.608 12.913.930 15.066.251
541 N-1-12-I
6.920.079 8.304.095 9.688.111
542 N-1-12-II
16.225.256 19.470.308 22.715.359
543 N-1-12-III
29.566.678 35.480.013 41.393.349
547 N-1-30-I
BAWAH RINGAN
11.289.471 13.547.366 15.805.260
548 N-1-30-II
BAWAH SEDANG
17.078.764 20.494.517 23.910.270
549 N-1-30-III
BAWAH BERAT
19.655.987 23.587.185 27.518.382
553 N-4-10-I
RINGAN
4.786.192 5.743.431 6.700.669
554 N-4-10-II
SEDANG
5.788.943 6.946.732 8.104.521
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
555 N-4-10-III
BERAT
11.503.599 13.804.319 16.105.039
565 N-4-14-I
3.321.099 3.985.318 4.649.538
566 N-4-14-II
4.712.430 5.654.916 6.597.402
567 N-4-14-III
7.642.757 9.171.308 10.699.860
568 N-4-15-I
URIN RINGAN
4.359.288 5.231.146 6.103.003
569 N-4-15-II
URIN SEDANG
5.409.151 6.490.981 7.572.811
570 N-4-15-III
URIN BERAT
6.172.812 7.407.374 8.641.937
571 N-4-16-I
(RINGAN)
4.804.170 5.765.004 6.725.839
572 N-4-16-II
(SEDANG)
7.383.877 8.860.653 10.337.428
573 N-4-16-III
(BERAT)
13.101.258 15.721.509 18.341.761
577 O-6-11-I
4.465.742 5.358.890 6.252.038
578 O-6-11-II
4.963.113 5.955.736 6.948.358
579 O-6-11-III
8.918.268 10.701.921 12.485.575
580 O-6-12-I
3.163.933 3.796.720 4.429.507
581 O-6-12-II
3.799.862 4.559.834 5.319.807
582 O-6-12-III
4.774.588 5.729.506 6.684.424
586 P-8-01-I
RINGAN
88.776.607 106.531.929 124.287.250
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
587 P-8-01-II
SEDANG
109.847.638 131.817.165 153.786.693
588 P-8-01-III
BERAT
128.930.281 154.716.337 180.502.394
589 P-8-02-I
105.422.913 126.507.495 147.592.078
590 P-8-02-II
120.930.688 145.116.826 169.302.964
591 P-8-02-III
138.171.884 165.806.261 193.440.638
592 P-8-03-I
5.949.565 7.139.478 8.329.391
593 P-8-03-II
8.329.391 9.995.270 11.661.148
594 P-8-03-III
11.592.072 13.910.487 16.228.901
595 P-8-04-I
47.927.985 57.513.582 67.099.179
596 P-8-04-II
62.200.191 74.640.230 87.080.268
597 P-8-04-III
89.179.418 107.015.302 124.851.186
598 P-8-05-I
26.061.684 31.274.021 36.486.358
599 P-8-05-II
36.938.924 44.326.709 51.714.494
600 P-8-05-III
54.424.546 65.309.455 76.194.364
601 P-8-06-I
5.159.639 6.191.567 7.223.494
602 P-8-06-II
9.573.678 11.488.414 13.403.150
603 P-8-06-III
18.642.070 22.370.484 26.098.898
604 P-8-07-I
8.329.391 9.995.270 11.661.148
605 P-8-07-II
23.353.608 28.024.330 32.695.051
606 P-8-07-III
30.937.739 37.125.287 43.312.835
607 P-8-08-I
4.819.421 5.783.305 6.747.189
608 P-8-08-II
6.838.529 8.206.235 9.573.941
609 P-8-08-III
12.507.510 15.009.012 17.510.514
610 P-8-10-I
3.377.924 4.053.509 4.729.094
611 P-8-10-II
5.316.894 6.380.273 7.443.652
612 P-8-10-III
10.439.231 12.527.077 14.614.924
613 P-8-11-I
RINGAN
8.454.190 10.145.027 11.835.865
614 P-8-11-II
SEDANG
18.014.096 21.616.915 25.219.734
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
615 P-8-11-III
BERAT
21.590.972 25.909.167 30.227.361
616 P-8-12-I
RINGAN
10.756.352 12.907.622 15.058.893
617 P-8-12-II
SEDANG
13.606.552 16.327.863 19.049.173
618 P-8-12-III
BERAT
14.400.816 17.280.979 20.161.142
619 P-8-13-I
RINGAN
2.704.251 3.245.101 3.785.951
620 P-8-13-II
SEDANG
6.699.938 8.039.925 9.379.913
621 P-8-13-III
BERAT
16.321.567 19.585.880 22.850.194
622 P-8-14-I
4.608.129 5.529.755 6.451.381
623 P-8-14-II
9.380.368 11.256.442 13.132.515
624 P-8-14-III
10.291.963 12.350.356 14.408.749
625 P-8-15-I
RINGAN
3.456.148 4.147.377 4.838.607
626 P-8-15-II
SEDANG
6.921.104 8.305.325 9.689.546
627 P-8-15-III
BERAT
8.120.727 9.744.872 11.369.017
628 P-8-16-I
3.127.898 3.753.478 4.379.058
629 P-8-16-II
6.467.035 7.760.442 9.053.849
630 P-8-16-III
16.985.920 20.383.104 23.780.288
631 P-8-17-I
RINGAN
2.295.158 2.754.189 3.213.221
632 P-8-17-II
SEDANG
5.967.211 7.160.653 8.354.095
633 P-8-17-III
BERAT
14.143.152 16.971.782 19.800.412
634 S-4-10-I
3.526.638 4.231.966 4.937.293
635 S-4-10-II
4.345.333 5.214.400 6.083.466
636 S-4-10-III
5.948.361 7.138.033 8.327.705
646 S-4-14-I
KANAK-KANAK RINGAN
2.153.005 2.583.606 3.014.207
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
647 S-4-14-II
KANAK-KANAK SEDANG
4.573.086 5.487.703 6.402.320
648 S-4-14-III
KANAK-KANAK BERAT
8.672.128 10.406.554 12.140.979
649 S-4-15-I
YANG LAIN (RINGAN)
1.628.415 1.954.098 2.279.781
650 S-4-15-II
YANG LAIN (SEDANG)
3.073.086 3.687.704 4.302.321
651 S-4-15-III
YANG LAIN (BERAT)
3.980.190 4.776.228 5.572.266
655 S-4-17-I
3.234.407 3.881.288 4.528.169
656 S-4-17-II
4.800.118 5.760.142 6.720.166
657 S-4-17-III
7.377.730 8.853.275 10.328.821
658 T-1-10-I
RINGAN
2.719.261 3.263.114 3.806.966
659 T-1-10-II
SEDANG
3.652.321 4.382.785 5.113.250
660 T-1-10-III
BERAT
6.644.123 7.972.948 9.301.773
661 T-4-10-I
1.489.070 1.786.885 2.084.699
662 T-4-10-II
2.837.431 3.404.917 3.972.403
663 T-4-10-III
4.124.315 4.949.179 5.774.042
664 T-4-11-I
1.438.098 1.725.717 2.013.337
665 T-4-11-II
2.263.160 2.715.792 3.168.425
666 T-4-11-III
3.645.288 4.374.346 5.103.404
667 T-4-12-I
LAIN (RINGAN)
3.369.540 4.043.448 4.717.356
668 T-4-12-II
LAIN (SEDANG)
5.086.732 6.104.078 7.121.424
669 T-4-12-III
LAIN (BERAT)
7.873.518 9.448.222 11.022.926
673 U-1-11-I
(RINGAN)
12.622.428 15.146.913 17.671.399
674 U-1-11-II
(SEDANG)
19.038.609 22.846.330 26.654.052
675 U-1-11-III
(BERAT)
28.823.760 34.588.512 40.353.264
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
682 U-1-14-I
MULUT (RINGAN)
5.140.770 6.168.924 7.197.078
683 U-1-14-II
MULUT (SEDANG)
6.308.958 7.570.750 8.832.541
684 U-1-14-III
MULUT (BERAT)
7.476.134 8.971.361 10.466.587
688 U-1-20-I
7.804.428 9.365.314 10.926.199
689 U-1-20-II
13.937.681 16.725.217 19.512.753
690 U-1-20-III
33.322.279 39.986.734 46.651.190
694 U-4-10-I
TELINGA RINGAN
6.239.276 7.487.132 8.734.987
695 U-4-10-II
TELINGA SEDANG
14.283.465 17.140.158 19.996.851
696 U-4-10-III
TELINGA BERAT
21.929.637 26.315.564 30.701.492
703 U-4-13-I
3.404.323 4.085.187 4.766.052
704 U-4-13-II
4.013.313 4.815.975 5.618.638
705 U-4-13-III
4.800.159 5.760.191 6.720.223
709 U-4-15-I
3.849.639 4.619.567 5.389.495
710 U-4-15-II
4.796.118 5.755.342 6.714.566
711 U-4-15-III
6.712.252 8.054.702 9.397.152
712 V-1-10-I
RINGAN
11.231.156 13.477.388 15.723.619
713 V-1-10-II
SEDANG
12.934.617 15.521.540 18.108.464
718 V-1-12-I
MODERAT (RINGAN)
6.279.024 7.534.829 8.790.634
719 V-1-12-II
MODERAT (SEDANG)
22.153.630 26.584.356 31.015.082
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
720 V-1-12-III
MODERAT (BERAT)
22.912.560 27.495.072 32.077.584
721 V-1-13-I
KOMPLEK (RINGAN)
9.519.781 11.423.738 13.327.694
722 V-1-13-II
KOMPLEK (SEDANG)
18.189.160 21.826.992 25.464.824
723 V-1-13-III
KOMPLEK (BERAT)
28.536.577 34.243.892 39.951.208
724 V-1-14-I
RINGAN
11.488.109 13.785.730 16.083.352
725 V-1-14-II
SEDANG
16.691.994 20.030.393 23.368.792
726 V-1-14-III
BERAT
20.833.326 24.999.991 29.166.656
733 V-4-11-I
TUMOR (RINGAN)
4.800.239 5.760.286 6.720.334
734 V-4-11-II
TUMOR (SEDANG)
6.704.063 8.044.876 9.385.688
735 V-4-11-III
TUMOR (BERAT)
8.706.344 10.447.612 12.188.881
736 W-1-01-I
13.083.837 15.700.605 18.317.372
737 W-1-01-II
15.681.892 18.818.270 21.954.649
738 W-1-01-III
28.334.689 34.001.627 39.668.565
742 W-1-11-I
RINGAN
3.770.962 4.525.154 5.279.346
743 W-1-11-II
SEDANG
6.629.779 7.955.735 9.281.691
744 W-1-11-III
BERAT
13.960.448 16.752.537 19.544.627
745 W-1-12-I
3.435.409 4.122.490 4.809.572
746 W-1-12-II
3.895.081 4.674.097 5.453.113
747 W-1-12-III
5.983.637 7.180.365 8.377.092
748 W-1-13-I
RINGAN
4.170.080 5.004.097 5.838.113
749 W-1-13-II
SEDANG
4.527.321 5.432.785 6.338.249
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
763 W-4-12-I
3.844.056 4.612.867 5.381.678
764 W-4-12-II
5.277.588 6.333.106 7.388.624
765 W-4-12-III
5.752.781 6.903.338 8.053.894
787 Z-4-12-I
2.872.321 3.446.785 4.021.249
788 Z-4-12-II
5.767.219 6.920.663 8.074.107
789 Z-4-12-III
12.167.338 14.600.805 17.034.273
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 3.028.312
33 F-3-10-0 TERAPI SHOCK 593.769
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT
5.213.370
80 I-2-42-0
LAIN
5.009.620
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
179 O-7-12-0
1.898.360
191 Q-5-12-0 GIGI 297.101
195 Q-5-16-0 VAKSINASI 215.717
196 Q-5-17-0 PASANG INFUS 205.783
200 Q-5-21-0 ABORSI 285.927
205 Q-5-26-0 BRONKIAL AKUT 459.439
210 Q-5-31-0 FRAKTUR 309.329
214 Q-5-35-0 INFEKSI AKUT 606.456
217 Q-5-38-0 PARU AKUT 482.243
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
269 Z-3-11-0
EMPEDU
3.427.094
276 Z-3-18-0 CT-SCAN KEPALA 585.278
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 178.315
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.971.446 2.365.735 2.760.024
8 A-4-12-II DEMAM SEDANG 3.118.150 3.741.780 4.365.410
9 A-4-12-III DEMAM BERAT 3.564.005 4.276.806 4.989.607
13 A-4-14-I
RINGAN
3.088.537 3.706.245 4.323.952
14 A-4-14-II
SEDANG
3.972.640 4.767.168 5.561.696
15 A-4-14-III
BERAT
4.551.711 5.462.053 6.372.395
28 B-1-12-I
RINGAN
6.832.278 8.198.733 9.565.189
29 B-1-12-II
SEDANG
14.643.243 17.571.891 20.500.540
30 B-1-12-III
BERAT
17.315.807 20.778.969 24.242.130
31 B-1-13-I
(RINGAN)
5.494.142 6.592.971 7.691.799
32 B-1-13-II
(SEDANG)
8.949.160 10.738.992 12.528.824
33 B-1-13-III
(BERAT)
13.193.573 15.832.288 18.471.003
34 B-1-14-I
RINGAN
7.431.513 8.917.815 10.404.118
35 B-1-14-II
SEDANG
8.265.342 9.918.410 11.571.478
36 B-1-14-III
BERAT
12.930.145 15.516.174 18.102.202
40 B-4-11-I
RINGAN
4.082.364 4.898.836 5.715.309
41 B-4-11-II
SEDANG
6.222.893 7.467.472 8.712.050
Rumah Sakit Kelas B
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
46 B-4-13-I
2.976.332 3.571.598 4.166.865
47 B-4-13-II
4.330.161 5.196.194 6.062.226
48 B-4-13-III
5.421.377 6.505.653 7.589.928
73 D-1-20-I
4.364.855 5.237.826 6.110.797
74 D-1-20-II
12.831.762 15.398.114 17.964.466
75 D-1-20-III
20.131.095 24.157.315 28.183.534
85 D-4-13-I
SEL SICKLE RINGAN
1.983.830 2.380.595 2.777.361
86 D-4-13-II
SEL SICKLE SEDANG
2.975.233 3.570.279 4.165.326
87 D-4-13-III
SEL SICKLE BERAT
4.106.161 4.927.393 5.748.625
88 D-4-14-I
2.465.425 2.958.510 3.451.595
89 D-4-14-II
4.420.066 5.304.080 6.188.093
90 D-4-14-III
6.197.898 7.437.477 8.677.057
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
5.913.534 7.096.241 8.278.947
98 E-1-20-II
TIROGLOSAL SEDANG
9.675.735 11.610.882 13.546.029
99 E-1-20-III
TIROGLOSAL BERAT
18.151.428 21.781.713 25.411.999
100 E-4-10-I
METABOLIK RINGAN
3.096.174 3.715.409 4.334.644
101 E-4-10-II
METABOLIK SEDANG
4.286.028 5.143.233 6.000.439
102 E-4-10-III
METABOLIK BERAT
6.539.011 7.846.813 9.154.616
130 F-4-16-I
MENTAL RINGAN
5.836.931 7.004.317 8.171.703
131 F-4-16-II
MENTAL SEDANG
6.782.801 8.139.361 9.495.921
132 F-4-16-III
MENTAL BERAT
9.053.907 10.864.688 12.675.470
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
142 G-1-01-I
RINGAN
8.946.041 10.735.249 12.524.457
163 G-4-10-I
RINGAN
2.962.294 3.554.753 4.147.212
164 G-4-10-II
SEDANG
4.055.571 4.866.686 5.677.800
166 G-4-11-I
DEGENERATIF RINGAN
5.380.794 6.456.953 7.533.112
167 G-4-11-II
DEGENERATIF SEDANG
6.785.332 8.142.399 9.499.465
168 G-4-11-III
DEGENERATIF BERAT
8.704.616 10.445.540 12.186.463
172 G-4-13-I
RINGAN
2.737.508 3.285.010 3.832.512
173 G-4-13-II
SEDANG
3.797.083 4.556.500 5.315.917
174 G-4-13-III
BERAT
4.451.352 5.341.623 6.231.893
175 G-4-14-I
INFARK RINGAN
3.729.072 4.474.886 5.220.701
176 G-4-14-II
INFARK SEDANG
6.743.542 8.092.251 9.440.959
177 G-4-14-III
INFARK BERAT
8.432.351 10.118.822 11.805.292
178 G-4-15-I
2.906.677 3.488.012 4.069.347
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
179 G-4-15-II
3.469.132 4.162.958 4.856.784
180 G-4-15-III
4.952.630 5.943.156 6.933.682
185 G-4-17-II
SEDANG
4.796.408 5.755.689 6.714.971
187 G-4-18-I
PERSARAFAN RINGAN
2.997.959 3.597.551 4.197.143
188 G-4-18-II
PERSARAFAN SEDANG
5.733.636 6.880.364 8.027.091
189 G-4-18-III
PERSARAFAN BERAT
6.069.404 7.283.285 8.497.166
190 G-4-19-I
3.286.478 3.943.773 4.601.069
191 G-4-19-II
4.432.832 5.319.399 6.205.965
192 G-4-19-III
6.798.403 8.158.084 9.517.765
211 G-4-26-I
(RINGAN)
3.311.647 3.973.977 4.636.306
212 G-4-26-II
(SEDANG)
4.537.059 5.444.471 6.351.883
213 G-4-26-III
(BERAT)
5.448.823 6.538.588 7.628.352
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
229 I-1-01-I
RINGAN
41.614.836 49.937.804 58.260.771
230 I-1-01-II
SEDANG
42.530.580 51.036.696 59.542.812
231 I-1-01-III
BERAT
67.133.704 80.560.445 93.987.186
232 I-1-02-I
RINGAN
23.087.671 27.705.206 32.322.740
233 I-1-02-II
SEDANG
29.783.096 35.739.715 41.696.335
234 I-1-02-III
BERAT
36.709.398 44.051.277 51.393.157
235 I-1-03-I
14.196.418 17.035.701 19.874.985
236 I-1-03-II
16.187.770 19.425.324 22.662.879
237 I-1-03-III
26.779.001 32.134.801 37.490.601
238 I-1-04-I
JANTUNG RINGAN
23.099.313 27.719.175 32.339.038
239 I-1-04-II
JANTUNG SEDANG
55.078.736 66.094.483 77.110.230
240 I-1-04-III
JANTUNG BERAT
87.987.958 105.585.549 123.183.141
241 I-1-05-I
30.557.212 36.668.655 42.780.097
242 I-1-05-II
36.668.655 44.002.386 51.336.117
243 I-1-05-III
50.455.837 60.547.005 70.638.172
247 I-1-07-I
25.225.419 30.270.503 35.315.586
248 I-1-07-II
31.120.679 37.344.814 43.568.950
249 I-1-07-III
33.952.458 40.742.950 47.533.441
250 I-1-11-I
4.059.522 4.871.427 5.683.331
251 I-1-11-II
4.513.783 5.416.539 6.319.296
252 I-1-11-III
6.006.469 7.207.763 8.409.057
253 I-1-12-I
RINGAN
12.265.655 14.718.786 17.171.917
254 I-1-12-II
SEDANG
13.972.142 16.766.571 19.560.999
255 I-1-12-III
BERAT
22.594.628 27.113.553 31.632.479
256 I-1-13-I
RINGAN
12.928.710 15.514.452 18.100.194
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
257 I-1-13-II
SEDANG
15.687.735 18.825.282 21.962.829
258 I-1-13-III
BERAT
18.347.472 22.016.967 25.686.461
259 I-1-14-I
PERMANEN RINGAN
23.766.721 28.520.065 33.273.409
260 I-1-14-II
PERMANEN SEDANG
29.538.638 35.446.366 41.354.094
261 I-1-14-III
PERMANEN BERAT
38.705.802 46.446.963 54.188.123
265 I-1-16-I
(RINGAN)
10.185.737 12.222.885 14.260.032
266 I-1-16-II
(SEDANG)
26.482.917 31.779.501 37.076.084
267 I-1-16-III
(BERAT)
30.547.395 36.656.874 42.766.353
268 I-1-17-I
VENA RINGAN
25.725.230 30.870.276 36.015.322
269 I-1-17-II
VENA SEDANG
32.210.402 38.652.482 45.094.562
270 I-1-17-III
VENA BERAT
39.843.777 47.812.533 55.781.288
271 I-1-20-I
RINGAN
22.385.499 26.862.599 31.339.699
272 I-1-20-II
SEDANG
27.965.579 33.558.695 39.151.811
274 I-1-30-I
11.555.772 13.866.926 16.178.081
275 I-1-30-II
24.038.340 28.846.008 33.653.676
276 I-1-30-III
37.250.697 44.700.836 52.150.976
289 I-4-13-I
RINGAN
5.816.196 6.979.435 8.142.674
290 I-4-13-II
SEDANG
7.375.358 8.850.429 10.325.501
291 I-4-13-III
BERAT
13.424.818 16.109.782 18.794.746
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
295 I-4-15-I
(RINGAN)
3.965.946 4.759.136 5.552.325
296 I-4-15-II
(SEDANG)
5.692.005 6.830.406 7.968.807
297 I-4-15-III
(BERAT)
6.487.516 7.785.019 9.082.523
306 I-4-18-III
BERAT
8.887.467 10.664.960 12.442.454
319 I-4-23-I
2.374.597 2.849.516 3.324.435
320 I-4-23-II
2.915.457 3.498.549 4.081.640
321 I-4-23-III
5.696.538 6.835.846 7.975.153
322 I-4-24-I
(RINGAN)
3.187.195 3.824.635 4.462.074
323 I-4-24-II
(SEDANG)
7.960.403 9.552.483 11.144.564
324 I-4-24-III
(BERAT)
10.017.642 12.021.171 14.024.699
325 J-1-01-I
TRAKEOSTOMI RINGAN
30.386.921 36.464.306 42.541.690
326 J-1-01-II
TRAKEOSTOMI SEDANG
32.462.238 38.954.685 45.447.133
327 J-1-01-III
TRAKEOSTOMI BERAT
46.686.132 56.023.358 65.360.585
328 J-1-02-I
TRAKEOSTOMI RINGAN
13.101.546 15.721.855 18.342.164
329 J-1-02-II
TRAKEOSTOMI SEDANG
13.249.492 15.899.390 18.549.289
330 J-1-02-III
TRAKEOSTOMI BERAT
20.827.052 24.992.463 29.157.873
334 J-1-20-I
RINGAN
12.644.925 15.173.910 17.702.895
335 J-1-20-II
SEDANG
15.926.647 19.111.976 22.297.306
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
337 J-1-30-I
RINGAN
3.661.565 4.393.878 5.126.191
338 J-1-30-II
SEDANG
11.724.557 14.069.469 16.414.380
339 J-1-30-III
BERAT
35.005.233 42.006.280 49.007.327
373 J-4-21-I
LAIN-LAIN (RINGAN)
2.317.775 2.781.330 3.244.885
374 J-4-21-II
LAIN-LAIN (SEDANG)
4.326.732 5.192.078 6.057.424
375 J-4-21-III
LAIN-LAIN (BERAT)
6.053.635 7.264.362 8.475.089
376 K-1-10-I
(RINGAN)
5.328.719 6.394.462 7.460.206
377 K-1-10-II
(SEDANG)
10.011.694 12.014.033 14.016.371
378 K-1-10-III
(BERAT)
11.715.150 14.058.180 16.401.210
382 K-1-12-I
FEMORAL (RINGAN)
3.319.751 3.983.701 4.647.652
383 K-1-12-II
FEMORAL (SEDANG)
4.315.176 5.178.211 6.041.246
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
384 K-1-12-III
FEMORAL (BERAT)
8.606.521 10.327.826 12.049.130
394 K-1-30-I
KOMPLEKS (RINGAN)
7.616.796 9.140.155 10.663.514
395 K-1-30-II
KOMPLEKS (SEDANG)
10.686.366 12.823.639 14.960.912
396 K-1-30-III
KOMPLEKS (BERAT)
19.662.538 23.595.046 27.527.554
412 K-4-13-I
3.137.819 3.765.383 4.392.947
413 K-4-13-II
4.021.116 4.825.339 5.629.562
414 K-4-13-III
6.258.186 7.509.823 8.761.460
415 K-4-14-I
RINGAN
2.489.057 2.986.868 3.484.680
416 K-4-14-II
SEDANG
3.341.161 4.009.393 4.677.625
417 K-4-14-III
BERAT
5.866.015 7.039.218 8.212.421
424 K-4-17-I
(RINGAN)
2.804.510 3.365.412 3.926.314
425 K-4-17-II
(SEDANG)
3.968.865 4.762.638 5.556.411
426 K-4-17-III
(BERAT)
4.476.888 5.372.266 6.267.643
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
430 L-1-20-I
RINGAN
27.178.893 32.614.671 38.050.450
431 L-1-20-II
SEDANG
28.010.368 33.612.442 39.214.515
432 L-1-20-III
BERAT
39.394.787 47.273.744 55.152.701
433 L-1-30-I
RINGAN
8.504.075 10.204.890 11.905.705
434 L-1-30-II
SEDANG
15.858.427 19.030.112 22.201.798
435 L-1-30-III
BERAT
18.835.565 22.602.678 26.369.791
436 L-1-40-I
PAYUDARA RINGAN
4.042.290 4.850.748 5.659.207
437 L-1-40-II
PAYUDARA SEDANG
8.716.442 10.459.730 12.203.019
438 L-1-40-III
PAYUDARA BERAT
14.910.433 17.892.520 20.874.607
451 L-4-13-I
PAYUDARA RINGAN
1.974.052 2.368.862 2.763.672
452 L-4-13-II
PAYUDARA SEDANG
2.638.993 3.166.792 3.694.591
453 L-4-13-III
PAYUDARA BERAT
3.483.525 4.180.229 4.876.934
454 L-4-14-I
(RINGAN)
2.284.903 2.741.884 3.198.865
455 L-4-14-II
(SEDANG)
3.395.511 4.074.613 4.753.715
456 L-4-14-III
(BERAT)
6.009.981 7.211.978 8.413.974
457 M-1-01-I
9.404.394 11.285.273 13.166.152
458 M-1-01-II
10.496.825 12.596.190 14.695.556
459 M-1-01-III
14.745.196 17.694.235 20.643.274
463 M-1-03-I
17.340.031 20.808.038 24.276.044
464 M-1-03-II
20.189.456 24.227.347 28.265.239
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
465 M-1-03-III
25.467.262 30.560.714 35.654.167
466 M-1-04-I
6.050.285 7.260.342 8.470.399
467 M-1-04-II
7.748.843 9.298.612 10.848.381
468 M-1-04-III
9.696.217 11.635.460 13.574.704
469 M-1-05-I
7.674.330 9.209.195 10.744.061
470 M-1-05-II
8.912.375 10.694.850 12.477.325
471 M-1-05-III
15.776.497 18.931.796 22.087.096
472 M-1-07-I
7.555.708 9.066.850 10.577.992
473 M-1-07-II
10.122.288 12.146.746 14.171.203
474 M-1-07-III
20.620.061 24.744.073 28.868.085
475 M-1-10-I
WAJAH RINGAN
18.652.303 22.382.763 26.113.224
476 M-1-10-II
WAJAH SEDANG
44.596.929 53.516.315 62.435.701
477 M-1-10-III
WAJAH BERAT
96.191.378 115.429.653 134.667.929
478 M-1-20-I
MAYOR RINGAN
6.432.458 7.718.949 9.005.441
479 M-1-20-II
MAYOR SEDANG
7.302.514 8.763.016 10.223.519
480 M-1-20-III
MAYOR BERAT
17.918.836 21.502.603 25.086.370
484 M-1-40-I
3.810.981 4.573.178 5.335.374
485 M-1-40-II
6.272.941 7.527.529 8.782.117
486 M-1-40-III
9.291.239 11.149.487 13.007.735
490 M-1-60-I
3.881.401 4.657.682 5.433.962
491 M-1-60-II
7.783.842 9.340.610 10.897.379
492 M-1-60-III
12.069.917 14.483.901 16.897.884
493 M-1-70-I
(RINGAN)
22.227.105 26.672.526 31.117.947
494 M-1-70-II
(SEDANG)
24.449.816 29.339.779 34.229.742
495 M-1-70-III
(BERAT)
26.894.797 32.273.756 37.652.716
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
502 M-4-11-I
RINGAN
3.523.129 4.227.754 4.932.380
503 M-4-11-II
SEDANG
6.552.313 7.862.775 9.173.238
504 M-4-11-III
BERAT
11.711.651 14.053.981 16.396.311
506 M-4-12-II
SEDANG
3.478.797 4.174.556 4.870.315
508 M-4-13-I
4.430.850 5.317.020 6.203.190
509 M-4-13-II
5.513.095 6.615.714 7.718.333
510 M-4-13-III
11.267.113 13.520.536 15.773.958
520 M-4-17-I
RINGAN
2.842.459 3.410.951 3.979.443
521 M-4-17-II
SEDANG
3.720.237 4.464.284 5.208.332
522 M-4-17-III
BERAT
5.126.775 6.152.130 7.177.484
526 M-4-19-I
2.902.613 3.483.136 4.063.658
527 M-4-19-II
4.637.057 5.564.468 6.491.879
528 M-4-19-III
7.404.142 8.884.970 10.365.799
529 M-4-20-I
2.080.793 2.496.951 2.913.110
530 M-4-20-II
2.973.807 3.568.569 4.163.330
531 M-4-20-III
3.292.936 3.951.524 4.610.111
532 M-4-21-I
2.074.334 2.489.201 2.904.068
533 M-4-21-II
3.473.749 4.168.499 4.863.248
534 M-4-21-III
5.875.095 7.050.114 8.225.133
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
541 N-1-12-I
3.777.803 4.533.363 5.288.924
542 N-1-12-II
12.536.008 15.043.209 17.550.411
543 N-1-12-III
22.772.467 27.326.960 31.881.453
547 N-1-30-I
BAWAH RINGAN
7.479.784 8.975.741 10.471.697
548 N-1-30-II
BAWAH SEDANG
11.179.902 13.415.882 15.651.862
549 N-1-30-III
BAWAH BERAT
11.740.497 14.088.597 16.436.696
553 N-4-10-I
RINGAN
3.037.713 3.645.256 4.252.799
554 N-4-10-II
SEDANG
4.093.901 4.912.682 5.731.462
555 N-4-10-III
BERAT
7.162.360 8.594.832 10.027.304
565 N-4-14-I
1.730.205 2.076.245 2.422.286
566 N-4-14-II
2.572.868 3.087.442 3.602.016
567 N-4-14-III
4.172.372 5.006.847 5.841.321
568 N-4-15-I
URIN RINGAN
2.784.636 3.341.563 3.898.490
569 N-4-15-II
URIN SEDANG
3.809.364 4.571.237 5.333.109
570 N-4-15-III
URIN BERAT
4.347.172 5.216.606 6.086.040
571 N-4-16-I
(RINGAN)
3.353.974 4.024.768 4.695.563
572 N-4-16-II
(SEDANG)
4.030.954 4.837.144 5.643.335
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
573 N-4-16-III
(BERAT)
7.175.654 8.610.785 10.045.916
577 O-6-11-I
2.528.893 3.034.672 3.540.451
578 O-6-11-II
3.576.456 4.291.747 5.007.038
579 O-6-11-III
6.073.519 7.288.223 8.502.927
580 O-6-12-I
2.435.646 2.922.775 3.409.904
581 O-6-12-II
2.925.204 3.510.245 4.095.286
582 O-6-12-III
3.819.671 4.583.605 5.347.539
586 P-8-01-I
RINGAN
48.466.546 58.159.855 67.853.164
587 P-8-01-II
SEDANG
59.969.769 71.963.723 83.957.677
588 P-8-01-III
BERAT
70.387.698 84.465.237 98.542.777
589 P-8-02-I
78.198.463 93.838.156 109.477.848
590 P-8-02-II
89.701.686 107.642.023 125.582.361
591 P-8-02-III
102.490.590 122.988.708 143.486.826
592 P-8-03-I
2.709.858 3.251.830 3.793.802
593 P-8-03-II
4.038.844 4.846.613 5.654.381
594 P-8-03-III
7.340.101 8.808.122 10.276.142
595 P-8-04-I
32.630.724 39.156.869 45.683.014
596 P-8-04-II
42.182.791 50.619.350 59.055.908
597 P-8-04-III
60.479.505 72.575.406 84.671.307
598 P-8-05-I
17.718.607 21.262.328 24.806.049
599 P-8-05-II
25.104.818 30.125.782 35.146.745
600 P-8-05-III
36.864.871 44.237.846 51.610.820
601 P-8-06-I
3.003.031 3.603.637 4.204.243
602 P-8-06-II
6.520.402 7.824.482 9.128.563
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
603 P-8-06-III
11.907.506 14.289.007 16.670.508
604 P-8-07-I
4.695.716 5.634.859 6.574.002
605 P-8-07-II
11.620.162 13.944.195 16.268.227
606 P-8-07-III
15.621.098 18.745.318 21.869.537
607 P-8-08-I
3.887.666 4.665.199 5.442.732
608 P-8-08-II
5.516.413 6.619.696 7.722.979
609 P-8-08-III
8.932.287 10.718.745 12.505.202
610 P-8-10-I
2.299.932 2.759.918 3.219.904
611 P-8-10-II
3.944.033 4.732.839 5.521.646
612 P-8-10-III
7.743.298 9.291.958 10.840.618
613 P-8-11-I
RINGAN
2.776.072 3.331.286 3.886.500
614 P-8-11-II
SEDANG
13.773.479 16.528.175 19.282.871
615 P-8-11-III
BERAT
14.062.036 16.874.443 19.686.850
616 P-8-12-I
RINGAN
3.745.050 4.494.060 5.243.071
617 P-8-12-II
SEDANG
5.831.092 6.997.311 8.163.529
618 P-8-12-III
BERAT
6.872.464 8.246.957 9.621.450
619 P-8-13-I
RINGAN
2.181.429 2.617.715 3.054.001
620 P-8-13-II
SEDANG
5.359.950 6.431.940 7.503.930
621 P-8-13-III
BERAT
13.057.254 15.668.704 18.280.155
622 P-8-14-I
3.528.118 4.233.741 4.939.365
623 P-8-14-II
7.221.419 8.665.702 10.109.986
624 P-8-14-III
7.932.343 9.518.812 11.105.280
625 P-8-15-I
RINGAN
2.659.739 3.191.686 3.723.634
626 P-8-15-II
SEDANG
5.320.225 6.384.270 7.448.315
627 P-8-15-III
BERAT
6.236.968 7.484.362 8.731.755
628 P-8-16-I
2.413.197 2.895.836 3.378.476
629 P-8-16-II
5.173.628 6.208.354 7.243.080
630 P-8-16-III
13.588.736 16.306.483 19.024.230
631 P-8-17-I
RINGAN
1.851.427 2.221.713 2.591.998
632 P-8-17-II
SEDANG
4.813.550 5.776.260 6.738.970
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
633 P-8-17-III
BERAT
9.097.818 10.917.382 12.736.945
634 S-4-10-I
1.925.274 2.310.328 2.695.383
635 S-4-10-II
2.478.515 2.974.218 3.469.921
636 S-4-10-III
3.224.084 3.868.901 4.513.718
646 S-4-14-I
KANAK-KANAK RINGAN
1.175.275 1.410.330 1.645.385
647 S-4-14-II
KANAK-KANAK SEDANG
2.496.679 2.996.014 3.495.350
648 S-4-14-III
KANAK-KANAK BERAT
4.734.592 5.681.511 6.628.429
649 S-4-15-I
YANG LAIN (RINGAN)
888.871 1.066.646 1.244.420
650 S-4-15-II
YANG LAIN (SEDANG)
1.677.603 2.013.124 2.348.645
651 S-4-15-III
YANG LAIN (BERAT)
2.172.886 2.607.463 3.042.040
655 S-4-17-I
2.008.765 2.410.518 2.812.272
656 S-4-17-II
2.895.449 3.474.539 4.053.629
657 S-4-17-III
4.027.676 4.833.211 5.638.746
658 T-1-10-I
RINGAN
2.093.325 2.511.990 2.930.655
659 T-1-10-II
SEDANG
2.811.193 3.373.432 3.935.670
660 T-1-10-III
BERAT
5.114.477 6.137.372 7.160.267
661 T-4-10-I
812.772 975.326 1.137.880
662 T-4-10-II
1.548.963 1.858.755 2.168.548
663 T-4-10-III
2.251.771 2.702.126 3.152.480
664 T-4-11-I
1.109.226 1.331.072 1.552.917
665 T-4-11-II
1.745.607 2.094.728 2.443.850
666 T-4-11-III
2.811.658 3.373.990 3.936.322
667 T-4-12-I
LAIN (RINGAN)
1.827.446 2.192.935 2.558.424
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
668 T-4-12-II
LAIN (SEDANG)
2.722.942 3.267.530 3.812.119
669 T-4-12-III
LAIN (BERAT)
4.177.698 5.013.238 5.848.778
673 U-1-11-I
(RINGAN)
6.328.029 7.593.635 8.859.241
674 U-1-11-II
(SEDANG)
8.658.117 10.389.740 12.121.364
675 U-1-11-III
(BERAT)
19.670.138 23.604.166 27.538.193
682 U-1-14-I
MULUT (RINGAN)
3.965.534 4.758.640 5.551.747
683 U-1-14-II
MULUT (SEDANG)
4.866.507 5.839.809 6.813.110
684 U-1-14-III
MULUT (BERAT)
5.766.948 6.920.338 8.073.728
688 U-1-20-I
6.023.223 7.227.868 8.432.513
689 U-1-20-II
8.817.137 10.580.564 12.343.992
690 U-1-20-III
15.951.116 19.141.340 22.331.563
694 U-4-10-I
TELINGA RINGAN
4.810.925 5.773.110 6.735.295
695 U-4-10-II
TELINGA SEDANG
11.426.772 13.712.126 15.997.481
696 U-4-10-III
TELINGA BERAT
14.246.783 17.096.140 19.945.497
703 U-4-13-I
1.981.047 2.377.256 2.773.465
704 U-4-13-II
2.259.176 2.711.012 3.162.847
705 U-4-13-III
2.889.228 3.467.074 4.044.919
709 U-4-15-I
2.136.558 2.563.869 2.991.181
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
710 U-4-15-II
2.800.552 3.360.663 3.920.773
711 U-4-15-III
3.809.079 4.570.895 5.332.710
712 V-1-10-I
RINGAN
6.589.936 7.907.924 9.225.911
713 V-1-10-II
SEDANG
7.430.229 8.916.274 10.402.320
718 V-1-12-I
MODERAT (RINGAN)
4.844.560 5.813.472 6.782.384
719 V-1-12-II
MODERAT (SEDANG)
12.081.502 14.497.802 16.914.103
720 V-1-12-III
MODERAT (BERAT)
12.508.792 15.010.550 17.512.309
721 V-1-13-I
KOMPLEK (RINGAN)
7.356.126 8.827.351 10.298.576
722 V-1-13-II
KOMPLEK (SEDANG)
10.463.740 12.556.488 14.649.236
723 V-1-13-III
KOMPLEK (BERAT)
12.973.055 15.567.666 18.162.277
724 V-1-14-I
RINGAN
7.829.750 9.395.699 10.961.649
725 V-1-14-II
SEDANG
10.457.124 12.548.549 14.639.973
726 V-1-14-III
BERAT
14.217.160 17.060.592 19.904.024
733 V-4-11-I
TUMOR (RINGAN)
2.732.686 3.279.223 3.825.760
734 V-4-11-II
TUMOR (SEDANG)
3.836.622 4.603.946 5.371.271
735 V-4-11-III
TUMOR (BERAT)
6.723.269 8.067.922 9.412.576
736 W-1-01-I
10.018.215 12.021.858 14.025.501
737 W-1-01-II
11.235.348 13.482.418 15.729.487
738 W-1-01-III
17.789.371 21.347.245 24.905.119
742 W-1-11-I
RINGAN
3.041.909 3.650.291 4.258.673
743 W-1-11-II
SEDANG
5.348.022 6.417.626 7.487.230
744 W-1-11-III
BERAT
11.261.428 13.513.713 15.765.999
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
745 W-1-12-I
2.646.749 3.176.098 3.705.448
746 W-1-12-II
2.992.457 3.590.948 4.189.439
747 W-1-12-III
4.596.791 5.516.149 6.435.507
748 W-1-13-I
RINGAN
2.276.618 2.731.942 3.187.266
749 W-1-13-II
SEDANG
2.471.751 2.966.102 3.460.452
763 W-4-12-I
1.982.979 2.379.575 2.776.170
764 W-4-12-II
3.208.476 3.850.171 4.491.866
765 W-4-12-III
4.080.535 4.896.643 5.712.750
787 Z-4-12-I
1.542.042 1.850.451 2.158.859
788 Z-4-12-II
4.005.650 4.806.780 5.607.909
789 Z-4-12-III
5.177.245 6.212.694 7.248.143
24 D-2-11-0 PROSEDUR LIMPA 1.323.342
31 E-2-22-0
THYROGLOSSAL 183.483
33 F-3-10-0 TERAPI SHOCK 259.212
Rumah Sakit Kelas B
Rawat Jalan
Rumah Sakit Kelas B
Rawat Jalan
72 I-2-16-0
80 I-2-42-0
Rumah Sakit Kelas B
Rawat Jalan
Rumah Sakit Kelas B
Rawat Jalan
179 O-7-12-0
ATAU PELEBARAN DAN KURETASE 1.461.387
181 P-9-10-0
LAIN 185.557
191 Q-5-12-0 GIGI 130.049
195 Q-5-16-0 VAKSINASI 103.672
196 Q-5-17-0 PASANG INFUS 89.496
200 Q-5-21-0 ABORSI 101.789
205 Q-5-26-0 BRONKIAL AKUT 200.795
210 Q-5-31-0 FRAKTUR 136.056
214 Q-5-35-0 INFEKSI AKUT 263.907
217 Q-5-38-0 PARU AKUT 209.854
Rumah Sakit Kelas B
Rawat Jalan
238 U-3-10-0
TENGGOROKAN 201.604
241 U-3-13-0
TENGGOROKAN 196.035
269 Z-3-11-0
SALURAN EMPEDU 1.497.606
276 Z-3-18-0 CT-SCAN KEPALA 255.761
Rumah Sakit Kelas B
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 77.818
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.575.610 1.890.732 2.205.854
8 A-4-12-II DEMAM SEDANG 2.012.578 2.415.093 2.817.609
9 A-4-12-III DEMAM BERAT 2.148.121 2.577.745 3.007.370
13 A-4-14-I
RINGAN
2.807.761 3.369.313 3.930.865
14 A-4-14-II
SEDANG
3.611.491 4.333.789 5.056.087
15 A-4-14-III
BERAT
4.137.919 4.965.503 5.793.087
28 B-1-12-I
RINGAN
5.465.822 6.558.987 7.652.151
29 B-1-12-II
SEDANG
11.714.594 14.057.513 16.400.432
30 B-1-12-III
BERAT
13.852.646 16.623.175 19.393.704
31 B-1-13-I
(RINGAN)
4.395.314 5.274.376 6.153.439
32 B-1-13-II
(SEDANG)
7.159.328 8.591.194 10.023.060
33 B-1-13-III
(BERAT)
10.554.859 12.665.830 14.776.802
34 B-1-14-I
RINGAN
5.945.210 7.134.252 8.323.294
35 B-1-14-II
SEDANG
6.612.273 7.934.728 9.257.183
36 B-1-14-III
BERAT
10.344.116 12.412.939 14.481.762
40 B-4-11-I
RINGAN
2.835.888 3.403.065 3.970.243
41 B-4-11-II
SEDANG
4.250.798 5.100.957 5.951.117
Rumah Sakit Kelas C
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
46 B-4-13-I
2.360.598 2.832.717 3.304.837
47 B-4-13-II
3.574.491 4.289.389 5.004.287
48 B-4-13-III
4.443.948 5.332.738 6.221.527
73 D-1-20-I
3.577.908 4.293.490 5.009.071
74 D-1-20-II
9.519.063 11.422.876 13.326.688
75 D-1-20-III
16.501.627 19.801.952 23.102.277
85 D-4-13-I
SEL SICKLE RINGAN
1.570.724 1.884.869 2.199.014
86 D-4-13-II
SEL SICKLE SEDANG
2.353.689 2.824.427 3.295.165
87 D-4-13-III
SEL SICKLE BERAT
2.749.767 3.299.721 3.849.674
88 D-4-14-I
1.896.066 2.275.280 2.654.493
89 D-4-14-II
3.623.165 4.347.798 5.072.431
90 D-4-14-III
5.080.468 6.096.562 7.112.656
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.847.373 5.816.847 6.786.322
98 E-1-20-II
TIROGLOSAL SEDANG
7.732.998 9.279.598 10.826.198
99 E-1-20-III
TIROGLOSAL BERAT
13.941.624 16.729.949 19.518.274
100 E-4-10-I
METABOLIK RINGAN
1.966.207 2.359.449 2.752.690
101 E-4-10-II
METABOLIK SEDANG
3.428.822 4.114.586 4.800.351
102 E-4-10-III
METABOLIK BERAT
4.346.012 5.215.215 6.084.417
130 F-4-16-I
RINGAN
4.669.545 5.603.454 6.537.362
131 F-4-16-II
SEDANG
5.426.241 6.511.489 7.596.737
132 F-4-16-III
BERAT
7.243.126 8.691.751 10.140.376
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
142 G-1-01-I
RINGAN
7.296.479 8.755.774 10.215.070
163 G-4-10-I
RINGAN
2.362.428 2.834.914 3.307.399
164 G-4-10-II
SEDANG
2.743.620 3.292.343 3.841.067
166 G-4-11-I
DEGENERATIF RINGAN
3.341.426 4.009.711 4.677.996
167 G-4-11-II
DEGENERATIF SEDANG
5.428.266 6.513.919 7.599.572
168 G-4-11-III
DEGENERATIF BERAT
6.600.103 7.920.124 9.240.144
172 G-4-13-I
RINGAN
2.190.007 2.628.008 3.066.009
173 G-4-13-II
SEDANG
2.741.965 3.290.358 3.838.751
174 G-4-13-III
BERAT
3.259.205 3.911.045 4.562.886
175 G-4-14-I
INFARK RINGAN
2.965.049 3.558.058 4.151.068
176 G-4-14-II
INFARK SEDANG
5.394.834 6.473.800 7.552.767
177 G-4-14-III
INFARK BERAT
6.745.881 8.095.057 9.444.234
178 G-4-15-I
2.382.627 2.859.152 3.335.678
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
179 G-4-15-II
2.843.676 3.412.411 3.981.146
180 G-4-15-III
3.696.648 4.435.978 5.175.307
187 G-4-18-I
PERSARAFAN RINGAN
2.355.342 2.826.410 3.297.479
188 G-4-18-II
PERSARAFAN SEDANG
4.586.909 5.504.291 6.421.673
189 G-4-18-III
PERSARAFAN BERAT
4.855.524 5.826.628 6.797.733
190 G-4-19-I
2.629.182 3.155.018 3.680.855
191 G-4-19-II
3.633.629 4.360.355 5.087.081
192 G-4-19-III
4.567.793 5.481.352 6.394.911
211 G-4-26-I
(RINGAN)
2.361.689 2.834.027 3.306.364
212 G-4-26-II
(SEDANG)
2.740.364 3.288.437 3.836.510
213 G-4-26-III
(BERAT)
4.023.825 4.828.590 5.633.355
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
229 I-1-01-I
RINGAN
33.941.468 40.729.761 47.518.055
230 I-1-01-II
SEDANG
34.688.357 41.626.028 48.563.700
231 I-1-01-III
BERAT
54.754.906 65.705.887 76.656.868
232 I-1-02-I
RINGAN
18.830.531 22.596.637 26.362.743
233 I-1-02-II
SEDANG
24.291.385 29.149.662 34.007.938
234 I-1-02-III
BERAT
29.940.544 35.928.653 41.916.761
235 I-1-03-I
11.578.737 13.894.485 16.210.232
236 I-1-03-II
13.269.250 15.923.100 18.576.950
237 I-1-03-III
21.950.970 26.341.164 30.731.357
238 I-1-04-I
JANTUNG RINGAN
18.032.333 21.638.800 25.245.267
239 I-1-04-II
JANTUNG SEDANG
18.479.450 22.175.340 25.871.230
240 I-1-04-III
JANTUNG BERAT
42.873.181 51.447.818 60.022.454
241 I-1-05-I
24.922.761 29.907.313 34.891.866
242 I-1-05-II
29.907.313 35.888.776 41.870.239
243 I-1-05-III
41.152.275 49.382.730 57.613.184
247 I-1-07-I
20.180.335 24.216.402 28.252.469
248 I-1-07-II
24.896.543 29.875.851 34.855.160
249 I-1-07-III
27.161.966 32.594.360 38.026.753
250 I-1-11-I
3.247.618 3.897.141 4.546.665
251 I-1-11-II
3.611.026 4.333.232 5.055.437
252 I-1-11-III
4.805.175 5.766.211 6.727.246
253 I-1-12-I
RINGAN
8.998.562 10.798.275 12.597.987
254 I-1-12-II
SEDANG
10.225.966 12.271.159 14.316.352
255 I-1-12-III
BERAT
17.409.744 20.891.693 24.373.642
256 I-1-13-I
RINGAN
4.294.708 5.153.650 6.012.592
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
257 I-1-13-II
SEDANG
6.151.822 7.382.187 8.612.551
258 I-1-13-III
BERAT
14.677.978 17.613.573 20.549.169
259 I-1-14-I
PERMANEN RINGAN
19.384.370 23.261.244 27.138.118
260 I-1-14-II
PERMANEN SEDANG
24.092.003 28.910.403 33.728.804
261 I-1-14-III
PERMANEN BERAT
31.568.831 37.882.597 44.196.363
265 I-1-16-I
(RINGAN)
8.307.587 9.969.104 11.630.622
266 I-1-16-II
(SEDANG)
21.599.726 25.919.672 30.239.617
267 I-1-16-III
(BERAT)
24.914.754 29.897.705 34.880.656
268 I-1-17-I
VENA RINGAN
11.711.755 14.054.106 16.396.457
269 I-1-17-II
VENA SEDANG
15.206.507 18.247.809 21.289.110
270 I-1-17-III
VENA BERAT
31.875.022 38.250.026 44.625.030
271 I-1-20-I
RINGAN
10.391.887 12.470.264 14.548.642
272 I-1-20-II
SEDANG
13.140.186 15.768.223 18.396.260
274 I-1-30-I
9.425.001 11.310.001 13.195.001
275 I-1-30-II
19.605.906 23.527.087 27.448.268
276 I-1-30-III
30.382.033 36.458.439 42.534.846
289 I-4-13-I
RINGAN
4.652.956 5.583.548 6.514.139
290 I-4-13-II
SEDANG
5.900.286 7.080.343 8.260.401
291 I-4-13-III
BERAT
10.234.125 12.280.950 14.327.775
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
295 I-4-15-I
(RINGAN)
3.141.496 3.769.796 4.398.095
296 I-4-15-II
(SEDANG)
4.502.481 5.402.978 6.303.474
297 I-4-15-III
(BERAT)
5.131.746 6.158.095 7.184.444
306 I-4-18-III
BERAT
6.390.465 7.668.559 8.946.652
319 I-4-23-I
1.936.744 2.324.093 2.711.442
320 I-4-23-II
2.377.876 2.853.451 3.329.026
321 I-4-23-III
4.646.152 5.575.383 6.504.613
322 I-4-24-I
(RINGAN)
2.312.009 2.774.411 3.236.813
323 I-4-24-II
(SEDANG)
6.368.322 7.641.987 8.915.651
324 I-4-24-III
(BERAT)
8.014.114 9.616.937 11.219.759
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.930.393 22.716.472 26.502.551
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.622.414 24.746.897 28.871.380
327 J-1-01-III
TRAKEOSTOMI BERAT
37.348.906 44.818.687 52.288.468
328 J-1-02-I
TRAKEOSTOMI RINGAN
8.875.575 10.650.690 12.425.805
329 J-1-02-II
TRAKEOSTOMI SEDANG
10.209.076 12.250.891 14.292.706
330 J-1-02-III
TRAKEOSTOMI BERAT
16.661.642 19.993.970 23.326.298
334 J-1-20-I
RINGAN
5.830.044 6.996.053 8.162.062
335 J-1-20-II
SEDANG
7.703.429 9.244.115 10.784.801
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
337 J-1-30-I
RINGAN
2.929.252 3.515.102 4.100.953
338 J-1-30-II
SEDANG
9.610.717 11.532.861 13.455.004
339 J-1-30-III
BERAT
25.904.379 31.085.255 36.266.130
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.567.417 1.880.900 2.194.384
374 J-4-21-II
LAIN-LAIN (SEDANG)
3.172.011 3.806.413 4.440.815
375 J-4-21-III
LAIN-LAIN (BERAT)
4.500.613 5.400.736 6.300.859
376 K-1-10-I
(RINGAN)
4.237.737 5.085.284 5.932.831
377 K-1-10-II
(SEDANG)
8.009.355 9.611.226 11.213.097
378 K-1-10-III
(BERAT)
9.372.120 11.246.544 13.120.968
382 K-1-12-I
FEMORAL (RINGAN)
2.655.801 3.186.961 3.718.121
383 K-1-12-II
FEMORAL (SEDANG)
3.452.141 4.142.569 4.832.997
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
384 K-1-12-III
FEMORAL (BERAT)
6.885.217 8.262.260 9.639.304
394 K-1-30-I
KOMPLEKS (RINGAN)
6.093.437 7.312.124 8.530.811
395 K-1-30-II
KOMPLEKS (SEDANG)
8.464.432 10.157.318 11.850.205
396 K-1-30-III
KOMPLEKS (BERAT)
15.730.031 18.876.037 22.022.043
412 K-4-13-I
2.359.484 2.831.380 3.303.277
413 K-4-13-II
3.049.445 3.659.334 4.269.224
414 K-4-13-III
5.001.640 6.001.968 7.002.296
415 K-4-14-I
RINGAN
1.968.890 2.362.668 2.756.446
416 K-4-14-II
SEDANG
2.664.831 3.197.797 3.730.763
417 K-4-14-III
BERAT
4.015.032 4.818.038 5.621.045
424 K-4-17-I
(RINGAN)
2.549.555 3.059.466 3.569.376
425 K-4-17-II
(SEDANG)
3.608.059 4.329.671 5.051.282
426 K-4-17-III
(BERAT)
4.069.898 4.883.878 5.697.858
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
430 L-1-20-I
RINGAN
21.743.114 26.091.737 30.440.360
431 L-1-20-II
SEDANG
22.408.294 26.889.953 31.371.612
432 L-1-20-III
BERAT
33.677.552 40.413.063 47.148.573
433 L-1-30-I
RINGAN
6.970.861 8.365.033 9.759.205
434 L-1-30-II
SEDANG
12.686.741 15.224.090 17.761.438
435 L-1-30-III
BERAT
15.068.452 18.082.142 21.095.833
436 L-1-40-I
PAYUDARA RINGAN
3.313.499 3.976.199 4.638.899
437 L-1-40-II
PAYUDARA SEDANG
7.028.762 8.434.515 9.840.267
438 L-1-40-III
PAYUDARA BERAT
11.933.593 14.320.311 16.707.030
451 L-4-13-I
PAYUDARA RINGAN
1.480.604 1.776.725 2.072.846
452 L-4-13-II
PAYUDARA SEDANG
2.111.195 2.533.434 2.955.673
453 L-4-13-III
PAYUDARA BERAT
2.555.649 3.066.779 3.577.909
454 L-4-14-I
(RINGAN)
1.570.347 1.884.417 2.198.486
455 L-4-14-II
(SEDANG)
2.356.851 2.828.221 3.299.591
456 L-4-14-III
(BERAT)
4.807.985 5.769.582 6.731.179
457 M-1-01-I
7.670.316 9.204.379 10.738.442
458 M-1-01-II
8.561.313 10.273.576 11.985.839
459 M-1-01-III
12.026.326 14.431.591 16.836.856
463 M-1-03-I
13.789.477 16.547.372 19.305.267
464 M-1-03-II
16.045.786 19.254.943 22.464.100
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
465 M-1-03-III
16.387.445 19.664.935 22.942.424
466 M-1-04-I
4.840.228 5.808.273 6.776.319
467 M-1-04-II
6.199.075 7.438.890 8.678.705
468 M-1-04-III
7.756.974 9.308.368 10.859.763
469 M-1-05-I
6.139.464 7.367.356 8.595.249
470 M-1-05-II
7.129.900 8.555.880 9.981.860
471 M-1-05-III
12.621.198 15.145.437 17.669.677
472 M-1-07-I
6.162.510 7.395.012 8.627.514
473 M-1-07-II
8.255.837 9.907.005 11.558.172
474 M-1-07-III
16.817.923 20.181.508 23.545.092
475 M-1-10-I
WAJAH RINGAN
5.217.227 6.260.673 7.304.118
476 M-1-10-II
WAJAH SEDANG
12.837.743 15.405.292 17.972.841
477 M-1-10-III
WAJAH BERAT
17.497.304 20.996.765 24.496.225
478 M-1-20-I
MAYOR RINGAN
5.145.966 6.175.159 7.204.352
479 M-1-20-II
MAYOR SEDANG
5.436.862 6.524.234 7.611.607
480 M-1-20-III
MAYOR BERAT
14.335.069 17.202.082 20.069.096
484 M-1-40-I
2.992.163 3.590.595 4.189.028
485 M-1-40-II
5.494.336 6.593.203 7.692.070
486 M-1-40-III
8.907.726 10.689.272 12.470.817
490 M-1-60-I
2.982.766 3.579.319 4.175.872
491 M-1-60-II
5.996.340 7.195.607 8.394.875
492 M-1-60-III
9.893.812 11.872.574 13.851.336
493 M-1-70-I
(RINGAN)
9.228.736 11.074.483 12.920.230
494 M-1-70-II
(SEDANG)
11.573.920 13.888.704 16.203.488
495 M-1-70-III
(BERAT)
12.180.330 14.616.397 17.052.463
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
502 M-4-11-I
RINGAN
2.085.210 2.502.252 2.919.294
503 M-4-11-II
SEDANG
4.771.545 5.725.854 6.680.163
504 M-4-11-III
BERAT
9.369.321 11.243.185 13.117.049
505 M-4-12-I
RINGAN
1.568.959 1.882.751 2.196.543
506 M-4-12-II
SEDANG
2.851.598 3.421.918 3.992.238
508 M-4-13-I
3.544.680 4.253.616 4.962.552
509 M-4-13-II
3.915.621 4.698.745 5.481.870
510 M-4-13-III
8.635.423 10.362.507 12.089.592
520 M-4-17-I
RINGAN
1.960.630 2.352.756 2.744.882
521 M-4-17-II
SEDANG
2.757.360 3.308.832 3.860.304
522 M-4-17-III
BERAT
3.852.785 4.623.342 5.393.899
526 M-4-19-I
2.322.090 2.786.509 3.250.927
527 M-4-19-II
3.709.645 4.451.574 5.193.503
528 M-4-19-III
5.634.981 6.761.978 7.888.974
529 M-4-20-I
1.569.192 1.883.030 2.196.869
530 M-4-20-II
2.360.229 2.832.275 3.304.321
531 M-4-20-III
2.609.924 3.131.909 3.653.893
532 M-4-21-I
1.566.111 1.879.333 2.192.556
533 M-4-21-II
2.057.801 2.469.361 2.880.921
534 M-4-21-III
4.815.865 5.779.037 6.742.210
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
541 N-1-12-I
3.096.696 3.716.036 4.335.375
542 N-1-12-II
10.028.806 12.034.567 14.040.329
543 N-1-12-III
18.217.973 21.861.568 25.505.163
547 N-1-30-I
BAWAH RINGAN
5.983.827 7.180.592 8.377.358
548 N-1-30-II
BAWAH SEDANG
7.789.620 9.347.544 10.905.468
549 N-1-30-III
BAWAH BERAT
8.950.118 10.740.142 12.530.166
553 N-4-10-I
RINGAN
1.963.753 2.356.504 2.749.254
554 N-4-10-II
SEDANG
3.275.121 3.930.145 4.585.170
555 N-4-10-III
BERAT
4.381.378 5.257.653 6.133.929
565 N-4-14-I
1.359.475 1.631.370 1.903.265
566 N-4-14-II
2.098.457 2.518.148 2.937.839
567 N-4-14-III
3.403.028 4.083.633 4.764.239
568 N-4-15-I
URIN RINGAN
1.950.931 2.341.117 2.731.303
569 N-4-15-II
URIN SEDANG
2.420.595 2.904.714 3.388.833
570 N-4-15-III
URIN BERAT
2.762.336 3.314.803 3.867.270
571 N-4-16-I
(RINGAN)
2.625.563 3.150.675 3.675.788
572 N-4-16-II
(SEDANG)
3.138.996 3.766.795 4.394.594
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
573 N-4-16-III
(BERAT)
5.360.158 6.432.190 7.504.222
577 O-6-11-I
2.072.955 2.487.546 2.902.137
578 O-6-11-II
2.753.975 3.304.770 3.855.564
579 O-6-11-III
4.676.786 5.612.143 6.547.500
580 O-6-12-I
1.948.517 2.338.220 2.727.923
581 O-6-12-II
2.340.164 2.808.196 3.276.229
582 O-6-12-III
3.055.737 3.666.884 4.278.031
586 P-8-01-I
RINGAN
39.529.789 47.435.747 55.341.704
587 P-8-01-II
SEDANG
48.911.930 58.694.316 68.476.702
588 P-8-01-III
BERAT
57.408.895 68.890.674 80.372.453
589 P-8-02-I
62.558.770 75.070.524 87.582.278
590 P-8-02-II
71.761.349 86.113.619 100.465.888
591 P-8-02-III
81.992.472 98.390.967 114.789.461
592 P-8-03-I
2.152.309 2.582.771 3.013.233
593 P-8-03-II
3.019.871 3.623.846 4.227.820
594 P-8-03-III
4.756.479 5.707.774 6.659.070
595 P-8-04-I
19.330.253 23.196.304 27.062.355
596 P-8-04-II
33.746.233 40.495.480 47.244.726
597 P-8-04-III
48.383.604 58.060.325 67.737.046
598 P-8-05-I
14.174.885 17.009.862 19.844.839
599 P-8-05-II
20.083.854 24.100.625 28.117.396
600 P-8-05-III
29.491.897 35.390.277 41.288.656
601 P-8-06-I
2.116.984 2.540.381 2.963.778
602 P-8-06-II
5.216.322 6.259.586 7.302.850
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
603 P-8-06-III
8.342.463 10.010.955 11.679.448
604 P-8-07-I
3.029.751 3.635.701 4.241.651
605 P-8-07-II
8.476.779 10.172.135 11.867.491
606 P-8-07-III
11.194.332 13.433.198 15.672.064
607 P-8-08-I
3.534.242 4.241.090 4.947.938
608 P-8-08-II
5.014.921 6.017.905 7.020.890
609 P-8-08-III
8.120.261 9.744.313 11.368.366
610 P-8-10-I
1.839.945 2.207.934 2.575.924
611 P-8-10-II
3.155.226 3.786.271 4.417.316
612 P-8-10-III
6.194.639 7.433.566 8.672.494
613 P-8-11-I
RINGAN
2.203.274 2.643.929 3.084.584
614 P-8-11-II
SEDANG
11.018.783 13.222.540 15.426.297
615 P-8-11-III
BERAT
11.249.629 13.499.554 15.749.480
616 P-8-12-I
RINGAN
2.996.040 3.595.248 4.194.456
617 P-8-12-II
SEDANG
4.664.874 5.597.849 6.530.823
618 P-8-12-III
BERAT
5.497.972 6.597.566 7.697.160
619 P-8-13-I
RINGAN
1.983.117 2.379.741 2.776.364
620 P-8-13-II
SEDANG
3.429.021 4.114.825 4.800.629
621 P-8-13-III
BERAT
5.104.519 6.125.423 7.146.327
622 P-8-14-I
2.095.672 2.514.806 2.933.941
623 P-8-14-II
5.777.135 6.932.562 8.087.989
624 P-8-14-III
6.345.874 7.615.049 8.884.224
625 P-8-15-I
RINGAN
2.127.791 2.553.349 2.978.907
626 P-8-15-II
SEDANG
4.256.180 5.107.416 5.958.652
627 P-8-15-III
BERAT
4.989.574 5.987.489 6.985.404
628 P-8-16-I
1.930.557 2.316.669 2.702.780
629 P-8-16-II
2.624.547 3.149.457 3.674.366
630 P-8-16-III
2.729.866 3.275.839 3.821.812
631 P-8-17-I
RINGAN
1.683.116 2.019.739 2.356.362
632 P-8-17-II
SEDANG
4.375.955 5.251.146 6.126.337
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
633 P-8-17-III
BERAT
8.270.744 9.924.892 11.579.041
634 S-4-10-I
1.570.272 1.884.326 2.198.381
635 S-4-10-II
1.964.518 2.357.421 2.750.325
636 S-4-10-III
2.554.898 3.065.878 3.576.857
646 S-4-14-I
KANAK-KANAK RINGAN
958.566 1.150.279 1.341.992
647 S-4-14-II
KANAK-KANAK SEDANG
2.036.316 2.443.579 2.850.842
648 S-4-14-III
KANAK-KANAK BERAT
3.861.580 4.633.896 5.406.212
649 S-4-15-I
YANG LAIN (RINGAN)
724.972 869.967 1.014.961
650 S-4-15-II
YANG LAIN (SEDANG)
1.368.270 1.641.924 1.915.577
651 S-4-15-III
YANG LAIN (BERAT)
1.772.227 2.126.673 2.481.118
655 S-4-17-I
1.465.476 1.758.571 2.051.666
656 S-4-17-II
1.963.077 2.355.693 2.748.308
657 S-4-17-III
3.209.077 3.850.892 4.492.708
658 T-1-10-I
RINGAN
1.674.660 2.009.592 2.344.524
659 T-1-10-II
SEDANG
2.248.954 2.698.745 3.148.536
660 T-1-10-III
BERAT
4.091.581 4.909.898 5.728.214
661 T-4-10-I
662.905 795.485 928.066
662 T-4-10-II
1.263.349 1.516.019 1.768.689
663 T-4-10-III
1.836.567 2.203.880 2.571.193
664 T-4-11-I
887.381 1.064.857 1.242.334
665 T-4-11-II
1.396.485 1.675.783 1.955.080
666 T-4-11-III
2.249.327 2.699.192 3.149.057
667 T-4-12-I
LAIN (RINGAN)
1.378.928 1.654.714 1.930.500
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
668 T-4-12-II
LAIN (SEDANG)
2.084.202 2.501.043 2.917.883
669 T-4-12-III
LAIN (BERAT)
3.226.546 3.871.856 4.517.165
673 U-1-11-I
(RINGAN)
5.187.138 6.224.566 7.261.993
674 U-1-11-II
(SEDANG)
6.878.757 8.254.509 9.630.260
675 U-1-11-III
(BERAT)
12.899.021 15.478.825 18.058.629
682 U-1-14-I
MULUT (RINGAN)
3.172.427 3.806.912 4.441.398
683 U-1-14-II
MULUT (SEDANG)
3.893.206 4.671.847 5.450.488
684 U-1-14-III
MULUT (BERAT)
4.613.559 5.536.270 6.458.982
688 U-1-20-I
4.818.579 5.782.294 6.746.010
689 U-1-20-II
6.324.045 7.588.855 8.853.664
690 U-1-20-III
12.704.333 15.245.200 17.786.067
694 U-4-10-I
TELINGA RINGAN
3.848.740 4.618.488 5.388.236
695 U-4-10-II
TELINGA SEDANG
6.391.870 7.670.244 8.948.619
696 U-4-10-III
TELINGA BERAT
9.813.619 11.776.343 13.739.067
703 U-4-13-I
1.542.426 1.850.912 2.159.397
704 U-4-13-II
1.800.138 2.160.165 2.520.193
705 U-4-13-III
2.036.759 2.444.111 2.851.462
709 U-4-15-I
1.575.117 1.890.141 2.205.164
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
710 U-4-15-II
1.969.629 2.363.554 2.757.480
711 U-4-15-III
2.753.754 3.304.505 3.855.256
712 V-1-10-I
RINGAN
4.607.857 5.529.428 6.450.999
713 V-1-10-II
SEDANG
5.289.621 6.347.545 7.405.469
718 V-1-12-I
MODERAT (RINGAN)
3.875.648 4.650.777 5.425.907
719 V-1-12-II
MODERAT (SEDANG)
8.919.535 10.703.442 12.487.350
720 V-1-12-III
MODERAT (BERAT)
10.253.561 12.304.273 14.354.985
721 V-1-13-I
KOMPLEK (RINGAN)
5.637.400 6.764.880 7.892.360
722 V-1-13-II
KOMPLEK (SEDANG)
8.577.215 10.292.658 12.008.101
723 V-1-13-III
KOMPLEK (BERAT)
11.895.796 14.274.956 16.654.115
724 V-1-14-I
RINGAN
6.263.800 7.516.560 8.769.320
725 V-1-14-II
SEDANG
7.615.118 9.138.142 10.661.166
726 V-1-14-III
BERAT
9.323.139 11.187.767 13.052.395
733 V-4-11-I
TUMOR (RINGAN)
2.016.005 2.419.206 2.822.407
734 V-4-11-II
TUMOR (SEDANG)
2.940.492 3.528.590 4.116.688
735 V-4-11-III
TUMOR (BERAT)
5.378.615 6.454.338 7.530.061
736 W-1-01-I
8.014.572 9.617.487 11.220.401
737 W-1-01-II
8.988.278 10.785.934 12.583.590
738 W-1-01-III
12.680.083 15.216.100 17.752.116
742 W-1-11-I
RINGAN
2.765.372 3.318.446 3.871.521
743 W-1-11-II
SEDANG
4.861.838 5.834.206 6.806.573
744 W-1-11-III
BERAT
10.237.662 12.285.194 14.332.726
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
745 W-1-12-I
2.117.399 2.540.879 2.964.359
746 W-1-12-II
2.393.965 2.872.759 3.351.552
747 W-1-12-III
3.677.433 4.412.919 5.148.406
748 W-1-13-I
RINGAN
1.856.832 2.228.199 2.599.565
749 W-1-13-II
SEDANG
2.015.985 2.419.181 2.822.378
763 W-4-12-I
1.571.530 1.885.836 2.200.142
764 W-4-12-II
2.156.612 2.587.934 3.019.257
765 W-4-12-III
3.264.428 3.917.314 4.570.200
787 Z-4-12-I
1.180.147 1.416.176 1.652.205
788 Z-4-12-II
3.204.520 3.845.424 4.486.328
789 Z-4-12-III
4.141.796 4.970.155 5.798.515
24 D-2-11-0 PROSEDUR LIMPA 1.280.011
33 F-3-10-0 TERAPI SHOCK 251.198
Rumah Sakit Kelas C
Rawat Jalan
Rumah Sakit Kelas C
Rawat Jalan
72 I-2-16-0 PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK PENGGANTIAN 2.203.593
80 I-2-42-0 PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN LA 2.123.896
Rumah Sakit Kelas C
Rawat Jalan
179 O-7-12-0 PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU PELEBAR 1.169.110
Rumah Sakit Kelas C
Rawat Jalan
191 Q-5-12-0 GIGI 125.646
195 Q-5-16-0 VAKSINASI 100.387
196 Q-5-17-0 PASANG INFUS 86.566
200 Q-5-21-0 ABORSI 81.431
205 Q-5-26-0 BRONKIAL AKUT 194.089
210 Q-5-31-0 FRAKTUR 131.450
214 Q-5-35-0 INFEKSI AKUT 255.846
217 Q-5-38-0 PARU AKUT 203.444
Rumah Sakit Kelas C
Rawat Jalan
276 Z-3-18-0 CT-SCAN KEPALA 247.386
288 Z-3-30-0 FOTOTERAPI 75.368
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.314.355 1.577.226 1.840.096
8 A-4-12-II DEMAM SEDANG 1.696.265 2.035.518 2.374.771
9 A-4-12-III DEMAM BERAT 2.100.186 2.520.224 2.940.261
13 A-4-14-I
RINGAN
2.552.510 3.063.012 3.573.514
14 A-4-14-II
SEDANG
3.283.174 3.939.808 4.596.443
15 A-4-14-III
BERAT
3.761.745 4.514.093 5.266.442
28 B-1-12-I
RINGAN
4.017.243 4.820.692 5.624.140
29 B-1-12-II
SEDANG
8.609.934 10.331.921 12.053.908
30 B-1-12-III
BERAT
10.478.615 12.574.338 14.670.061
31 B-1-13-I
(RINGAN)
3.238.203 3.885.843 4.533.484
32 B-1-13-II
(SEDANG)
5.274.562 6.329.475 7.384.387
33 B-1-13-III
(BERAT)
7.776.185 9.331.422 10.886.659
34 B-1-14-I
RINGAN
4.394.925 5.273.910 6.152.895
35 B-1-14-II
SEDANG
4.888.043 5.865.652 6.843.260
36 B-1-14-III
BERAT
7.646.762 9.176.115 10.705.467
40 B-4-11-I
RINGAN
2.390.177 2.868.213 3.346.248
41 B-4-11-II
SEDANG
3.582.709 4.299.251 5.015.793
Rumah Sakit Kelas D
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
46 B-4-13-I
1.967.358 2.360.829 2.754.301
47 B-4-13-II
2.545.728 3.054.873 3.564.019
48 B-4-13-III
3.745.502 4.494.603 5.243.703
73 D-1-20-I
3.015.576 3.618.691 4.221.806
74 D-1-20-II
8.687.860 10.425.432 12.163.004
75 D-1-20-III
13.908.102 16.689.722 19.471.342
85 D-4-13-I
SEL SICKLE RINGAN
1.316.070 1.579.283 1.842.497
86 D-4-13-II
SEL SICKLE SEDANG
1.973.213 2.367.856 2.762.499
87 D-4-13-III
SEL SICKLE BERAT
2.420.270 2.904.324 3.388.378
88 D-4-14-I
1.646.787 1.976.145 2.305.502
89 D-4-14-II
3.053.720 3.664.464 4.275.208
90 D-4-14-III
4.281.982 5.138.378 5.994.775
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.085.522 4.902.626 5.719.731
98 E-1-20-II
TIROGLOSAL SEDANG
5.949.417 7.139.300 8.329.184
99 E-1-20-III
TIROGLOSAL BERAT
9.874.327 11.849.193 13.824.058
100 E-4-10-I
METABOLIK RINGAN
1.820.720 2.184.865 2.549.009
101 E-4-10-II
METABOLIK SEDANG
2.798.255 3.357.905 3.917.556
102 E-4-10-III
METABOLIK BERAT
3.876.632 4.651.958 5.427.284
130 F-4-16-I
RINGAN
3.457.623 4.149.148 4.840.672
131 F-4-16-II
SEDANG
4.005.271 4.806.325 5.607.379
132 F-4-16-III
BERAT
5.346.368 6.415.641 7.484.915
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
142 G-1-01-I
RINGAN
6.087.901 7.305.481 8.523.061
163 G-4-10-I
RINGAN
1.965.926 2.359.111 2.752.297
164 G-4-10-II
SEDANG
2.396.805 2.876.166 3.355.527
166 G-4-11-I
DEGENERATIF RINGAN
3.154.212 3.785.055 4.415.897
167 G-4-11-II
DEGENERATIF SEDANG
4.523.753 5.428.504 6.333.254
168 G-4-11-III
DEGENERATIF BERAT
6.013.815 7.216.578 8.419.341
172 G-4-13-I
RINGAN
1.614.777 1.937.733 2.260.688
173 G-4-13-II
SEDANG
2.295.401 2.754.482 3.213.562
174 G-4-13-III
BERAT
2.715.388 3.258.466 3.801.543
175 G-4-14-I
INFARK RINGAN
2.576.328 3.091.594 3.606.860
176 G-4-14-II
INFARK SEDANG
3.980.167 4.776.200 5.572.234
177 G-4-14-III
INFARK BERAT
4.976.934 5.972.321 6.967.708
178 G-4-15-I
1.967.992 2.361.590 2.755.188
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
179 G-4-15-II
2.396.742 2.876.090 3.355.438
180 G-4-15-III
3.087.836 3.705.403 4.322.970
187 G-4-18-I
PERSARAFAN RINGAN
1.965.077 2.358.092 2.751.108
188 G-4-18-II
PERSARAFAN SEDANG
3.369.426 4.043.311 4.717.196
189 G-4-18-III
PERSARAFAN BERAT
3.577.022 4.292.426 5.007.830
190 G-4-19-I
1.964.026 2.356.831 2.749.636
191 G-4-19-II
3.062.540 3.675.048 4.287.556
192 G-4-19-III
3.849.883 4.619.860 5.389.836
211 G-4-26-I
(RINGAN)
2.287.939 2.745.527 3.203.115
212 G-4-26-II
(SEDANG)
2.676.281 3.211.537 3.746.793
213 G-4-26-III
(BERAT)
3.391.409 4.069.691 4.747.973
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
229 I-1-01-I
RINGAN
28.319.454 33.983.344 39.647.235
230 I-1-01-II
SEDANG
28.942.629 34.731.155 40.519.681
231 I-1-01-III
BERAT
45.685.385 54.822.462 63.959.539
232 I-1-02-I
RINGAN
15.711.470 18.853.764 21.996.058
233 I-1-02-II
SEDANG
20.267.796 24.321.355 28.374.914
234 I-1-02-III
BERAT
24.981.237 29.977.484 34.973.732
235 I-1-03-I
9.709.892 11.651.871 13.593.849
236 I-1-03-II
11.183.751 13.420.501 15.657.251
237 I-1-03-III
18.500.983 22.201.180 25.901.377
238 I-1-04-I
JANTUNG RINGAN
14.123.515 16.948.217 19.772.920
239 I-1-04-II
JANTUNG SEDANG
15.198.231 18.237.877 21.277.523
240 I-1-04-III
JANTUNG BERAT
31.518.798 37.822.558 44.126.318
241 I-1-05-I
20.794.592 24.953.511 29.112.429
242 I-1-05-II
24.953.511 29.944.213 34.934.915
243 I-1-05-III
34.335.873 41.203.048 48.070.223
247 I-1-07-I
15.423.470 18.508.165 21.592.859
248 I-1-07-II
19.027.984 22.833.581 26.639.178
249 I-1-07-III
20.759.407 24.911.288 29.063.170
250 I-1-11-I
2.386.918 2.864.302 3.341.685
251 I-1-11-II
2.654.014 3.184.817 3.715.620
252 I-1-11-III
3.531.684 4.238.021 4.944.358
253 I-1-12-I
RINGAN
7.541.908 9.050.289 10.558.671
254 I-1-12-II
SEDANG
8.618.773 10.342.527 12.066.282
255 I-1-12-III
BERAT
14.595.442 17.514.530 20.433.619
256 I-1-13-I
RINGAN
3.741.390 4.489.668 5.237.945
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
257 I-1-13-II
SEDANG
5.151.503 6.181.803 7.212.104
258 I-1-13-III
BERAT
11.218.117 13.461.740 15.705.364
259 I-1-14-I
PERMANEN RINGAN
16.173.572 19.408.286 22.643.001
260 I-1-14-II
PERMANEN SEDANG
20.101.439 24.121.727 28.142.015
261 I-1-14-III
PERMANEN BERAT
26.339.817 31.607.780 36.875.744
265 I-1-16-I
(RINGAN)
6.931.531 8.317.837 9.704.143
266 I-1-16-II
(SEDANG)
18.021.980 21.626.376 25.230.772
267 I-1-16-III
(BERAT)
20.787.912 24.945.494 29.103.076
268 I-1-17-I
VENA RINGAN
2.657.155 3.188.586 3.720.018
269 I-1-17-II
VENA SEDANG
4.482.251 5.378.701 6.275.151
270 I-1-17-III
VENA BERAT
26.104.017 31.324.821 36.545.624
271 I-1-20-I
RINGAN
3.222.071 3.866.485 4.510.899
272 I-1-20-II
SEDANG
5.332.739 6.399.287 7.465.835
274 I-1-30-I
7.863.858 9.436.629 11.009.401
275 I-1-30-II
16.358.413 19.630.095 22.901.778
276 I-1-30-III
25.349.598 30.419.518 35.489.438
289 I-4-13-I
RINGAN
3.428.994 4.114.793 4.800.592
290 I-4-13-II
SEDANG
4.993.552 5.992.263 6.990.973
291 I-4-13-III
BERAT
8.532.901 10.239.481 11.946.061
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
295 I-4-15-I
(RINGAN)
2.632.879 3.159.455 3.686.031
296 I-4-15-II
(SEDANG)
3.932.473 4.718.967 5.505.462
297 I-4-15-III
(BERAT)
4.482.073 5.378.487 6.274.902
306 I-4-18-III
BERAT
5.386.090 6.463.308 7.540.526
319 I-4-23-I
1.615.945 1.939.134 2.262.323
320 I-4-23-II
1.984.008 2.380.809 2.777.611
321 I-4-23-III
3.876.570 4.651.885 5.427.199
322 I-4-24-I
(RINGAN)
1.948.636 2.338.363 2.728.090
323 I-4-24-II
(SEDANG)
4.679.531 5.615.438 6.551.344
324 I-4-24-III
(BERAT)
5.939.259 7.127.110 8.314.962
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.579.346 22.295.215 26.011.084
326 J-1-01-II
TRAKEOSTOMI SEDANG
19.848.248 23.817.897 27.787.547
327 J-1-01-III
TRAKEOSTOMI BERAT
27.613.439 33.136.127 38.658.815
328 J-1-02-I
TRAKEOSTOMI RINGAN
7.480.620 8.976.745 10.472.869
329 J-1-02-II
TRAKEOSTOMI SEDANG
9.153.763 10.984.516 12.815.268
330 J-1-02-III
TRAKEOSTOMI BERAT
12.305.009 14.766.011 17.227.013
334 J-1-20-I
RINGAN
3.204.711 3.845.653 4.486.596
335 J-1-20-II
SEDANG
3.953.628 4.744.353 5.535.079
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
337 J-1-30-I
RINGAN
2.160.941 2.593.130 3.025.318
338 J-1-30-II
SEDANG
8.100.222 9.720.266 11.340.310
339 J-1-30-III
BERAT
21.721.080 26.065.295 30.409.511
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.409.141 1.690.969 1.972.797
374 J-4-21-II
LAIN-LAIN (SEDANG)
2.631.371 3.157.645 3.683.919
375 J-4-21-III
LAIN-LAIN (BERAT)
3.768.946 4.522.735 5.276.524
376 K-1-10-I
(RINGAN)
3.549.744 4.259.692 4.969.641
377 K-1-10-II
(SEDANG)
5.886.676 7.064.011 8.241.347
378 K-1-10-III
(BERAT)
6.904.358 8.285.230 9.666.102
382 K-1-12-I
FEMORAL (RINGAN)
1.960.555 2.352.666 2.744.777
383 K-1-12-II
FEMORAL (SEDANG)
2.553.095 3.063.714 3.574.333
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
384 K-1-12-III
FEMORAL (BERAT)
5.077.889 6.093.466 7.109.044
394 K-1-30-I
KOMPLEKS (RINGAN)
4.604.482 5.525.379 6.446.275
395 K-1-30-II
KOMPLEKS (SEDANG)
7.092.618 8.511.142 9.929.666
396 K-1-30-III
KOMPLEKS (BERAT)
13.176.855 15.812.226 18.447.597
412 K-4-13-I
1.966.795 2.360.154 2.753.513
413 K-4-13-II
2.555.732 3.066.878 3.578.024
414 K-4-13-III
4.172.307 5.006.768 5.841.229
415 K-4-14-I
RINGAN
1.642.248 1.970.697 2.299.147
416 K-4-14-II
SEDANG
2.227.538 2.673.046 3.118.554
417 K-4-14-III
BERAT
3.586.633 4.303.959 5.021.286
424 K-4-17-I
(RINGAN)
2.317.777 2.781.332 3.244.888
425 K-4-17-II
(SEDANG)
3.280.053 3.936.064 4.592.075
426 K-4-17-III
(BERAT)
3.699.908 4.439.889 5.179.871
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
430 L-1-20-I
RINGAN
16.034.514 19.241.417 22.448.319
431 L-1-20-II
SEDANG
16.669.034 20.002.840 23.336.647
432 L-1-20-III
BERAT
28.183.216 33.819.859 39.456.502
433 L-1-30-I
RINGAN
5.875.266 7.050.319 8.225.372
434 L-1-30-II
SEDANG
10.572.748 12.687.297 14.801.847
435 L-1-30-III
BERAT
11.165.043 13.398.052 15.631.060
436 L-1-40-I
PAYUDARA RINGAN
2.792.724 3.351.268 3.909.813
437 L-1-40-II
PAYUDARA SEDANG
4.895.923 5.875.108 6.854.292
438 L-1-40-III
PAYUDARA BERAT
8.286.793 9.944.152 11.601.510
451 L-4-13-I
PAYUDARA RINGAN
1.363.826 1.636.591 1.909.356
452 L-4-13-II
PAYUDARA SEDANG
1.704.709 2.045.651 2.386.593
453 L-4-13-III
PAYUDARA BERAT
2.406.685 2.888.022 3.369.360
454 L-4-14-I
(RINGAN)
1.352.522 1.623.026 1.893.531
455 L-4-14-II
(SEDANG)
2.005.348 2.406.417 2.807.487
456 L-4-14-III
(BERAT)
3.695.418 4.434.502 5.173.585
457 M-1-01-I
6.399.816 7.679.780 8.959.743
458 M-1-01-II
7.143.230 8.571.876 10.000.522
459 M-1-01-III
10.034.303 12.041.164 14.048.025
463 M-1-03-I
11.484.673 13.781.608 16.078.543
464 M-1-03-II
13.443.044 16.131.653 18.820.262
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
465 M-1-03-III
15.571.340 18.685.608 21.799.875
466 M-1-04-I
3.573.226 4.287.871 5.002.516
467 M-1-04-II
4.595.083 5.514.099 6.433.116
468 M-1-04-III
5.749.880 6.899.856 8.049.831
469 M-1-05-I
4.540.834 5.449.001 6.357.168
470 M-1-05-II
5.240.299 6.288.358 7.336.418
471 M-1-05-III
8.925.656 10.710.787 12.495.918
472 M-1-07-I
5.141.761 6.170.113 7.198.465
473 M-1-07-II
6.888.353 8.266.023 9.643.694
474 M-1-07-III
14.032.228 16.838.673 19.645.119
475 M-1-10-I
WAJAH RINGAN
3.853.825 4.624.590 5.395.355
476 M-1-10-II
WAJAH SEDANG
10.820.063 12.984.076 15.148.088
477 M-1-10-III
WAJAH BERAT
15.943.017 19.131.620 22.320.224
478 M-1-20-I
MAYOR RINGAN
3.802.559 4.563.071 5.323.582
479 M-1-20-II
MAYOR SEDANG
4.319.217 5.183.060 6.046.903
480 M-1-20-III
MAYOR BERAT
10.537.260 12.644.712 14.752.164
484 M-1-40-I
2.252.255 2.702.706 3.153.157
485 M-1-40-II
3.699.609 4.439.531 5.179.452
486 M-1-40-III
6.193.868 7.432.641 8.671.415
490 M-1-60-I
2.304.474 2.765.368 3.226.263
491 M-1-60-II
4.611.691 5.534.029 6.456.367
492 M-1-60-III
8.005.270 9.606.324 11.207.378
493 M-1-70-I
(RINGAN)
3.082.102 3.698.522 4.314.942
494 M-1-70-II
(SEDANG)
6.284.072 7.540.886 8.797.700
495 M-1-70-III
(BERAT)
8.788.585 10.546.302 12.304.019
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
502 M-4-11-I
RINGAN
2.074.622 2.489.546 2.904.471
503 M-4-11-II
SEDANG
4.041.821 4.850.185 5.658.549
504 M-4-11-III
BERAT
6.886.217 8.263.460 9.640.704
505 M-4-12-I
RINGAN
1.314.403 1.577.284 1.840.165
506 M-4-12-II
SEDANG
2.391.402 2.869.682 3.347.963
508 M-4-13-I
2.908.112 3.489.734 4.071.357
509 M-4-13-II
3.288.101 3.945.721 4.603.341
510 M-4-13-III
7.784.184 9.341.021 10.897.858
520 M-4-17-I
RINGAN
1.673.804 2.008.565 2.343.326
521 M-4-17-II
SEDANG
2.296.325 2.755.591 3.214.856
522 M-4-17-III
BERAT
3.220.458 3.864.550 4.508.642
526 M-4-19-I
1.708.651 2.050.382 2.392.112
527 M-4-19-II
2.877.916 3.453.499 4.029.082
528 M-4-19-III
4.923.631 5.908.358 6.893.084
529 M-4-20-I
1.315.377 1.578.453 1.841.528
530 M-4-20-II
1.968.226 2.361.872 2.755.517
531 M-4-20-III
2.187.964 2.625.557 3.063.150
532 M-4-21-I
1.310.989 1.573.187 1.835.385
533 M-4-21-II
2.044.595 2.453.514 2.862.433
534 M-4-21-III
4.058.966 4.870.759 5.682.552
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
541 N-1-12-I
2.609.995 3.131.995 3.653.994
542 N-1-12-II
7.385.889 8.863.066 10.340.244
543 N-1-12-III
13.459.124 16.150.948 18.842.773
547 N-1-30-I
BAWAH RINGAN
5.115.931 6.139.117 7.162.304
548 N-1-30-II
BAWAH SEDANG
7.723.932 9.268.718 10.813.505
549 N-1-30-III
BAWAH BERAT
8.111.234 9.733.481 11.355.728
553 N-4-10-I
RINGAN
1.798.558 2.158.269 2.517.981
554 N-4-10-II
SEDANG
2.630.394 3.156.473 3.682.551
555 N-4-10-III
BERAT
4.209.753 5.051.704 5.893.655
565 N-4-14-I
1.138.067 1.365.681 1.593.294
566 N-4-14-II
1.750.871 2.101.046 2.451.220
567 N-4-14-III
2.839.355 3.407.226 3.975.097
568 N-4-15-I
URIN RINGAN
1.644.307 1.973.169 2.302.030
569 N-4-15-II
URIN SEDANG
2.264.572 2.717.487 3.170.401
570 N-4-15-III
URIN BERAT
2.584.286 3.101.143 3.618.000
571 N-4-16-I
(RINGAN)
2.027.534 2.433.041 2.838.548
572 N-4-16-II
(SEDANG)
2.631.722 3.158.067 3.684.411
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
573 N-4-16-III
(BERAT)
4.517.714 5.421.257 6.324.799
577 O-6-11-I
1.747.153 2.096.584 2.446.014
578 O-6-11-II
2.115.231 2.538.277 2.961.323
579 O-6-11-III
3.581.479 4.297.774 5.014.070
580 O-6-12-I
1.432.111 1.718.533 2.004.956
581 O-6-12-II
1.719.962 2.063.954 2.407.947
582 O-6-12-III
2.160.886 2.593.063 3.025.240
586 P-8-01-I
RINGAN
32.982.134 39.578.561 46.174.987
587 P-8-01-II
SEDANG
40.810.231 48.972.278 57.134.324
588 P-8-01-III
BERAT
47.899.771 57.479.726 67.059.680
589 P-8-02-I
47.812.553 57.375.064 66.937.575
590 P-8-02-II
54.845.920 65.815.104 76.784.288
591 P-8-02-III
62.665.385 75.198.462 87.731.539
592 P-8-03-I
1.802.407 2.162.888 2.523.370
593 P-8-03-II
2.526.391 3.031.669 3.536.948
594 P-8-03-III
4.351.555 5.221.866 6.092.177
595 P-8-04-I
19.181.176 23.017.411 26.853.646
596 P-8-04-II
25.027.472 30.032.967 35.038.461
597 P-8-04-III
35.883.096 43.059.715 50.236.334
598 P-8-05-I
10.449.950 12.539.940 14.629.930
599 P-8-05-II
14.849.995 17.819.994 20.789.993
600 P-8-05-III
21.879.474 26.255.369 30.631.263
601 P-8-06-I
1.805.010 2.166.011 2.527.013
602 P-8-06-II
4.330.188 5.196.226 6.062.264
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
603 P-8-06-III
7.945.365 9.534.437 11.123.510
604 P-8-07-I
2.778.414 3.334.097 3.889.780
605 P-8-07-II
7.068.765 8.482.518 9.896.271
606 P-8-07-III
9.368.733 11.242.479 13.116.226
607 P-8-08-I
3.212.947 3.855.536 4.498.126
608 P-8-08-II
4.559.019 5.470.823 6.382.627
609 P-8-08-III
7.382.056 8.858.467 10.334.878
610 P-8-10-I
1.361.250 1.633.500 1.905.751
611 P-8-10-II
2.411.483 2.893.780 3.376.076
612 P-8-10-III
4.734.452 5.681.342 6.628.233
613 P-8-11-I
RINGAN
1.842.483 2.210.979 2.579.476
614 P-8-11-II
SEDANG
8.121.743 9.746.092 11.370.440
615 P-8-11-III
BERAT
8.291.895 9.950.274 11.608.653
616 P-8-12-I
RINGAN
2.211.276 2.653.532 3.095.787
617 P-8-12-II
SEDANG
3.438.393 4.126.072 4.813.750
618 P-8-12-III
BERAT
4.064.558 4.877.469 5.690.381
619 P-8-13-I
RINGAN
1.802.834 2.163.401 2.523.968
620 P-8-13-II
SEDANG
3.117.292 3.740.750 4.364.208
621 P-8-13-III
BERAT
4.640.472 5.568.566 6.496.661
622 P-8-14-I
2.084.234 2.501.080 2.917.927
623 P-8-14-II
4.249.726 5.099.671 5.949.616
624 P-8-14-III
4.662.035 5.594.442 6.526.849
625 P-8-15-I
RINGAN
1.572.501 1.887.001 2.201.501
626 P-8-15-II
SEDANG
3.132.629 3.759.155 4.385.681
627 P-8-15-III
BERAT
3.677.724 4.413.269 5.148.813
628 P-8-16-I
1.423.475 1.708.170 1.992.865
629 P-8-16-II
2.012.134 2.414.561 2.816.988
630 P-8-16-III
2.610.497 3.132.597 3.654.696
631 P-8-17-I
RINGAN
1.530.105 1.836.126 2.142.147
632 P-8-17-II
SEDANG
3.978.141 4.773.769 5.569.397
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
633 P-8-17-III
BERAT
7.518.858 9.022.630 10.526.401
634 S-4-10-I
1.316.825 1.580.190 1.843.555
635 S-4-10-II
1.645.279 1.974.335 2.303.391
636 S-4-10-III
2.130.196 2.556.235 2.982.274
646 S-4-14-I
KANAK-KANAK RINGAN
799.791 959.749 1.119.707
647 S-4-14-II
KANAK-KANAK SEDANG
1.699.023 2.038.828 2.378.633
648 S-4-14-III
KANAK-KANAK BERAT
3.221.954 3.866.344 4.510.735
649 S-4-15-I
YANG LAIN (RINGAN)
604.889 725.867 846.845
650 S-4-15-II
YANG LAIN (SEDANG)
1.141.631 1.369.958 1.598.284
651 S-4-15-III
YANG LAIN (BERAT)
1.478.678 1.774.414 2.070.149
655 S-4-17-I
1.387.809 1.665.371 1.942.932
656 S-4-17-II
1.707.917 2.049.501 2.391.084
657 S-4-17-III
2.685.235 3.222.282 3.759.329
658 T-1-10-I
RINGAN
1.230.833 1.477.000 1.723.166
659 T-1-10-II
SEDANG
1.652.925 1.983.511 2.314.096
660 T-1-10-III
BERAT
3.007.210 3.608.652 4.210.094
661 T-4-10-I
553.102 663.722 774.343
662 T-4-10-II
1.054.090 1.264.908 1.475.726
663 T-4-10-III
1.532.361 1.838.833 2.145.305
664 T-4-11-I
654.933 785.919 916.906
665 T-4-11-II
1.030.677 1.236.813 1.442.948
666 T-4-11-III
1.660.118 1.992.141 2.324.165
667 T-4-12-I
LAIN (RINGAN)
1.145.483 1.374.580 1.603.676
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
668 T-4-12-II
LAIN (SEDANG)
1.731.716 2.078.059 2.424.403
669 T-4-12-III
LAIN (BERAT)
2.702.753 3.243.304 3.783.855
673 U-1-11-I
(RINGAN)
4.371.887 5.246.264 6.120.641
674 U-1-11-II
(SEDANG)
5.751.625 6.901.950 8.052.275
675 U-1-11-III
(BERAT)
10.871.710 13.046.052 15.220.394
682 U-1-14-I
MULUT (RINGAN)
2.335.413 2.802.495 3.269.578
683 U-1-14-II
MULUT (SEDANG)
2.866.021 3.439.225 4.012.430
684 U-1-14-III
MULUT (BERAT)
3.396.316 4.075.579 4.754.842
688 U-1-20-I
3.546.080 4.255.296 4.964.512
689 U-1-20-II
6.091.553 7.309.864 8.528.174
690 U-1-20-III
10.629.463 12.755.356 14.881.248
694 U-4-10-I
TELINGA RINGAN
2.840.238 3.408.286 3.976.334
695 U-4-10-II
TELINGA SEDANG
5.387.274 6.464.729 7.542.184
696 U-4-10-III
TELINGA BERAT
8.271.234 9.925.481 11.579.728
703 U-4-13-I
1.314.613 1.577.536 1.840.459
704 U-4-13-II
1.499.775 1.799.730 2.099.685
705 U-4-13-III
1.996.100 2.395.320 2.794.540
709 U-4-15-I
1.308.992 1.570.791 1.832.589
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
710 U-4-15-II
1.660.066 1.992.080 2.324.093
711 U-4-15-III
2.303.099 2.763.719 3.224.339
712 V-1-10-I
RINGAN
3.883.650 4.660.380 5.437.110
713 V-1-10-II
SEDANG
4.426.418 5.311.701 6.196.985
718 V-1-12-I
MODERAT (RINGAN)
2.857.625 3.429.149 4.000.674
719 V-1-12-II
MODERAT (SEDANG)
8.015.164 9.618.197 11.221.230
720 V-1-12-III
MODERAT (BERAT)
8.642.031 10.370.437 12.098.843
721 V-1-13-I
KOMPLEK (RINGAN)
4.330.374 5.196.449 6.062.523
722 V-1-13-II
KOMPLEK (SEDANG)
7.229.152 8.674.983 10.120.813
723 V-1-13-III
KOMPLEK (BERAT)
8.658.956 10.390.748 12.122.539
724 V-1-14-I
RINGAN
5.220.062 6.264.074 7.308.086
725 V-1-14-II
SEDANG
6.450.519 7.740.623 9.030.727
726 V-1-14-III
BERAT
7.857.842 9.429.410 11.000.978
733 V-4-11-I
TUMOR (RINGAN)
1.887.948 2.265.538 2.643.128
734 V-4-11-II
TUMOR (SEDANG)
2.650.632 3.180.758 3.710.885
735 V-4-11-III
TUMOR (BERAT)
3.964.478 4.757.374 5.550.270
736 W-1-01-I
5.917.754 7.101.305 8.284.856
737 W-1-01-II
7.141.259 8.569.511 9.997.763
738 W-1-01-III
11.862.772 14.235.326 16.607.881
742 W-1-11-I
RINGAN
2.513.974 3.016.769 3.519.564
743 W-1-11-II
SEDANG
4.419.853 5.303.823 6.187.794
744 W-1-11-III
BERAT
9.306.965 11.168.358 13.029.751
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
745 W-1-12-I
1.562.149 1.874.579 2.187.008
746 W-1-12-II
1.766.905 2.120.286 2.473.667
747 W-1-12-III
2.714.189 3.257.027 3.799.865
748 W-1-13-I
RINGAN
1.549.269 1.859.123 2.168.977
749 W-1-13-II
SEDANG
1.682.060 2.018.472 2.354.884
763 W-4-12-I
1.316.699 1.580.038 1.843.378
764 W-4-12-II
1.994.995 2.393.994 2.792.993
765 W-4-12-III
2.407.361 2.888.833 3.370.305
787 Z-4-12-I
988.089 1.185.707 1.383.325
788 Z-4-12-II
2.407.646 2.889.175 3.370.705
789 Z-4-12-III
3.053.398 3.664.077 4.274.757
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.234.066
31 E-2-22-0 PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROG 171.576
33 F-3-10-0 TERAPI SHOCK 242.391
Rumah Sakit Kelas D
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
67 I-2-11-0 PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTU 2.126.802
70 I-2-14-0 PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUN 3.363.534
72 I-2-16-0 PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK 2.124.498
80 I-2-42-0 PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULA 2.052.015
102 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORA 866.767
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
178 O-7-11-0 PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN KURE 1.786.297
179 O-7-12-0 PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN 859.267
181 P-9-10-0 NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN 173.039
185 P-9-14-0 NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDIT 141.403
191 Q-5-12-0 GIGI 121.610
195 Q-5-16-0 VAKSINASI 97.177
196 Q-5-17-0 PASANG INFUS 83.659
200 Q-5-21-0 ABORSI 65.145
205 Q-5-26-0 BRONKIAL AKUT 187.765
210 Q-5-31-0 FRAKTUR 127.227
214 Q-5-35-0 INFEKSI AKUT 248.709
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
217 Q-5-38-0 PARU AKUT 196.236
238 U-3-10-0 PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGO 190.325
239 U-3-11-0 PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGORO 178.177
241 U-3-13-0 PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENG 184.757
269 Z-3-11-0 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SA 1.396.573
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Jalan
276 Z-3-18-0 CT-SCAN KEPALA 238.506
288 Z-3-30-0 FOTOTERAPI 73.170
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 3.664.865 4.397.838 5.130.811
8 A-4-12-II DEMAM SEDANG 4.563.925 5.476.710 6.389.495
9 A-4-12-III DEMAM BERAT 4.871.006 5.845.207 6.819.408
13 A-4-14-I
RINGAN
3.885.515 4.662.619 5.439.722
14 A-4-14-II
SEDANG
4.997.756 5.997.307 6.996.858
15 A-4-14-III
BERAT
5.726.252 6.871.503 8.016.753
28 B-1-12-I
RINGAN
9.007.236 10.808.684 12.610.131
29 B-1-12-II
SEDANG
19.304.489 23.165.386 27.026.284
30 B-1-12-III
BERAT
23.494.788 28.193.745 32.892.703
31 B-1-13-I
(RINGAN)
7.247.203 8.696.643 10.146.084
32 B-1-13-II
(SEDANG)
11.804.565 14.165.478 16.526.391
33 B-1-13-III
(BERAT)
17.403.212 20.883.854 24.364.496
34 B-1-14-I
RINGAN
9.857.882 11.829.458 13.801.034
35 B-1-14-II
SEDANG
10.963.748 13.156.497 15.349.247
36 B-1-14-III
BERAT
17.151.589 20.581.906 24.012.224
40 B-4-11-I
RINGAN
6.430.670 7.716.805 9.002.939
41 B-4-11-II
SEDANG
9.639.420 11.567.304 13.495.189
Rumah Sakit Kelas A
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
46 B-4-13-I
5.837.931 7.005.518 8.173.104
47 B-4-13-II
6.801.015 8.161.218 9.521.421
48 B-4-13-III
10.077.513 12.093.015 14.108.518
73 D-1-20-I
8.559.977 10.271.972 11.983.967
74 D-1-20-II
23.590.093 28.308.112 33.026.131
75 D-1-20-III
37.420.859 44.905.031 52.389.203
85 D-4-13-I
SEL SICKLE RINGAN
3.762.888 4.515.466 5.268.044
86 D-4-13-II
SEL SICKLE SEDANG
5.325.844 6.391.013 7.456.182
87 D-4-13-III
SEL SICKLE BERAT
6.811.909 8.174.290 9.536.672
88 D-4-14-I
4.226.056 5.071.267 5.916.479
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
89 D-4-14-II
8.914.700 10.697.640 12.480.580
90 D-4-14-III
11.520.723 13.824.867 16.129.012
97 E-1-20-I
TIROGLOSAL RINGAN
9.915.250 11.898.299 13.881.349
98 E-1-20-II
TIROGLOSAL SEDANG
13.345.651 16.014.781 18.683.911
99 E-1-20-III
TIROGLOSAL BERAT
26.567.673 31.881.208 37.194.743
100 E-4-10-I
METABOLIK RINGAN
4.863.836 5.836.603 6.809.370
101 E-4-10-II
METABOLIK SEDANG
6.796.243 8.155.492 9.514.741
102 E-4-10-III
METABOLIK BERAT
12.184.652 14.621.583 17.058.513
130 F-4-16-I
MENTAL RINGAN
7.693.314 9.231.977 10.770.639
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
131 F-4-16-II
MENTAL SEDANG
8.944.811 10.733.773 12.522.735
132 F-4-16-III
MENTAL BERAT
11.939.794 14.327.753 16.715.712
142 G-1-01-I
RINGAN
16.629.491 19.955.389 23.281.287
163 G-4-10-I
RINGAN
5.587.891 6.705.470 7.823.048
164 G-4-10-II
SEDANG
6.830.261 8.196.313 9.562.365
166 G-4-11-I
DEGENERATIF RINGAN
7.577.197 9.092.637 10.608.076
167 G-4-11-II
DEGENERATIF SEDANG
10.065.318 12.078.382 14.091.446
168 G-4-11-III
DEGENERATIF BERAT
14.789.434 17.747.321 20.705.208
172 G-4-13-I
RINGAN
3.898.350 4.678.021 5.457.691
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
173 G-4-13-II
SEDANG
6.797.849 8.157.419 9.516.988
174 G-4-13-III
BERAT
8.062.387 9.674.865 11.287.342
175 G-4-14-I
INFARK RINGAN
6.612.978 7.935.573 9.258.169
176 G-4-14-II
INFARK SEDANG
8.841.177 10.609.413 12.377.648
177 G-4-14-III
INFARK BERAT
11.096.684 13.316.021 15.535.358
178 G-4-15-I
5.403.371 6.484.046 7.564.720
179 G-4-15-II
6.448.693 7.738.432 9.028.171
180 G-4-15-III
9.101.765 10.922.117 12.742.470
187 G-4-18-I
PERSARAFAN RINGAN
5.842.985 7.011.582 8.180.179
188 G-4-18-II
PERSARAFAN SEDANG
7.810.401 9.372.481 10.934.561
189 G-4-18-III
PERSARAFAN BERAT
8.739.194 10.487.033 12.234.872
190 G-4-19-I
4.875.008 5.850.010 6.825.012
191 G-4-19-II
8.239.881 9.887.858 11.535.834
192 G-4-19-III
11.963.782 14.356.538 16.749.294
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
211 G-4-26-I
(RINGAN)
5.842.205 7.010.646 8.179.087
212 G-4-26-II
(SEDANG)
6.796.304 8.155.565 9.514.826
213 G-4-26-III
(BERAT)
10.630.716 12.756.859 14.883.002
229 I-1-01-I
RINGAN
77.356.591 92.827.910 108.299.228
230 I-1-01-II
SEDANG
79.058.359 94.870.031 110.681.702
231 I-1-01-III
BERAT
124.792.577 149.751.093 174.709.608
232 I-1-02-I
RINGAN
42.917.118 51.500.541 60.083.965
233 I-1-02-II
SEDANG
55.362.548 66.435.057 77.507.567
234 I-1-02-III
BERAT
68.237.752 81.885.303 95.532.853
235 I-1-03-I
26.389.525 31.667.430 36.945.335
236 I-1-03-II
32.047.052 38.456.463 44.865.873
237 I-1-03-III
49.778.255 59.733.906 69.689.558
238 I-1-04-I
JANTUNG RINGAN
44.269.335 53.123.202 61.977.069
239 I-1-04-II
JANTUNG SEDANG
69.868.900 83.842.680 97.816.460
240 I-1-04-III
JANTUNG BERAT
111.615.159 133.938.191 156.261.223
241 I-1-05-I
56.801.598 68.161.918 79.522.238
242 I-1-05-II
68.162.195 81.794.634 95.427.073
243 I-1-05-III
93.790.604 112.548.725 131.306.846
247 I-1-07-I
34.511.371 41.413.645 48.315.919
248 I-1-07-II
42.576.864 51.092.237 59.607.609
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
249 I-1-07-III
46.451.198 55.741.438 65.031.678
250 I-1-11-I
5.352.076 6.422.491 7.492.906
251 I-1-11-II
5.950.987 7.141.184 8.331.382
252 I-1-11-III
7.918.937 9.502.724 11.086.512
253 I-1-12-I
RINGAN
22.253.012 26.703.614 31.154.216
254 I-1-12-II
SEDANG
25.160.918 30.193.102 35.225.286
255 I-1-12-III
BERAT
42.000.035 50.400.042 58.800.049
256 I-1-13-I
RINGAN
16.400.427 19.680.512 22.960.597
257 I-1-13-II
SEDANG
19.900.326 23.880.391 27.860.456
258 I-1-13-III
BERAT
25.101.544 30.121.853 35.142.162
259 I-1-14-I
PERMANEN RINGAN
44.179.406 53.015.287 61.851.168
260 I-1-14-II
PERMANEN SEDANG
54.908.512 65.890.215 76.871.917
261 I-1-14-III
PERMANEN BERAT
71.949.061 86.338.873 100.728.685
265 I-1-16-I
(RINGAN)
18.933.635 22.720.362 26.507.089
266 I-1-16-II
(SEDANG)
49.227.867 59.073.440 68.919.014
267 I-1-16-III
(BERAT)
56.783.576 68.140.291 79.497.006
268 I-1-17-I
VENA RINGAN
32.633.166 39.159.799 45.686.432
269 I-1-17-II
VENA SEDANG
40.859.786 49.031.743 57.203.700
270 I-1-17-III
VENA BERAT
50.542.934 60.651.521 70.760.107
271 I-1-20-I
RINGAN
28.396.625 34.075.950 39.755.275
272 I-1-20-II
SEDANG
35.475.111 42.570.133 49.665.155
274 I-1-30-I
21.480.394 25.776.473 30.072.552
275 I-1-30-II
44.684.044 53.620.853 62.557.662
276 I-1-30-III
69.244.256 83.093.107 96.941.958
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
289 I-4-13-I
RINGAN
7.695.201 9.234.241 10.773.281
290 I-4-13-II
SEDANG
11.146.066 13.375.279 15.604.493
291 I-4-13-III
BERAT
24.954.634 29.945.560 34.936.487
295 I-4-15-I
(RINGAN)
7.780.081 9.336.097 10.892.114
296 I-4-15-II
(SEDANG)
10.041.146 12.049.375 14.057.604
297 I-4-15-III
(BERAT)
11.444.301 13.733.161 16.022.021
306 I-4-18-III
BERAT
14.332.301 17.198.762 20.065.222
319 I-4-23-I
4.414.197 5.297.037 6.179.876
320 I-4-23-II
5.419.315 6.503.178 7.587.040
321 I-4-23-III
10.589.083 12.706.899 14.824.716
322 I-4-24-I
(RINGAN)
5.148.867 6.178.641 7.208.414
323 I-4-24-II
(SEDANG)
11.856.645 14.227.974 16.599.303
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
324 I-4-24-III
(BERAT)
14.990.586 17.988.703 20.986.820
325 J-1-01-I
TRAKEOSTOMI RINGAN
75.098.400 90.118.080 105.137.760
326 J-1-01-II
TRAKEOSTOMI SEDANG
83.442.667 100.131.200 116.819.734
327 J-1-01-III
TRAKEOSTOMI BERAT
92.714.074 111.256.889 129.799.704
328 J-1-02-I
TRAKEOSTOMI RINGAN
39.852.050 47.822.460 55.792.871
329 J-1-02-II
TRAKEOSTOMI SEDANG
54.480.926 65.377.111 76.273.297
330 J-1-02-III
TRAKEOSTOMI BERAT
88.360.044 106.032.052 123.704.061
334 J-1-20-I
RINGAN
16.040.437 19.248.524 22.456.612
335 J-1-20-II
SEDANG
20.203.392 24.244.071 28.284.749
337 J-1-30-I
RINGAN
9.643.968 11.572.761 13.501.555
338 J-1-30-II
SEDANG
21.794.407 26.153.288 30.512.169
339 J-1-30-III
BERAT
72.838.361 87.406.033 101.973.705
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
3.885.942 4.663.131 5.440.319
374 J-4-21-II
LAIN-LAIN (SEDANG)
8.846.484 10.615.781 12.385.078
375 J-4-21-III
LAIN-LAIN (BERAT)
12.617.980 15.141.576 17.665.172
376 K-1-10-I
(RINGAN)
10.476.501 12.571.802 14.667.102
377 K-1-10-II
(SEDANG)
13.165.970 15.799.165 18.432.359
378 K-1-10-III
(BERAT)
15.430.966 18.517.159 21.603.352
382 K-1-12-I
FEMORAL (RINGAN)
4.395.811 5.274.973 6.154.135
383 K-1-12-II
FEMORAL (SEDANG)
5.717.269 6.860.723 8.004.176
384 K-1-12-III
FEMORAL (BERAT)
11.326.673 13.592.007 15.857.342
394 K-1-30-I
KOMPLEKS (RINGAN)
10.236.443 12.283.731 14.331.020
395 K-1-30-II
KOMPLEKS (SEDANG)
20.043.217 24.051.860 28.060.503
396 K-1-30-III
KOMPLEKS (BERAT)
29.459.477 35.351.373 41.243.268
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
412 K-4-13-I
5.838.432 7.006.118 8.173.805
413 K-4-13-II
7.552.345 9.062.814 10.573.283
414 K-4-13-III
11.633.018 13.959.622 16.286.226
415 K-4-14-I
RINGAN
4.627.005 5.552.406 6.477.807
416 K-4-14-II
SEDANG
6.210.931 7.453.117 8.695.303
417 K-4-14-III
BERAT
9.966.063 11.959.275 13.952.488
424 K-4-17-I
(RINGAN)
3.528.197 4.233.836 4.939.476
425 K-4-17-II
(SEDANG)
4.993.006 5.991.608 6.990.209
426 K-4-17-III
(BERAT)
5.632.122 6.758.547 7.884.971
430 L-1-20-I
RINGAN
35.876.267 43.051.521 50.226.774
431 L-1-20-II
SEDANG
37.491.443 44.989.732 52.488.020
432 L-1-20-III
BERAT
57.197.218 68.636.662 80.076.105
433 L-1-30-I
RINGAN
15.808.067 18.969.681 22.131.294
434 L-1-30-II
SEDANG
23.612.162 28.334.594 33.057.026
435 L-1-30-III
BERAT
24.964.725 29.957.670 34.950.615
436 L-1-40-I
PAYUDARA RINGAN
6.567.339 7.880.806 9.194.274
437 L-1-40-II
PAYUDARA SEDANG
13.172.581 15.807.097 18.441.613
438 L-1-40-III
PAYUDARA BERAT
32.026.792 38.432.151 44.837.509
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
451 L-4-13-I
PAYUDARA RINGAN
3.310.085 3.972.102 4.634.119
452 L-4-13-II
PAYUDARA SEDANG
3.890.192 4.668.231 5.446.269
453 L-4-13-III
PAYUDARA BERAT
5.724.543 6.869.452 8.014.360
454 L-4-14-I
(RINGAN)
3.883.565 4.660.278 5.436.991
455 L-4-14-II
(SEDANG)
5.833.200 6.999.840 8.166.480
456 L-4-14-III
(BERAT)
8.222.629 9.867.155 11.511.681
457 M-1-01-I
17.481.414 20.977.697 24.473.980
458 M-1-01-II
19.512.444 23.414.933 27.317.421
459 M-1-01-III
27.409.199 32.891.039 38.372.879
463 M-1-03-I
32.528.569 39.034.282 45.539.996
464 M-1-03-II
39.052.525 46.863.030 54.673.535
465 M-1-03-III
40.618.000 48.741.600 56.865.200
466 M-1-04-I
8.017.853 9.621.424 11.224.994
467 M-1-04-II
10.251.011 12.301.213 14.351.415
468 M-1-04-III
12.827.009 15.392.411 17.957.812
469 M-1-05-I
11.476.975 13.772.370 16.067.765
470 M-1-05-II
11.749.473 14.099.368 16.449.263
471 M-1-05-III
20.012.923 24.015.508 28.018.092
472 M-1-07-I
14.045.300 16.854.360 19.663.419
473 M-1-07-II
18.815.794 22.578.952 26.342.111
474 M-1-07-III
38.329.624 45.995.549 53.661.474
475 M-1-10-I
WAJAH RINGAN
23.660.962 28.393.154 33.125.347
476 M-1-10-II
WAJAH SEDANG
56.572.438 67.886.926 79.201.414
477 M-1-10-III
WAJAH BERAT
122.021.424 146.425.709 170.829.994
478 M-1-20-I
MAYOR RINGAN
8.487.426 10.184.912 11.882.397
479 M-1-20-II
MAYOR SEDANG
12.109.663 14.531.596 16.953.528
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
480 M-1-20-III
MAYOR BERAT
30.042.751 36.051.301 42.059.851
484 M-1-40-I
5.692.964 6.831.556 7.970.149
485 M-1-40-II
10.522.710 12.627.252 14.731.794
486 M-1-40-III
18.321.475 21.985.770 25.650.065
490 M-1-60-I
5.123.068 6.147.682 7.172.296
491 M-1-60-II
10.283.447 12.340.136 14.396.826
492 M-1-60-III
17.904.164 21.484.996 25.065.829
493 M-1-70-I
(RINGAN)
28.195.698 33.834.837 39.473.977
494 M-1-70-II
(SEDANG)
31.015.267 37.218.321 43.421.374
495 M-1-70-III
(BERAT)
34.116.794 40.940.153 47.763.512
502 M-4-11-I
RINGAN
4.870.819 5.844.982 6.819.146
503 M-4-11-II
SEDANG
10.678.931 12.814.717 14.950.503
504 M-4-11-III
BERAT
15.439.986 18.527.984 21.615.981
505 M-4-12-I
RINGAN
3.887.993 4.665.591 5.443.190
506 M-4-12-II
SEDANG
6.466.716 7.760.059 9.053.402
508 M-4-13-I
6.473.823 7.768.587 9.063.352
509 M-4-13-II
9.726.684 11.672.021 13.617.358
510 M-4-13-III
19.247.416 23.096.899 26.946.382
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
520 M-4-17-I
RINGAN
4.864.800 5.837.761 6.810.721
521 M-4-17-II
SEDANG
6.803.913 8.164.695 9.525.478
522 M-4-17-III
BERAT
9.501.159 11.401.390 13.301.622
526 M-4-19-I
3.834.498 4.601.398 5.368.298
527 M-4-19-II
6.458.829 7.750.595 9.042.361
528 M-4-19-III
12.614.463 15.137.356 17.660.249
529 M-4-20-I
3.867.968 4.641.562 5.415.155
530 M-4-20-II
5.664.009 6.796.810 7.929.612
531 M-4-20-III
6.330.159 7.596.190 8.862.222
532 M-4-21-I
3.894.743 4.673.692 5.452.640
533 M-4-21-II
4.871.236 5.845.483 6.819.730
534 M-4-21-III
10.921.118 13.105.342 15.289.565
541 N-1-12-I
7.022.650 8.427.180 9.831.710
542 N-1-12-II
16.465.749 19.758.899 23.052.049
543 N-1-12-III
30.004.919 36.005.903 42.006.887
547 N-1-30-I
BAWAH RINGAN
11.456.805 13.748.166 16.039.528
548 N-1-30-II
BAWAH SEDANG
17.331.908 20.798.290 24.264.671
549 N-1-30-III
BAWAH BERAT
19.947.331 23.936.797 27.926.264
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
553 N-4-10-I
RINGAN
4.857.134 5.828.561 6.799.987
554 N-4-10-II
SEDANG
5.874.748 7.049.697 8.224.647
555 N-4-10-III
BERAT
11.674.107 14.008.928 16.343.750
565 N-4-14-I
3.370.324 4.044.389 4.718.454
566 N-4-14-II
4.782.278 5.738.734 6.695.190
567 N-4-14-III
7.756.039 9.307.247 10.858.454
568 N-4-15-I
URIN RINGAN
4.423.902 5.308.682 6.193.463
569 N-4-15-II
URIN SEDANG
5.489.326 6.587.191 7.685.057
570 N-4-15-III
URIN BERAT
6.264.306 7.517.167 8.770.029
571 N-4-16-I
(RINGAN)
4.875.378 5.850.454 6.825.530
572 N-4-16-II
(SEDANG)
7.493.322 8.991.986 10.490.651
573 N-4-16-III
(BERAT)
13.295.446 15.954.535 18.613.625
577 O-6-11-I
4.531.933 5.438.320 6.344.707
578 O-6-11-II
5.036.677 6.044.012 7.051.348
579 O-6-11-III
9.050.455 10.860.547 12.670.638
580 O-6-12-I
3.210.830 3.852.995 4.495.161
581 O-6-12-II
3.856.184 4.627.421 5.398.658
582 O-6-12-III
4.845.358 5.814.430 6.783.501
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
586 P-8-01-I
RINGAN
90.092.466 108.110.959 126.129.452
587 P-8-01-II
SEDANG
111.475.814 133.770.977 156.066.140
588 P-8-01-III
BERAT
130.841.303 157.009.564 183.177.824
589 P-8-02-I
106.985.505 128.382.606 149.779.707
590 P-8-02-II
122.723.139 147.267.767 171.812.395
591 P-8-02-III
140.219.887 168.263.864 196.307.841
592 P-8-03-I
6.037.750 7.245.301 8.452.851
593 P-8-03-II
8.452.851 10.143.421 11.833.991
594 P-8-03-III
11.763.892 14.116.670 16.469.448
595 P-8-04-I
48.638.380 58.366.056 68.093.732
596 P-8-04-II
63.122.131 75.746.557 88.370.983
597 P-8-04-III
90.501.248 108.601.497 126.701.747
598 P-8-05-I
26.447.974 31.737.569 37.027.164
599 P-8-05-II
37.486.438 44.983.725 52.481.013
600 P-8-05-III
55.231.234 66.277.481 77.323.727
601 P-8-06-I
5.236.116 6.283.339 7.330.562
602 P-8-06-II
9.715.581 11.658.697 13.601.813
603 P-8-06-III
18.918.385 22.702.062 26.485.739
604 P-8-07-I
8.452.851 10.143.421 11.833.991
605 P-8-07-II
23.699.758 28.439.710 33.179.662
606 P-8-07-III
31.396.302 37.675.563 43.954.823
607 P-8-08-I
4.890.855 5.869.026 6.847.197
608 P-8-08-II
6.939.891 8.327.869 9.715.847
609 P-8-08-III
12.692.898 15.231.478 17.770.057
610 P-8-10-I
3.427.992 4.113.591 4.799.189
611 P-8-10-II
5.395.702 6.474.842 7.553.983
612 P-8-10-III
10.593.963 12.712.755 14.831.548
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
613 P-8-11-I
RINGAN
8.579.499 10.295.398 12.011.298
614 P-8-11-II
SEDANG
18.281.103 21.937.324 25.593.545
615 P-8-11-III
BERAT
21.910.997 26.293.196 30.675.395
616 P-8-12-I
RINGAN
10.915.784 13.098.941 15.282.098
617 P-8-12-II
SEDANG
13.808.231 16.569.877 19.331.523
618 P-8-12-III
BERAT
14.614.267 17.537.120 20.459.973
619 P-8-13-I
RINGAN
2.744.334 3.293.201 3.842.067
620 P-8-13-II
SEDANG
6.799.245 8.159.094 9.518.943
621 P-8-13-III
BERAT
16.563.487 19.876.185 23.188.882
622 P-8-14-I
4.676.432 5.611.718 6.547.005
623 P-8-14-II
9.519.405 11.423.286 13.327.167
624 P-8-14-III
10.444.512 12.533.415 14.622.317
625 P-8-15-I
RINGAN
3.507.375 4.208.850 4.910.325
626 P-8-15-II
SEDANG
7.023.690 8.428.428 9.833.165
627 P-8-15-III
BERAT
8.241.093 9.889.312 11.537.530
628 P-8-16-I
3.174.261 3.809.113 4.443.965
629 P-8-16-II
6.562.891 7.875.469 9.188.047
630 P-8-16-III
17.237.688 20.685.225 24.132.763
631 P-8-17-I
RINGAN
2.329.177 2.795.012 3.260.847
632 P-8-17-II
SEDANG
6.055.658 7.266.789 8.477.921
633 P-8-17-III
BERAT
14.352.783 17.223.340 20.093.897
634 S-4-10-I
3.578.910 4.294.692 5.010.475
635 S-4-10-II
4.409.740 5.291.688 6.173.636
636 S-4-10-III
6.036.528 7.243.834 8.451.139
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
646 S-4-14-I
KANAK-KANAK RINGAN
2.184.917 2.621.900 3.058.884
647 S-4-14-II
KANAK-KANAK SEDANG
4.640.869 5.569.042 6.497.216
648 S-4-14-III
KANAK-KANAK BERAT
8.800.667 10.560.801 12.320.934
649 S-4-15-I
YANG LAIN (RINGAN)
1.652.551 1.983.062 2.313.572
650 S-4-15-II
YANG LAIN (SEDANG)
3.118.636 3.742.363 4.366.090
651 S-4-15-III
YANG LAIN (BERAT)
4.039.185 4.847.022 5.654.859
655 S-4-17-I
3.282.347 3.938.817 4.595.286
656 S-4-17-II
4.871.266 5.845.520 6.819.773
657 S-4-17-III
7.487.083 8.984.500 10.481.917
658 T-1-10-I
RINGAN
2.759.567 3.311.480 3.863.393
659 T-1-10-II
SEDANG
3.706.456 4.447.748 5.189.039
660 T-1-10-III
BERAT
6.742.603 8.091.124 9.439.645
661 T-4-10-I
1.511.142 1.813.370 2.115.598
662 T-4-10-II
2.879.487 3.455.385 4.031.282
663 T-4-10-III
4.185.447 5.022.536 5.859.625
664 T-4-11-I
1.459.414 1.751.296 2.043.179
665 T-4-11-II
2.296.705 2.756.046 3.215.387
666 T-4-11-III
3.699.319 4.439.183 5.179.047
667 T-4-12-I
LAIN (RINGAN)
3.419.484 4.103.380 4.787.277
668 T-4-12-II
LAIN (SEDANG)
5.162.128 6.194.554 7.226.979
669 T-4-12-III
LAIN (BERAT)
7.990.221 9.588.265 11.186.309
673 U-1-11-I
(RINGAN)
12.809.519 15.371.423 17.933.327
674 U-1-11-II
(SEDANG)
19.320.801 23.184.962 27.049.122
675 U-1-11-III
(BERAT)
29.250.990 35.101.188 40.951.386
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
682 U-1-14-I
MULUT (RINGAN)
5.216.967 6.260.361 7.303.754
683 U-1-14-II
MULUT (SEDANG)
6.402.470 7.682.964 8.963.458
684 U-1-14-III
MULUT (BERAT)
7.586.946 9.104.335 10.621.725
688 U-1-20-I
7.920.106 9.504.128 11.088.149
689 U-1-20-II
14.144.267 16.973.120 19.801.974
690 U-1-20-III
33.816.186 40.579.423 47.342.660
694 U-4-10-I
TELINGA RINGAN
6.331.756 7.598.107 8.864.458
695 U-4-10-II
TELINGA SEDANG
14.495.176 17.394.211 20.293.247
696 U-4-10-III
TELINGA BERAT
22.254.681 26.705.617 31.156.553
703 U-4-13-I
3.454.782 4.145.738 4.836.695
704 U-4-13-II
4.072.799 4.887.358 5.701.918
705 U-4-13-III
4.871.308 5.845.570 6.819.831
709 U-4-15-I
3.906.699 4.688.039 5.469.379
710 U-4-15-II
4.867.207 5.840.649 6.814.090
711 U-4-15-III
6.811.742 8.174.090 9.536.438
712 V-1-10-I
RINGAN
11.397.626 13.677.151 15.956.677
713 V-1-10-II
SEDANG
13.126.336 15.751.603 18.376.870
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
718 V-1-12-I
MODERAT (RINGAN)
6.372.093 7.646.511 8.920.930
719 V-1-12-II
MODERAT (SEDANG)
22.481.994 26.978.393 31.474.792
720 V-1-12-III
MODERAT (BERAT)
23.252.173 27.902.608 32.553.042
721 V-1-13-I
KOMPLEK (RINGAN)
9.660.885 11.593.062 13.525.239
722 V-1-13-II
KOMPLEK (SEDANG)
18.458.762 22.150.515 25.842.267
723 V-1-13-III
KOMPLEK (BERAT)
28.959.550 34.751.460 40.543.370
724 V-1-14-I
RINGAN
11.658.387 13.990.064 16.321.742
725 V-1-14-II
SEDANG
16.939.405 20.327.286 23.715.167
726 V-1-14-III
BERAT
21.142.120 25.370.544 29.598.968
733 V-4-11-I
TUMOR (RINGAN)
4.871.388 5.845.666 6.819.944
734 V-4-11-II
TUMOR (SEDANG)
6.803.432 8.164.118 9.524.804
735 V-4-11-III
TUMOR (BERAT)
8.835.390 10.602.468 12.369.546
736 W-1-01-I
13.277.768 15.933.321 18.588.875
737 W-1-01-II
15.914.331 19.097.197 22.280.063
738 W-1-01-III
28.754.670 34.505.604 40.256.538
742 W-1-11-I
RINGAN
3.826.855 4.592.227 5.357.598
743 W-1-11-II
SEDANG
6.728.046 8.073.656 9.419.265
744 W-1-11-III
BERAT
14.167.371 17.000.845 19.834.320
745 W-1-12-I
3.486.329 4.183.594 4.880.860
746 W-1-12-II
3.952.814 4.743.377 5.533.940
747 W-1-12-III
6.072.327 7.286.793 8.501.258
748 W-1-13-I
RINGAN
4.231.890 5.078.268 5.924.646
749 W-1-13-II
SEDANG
4.594.425 5.513.310 6.432.195
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
763 W-4-12-I
3.901.033 4.681.240 5.461.446
764 W-4-12-II
5.355.813 6.426.976 7.498.139
765 W-4-12-III
5.838.050 7.005.660 8.173.270
787 Z-4-12-I
2.914.895 3.497.874 4.080.852
788 Z-4-12-II
5.852.702 7.023.242 8.193.782
789 Z-4-12-III
12.347.684 14.817.220 17.286.757
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 3.073.198
33 F-3-10-0 TERAPI SHOCK 602.570
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
72 I-2-16-0
80 I-2-42-0
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
179 O-7-12-0
181 P-9-10-0
LAIN 430.919
191 Q-5-12-0 GIGI 301.504
195 Q-5-16-0 VAKSINASI 218.914
196 Q-5-17-0 PASANG INFUS 208.833
200 Q-5-21-0 ABORSI 290.165
205 Q-5-26-0 BRONKIAL AKUT 466.249
210 Q-5-31-0 FRAKTUR 313.914
214 Q-5-35-0 INFEKSI AKUT 615.445
217 Q-5-38-0 PARU AKUT 489.391
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
241 U-3-13-0
TENGGOROKAN 456.685
269 Z-3-11-0
EMPEDU 3.477.891
276 Z-3-18-0 CT-SCAN KEPALA 593.953
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 180.958
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 2.000.667 2.400.800 2.800.933
8 A-4-12-II DEMAM SEDANG 3.164.368 3.797.241 4.430.115
9 A-4-12-III DEMAM BERAT 3.616.831 4.340.198 5.063.564
13 A-4-14-I
RINGAN
3.134.316 3.761.179 4.388.042
14 A-4-14-II
SEDANG
4.031.523 4.837.828 5.644.132
15 A-4-14-III
BERAT
4.619.177 5.543.012 6.466.848
28 B-1-12-I
RINGAN
6.933.547 8.320.256 9.706.966
29 B-1-12-II
SEDANG
14.860.287 17.832.344 20.804.402
30 B-1-12-III
BERAT
17.572.465 21.086.958 24.601.450
31 B-1-13-I
(RINGAN)
5.575.577 6.690.693 7.805.808
32 B-1-13-II
(SEDANG)
9.081.806 10.898.167 12.714.528
33 B-1-13-III
(BERAT)
13.389.130 16.066.956 18.744.782
34 B-1-14-I
RINGAN
7.541.663 9.049.996 10.558.329
35 B-1-14-II
SEDANG
8.387.852 10.065.422 11.742.992
36 B-1-14-III
BERAT
13.121.797 15.746.156 18.370.516
40 B-4-11-I
RINGAN
4.142.873 4.971.447 5.800.022
41 B-4-11-II
SEDANG
6.315.130 7.578.156 8.841.182
46 B-4-13-I
3.020.447 3.624.537 4.228.626
Rumah Sakit Kelas B
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
47 B-4-13-II
4.394.344 5.273.212 6.152.081
48 B-4-13-III
5.501.734 6.602.080 7.702.427
73 D-1-20-I
4.429.551 5.315.462 6.201.372
74 D-1-20-II
13.021.956 15.626.347 18.230.738
75 D-1-20-III
20.429.481 24.515.378 28.601.274
85 D-4-13-I
SEL SICKLE RINGAN
2.013.234 2.415.881 2.818.528
86 D-4-13-II
SEL SICKLE SEDANG
3.019.332 3.623.198 4.227.065
87 D-4-13-III
SEL SICKLE BERAT
4.167.023 5.000.427 5.833.832
88 D-4-14-I
2.501.968 3.002.361 3.502.755
89 D-4-14-II
4.485.581 5.382.698 6.279.814
90 D-4-14-III
6.289.764 7.547.716 8.805.669
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
6.001.185 7.201.422 8.401.659
98 E-1-20-II
TIROGLOSAL SEDANG
9.819.150 11.782.980 13.746.810
99 E-1-20-III
TIROGLOSAL BERAT
18.420.470 22.104.565 25.788.659
100 E-4-10-I
METABOLIK RINGAN
3.142.066 3.770.479 4.398.892
101 E-4-10-II
METABOLIK SEDANG
4.349.556 5.219.467 6.089.378
102 E-4-10-III
METABOLIK BERAT
6.635.933 7.963.120 9.290.307
130 F-4-16-I
RINGAN
5.923.447 7.108.136 8.292.825
131 F-4-16-II
SEDANG
6.883.337 8.260.004 9.636.671
132 F-4-16-III
BERAT
9.188.105 11.025.726 12.863.347
142 G-1-01-I
RINGAN
9.078.640 10.894.369 12.710.097
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
163 G-4-10-I
RINGAN
3.006.202 3.607.442 4.208.682
164 G-4-10-II
SEDANG
4.115.684 4.938.820 5.761.957
166 G-4-11-I
DEGENERATIF RINGAN
5.460.549 6.552.659 7.644.769
167 G-4-11-II
DEGENERATIF SEDANG
6.885.905 8.263.087 9.640.268
168 G-4-11-III
DEGENERATIF BERAT
8.833.637 10.600.365 12.367.092
172 G-4-13-I
RINGAN
2.778.084 3.333.701 3.889.318
173 G-4-13-II
SEDANG
3.853.364 4.624.037 5.394.710
174 G-4-13-III
BERAT
4.517.331 5.420.797 6.324.263
175 G-4-14-I
INFARK RINGAN
3.784.345 4.541.214 5.298.083
176 G-4-14-II
INFARK SEDANG
6.843.496 8.212.195 9.580.894
177 G-4-14-III
INFARK BERAT
8.557.337 10.268.804 11.980.272
178 G-4-15-I
2.949.760 3.539.712 4.129.664
179 G-4-15-II
3.520.552 4.224.662 4.928.772
180 G-4-15-III
5.026.038 6.031.246 7.036.454
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
3.042.395 3.650.874 4.259.354
188 G-4-18-II
PERSARAFAN SEDANG
5.818.621 6.982.345 8.146.070
189 G-4-18-III
PERSARAFAN BERAT
6.159.366 7.391.239 8.623.112
190 G-4-19-I
3.335.190 4.002.228 4.669.266
191 G-4-19-II
4.498.536 5.398.244 6.297.951
192 G-4-19-III
6.899.170 8.279.004 9.658.838
211 G-4-26-I
(RINGAN)
3.360.733 4.032.879 4.705.026
212 G-4-26-II
(SEDANG)
4.604.308 5.525.170 6.446.032
213 G-4-26-III
(BERAT)
5.529.586 6.635.504 7.741.421
229 I-1-01-I
RINGAN
42.231.657 50.677.988 59.124.320
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
230 I-1-01-II
SEDANG
43.160.974 51.793.168 60.425.363
231 I-1-01-III
BERAT
68.128.769 81.754.523 95.380.277
232 I-1-02-I
RINGAN
23.429.880 28.115.856 32.801.832
233 I-1-02-II
SEDANG
30.224.545 36.269.454 42.314.363
234 I-1-02-III
BERAT
37.253.509 44.704.211 52.154.913
235 I-1-03-I
14.406.839 17.288.207 20.169.574
236 I-1-03-II
16.427.708 19.713.249 22.998.791
237 I-1-03-III
27.175.922 32.611.107 38.046.291
238 I-1-04-I
JANTUNG RINGAN
23.441.694 28.130.033 32.818.372
239 I-1-04-II
JANTUNG SEDANG
55.895.120 67.074.144 78.253.168
240 I-1-04-III
JANTUNG BERAT
89.292.127 107.150.553 125.008.978
241 I-1-05-I
31.010.135 37.212.162 43.414.189
242 I-1-05-II
37.212.162 44.654.595 52.097.027
243 I-1-05-III
51.203.701 61.444.441 71.685.181
247 I-1-07-I
25.599.313 30.719.176 35.839.039
248 I-1-07-II
31.581.953 37.898.344 44.214.735
249 I-1-07-III
34.455.706 41.346.847 48.237.988
250 I-1-11-I
4.119.693 4.943.632 5.767.570
251 I-1-11-II
4.580.687 5.496.824 6.412.962
252 I-1-11-III
6.095.498 7.314.598 8.533.697
253 I-1-12-I
RINGAN
12.447.458 14.936.950 17.426.442
254 I-1-12-II
SEDANG
14.179.239 17.015.087 19.850.935
255 I-1-12-III
BERAT
22.929.528 27.515.434 32.101.340
256 I-1-13-I
RINGAN
13.120.341 15.744.410 18.368.478
257 I-1-13-II
SEDANG
15.920.261 19.104.313 22.288.365
258 I-1-13-III
BERAT
18.619.421 22.343.305 26.067.189
259 I-1-14-I
PERMANEN RINGAN
24.118.994 28.942.793 33.766.592
260 I-1-14-II
PERMANEN SEDANG
29.976.464 35.971.757 41.967.050
261 I-1-14-III
PERMANEN BERAT
39.279.505 47.135.406 54.991.307
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
265 I-1-16-I
(RINGAN)
10.336.712 12.404.054 14.471.396
266 I-1-16-II
(SEDANG)
26.875.451 32.250.541 37.625.631
267 I-1-16-III
(BERAT)
31.000.173 37.200.207 43.400.242
268 I-1-17-I
VENA RINGAN
26.106.533 31.327.839 36.549.146
269 I-1-17-II
VENA SEDANG
32.687.828 39.225.394 45.762.960
270 I-1-17-III
VENA BERAT
40.434.347 48.521.216 56.608.086
271 I-1-20-I
RINGAN
22.717.300 27.260.760 31.804.220
272 I-1-20-II
SEDANG
28.380.089 34.056.106 39.732.124
274 I-1-30-I
11.727.053 14.072.464 16.417.875
275 I-1-30-II
24.394.640 29.273.568 34.152.496
276 I-1-30-III
37.802.832 45.363.398 52.923.964
289 I-4-13-I
RINGAN
5.902.404 7.082.885 8.263.366
290 I-4-13-II
SEDANG
7.484.676 8.981.612 10.478.547
291 I-4-13-III
BERAT
13.623.803 16.348.563 19.073.324
295 I-4-15-I
(RINGAN)
4.024.730 4.829.676 5.634.622
296 I-4-15-II
(SEDANG)
5.776.373 6.931.647 8.086.922
297 I-4-15-III
(BERAT)
6.583.675 7.900.410 9.217.145
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
306 I-4-18-III
BERAT
9.019.198 10.823.038 12.626.877
319 I-4-23-I
2.409.793 2.891.752 3.373.711
320 I-4-23-II
2.958.671 3.550.405 4.142.139
321 I-4-23-III
5.780.973 6.937.167 8.093.362
322 I-4-24-I
(RINGAN)
3.234.436 3.881.324 4.528.211
323 I-4-24-II
(SEDANG)
8.078.393 9.694.071 11.309.750
324 I-4-24-III
(BERAT)
10.166.125 12.199.350 14.232.575
325 J-1-01-I
TRAKEOSTOMI RINGAN
30.837.320 37.004.785 43.172.249
326 J-1-01-II
TRAKEOSTOMI SEDANG
32.943.397 39.532.077 46.120.756
327 J-1-01-III
TRAKEOSTOMI BERAT
47.378.120 56.853.744 66.329.368
328 J-1-02-I
TRAKEOSTOMI RINGAN
13.295.739 15.954.886 18.614.034
329 J-1-02-II
TRAKEOSTOMI SEDANG
13.445.878 16.135.053 18.824.229
330 J-1-02-III
TRAKEOSTOMI BERAT
21.135.753 25.362.904 29.590.055
334 J-1-20-I
RINGAN
12.832.350 15.398.820 17.965.289
335 J-1-20-II
SEDANG
16.162.714 19.395.256 22.627.799
337 J-1-30-I
RINGAN
3.715.837 4.459.005 5.202.172
338 J-1-30-II
SEDANG
11.898.340 14.278.008 16.657.676
339 J-1-30-III
BERAT
35.524.086 42.628.903 49.733.720
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
2.352.129 2.822.555 3.292.981
374 J-4-21-II
LAIN-LAIN (SEDANG)
4.390.863 5.269.036 6.147.208
375 J-4-21-III
LAIN-LAIN (BERAT)
6.143.362 7.372.035 8.600.707
376 K-1-10-I
(RINGAN)
5.407.702 6.489.242 7.570.782
377 K-1-10-II
(SEDANG)
10.160.089 12.192.106 14.224.124
378 K-1-10-III
(BERAT)
11.888.794 14.266.552 16.644.311
382 K-1-12-I
FEMORAL (RINGAN)
3.368.957 4.042.748 4.716.540
383 K-1-12-II
FEMORAL (SEDANG)
4.379.136 5.254.963 6.130.790
384 K-1-12-III
FEMORAL (BERAT)
8.734.088 10.480.906 12.227.724
394 K-1-30-I
KOMPLEKS (RINGAN)
7.729.693 9.275.631 10.821.570
395 K-1-30-II
KOMPLEKS (SEDANG)
10.844.760 13.013.712 15.182.665
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
19.953.979 23.944.775 27.935.571
412 K-4-13-I
3.184.328 3.821.194 4.458.059
413 K-4-13-II
4.080.717 4.896.861 5.713.004
414 K-4-13-III
6.350.946 7.621.135 8.891.324
415 K-4-14-I
RINGAN
2.525.950 3.031.140 3.536.330
416 K-4-14-II
SEDANG
3.390.684 4.068.821 4.746.958
417 K-4-14-III
BERAT
5.952.962 7.143.554 8.334.147
424 K-4-17-I
(RINGAN)
2.846.079 3.415.295 3.984.510
425 K-4-17-II
(SEDANG)
4.027.692 4.833.230 5.638.768
426 K-4-17-III
(BERAT)
4.543.245 5.451.894 6.360.543
430 L-1-20-I
RINGAN
27.581.742 33.098.090 38.614.439
431 L-1-20-II
SEDANG
28.425.542 34.110.650 39.795.758
432 L-1-20-III
BERAT
39.978.701 47.974.442 55.970.182
433 L-1-30-I
RINGAN
8.630.123 10.356.148 12.082.173
434 L-1-30-II
SEDANG
16.093.483 19.312.179 22.530.876
435 L-1-30-III
BERAT
19.114.748 22.937.698 26.760.648
436 L-1-40-I
PAYUDARA RINGAN
4.102.206 4.922.647 5.743.088
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
437 L-1-40-II
PAYUDARA SEDANG
8.845.638 10.614.766 12.383.894
438 L-1-40-III
PAYUDARA BERAT
15.131.438 18.157.726 21.184.013
451 L-4-13-I
PAYUDARA RINGAN
2.003.311 2.403.973 2.804.636
452 L-4-13-II
PAYUDARA SEDANG
2.678.109 3.213.731 3.749.353
453 L-4-13-III
PAYUDARA BERAT
3.535.158 4.242.189 4.949.221
454 L-4-14-I
(RINGAN)
2.318.771 2.782.525 3.246.279
455 L-4-14-II
(SEDANG)
3.445.839 4.135.007 4.824.175
456 L-4-14-III
(BERAT)
6.099.062 7.318.875 8.538.687
457 M-1-01-I
9.543.787 11.452.545 13.361.302
458 M-1-01-II
10.652.411 12.782.893 14.913.375
459 M-1-01-III
14.963.751 17.956.501 20.949.252
463 M-1-03-I
17.597.048 21.116.457 24.635.867
464 M-1-03-II
20.488.707 24.586.448 28.684.190
465 M-1-03-III
25.844.741 31.013.689 36.182.638
466 M-1-04-I
6.139.963 7.367.955 8.595.948
467 M-1-04-II
7.863.698 9.436.437 11.009.177
468 M-1-04-III
9.839.936 11.807.923 13.775.910
469 M-1-05-I
7.788.079 9.345.695 10.903.311
470 M-1-05-II
9.044.475 10.853.370 12.662.265
471 M-1-05-III
16.010.338 19.212.406 22.414.474
472 M-1-07-I
7.667.700 9.201.240 10.734.780
473 M-1-07-II
10.272.322 12.326.786 14.381.251
474 M-1-07-III
20.925.694 25.110.833 29.295.972
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
475 M-1-10-I
WAJAH RINGAN
18.928.769 22.714.523 26.500.277
476 M-1-10-II
WAJAH SEDANG
45.257.951 54.309.541 63.361.131
477 M-1-10-III
WAJAH BERAT
97.617.139 117.140.567 136.663.995
478 M-1-20-I
MAYOR RINGAN
6.527.800 7.833.360 9.138.920
479 M-1-20-II
MAYOR SEDANG
7.410.752 8.892.903 10.375.053
480 M-1-20-III
MAYOR BERAT
18.184.431 21.821.318 25.458.204
484 M-1-40-I
3.867.468 4.640.962 5.414.455
485 M-1-40-II
6.365.919 7.639.103 8.912.287
486 M-1-40-III
9.428.955 11.314.746 13.200.537
490 M-1-60-I
3.938.932 4.726.718 5.514.505
491 M-1-60-II
7.899.215 9.479.058 11.058.901
492 M-1-60-III
12.248.819 14.698.583 17.148.347
493 M-1-70-I
(RINGAN)
22.556.558 27.067.870 31.579.181
494 M-1-70-II
(SEDANG)
24.812.214 29.774.657 34.737.100
495 M-1-70-III
(BERAT)
27.293.435 32.752.122 38.210.810
502 M-4-11-I
RINGAN
3.575.349 4.290.419 5.005.488
503 M-4-11-II
SEDANG
6.649.432 7.979.318 9.309.205
504 M-4-11-III
BERAT
11.885.242 14.262.291 16.639.339
506 M-4-12-II
SEDANG
3.530.360 4.236.432 4.942.504
508 M-4-13-I
4.496.525 5.395.830 6.295.135
509 M-4-13-II
5.594.811 6.713.773 7.832.735
510 M-4-13-III
11.434.116 13.720.939 16.007.762
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
520 M-4-17-I
RINGAN
2.884.590 3.461.509 4.038.427
521 M-4-17-II
SEDANG
3.775.379 4.530.455 5.285.530
522 M-4-17-III
BERAT
5.202.764 6.243.317 7.283.870
526 M-4-19-I
2.945.636 3.534.763 4.123.890
527 M-4-19-II
4.705.788 5.646.945 6.588.103
528 M-4-19-III
7.513.887 9.016.665 10.519.442
529 M-4-20-I
2.111.635 2.533.962 2.956.289
530 M-4-20-II
3.017.885 3.621.462 4.225.040
531 M-4-20-III
3.341.745 4.010.094 4.678.443
532 M-4-21-I
2.105.081 2.526.097 2.947.113
533 M-4-21-II
3.525.237 4.230.285 4.935.332
534 M-4-21-III
5.962.177 7.154.612 8.347.048
541 N-1-12-I
3.833.798 4.600.558 5.367.317
542 N-1-12-II
12.721.818 15.266.182 17.810.545
543 N-1-12-III
23.110.003 27.732.004 32.354.004
547 N-1-30-I
BAWAH RINGAN
7.590.650 9.108.780 10.626.910
548 N-1-30-II
BAWAH SEDANG
11.345.612 13.614.734 15.883.856
549 N-1-30-III
BAWAH BERAT
11.914.516 14.297.420 16.680.323
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
553 N-4-10-I
RINGAN
3.082.739 3.699.287 4.315.834
554 N-4-10-II
SEDANG
4.154.582 4.985.498 5.816.414
555 N-4-10-III
BERAT
7.268.522 8.722.226 10.175.930
565 N-4-14-I
1.755.850 2.107.020 2.458.190
566 N-4-14-II
2.611.004 3.133.205 3.655.405
567 N-4-14-III
4.234.216 5.081.059 5.927.902
568 N-4-15-I
URIN RINGAN
2.825.910 3.391.092 3.956.274
569 N-4-15-II
URIN SEDANG
3.865.827 4.638.992 5.412.158
570 N-4-15-III
URIN BERAT
4.411.606 5.293.927 6.176.249
571 N-4-16-I
(RINGAN)
3.403.687 4.084.424 4.765.161
572 N-4-16-II
(SEDANG)
4.090.701 4.908.841 5.726.981
573 N-4-16-III
(BERAT)
7.282.013 8.738.415 10.194.818
577 O-6-11-I
2.566.377 3.079.652 3.592.928
578 O-6-11-II
3.629.466 4.355.359 5.081.253
579 O-6-11-III
6.163.542 7.396.250 8.628.958
580 O-6-12-I
2.471.747 2.966.097 3.460.446
581 O-6-12-II
2.968.562 3.562.275 4.155.987
582 O-6-12-III
3.876.286 4.651.544 5.426.801
586 P-8-01-I
RINGAN
49.184.923 59.021.908 68.858.893
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
587 P-8-01-II
SEDANG
60.858.649 73.030.379 85.202.109
588 P-8-01-III
BERAT
71.430.994 85.717.192 100.003.391
589 P-8-02-I
79.357.531 95.229.037 111.100.543
590 P-8-02-II
91.031.257 109.237.508 127.443.759
591 P-8-02-III
104.009.719 124.811.663 145.613.607
592 P-8-03-I
2.750.024 3.300.029 3.850.034
593 P-8-03-II
4.098.708 4.918.450 5.738.191
594 P-8-03-III
7.448.897 8.938.677 10.428.456
595 P-8-04-I
33.114.381 39.737.257 46.360.133
596 P-8-04-II
42.808.030 51.369.637 59.931.243
597 P-8-04-III
61.375.941 73.651.129 85.926.317
598 P-8-05-I
17.981.234 21.577.481 25.173.728
599 P-8-05-II
25.476.925 30.572.310 35.667.695
600 P-8-05-III
37.411.288 44.893.545 52.375.803
601 P-8-06-I
3.047.542 3.657.051 4.266.559
602 P-8-06-II
6.617.048 7.940.458 9.263.868
603 P-8-06-III
12.084.000 14.500.800 16.917.600
604 P-8-07-I
4.765.316 5.718.379 6.671.443
605 P-8-07-II
11.792.398 14.150.878 16.509.357
606 P-8-07-III
15.852.636 19.023.163 22.193.691
607 P-8-08-I
3.945.289 4.734.347 5.523.405
608 P-8-08-II
5.598.178 6.717.814 7.837.450
609 P-8-08-III
9.064.683 10.877.619 12.690.556
610 P-8-10-I
2.334.022 2.800.826 3.267.630
611 P-8-10-II
4.002.492 4.802.990 5.603.488
612 P-8-10-III
7.858.070 9.429.685 11.001.299
613 P-8-11-I
RINGAN
2.817.219 3.380.663 3.944.107
614 P-8-11-II
SEDANG
13.977.631 16.773.158 19.568.684
615 P-8-11-III
BERAT
14.270.465 17.124.558 19.978.651
616 P-8-12-I
RINGAN
3.800.560 4.560.672 5.320.784
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
617 P-8-12-II
SEDANG
5.917.522 7.101.026 8.284.530
618 P-8-12-III
BERAT
6.974.329 8.369.195 9.764.061
619 P-8-13-I
RINGAN
2.213.763 2.656.515 3.099.268
620 P-8-13-II
SEDANG
5.439.396 6.527.275 7.615.154
621 P-8-13-III
BERAT
13.250.790 15.900.948 18.551.106
622 P-8-14-I
3.580.412 4.296.494 5.012.577
623 P-8-14-II
7.328.456 8.794.147 10.259.838
624 P-8-14-III
8.049.917 9.659.901 11.269.884
625 P-8-15-I
RINGAN
2.699.162 3.238.994 3.778.826
626 P-8-15-II
SEDANG
5.399.082 6.478.898 7.558.714
627 P-8-15-III
BERAT
6.329.413 7.595.296 8.861.178
628 P-8-16-I
2.448.966 2.938.759 3.428.552
629 P-8-16-II
5.250.312 6.300.375 7.350.437
630 P-8-16-III
13.790.150 16.548.180 19.306.210
631 P-8-17-I
RINGAN
1.878.869 2.254.643 2.630.417
632 P-8-17-II
SEDANG
4.884.897 5.861.877 6.838.856
633 P-8-17-III
BERAT
9.232.667 11.079.201 12.925.734
634 S-4-10-I
1.953.810 2.344.572 2.735.334
635 S-4-10-II
2.515.252 3.018.302 3.521.353
636 S-4-10-III
3.271.872 3.926.246 4.580.620
646 S-4-14-I
KANAK-KANAK RINGAN
1.192.695 1.431.234 1.669.773
647 S-4-14-II
KANAK-KANAK SEDANG
2.533.685 3.040.422 3.547.159
648 S-4-14-III
KANAK-KANAK BERAT
4.804.769 5.765.723 6.726.677
649 S-4-15-I
YANG LAIN (RINGAN)
902.046 1.082.456 1.262.865
650 S-4-15-II
YANG LAIN (SEDANG)
1.702.469 2.042.963 2.383.456
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
651 S-4-15-III
YANG LAIN (BERAT)
2.205.093 2.646.111 3.087.130
655 S-4-17-I
LAIN-LAIN RINGAN
2.038.540 2.446.247 2.853.955
656 S-4-17-II
LAIN-LAIN SEDANG
2.938.366 3.526.039 4.113.712
657 S-4-17-III
LAIN-LAIN BERAT
4.087.375 4.904.850 5.722.325
658 T-1-10-I
RINGAN
2.124.352 2.549.223 2.974.093
659 T-1-10-II
SEDANG
2.852.861 3.423.433 3.994.005
660 T-1-10-III
BERAT
5.190.284 6.228.341 7.266.398
661 T-4-10-I
824.819 989.782 1.154.746
662 T-4-10-II
1.571.922 1.886.306 2.200.690
663 T-4-10-III
2.285.147 2.742.177 3.199.206
664 T-4-11-I
1.125.668 1.350.801 1.575.935
665 T-4-11-II
1.771.480 2.125.776 2.480.073
666 T-4-11-III
2.853.333 3.424.000 3.994.666
667 T-4-12-I
LAIN (RINGAN)
1.854.533 2.225.439 2.596.346
668 T-4-12-II
LAIN (SEDANG)
2.763.302 3.315.962 3.868.623
669 T-4-12-III
LAIN (BERAT)
4.239.621 5.087.545 5.935.469
673 U-1-11-I
(RINGAN)
6.421.824 7.706.189 8.990.553
674 U-1-11-II
(SEDANG)
8.786.449 10.543.738 12.301.028
675 U-1-11-III
(BERAT)
19.961.692 23.954.030 27.946.368
682 U-1-14-I
MULUT (RINGAN)
4.024.311 4.829.174 5.634.036
683 U-1-14-II
MULUT (SEDANG)
4.938.639 5.926.367 6.914.095
684 U-1-14-III
MULUT (BERAT)
5.852.427 7.022.912 8.193.397
688 U-1-20-I
6.112.500 7.335.001 8.557.501
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
689 U-1-20-II
8.947.826 10.737.391 12.526.956
690 U-1-20-III
16.187.546 19.425.055 22.662.564
694 U-4-10-I
TELINGA RINGAN
4.882.233 5.858.679 6.835.126
695 U-4-10-II
TELINGA SEDANG
11.596.141 13.915.369 16.234.597
696 U-4-10-III
TELINGA BERAT
14.457.951 17.349.541 20.241.131
703 U-4-13-I
2.010.410 2.412.492 2.814.574
704 U-4-13-II
2.292.662 2.751.195 3.209.727
705 U-4-13-III
2.932.053 3.518.463 4.104.874
709 U-4-15-I
2.168.226 2.601.871 3.035.517
710 U-4-15-II
2.842.062 3.410.475 3.978.887
711 U-4-15-III
3.865.537 4.638.645 5.411.752
712 V-1-10-I
RINGAN
6.687.613 8.025.136 9.362.659
713 V-1-10-II
SEDANG
7.540.360 9.048.432 10.556.505
718 V-1-12-I
MODERAT (RINGAN)
4.916.367 5.899.640 6.882.913
719 V-1-12-II
MODERAT (SEDANG)
12.260.576 14.712.691 17.164.806
720 V-1-12-III
MODERAT (BERAT)
12.694.199 15.233.039 17.771.879
721 V-1-13-I
KOMPLEK (RINGAN)
7.465.159 8.958.191 10.451.223
722 V-1-13-II
KOMPLEK (SEDANG)
10.618.835 12.742.602 14.866.369
723 V-1-13-III
KOMPLEK (BERAT)
13.165.343 15.798.412 18.431.481
724 V-1-14-I
RINGAN
7.945.803 9.534.964 11.124.124
725 V-1-14-II
SEDANG
10.612.121 12.734.545 14.856.969
726 V-1-14-III
BERAT
14.427.888 17.313.466 20.199.044
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
2.773.190 3.327.828 3.882.466
734 V-4-11-II
TUMOR (SEDANG)
3.893.489 4.672.187 5.450.884
735 V-4-11-III
TUMOR (BERAT)
6.822.922 8.187.506 9.552.091
736 W-1-01-I
10.166.707 12.200.048 14.233.389
737 W-1-01-II
11.401.880 13.682.256 15.962.632
738 W-1-01-III
18.053.047 21.663.657 25.274.266
742 W-1-11-I
RINGAN
3.086.997 3.704.396 4.321.795
743 W-1-11-II
SEDANG
5.427.291 6.512.749 7.598.207
744 W-1-11-III
BERAT
11.428.346 13.714.015 15.999.684
745 W-1-12-I
2.685.979 3.223.175 3.760.371
746 W-1-12-II
3.036.811 3.644.174 4.251.536
747 W-1-12-III
4.664.925 5.597.910 6.530.895
748 W-1-13-I
RINGAN
2.310.363 2.772.435 3.234.508
749 W-1-13-II
SEDANG
2.508.388 3.010.065 3.511.743
763 W-4-12-I
2.012.371 2.414.845 2.817.319
764 W-4-12-II
3.256.032 3.907.239 4.558.445
765 W-4-12-III
4.141.018 4.969.221 5.797.425
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
787 Z-4-12-I
1.564.899 1.877.878 2.190.858
788 Z-4-12-II
4.065.022 4.878.026 5.691.031
789 Z-4-12-III
5.253.983 6.304.779 7.355.576
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.342.957
31 E-2-22-0
THYROGLOSSAL
186.202
33 F-3-10-0 TERAPI SHOCK 263.054
Rumah Sakit Kelas B
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
67 I-2-11-0
JANTUNG
2.314.467
72 I-2-16-0
PENGGANTIAN ALAT
2.311.958
80 I-2-42-0
PERKUTAN LAIN
2.205.828
102 K-2-12-0
FEMORALIS
943.249
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
178 O-7-11-0
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN
KURETASE
2.193.456
179 O-7-12-0
ATAU PELEBARAN DAN KURETASE
1.483.048
181 P-9-10-0
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN
AKUT LAIN
188.307
191 Q-5-12-0 GIGI 131.977
195 Q-5-16-0 VAKSINASI 105.209
196 Q-5-17-0 PASANG INFUS 90.823
200 Q-5-21-0 ABORSI 103.298
205 Q-5-26-0 BRONKIAL AKUT 203.771
210 Q-5-31-0 FRAKTUR 138.073
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
214 Q-5-35-0 INFEKSI AKUT 267.819
217 Q-5-38-0 PARU AKUT 212.965
238 U-3-10-0
TENGGOROKAN
204.592
239 U-3-11-0
TENGGOROKAN
193.366
241 U-3-13-0
TENGGOROKAN
198.940
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
269 Z-3-11-0
SALURAN EMPEDU
1.519.804
276 Z-3-18-0 CT-SCAN KEPALA 259.551
288 Z-3-30-0 FOTOTERAPI 78.971
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.598.964 1.918.757 2.238.550
8 A-4-12-II DEMAM SEDANG 2.042.408 2.450.890 2.859.372
9 A-4-12-III DEMAM BERAT 2.179.961 2.615.953 3.051.945
13 A-4-14-I
RINGAN
2.849.378 3.419.254 3.989.129
14 A-4-14-II
SEDANG
3.665.021 4.398.025 5.131.029
15 A-4-14-III
BERAT
4.199.252 5.039.102 5.878.952
28 B-1-12-I
RINGAN
5.546.837 6.656.205 7.765.572
29 B-1-12-II
SEDANG
11.888.230 14.265.875 16.643.521
30 B-1-12-III
BERAT
14.057.972 16.869.566 19.681.160
31 B-1-13-I
(RINGAN)
4.460.462 5.352.554 6.244.646
32 B-1-13-II
(SEDANG)
7.265.445 8.718.534 10.171.623
33 B-1-13-III
(BERAT)
10.711.304 12.853.565 14.995.826
34 B-1-14-I
RINGAN
6.033.331 7.239.997 8.446.663
35 B-1-14-II
SEDANG
6.710.281 8.052.338 9.394.394
36 B-1-14-III
BERAT
10.497.438 12.596.925 14.696.413
40 B-4-11-I
RINGAN
2.877.922 3.453.506 4.029.090
41 B-4-11-II
SEDANG
4.313.804 5.176.564 6.039.325
46 B-4-13-I
2.395.587 2.874.704 3.353.822
Rumah Sakit Kelas C
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
47 B-4-13-II
3.627.472 4.352.967 5.078.461
48 B-4-13-III
4.509.817 5.411.780 6.313.744
73 D-1-20-I
3.630.940 4.357.128 5.083.316
74 D-1-20-II
9.660.156 11.592.187 13.524.218
75 D-1-20-III
16.746.216 20.095.459 23.444.702
85 D-4-13-I
SEL SICKLE RINGAN
1.594.006 1.912.807 2.231.608
86 D-4-13-II
SEL SICKLE SEDANG
2.388.576 2.866.291 3.344.007
87 D-4-13-III
SEL SICKLE BERAT
2.790.525 3.348.629 3.906.734
88 D-4-14-I
1.924.170 2.309.004 2.693.838
89 D-4-14-II
3.676.868 4.412.242 5.147.616
90 D-4-14-III
5.155.772 6.186.926 7.218.080
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.919.221 5.903.066 6.886.910
98 E-1-20-II
TIROGLOSAL SEDANG
7.847.618 9.417.142 10.986.665
99 E-1-20-III
TIROGLOSAL BERAT
14.148.269 16.977.923 19.807.576
100 E-4-10-I
METABOLIK RINGAN
1.995.351 2.394.421 2.793.491
101 E-4-10-II
METABOLIK SEDANG
3.479.644 4.175.573 4.871.502
102 E-4-10-III
METABOLIK BERAT
4.410.430 5.292.515 6.174.601
130 F-4-16-I
RINGAN
4.738.757 5.686.509 6.634.260
131 F-4-16-II
SEDANG
5.506.669 6.608.003 7.709.337
132 F-4-16-III
BERAT
7.350.484 8.820.581 10.290.678
142 G-1-01-I
RINGAN
7.404.628 8.885.554 10.366.479
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
163 G-4-10-I
RINGAN
2.397.444 2.876.933 3.356.422
164 G-4-10-II
SEDANG
2.784.286 3.341.143 3.898.000
166 G-4-11-I
DEGENERATIF RINGAN
3.390.953 4.069.143 4.747.334
167 G-4-11-II
DEGENERATIF SEDANG
5.508.724 6.610.469 7.712.214
168 G-4-11-III
DEGENERATIF BERAT
6.697.931 8.037.517 9.377.103
172 G-4-13-I
RINGAN
2.222.467 2.666.961 3.111.454
173 G-4-13-II
SEDANG
2.782.607 3.339.128 3.895.649
174 G-4-13-III
BERAT
3.307.513 3.969.015 4.630.518
175 G-4-14-I
INFARK RINGAN
3.008.997 3.610.796 4.212.596
176 G-4-14-II
INFARK SEDANG
5.474.797 6.569.756 7.664.715
177 G-4-14-III
INFARK BERAT
6.845.870 8.215.043 9.584.217
178 G-4-15-I
2.417.943 2.901.531 3.385.120
179 G-4-15-II
2.885.825 3.462.990 4.040.156
180 G-4-15-III
3.751.440 4.501.728 5.252.017
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
2.390.253 2.868.304 3.346.354
188 G-4-18-II
PERSARAFAN SEDANG
4.654.897 5.585.876 6.516.856
189 G-4-18-III
PERSARAFAN BERAT
4.927.493 5.912.991 6.898.490
190 G-4-19-I
2.668.152 3.201.783 3.735.413
191 G-4-19-II
3.687.488 4.424.985 5.162.483
192 G-4-19-III
4.635.498 5.562.597 6.489.697
211 G-4-26-I
(RINGAN)
2.396.694 2.876.033 3.355.372
212 G-4-26-II
(SEDANG)
2.780.982 3.337.178 3.893.375
213 G-4-26-III
(BERAT)
4.083.467 4.900.160 5.716.853
229 I-1-01-I
RINGAN
34.444.553 41.333.463 48.222.374
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
230 I-1-01-II
SEDANG
35.202.512 42.243.015 49.283.517
231 I-1-01-III
BERAT
55.566.490 66.679.789 77.793.087
232 I-1-02-I
RINGAN
19.109.639 22.931.567 26.753.495
233 I-1-02-II
SEDANG
24.651.435 29.581.722 34.512.009
234 I-1-02-III
BERAT
30.384.327 36.461.192 42.538.057
235 I-1-03-I
11.750.359 14.100.430 16.450.502
236 I-1-03-II
13.465.929 16.159.115 18.852.300
237 I-1-03-III
22.276.330 26.731.596 31.186.862
238 I-1-04-I
JANTUNG RINGAN
18.299.611 21.959.533 25.619.455
239 I-1-04-II
JANTUNG SEDANG
18.753.355 22.504.026 26.254.697
240 I-1-04-III
JANTUNG BERAT
43.508.653 52.210.384 60.912.115
241 I-1-05-I
25.292.170 30.350.604 35.409.038
242 I-1-05-II
30.350.604 36.420.724 42.490.845
243 I-1-05-III
41.762.239 50.114.687 58.467.135
247 I-1-07-I
20.479.451 24.575.341 28.671.231
248 I-1-07-II
25.265.563 30.318.675 35.371.788
249 I-1-07-III
27.564.565 33.077.478 38.590.391
250 I-1-11-I
3.295.755 3.954.905 4.614.056
251 I-1-11-II
3.664.549 4.397.459 5.130.369
252 I-1-11-III
4.876.398 5.851.678 6.826.958
253 I-1-12-I
RINGAN
9.131.940 10.958.328 12.784.716
254 I-1-12-II
SEDANG
10.377.536 12.453.043 14.528.551
255 I-1-12-III
BERAT
17.667.794 21.201.353 24.734.911
256 I-1-13-I
RINGAN
4.358.365 5.230.038 6.101.711
257 I-1-13-II
SEDANG
6.243.006 7.491.607 8.740.208
258 I-1-13-III
BERAT
14.895.537 17.874.644 20.853.752
259 I-1-14-I
PERMANEN RINGAN
19.671.688 23.606.025 27.540.363
260 I-1-14-II
PERMANEN SEDANG
24.449.097 29.338.917 34.228.736
261 I-1-14-III
PERMANEN BERAT
32.036.748 38.444.098 44.851.448
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
265 I-1-16-I
(RINGAN)
8.430.723 10.116.868 11.803.013
266 I-1-16-II
(SEDANG)
21.919.880 26.303.857 30.687.833
267 I-1-16-III
(BERAT)
25.284.044 30.340.853 35.397.662
268 I-1-17-I
VENA RINGAN
11.885.348 14.262.418 16.639.488
269 I-1-17-II
VENA SEDANG
15.431.900 18.518.280 21.604.660
270 I-1-17-III
VENA BERAT
32.347.478 38.816.973 45.286.469
271 I-1-20-I
RINGAN
10.545.917 12.655.100 14.764.284
272 I-1-20-II
SEDANG
13.334.951 16.001.942 18.668.932
274 I-1-30-I
9.564.699 11.477.639 13.390.579
275 I-1-30-II
19.896.507 23.875.808 27.855.110
276 I-1-30-III
30.832.359 36.998.831 43.165.303
289 I-4-13-I
RINGAN
4.721.923 5.666.308 6.610.692
290 I-4-13-II
SEDANG
5.987.741 7.185.289 8.382.837
291 I-4-13-III
BERAT
10.385.816 12.462.980 14.540.143
295 I-4-15-I
(RINGAN)
3.188.060 3.825.672 4.463.284
296 I-4-15-II
(SEDANG)
4.569.218 5.483.061 6.396.905
297 I-4-15-III
(BERAT)
5.207.809 6.249.371 7.290.933
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
306 I-4-18-III
BERAT
6.485.186 7.782.223 9.079.260
319 I-4-23-I
1.965.451 2.358.541 2.751.631
320 I-4-23-II
2.413.121 2.895.745 3.378.369
321 I-4-23-III
4.715.018 5.658.022 6.601.025
322 I-4-24-I
(RINGAN)
2.346.278 2.815.534 3.284.790
323 I-4-24-II
(SEDANG)
6.462.714 7.755.257 9.047.800
324 I-4-24-III
(BERAT)
8.132.900 9.759.480 11.386.060
325 J-1-01-I
TRAKEOSTOMI RINGAN
19.210.982 23.053.179 26.895.375
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.928.082 25.113.699 29.299.315
327 J-1-01-III
TRAKEOSTOMI BERAT
37.902.496 45.482.995 53.063.494
328 J-1-02-I
TRAKEOSTOMI RINGAN
9.007.130 10.808.556 12.609.982
329 J-1-02-II
TRAKEOSTOMI SEDANG
10.360.396 12.432.475 14.504.554
330 J-1-02-III
TRAKEOSTOMI BERAT
16.908.603 20.290.323 23.672.044
334 J-1-20-I
RINGAN
5.916.458 7.099.749 8.283.041
335 J-1-20-II
SEDANG
7.817.610 9.381.132 10.944.654
337 J-1-30-I
RINGAN
2.972.670 3.567.204 4.161.738
338 J-1-30-II
SEDANG
9.753.169 11.703.802 13.654.436
339 J-1-30-III
BERAT
26.288.337 31.546.004 36.803.672
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.590.649 1.908.779 2.226.909
374 J-4-21-II
LAIN-LAIN (SEDANG)
3.219.027 3.862.832 4.506.638
375 J-4-21-III
LAIN-LAIN (BERAT)
4.567.322 5.480.786 6.394.251
376 K-1-10-I
(RINGAN)
4.300.549 5.160.659 6.020.769
377 K-1-10-II
(SEDANG)
8.128.071 9.753.685 11.379.299
378 K-1-10-III
(BERAT)
9.511.035 11.413.242 13.315.449
382 K-1-12-I
FEMORAL (RINGAN)
2.695.166 3.234.199 3.773.232
383 K-1-12-II
FEMORAL (SEDANG)
3.503.309 4.203.971 4.904.632
384 K-1-12-III
FEMORAL (BERAT)
6.987.271 8.384.725 9.782.179
394 K-1-30-I
KOMPLEKS (RINGAN)
6.183.754 7.420.505 8.657.256
395 K-1-30-II
KOMPLEKS (SEDANG)
8.589.893 10.307.872 12.025.850
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
15.963.183 19.155.820 22.348.457
412 K-4-13-I
2.394.456 2.873.347 3.352.239
413 K-4-13-II
3.094.645 3.713.574 4.332.503
414 K-4-13-III
5.075.775 6.090.930 7.106.085
415 K-4-14-I
RINGAN
1.998.073 2.397.688 2.797.303
416 K-4-14-II
SEDANG
2.704.329 3.245.195 3.786.061
417 K-4-14-III
BERAT
4.074.543 4.889.452 5.704.360
424 K-4-17-I
(RINGAN)
2.587.344 3.104.813 3.622.282
425 K-4-17-II
(SEDANG)
3.661.538 4.393.846 5.126.153
426 K-4-17-III
(BERAT)
4.130.223 4.956.268 5.782.312
430 L-1-20-I
RINGAN
22.065.394 26.478.472 30.891.551
431 L-1-20-II
SEDANG
22.740.433 27.288.520 31.836.606
432 L-1-20-III
BERAT
34.176.725 41.012.071 47.847.416
433 L-1-30-I
RINGAN
7.074.184 8.489.021 9.903.857
434 L-1-30-II
SEDANG
12.874.786 15.449.743 18.024.701
435 L-1-30-III
BERAT
15.291.799 18.350.158 21.408.518
436 L-1-40-I
PAYUDARA RINGAN
3.362.612 4.035.135 4.707.657
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
437 L-1-40-II
PAYUDARA SEDANG
7.132.943 8.559.532 9.986.121
438 L-1-40-III
PAYUDARA BERAT
12.110.474 14.532.569 16.954.664
451 L-4-13-I
PAYUDARA RINGAN
1.502.550 1.803.060 2.103.570
452 L-4-13-II
PAYUDARA SEDANG
2.142.487 2.570.985 2.999.482
453 L-4-13-III
PAYUDARA BERAT
2.593.529 3.112.235 3.630.941
454 L-4-14-I
(RINGAN)
1.593.623 1.912.348 2.231.073
455 L-4-14-II
(SEDANG)
2.391.784 2.870.141 3.348.498
456 L-4-14-III
(BERAT)
4.879.250 5.855.100 6.830.950
457 M-1-01-I
7.784.006 9.340.808 10.897.609
458 M-1-01-II
8.688.210 10.425.853 12.163.495
459 M-1-01-III
12.204.582 14.645.498 17.086.414
463 M-1-03-I
13.993.866 16.792.639 19.591.412
464 M-1-03-II
16.283.619 19.540.342 22.797.066
465 M-1-03-III
16.630.342 19.956.411 23.282.479
466 M-1-04-I
4.911.970 5.894.364 6.876.758
467 M-1-04-II
6.290.958 7.549.150 8.807.342
468 M-1-04-III
7.871.948 9.446.338 11.020.728
469 M-1-05-I
6.230.464 7.476.556 8.722.649
470 M-1-05-II
7.235.580 8.682.696 10.129.812
471 M-1-05-III
12.808.271 15.369.925 17.931.579
472 M-1-07-I
6.253.851 7.504.621 8.755.392
473 M-1-07-II
8.378.206 10.053.848 11.729.489
474 M-1-07-III
17.067.201 20.480.641 23.894.081
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
475 M-1-10-I
WAJAH RINGAN
5.294.558 6.353.469 7.412.381
476 M-1-10-II
WAJAH SEDANG
13.028.026 15.633.631 18.239.237
477 M-1-10-III
WAJAH BERAT
17.756.651 21.307.982 24.859.312
478 M-1-20-I
MAYOR RINGAN
5.222.240 6.266.688 7.311.136
479 M-1-20-II
MAYOR SEDANG
5.517.448 6.620.937 7.724.427
480 M-1-20-III
MAYOR BERAT
14.547.545 17.457.054 20.366.563
484 M-1-40-I
3.036.513 3.643.815 4.251.118
485 M-1-40-II
5.575.774 6.690.928 7.806.083
486 M-1-40-III
9.039.758 10.847.709 12.655.661
490 M-1-60-I
3.026.977 3.632.372 4.237.768
491 M-1-60-II
6.085.218 7.302.262 8.519.305
492 M-1-60-III
10.040.459 12.048.551 14.056.643
493 M-1-70-I
(RINGAN)
9.365.525 11.238.630 13.111.735
494 M-1-70-II
(SEDANG)
11.745.470 14.094.564 16.443.658
495 M-1-70-III
(BERAT)
12.360.869 14.833.043 17.305.217
502 M-4-11-I
RINGAN
2.116.118 2.539.341 2.962.565
503 M-4-11-II
SEDANG
4.842.269 5.810.723 6.779.177
504 M-4-11-III
BERAT
9.508.194 11.409.833 13.311.471
506 M-4-12-II
SEDANG
2.893.865 3.472.638 4.051.411
508 M-4-13-I
3.597.220 4.316.664 5.036.108
509 M-4-13-II
3.973.659 4.768.391 5.563.123
510 M-4-13-III
8.763.418 10.516.102 12.268.786
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
520 M-4-17-I
RINGAN
1.989.691 2.387.629 2.785.567
521 M-4-17-II
SEDANG
2.798.230 3.357.876 3.917.522
522 M-4-17-III
BERAT
3.909.891 4.691.869 5.473.848
526 M-4-19-I
2.356.509 2.827.811 3.299.112
527 M-4-19-II
3.764.630 4.517.556 5.270.482
528 M-4-19-III
5.718.504 6.862.205 8.005.905
529 M-4-20-I
1.592.451 1.910.941 2.229.431
530 M-4-20-II
2.395.213 2.874.255 3.353.298
531 M-4-20-III
2.648.608 3.178.330 3.708.052
532 M-4-21-I
1.589.324 1.907.189 2.225.054
533 M-4-21-II
2.088.302 2.505.962 2.923.622
534 M-4-21-III
4.887.246 5.864.695 6.842.144
541 N-1-12-I
3.142.596 3.771.115 4.399.635
542 N-1-12-II
10.177.454 12.212.945 14.248.436
543 N-1-12-III
18.488.003 22.185.603 25.883.204
547 N-1-30-I
BAWAH RINGAN
6.072.520 7.287.024 8.501.528
548 N-1-30-II
BAWAH SEDANG
7.905.078 9.486.094 11.067.110
549 N-1-30-III
BAWAH BERAT
9.082.778 10.899.334 12.715.890
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
553 N-4-10-I
RINGAN
1.992.860 2.391.432 2.790.004
554 N-4-10-II
SEDANG
3.323.665 3.988.398 4.653.132
555 N-4-10-III
BERAT
4.446.319 5.335.583 6.224.847
565 N-4-14-I
1.379.625 1.655.550 1.931.475
566 N-4-14-II
2.129.560 2.555.472 2.981.384
567 N-4-14-III
3.453.468 4.144.162 4.834.855
568 N-4-15-I
URIN RINGAN
1.979.848 2.375.817 2.771.787
569 N-4-15-II
URIN SEDANG
2.456.473 2.947.768 3.439.062
570 N-4-15-III
URIN BERAT
2.803.279 3.363.935 3.924.591
571 N-4-16-I
(RINGAN)
2.664.479 3.197.375 3.730.271
572 N-4-16-II
(SEDANG)
3.185.523 3.822.627 4.459.732
573 N-4-16-III
(BERAT)
5.439.607 6.527.529 7.615.450
577 O-6-11-I
2.103.681 2.524.417 2.945.153
578 O-6-11-II
2.794.794 3.353.753 3.912.712
579 O-6-11-III
4.746.106 5.695.327 6.644.548
580 O-6-12-I
1.977.398 2.372.877 2.768.357
581 O-6-12-II
2.374.850 2.849.820 3.324.790
582 O-6-12-III
3.101.029 3.721.235 4.341.441
586 P-8-01-I
RINGAN
40.115.705 48.138.846 56.161.987
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
587 P-8-01-II
SEDANG
49.636.909 59.564.291 69.491.673
588 P-8-01-III
BERAT
58.259.817 69.911.781 81.563.744
589 P-8-02-I
63.486.025 76.183.230 88.880.435
590 P-8-02-II
72.825.005 87.390.006 101.955.007
591 P-8-02-III
83.207.776 99.849.331 116.490.886
592 P-8-03-I
2.184.211 2.621.053 3.057.895
593 P-8-03-II
3.064.632 3.677.559 4.290.485
594 P-8-03-III
4.826.980 5.792.376 6.757.772
595 P-8-04-I
19.616.769 23.540.123 27.463.477
596 P-8-04-II
34.246.424 41.095.709 47.944.994
597 P-8-04-III
49.100.753 58.920.903 68.741.054
598 P-8-05-I
14.384.987 17.261.985 20.138.982
599 P-8-05-II
20.381.540 24.457.848 28.534.156
600 P-8-05-III
29.929.030 35.914.836 41.900.642
601 P-8-06-I
2.148.362 2.578.035 3.007.707
602 P-8-06-II
5.293.639 6.352.366 7.411.094
603 P-8-06-III
8.466.116 10.159.339 11.852.562
604 P-8-07-I
3.074.658 3.689.590 4.304.521
605 P-8-07-II
8.602.423 10.322.908 12.043.392
606 P-8-07-III
11.360.255 13.632.306 15.904.358
607 P-8-08-I
3.586.627 4.303.952 5.021.277
608 P-8-08-II
5.089.253 6.107.104 7.124.954
609 P-8-08-III
8.240.621 9.888.745 11.536.869
610 P-8-10-I
1.867.217 2.240.661 2.614.104
611 P-8-10-II
3.201.993 3.842.392 4.482.791
612 P-8-10-III
6.286.456 7.543.748 8.801.039
613 P-8-11-I
RINGAN
2.235.931 2.683.118 3.130.304
614 P-8-11-II
SEDANG
11.182.105 13.418.526 15.654.947
615 P-8-11-III
BERAT
11.416.372 13.699.647 15.982.921
616 P-8-12-I
RINGAN
3.040.448 3.648.538 4.256.627
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
617 P-8-12-II
SEDANG
4.734.017 5.680.821 6.627.624
618 P-8-12-III
BERAT
5.579.463 6.695.356 7.811.249
619 P-8-13-I
RINGAN
2.012.511 2.415.014 2.817.516
620 P-8-13-II
SEDANG
3.479.846 4.175.816 4.871.785
621 P-8-13-III
BERAT
5.180.179 6.216.215 7.252.251
622 P-8-14-I
2.126.734 2.552.081 2.977.428
623 P-8-14-II
5.862.764 7.035.317 8.207.870
624 P-8-14-III
6.439.934 7.727.921 9.015.907
625 P-8-15-I
RINGAN
2.159.329 2.591.195 3.023.061
626 P-8-15-II
SEDANG
4.319.265 5.183.118 6.046.972
627 P-8-15-III
BERAT
5.063.531 6.076.237 7.088.943
628 P-8-16-I
1.959.172 2.351.007 2.742.841
629 P-8-16-II
2.663.449 3.196.139 3.728.828
630 P-8-16-III
2.770.328 3.324.394 3.878.460
631 P-8-17-I
RINGAN
1.708.063 2.049.676 2.391.288
632 P-8-17-II
SEDANG
4.440.816 5.328.979 6.217.142
633 P-8-17-III
BERAT
8.393.334 10.072.001 11.750.667
634 S-4-10-I
1.593.547 1.912.256 2.230.965
635 S-4-10-II
1.993.636 2.392.363 2.791.091
636 S-4-10-III
2.592.767 3.111.320 3.629.874
646 S-4-14-I
KANAK-KANAK RINGAN
972.774 1.167.329 1.361.884
647 S-4-14-II
KANAK-KANAK SEDANG
2.066.498 2.479.798 2.893.097
648 S-4-14-III
KANAK-KANAK BERAT
3.918.817 4.702.580 5.486.344
649 S-4-15-I
YANG LAIN (RINGAN)
735.718 882.861 1.030.005
650 S-4-15-II
YANG LAIN (SEDANG)
1.388.550 1.666.260 1.943.970
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
651 S-4-15-III
YANG LAIN (BERAT)
1.798.495 2.158.194 2.517.893
655 S-4-17-I
LAIN-LAIN RINGAN
1.487.197 1.784.636 2.082.076
656 S-4-17-II
LAIN-LAIN SEDANG
1.992.174 2.390.609 2.789.044
657 S-4-17-III
LAIN-LAIN BERAT
3.256.642 3.907.971 4.559.299
658 T-1-10-I
RINGAN
1.699.482 2.039.378 2.379.275
659 T-1-10-II
SEDANG
2.282.289 2.738.747 3.195.204
660 T-1-10-III
BERAT
4.152.227 4.982.673 5.813.118
661 T-4-10-I
672.730 807.276 941.822
662 T-4-10-II
1.282.075 1.538.490 1.794.905
663 T-4-10-III
1.863.789 2.236.546 2.609.304
664 T-4-11-I
900.534 1.080.641 1.260.748
665 T-4-11-II
1.417.184 1.700.621 1.984.058
666 T-4-11-III
2.282.667 2.739.200 3.195.733
667 T-4-12-I
LAIN (RINGAN)
1.399.367 1.679.241 1.959.114
668 T-4-12-II
LAIN (SEDANG)
2.115.095 2.538.114 2.961.133
669 T-4-12-III
LAIN (BERAT)
3.274.371 3.929.245 4.584.119
673 U-1-11-I
(RINGAN)
5.264.022 6.316.827 7.369.631
674 U-1-11-II
(SEDANG)
6.980.715 8.376.858 9.773.001
675 U-1-11-III
(BERAT)
13.090.212 15.708.254 18.326.297
682 U-1-14-I
MULUT (RINGAN)
3.219.449 3.863.339 4.507.229
683 U-1-14-II
MULUT (SEDANG)
3.950.912 4.741.094 5.531.276
684 U-1-14-III
MULUT (BERAT)
4.681.941 5.618.330 6.554.718
688 U-1-20-I
4.890.000 5.868.000 6.846.001
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
689 U-1-20-II
6.417.781 7.701.338 8.984.894
690 U-1-20-III
12.892.639 15.471.166 18.049.694
694 U-4-10-I
TELINGA RINGAN
3.905.786 4.686.944 5.468.101
695 U-4-10-II
TELINGA SEDANG
6.486.612 7.783.934 9.081.256
696 U-4-10-III
TELINGA BERAT
9.959.078 11.950.894 13.942.709
703 U-4-13-I
1.565.288 1.878.346 2.191.404
704 U-4-13-II
1.826.819 2.192.183 2.557.547
705 U-4-13-III
2.066.948 2.480.338 2.893.727
709 U-4-15-I
1.598.464 1.918.157 2.237.849
710 U-4-15-II
1.998.823 2.398.587 2.798.352
711 U-4-15-III
2.794.571 3.353.485 3.912.399
712 V-1-10-I
RINGAN
4.676.155 5.611.386 6.546.617
713 V-1-10-II
SEDANG
5.368.024 6.441.629 7.515.234
718 V-1-12-I
MODERAT (RINGAN)
3.933.093 4.719.712 5.506.331
719 V-1-12-II
MODERAT (SEDANG)
9.051.742 10.862.090 12.672.439
720 V-1-12-III
MODERAT (BERAT)
10.405.541 12.486.649 14.567.757
721 V-1-13-I
KOMPLEK (RINGAN)
5.720.959 6.865.150 8.009.342
722 V-1-13-II
KOMPLEK (SEDANG)
8.704.347 10.445.217 12.186.086
723 V-1-13-III
KOMPLEK (BERAT)
12.072.118 14.486.541 16.900.965
724 V-1-14-I
RINGAN
6.356.643 7.627.971 8.899.300
725 V-1-14-II
SEDANG
7.727.991 9.273.589 10.819.187
726 V-1-14-III
BERAT
9.461.328 11.353.594 13.245.859
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
2.045.886 2.455.063 2.864.241
734 V-4-11-II
TUMOR (SEDANG)
2.984.076 3.580.891 4.177.706
735 V-4-11-III
TUMOR (BERAT)
5.458.337 6.550.005 7.641.672
736 W-1-01-I
8.133.365 9.760.038 11.386.711
737 W-1-01-II
9.121.504 10.945.805 12.770.105
738 W-1-01-III
12.868.029 15.441.635 18.015.240
742 W-1-11-I
RINGAN
2.806.361 3.367.633 3.928.905
743 W-1-11-II
SEDANG
4.933.901 5.920.681 6.907.461
744 W-1-11-III
BERAT
10.389.406 12.467.287 14.545.168
745 W-1-12-I
2.148.783 2.578.540 3.008.297
746 W-1-12-II
2.429.449 2.915.339 3.401.229
747 W-1-12-III
3.731.940 4.478.328 5.224.716
748 W-1-13-I
RINGAN
1.884.354 2.261.225 2.638.096
749 W-1-13-II
SEDANG
2.045.866 2.455.039 2.864.212
763 W-4-12-I
1.594.824 1.913.788 2.232.753
764 W-4-12-II
2.188.577 2.626.293 3.064.008
765 W-4-12-III
3.312.814 3.975.377 4.637.940
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
787 Z-4-12-I
1.197.639 1.437.167 1.676.695
788 Z-4-12-II
3.252.017 3.902.421 4.552.824
789 Z-4-12-III
4.203.186 5.043.824 5.884.461
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.298.983
33 F-3-10-0 TERAPI SHOCK 254.922
Rumah Sakit Kelas C
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
72 I-2-16-0
ALAT
2.236.255
80 I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN LAIN
2.155.376
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
179 O-7-12-0
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU PELEBARAN
DAN KURETASE
1.186.439
191 Q-5-12-0 GIGI 127.509
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
195 Q-5-16-0 VAKSINASI 101.874
196 Q-5-17-0 PASANG INFUS 87.849
200 Q-5-21-0 ABORSI 82.638
205 Q-5-26-0 BRONKIAL AKUT 196.966
210 Q-5-31-0 FRAKTUR 133.398
214 Q-5-35-0 INFEKSI AKUT 259.638
217 Q-5-38-0 PARU AKUT 206.459
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN EMPEDU
1.470.039
276 Z-3-18-0 CT-SCAN KEPALA 251.053
288 Z-3-30-0 FOTOTERAPI 76.485
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.333.836 1.600.603 1.867.371
8 A-4-12-II DEMAM SEDANG 1.721.407 2.065.689 2.409.970
9 A-4-12-III DEMAM BERAT 2.131.316 2.557.579 2.983.842
13 A-4-14-I
RINGAN
2.590.344 3.108.412 3.626.481
14 A-4-14-II
SEDANG
3.331.837 3.998.205 4.664.572
15 A-4-14-III
BERAT
3.817.502 4.581.002 5.344.502
28 B-1-12-I
RINGAN
4.076.787 4.892.145 5.707.502
29 B-1-12-II
SEDANG
8.737.552 10.485.063 12.232.573
30 B-1-12-III
BERAT
10.633.930 12.760.716 14.887.502
31 B-1-13-I
(RINGAN)
3.286.200 3.943.440 4.600.680
32 B-1-13-II
(SEDANG)
5.352.742 6.423.291 7.493.839
33 B-1-13-III
(BERAT)
7.891.444 9.469.733 11.048.022
34 B-1-14-I
RINGAN
4.460.067 5.352.080 6.244.094
35 B-1-14-II
SEDANG
4.960.494 5.952.593 6.944.692
36 B-1-14-III
BERAT
7.760.104 9.312.125 10.864.145
40 B-4-11-I
RINGAN
2.425.605 2.910.726 3.395.847
41 B-4-11-II
SEDANG
3.635.812 4.362.975 5.090.137
Rumah Sakit Kelas D
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
46 B-4-13-I
1.996.518 2.395.822 2.795.125
47 B-4-13-II
2.583.461 3.100.153 3.616.845
48 B-4-13-III
3.801.019 4.561.222 5.321.426
73 D-1-20-I
3.060.273 3.672.328 4.284.383
74 D-1-20-II
8.816.633 10.579.959 12.343.286
75 D-1-20-III
14.114.249 16.937.099 19.759.949
85 D-4-13-I
SEL SICKLE RINGAN
1.335.576 1.602.692 1.869.807
86 D-4-13-II
SEL SICKLE SEDANG
2.002.460 2.402.953 2.803.445
87 D-4-13-III
SEL SICKLE BERAT
2.456.144 2.947.373 3.438.601
88 D-4-14-I
1.671.196 2.005.435 2.339.675
89 D-4-14-II
3.098.983 3.718.779 4.338.576
90 D-4-14-III
4.345.450 5.214.540 6.083.630
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.146.078 4.975.294 5.804.509
98 E-1-20-II
TIROGLOSAL SEDANG
6.037.600 7.245.120 8.452.640
99 E-1-20-III
TIROGLOSAL BERAT
10.020.686 12.024.823 14.028.960
100 E-4-10-I
METABOLIK RINGAN
1.847.707 2.217.249 2.586.790
101 E-4-10-II
METABOLIK SEDANG
2.839.731 3.407.677 3.975.623
102 E-4-10-III
METABOLIK BERAT
3.934.092 4.720.910 5.507.728
130 F-4-16-I
RINGAN
3.508.872 4.210.647 4.912.421
131 F-4-16-II
SEDANG
4.064.637 4.877.565 5.690.492
132 F-4-16-III
BERAT
5.425.612 6.510.735 7.595.857
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
142 G-1-01-I
RINGAN
6.178.136 7.413.764 8.649.391
163 G-4-10-I
RINGAN
1.995.065 2.394.078 2.793.091
164 G-4-10-II
SEDANG
2.432.331 2.918.797 3.405.264
166 G-4-11-I
DEGENERATIF RINGAN
3.200.964 3.841.157 4.481.350
167 G-4-11-II
DEGENERATIF SEDANG
4.590.805 5.508.966 6.427.127
168 G-4-11-III
DEGENERATIF BERAT
6.102.953 7.323.543 8.544.134
172 G-4-13-I
RINGAN
1.638.712 1.966.454 2.294.197
173 G-4-13-II
SEDANG
2.329.424 2.795.309 3.261.194
174 G-4-13-III
BERAT
2.755.636 3.306.763 3.857.890
175 G-4-14-I
INFARK RINGAN
2.614.515 3.137.418 3.660.321
176 G-4-14-II
INFARK SEDANG
4.039.162 4.846.994 5.654.826
177 G-4-14-III
INFARK BERAT
5.050.703 6.060.844 7.070.984
178 G-4-15-I
1.997.161 2.396.594 2.796.026
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
179 G-4-15-II
2.432.266 2.918.720 3.405.173
180 G-4-15-III
3.133.604 3.760.325 4.387.046
187 G-4-18-I
PERSARAFAN RINGAN
1.994.204 2.393.044 2.791.885
188 G-4-18-II
PERSARAFAN SEDANG
3.419.368 4.103.241 4.787.115
189 G-4-18-III
PERSARAFAN BERAT
3.630.041 4.356.049 5.082.057
190 G-4-19-I
1.993.137 2.391.764 2.790.392
191 G-4-19-II
3.107.933 3.729.520 4.351.106
192 G-4-19-III
3.906.947 4.688.336 5.469.725
211 G-4-26-I
(RINGAN)
2.321.852 2.786.222 3.250.592
212 G-4-26-II
(SEDANG)
2.715.949 3.259.139 3.802.328
213 G-4-26-III
(BERAT)
3.441.677 4.130.012 4.818.348
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
229 I-1-01-I
RINGAN
28.739.208 34.487.050 40.234.892
230 I-1-01-II
SEDANG
29.371.621 35.245.945 41.120.269
231 I-1-01-III
BERAT
46.362.540 55.635.048 64.907.556
232 I-1-02-I
RINGAN
15.944.347 19.133.217 22.322.086
233 I-1-02-II
SEDANG
20.568.208 24.681.850 28.795.491
234 I-1-02-III
BERAT
25.351.512 30.421.815 35.492.117
235 I-1-03-I
9.853.814 11.824.576 13.795.339
236 I-1-03-II
11.349.518 13.619.422 15.889.325
237 I-1-03-III
18.775.207 22.530.249 26.285.290
238 I-1-04-I
JANTUNG RINGAN
14.332.855 17.199.426 20.065.997
239 I-1-04-II
JANTUNG SEDANG
15.423.501 18.508.201 21.592.901
240 I-1-04-III
JANTUNG BERAT
31.985.974 38.383.169 44.780.364
241 I-1-05-I
21.102.813 25.323.375 29.543.938
242 I-1-05-II
25.323.375 30.388.050 35.452.725
243 I-1-05-III
34.844.804 41.813.765 48.782.726
247 I-1-07-I
15.652.079 18.782.495 21.912.911
248 I-1-07-II
19.310.019 23.172.023 27.034.027
249 I-1-07-III
21.067.106 25.280.527 29.493.948
250 I-1-11-I
2.422.297 2.906.757 3.391.216
251 I-1-11-II
2.693.352 3.232.023 3.770.693
252 I-1-11-III
3.584.031 4.300.837 5.017.644
253 I-1-12-I
RINGAN
7.653.695 9.184.434 10.715.173
254 I-1-12-II
SEDANG
8.746.521 10.495.826 12.245.130
255 I-1-12-III
BERAT
14.811.778 17.774.133 20.736.489
256 I-1-13-I
RINGAN
3.796.845 4.556.214 5.315.583
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
257 I-1-13-II
SEDANG
5.227.859 6.273.431 7.319.002
258 I-1-13-III
BERAT
11.384.393 13.661.272 15.938.151
259 I-1-14-I
PERMANEN RINGAN
16.413.299 19.695.958 22.978.618
260 I-1-14-II
PERMANEN SEDANG
20.399.385 24.479.263 28.559.140
261 I-1-14-III
PERMANEN BERAT
26.730.229 32.076.275 37.422.321
265 I-1-16-I
(RINGAN)
7.034.271 8.441.125 9.847.979
266 I-1-16-II
(SEDANG)
18.289.104 21.946.925 25.604.746
267 I-1-16-III
(BERAT)
21.096.033 25.315.240 29.534.446
268 I-1-17-I
VENA RINGAN
2.696.540 3.235.848 3.775.156
269 I-1-17-II
VENA SEDANG
4.548.687 5.458.425 6.368.162
270 I-1-17-III
VENA BERAT
26.490.935 31.789.122 37.087.309
271 I-1-20-I
RINGAN
3.269.828 3.923.794 4.577.760
272 I-1-20-II
SEDANG
5.411.782 6.494.138 7.576.495
274 I-1-30-I
7.980.417 9.576.500 11.172.584
275 I-1-30-II
16.600.879 19.921.055 23.241.231
276 I-1-30-III
25.725.333 30.870.400 36.015.467
289 I-4-13-I
RINGAN
3.479.819 4.175.783 4.871.747
290 I-4-13-II
SEDANG
5.067.568 6.081.081 7.094.595
291 I-4-13-III
BERAT
8.659.377 10.391.252 12.123.127
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
295 I-4-15-I
(RINGAN)
2.671.904 3.206.285 3.740.666
296 I-4-15-II
(SEDANG)
3.990.760 4.788.912 5.587.065
297 I-4-15-III
(BERAT)
4.548.507 5.458.208 6.367.909
306 I-4-18-III
BERAT
5.465.923 6.559.108 7.652.293
319 I-4-23-I
1.639.897 1.967.876 2.295.855
320 I-4-23-II
2.013.415 2.416.098 2.818.781
321 I-4-23-III
3.934.029 4.720.835 5.507.641
322 I-4-24-I
(RINGAN)
1.977.519 2.373.023 2.768.526
323 I-4-24-II
(SEDANG)
4.748.892 5.698.671 6.648.449
324 I-4-24-III
(BERAT)
6.027.291 7.232.749 8.438.207
325 J-1-01-I
TRAKEOSTOMI RINGAN
18.854.732 22.625.678 26.396.624
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.142.441 24.170.930 28.199.418
327 J-1-01-III
TRAKEOSTOMI BERAT
28.022.730 33.627.275 39.231.821
328 J-1-02-I
TRAKEOSTOMI RINGAN
7.591.499 9.109.799 10.628.099
329 J-1-02-II
TRAKEOSTOMI SEDANG
9.289.441 11.147.330 13.005.218
330 J-1-02-III
TRAKEOSTOMI BERAT
12.487.396 14.984.875 17.482.354
334 J-1-20-I
RINGAN
3.252.212 3.902.654 4.553.097
335 J-1-20-II
SEDANG
4.012.229 4.814.674 5.617.120
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
337 J-1-30-I
RINGAN
2.192.971 2.631.566 3.070.160
338 J-1-30-II
SEDANG
8.220.284 9.864.341 11.508.398
339 J-1-30-III
BERAT
22.043.032 26.451.639 30.860.245
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.430.027 1.716.033 2.002.038
374 J-4-21-II
LAIN-LAIN (SEDANG)
2.670.374 3.204.448 3.738.523
375 J-4-21-III
LAIN-LAIN (BERAT)
3.824.810 4.589.772 5.354.734
376 K-1-10-I
(RINGAN)
3.602.358 4.322.830 5.043.302
377 K-1-10-II
(SEDANG)
5.973.929 7.168.715 8.363.501
378 K-1-10-III
(BERAT)
7.006.696 8.408.035 9.809.374
382 K-1-12-I
FEMORAL (RINGAN)
1.989.615 2.387.538 2.785.461
383 K-1-12-II
FEMORAL (SEDANG)
2.590.937 3.109.125 3.627.312
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
384 K-1-12-III
FEMORAL (BERAT)
5.153.154 6.183.784 7.214.415
394 K-1-30-I
KOMPLEKS (RINGAN)
4.672.731 5.607.277 6.541.823
395 K-1-30-II
KOMPLEKS (SEDANG)
7.197.746 8.637.295 10.076.844
396 K-1-30-III
KOMPLEKS (BERAT)
13.372.164 16.046.597 18.721.030
412 K-4-13-I
1.995.947 2.395.137 2.794.326
413 K-4-13-II
2.593.613 3.112.336 3.631.058
414 K-4-13-III
4.234.149 5.080.979 5.927.809
415 K-4-14-I
RINGAN
1.666.589 1.999.907 2.333.225
416 K-4-14-II
SEDANG
2.260.555 2.712.666 3.164.777
417 K-4-14-III
BERAT
3.639.794 4.367.753 5.095.712
424 K-4-17-I
(RINGAN)
2.352.131 2.822.558 3.292.984
425 K-4-17-II
(SEDANG)
3.328.671 3.994.405 4.660.139
426 K-4-17-III
(BERAT)
3.754.748 4.505.698 5.256.647
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
430 L-1-20-I
RINGAN
16.272.180 19.526.615 22.781.051
431 L-1-20-II
SEDANG
16.916.104 20.299.325 23.682.546
432 L-1-20-III
BERAT
28.600.951 34.321.141 40.041.332
433 L-1-30-I
RINGAN
5.962.350 7.154.820 8.347.290
434 L-1-30-II
SEDANG
10.729.458 12.875.350 15.021.242
435 L-1-30-III
BERAT
11.330.533 13.596.639 15.862.746
436 L-1-40-I
PAYUDARA RINGAN
2.834.118 3.400.941 3.967.765
437 L-1-40-II
PAYUDARA SEDANG
4.968.491 5.962.189 6.955.888
438 L-1-40-III
PAYUDARA BERAT
8.409.621 10.091.545 11.773.469
451 L-4-13-I
PAYUDARA RINGAN
1.384.041 1.660.849 1.937.657
452 L-4-13-II
PAYUDARA SEDANG
1.729.977 2.075.972 2.421.968
453 L-4-13-III
PAYUDARA BERAT
2.442.358 2.930.829 3.419.301
454 L-4-14-I
(RINGAN)
1.372.569 1.647.083 1.921.597
455 L-4-14-II
(SEDANG)
2.035.071 2.442.086 2.849.100
456 L-4-14-III
(BERAT)
3.750.192 4.500.231 5.250.269
457 M-1-01-I
6.494.675 7.793.610 9.092.545
458 M-1-01-II
7.249.108 8.698.930 10.148.752
459 M-1-01-III
10.183.033 12.219.640 14.256.246
463 M-1-03-I
11.654.901 13.985.881 16.316.861
464 M-1-03-II
13.642.299 16.370.759 19.099.218
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
465 M-1-03-III
15.802.140 18.962.568 22.122.996
466 M-1-04-I
3.626.188 4.351.426 5.076.664
467 M-1-04-II
4.663.191 5.595.830 6.528.468
468 M-1-04-III
5.835.105 7.002.126 8.169.147
469 M-1-05-I
4.608.139 5.529.767 6.451.394
470 M-1-05-II
5.317.971 6.381.565 7.445.159
471 M-1-05-III
9.057.953 10.869.543 12.681.134
472 M-1-07-I
5.217.973 6.261.567 7.305.162
473 M-1-07-II
6.990.453 8.388.543 9.786.634
474 M-1-07-III
14.240.215 17.088.258 19.936.301
475 M-1-10-I
WAJAH RINGAN
3.910.947 4.693.136 5.475.326
476 M-1-10-II
WAJAH SEDANG
10.980.440 13.176.528 15.372.615
477 M-1-10-III
WAJAH BERAT
16.179.326 19.415.192 22.651.057
478 M-1-20-I
MAYOR RINGAN
3.858.921 4.630.705 5.402.489
479 M-1-20-II
MAYOR SEDANG
4.383.237 5.259.884 6.136.531
480 M-1-20-III
MAYOR BERAT
10.693.445 12.832.134 14.970.823
484 M-1-40-I
2.285.638 2.742.766 3.199.893
485 M-1-40-II
3.754.445 4.505.334 5.256.223
486 M-1-40-III
6.285.674 7.542.809 8.799.943
490 M-1-60-I
2.338.631 2.806.357 3.274.083
491 M-1-60-II
4.680.046 5.616.055 6.552.064
492 M-1-60-III
8.123.925 9.748.710 11.373.495
493 M-1-70-I
(RINGAN)
3.127.785 3.753.342 4.378.899
494 M-1-70-II
(SEDANG)
6.377.215 7.652.658 8.928.101
495 M-1-70-III
(BERAT)
8.918.851 10.702.621 12.486.391
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
502 M-4-11-I
RINGAN
2.105.372 2.526.447 2.947.521
503 M-4-11-II
SEDANG
4.101.729 4.922.075 5.742.421
504 M-4-11-III
BERAT
6.988.285 8.385.942 9.783.599
505 M-4-12-I
RINGAN
1.333.886 1.600.663 1.867.440
506 M-4-12-II
SEDANG
2.426.848 2.912.217 3.397.587
508 M-4-13-I
2.951.216 3.541.460 4.131.703
509 M-4-13-II
3.336.837 4.004.205 4.671.572
510 M-4-13-III
7.899.562 9.479.475 11.059.387
520 M-4-17-I
RINGAN
1.698.614 2.038.336 2.378.059
521 M-4-17-II
SEDANG
2.330.362 2.796.434 3.262.507
522 M-4-17-III
BERAT
3.268.192 3.921.831 4.575.469
526 M-4-19-I
1.733.977 2.080.773 2.427.568
527 M-4-19-II
2.920.573 3.504.687 4.088.802
528 M-4-19-III
4.996.610 5.995.932 6.995.254
529 M-4-20-I
1.334.874 1.601.849 1.868.824
530 M-4-20-II
1.997.400 2.396.880 2.796.360
531 M-4-20-III
2.220.395 2.664.474 3.108.553
532 M-4-21-I
1.330.421 1.596.505 1.862.590
533 M-4-21-II
2.074.900 2.489.880 2.904.860
534 M-4-21-III
4.119.128 4.942.954 5.766.779
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
541 N-1-12-I
2.648.681 3.178.417 3.708.154
542 N-1-12-II
7.495.363 8.994.436 10.493.509
543 N-1-12-III
13.658.616 16.390.340 19.122.063
547 N-1-30-I
BAWAH RINGAN
5.191.760 6.230.112 7.268.464
548 N-1-30-II
BAWAH SEDANG
7.838.417 9.406.100 10.973.784
549 N-1-30-III
BAWAH BERAT
8.231.460 9.877.752 11.524.044
553 N-4-10-I
RINGAN
1.825.216 2.190.259 2.555.302
554 N-4-10-II
SEDANG
2.669.382 3.203.258 3.737.135
555 N-4-10-III
BERAT
4.272.151 5.126.581 5.981.011
565 N-4-14-I
1.154.936 1.385.923 1.616.910
566 N-4-14-II
1.776.823 2.132.188 2.487.552
567 N-4-14-III
2.881.441 3.457.729 4.034.017
568 N-4-15-I
URIN RINGAN
1.668.679 2.002.415 2.336.151
569 N-4-15-II
URIN SEDANG
2.298.138 2.757.766 3.217.393
570 N-4-15-III
URIN BERAT
2.622.590 3.147.108 3.671.626
571 N-4-16-I
(RINGAN)
2.057.586 2.469.104 2.880.621
572 N-4-16-II
(SEDANG)
2.670.730 3.204.876 3.739.022
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
573 N-4-16-III
(BERAT)
4.584.676 5.501.611 6.418.546
577 O-6-11-I
1.773.050 2.127.660 2.482.269
578 O-6-11-II
2.146.583 2.575.900 3.005.216
579 O-6-11-III
3.634.564 4.361.477 5.088.389
580 O-6-12-I
1.453.338 1.744.006 2.034.673
581 O-6-12-II
1.745.455 2.094.546 2.443.638
582 O-6-12-III
2.192.915 2.631.497 3.070.080
586 P-8-01-I
RINGAN
33.470.999 40.165.199 46.859.399
587 P-8-01-II
SEDANG
41.415.126 49.698.151 57.981.176
588 P-8-01-III
BERAT
48.609.748 58.331.698 68.053.647
589 P-8-02-I
48.521.237 58.225.485 67.929.732
590 P-8-02-II
55.658.854 66.790.624 77.922.395
591 P-8-02-III
63.594.220 76.313.064 89.031.908
592 P-8-03-I
1.829.123 2.194.947 2.560.772
593 P-8-03-II
2.563.838 3.076.605 3.589.373
594 P-8-03-III
4.416.055 5.299.266 6.182.477
595 P-8-04-I
19.465.482 23.358.578 27.251.675
596 P-8-04-II
25.398.433 30.478.120 35.557.806
597 P-8-04-III
36.414.960 43.697.952 50.980.944
598 P-8-05-I
10.604.840 12.725.808 14.846.776
599 P-8-05-II
15.070.103 18.084.124 21.098.145
600 P-8-05-III
22.203.774 26.644.529 31.085.284
601 P-8-06-I
1.831.764 2.198.116 2.564.469
602 P-8-06-II
4.394.371 5.273.245 6.152.119
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
603 P-8-06-III
8.063.132 9.675.758 11.288.384
604 P-8-07-I
2.819.596 3.383.515 3.947.434
605 P-8-07-II
7.173.539 8.608.247 10.042.955
606 P-8-07-III
9.507.597 11.409.117 13.310.636
607 P-8-08-I
3.260.570 3.912.684 4.564.798
608 P-8-08-II
4.626.594 5.551.912 6.477.231
609 P-8-08-III
7.491.473 8.989.768 10.488.063
610 P-8-10-I
1.381.427 1.657.712 1.933.998
611 P-8-10-II
2.447.226 2.936.672 3.426.117
612 P-8-10-III
4.804.627 5.765.552 6.726.477
613 P-8-11-I
RINGAN
1.869.792 2.243.750 2.617.709
614 P-8-11-II
SEDANG
8.242.125 9.890.550 11.538.975
615 P-8-11-III
BERAT
8.414.799 10.097.758 11.780.718
616 P-8-12-I
RINGAN
2.244.052 2.692.863 3.141.673
617 P-8-12-II
SEDANG
3.489.357 4.187.229 4.885.100
618 P-8-12-III
BERAT
4.124.803 4.949.764 5.774.724
619 P-8-13-I
RINGAN
1.829.556 2.195.467 2.561.378
620 P-8-13-II
SEDANG
3.163.497 3.796.196 4.428.895
621 P-8-13-III
BERAT
4.709.254 5.651.104 6.592.955
622 P-8-14-I
2.115.127 2.538.152 2.961.177
623 P-8-14-II
4.312.716 5.175.259 6.037.802
624 P-8-14-III
4.731.136 5.677.364 6.623.591
625 P-8-15-I
RINGAN
1.595.808 1.914.970 2.234.132
626 P-8-15-II
SEDANG
3.179.062 3.814.874 4.450.686
627 P-8-15-III
BERAT
3.732.236 4.478.683 5.225.130
628 P-8-16-I
1.444.574 1.733.489 2.022.404
629 P-8-16-II
2.041.958 2.450.350 2.858.742
630 P-8-16-III
2.649.190 3.179.029 3.708.867
631 P-8-17-I
RINGAN
1.552.785 1.863.341 2.173.898
632 P-8-17-II
SEDANG
4.037.105 4.844.526 5.651.947
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
633 P-8-17-III
BERAT
7.630.303 9.156.364 10.682.425
634 S-4-10-I
1.336.343 1.603.612 1.870.881
635 S-4-10-II
1.669.666 2.003.599 2.337.532
636 S-4-10-III
2.161.770 2.594.124 3.026.478
646 S-4-14-I
KANAK-KANAK RINGAN
811.645 973.974 1.136.303
647 S-4-14-II
KANAK-KANAK SEDANG
1.724.206 2.069.048 2.413.889
648 S-4-14-III
KANAK-KANAK BERAT
3.269.710 3.923.652 4.577.594
649 S-4-15-I
YANG LAIN (RINGAN)
613.855 736.626 859.397
650 S-4-15-II
YANG LAIN (SEDANG)
1.158.553 1.390.263 1.621.974
651 S-4-15-III
YANG LAIN (BERAT)
1.500.595 1.800.714 2.100.833
655 S-4-17-I
1.408.379 1.690.055 1.971.731
656 S-4-17-II
1.733.232 2.079.878 2.426.525
657 S-4-17-III
2.725.036 3.270.043 3.815.050
658 T-1-10-I
RINGAN
1.249.077 1.498.892 1.748.707
659 T-1-10-II
SEDANG
1.677.425 2.012.910 2.348.395
660 T-1-10-III
BERAT
3.051.783 3.662.140 4.272.497
661 T-4-10-I
561.300 673.560 785.820
662 T-4-10-II
1.069.714 1.283.656 1.497.599
663 T-4-10-III
1.555.073 1.866.088 2.177.103
664 T-4-11-I
664.640 797.568 930.496
665 T-4-11-II
1.045.954 1.255.145 1.464.336
666 T-4-11-III
1.684.724 2.021.669 2.358.614
667 T-4-12-I
LAIN (RINGAN)
1.162.461 1.394.954 1.627.446
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
668 T-4-12-II
LAIN (SEDANG)
1.757.384 2.108.861 2.460.337
669 T-4-12-III
LAIN (BERAT)
2.742.814 3.291.377 3.839.940
673 U-1-11-I
(RINGAN)
4.436.687 5.324.025 6.211.362
674 U-1-11-II
(SEDANG)
5.836.876 7.004.252 8.171.627
675 U-1-11-III
(BERAT)
11.032.852 13.239.422 15.445.992
682 U-1-14-I
MULUT (RINGAN)
2.370.029 2.844.034 3.318.040
683 U-1-14-II
MULUT (SEDANG)
2.908.502 3.490.202 4.071.902
684 U-1-14-III
MULUT (BERAT)
3.446.656 4.135.988 4.825.319
688 U-1-20-I
3.598.641 4.318.369 5.038.097
689 U-1-20-II
6.181.843 7.418.212 8.654.580
690 U-1-20-III
10.787.014 12.944.417 15.101.820
694 U-4-10-I
TELINGA RINGAN
2.882.337 3.458.804 4.035.271
695 U-4-10-II
TELINGA SEDANG
5.467.125 6.560.550 7.653.975
696 U-4-10-III
TELINGA BERAT
8.393.831 10.072.598 11.751.364
703 U-4-13-I
1.334.099 1.600.919 1.867.738
704 U-4-13-II
1.522.005 1.826.405 2.130.806
705 U-4-13-III
2.025.686 2.430.824 2.835.961
709 U-4-15-I
1.328.394 1.594.073 1.859.752
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
710 U-4-15-II
1.684.672 2.021.606 2.358.541
711 U-4-15-III
2.337.236 2.804.683 3.272.130
712 V-1-10-I
RINGAN
3.941.214 4.729.457 5.517.699
713 V-1-10-II
SEDANG
4.492.027 5.390.432 6.288.837
718 V-1-12-I
MODERAT (RINGAN)
2.899.981 3.479.977 4.059.973
719 V-1-12-II
MODERAT (SEDANG)
8.133.966 9.760.759 11.387.553
720 V-1-12-III
MODERAT (BERAT)
8.770.124 10.524.149 12.278.174
721 V-1-13-I
KOMPLEK (RINGAN)
4.394.559 5.273.471 6.152.383
722 V-1-13-II
KOMPLEK (SEDANG)
7.336.304 8.803.565 10.270.826
723 V-1-13-III
KOMPLEK (BERAT)
8.787.301 10.544.761 12.302.221
724 V-1-14-I
RINGAN
5.297.434 6.356.921 7.416.408
725 V-1-14-II
SEDANG
6.546.130 7.855.356 9.164.582
726 V-1-14-III
BERAT
7.974.312 9.569.174 11.164.036
733 V-4-11-I
TUMOR (RINGAN)
1.915.932 2.299.118 2.682.305
734 V-4-11-II
TUMOR (SEDANG)
2.689.920 3.227.904 3.765.888
735 V-4-11-III
TUMOR (BERAT)
4.023.240 4.827.889 5.632.537
736 W-1-01-I
6.005.468 7.206.561 8.407.655
737 W-1-01-II
7.247.108 8.696.530 10.145.951
738 W-1-01-III
12.038.603 14.446.324 16.854.045
742 W-1-11-I
RINGAN
2.551.237 3.061.484 3.571.732
743 W-1-11-II
SEDANG
4.485.364 5.382.437 6.279.510
744 W-1-11-III
BERAT
9.444.914 11.333.897 13.222.880
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
745 W-1-12-I
1.585.303 1.902.364 2.219.424
746 W-1-12-II
1.793.094 2.151.713 2.510.332
747 W-1-12-III
2.754.419 3.305.303 3.856.187
748 W-1-13-I
RINGAN
1.572.233 1.886.679 2.201.126
749 W-1-13-II
SEDANG
1.706.992 2.048.390 2.389.788
763 W-4-12-I
1.336.215 1.603.458 1.870.701
764 W-4-12-II
2.024.565 2.429.478 2.834.391
765 W-4-12-III
2.443.043 2.931.652 3.420.260
787 Z-4-12-I
1.002.735 1.203.282 1.403.829
788 Z-4-12-II
2.443.333 2.931.999 3.420.666
789 Z-4-12-III
3.098.655 3.718.387 4.338.118
24 D-2-11-0 PROSEDUR LIMPA 1.252.357
33 F-3-10-0 TERAPI SHOCK 245.983
Rumah Sakit Kelas D
Rawat Jalan
Rumah Sakit Kelas D
Rawat Jalan
72 I-2-16-0
ALAT
2.155.987
80 I-2-42-0 PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN LAIN 2.082.430
Rumah Sakit Kelas D
Rawat Jalan
179 O-7-12-0
872.003
Rumah Sakit Kelas D
Rawat Jalan
191 Q-5-12-0 GIGI 123.413
195 Q-5-16-0 VAKSINASI 98.617
196 Q-5-17-0 PASANG INFUS 84.899
200 Q-5-21-0 ABORSI 66.110
205 Q-5-26-0 BRONKIAL AKUT 190.548
210 Q-5-31-0 FRAKTUR 129.113
214 Q-5-35-0 INFEKSI AKUT 252.396
217 Q-5-38-0 PARU AKUT 199.144
Rumah Sakit Kelas D
Rawat Jalan
276 Z-3-18-0 CT-SCAN KEPALA 242.041
288 Z-3-30-0 FOTOTERAPI 74.254
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 3.696.982 4.436.378 5.175.775
8 A-4-12-II DEMAM SEDANG 4.603.921 5.524.705 6.445.489
9 A-4-12-III DEMAM BERAT 4.913.692 5.896.431 6.879.169
13 A-4-14-I
RINGAN
3.919.566 4.703.479 5.487.392
14 A-4-14-II
SEDANG
5.041.553 6.049.864 7.058.175
15 A-4-14-III
BERAT
5.776.434 6.931.721 8.087.007
28 B-1-12-I
RINGAN
9.086.170 10.903.404 12.720.638
29 B-1-12-II
SEDANG
19.473.661 23.368.394 27.263.126
30 B-1-12-III
BERAT
23.700.681 28.440.818 33.180.954
31 B-1-13-I
(RINGAN)
7.310.713 8.772.855 10.234.998
32 B-1-13-II
(SEDANG)
11.908.013 14.289.615 16.671.218
33 B-1-13-III
(BERAT)
17.555.723 21.066.867 24.578.012
34 B-1-14-I
RINGAN
9.944.270 11.933.124 13.921.978
35 B-1-14-II
SEDANG
11.059.827 13.271.793 15.483.758
36 B-1-14-III
BERAT
17.301.895 20.762.274 24.222.653
40 B-4-11-I
RINGAN
6.487.025 7.784.430 9.081.835
41 B-4-11-II
SEDANG
9.723.894 11.668.673 13.613.452
Rumah Sakit Kelas A
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
46 B-4-13-I
5.889.091 7.066.910 8.244.728
47 B-4-13-II
6.860.615 8.232.738 9.604.861
48 B-4-13-III
10.165.826 12.198.991 14.232.156
68 D-1-10-II
SEDANG
58.623.070 70.347.684 82.072.298
73 D-1-20-I
8.634.991 10.361.989 12.088.987
74 D-1-20-II
23.796.823 28.556.187 33.315.552
75 D-1-20-III
37.748.793 45.298.552 52.848.310
85 D-4-13-I
SEL SICKLE RINGAN
3.795.864 4.555.037 5.314.210
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
86 D-4-13-II
SEL SICKLE SEDANG
5.372.517 6.447.020 7.521.523
87 D-4-13-III
SEL SICKLE BERAT
6.871.604 8.245.925 9.620.246
88 D-4-14-I
4.263.091 5.115.709 5.968.327
89 D-4-14-II
8.992.823 10.791.387 12.589.952
90 D-4-14-III
11.621.683 13.946.020 16.270.356
97 E-1-20-I
TIROGLOSAL RINGAN
10.002.141 12.002.569 14.002.997
98 E-1-20-II
TIROGLOSAL SEDANG
13.462.604 16.155.125 18.847.645
99 E-1-20-III
TIROGLOSAL BERAT
26.800.496 32.160.595 37.520.695
100 E-4-10-I
METABOLIK RINGAN
4.906.459 5.887.751 6.869.043
101 E-4-10-II
METABOLIK SEDANG
6.855.801 8.226.962 9.598.122
102 E-4-10-III
METABOLIK BERAT
12.291.431 14.749.717 17.208.003
119 F-4-12-II
SEDANG
4.199.808 5.039.769 5.879.731
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
130 F-4-16-I
MENTAL RINGAN
7.760.733 9.312.880 10.865.027
131 F-4-16-II
MENTAL SEDANG
9.023.198 10.827.837 12.632.477
132 F-4-16-III
MENTAL BERAT
12.044.427 14.453.312 16.862.198
142 G-1-01-I
RINGAN
16.775.221 20.130.265 23.485.310
163 G-4-10-I
RINGAN
5.636.860 6.764.232 7.891.604
164 G-4-10-II
SEDANG
6.890.117 8.268.140 9.646.164
166 G-4-11-I
DEGENERATIF RINGAN
7.643.599 9.172.319 10.701.039
167 G-4-11-II
DEGENERATIF SEDANG
10.153.525 12.184.230 14.214.935
168 G-4-11-III
DEGENERATIF BERAT
14.919.040 17.902.848 20.886.656
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
172 G-4-13-I
RINGAN
3.932.513 4.719.016 5.505.519
173 G-4-13-II
SEDANG
6.857.421 8.228.905 9.600.389
174 G-4-13-III
BERAT
8.133.041 9.759.649 11.386.258
175 G-4-14-I
INFARK RINGAN
6.670.930 8.005.116 9.339.302
176 G-4-14-II
INFARK SEDANG
8.918.656 10.702.387 12.486.118
177 G-4-14-III
INFARK BERAT
11.193.929 13.432.715 15.671.500
178 G-4-15-I
KECEDERAAN PEMBULUH DARAH OTAK NON SPESIFIK
& PENYUMBATAN PRE-CEREBRAL TANPA INFARK
RINGAN
5.450.723 6.540.868 7.631.012
179 G-4-15-II
& PENYUMBATAN PRE-CEREBRAL TANPA INFARK
SEDANG
6.505.206 7.806.247 9.107.288
180 G-4-15-III
& PENYUMBATAN PRE-CEREBRAL TANPA INFARK BERAT
9.181.527 11.017.832 12.854.138
184 G-4-17-I
RINGAN
5.984.957 7.181.948 8.378.940
185 G-4-17-II
SEDANG
7.847.539 9.417.047 10.986.555
187 G-4-18-I
PERSARAFAN RINGAN
5.894.190 7.073.028 8.251.866
188 G-4-18-II
PERSARAFAN SEDANG
7.878.847 9.454.616 11.030.385
189 G-4-18-III
PERSARAFAN BERAT
8.815.779 10.578.935 12.342.091
190 G-4-19-I
4.917.730 5.901.276 6.884.822
191 G-4-19-II
8.312.091 9.974.509 11.636.927
192 G-4-19-III
12.068.625 14.482.350 16.896.075
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
211 G-4-26-I
(RINGAN)
5.893.402 7.072.083 8.250.763
212 G-4-26-II
(SEDANG)
6.855.863 8.227.036 9.598.208
213 G-4-26-III
(BERAT)
10.723.877 12.868.652 15.013.427
229 I-1-01-I
RINGAN
78.034.497 93.641.397 109.248.296
230 I-1-01-II
SEDANG
79.751.178 95.701.414 111.651.649
231 I-1-01-III
BERAT
125.886.183 151.063.420 176.240.656
232 I-1-02-I
RINGAN
43.293.217 51.951.860 60.610.504
233 I-1-02-II
SEDANG
55.847.711 67.017.254 78.186.796
234 I-1-02-III
BERAT
68.835.746 82.602.896 96.370.045
235 I-1-03-I
26.620.787 31.944.944 37.269.101
236 I-1-03-II
32.327.893 38.793.472 45.259.050
237 I-1-03-III
50.214.482 60.257.378 70.300.274
238 I-1-04-I
JANTUNG RINGAN
44.657.284 53.588.741 62.520.198
239 I-1-04-II
JANTUNG SEDANG
70.481.188 84.577.426 98.673.664
240 I-1-04-III
JANTUNG BERAT
112.593.286 135.111.943 157.630.600
241 I-1-05-I
57.299.373 68.759.247 80.219.122
242 I-1-05-II
68.759.527 82.511.433 96.263.338
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
243 I-1-05-III
94.612.528 113.535.033 132.457.539
247 I-1-07-I
34.813.808 41.776.569 48.739.331
248 I-1-07-II
42.949.981 51.539.978 60.129.974
249 I-1-07-III
46.858.268 56.229.922 65.601.575
250 I-1-11-I
5.398.978 6.478.774 7.558.569
251 I-1-11-II
6.003.138 7.203.765 8.404.393
252 I-1-11-III
7.988.334 9.586.001 11.183.667
253 I-1-12-I
RINGAN
22.448.023 26.937.628 31.427.233
254 I-1-12-II
SEDANG
25.381.413 30.457.696 35.533.979
255 I-1-12-III
BERAT
42.368.097 50.841.717 59.315.336
256 I-1-13-I
RINGAN
16.544.150 19.852.980 23.161.810
257 I-1-13-II
SEDANG
20.074.720 24.089.664 28.104.608
258 I-1-13-III
BERAT
25.321.519 30.385.823 35.450.126
259 I-1-14-I
PERMANEN RINGAN
44.566.567 53.479.881 62.393.194
260 I-1-14-II
PERMANEN SEDANG
55.389.697 66.467.636 77.545.575
261 I-1-14-III
PERMANEN BERAT
72.579.579 87.095.494 101.611.410
265 I-1-16-I
(RINGAN)
19.099.558 22.919.469 26.739.381
266 I-1-16-II
(SEDANG)
49.659.270 59.591.124 69.522.978
267 I-1-16-III
(BERAT)
57.281.192 68.737.431 80.193.669
268 I-1-17-I
VENA RINGAN
32.919.143 39.502.972 46.086.800
269 I-1-17-II
VENA SEDANG
41.217.856 49.461.427 57.704.998
270 I-1-17-III
VENA BERAT
50.985.861 61.183.033 71.380.206
271 I-1-20-I
RINGAN
28.645.476 34.374.571 40.103.666
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
272 I-1-20-II
SEDANG
35.785.993 42.943.192 50.100.390
274 I-1-30-I
21.668.635 26.002.362 30.336.089
275 I-1-30-II
45.075.628 54.090.753 63.105.879
276 I-1-30-III
69.851.070 83.821.284 97.791.498
289 I-4-13-I
RINGAN
7.762.637 9.315.164 10.867.691
290 I-4-13-II
SEDANG
11.243.743 13.492.492 15.741.241
291 I-4-13-III
BERAT
25.173.321 30.207.985 35.242.649
295 I-4-15-I
(RINGAN)
7.848.261 9.417.913 10.987.565
296 I-4-15-II
(SEDANG)
10.129.140 12.154.968 14.180.796
297 I-4-15-III
(BERAT)
11.544.592 13.853.510 16.162.429
306 I-4-18-III
BERAT
14.457.901 17.349.481 20.241.061
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
319 I-4-23-I
4.452.881 5.343.457 6.234.033
320 I-4-23-II
5.466.806 6.560.167 7.653.529
321 I-4-23-III
10.681.879 12.818.255 14.954.631
322 I-4-24-I
(RINGAN)
5.193.989 6.232.787 7.271.584
323 I-4-24-II
(SEDANG)
11.960.549 14.352.659 16.744.769
324 I-4-24-III
(BERAT)
15.121.954 18.146.345 21.170.736
325 J-1-01-I
TRAKEOSTOMI RINGAN
75.756.516 90.907.820 106.059.123
326 J-1-01-II
TRAKEOSTOMI SEDANG
84.173.907 101.008.689 117.843.470
327 J-1-01-III
TRAKEOSTOMI BERAT
93.526.564 112.231.877 130.937.189
328 J-1-02-I
TRAKEOSTOMI RINGAN
40.201.289 48.241.547 56.281.805
329 J-1-02-II
TRAKEOSTOMI SEDANG
54.958.364 65.950.036 76.941.709
330 J-1-02-III
TRAKEOSTOMI BERAT
89.134.377 106.961.252 124.788.128
334 J-1-20-I
RINGAN
16.181.006 19.417.207 22.653.408
335 J-1-20-II
SEDANG
20.380.442 24.456.531 28.532.619
336 J-1-20-III
BERAT
31.470.758 37.764.910 44.059.062
337 J-1-30-I
RINGAN
9.728.482 11.674.178 13.619.874
338 J-1-30-II
SEDANG
21.985.399 26.382.479 30.779.559
339 J-1-30-III
BERAT
73.476.672 88.172.006 102.867.340
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
3.919.997 4.703.996 5.487.995
374 J-4-21-II
LAIN-LAIN (SEDANG)
8.924.009 10.708.811 12.493.613
375 J-4-21-III
LAIN-LAIN (BERAT)
12.728.556 15.274.267 17.819.979
376 K-1-10-I
(RINGAN)
10.568.311 12.681.973 14.795.635
377 K-1-10-II
(SEDANG)
13.281.349 15.937.619 18.593.889
378 K-1-10-III
(BERAT)
15.566.194 18.679.432 21.792.671
382 K-1-12-I
FEMORAL (RINGAN)
4.434.333 5.321.199 6.208.066
383 K-1-12-II
FEMORAL (SEDANG)
5.767.371 6.920.846 8.074.320
384 K-1-12-III
FEMORAL (BERAT)
11.425.933 13.711.119 15.996.306
394 K-1-30-I
KOMPLEKS (RINGAN)
10.326.149 12.391.378 14.456.608
395 K-1-30-II
KOMPLEKS (SEDANG)
20.218.863 24.262.636 28.306.408
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
29.717.642 35.661.171 41.604.699
412 K-4-13-I
5.889.596 7.067.516 8.245.435
413 K-4-13-II
7.618.529 9.142.235 10.665.941
414 K-4-13-III
11.734.963 14.081.956 16.428.948
415 K-4-14-I
RINGAN
4.667.553 5.601.064 6.534.575
416 K-4-14-II
SEDANG
6.265.360 7.518.432 8.771.504
417 K-4-14-III
BERAT
10.053.399 12.064.079 14.074.759
424 K-4-17-I
(RINGAN)
3.559.116 4.270.939 4.982.762
425 K-4-17-II
(SEDANG)
5.036.762 6.044.114 7.051.467
426 K-4-17-III
(BERAT)
5.681.479 6.817.774 7.954.070
430 L-1-20-I
RINGAN
36.190.665 43.428.798 50.666.931
431 L-1-20-II
SEDANG
37.819.995 45.383.994 52.947.993
432 L-1-20-III
BERAT
57.698.459 69.238.151 80.777.843
433 L-1-30-I
RINGAN
15.946.599 19.135.919 22.325.239
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
434 L-1-30-II
SEDANG
23.819.084 28.582.901 33.346.718
435 L-1-30-III
BERAT
25.183.501 30.220.201 35.256.901
436 L-1-40-I
PAYUDARA RINGAN
6.624.891 7.949.869 9.274.847
437 L-1-40-II
PAYUDARA SEDANG
13.288.017 15.945.620 18.603.224
438 L-1-40-III
PAYUDARA BERAT
32.307.456 38.768.947 45.230.438
451 L-4-13-I
PAYUDARA RINGAN
3.339.093 4.006.911 4.674.730
452 L-4-13-II
PAYUDARA SEDANG
3.924.284 4.709.140 5.493.997
453 L-4-13-III
PAYUDARA BERAT
5.774.709 6.929.651 8.084.593
454 L-4-14-I
(RINGAN)
3.917.598 4.701.118 5.484.637
455 L-4-14-II
(SEDANG)
5.884.318 7.061.182 8.238.046
456 L-4-14-III
(BERAT)
8.294.688 9.953.625 11.612.563
457 M-1-01-I
17.634.610 21.161.533 24.688.455
458 M-1-01-II
19.683.439 23.620.127 27.556.815
459 M-1-01-III
27.649.397 33.179.276 38.709.155
463 M-1-03-I
32.813.629 39.376.355 45.939.081
464 M-1-03-II
39.394.758 47.273.709 55.152.661
465 M-1-03-III
40.973.951 49.168.742 57.363.532
466 M-1-04-I
8.088.117 9.705.740 11.323.363
467 M-1-04-II
10.340.844 12.409.013 14.477.182
468 M-1-04-III
12.939.417 15.527.300 18.115.184
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
469 M-1-05-I
11.577.552 13.893.062 16.208.573
470 M-1-05-II
11.852.439 14.222.926 16.593.414
471 M-1-05-III
20.188.304 24.225.965 28.263.626
472 M-1-07-I
14.168.384 17.002.061 19.835.738
473 M-1-07-II
18.980.684 22.776.821 26.572.957
474 M-1-07-III
38.665.521 46.398.626 54.131.730
475 M-1-10-I
WAJAH RINGAN
23.868.312 28.641.974 33.415.637
476 M-1-10-II
WAJAH SEDANG
57.068.205 68.481.846 79.895.486
477 M-1-10-III
WAJAH BERAT
123.090.745 147.708.894 172.327.043
478 M-1-20-I
MAYOR RINGAN
8.561.805 10.274.166 11.986.527
479 M-1-20-II
MAYOR SEDANG
12.215.785 14.658.942 17.102.098
480 M-1-20-III
MAYOR BERAT
30.306.027 36.367.233 42.428.438
484 M-1-40-I
5.742.853 6.891.424 8.039.995
485 M-1-40-II
10.614.924 12.737.909 14.860.894
486 M-1-40-III
18.482.033 22.178.440 25.874.847
490 M-1-60-I
5.167.964 6.201.557 7.235.149
491 M-1-60-II
10.373.565 12.448.278 14.522.991
492 M-1-60-III
18.061.065 21.673.278 25.285.491
493 M-1-70-I
(RINGAN)
28.442.788 34.131.345 39.819.903
494 M-1-70-II
(SEDANG)
31.287.066 37.544.480 43.801.893
495 M-1-70-III
(BERAT)
34.415.773 41.298.928 48.182.082
502 M-4-11-I
RINGAN
4.913.504 5.896.204 6.878.905
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
503 M-4-11-II
SEDANG
10.772.514 12.927.017 15.081.520
504 M-4-11-III
BERAT
15.575.293 18.690.352 21.805.410
505 M-4-12-I
RINGAN
3.922.065 4.706.478 5.490.891
506 M-4-12-II
SEDANG
6.523.386 7.828.064 9.132.741
508 M-4-13-I
6.530.555 7.836.666 9.142.777
509 M-4-13-II
9.811.923 11.774.307 13.736.692
510 M-4-13-III
19.416.089 23.299.306 27.182.524
520 M-4-17-I
RINGAN
4.907.433 5.888.919 6.870.406
521 M-4-17-II
SEDANG
6.863.538 8.236.246 9.608.953
522 M-4-17-III
BERAT
9.584.421 11.501.305 13.418.189
526 M-4-19-I
3.868.102 4.641.722 5.415.342
527 M-4-19-II
6.515.430 7.818.516 9.121.602
528 M-4-19-III
12.725.009 15.270.011 17.815.012
529 M-4-20-I
3.901.865 4.682.238 5.462.611
530 M-4-20-II
5.713.645 6.856.373 7.999.102
531 M-4-20-III
6.385.632 7.662.759 8.939.885
532 M-4-21-I
3.928.874 4.714.649 5.500.424
533 M-4-21-II
4.913.925 5.896.709 6.879.494
534 M-4-21-III
11.016.824 13.220.189 15.423.554
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
541 N-1-12-I
7.084.192 8.501.030 9.917.869
542 N-1-12-II
16.610.045 19.932.054 23.254.063
543 N-1-12-III
30.267.864 36.321.437 42.375.009
547 N-1-30-I
BAWAH RINGAN
11.557.206 13.868.647 16.180.088
548 N-1-30-II
BAWAH SEDANG
17.483.794 20.980.553 24.477.312
549 N-1-30-III
BAWAH BERAT
20.122.137 24.146.565 28.170.992
553 N-4-10-I
RINGAN
4.899.699 5.879.639 6.859.578
554 N-4-10-II
SEDANG
5.926.230 7.111.477 8.296.723
555 N-4-10-III
BERAT
11.776.412 14.131.694 16.486.976
565 N-4-14-I
3.399.860 4.079.832 4.759.804
566 N-4-14-II
4.824.187 5.789.025 6.753.862
567 N-4-14-III
7.824.008 9.388.810 10.953.611
568 N-4-15-I
URIN RINGAN
4.462.670 5.355.204 6.247.739
569 N-4-15-II
URIN SEDANG
5.537.431 6.644.918 7.752.404
570 N-4-15-III
URIN BERAT
6.319.203 7.583.043 8.846.884
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
571 N-4-16-I
(RINGAN)
4.918.103 5.901.724 6.885.345
572 N-4-16-II
(SEDANG)
7.558.989 9.070.787 10.582.584
573 N-4-16-III
(BERAT)
13.411.959 16.094.351 18.776.743
577 O-6-11-I
4.571.648 5.485.978 6.400.308
578 O-6-11-II
5.080.815 6.096.978 7.113.141
579 O-6-11-III
9.129.768 10.955.722 12.781.675
580 O-6-12-I
3.238.967 3.886.761 4.534.554
581 O-6-12-II
3.889.977 4.667.973 5.445.968
582 O-6-12-III
4.887.820 5.865.384 6.842.948
586 P-8-01-I
RINGAN
90.881.981 109.058.378 127.234.774
587 P-8-01-II
SEDANG
112.452.720 134.943.264 157.433.808
588 P-8-01-III
BERAT
131.987.916 158.385.500 184.783.083
589 P-8-02-I
107.923.061 129.507.673 151.092.285
590 P-8-02-II
123.798.610 148.558.332 173.318.054
591 P-8-02-III
141.448.688 169.738.426 198.028.163
592 P-8-03-I
6.090.662 7.308.794 8.526.926
593 P-8-03-II
8.526.926 10.232.311 11.937.697
594 P-8-03-III
11.866.983 14.240.380 16.613.776
595 P-8-04-I
49.064.617 58.877.541 68.690.464
596 P-8-04-II
63.675.295 76.410.354 89.145.413
597 P-8-04-III
91.294.345 109.553.214 127.812.083
598 P-8-05-I
26.679.748 32.015.698 37.351.647
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
599 P-8-05-II
37.814.946 45.377.935 52.940.925
600 P-8-05-III
55.715.247 66.858.296 78.001.345
601 P-8-06-I
5.282.002 6.338.402 7.394.803
602 P-8-06-II
9.800.722 11.760.866 13.721.011
603 P-8-06-III
19.084.174 22.901.009 26.717.844
604 P-8-07-I
8.526.926 10.232.311 11.937.697
605 P-8-07-II
23.907.449 28.688.938 33.470.428
606 P-8-07-III
31.671.440 38.005.728 44.340.016
607 P-8-08-I
4.933.715 5.920.458 6.907.201
608 P-8-08-II
7.000.707 8.400.849 9.800.990
609 P-8-08-III
12.804.131 15.364.957 17.925.783
610 P-8-10-I
3.458.033 4.149.640 4.841.247
611 P-8-10-II
5.442.987 6.531.584 7.620.181
612 P-8-10-III
10.686.802 12.824.162 14.961.523
613 P-8-11-I
RINGAN
8.654.684 10.385.621 12.116.558
614 P-8-11-II
SEDANG
18.441.308 22.129.569 25.817.831
615 P-8-11-III
BERAT
22.103.011 26.523.613 30.944.216
616 P-8-12-I
RINGAN
11.011.443 13.213.732 15.416.021
617 P-8-12-II
SEDANG
13.929.237 16.715.085 19.500.932
618 P-8-12-III
BERAT
14.742.337 17.690.805 20.639.272
619 P-8-13-I
RINGAN
2.768.384 3.322.060 3.875.737
620 P-8-13-II
SEDANG
6.858.829 8.230.595 9.602.361
621 P-8-13-III
BERAT
16.708.640 20.050.368 23.392.096
622 P-8-14-I
4.717.413 5.660.896 6.604.378
623 P-8-14-II
9.602.828 11.523.393 13.443.959
624 P-8-14-III
10.536.042 12.643.250 14.750.458
625 P-8-15-I
ASPIRASI RINGAN
3.538.112 4.245.734 4.953.356
626 P-8-15-II
ASPIRASI SEDANG
7.085.241 8.502.289 9.919.337
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
627 P-8-15-III
ASPIRASI BERAT
8.313.313 9.975.976 11.638.638
628 P-8-16-I
3.202.078 3.842.493 4.482.909
629 P-8-16-II
6.620.404 7.944.484 9.268.565
630 P-8-16-III
17.388.748 20.866.498 24.344.248
631 P-8-17-I
RINGAN
2.349.588 2.819.506 3.289.424
632 P-8-17-II
SEDANG
6.108.726 7.330.471 8.552.216
633 P-8-17-III
BERAT
14.478.562 17.374.275 20.269.987
634 S-4-10-I
3.610.274 4.332.329 5.054.383
635 S-4-10-II
4.448.385 5.338.061 6.227.738
636 S-4-10-III
6.089.428 7.307.314 8.525.200
646 S-4-14-I
KANAK-KANAK RINGAN
2.204.064 2.644.877 3.085.690
647 S-4-14-II
KANAK-KANAK SEDANG
4.681.538 5.617.846 6.554.154
648 S-4-14-III
KANAK-KANAK BERAT
8.877.791 10.653.349 12.428.908
649 S-4-15-I
YANG LAIN (RINGAN)
1.667.033 2.000.440 2.333.847
650 S-4-15-II
YANG LAIN (SEDANG)
3.145.966 3.775.159 4.404.352
651 S-4-15-III
YANG LAIN (BERAT)
4.074.582 4.889.498 5.704.414
655 S-4-17-I
3.311.112 3.973.334 4.635.557
656 S-4-17-II
4.913.955 5.896.746 6.879.537
657 S-4-17-III
7.552.695 9.063.235 10.573.774
658 T-1-10-I
RINGAN
2.783.750 3.340.500 3.897.250
659 T-1-10-II
SEDANG
3.738.937 4.486.725 5.234.512
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
660 T-1-10-III
BERAT
6.801.691 8.162.030 9.522.368
661 T-4-10-I
1.524.384 1.829.261 2.134.138
662 T-4-10-II
2.904.722 3.485.666 4.066.610
663 T-4-10-III
4.222.125 5.066.550 5.910.975
664 T-4-11-I
1.472.203 1.766.644 2.061.084
665 T-4-11-II
2.316.832 2.780.199 3.243.565
666 T-4-11-III
3.731.738 4.478.085 5.224.433
667 T-4-12-I
LAIN (RINGAN)
3.449.450 4.139.340 4.829.230
668 T-4-12-II
LAIN (SEDANG)
5.207.366 6.248.839 7.290.312
669 T-4-12-III
LAIN (BERAT)
8.060.242 9.672.290 11.284.339
673 U-1-11-I
(RINGAN)
12.921.774 15.506.129 18.090.483
674 U-1-11-II
(SEDANG)
19.490.117 23.388.141 27.286.164
675 U-1-11-III
(BERAT)
29.507.327 35.408.793 41.310.258
682 U-1-14-I
MULUT (RINGAN)
5.262.685 6.315.223 7.367.760
683 U-1-14-II
MULUT (SEDANG)
6.458.578 7.750.293 9.042.009
684 U-1-14-III
MULUT (BERAT)
7.653.434 9.184.120 10.714.807
688 U-1-20-I
7.989.513 9.587.416 11.185.319
689 U-1-20-II
14.268.219 17.121.862 19.975.506
690 U-1-20-III
34.112.530 40.935.036 47.757.542
694 U-4-10-I
TELINGA RINGAN
6.387.243 7.664.692 8.942.141
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
695 U-4-10-II
TELINGA SEDANG
14.622.203 17.546.644 20.471.084
696 U-4-10-III
TELINGA BERAT
22.449.707 26.939.649 31.429.590
703 U-4-13-I
3.485.057 4.182.069 4.879.080
704 U-4-13-II
4.108.490 4.930.188 5.751.886
705 U-4-13-III
4.913.997 5.896.797 6.879.596
709 U-4-15-I
3.940.935 4.729.122 5.517.309
710 U-4-15-II
4.909.860 5.891.833 6.873.805
711 U-4-15-III
6.871.436 8.245.723 9.620.010
712 V-1-10-I
RINGAN
11.497.508 13.797.010 16.096.511
713 V-1-10-II
SEDANG
13.241.367 15.889.640 18.537.913
718 V-1-12-I
MODERAT (RINGAN)
6.427.934 7.713.521 8.999.108
719 V-1-12-II
MODERAT (SEDANG)
22.679.013 27.214.815 31.750.618
720 V-1-12-III
MODERAT (BERAT)
23.455.941 28.147.129 32.838.317
721 V-1-13-I
KOMPLEK (RINGAN)
9.745.547 11.694.656 13.643.766
722 V-1-13-II
KOMPLEK (SEDANG)
18.620.524 22.344.628 26.068.733
723 V-1-13-III
KOMPLEK (BERAT)
29.213.334 35.056.000 40.898.667
724 V-1-14-I
RINGAN
11.760.554 14.112.665 16.464.775
725 V-1-14-II
SEDANG
17.087.852 20.505.422 23.922.992
726 V-1-14-III
BERAT
21.327.397 25.592.876 29.858.355
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
4.914.078 5.896.894 6.879.710
734 V-4-11-II
TUMOR (SEDANG)
6.863.053 8.235.663 9.608.274
735 V-4-11-III
TUMOR (BERAT)
8.912.818 10.695.382 12.477.945
736 W-1-01-I
13.394.126 16.072.951 18.751.777
737 W-1-01-II
16.053.794 19.264.553 22.475.312
738 W-1-01-III
29.006.658 34.807.990 40.609.321
742 W-1-11-I
RINGAN
3.860.392 4.632.470 5.404.548
743 W-1-11-II
SEDANG
6.787.007 8.144.408 9.501.810
744 W-1-11-III
BERAT
14.291.525 17.149.830 20.008.135
745 W-1-12-I
3.516.881 4.220.257 4.923.633
746 W-1-12-II
3.987.454 4.784.945 5.582.436
747 W-1-12-III
6.125.542 7.350.650 8.575.758
748 W-1-13-I
RINGAN
4.268.976 5.122.771 5.976.566
749 W-1-13-II
SEDANG
4.634.688 5.561.626 6.488.563
763 W-4-12-I
3.935.219 4.722.263 5.509.307
764 W-4-12-II
5.402.748 6.483.298 7.563.848
765 W-4-12-III
5.889.211 7.067.053 8.244.895
No
Kode INA-
CBG
Rumah Sakit Kelas A
Rawat Inap
787 Z-4-12-I
2.940.439 3.528.527 4.116.615
788 Z-4-12-II
5.903.991 7.084.789 8.265.588
789 Z-4-12-III
12.455.891 14.947.069 17.438.248
24 D-2-11-0 PROSEDUR LIMPA 3.100.130
33 F-3-10-0 TERAPI SHOCK 607.851
Rumah Sakit Kelas A
Rawat Jalan
Rumah Sakit Kelas A
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT
5.337.007
80 I-2-42-0
LAIN
5.128.425
Rumah Sakit Kelas A
Rawat Jalan
179 O-7-12-0
1.943.380
Rumah Sakit Kelas A
Rawat Jalan
191 Q-5-12-0 GIGI 304.146
195 Q-5-16-0 VAKSINASI 220.832
196 Q-5-17-0 PASANG INFUS 210.663
200 Q-5-21-0 ABORSI 292.707
205 Q-5-26-0 BRONKIAL AKUT 470.335
210 Q-5-31-0 FRAKTUR 316.665
214 Q-5-35-0 INFEKSI AKUT 620.839
217 Q-5-38-0 PARU AKUT 493.679
Rumah Sakit Kelas A
Rawat Jalan
269 Z-3-11-0
EMPEDU
3.508.369
276 Z-3-18-0 CT-SCAN KEPALA 599.158
288 Z-3-30-0 FOTOTERAPI 182.543
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 2.018.199 2.421.839 2.825.479
8 A-4-12-II DEMAM SEDANG 3.192.098 3.830.518 4.468.938
9 A-4-12-III DEMAM BERAT 3.648.527 4.378.232 5.107.938
13 A-4-14-I
RINGAN
3.161.783 3.794.140 4.426.496
14 A-4-14-II
SEDANG
4.066.853 4.880.224 5.693.594
15 A-4-14-III
BERAT
4.659.657 5.591.588 6.523.519
28 B-1-12-I
RINGAN
6.994.308 8.393.170 9.792.032
29 B-1-12-II
SEDANG
14.990.513 17.988.616 20.986.719
30 B-1-12-III
BERAT
17.726.459 21.271.751 24.817.043
31 B-1-13-I
(RINGAN)
5.624.438 6.749.326 7.874.213
32 B-1-13-II
(SEDANG)
9.161.393 10.993.672 12.825.951
33 B-1-13-III
(BERAT)
13.506.464 16.207.757 18.909.050
34 B-1-14-I
RINGAN
7.607.754 9.129.305 10.650.856
35 B-1-14-II
SEDANG
8.461.358 10.153.629 11.845.901
36 B-1-14-III
BERAT
13.236.788 15.884.146 18.531.504
40 B-4-11-I
RINGAN
4.179.179 5.015.014 5.850.850
41 B-4-11-II
SEDANG
6.370.472 7.644.566 8.918.660
46 B-4-13-I
3.046.917 3.656.300 4.265.683
47 B-4-13-II
4.432.853 5.319.423 6.205.994
48 B-4-13-III
5.549.947 6.659.937 7.769.926
Rumah Sakit Kelas B
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
73 D-1-20-I
4.468.369 5.362.043 6.255.717
74 D-1-20-II
13.136.072 15.763.287 18.390.501
75 D-1-20-III
20.608.513 24.730.215 28.851.918
85 D-4-13-I
SEL SICKLE RINGAN
2.030.877 2.437.052 2.843.228
86 D-4-13-II
SEL SICKLE SEDANG
3.045.791 3.654.950 4.264.108
87 D-4-13-III
SEL SICKLE BERAT
4.203.540 5.044.248 5.884.956
88 D-4-14-I
2.523.893 3.028.672 3.533.451
89 D-4-14-II
4.524.890 5.429.868 6.334.846
90 D-4-14-III
6.344.883 7.613.860 8.882.837
97 E-1-20-I
TIROGLOSAL RINGAN
6.053.776 7.264.531 8.475.286
98 E-1-20-II
TIROGLOSAL SEDANG
9.905.199 11.886.239 13.867.278
99 E-1-20-III
TIROGLOSAL BERAT
18.581.896 22.298.275 26.014.655
100 E-4-10-I
METABOLIK RINGAN
3.169.601 3.803.521 4.437.441
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
101 E-4-10-II
METABOLIK SEDANG
4.387.672 5.265.207 6.142.741
102 E-4-10-III
METABOLIK BERAT
6.694.087 8.032.904 9.371.721
130 F-4-16-I
RINGAN
5.975.356 7.170.427 8.365.498
131 F-4-16-II
SEDANG
6.943.658 8.332.390 9.721.121
132 F-4-16-III
BERAT
9.268.624 11.122.349 12.976.074
142 G-1-01-I
RINGAN
9.158.200 10.989.840 12.821.480
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
164 G-4-10-II
SEDANG
4.151.751 4.982.101 5.812.451
166 G-4-11-I
DEGENERATIF RINGAN
5.508.402 6.610.082 7.711.763
167 G-4-11-II
DEGENERATIF SEDANG
6.946.249 8.335.499 9.724.749
168 G-4-11-III
DEGENERATIF BERAT
8.911.050 10.693.260 12.475.470
172 G-4-13-I
RINGAN
2.802.430 3.362.915 3.923.401
173 G-4-13-II
SEDANG
3.887.133 4.664.559 5.441.986
174 G-4-13-III
BERAT
4.556.918 5.468.302 6.379.685
175 G-4-14-I
KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK
RINGAN
3.817.508 4.581.010 5.344.512
176 G-4-14-II
SEDANG
6.903.468 8.284.162 9.664.855
177 G-4-14-III
BERAT
8.632.328 10.358.794 12.085.259
178 G-4-15-I
2.975.610 3.570.731 4.165.853
179 G-4-15-II
3.551.403 4.261.684 4.971.965
180 G-4-15-III
5.070.083 6.084.100 7.098.117
187 G-4-18-I
PERSARAFAN RINGAN
3.069.057 3.682.868 4.296.680
188 G-4-18-II
PERSARAFAN SEDANG
5.869.612 7.043.534 8.217.457
189 G-4-18-III
PERSARAFAN BERAT
6.213.343 7.456.011 8.698.680
190 G-4-19-I
3.364.418 4.037.301 4.710.185
191 G-4-19-II
4.537.959 5.445.550 6.353.142
192 G-4-19-III
6.959.630 8.351.556 9.743.483
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
211 G-4-26-I
(RINGAN)
3.390.184 4.068.221 4.746.258
212 G-4-26-II
(SEDANG)
4.644.658 5.573.589 6.502.521
213 G-4-26-III
(BERAT)
5.578.044 6.693.653 7.809.262
229 I-1-01-I
RINGAN
42.601.749 51.122.099 59.642.449
230 I-1-01-II
SEDANG
43.539.210 52.247.052 60.954.894
231 I-1-01-III
BERAT
68.725.808 82.470.969 96.216.131
232 I-1-02-I
RINGAN
23.635.205 28.362.246 33.089.287
233 I-1-02-II
SEDANG
30.489.415 36.587.298 42.685.181
234 I-1-02-III
BERAT
37.579.976 45.095.971 52.611.967
235 I-1-03-I
14.533.092 17.439.710 20.346.328
236 I-1-03-II
16.571.670 19.886.004 23.200.338
237 I-1-03-III
27.414.076 32.896.891 38.379.706
238 I-1-04-I
JANTUNG RINGAN
23.647.123 28.376.547 33.105.972
239 I-1-04-II
JANTUNG SEDANG
56.384.951 67.661.941 78.938.931
240 I-1-04-III
JANTUNG BERAT
90.074.629 108.089.555 126.104.480
241 I-1-05-I
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH KORONER
DENGAN KATETERISASI JANTUNG RINGAN
31.281.889 37.538.267 43.794.645
242 I-1-05-II
DENGAN KATETERISASI JANTUNG SEDANG
37.538.267 45.045.920 52.553.574
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
243 I-1-05-III
DENGAN KATETERISASI JANTUNG BERAT
51.652.419 61.982.902 72.313.386
247 I-1-07-I
TANPA KATETERISASI JANTUNG RINGAN
25.823.650 30.988.380 36.153.110
248 I-1-07-II
TANPA KATETERISASI JANTUNG SEDANG
31.858.718 38.230.462 44.602.206
249 I-1-07-III
TANPA KATETERISASI JANTUNG BERAT
34.757.655 41.709.186 48.660.717
250 I-1-11-I
4.155.796 4.986.955 5.818.114
251 I-1-11-II
4.620.829 5.544.995 6.469.161
252 I-1-11-III
6.148.915 7.378.698 8.608.481
253 I-1-12-I
RINGAN
12.556.540 15.067.848 17.579.156
254 I-1-12-II
SEDANG
14.303.498 17.164.197 20.024.897
255 I-1-12-III
BERAT
23.130.469 27.756.563 32.382.656
256 I-1-13-I
RINGAN
13.235.320 15.882.384 18.529.448
257 I-1-13-II
SEDANG
16.059.776 19.271.731 22.483.687
258 I-1-13-III
BERAT
18.782.590 22.539.108 26.295.626
259 I-1-14-I
PERMANEN RINGAN
24.330.358 29.196.430 34.062.502
260 I-1-14-II
PERMANEN SEDANG
30.239.160 36.286.991 42.334.823
261 I-1-14-III
PERMANEN BERAT
39.623.726 47.548.472 55.473.217
265 I-1-16-I
(RINGAN)
10.427.296 12.512.756 14.598.215
266 I-1-16-II
(SEDANG)
27.110.971 32.533.165 37.955.359
267 I-1-16-III
JANTUNG TIDAK TERMASUK PENGGANTIAN ALAT (BERAT)
31.271.839 37.526.207 43.780.575
268 I-1-17-I
VENA RINGAN
26.335.315 31.602.377 36.869.440
269 I-1-17-II
VENA SEDANG
32.974.285 39.569.141 46.163.998
270 I-1-17-III
VENA BERAT
40.788.689 48.946.427 57.104.165
271 I-1-20-I
RINGAN
22.916.381 27.499.657 32.082.933
272 I-1-20-II
SEDANG
28.628.794 34.354.553 40.080.312
274 I-1-30-I
11.829.822 14.195.786 16.561.751
275 I-1-30-II
24.608.420 29.530.103 34.451.787
276 I-1-30-III
38.134.113 45.760.935 53.387.758
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
289 I-4-13-I
RINGAN
5.954.129 7.144.955 8.335.781
290 I-4-13-II
SEDANG
7.550.267 9.060.321 10.570.374
291 I-4-13-III
BERAT
13.743.193 16.491.832 19.240.471
295 I-4-15-I
(RINGAN)
4.060.000 4.872.001 5.684.001
296 I-4-15-II
(SEDANG)
5.826.993 6.992.392 8.157.791
297 I-4-15-III
(BERAT)
6.641.370 7.969.644 9.297.918
306 I-4-18-III
BERAT
9.098.237 10.917.884 12.737.532
319 I-4-23-I
2.430.911 2.917.093 3.403.276
320 I-4-23-II
2.984.599 3.581.518 4.178.438
321 I-4-23-III
5.831.634 6.997.961 8.164.287
322 I-4-24-I
(RINGAN)
3.262.781 3.915.337 4.567.894
323 I-4-24-II
(SEDANG)
8.149.187 9.779.024 11.408.862
324 I-4-24-III
(BERAT)
10.255.215 12.306.258 14.357.301
325 J-1-01-I
TRAKEOSTOMI RINGAN
31.107.560 37.329.072 43.550.584
326 J-1-01-II
TRAKEOSTOMI SEDANG
33.232.093 39.878.512 46.524.931
327 J-1-01-III
TRAKEOSTOMI BERAT
47.793.313 57.351.976 66.910.638
328 J-1-02-I
TRAKEOSTOMI RINGAN
13.412.254 16.094.705 18.777.156
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
329 J-1-02-II
TRAKEOSTOMI SEDANG
13.563.709 16.276.451 18.989.193
330 J-1-02-III
TRAKEOSTOMI BERAT
21.320.974 25.585.169 29.849.364
334 J-1-20-I
RINGAN
12.944.805 15.533.765 18.122.726
335 J-1-20-II
SEDANG
16.304.354 19.565.225 22.826.095
337 J-1-30-I
RINGAN
3.748.400 4.498.081 5.247.761
338 J-1-30-II
SEDANG
12.002.610 14.403.132 16.803.654
339 J-1-30-III
BERAT
35.835.397 43.002.476 50.169.556
373 J-4-21-I
LAIN-LAIN (RINGAN)
2.372.742 2.847.290 3.321.839
374 J-4-21-II
LAIN-LAIN (SEDANG)
4.429.342 5.315.210 6.201.079
375 J-4-21-III
LAIN-LAIN (BERAT)
6.197.199 7.436.639 8.676.079
376 K-1-10-I
(RINGAN)
5.455.091 6.546.110 7.637.128
377 K-1-10-II
(SEDANG)
10.249.125 12.298.950 14.348.775
378 K-1-10-III
(BERAT)
11.992.980 14.391.576 16.790.172
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
382 K-1-12-I
FEMORAL (RINGAN)
3.398.480 4.078.177 4.757.873
383 K-1-12-II
FEMORAL (SEDANG)
4.417.512 5.301.015 6.184.517
384 K-1-12-III
FEMORAL (BERAT)
8.810.629 10.572.754 12.334.880
394 K-1-30-I
KOMPLEKS (RINGAN)
7.797.431 9.356.917 10.916.404
395 K-1-30-II
KOMPLEKS (SEDANG)
10.939.797 13.127.757 15.315.716
396 K-1-30-III
KOMPLEKS (BERAT)
20.128.844 24.154.612 28.180.381
412 K-4-13-I
3.212.234 3.854.680 4.497.127
413 K-4-13-II
4.116.478 4.939.774 5.763.070
414 K-4-13-III
6.406.601 7.687.922 8.969.242
415 K-4-14-I
RINGAN
2.548.086 3.057.703 3.567.320
416 K-4-14-II
SEDANG
3.420.398 4.104.478 4.788.557
417 K-4-14-III
BERAT
6.005.130 7.206.156 8.407.182
424 K-4-17-I
(RINGAN)
2.871.020 3.445.224 4.019.428
425 K-4-17-II
(SEDANG)
4.062.988 4.875.586 5.688.183
426 K-4-17-III
(BERAT)
4.583.059 5.499.671 6.416.283
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
430 L-1-20-I
RINGAN
27.823.452 33.388.142 38.952.832
431 L-1-20-II
SEDANG
28.674.646 34.409.575 40.144.504
432 L-1-20-III
BERAT
40.329.050 48.394.860 56.460.670
433 L-1-30-I
RINGAN
8.705.752 10.446.903 12.188.053
434 L-1-30-II
SEDANG
16.234.516 19.481.419 22.728.322
435 L-1-30-III
BERAT
19.282.258 23.138.710 26.995.162
436 L-1-40-I
PAYUDARA RINGAN
4.138.155 4.965.786 5.793.417
437 L-1-40-II
PAYUDARA SEDANG
8.923.156 10.707.787 12.492.419
438 L-1-40-III
PAYUDARA BERAT
15.264.041 18.316.849 21.369.657
451 L-4-13-I
PAYUDARA RINGAN
2.020.867 2.425.040 2.829.214
452 L-4-13-II
PAYUDARA SEDANG
2.701.578 3.241.894 3.782.210
453 L-4-13-III
PAYUDARA BERAT
3.566.138 4.279.365 4.992.593
454 L-4-14-I
(RINGAN)
2.339.091 2.806.909 3.274.727
455 L-4-14-II
(SEDANG)
3.476.037 4.171.244 4.866.451
456 L-4-14-III
(BERAT)
6.152.511 7.383.013 8.613.515
457 M-1-01-I
9.627.423 11.552.908 13.478.393
458 M-1-01-II
10.745.762 12.894.914 15.044.067
459 M-1-01-III
15.094.884 18.113.861 21.132.838
463 M-1-03-I
PROSEDUR FUSI TULANG BELAKANG PADA LENGKUNGAN
TULANG BELAKANG RINGAN
17.751.257 21.301.509 24.851.760
464 M-1-03-II
TULANG BELAKANG SEDANG
20.668.258 24.801.909 28.935.561
465 M-1-03-III
TULANG BELAKANG BERAT
26.071.229 31.285.474 36.499.720
466 M-1-04-I
6.193.770 7.432.524 8.671.278
467 M-1-04-II
7.932.610 9.519.133 11.105.655
468 M-1-04-III
9.926.167 11.911.400 13.896.633
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
469 M-1-05-I
7.856.329 9.427.595 10.998.861
470 M-1-05-II
9.123.736 10.948.483 12.773.230
471 M-1-05-III
16.150.643 19.380.772 22.610.900
472 M-1-07-I
7.734.895 9.281.874 10.828.853
473 M-1-07-II
10.362.342 12.434.811 14.507.279
474 M-1-07-III
21.109.074 25.330.889 29.552.703
475 M-1-10-I
WAJAH RINGAN
19.094.650 22.913.580 26.732.510
476 M-1-10-II
WAJAH SEDANG
45.654.564 54.785.476 63.916.389
477 M-1-10-III
WAJAH BERAT
98.472.596 118.167.115 137.861.635
478 M-1-20-I
MAYOR RINGAN
6.585.006 7.902.007 9.219.008
479 M-1-20-II
MAYOR SEDANG
7.475.696 8.970.835 10.465.974
480 M-1-20-III
MAYOR BERAT
18.343.789 22.012.546 25.681.304
484 M-1-40-I
3.901.360 4.681.632 5.461.904
485 M-1-40-II
6.421.706 7.706.047 8.990.388
486 M-1-40-III
9.511.585 11.413.901 13.316.218
490 M-1-60-I
3.973.450 4.768.141 5.562.831
491 M-1-60-II
7.968.439 9.562.127 11.155.815
492 M-1-60-III
12.356.160 14.827.392 17.298.624
493 M-1-70-I
(RINGAN)
22.754.230 27.305.076 31.855.922
494 M-1-70-II
(SEDANG)
25.029.653 30.035.584 35.041.514
495 M-1-70-III
(BERAT)
27.532.618 33.039.142 38.545.666
502 M-4-11-I
RINGAN
3.606.681 4.328.017 5.049.353
503 M-4-11-II
SEDANG
6.707.703 8.049.244 9.390.785
504 M-4-11-III
BERAT
11.989.397 14.387.277 16.785.156
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
508 M-4-13-I
4.535.929 5.443.115 6.350.301
509 M-4-13-II
5.643.840 6.772.608 7.901.376
510 M-4-13-III
11.534.317 13.841.181 16.148.044
520 M-4-17-I
RINGAN
2.909.869 3.491.843 4.073.817
521 M-4-17-II
SEDANG
3.808.464 4.570.157 5.331.850
522 M-4-17-III
BERAT
5.248.358 6.298.030 7.347.702
526 M-4-19-I
2.971.450 3.565.740 4.160.030
527 M-4-19-II
4.747.026 5.696.431 6.645.837
528 M-4-19-III
7.579.734 9.095.681 10.611.628
529 M-4-20-I
2.130.140 2.556.168 2.982.196
530 M-4-20-II
3.044.332 3.653.199 4.262.065
531 M-4-20-III
3.371.030 4.045.236 4.719.442
532 M-4-21-I
2.123.528 2.548.234 2.972.939
533 M-4-21-II
3.556.130 4.267.356 4.978.582
534 M-4-21-III
6.014.426 7.217.311 8.420.196
541 N-1-12-I
3.867.395 4.640.874 5.414.353
542 N-1-12-II
12.833.304 15.399.965 17.966.626
543 N-1-12-III
23.312.525 27.975.030 32.637.535
547 N-1-30-I
BAWAH RINGAN
7.657.170 9.188.604 10.720.038
548 N-1-30-II
BAWAH SEDANG
11.445.038 13.734.045 16.023.053
549 N-1-30-III
BAWAH BERAT
12.018.928 14.422.714 16.826.499
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
553 N-4-10-I
RINGAN
3.109.754 3.731.705 4.353.656
554 N-4-10-II
SEDANG
4.190.990 5.029.188 5.867.386
555 N-4-10-III
BERAT
7.332.219 8.798.662 10.265.106
565 N-4-14-I
1.771.237 2.125.484 2.479.732
566 N-4-14-II
2.633.885 3.160.662 3.687.439
567 N-4-14-III
4.271.322 5.125.586 5.979.851
568 N-4-15-I
URIN RINGAN
2.850.674 3.420.809 3.990.944
569 N-4-15-II
URIN SEDANG
3.899.705 4.679.645 5.459.586
570 N-4-15-III
URIN BERAT
4.450.267 5.340.320 6.230.373
571 N-4-16-I
(RINGAN)
3.433.515 4.120.218 4.806.920
572 N-4-16-II
(SEDANG)
4.126.549 4.951.859 5.777.169
573 N-4-16-III
(BERAT)
7.345.828 8.814.993 10.284.159
577 O-6-11-I
2.588.867 3.106.641 3.624.414
578 O-6-11-II
3.661.273 4.393.527 5.125.782
579 O-6-11-III
6.217.555 7.461.066 8.704.577
580 O-6-12-I
2.493.408 2.992.090 3.490.771
581 O-6-12-II
2.994.577 3.593.492 4.192.408
582 O-6-12-III
3.910.256 4.692.307 5.474.358
586 P-8-01-I
RINGAN
49.615.950 59.539.140 69.462.330
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
587 P-8-01-II
SEDANG
61.391.977 73.670.372 85.948.768
588 P-8-01-III
BERAT
72.056.971 86.468.365 100.879.760
589 P-8-02-I
80.052.972 96.063.566 112.074.161
590 P-8-02-II
91.828.999 110.194.799 128.560.598
591 P-8-02-III
104.921.197 125.905.436 146.889.676
592 P-8-03-I
2.774.124 3.328.949 3.883.773
593 P-8-03-II
4.134.627 4.961.552 5.788.477
594 P-8-03-III
7.514.175 9.017.010 10.519.845
595 P-8-04-I
33.404.575 40.085.490 46.766.405
596 P-8-04-II
43.183.174 51.819.809 60.456.443
597 P-8-04-III
61.913.802 74.296.562 86.679.323
598 P-8-05-I
18.138.811 21.766.573 25.394.335
599 P-8-05-II
25.700.189 30.840.227 35.980.265
600 P-8-05-III
37.739.137 45.286.965 52.834.792
601 P-8-06-I
3.074.249 3.689.099 4.303.949
602 P-8-06-II
6.675.036 8.010.043 9.345.050
603 P-8-06-III
12.189.897 14.627.876 17.065.856
604 P-8-07-I
4.807.076 5.768.492 6.729.907
605 P-8-07-II
11.895.739 14.274.887 16.654.035
606 P-8-07-III
15.991.559 19.189.871 22.388.182
607 P-8-08-I
3.979.864 4.775.836 5.571.809
608 P-8-08-II
5.647.237 6.776.685 7.906.132
609 P-8-08-III
9.144.120 10.972.944 12.801.768
610 P-8-10-I
2.354.476 2.825.371 3.296.266
611 P-8-10-II
4.037.567 4.845.080 5.652.594
612 P-8-10-III
7.926.934 9.512.321 11.097.707
613 P-8-11-I
RINGAN
2.841.907 3.410.289 3.978.670
614 P-8-11-II
SEDANG
14.100.123 16.920.147 19.740.172
615 P-8-11-III
BERAT
14.395.523 17.274.627 20.153.732
616 P-8-12-I
RINGAN
3.833.866 4.600.639 5.367.412
617 P-8-12-II
SEDANG
5.969.379 7.163.255 8.357.131
618 P-8-12-III
BERAT
7.035.448 8.442.537 9.849.627
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
619 P-8-13-I
RINGAN
2.233.163 2.679.795 3.126.428
620 P-8-13-II
SEDANG
5.487.063 6.584.476 7.681.889
621 P-8-13-III
BERAT
13.366.912 16.040.294 18.713.677
622 P-8-14-I
3.611.788 4.334.146 5.056.504
623 P-8-14-II
7.392.678 8.871.213 10.349.749
624 P-8-14-III
8.120.462 9.744.554 11.368.647
625 P-8-15-I
RINGAN
2.722.816 3.267.379 3.811.942
626 P-8-15-II
SEDANG
5.446.396 6.535.675 7.624.954
627 P-8-15-III
BERAT
6.384.880 7.661.856 8.938.832
628 P-8-16-I
2.470.427 2.964.512 3.458.597
629 P-8-16-II
5.296.323 6.355.588 7.414.852
630 P-8-16-III
13.910.999 16.693.198 19.475.398
631 P-8-17-I
RINGAN
1.895.335 2.274.401 2.653.468
632 P-8-17-II
SEDANG
4.927.706 5.913.247 6.898.788
633 P-8-17-III
BERAT
9.313.577 11.176.292 13.039.007
634 S-4-10-I
1.970.932 2.365.119 2.759.305
635 S-4-10-II
2.537.294 3.044.753 3.552.212
636 S-4-10-III
3.300.544 3.960.653 4.620.762
646 S-4-14-I
KANAK-KANAK RINGAN
1.203.147 1.443.777 1.684.406
647 S-4-14-II
KANAK-KANAK SEDANG
2.555.889 3.067.066 3.578.244
648 S-4-14-III
KANAK-KANAK BERAT
4.846.875 5.816.250 6.785.625
649 S-4-15-I
YANG LAIN (RINGAN)
909.951 1.091.942 1.273.932
650 S-4-15-II
YANG LAIN (SEDANG)
1.717.388 2.060.866 2.404.344
651 S-4-15-III
YANG LAIN (BERAT)
2.224.417 2.669.300 3.114.184
655 S-4-17-I
LAIN-LAIN RINGAN
2.056.404 2.467.685 2.878.966
656 S-4-17-II
LAIN-LAIN SEDANG
2.964.116 3.556.939 4.149.762
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
657 S-4-17-III
LAIN-LAIN BERAT
4.123.194 4.947.833 5.772.472
658 T-1-10-I
RINGAN
2.142.969 2.571.563 3.000.156
659 T-1-10-II
SEDANG
2.877.862 3.453.434 4.029.006
660 T-1-10-III
BERAT
5.235.769 6.282.922 7.330.076
661 T-4-10-I
832.047 998.456 1.164.866
662 T-4-10-II
1.585.697 1.902.836 2.219.976
663 T-4-10-III
2.305.173 2.766.208 3.227.242
664 T-4-11-I
1.135.532 1.362.639 1.589.745
665 T-4-11-II
1.787.005 2.144.405 2.501.806
666 T-4-11-III
2.878.338 3.454.006 4.029.673
667 T-4-12-I
LAIN (RINGAN)
1.870.785 2.244.942 2.619.098
668 T-4-12-II
LAIN (SEDANG)
2.787.518 3.345.021 3.902.525
669 T-4-12-III
LAIN (BERAT)
4.276.774 5.132.129 5.987.484
673 U-1-11-I
(RINGAN)
6.478.101 7.773.721 9.069.341
674 U-1-11-II
(SEDANG)
8.863.448 10.636.137 12.408.827
675 U-1-11-III
(BERAT)
20.136.624 24.163.948 28.191.273
682 U-1-14-I
MULUT (RINGAN)
4.059.578 4.871.494 5.683.409
683 U-1-14-II
MULUT (SEDANG)
4.981.919 5.978.302 6.974.686
684 U-1-14-III
MULUT (BERAT)
5.903.714 7.084.457 8.265.199
688 U-1-20-I
6.166.067 7.399.280 8.632.493
689 U-1-20-II
9.026.239 10.831.487 12.636.735
690 U-1-20-III
16.329.404 19.595.284 22.861.165
694 U-4-10-I
TELINGA RINGAN
4.925.018 5.910.021 6.895.025
695 U-4-10-II
TELINGA SEDANG
11.697.762 14.037.315 16.376.867
696 U-4-10-III
TELINGA BERAT
14.584.652 17.501.582 20.418.512
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
703 U-4-13-I
2.028.028 2.433.633 2.839.239
704 U-4-13-II
2.312.754 2.775.304 3.237.855
705 U-4-13-III
2.957.747 3.549.297 4.140.846
709 U-4-15-I
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG & TELINGA
LAIN-LAIN (RINGAN)
2.187.227 2.624.673 3.062.118
710 U-4-15-II
LAIN-LAIN (SEDANG)
2.866.969 3.440.362 4.013.756
711 U-4-15-III
LAIN-LAIN (BERAT)
3.899.413 4.679.295 5.459.178
712 V-1-10-I
RINGAN
6.746.220 8.095.463 9.444.707
713 V-1-10-II
SEDANG
7.606.440 9.127.727 10.649.015
718 V-1-12-I
MODERAT (RINGAN)
4.959.451 5.951.341 6.943.231
719 V-1-12-II
MODERAT (SEDANG)
12.368.020 14.841.624 17.315.228
720 V-1-12-III
MODERAT (BERAT)
12.805.443 15.366.532 17.927.620
721 V-1-13-I
KOMPLEK (RINGAN)
7.530.579 9.036.695 10.542.811
722 V-1-13-II
KOMPLEK (SEDANG)
10.711.892 12.854.270 14.996.649
723 V-1-13-III
KOMPLEK (BERAT)
13.280.716 15.936.860 18.593.003
724 V-1-14-I
RINGAN
8.015.435 9.618.522 11.221.609
725 V-1-14-II
SEDANG
10.705.119 12.846.143 14.987.166
726 V-1-14-III
BERAT
14.554.326 17.465.191 20.376.056
733 V-4-11-I
TUMOR (RINGAN)
2.797.492 3.356.991 3.916.489
734 V-4-11-II
TUMOR (SEDANG)
3.927.609 4.713.131 5.498.652
735 V-4-11-III
TUMOR (BERAT)
6.882.714 8.259.257 9.635.799
736 W-1-01-I
10.255.801 12.306.962 14.358.122
737 W-1-01-II
11.501.799 13.802.159 16.102.518
738 W-1-01-III
18.211.253 21.853.504 25.495.754
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Inap
742 W-1-11-I
RINGAN
3.114.049 3.736.859 4.359.669
743 W-1-11-II
SEDANG
5.474.852 6.569.823 7.664.793
744 W-1-11-III
BERAT
11.528.497 13.834.197 16.139.896
745 W-1-12-I
2.709.517 3.251.421 3.793.324
746 W-1-12-II
3.063.424 3.676.109 4.288.794
747 W-1-12-III
4.705.806 5.646.967 6.588.128
748 W-1-13-I
RINGAN
2.330.609 2.796.731 3.262.853
749 W-1-13-II
SEDANG
2.530.370 3.036.444 3.542.518
763 W-4-12-I
2.030.006 2.436.007 2.842.008
764 W-4-12-II
3.284.566 3.941.479 4.598.393
765 W-4-12-III
4.177.307 5.012.768 5.848.230
787 Z-4-12-I
1.578.613 1.894.335 2.210.058
788 Z-4-12-II
4.100.645 4.920.774 5.740.903
789 Z-4-12-III
5.300.026 6.360.031 7.420.036
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.354.726
33 F-3-10-0 TERAPI SHOCK 265.359
Rumah Sakit Kelas B
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
72 I-2-16-0
ALAT
2.332.219
80 I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR PERKUTAN LAIN
2.225.158
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
179 O-7-12-0
1.496.045
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
191 Q-5-12-0 GIGI 133.134
195 Q-5-16-0 VAKSINASI 106.130
196 Q-5-17-0 PASANG INFUS 91.619
200 Q-5-21-0 ABORSI 104.203
205 Q-5-26-0 BRONKIAL AKUT 205.557
210 Q-5-31-0 FRAKTUR 139.283
214 Q-5-35-0 INFEKSI AKUT 270.166
217 Q-5-38-0 PARU AKUT 214.831
No
Kode INA-
CBG
Rumah Sakit Kelas B
Rawat Jalan
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN EMPEDU
1.533.122
276 Z-3-18-0 CT-SCAN KEPALA 261.826
288 Z-3-30-0 FOTOTERAPI 79.663
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.612.976 1.935.572 2.258.167
8 A-4-12-II DEMAM SEDANG 2.060.307 2.472.368 2.884.429
9 A-4-12-III DEMAM BERAT 2.199.065 2.638.878 3.078.691
13 A-4-14-I
RINGAN
2.874.348 3.449.218 4.024.088
14 A-4-14-II
SEDANG
3.697.139 4.436.567 5.175.995
15 A-4-14-III
BERAT
4.236.051 5.083.262 5.930.472
28 B-1-12-I
RINGAN
5.595.447 6.714.536 7.833.625
29 B-1-12-II
SEDANG
11.992.411 14.390.893 16.789.375
30 B-1-12-III
BERAT
14.181.167 17.017.401 19.853.634
31 B-1-13-I
(RINGAN)
4.499.550 5.399.461 6.299.371
32 B-1-13-II
(SEDANG)
7.329.115 8.794.938 10.260.761
33 B-1-13-III
(BERAT)
10.805.172 12.966.206 15.127.240
34 B-1-14-I
RINGAN
6.086.203 7.303.444 8.520.684
35 B-1-14-II
SEDANG
6.769.086 8.122.903 9.476.721
36 B-1-14-III
BERAT
10.589.431 12.707.317 14.825.203
40 B-4-11-I
RINGAN
2.903.142 3.483.770 4.064.399
41 B-4-11-II
SEDANG
4.351.607 5.221.929 6.092.250
46 B-4-13-I
2.416.580 2.899.896 3.383.212
Rumah Sakit Kelas C
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
47 B-4-13-II
3.659.261 4.391.113 5.122.966
48 B-4-13-III
4.549.338 5.459.206 6.369.073
73 D-1-20-I
3.662.760 4.395.311 5.127.863
74 D-1-20-II
9.744.812 11.693.774 13.642.736
75 D-1-20-III
16.892.969 20.271.563 23.650.157
85 D-4-13-I
SEL SICKLE RINGAN
1.607.975 1.929.570 2.251.164
86 D-4-13-II
SEL SICKLE SEDANG
2.409.508 2.891.410 3.373.311
87 D-4-13-III
SEL SICKLE BERAT
2.814.979 3.377.975 3.940.971
88 D-4-14-I
1.941.032 2.329.239 2.717.445
89 D-4-14-II
3.709.090 4.450.908 5.192.726
90 D-4-14-III
5.200.954 6.241.144 7.281.335
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.962.330 5.954.796 6.947.263
98 E-1-20-II
TIROGLOSAL SEDANG
7.916.390 9.499.668 11.082.946
99 E-1-20-III
TIROGLOSAL BERAT
14.272.256 17.126.707 19.981.158
100 E-4-10-I
METABOLIK RINGAN
2.012.837 2.415.404 2.817.971
101 E-4-10-II
METABOLIK SEDANG
3.510.138 4.212.166 4.914.193
102 E-4-10-III
METABOLIK BERAT
4.449.080 5.338.896 6.228.712
130 F-4-16-I
RINGAN
4.780.285 5.736.342 6.692.399
131 F-4-16-II
SEDANG
5.554.926 6.665.912 7.776.897
132 F-4-16-III
BERAT
7.414.899 8.897.879 10.380.859
142 G-1-01-I
RINGAN
7.469.518 8.963.421 10.457.325
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
163 G-4-10-I
RINGAN
2.418.454 2.902.145 3.385.836
164 G-4-10-II
SEDANG
2.808.686 3.370.423 3.932.160
166 G-4-11-I
DEGENERATIF RINGAN
3.420.669 4.104.803 4.788.936
167 G-4-11-II
DEGENERATIF SEDANG
5.556.999 6.668.399 7.779.799
168 G-4-11-III
DEGENERATIF BERAT
6.756.627 8.107.953 9.459.278
172 G-4-13-I
RINGAN
2.241.944 2.690.332 3.138.721
173 G-4-13-II
SEDANG
2.806.992 3.368.390 3.929.789
174 G-4-13-III
BERAT
3.336.498 4.003.797 4.671.097
175 G-4-14-I
INFARK RINGAN
3.035.366 3.642.439 4.249.513
176 G-4-14-II
INFARK SEDANG
5.522.774 6.627.329 7.731.884
177 G-4-14-III
INFARK BERAT
6.905.863 8.287.035 9.668.208
178 G-4-15-I
2.439.132 2.926.958 3.414.785
179 G-4-15-II
2.911.115 3.493.338 4.075.561
180 G-4-15-III
3.784.316 4.541.179 5.298.042
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
187 G-4-18-I
PERSARAFAN RINGAN
2.411.200 2.893.440 3.375.680
188 G-4-18-II
PERSARAFAN SEDANG
4.695.690 5.634.828 6.573.965
189 G-4-18-III
PERSARAFAN BERAT
4.970.674 5.964.809 6.958.944
190 G-4-19-I
2.691.534 3.229.841 3.768.148
191 G-4-19-II
3.719.803 4.463.763 5.207.724
192 G-4-19-III
4.676.120 5.611.345 6.546.569
211 G-4-26-I
(RINGAN)
2.417.697 2.901.237 3.384.776
212 G-4-26-II
(SEDANG)
2.805.353 3.366.423 3.927.494
213 G-4-26-III
(BERAT)
4.119.252 4.943.102 5.766.952
229 I-1-01-I
RINGAN
34.746.404 41.695.684 48.644.965
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
230 I-1-01-II
SEDANG
35.511.006 42.613.207 49.715.408
231 I-1-01-III
BERAT
56.053.441 67.264.129 78.474.818
232 I-1-02-I
RINGAN
19.277.105 23.132.525 26.987.946
233 I-1-02-II
SEDANG
24.867.465 29.840.958 34.814.451
234 I-1-02-III
BERAT
30.650.596 36.780.716 42.910.835
235 I-1-03-I
11.853.332 14.223.998 16.594.664
236 I-1-03-II
13.583.936 16.300.723 19.017.510
237 I-1-03-III
22.471.546 26.965.855 31.460.164
238 I-1-04-I
JANTUNG RINGAN
18.459.978 22.151.973 25.843.969
239 I-1-04-II
JANTUNG SEDANG
18.917.698 22.701.238 26.484.777
240 I-1-04-III
JANTUNG BERAT
43.889.937 52.667.924 61.445.911
241 I-1-05-I
25.513.815 30.616.578 35.719.341
242 I-1-05-II
30.616.578 36.739.893 42.863.209
243 I-1-05-III
42.128.218 50.553.861 58.979.505
247 I-1-07-I
20.658.920 24.790.704 28.922.488
248 I-1-07-II
25.486.975 30.584.370 35.681.765
249 I-1-07-III
27.806.124 33.367.348 38.928.573
250 I-1-11-I
3.324.636 3.989.564 4.654.491
251 I-1-11-II
3.696.663 4.435.996 5.175.329
252 I-1-11-III
4.919.132 5.902.959 6.886.785
253 I-1-12-I
RINGAN
9.211.967 11.054.360 12.896.754
254 I-1-12-II
SEDANG
10.468.479 12.562.174 14.655.870
255 I-1-12-III
BERAT
17.822.624 21.387.148 24.951.673
256 I-1-13-I
RINGAN
4.396.559 5.275.871 6.155.183
257 I-1-13-II
SEDANG
6.297.715 7.557.259 8.816.802
258 I-1-13-III
BERAT
15.026.072 18.031.287 21.036.501
259 I-1-14-I
PERMANEN RINGAN
19.844.078 23.812.894 27.781.710
260 I-1-14-II
PERMANEN SEDANG
24.663.354 29.596.025 34.528.696
261 I-1-14-III
PERMANEN BERAT
32.317.499 38.780.999 45.244.498
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
265 I-1-16-I
(RINGAN)
8.504.605 10.205.526 11.906.447
266 I-1-16-II
(SEDANG)
22.111.973 26.534.367 30.956.762
267 I-1-16-III
(BERAT)
25.505.618 30.606.742 35.707.865
268 I-1-17-I
VENA RINGAN
11.989.504 14.387.405 16.785.306
269 I-1-17-II
VENA SEDANG
15.567.136 18.680.563 21.793.990
270 I-1-17-III
VENA BERAT
32.630.951 39.157.141 45.683.332
271 I-1-20-I
RINGAN
10.638.335 12.766.002 14.893.669
272 I-1-20-II
SEDANG
13.451.811 16.142.173 18.832.535
274 I-1-30-I
9.648.519 11.578.222 13.507.926
275 I-1-30-II
20.070.868 24.085.041 28.099.215
276 I-1-30-III
31.102.555 37.323.066 43.543.577
289 I-4-13-I
RINGAN
4.763.303 5.715.964 6.668.625
290 I-4-13-II
SEDANG
6.040.214 7.248.257 8.456.300
291 I-4-13-III
BERAT
10.476.831 12.572.198 14.667.564
295 I-4-15-I
(RINGAN)
3.215.998 3.859.198 4.502.398
296 I-4-15-II
(SEDANG)
4.609.260 5.531.112 6.452.963
297 I-4-15-III
(BERAT)
5.253.447 6.304.136 7.354.826
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
306 I-4-18-III
BERAT
6.542.018 7.850.422 9.158.825
319 I-4-23-I
1.982.675 2.379.210 2.775.745
320 I-4-23-II
2.434.268 2.921.121 3.407.975
321 I-4-23-III
4.756.338 5.707.605 6.658.873
322 I-4-24-I
(RINGAN)
2.366.840 2.840.208 3.313.576
323 I-4-24-II
(SEDANG)
6.519.350 7.823.220 9.127.089
324 I-4-24-III
(BERAT)
8.204.172 9.845.006 11.485.841
325 J-1-01-I
TRAKEOSTOMI RINGAN
19.379.336 23.255.203 27.131.070
326 J-1-01-II
TRAKEOSTOMI SEDANG
21.111.483 25.333.780 29.556.076
327 J-1-01-III
TRAKEOSTOMI BERAT
38.234.650 45.881.580 53.528.511
328 J-1-02-I
TRAKEOSTOMI RINGAN
9.086.063 10.903.276 12.720.489
329 J-1-02-II
TRAKEOSTOMI SEDANG
10.451.188 12.541.426 14.631.663
330 J-1-02-III
TRAKEOSTOMI BERAT
17.056.779 20.468.135 23.879.491
334 J-1-20-I
RINGAN
5.968.306 7.161.967 8.355.628
335 J-1-20-II
SEDANG
7.886.119 9.463.343 11.040.567
337 J-1-30-I
RINGAN
2.998.720 3.598.464 4.198.208
338 J-1-30-II
SEDANG
9.838.639 11.806.367 13.774.095
339 J-1-30-III
BERAT
26.518.712 31.822.454 37.126.197
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.604.589 1.925.507 2.246.424
374 J-4-21-II
LAIN-LAIN (SEDANG)
3.247.237 3.896.684 4.546.131
375 J-4-21-III
LAIN-LAIN (BERAT)
4.607.347 5.528.817 6.450.286
376 K-1-10-I
(RINGAN)
4.338.236 5.205.884 6.073.531
377 K-1-10-II
(SEDANG)
8.199.300 9.839.160 11.479.020
378 K-1-10-III
(BERAT)
9.594.384 11.513.260 13.432.137
382 K-1-12-I
FEMORAL (RINGAN)
2.718.784 3.262.541 3.806.298
383 K-1-12-II
FEMORAL (SEDANG)
3.534.010 4.240.812 4.947.614
384 K-1-12-III
FEMORAL (BERAT)
7.048.503 8.458.203 9.867.904
394 K-1-30-I
KOMPLEKS (RINGAN)
6.237.945 7.485.534 8.733.123
395 K-1-30-II
KOMPLEKS (SEDANG)
8.665.170 10.398.203 12.131.237
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
396 K-1-30-III
KOMPLEKS (BERAT)
16.103.075 19.323.690 22.544.305
412 K-4-13-I
2.415.440 2.898.528 3.381.616
413 K-4-13-II
3.121.764 3.746.117 4.370.470
414 K-4-13-III
5.120.256 6.144.307 7.168.358
415 K-4-14-I
RINGAN
2.015.583 2.418.700 2.821.816
416 K-4-14-II
SEDANG
2.728.028 3.273.634 3.819.239
417 K-4-14-III
BERAT
4.110.250 4.932.300 5.754.350
424 K-4-17-I
(RINGAN)
2.610.018 3.132.022 3.654.026
425 K-4-17-II
(SEDANG)
3.693.625 4.432.350 5.171.076
426 K-4-17-III
(BERAT)
4.166.418 4.999.701 5.832.985
430 L-1-20-I
RINGAN
22.258.761 26.710.514 31.162.266
431 L-1-20-II
SEDANG
22.939.716 27.527.660 32.115.603
432 L-1-20-III
BERAT
34.476.229 41.371.475 48.266.721
433 L-1-30-I
RINGAN
7.136.178 8.563.413 9.990.649
434 L-1-30-II
SEDANG
12.987.613 15.585.135 18.182.658
435 L-1-30-III
BERAT
15.425.807 18.510.968 21.596.129
436 L-1-40-I
PAYUDARA RINGAN
3.392.080 4.070.496 4.748.912
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
437 L-1-40-II
PAYUDARA SEDANG
7.195.452 8.634.543 10.073.633
438 L-1-40-III
PAYUDARA BERAT
12.216.603 14.659.923 17.103.244
451 L-4-13-I
PAYUDARA RINGAN
1.515.717 1.818.861 2.122.004
452 L-4-13-II
PAYUDARA SEDANG
2.161.263 2.593.515 3.025.768
453 L-4-13-III
PAYUDARA BERAT
2.616.258 3.139.509 3.662.761
454 L-4-14-I
(RINGAN)
1.607.589 1.929.107 2.250.624
455 L-4-14-II
(SEDANG)
2.412.744 2.895.293 3.377.842
456 L-4-14-III
(BERAT)
4.922.009 5.906.410 6.890.812
457 M-1-01-I
7.852.221 9.422.665 10.993.109
458 M-1-01-II
8.764.349 10.517.218 12.270.088
459 M-1-01-III
12.311.535 14.773.842 17.236.149
463 M-1-03-I
14.116.500 16.939.800 19.763.100
464 M-1-03-II
16.426.318 19.711.582 22.996.846
465 M-1-03-III
16.776.080 20.131.297 23.486.513
466 M-1-04-I
4.955.016 5.946.019 6.937.022
467 M-1-04-II
6.346.088 7.615.306 8.884.524
468 M-1-04-III
7.940.933 9.529.120 11.117.307
469 M-1-05-I
6.285.064 7.542.076 8.799.089
470 M-1-05-II
7.298.988 8.758.786 10.218.584
471 M-1-05-III
12.920.515 15.504.617 18.088.720
472 M-1-07-I
6.308.656 7.570.387 8.832.119
473 M-1-07-II
8.451.628 10.141.953 11.832.279
474 M-1-07-III
17.216.767 20.660.121 24.103.474
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
475 M-1-10-I
WAJAH RINGAN
5.340.956 6.409.147 7.477.338
476 M-1-10-II
WAJAH SEDANG
13.142.196 15.770.635 18.399.074
477 M-1-10-III
WAJAH BERAT
17.912.260 21.494.712 25.077.164
478 M-1-20-I
MAYOR RINGAN
5.268.005 6.321.606 7.375.207
479 M-1-20-II
MAYOR SEDANG
5.565.799 6.678.959 7.792.119
480 M-1-20-III
MAYOR BERAT
14.675.031 17.610.037 20.545.043
484 M-1-40-I
3.063.123 3.675.748 4.288.372
485 M-1-40-II
5.624.636 6.749.564 7.874.491
486 M-1-40-III
9.118.977 10.942.772 12.766.567
490 M-1-60-I
3.053.504 3.664.204 4.274.905
491 M-1-60-II
6.138.545 7.366.254 8.593.963
492 M-1-60-III
10.128.447 12.154.137 14.179.826
493 M-1-70-I
(RINGAN)
9.447.599 11.337.119 13.226.638
494 M-1-70-II
(SEDANG)
11.848.400 14.218.080 16.587.760
495 M-1-70-III
(BERAT)
12.469.192 14.963.030 17.456.869
502 M-4-11-I
RINGAN
2.134.662 2.561.594 2.988.527
503 M-4-11-II
SEDANG
4.884.704 5.861.645 6.838.586
504 M-4-11-III
BERAT
9.591.518 11.509.821 13.428.125
506 M-4-12-II
SEDANG
2.919.225 3.503.070 4.086.915
508 M-4-13-I
3.628.744 4.354.492 5.080.241
509 M-4-13-II
4.008.482 4.810.178 5.611.874
510 M-4-13-III
8.840.216 10.608.259 12.376.302
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
520 M-4-17-I
RINGAN
2.007.127 2.408.553 2.809.978
521 M-4-17-II
SEDANG
2.822.752 3.387.303 3.951.853
522 M-4-17-III
BERAT
3.944.155 4.732.986 5.521.817
526 M-4-19-I
2.377.160 2.852.592 3.328.024
527 M-4-19-II
3.797.621 4.557.145 5.316.669
528 M-4-19-III
5.768.617 6.922.341 8.076.064
529 M-4-20-I
1.606.406 1.927.687 2.248.968
530 M-4-20-II
2.416.203 2.899.443 3.382.684
531 M-4-20-III
2.671.819 3.206.183 3.740.547
532 M-4-21-I
1.603.252 1.923.903 2.244.553
533 M-4-21-II
2.106.602 2.527.923 2.949.243
534 M-4-21-III
4.930.075 5.916.090 6.902.105
541 N-1-12-I
3.170.136 3.804.163 4.438.190
542 N-1-12-II
10.266.643 12.319.972 14.373.301
543 N-1-12-III
18.650.020 22.380.024 26.110.028
547 N-1-30-I
BAWAH RINGAN
6.125.736 7.350.883 8.576.030
548 N-1-30-II
BAWAH SEDANG
7.974.354 9.569.224 11.164.095
549 N-1-30-III
BAWAH BERAT
9.162.374 10.994.849 12.827.324
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
553 N-4-10-I
RINGAN
2.010.324 2.412.389 2.814.454
554 N-4-10-II
SEDANG
3.352.792 4.023.350 4.693.909
555 N-4-10-III
BERAT
4.485.284 5.382.341 6.279.398
565 N-4-14-I
1.391.715 1.670.059 1.948.402
566 N-4-14-II
2.148.222 2.577.867 3.007.511
567 N-4-14-III
3.483.732 4.180.478 4.877.225
568 N-4-15-I
URIN RINGAN
1.997.198 2.396.637 2.796.077
569 N-4-15-II
URIN SEDANG
2.478.000 2.973.600 3.469.200
570 N-4-15-III
URIN BERAT
2.827.845 3.393.415 3.958.984
571 N-4-16-I
(RINGAN)
2.687.829 3.225.395 3.762.960
572 N-4-16-II
(SEDANG)
3.213.439 3.856.126 4.498.814
573 N-4-16-III
(BERAT)
5.487.277 6.584.732 7.682.187
577 O-6-11-I
2.122.116 2.546.539 2.970.962
578 O-6-11-II
2.819.286 3.383.143 3.947.001
579 O-6-11-III
4.787.698 5.745.237 6.702.777
580 O-6-12-I
1.994.726 2.393.672 2.792.617
581 O-6-12-II
2.395.662 2.874.794 3.353.926
582 O-6-12-III
3.128.205 3.753.846 4.379.487
586 P-8-01-I
RINGAN
40.467.254 48.560.705 56.654.156
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
587 P-8-01-II
SEDANG
50.071.897 60.086.276 70.100.656
588 P-8-01-III
BERAT
58.770.371 70.524.445 82.278.519
589 P-8-02-I
64.042.378 76.850.853 89.659.329
590 P-8-02-II
73.463.199 88.155.839 102.848.479
591 P-8-02-III
83.936.958 100.724.349 117.511.741
592 P-8-03-I
2.203.352 2.644.023 3.084.693
593 P-8-03-II
3.091.489 3.709.787 4.328.085
594 P-8-03-III
4.869.280 5.843.137 6.816.993
595 P-8-04-I
19.788.678 23.746.414 27.704.150
596 P-8-04-II
34.546.539 41.455.847 48.365.155
597 P-8-04-III
49.531.042 59.437.250 69.343.458
598 P-8-05-I
14.511.049 17.413.258 20.315.468
599 P-8-05-II
20.560.151 24.672.182 28.784.212
600 P-8-05-III
30.191.310 36.229.572 42.267.834
601 P-8-06-I
2.167.189 2.600.627 3.034.065
602 P-8-06-II
5.340.029 6.408.035 7.476.040
603 P-8-06-III
8.540.308 10.248.369 11.956.431
604 P-8-07-I
3.101.602 3.721.923 4.342.243
605 P-8-07-II
8.677.809 10.413.371 12.148.933
606 P-8-07-III
11.459.810 13.751.772 16.043.734
607 P-8-08-I
3.618.058 4.341.669 5.065.281
608 P-8-08-II
5.133.852 6.160.623 7.187.393
609 P-8-08-III
8.312.837 9.975.404 11.637.971
610 P-8-10-I
1.883.580 2.260.297 2.637.013
611 P-8-10-II
3.230.054 3.876.064 4.522.075
612 P-8-10-III
6.341.547 7.609.856 8.878.166
613 P-8-11-I
RINGAN
2.255.526 2.706.631 3.157.736
614 P-8-11-II
SEDANG
11.280.098 13.536.118 15.792.138
615 P-8-11-III
BERAT
11.516.418 13.819.702 16.122.985
616 P-8-12-I
RINGAN
3.067.093 3.680.511 4.293.930
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
617 P-8-12-II
SEDANG
4.775.503 5.730.604 6.685.705
618 P-8-12-III
BERAT
5.628.358 6.754.030 7.879.702
619 P-8-13-I
RINGAN
2.030.148 2.436.177 2.842.207
620 P-8-13-II
SEDANG
3.510.341 4.212.410 4.914.478
621 P-8-13-III
BERAT
5.225.575 6.270.690 7.315.805
622 P-8-14-I
2.145.372 2.574.446 3.003.520
623 P-8-14-II
5.914.142 7.096.971 8.279.799
624 P-8-14-III
6.496.370 7.795.643 9.094.917
625 P-8-15-I
RINGAN
2.178.252 2.613.903 3.049.553
626 P-8-15-II
SEDANG
4.357.117 5.228.540 6.099.963
627 P-8-15-III
BERAT
5.107.904 6.129.485 7.151.066
628 P-8-16-I
1.976.341 2.371.610 2.766.878
629 P-8-16-II
2.686.790 3.224.148 3.761.505
630 P-8-16-III
2.794.606 3.353.527 3.912.448
631 P-8-17-I
RINGAN
1.723.031 2.067.638 2.412.244
632 P-8-17-II
SEDANG
4.479.732 5.375.679 6.271.625
633 P-8-17-III
BERAT
8.466.888 10.160.265 11.853.643
634 S-4-10-I
1.607.512 1.929.014 2.250.516
635 S-4-10-II
2.011.107 2.413.328 2.815.550
636 S-4-10-III
2.615.488 3.138.586 3.661.684
646 S-4-14-I
KANAK-KANAK RINGAN
981.299 1.177.559 1.373.818
647 S-4-14-II
KANAK-KANAK SEDANG
2.084.608 2.501.529 2.918.451
648 S-4-14-III
KANAK-KANAK BERAT
3.953.159 4.743.791 5.534.422
649 S-4-15-I
YANG LAIN (RINGAN)
742.165 890.598 1.039.031
650 S-4-15-II
YANG LAIN (SEDANG)
1.400.719 1.680.862 1.961.006
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
651 S-4-15-III
YANG LAIN (BERAT)
1.814.256 2.177.107 2.539.959
655 S-4-17-I
LAIN-LAIN RINGAN
1.500.230 1.800.276 2.100.322
656 S-4-17-II
LAIN-LAIN SEDANG
2.009.632 2.411.559 2.813.485
657 S-4-17-III
LAIN-LAIN BERAT
3.285.182 3.942.218 4.599.254
658 T-1-10-I
RINGAN
1.714.375 2.057.250 2.400.125
659 T-1-10-II
SEDANG
2.302.289 2.762.747 3.223.205
660 T-1-10-III
BERAT
4.188.615 5.026.338 5.864.061
661 T-4-10-I
678.626 814.351 950.076
662 T-4-10-II
1.293.310 1.551.972 1.810.634
663 T-4-10-III
1.880.122 2.256.146 2.632.170
664 T-4-11-I
908.426 1.090.111 1.271.796
665 T-4-11-II
1.429.604 1.715.524 2.001.445
666 T-4-11-III
2.302.670 2.763.204 3.223.739
667 T-4-12-I
LAIN (RINGAN)
1.411.630 1.693.956 1.976.283
668 T-4-12-II
LAIN (SEDANG)
2.133.630 2.560.356 2.987.082
669 T-4-12-III
LAIN (BERAT)
3.303.065 3.963.678 4.624.291
673 U-1-11-I
(RINGAN)
5.310.153 6.372.184 7.434.214
674 U-1-11-II
(SEDANG)
7.041.890 8.450.268 9.858.646
675 U-1-11-III
(BERAT)
13.204.926 15.845.912 18.486.897
682 U-1-14-I
MULUT (RINGAN)
3.247.662 3.897.195 4.546.727
683 U-1-14-II
MULUT (SEDANG)
3.985.535 4.782.642 5.579.749
684 U-1-14-III
MULUT (BERAT)
4.722.971 5.667.565 6.612.159
688 U-1-20-I
4.932.853 5.919.424 6.905.995
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
689 U-1-20-II
6.474.023 7.768.827 9.063.632
690 U-1-20-III
13.005.622 15.606.746 18.207.871
694 U-4-10-I
TELINGA RINGAN
3.940.014 4.728.017 5.516.020
695 U-4-10-II
TELINGA SEDANG
6.543.456 7.852.148 9.160.839
696 U-4-10-III
TELINGA BERAT
10.046.353 12.055.624 14.064.895
703 U-4-13-I
1.579.006 1.894.807 2.210.608
704 U-4-13-II
1.842.829 2.211.394 2.579.960
705 U-4-13-III
2.085.061 2.502.074 2.919.086
709 U-4-15-I
1.612.472 1.934.966 2.257.461
710 U-4-15-II
2.016.339 2.419.607 2.822.875
711 U-4-15-III
2.819.061 3.382.873 3.946.685
712 V-1-10-I
RINGAN
4.717.134 5.660.561 6.603.987
713 V-1-10-II
SEDANG
5.415.066 6.498.079 7.581.092
718 V-1-12-I
MODERAT (RINGAN)
3.967.560 4.761.073 5.554.585
719 V-1-12-II
MODERAT (SEDANG)
9.131.066 10.957.279 12.783.492
720 V-1-12-III
MODERAT (BERAT)
10.496.728 12.596.074 14.695.420
721 V-1-13-I
KOMPLEK (RINGAN)
5.771.094 6.925.312 8.079.531
722 V-1-13-II
KOMPLEK (SEDANG)
8.780.627 10.536.752 12.292.878
723 V-1-13-III
KOMPLEK (BERAT)
12.177.910 14.613.492 17.049.074
724 V-1-14-I
RINGAN
6.412.348 7.694.818 8.977.288
725 V-1-14-II
SEDANG
7.795.714 9.354.857 10.914.000
726 V-1-14-III
BERAT
9.544.241 11.453.090 13.361.938
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
733 V-4-11-I
TUMOR (RINGAN)
2.063.815 2.476.578 2.889.341
734 V-4-11-II
TUMOR (SEDANG)
3.010.227 3.612.272 4.214.317
735 V-4-11-III
TUMOR (BERAT)
5.506.171 6.607.405 7.708.639
736 W-1-01-I
8.204.641 9.845.569 11.486.497
737 W-1-01-II
9.201.439 11.041.727 12.882.015
738 W-1-01-III
12.980.796 15.576.956 18.173.115
742 W-1-11-I
RINGAN
2.830.954 3.397.145 3.963.335
743 W-1-11-II
SEDANG
4.977.138 5.972.566 6.967.994
744 W-1-11-III
BERAT
10.480.452 12.576.542 14.672.633
745 W-1-12-I
2.167.614 2.601.137 3.034.659
746 W-1-12-II
2.450.739 2.940.887 3.431.035
747 W-1-12-III
3.764.645 4.517.573 5.270.502
748 W-1-13-I
RINGAN
1.900.868 2.281.041 2.661.215
749 W-1-13-II
SEDANG
2.063.794 2.476.553 2.889.312
763 W-4-12-I
1.608.800 1.930.559 2.252.319
764 W-4-12-II
2.207.757 2.649.308 3.090.859
765 W-4-12-III
3.341.846 4.010.215 4.678.584
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Inap
787 Z-4-12-I
1.208.134 1.449.761 1.691.388
788 Z-4-12-II
3.280.516 3.936.619 4.592.723
789 Z-4-12-III
4.240.020 5.088.025 5.936.029
No
Kode INA-
CBG
24 D-2-11-0 PROSEDUR LIMPA 1.302.778
33 F-3-10-0 TERAPI SHOCK 255.666
Rumah Sakit Kelas C
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
72 I-2-16-0
PENGGANTIAN ALAT
2.242.788
80 I-2-42-0
PERKUTAN LAIN
2.161.673
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
179 O-7-12-0
1.189.904
181 P-9-10-0
LAIN
182.674
191 Q-5-12-0 GIGI 127.881
195 Q-5-16-0 VAKSINASI 102.172
196 Q-5-17-0 PASANG INFUS 88.106
200 Q-5-21-0 ABORSI 82.879
205 Q-5-26-0 BRONKIAL AKUT 197.542
210 Q-5-31-0 FRAKTUR 133.788
214 Q-5-35-0 INFEKSI AKUT 260.397
217 Q-5-38-0 PARU AKUT 207.062
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
241 U-3-13-0
TENGGOROKAN
193.403
269 Z-3-11-0
EMPEDU
1.474.333
276 Z-3-18-0 CT-SCAN KEPALA 251.786
No
Kode INA-
CBG
Rumah Sakit Kelas C
Rawat Jalan
288 Z-3-30-0 FOTOTERAPI 76.709
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 1.345.525 1.614.630 1.883.735
8 A-4-12-II DEMAM SEDANG 1.736.493 2.083.791 2.431.090
9 A-4-12-III DEMAM BERAT 2.149.993 2.579.992 3.009.991
13 A-4-14-I
RINGAN
2.613.044 3.135.653 3.658.261
14 A-4-14-II
SEDANG
3.361.035 4.033.243 4.705.450
15 A-4-14-III
BERAT
3.850.956 4.621.147 5.391.338
28 B-1-12-I
RINGAN
4.112.514 4.935.016 5.757.519
29 B-1-12-II
SEDANG
8.814.123 10.576.947 12.339.772
30 B-1-12-III
BERAT
10.727.119 12.872.543 15.017.967
31 B-1-13-I
(RINGAN)
3.314.998 3.977.998 4.640.997
32 B-1-13-II
(SEDANG)
5.399.651 6.479.581 7.559.511
33 B-1-13-III
(BERAT)
7.960.600 9.552.720 11.144.840
34 B-1-14-I
RINGAN
4.499.152 5.398.983 6.298.813
35 B-1-14-II
SEDANG
5.003.965 6.004.758 7.005.551
36 B-1-14-III
BERAT
7.828.109 9.393.730 10.959.352
40 B-4-11-I
RINGAN
2.446.861 2.936.234 3.425.606
41 B-4-11-II
SEDANG
3.667.675 4.401.209 5.134.744
Rumah Sakit Kelas D
Rawat Inap
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
46 B-4-13-I
2.014.014 2.416.817 2.819.620
47 B-4-13-II
2.606.101 3.127.321 3.648.541
48 B-4-13-III
3.834.329 4.601.194 5.368.060
73 D-1-20-I
3.087.092 3.704.510 4.321.928
74 D-1-20-II
8.893.896 10.672.675 12.451.455
75 D-1-20-III
14.237.938 17.085.526 19.933.113
85 D-4-13-I
SEL SICKLE RINGAN
1.347.281 1.616.737 1.886.193
86 D-4-13-II
SEL SICKLE SEDANG
2.020.009 2.424.011 2.828.012
87 D-4-13-III
SEL SICKLE BERAT
2.477.668 2.973.202 3.468.735
88 D-4-14-I
1.685.841 2.023.010 2.360.178
89 D-4-14-II
3.126.140 3.751.369 4.376.597
90 D-4-14-III
4.383.531 5.260.237 6.136.943
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
97 E-1-20-I
TIROGLOSAL RINGAN
4.182.412 5.018.894 5.855.376
98 E-1-20-II
TIROGLOSAL SEDANG
6.090.510 7.308.612 8.526.714
99 E-1-20-III
TIROGLOSAL BERAT
10.108.501 12.130.201 14.151.901
100 E-4-10-I
METABOLIK RINGAN
1.863.900 2.236.680 2.609.459
101 E-4-10-II
METABOLIK SEDANG
2.864.616 3.437.540 4.010.463
102 E-4-10-III
METABOLIK BERAT
3.968.568 4.762.281 5.555.995
130 F-4-16-I
RINGAN
3.539.622 4.247.546 4.955.471
131 F-4-16-II
SEDANG
4.100.257 4.920.309 5.740.360
132 F-4-16-III
BERAT
5.473.159 6.567.791 7.662.422
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
142 G-1-01-I
RINGAN
6.232.278 7.478.733 8.725.189
163 G-4-10-I
RINGAN
2.012.549 2.415.059 2.817.568
164 G-4-10-II
SEDANG
2.453.647 2.944.376 3.435.105
166 G-4-11-I
DEGENERATIF RINGAN
3.229.016 3.874.819 4.520.622
167 G-4-11-II
DEGENERATIF SEDANG
4.631.036 5.557.243 6.483.450
168 G-4-11-III
DEGENERATIF BERAT
6.156.435 7.387.723 8.619.010
172 G-4-13-I
RINGAN
1.653.072 1.983.687 2.314.301
173 G-4-13-II
SEDANG
2.349.838 2.819.805 3.289.773
174 G-4-13-III
BERAT
2.779.785 3.335.742 3.891.699
175 G-4-14-I
INFARK RINGAN
2.637.427 3.164.912 3.692.398
176 G-4-14-II
INFARK SEDANG
4.074.558 4.889.470 5.704.382
177 G-4-14-III
INFARK BERAT
5.094.964 6.113.957 7.132.950
178 G-4-15-I
2.014.663 2.417.596 2.820.529
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
179 G-4-15-II
2.453.581 2.944.298 3.435.014
180 G-4-15-III
3.161.065 3.793.278 4.425.491
187 G-4-18-I
PERSARAFAN RINGAN
2.011.679 2.414.015 2.816.351
188 G-4-18-II
PERSARAFAN SEDANG
3.449.333 4.139.200 4.829.066
189 G-4-18-III
PERSARAFAN BERAT
3.661.852 4.394.222 5.126.593
190 G-4-19-I
2.010.604 2.412.724 2.814.845
191 G-4-19-II
3.135.169 3.762.203 4.389.237
192 G-4-19-III
3.941.185 4.729.422 5.517.659
211 G-4-26-I
(RINGAN)
2.342.199 2.810.639 3.279.078
212 G-4-26-II
(SEDANG)
2.739.750 3.287.700 3.835.650
213 G-4-26-III
(BERAT)
3.471.838 4.166.205 4.860.573
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
229 I-1-01-I
RINGAN
28.991.061 34.789.274 40.587.486
230 I-1-01-II
SEDANG
29.629.016 35.554.819 41.480.622
231 I-1-01-III
BERAT
46.768.833 56.122.600 65.476.366
232 I-1-02-I
RINGAN
16.084.074 19.300.889 22.517.703
233 I-1-02-II
SEDANG
20.748.455 24.898.146 29.047.837
234 I-1-02-III
BERAT
25.573.677 30.688.413 35.803.148
235 I-1-03-I
9.940.166 11.928.200 13.916.233
236 I-1-03-II
11.448.978 13.738.774 16.028.569
237 I-1-03-III
18.939.742 22.727.690 26.515.639
238 I-1-04-I
JANTUNG RINGAN
14.458.460 17.350.151 20.241.843
239 I-1-04-II
JANTUNG SEDANG
15.558.663 18.670.396 21.782.128
240 I-1-04-III
JANTUNG BERAT
32.266.280 38.719.536 45.172.792
241 I-1-05-I
21.287.745 25.545.294 29.802.843
242 I-1-05-II
25.545.294 30.654.352 35.763.411
243 I-1-05-III
35.150.163 42.180.195 49.210.228
247 I-1-07-I
15.789.244 18.947.093 22.104.942
248 I-1-07-II
19.479.241 23.375.089 27.270.937
249 I-1-07-III
21.251.725 25.502.070 29.752.415
250 I-1-11-I
2.443.525 2.932.230 3.420.935
251 I-1-11-II
2.716.955 3.260.346 3.803.737
252 I-1-11-III
3.615.439 4.338.527 5.061.615
253 I-1-12-I
RINGAN
7.720.767 9.264.920 10.809.074
254 I-1-12-II
SEDANG
8.823.171 10.587.805 12.352.439
255 I-1-12-III
BERAT
14.941.579 17.929.895 20.918.211
256 I-1-13-I
RINGAN
3.830.118 4.596.142 5.362.166
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
257 I-1-13-II
SEDANG
5.273.673 6.328.407 7.383.142
258 I-1-13-III
BERAT
11.484.159 13.780.991 16.077.823
259 I-1-14-I
PERMANEN RINGAN
16.557.135 19.868.562 23.179.989
260 I-1-14-II
PERMANEN SEDANG
20.578.153 24.693.784 28.809.415
261 I-1-14-III
PERMANEN BERAT
26.964.477 32.357.372 37.750.267
265 I-1-16-I
(RINGAN)
7.095.915 8.515.098 9.934.281
266 I-1-16-II
(SEDANG)
18.449.379 22.139.255 25.829.130
267 I-1-16-III
(BERAT)
21.280.906 25.537.087 29.793.268
268 I-1-17-I
VENA RINGAN
2.720.171 3.264.205 3.808.239
269 I-1-17-II
VENA SEDANG
4.588.549 5.506.259 6.423.969
270 I-1-17-III
VENA BERAT
26.723.085 32.067.702 37.412.319
271 I-1-20-I
RINGAN
3.298.483 3.958.180 4.617.877
272 I-1-20-II
SEDANG
5.459.207 6.551.049 7.642.890
274 I-1-30-I
8.050.352 9.660.423 11.270.493
275 I-1-30-II
16.746.359 20.095.631 23.444.903
276 I-1-30-III
25.950.775 31.140.929 36.331.084
289 I-4-13-I
RINGAN
3.510.314 4.212.377 4.914.440
290 I-4-13-II
SEDANG
5.111.977 6.134.372 7.156.767
291 I-4-13-III
BERAT
8.735.262 10.482.314 12.229.367
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
295 I-4-15-I
(RINGAN)
2.695.319 3.234.383 3.773.447
296 I-4-15-II
(SEDANG)
4.025.733 4.830.880 5.636.026
297 I-4-15-III
(BERAT)
4.588.367 5.506.040 6.423.714
306 I-4-18-III
BERAT
5.513.823 6.616.588 7.719.353
319 I-4-23-I
1.654.268 1.985.121 2.315.975
320 I-4-23-II
2.031.059 2.437.271 2.843.483
321 I-4-23-III
3.968.505 4.762.206 5.555.907
322 I-4-24-I
(RINGAN)
1.994.849 2.393.818 2.792.788
323 I-4-24-II
(SEDANG)
4.790.509 5.748.610 6.706.712
324 I-4-24-III
(BERAT)
6.080.111 7.296.133 8.512.155
325 J-1-01-I
TRAKEOSTOMI RINGAN
19.019.963 22.823.956 26.627.948
326 J-1-01-II
TRAKEOSTOMI SEDANG
20.318.957 24.382.749 28.446.540
327 J-1-01-III
TRAKEOSTOMI BERAT
28.268.304 33.921.964 39.575.625
328 J-1-02-I
TRAKEOSTOMI RINGAN
7.658.026 9.189.632 10.721.237
329 J-1-02-II
TRAKEOSTOMI SEDANG
9.370.848 11.245.018 13.119.188
330 J-1-02-III
TRAKEOSTOMI BERAT
12.596.827 15.116.193 17.635.558
334 J-1-20-I
RINGAN
3.280.712 3.936.855 4.592.997
335 J-1-20-II
SEDANG
4.047.389 4.856.867 5.666.345
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
337 J-1-30-I
RINGAN
2.212.189 2.654.627 3.097.065
338 J-1-30-II
SEDANG
8.292.322 9.950.786 11.609.251
339 J-1-30-III
BERAT
22.236.204 26.683.445 31.130.685
373 J-4-21-I
LAIN-LAIN (RINGAN)
1.442.559 1.731.071 2.019.583
374 J-4-21-II
LAIN-LAIN (SEDANG)
2.693.775 3.232.530 3.771.285
375 J-4-21-III
LAIN-LAIN (BERAT)
3.858.328 4.629.994 5.401.659
376 K-1-10-I
(RINGAN)
3.633.927 4.360.713 5.087.498
377 K-1-10-II
(SEDANG)
6.026.281 7.231.537 8.436.794
378 K-1-10-III
(BERAT)
7.068.098 8.481.718 9.895.337
382 K-1-12-I
FEMORAL (RINGAN)
2.007.050 2.408.461 2.809.871
383 K-1-12-II
FEMORAL (SEDANG)
2.613.643 3.136.371 3.659.100
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
384 K-1-12-III
FEMORAL (BERAT)
5.198.313 6.237.975 7.277.638
394 K-1-30-I
KOMPLEKS (RINGAN)
4.713.680 5.656.415 6.599.151
395 K-1-30-II
KOMPLEKS (SEDANG)
7.260.823 8.712.987 10.165.152
396 K-1-30-III
KOMPLEKS (BERAT)
13.489.350 16.187.219 18.885.089
412 K-4-13-I
2.013.439 2.416.126 2.818.814
413 K-4-13-II
2.616.342 3.139.610 3.662.878
414 K-4-13-III
4.271.255 5.125.506 5.979.757
415 K-4-14-I
RINGAN
1.681.194 2.017.433 2.353.672
416 K-4-14-II
SEDANG
2.280.365 2.736.438 3.192.511
417 K-4-14-III
BERAT
3.671.691 4.406.029 5.140.367
424 K-4-17-I
(RINGAN)
2.372.744 2.847.293 3.321.842
425 K-4-17-II
(SEDANG)
3.357.841 4.029.410 4.700.978
426 K-4-17-III
(BERAT)
3.787.652 4.545.183 5.302.713
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
430 L-1-20-I
RINGAN
16.414.779 19.697.735 22.980.691
431 L-1-20-II
SEDANG
17.064.347 20.477.216 23.890.085
432 L-1-20-III
BERAT
28.851.592 34.621.911 40.392.229
433 L-1-30-I
RINGAN
6.014.600 7.217.520 8.420.440
434 L-1-30-II
SEDANG
10.823.485 12.988.182 15.152.879
435 L-1-30-III
BERAT
11.429.827 13.715.792 16.001.757
436 L-1-40-I
PAYUDARA RINGAN
2.858.954 3.430.745 4.002.536
437 L-1-40-II
PAYUDARA SEDANG
5.012.032 6.014.438 7.016.845
438 L-1-40-III
PAYUDARA BERAT
8.483.318 10.179.981 11.876.645
451 L-4-13-I
PAYUDARA RINGAN
1.396.170 1.675.404 1.954.637
452 L-4-13-II
PAYUDARA SEDANG
1.745.137 2.094.165 2.443.192
453 L-4-13-III
PAYUDARA BERAT
2.463.761 2.956.513 3.449.265
454 L-4-14-I
(RINGAN)
1.384.597 1.661.517 1.938.436
455 L-4-14-II
(SEDANG)
2.052.906 2.463.487 2.874.068
456 L-4-14-III
(BERAT)
3.783.057 4.539.668 5.296.279
457 M-1-01-I
6.551.591 7.861.909 9.172.227
458 M-1-01-II
7.312.635 8.775.162 10.237.689
459 M-1-01-III
10.272.271 12.326.725 14.381.179
463 M-1-03-I
11.757.037 14.108.445 16.459.852
464 M-1-03-II
13.761.852 16.514.222 19.266.592
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
465 M-1-03-III
15.940.620 19.128.744 22.316.869
466 M-1-04-I
3.657.966 4.389.559 5.121.153
467 M-1-04-II
4.704.057 5.644.868 6.585.680
468 M-1-04-III
5.886.240 7.063.488 8.240.737
469 M-1-05-I
4.648.522 5.578.226 6.507.930
470 M-1-05-II
5.364.574 6.437.489 7.510.404
471 M-1-05-III
9.137.331 10.964.797 12.792.264
472 M-1-07-I
5.263.700 6.316.440 7.369.180
473 M-1-07-II
7.051.713 8.462.055 9.872.398
474 M-1-07-III
14.365.008 17.238.009 20.111.011
475 M-1-10-I
WAJAH RINGAN
3.945.220 4.734.264 5.523.308
476 M-1-10-II
WAJAH SEDANG
11.076.665 13.291.999 15.507.332
477 M-1-10-III
WAJAH BERAT
16.321.112 19.585.335 22.849.557
478 M-1-20-I
MAYOR RINGAN
3.892.738 4.671.286 5.449.833
479 M-1-20-II
MAYOR SEDANG
4.421.649 5.305.978 6.190.308
480 M-1-20-III
MAYOR BERAT
10.787.156 12.944.587 15.102.018
484 M-1-40-I
2.305.668 2.766.802 3.227.935
485 M-1-40-II
3.787.347 4.544.816 5.302.285
486 M-1-40-III
6.340.758 7.608.909 8.877.061
490 M-1-60-I
2.359.125 2.830.950 3.302.775
491 M-1-60-II
4.721.059 5.665.271 6.609.483
492 M-1-60-III
8.195.118 9.834.142 11.473.165
493 M-1-70-I
(RINGAN)
3.155.195 3.786.234 4.417.273
494 M-1-70-II
(SEDANG)
6.433.101 7.719.721 9.006.341
495 M-1-70-III
(BERAT)
8.997.010 10.796.412 12.595.814
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
502 M-4-11-I
RINGAN
2.123.822 2.548.587 2.973.351
503 M-4-11-II
SEDANG
4.137.674 4.965.209 5.792.744
504 M-4-11-III
BERAT
7.049.526 8.459.432 9.869.337
505 M-4-12-I
RINGAN
1.345.575 1.614.690 1.883.805
506 M-4-12-II
SEDANG
2.448.115 2.937.738 3.427.361
508 M-4-13-I
2.977.079 3.572.495 4.167.911
509 M-4-13-II
3.366.079 4.039.295 4.712.511
510 M-4-13-III
7.968.789 9.562.547 11.156.305
520 M-4-17-I
RINGAN
1.713.499 2.056.199 2.398.899
521 M-4-17-II
SEDANG
2.350.784 2.820.940 3.291.097
522 M-4-17-III
BERAT
3.296.833 3.956.199 4.615.566
526 M-4-19-I
1.749.173 2.099.007 2.448.842
527 M-4-19-II
2.946.167 3.535.400 4.124.634
528 M-4-19-III
5.040.397 6.048.477 7.056.556
529 M-4-20-I
1.346.572 1.615.887 1.885.201
530 M-4-20-II
2.014.904 2.417.884 2.820.865
531 M-4-20-III
2.239.853 2.687.824 3.135.794
532 M-4-21-I
1.342.080 1.610.496 1.878.912
533 M-4-21-II
2.093.083 2.511.700 2.930.317
534 M-4-21-III
4.155.226 4.986.271 5.817.316
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
541 N-1-12-I
2.671.893 3.206.271 3.740.650
542 N-1-12-II
7.561.048 9.073.258 10.585.467
543 N-1-12-III
13.778.312 16.533.975 19.289.637
547 N-1-30-I
BAWAH RINGAN
5.237.258 6.284.709 7.332.161
548 N-1-30-II
BAWAH SEDANG
7.907.108 9.488.530 11.069.951
549 N-1-30-III
BAWAH BERAT
8.303.595 9.964.315 11.625.034
553 N-4-10-I
RINGAN
1.841.211 2.209.453 2.577.696
554 N-4-10-II
SEDANG
2.692.775 3.231.330 3.769.885
555 N-4-10-III
BERAT
4.309.589 5.171.507 6.033.425
565 N-4-14-I
1.165.057 1.398.068 1.631.080
566 N-4-14-II
1.792.394 2.150.873 2.509.352
567 N-4-14-III
2.906.692 3.488.030 4.069.369
568 N-4-15-I
URIN RINGAN
1.683.303 2.019.963 2.356.624
569 N-4-15-II
URIN SEDANG
2.318.278 2.781.933 3.245.589
570 N-4-15-III
URIN BERAT
2.645.573 3.174.688 3.703.802
571 N-4-16-I
(RINGAN)
2.075.618 2.490.741 2.905.865
572 N-4-16-II
(SEDANG)
2.694.135 3.232.962 3.771.789
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
573 N-4-16-III
(BERAT)
4.624.853 5.549.824 6.474.795
577 O-6-11-I
1.788.588 2.146.305 2.504.023
578 O-6-11-II
2.165.395 2.598.473 3.031.552
579 O-6-11-III
3.666.415 4.399.698 5.132.981
580 O-6-12-I
1.466.074 1.759.289 2.052.504
581 O-6-12-II
1.760.751 2.112.902 2.465.052
582 O-6-12-III
2.212.132 2.654.558 3.096.985
586 P-8-01-I
RINGAN
33.764.319 40.517.183 47.270.046
587 P-8-01-II
SEDANG
41.778.063 50.133.675 58.489.288
588 P-8-01-III
BERAT
49.035.734 58.842.881 68.650.028
589 P-8-02-I
48.946.448 58.735.737 68.525.027
590 P-8-02-II
56.146.614 67.375.937 78.605.259
591 P-8-02-III
64.151.521 76.981.825 89.812.129
592 P-8-03-I
1.845.152 2.214.182 2.583.213
593 P-8-03-II
2.586.306 3.103.567 3.620.828
594 P-8-03-III
4.454.754 5.345.705 6.236.656
595 P-8-04-I
19.636.066 23.563.279 27.490.492
596 P-8-04-II
25.621.009 30.745.211 35.869.413
597 P-8-04-III
36.734.078 44.080.894 51.427.710
598 P-8-05-I
10.697.775 12.837.330 14.976.885
599 P-8-05-II
15.202.169 18.242.602 21.283.036
600 P-8-05-III
22.398.355 26.878.026 31.357.697
601 P-8-06-I
1.847.816 2.217.379 2.586.942
602 P-8-06-II
4.432.881 5.319.457 6.206.033
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
603 P-8-06-III
8.133.792 9.760.551 11.387.309
604 P-8-07-I
2.844.305 3.413.166 3.982.027
605 P-8-07-II
7.236.404 8.683.685 10.130.966
606 P-8-07-III
9.590.916 11.509.099 13.427.282
607 P-8-08-I
3.289.143 3.946.972 4.604.801
608 P-8-08-II
4.667.138 5.600.566 6.533.994
609 P-8-08-III
7.557.124 9.068.549 10.579.974
610 P-8-10-I
1.393.533 1.672.240 1.950.946
611 P-8-10-II
2.468.672 2.962.407 3.456.141
612 P-8-10-III
4.846.731 5.816.078 6.785.424
613 P-8-11-I
RINGAN
1.886.178 2.263.413 2.640.649
614 P-8-11-II
SEDANG
8.314.354 9.977.224 11.640.095
615 P-8-11-III
BERAT
8.488.541 10.186.249 11.883.957
616 P-8-12-I
RINGAN
2.263.718 2.716.461 3.169.205
617 P-8-12-II
SEDANG
3.519.936 4.223.923 4.927.910
618 P-8-12-III
BERAT
4.160.950 4.993.140 5.825.330
619 P-8-13-I
RINGAN
1.845.589 2.214.707 2.583.825
620 P-8-13-II
SEDANG
3.191.220 3.829.463 4.467.707
621 P-8-13-III
BERAT
4.750.523 5.700.627 6.650.732
622 P-8-14-I
2.133.662 2.560.395 2.987.127
623 P-8-14-II
4.350.510 5.220.612 6.090.713
624 P-8-14-III
4.772.597 5.727.117 6.681.636
625 P-8-15-I
RINGAN
1.609.793 1.931.752 2.253.710
626 P-8-15-II
SEDANG
3.206.921 3.848.305 4.489.689
627 P-8-15-III
BERAT
3.764.943 4.517.931 5.270.920
628 P-8-16-I
1.457.234 1.748.680 2.040.127
629 P-8-16-II
2.059.853 2.471.823 2.883.794
630 P-8-16-III
2.672.406 3.206.888 3.741.369
631 P-8-17-I
RINGAN
1.566.392 1.879.671 2.192.949
632 P-8-17-II
SEDANG
4.072.484 4.886.981 5.701.477
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
633 P-8-17-III
BERAT
7.697.171 9.236.605 10.776.039
634 S-4-10-I
1.348.054 1.617.665 1.887.276
635 S-4-10-II
1.684.298 2.021.157 2.358.017
636 S-4-10-III
2.180.714 2.616.857 3.053.000
646 S-4-14-I
KANAK-KANAK RINGAN
818.758 982.509 1.146.261
647 S-4-14-II
KANAK-KANAK SEDANG
1.739.316 2.087.180 2.435.043
648 S-4-14-III
KANAK-KANAK BERAT
3.298.364 3.958.036 4.617.709
649 S-4-15-I
YANG LAIN (RINGAN)
619.234 743.081 866.928
650 S-4-15-II
YANG LAIN (SEDANG)
1.168.706 1.402.447 1.636.188
651 S-4-15-III
YANG LAIN (BERAT)
1.513.746 1.816.495 2.119.244
655 S-4-17-I
1.420.721 1.704.866 1.989.010
656 S-4-17-II
1.748.421 2.098.105 2.447.789
657 S-4-17-III
2.748.916 3.298.700 3.848.483
658 T-1-10-I
RINGAN
1.260.023 1.512.027 1.764.032
659 T-1-10-II
SEDANG
1.692.125 2.030.550 2.368.975
660 T-1-10-III
BERAT
3.078.527 3.694.233 4.309.938
661 T-4-10-I
566.219 679.463 792.707
662 T-4-10-II
1.079.088 1.294.906 1.510.723
663 T-4-10-III
1.568.701 1.882.441 2.196.182
664 T-4-11-I
670.465 804.557 938.650
665 T-4-11-II
1.055.120 1.266.144 1.477.168
666 T-4-11-III
1.699.488 2.039.386 2.379.283
667 T-4-12-I
LAIN (RINGAN)
1.172.649 1.407.178 1.641.708
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
668 T-4-12-II
LAIN (SEDANG)
1.772.784 2.127.341 2.481.898
669 T-4-12-III
LAIN (BERAT)
2.766.850 3.320.220 3.873.590
673 U-1-11-I
(RINGAN)
4.475.568 5.370.681 6.265.795
674 U-1-11-II
(SEDANG)
5.888.027 7.065.633 8.243.238
675 U-1-11-III
(BERAT)
11.129.537 13.355.444 15.581.352
682 U-1-14-I
MULUT (RINGAN)
2.390.798 2.868.958 3.347.117
683 U-1-14-II
MULUT (SEDANG)
2.933.990 3.520.788 4.107.586
684 U-1-14-III
MULUT (BERAT)
3.476.861 4.172.233 4.867.605
688 U-1-20-I
3.630.177 4.356.212 5.082.248
689 U-1-20-II
6.236.017 7.483.220 8.730.424
690 U-1-20-III
10.881.545 13.057.854 15.234.163
694 U-4-10-I
TELINGA RINGAN
2.907.596 3.489.115 4.070.634
695 U-4-10-II
TELINGA SEDANG
5.515.035 6.618.043 7.721.050
696 U-4-10-III
TELINGA BERAT
8.467.390 10.160.868 11.854.346
703 U-4-13-I
1.345.790 1.614.948 1.884.106
704 U-4-13-II
1.535.342 1.842.411 2.149.479
705 U-4-13-III
2.043.438 2.452.126 2.860.814
709 U-4-15-I
1.340.036 1.608.043 1.876.050
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
710 U-4-15-II
1.699.435 2.039.323 2.379.210
711 U-4-15-III
2.357.718 2.829.262 3.300.805
712 V-1-10-I
RINGAN
3.975.752 4.770.903 5.566.053
713 V-1-10-II
SEDANG
4.531.392 5.437.670 6.343.949
718 V-1-12-I
MODERAT (RINGAN)
2.925.394 3.510.473 4.095.552
719 V-1-12-II
MODERAT (SEDANG)
8.205.247 9.846.297 11.487.346
720 V-1-12-III
MODERAT (BERAT)
8.846.980 10.616.376 12.385.773
721 V-1-13-I
KOMPLEK (RINGAN)
4.433.070 5.319.684 6.206.299
722 V-1-13-II
KOMPLEK (SEDANG)
7.400.595 8.880.714 10.360.833
723 V-1-13-III
KOMPLEK (BERAT)
8.864.307 10.637.168 12.410.030
724 V-1-14-I
RINGAN
5.343.858 6.412.629 7.481.401
725 V-1-14-II
SEDANG
6.603.496 7.924.195 9.244.894
726 V-1-14-III
BERAT
8.044.194 9.653.033 11.261.871
733 V-4-11-I
TUMOR (RINGAN)
1.932.722 2.319.266 2.705.811
734 V-4-11-II
TUMOR (SEDANG)
2.713.493 3.256.191 3.798.890
735 V-4-11-III
TUMOR (BERAT)
4.058.498 4.870.197 5.681.897
736 W-1-01-I
6.058.096 7.269.715 8.481.335
737 W-1-01-II
7.310.617 8.772.741 10.234.864
738 W-1-01-III
12.144.102 14.572.923 17.001.743
742 W-1-11-I
RINGAN
2.573.594 3.088.313 3.603.032
743 W-1-11-II
SEDANG
4.524.671 5.429.606 6.334.540
744 W-1-11-III
BERAT
9.527.684 11.433.220 13.338.757
No
Kode INA-
CBG
Rumah Sakit Kelas D
Rawat Inap
745 W-1-12-I
1.599.196 1.919.035 2.238.874
746 W-1-12-II
1.808.808 2.170.570 2.532.331
747 W-1-12-III
2.778.557 3.334.269 3.889.980
748 W-1-13-I
RINGAN
1.586.011 1.903.213 2.220.415
749 W-1-13-II
SEDANG
1.721.951 2.066.341 2.410.731
763 W-4-12-I
1.347.925 1.617.510 1.887.095
764 W-4-12-II
2.042.307 2.450.768 2.859.230
765 W-4-12-III
2.464.452 2.957.343 3.450.233
787 Z-4-12-I
1.011.522 1.213.827 1.416.131
788 Z-4-12-II
2.464.744 2.957.693 3.450.642
789 Z-4-12-III
3.125.810 3.750.972 4.376.134
24 D-2-11-0 PROSEDUR LIMPA 1.263.332
33 F-3-10-0 TERAPI SHOCK 248.139
Rumah Sakit Kelas D
Rawat Jalan
Rumah Sakit Kelas D
Rawat Jalan
72 I-2-16-0
80 I-2-42-0
Rumah Sakit Kelas D
Rawat Jalan
179 O-7-12-0
PELEBARAN DAN KURETASE 879.645
Rumah Sakit Kelas D
Rawat Jalan
191 Q-5-12-0 GIGI 124.494
195 Q-5-16-0 VAKSINASI 99.481
196 Q-5-17-0 PASANG INFUS 85.643
200 Q-5-21-0 ABORSI 66.690
205 Q-5-26-0 BRONKIAL AKUT 192.218
210 Q-5-31-0 FRAKTUR 130.244
214 Q-5-35-0 INFEKSI AKUT 254.607
217 Q-5-38-0 PARU AKUT 200.890
Rumah Sakit Kelas D
Rawat Jalan
269 Z-3-11-0
EMPEDU 1.429.694
276 Z-3-18-0 CT-SCAN KEPALA 244.162
288 Z-3-30-0 FOTOTERAPI 74.905
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 2.867.929
2 2.867.929
1 2.867.929
3 4.399.047
2 4.399.047
1 4.399.047
3 4.399.047
2 4.399.047
1 4.399.047
3 4.399.047
2 4.399.047
1 4.399.047
3 2.855.619
2 2.855.619
1 2.855.619
3 12.566.180
2 12.566.180
1 12.566.180
3 20.293.211
2 20.293.211
1 20.293.211
3 14.617.874
2 14.617.874
1 14.617.874
3 14.977.058
2 14.977.058
1 14.977.058
3 46.278.034
2 46.278.034
1 46.278.034
3 7.221.893
2 7.221.893
1 7.221.893
3 23.139.017
2 23.139.017
1 23.139.017
3 21.447.727
2 21.447.727
1 21.447.727
Tarif INA-CBG 2013
Top Up Special CMG
RS Umum Rujukan Nasional
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR01 Subdural grid electrode
RR02 Cote graft
RR03 TMJ Prothesis
RR04 Liquid Embolic (for AVM)
RR05 Hip Implant/ knee implant
YY01 Tumor pineal - Endoskopy
YY02 Hip Replacement / knee replacement
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Tarif INA-CBG 2013
Top Up Special CMG
RS Umum Rujukan Nasional
3 6.957.377
2 6.957.377
1 6.957.377
3 11.212.929
2 11.212.929
1 11.212.929
3 45.307.026
2 45.307.026
1 45.307.026
3 5.834.889
2 5.834.889
1 5.834.889
3 28.559.587
2 28.559.587
1 28.559.587
3 33.130.019
2 33.130.019
1 33.130.019
3 10.229.736
2 10.229.736
1 10.229.736
3 11.768.421
2 11.768.421
1 11.768.421
3 6.957.377
2 6.957.377
1 6.957.377
YY13 Phacoemulsification 0 4.174.426
YY14 Microlaringoscopy 0 1.742.897
YY15 Cholangiograph 0 6.355.624
II01 Other CT Scan 0 1.259.967
II02 Nuclear Medicine 0 1.256.454
II03 MRI 0 2.992.829
II04 Diagnostic and Imaging Procedure of Eye 0 876.612
YY07 Stereotactic Surgery & Radiotheraphy
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY06 Repair of septal defect of heart with prosthesis
YY12 Vitrectomy
YY09 Lobektomi / bilobektomi
YY10 Air plumbage
YY11 Timektomi
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 5.315.366 6.378.439 7.441.512
8 A-4-12-II DEMAM SEDANG 6.619.751 7.943.701 9.267.651
9 A-4-12-III DEMAM BERAT 8.019.433 9.623.319 11.227.206
46 B-4-13-I
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU HEPATITIS ALKOHOLIK
RINGAN
8.675.369 10.410.443 12.145.517
47 B-4-13-II
SEDANG
10.228.747 12.274.497 14.320.246
48 B-4-13-III
BERAT
14.616.991 17.540.390 20.463.788
Tarif INA-CBG 2013
Rumah Sakit Umum Rujukan Nasional
Rawat Inap
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
73 D-1-20-I
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK DARAH LAIN-LAIN
(RINGAN)
11.768.421 14.122.105 16.475.789
74 D-1-20-II
(SEDANG)
34.596.698 41.516.037 48.435.377
75 D-1-20-III
(BERAT)
54.276.992 65.132.391 75.987.789
85 D-4-13-I
RINGAN
5.865.396 7.038.475 8.211.555
86 D-4-13-II
SEDANG
8.235.886 9.883.063 11.530.241
87 D-4-13-III
BERAT
10.246.626 12.295.951 14.345.276
88 D-4-14-I
GANGGUAN PADA DARAH & ORGAN PEMBENTUK DARAH LAIN-LAIN
(RINGAN)
7.263.268 8.715.921 10.168.575
89 D-4-14-II
(SEDANG)
13.406.941 16.088.329 18.769.717
90 D-4-14-III
(BERAT)
16.710.628 20.052.753 23.394.879
97 E-1-20-I
RINGAN
15.943.933 19.132.719 22.321.506
98 E-1-20-II
SEDANG
22.826.555 27.391.866 31.957.177
99 E-1-20-III
BERAT
38.535.006 46.242.007 53.949.008
100 E-4-10-I
RINGAN
7.318.181 8.781.818 10.245.454
101 E-4-10-II
SEDANG
10.689.196 12.827.036 14.964.875
102 E-4-10-III PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK BERAT 16.260.406 19.512.487 22.764.568
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
166 G-4-11-I TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF RINGAN 12.144.597 14.573.516 17.002.435
167 G-4-11-II TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF SEDANG 17.288.260 20.745.912 24.203.565
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
178 G-4-15-I
7.836.914 9.404.296 10.971.679
179 G-4-15-II
9.353.392 11.224.070 13.094.749
180 G-4-15-III
13.733.133 16.479.760 19.226.387
190 G-4-19-I
7.531.786 9.038.143 10.544.500
191 G-4-19-II
11.951.699 14.342.039 16.732.379
192 G-4-19-III
17.954.089 21.544.907 25.135.725
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
235 I-1-03-I
ANOMALI RINGAN
40.586.421 48.703.705 56.820.989
236 I-1-03-II
ANOMALI SEDANG
49.287.555 59.145.066 69.002.577
237 I-1-03-III
ANOMALI BERAT
76.557.696 91.869.235 107.180.774
238 I-1-04-I PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG RINGAN 47.894.985 57.473.982 67.052.979
239 I-1-04-II PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG SEDANG 75.591.150 90.709.380 105.827.610
240 I-1-04-III PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG BERAT 120.756.420 144.907.704 169.058.988
241 I-1-05-I
82.387.646 98.865.175 115.342.705
242 I-1-05-II
98.865.175 118.638.210 138.411.245
243 I-1-05-III
136.037.857 163.245.429 190.453.000
247 I-1-07-I
59.170.604 71.004.725 82.838.846
248 I-1-07-II
72.998.960 87.598.752 102.198.544
249 I-1-07-III
79.641.391 95.569.669 111.497.948
250 I-1-11-I
9.120.992 10.945.190 12.769.388
251 I-1-11-II
10.141.631 12.169.957 14.198.283
252 I-1-11-III
13.495.419 16.194.503 18.893.587
259 I-1-14-I PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN RINGAN 64.079.280 76.895.136 89.710.992
260 I-1-14-II PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN SEDANG 79.641.391 95.569.669 111.497.948
261 I-1-14-III PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN BERAT 104.357.685 125.229.222 146.100.759
265 I-1-16-I
27.462.549 32.955.058 38.447.568
266 I-1-16-II
71.402.627 85.683.152 99.963.677
267 I-1-16-III
82.361.178 98.833.413 115.305.649
268 I-1-17-I PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA RINGAN 34.952.758 41.943.310 48.933.861
269 I-1-17-II PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA SEDANG 43.764.132 52.516.959 61.269.785
274 I-1-30-I
JANTUNG RINGAN
64.165.611 76.998.733 89.831.855
275 I-1-30-II
JANTUNG SEDANG
70.582.172 84.698.606 98.815.040
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
276 I-1-30-III
JANTUNG BERAT
100.434.464 120.521.357 140.608.249
319 I-4-23-I
6.402.332 7.682.799 8.963.265
320 I-4-23-II
7.860.589 9.432.706 11.004.824
321 I-4-23-III
15.358.874 18.430.648 21.502.423
325 J-1-01-I
PROSEDUR VENTILASI MEKANIKAL LONG TERM DENGAN TRAKEOSTOMI
RINGAN
81.248.945 97.498.734 113.748.523
326 J-1-01-II
SEDANG
90.276.606 108.331.927 126.387.248
327 J-1-01-III
BERAT
100.307.340 120.368.808 140.430.276
328 J-1-02-I
PROSEDUR VENTILASI MEKANIKAL LONG TERM TANPA TRAKEOSTOMI
RINGAN
43.115.926 51.739.111 60.362.296
329 J-1-02-II
SEDANG
58.942.904 70.731.485 82.520.066
330 J-1-02-III
BERAT
95.596.715 114.716.058 133.835.401
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
373 J-4-21-I
(RINGAN)
5.842.937 7.011.525 8.180.112
374 J-4-21-II
(SEDANG)
11.706.710 14.048.052 16.389.394
375 J-4-21-III
(BERAT)
16.748.690 20.098.428 23.448.165
382 K-1-12-I PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (RINGAN) 7.468.984 8.962.781 10.456.577
383 K-1-12-II PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (SEDANG) 9.777.912 11.733.494 13.689.076
384 K-1-12-III PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (BERAT) 19.465.102 23.358.122 27.251.143
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
394 K-1-30-I
(RINGAN)
17.558.475 21.070.170 24.581.865
395 K-1-30-II
(SEDANG)
31.564.070 37.876.885 44.189.699
396 K-1-30-III
(BERAT)
50.628.064 60.753.676 70.879.289
412 K-4-13-I
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT PERADANGAN USUS
BESAR (RINGAN)
8.528.341 10.234.010 11.939.678
413 K-4-13-II
BESAR (SEDANG)
11.269.895 13.523.874 15.777.853
414 K-4-13-III
BESAR (BERAT)
16.873.176 20.247.811 23.622.446
436 L-1-40-I
RINGAN
12.711.722 15.254.067 17.796.411
437 L-1-40-II
SEDANG
19.106.560 22.927.872 26.749.184
438 L-1-40-III
BERAT
35.178.553 42.214.264 49.249.974
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
451 L-4-13-I
RINGAN
5.322.392 6.386.870 7.451.349
452 L-4-13-II
SEDANG
6.545.977 7.855.173 9.164.368
453 L-4-13-III TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA BERAT 9.392.198 11.270.638 13.149.077
457 M-1-01-I
PROSEDUR BILATERAL DAN MULTIPLE SENDI ANGGOTA TUBUH BAWAH
MAYOR (RINGAN)
25.355.910 30.427.091 35.498.273
458 M-1-01-II
MAYOR (SEDANG)
28.301.297 33.961.556 39.621.816
459 M-1-01-III
MAYOR (BERAT)
39.755.655 47.706.785 55.657.916
463 M-1-03-I
BELAKANG RINGAN
51.260.574 61.512.688 71.764.803
464 M-1-03-II
BELAKANG SEDANG
59.956.668 71.948.001 83.939.335
465 M-1-03-III
BELAKANG BERAT
61.111.174 73.333.409 85.555.644
466 M-1-04-I
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA TUBUH BAGIAN BAWAH
MAYOR (RINGAN)
46.278.034 55.533.641 64.789.248
467 M-1-04-II
MAYOR (SEDANG)
50.905.837 61.087.005 71.268.172
468 M-1-04-III
MAYOR (BERAT)
55.996.421 67.195.705 78.394.990
469 M-1-05-I
PROSEDUR PADA SENDI LENGAN/ANGGOTA TUBUH BAGIAN BAWAH
MAYOR (RINGAN)
17.362.295 20.834.755 24.307.214
470 M-1-05-II
MAYOR (SEDANG)
20.024.449 24.029.338 28.034.228
471 M-1-05-III
MAYOR (BERAT)
34.107.090 40.928.507 47.749.925
472 M-1-07-I
BELAKANG RINGAN
20.371.526 24.445.831 28.520.136
473 M-1-07-II
BELAKANG SEDANG
27.291.478 32.749.774 38.208.069
474 M-1-07-III
BELAKANG BERAT
55.595.329 66.714.394 77.833.460
478 M-1-20-I PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR RINGAN 19.635.616 23.562.739 27.489.862
479 M-1-20-II PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR SEDANG 21.599.178 25.919.013 30.238.849
480 M-1-20-III PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR BERAT 40.383.411 48.460.093 56.536.776
484 M-1-40-I
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI INTERNAL
RINGAN
8.603.831 10.324.598 12.045.364
485 M-1-40-II
INTERNAL SEDANG
15.714.710 18.857.652 22.000.594
486 M-1-40-III
INTERNAL BERAT
27.541.256 33.049.507 38.557.758
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
490 M-1-60-I
LAIN-LAIN (RINGAN)
14.617.874 17.541.448 20.465.023
491 M-1-60-II
LAIN-LAIN (SEDANG)
17.596.706 21.116.047 24.635.388
492 M-1-60-III
LAIN-LAIN (BERAT)
30.752.786 36.903.343 43.053.900
508 M-4-13-I
PATOLOGIS RINGAN
11.110.110 13.332.132 15.554.154
509 M-4-13-II
PATOLOGIS SEDANG
14.651.594 17.581.913 20.512.231
510 M-4-13-III
PATOLOGIS BERAT
30.378.129 36.453.755 42.529.380
526 M-4-19-I
6.564.707 7.877.649 9.190.590
527 M-4-19-II
11.057.069 13.268.483 15.479.897
528 M-4-19-III
21.595.275 25.914.329 30.233.384
529 M-4-20-I
5.610.185 6.732.223 7.854.260
530 M-4-20-II
8.215.072 9.858.086 11.501.100
531 M-4-20-III
9.181.322 11.017.587 12.853.851
532 M-4-21-I
LAIN-LAIN (RINGAN)
5.852.086 7.022.504 8.192.921
533 M-4-21-II
LAIN-LAIN (SEDANG)
7.869.067 9.442.881 11.016.694
534 M-4-21-III
LAIN-LAIN (BERAT)
15.840.296 19.008.355 22.176.414
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
541 N-1-12-I
DIALISIS RINGAN
10.185.624 12.222.749 14.259.874
542 N-1-12-II
DIALISIS SEDANG
28.309.052 33.970.863 39.632.673
543 N-1-12-III
DIALISIS BERAT
51.546.111 61.855.333 72.164.556
565 N-4-14-I
5.075.838 6.091.006 7.106.174
566 N-4-14-II
6.936.908 8.324.290 9.711.671
567 N-4-14-III
11.249.454 13.499.344 15.749.235
577 O-6-11-I
PROSEDUR PERSALINAN VAGINAL DENGAN STERILISASI &/ DILATASI &
KURET RINGAN
6.102.417 7.322.901 8.543.384
578 O-6-11-II
KURET SEDANG
8.072.156 9.686.587 11.301.018
579 O-6-11-III
KURET BERAT
13.770.123 16.524.147 19.278.172
580 O-6-12-I
5.472.443 6.566.932 7.661.420
581 O-6-12-II
6.572.390 7.886.868 9.201.347
582 O-6-12-III
8.257.267 9.908.720 11.560.173
586 P-8-01-I
130.674.375 156.809.250 182.944.126
587 P-8-01-II
161.689.099 194.026.919 226.364.738
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
588 P-8-01-III
189.777.676 227.733.211 265.688.746
589 P-8-02-I
183.428.086 220.113.703 256.799.320
590 P-8-02-II
210.410.895 252.493.074 294.575.253
591 P-8-02-III
240.409.492 288.491.390 336.573.289
592 P-8-03-I
8.055.035 9.666.042 11.277.049
593 P-8-03-II
11.220.535 13.464.642 15.708.749
594 P-8-03-III
17.717.587 21.261.105 24.804.622
595 P-8-04-I
73.746.433 88.495.719 103.245.006
596 P-8-04-II
95.500.373 114.600.448 133.700.523
597 P-8-04-III
136.923.498 164.308.197 191.692.897
598 P-8-05-I
40.053.159 48.063.791 56.074.423
599 P-8-05-II
56.820.882 68.185.059 79.549.235
600 P-8-05-III
83.717.942 100.461.531 117.205.119
601 P-8-06-I
7.894.284 9.473.141 11.051.998
602 P-8-06-II
16.558.054 19.869.665 23.181.276
603 P-8-06-III
30.869.942 37.043.931 43.217.919
604 P-8-07-I
11.250.277 13.500.333 15.750.388
605 P-8-07-II
31.625.578 37.950.694 44.275.810
606 P-8-07-III
41.858.854 50.230.625 58.602.395
607 P-8-08-I
8.404.395 10.085.274 11.766.153
608 P-8-08-II
11.915.225 14.298.270 16.681.315
609 P-8-08-III
16.299.274 19.559.129 22.818.984
610 P-8-10-I
PASIEN AKUT LAIN RINGAN
5.193.850 6.232.620 7.271.390
611 P-8-10-II
PASIEN AKUT LAIN SEDANG
9.251.414 11.101.697 12.951.979
612 P-8-10-III
PASIEN AKUT LAIN BERAT
18.163.252 21.795.902 25.428.553
622 P-8-14-I
HEREDITER RINGAN
8.009.741 9.611.689 11.213.637
623 P-8-14-II
HEREDITER SEDANG
16.315.075 19.578.090 22.841.105
624 P-8-14-III
HEREDITER BERAT
17.859.630 21.431.556 25.003.482
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
628 P-8-16-I
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL
RINGAN
5.441.029 6.529.235 7.617.440
629 P-8-16-II
SEDANG
7.735.243 9.282.292 10.829.341
630 P-8-16-III
BERAT
18.462.957 22.155.548 25.848.139
634 S-4-10-I
TEMPAT (RINGAN)
5.190.878 6.229.054 7.267.229
635 S-4-10-II
TEMPAT (SEDANG)
7.320.503 8.784.603 10.248.704
636 S-4-10-III
TEMPAT (BERAT)
9.036.071 10.843.285 12.650.499
646 S-4-14-I
RINGAN
3.168.750 3.802.500 4.436.250
647 S-4-14-II
SEDANG
6.731.487 8.077.785 9.424.082
648 S-4-14-III
BERAT
12.765.298 15.318.358 17.871.418
649 S-4-15-I
(RINGAN)
2.396.555 2.875.866 3.355.176
650 S-4-15-II
(SEDANG)
4.523.115 5.427.738 6.332.361
651 S-4-15-III
(BERAT)
5.858.485 7.030.182 8.201.879
655 S-4-17-I
RINGAN
5.415.987 6.499.184 7.582.381
656 S-4-17-II
SEDANG
7.331.746 8.798.095 10.264.444
657 S-4-17-III
BERAT
10.859.327 13.031.192 15.203.057
661 T-4-10-I
2.191.376 2.629.651 3.067.927
662 T-4-10-II
4.176.277 5.011.533 5.846.788
663 T-4-10-III
6.071.173 7.285.408 8.499.643
664 T-4-11-I
KOKAIN RINGAN
2.507.596 3.009.115 3.510.635
665 T-4-11-II
KOKAIN SEDANG
3.946.243 4.735.491 5.524.740
666 T-4-11-III
KOKAIN BERAT
6.356.235 7.627.481 8.898.728
667 T-4-12-I PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (RINGAN) 5.122.897 6.147.476 7.172.056
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
668 T-4-12-II PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (SEDANG) 7.730.488 9.276.586 10.822.684
682 U-1-14-I
(RINGAN)
8.960.876 10.753.051 12.545.226
683 U-1-14-II
(SEDANG)
10.996.797 13.196.156 15.395.515
684 U-1-14-III PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT (BERAT) 13.031.514 15.637.816 18.244.119
688 U-1-20-I
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN TELINGA LAIN-LAIN
(RINGAN)
13.588.640 16.306.368 19.024.096
689 U-1-20-II
(SEDANG)
23.772.560 28.527.072 33.281.584
690 U-1-20-III
(BERAT)
47.429.738 56.915.686 66.401.633
703 U-4-13-I
5.700.375 6.840.451 7.980.526
704 U-4-13-II
6.669.627 8.003.552 9.337.478
705 U-4-13-III
7.789.870 9.347.843 10.905.817
709 U-4-15-I
(RINGAN)
5.832.997 6.999.596 8.166.196
710 U-4-15-II
(SEDANG)
7.316.218 8.779.462 10.242.706
711 U-4-15-III
(BERAT)
10.242.080 12.290.496 14.338.912
718 V-1-12-I
(RINGAN)
10.942.908 13.131.490 15.320.071
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
719 V-1-12-II
(SEDANG)
33.976.051 40.771.261 47.566.472
720 V-1-12-III
(BERAT)
39.627.950 47.553.540 55.479.129
721 V-1-13-I PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (RINGAN) 16.547.406 19.856.887 23.166.368
722 V-1-13-II PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (SEDANG) 28.212.092 33.854.511 39.496.929
733 V-4-11-I DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (RINGAN) 7.367.804 8.841.365 10.314.925
734 V-4-11-II DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (SEDANG) 10.344.211 12.413.053 14.481.895
736 W-1-01-I
PROSEDUR OPERASI PENGANGKATAN RAHIM DAN VULVA RADIKAL &
EVISCERASI RINGAN
22.689.138 27.226.966 31.764.794
737 W-1-01-II
EVISCERASI SEDANG
27.414.698 32.897.638 38.380.578
738 W-1-01-III
EVISCERASI BERAT
49.005.969 58.807.163 68.608.356
745 W-1-12-I
PROSEDUR OPERASI MEMBUKA TUBA YANG TERHALANG/TERGANGGU
RINGAN
5.946.752 7.136.102 8.325.453
746 W-1-12-II
SEDANG
6.786.838 8.144.205 9.501.573
747 W-1-12-III
BERAT
10.425.438 12.510.526 14.595.613
763 W-4-12-I
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI WANITA LAIN-LAIN
(RINGAN)
5.841.957 7.010.349 8.178.740
764 W-4-12-II
(SEDANG)
8.045.075 9.654.090 11.263.105
765 W-4-12-III
(BERAT)
9.209.410 11.051.291 12.893.173
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
787 Z-4-12-I
LAIN (RINGAN)
4.395.014 5.274.016 6.153.019
788 Z-4-12-II
LAIN (SEDANG)
9.179.948 11.015.938 12.851.928
789 Z-4-12-III
LAIN (BERAT)
13.225.367 15.870.440 18.515.514
No
Kode INA-
CBG
6 B-3-10-0 PROSEDUR PADA PERKUTAN HATI & SALURAN EMPEDU 1.426.504
15 C-3-16-0 KEMOTERAPI PADA TUMOR OTAK 1.002.757
24 D-2-11-0 PROSEDUR LIMPA 4.175.775
31 E-2-22-0
THYROGLOSSAL
581.661
33 F-3-10-0 TERAPI SHOCK 943.206
34 F-5-10-0 PELAYANAN KESEHATAN MENTAL EKSTENSIF 1.157.867
40 F-5-16-0
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN
MENTAL
544.593
Tarif INA-CBG 2013
Rawat Jalan
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
50 G-3-11-0 PROSEDUR INJEKSI PADA SARAF PERIFER 1.045.986
63 H-3-10-0 PROSEDUR LASER SEDANG PADA MATA 1.348.503
67 I-2-11-0
PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM
BANTU JANTUNG
7.196.575
70 I-2-14-0
JANTUNG
11.381.371
72 I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK
TERMASUK PENGGANTIAN ALAT
7.188.776
76 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH 1.229.562
80 I-2-42-0
7.991.708
81 I-3-10-0 PROSEDUR RESUSITASI 1.008.147
84 I-3-13-0 PROSEDUR EKOKARDIOGRAFI 1.021.989
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
102 K-2-12-0
FEMORALIS
2.932.927
112 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM 1.069.298
114 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL 1.068.611
120 K-3-16-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL 1.001.270
124 L-2-32-0 PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR 1.003.157
128 L-2-52-0
PAYUDARA
3.667.358
129 L-2-53-0
PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN
PAYUDARA
715.021
135 M-2-22-0 PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA 1.002.256
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
157 M-3-14-0 PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP 1.164.174
162 N-2-12-0
DIALISIS
5.215.905
163 N-2-21-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN
KEMIH
5.448.140
166 N-2-24-0 PROSEDUR KECIL PADA GINJAL DAN URETER 3.455.612
168 N-2-32-0 PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA 1.006.864
170 N-2-42-0 PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA 1.692.647
171 N-3-10-0 PROSEDUR PADA GINJAL DAN URETER 1.006.597
172 N-3-11-0 PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH 1.163.646
173 N-3-12-0
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN
KEMIH
901.057
174 N-3-13-0 PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH 1.069.298
178 O-7-11-0
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN
DAN KURETASE
3.661.450
179 O-7-12-0
3.283.466
181 P-9-10-0
PASIEN AKUT LAIN
585.521
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
185 P-9-14-0
HEREDITER
547.522
191 Q-5-12-0 GIGI 474.593
195 Q-5-16-0 VAKSINASI 285.556
196 Q-5-17-0 PASANG INFUS 326.007
200 Q-5-21-0 ABORSI 371.619
205 Q-5-26-0 BRONKIAL AKUT 727.771
208 Q-5-29-0 GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN 1.199.361
209 Q-5-30-0 INFARK MIOKARD AKUT DAN ARITMIA 1.382.587
210 Q-5-31-0 FRAKTUR 492.558
214 Q-5-35-0 INFEKSI AKUT 968.569
215 Q-5-36-0 KEKACAUAN METABOLIK AKUT 1.120.386
217 Q-5-38-0 PARU AKUT 766.422
229 U-2-14-0 PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT 1.352.147
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
231 U-2-21-0
TENGGOROKAN
891.691
232 U-2-22-0
TENGGOROKAN
1.728.915
238 U-3-10-0
TENGGOROKAN
693.640
239 U-3-11-0
TENGGOROKAN
740.109
241 U-3-13-0
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT
DAN TENGGOROKAN
716.270
242 U-3-14-0
TENGGOROKAN
657.663
243 U-3-15-0
TENGGOROKAN
573.124
248 V-2-13-0 PROSEDUR KECIL PADA PROSTAT DAN SKROTUM 1.003.163
249 V-2-14-0 PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL 1.069.298
251 V-3-10-0 PROSEDUR STERILISASI PADA LAKI-LAKI 1.221.143
252 V-3-11-0
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-
LAKI
2.416.524
262 W-2-32-0
INTERMEDIATE
4.195.807
266 W-3-11-0 PROSEDUR SEDANG GINEKOLOGI 1.178.341
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI
DAN SALURAN EMPEDU
4.725.659
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
276 Z-3-18-0 CT-SCAN KEPALA 807.046
282 Z-3-24-0 PROSEDUR ULTRASOUND PEMBULUH DARAH 1.260.046
288 Z-3-30-0 FOTOTERAPI 283.451
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 2.547.318
2 2.547.318
1 2.547.318
3 3.323.015
2 3.323.015
1 3.323.015
3 3.323.015
2 3.323.015
1 3.323.015
3 3.323.015
2 3.323.015
1 3.323.015
3 2.534.057
2 2.534.057
1 2.534.057
3 10.032.070
2 10.032.070
1 10.032.070
3 20.293.211
2 20.293.211
1 20.293.211
3 7.800.717
2 7.800.717
1 7.800.717
3 9.008.608
2 9.008.608
1 9.008.608
3 12.100.048
2 12.100.048
1 12.100.048
3 6.383.729
2 6.383.729
1 6.383.729
3 6.050.024
2 6.050.024
1 6.050.024
3 21.447.727
2 21.447.727
1 21.447.727
Tarif INA-CBG 2013
Top Up Special CMG
RS Khusus Rujukan Nasional
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Tarif INA-CBG 2013
Top Up Special CMG
RS Khusus Rujukan Nasional
3 6.638.242
2 6.638.242
1 6.638.242
3 9.543.144
2 9.543.144
1 9.543.144
3 45.307.026
2 45.307.026
1 45.307.026
3 4.412.394
2 4.412.394
1 4.412.394
3 10.329.469
2 10.329.469
1 10.329.469
3 12.514.049
2 12.514.049
1 12.514.049
3 8.593.726
2 8.593.726
1 8.593.726
3 11.228.604
2 11.228.604
1 11.228.604
3 6.638.242
2 6.638.242
1 6.638.242
II01 Other CT Scan 0 1.309.216
II02 Nuclear Medicine 0 1.305.566
II03 MRI 0 3.109.811
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
No
Kode INA-
CBG
7 A-4-12-I DEMAM RINGAN 4.432.535 5.319.042 6.205.549
8 A-4-12-II DEMAM SEDANG 6.316.103 7.579.324 8.842.545
9 A-4-12-III DEMAM BERAT 6.741.482 8.089.778 9.438.074
46 B-4-13-I
ALKOHOLIK RINGAN
6.638.499 7.966.199 9.293.899
47 B-4-13-II
ALKOHOLIK SEDANG
8.660.203 10.392.244 12.124.284
48 B-4-13-III
ALKOHOLIK BERAT
13.946.511 16.735.813 19.525.115
Tarif INA-CBG 2013
Rumah Sakit Khusus Rujukan Nasional
Rawat Inap
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
73 D-1-20-I
(RINGAN)
11.228.604 13.474.325 15.720.046
74 D-1-20-II
(SEDANG)
29.378.677 35.254.412 41.130.148
75 D-1-20-III
(BERAT)
51.787.310 62.144.772 72.502.234
85 D-4-13-I
RINGAN
4.430.686 5.316.823 6.202.960
86 D-4-13-II
SEDANG
6.647.958 7.977.550 9.307.141
87 D-4-13-III
BERAT
8.214.540 9.857.448 11.500.356
88 D-4-14-I
(RINGAN)
5.544.082 6.652.898 7.761.714
89 D-4-14-II
(SEDANG)
11.370.636 13.644.763 15.918.890
90 D-4-14-III
(BERAT)
14.859.912 17.831.895 20.803.877
97 E-1-20-I
RINGAN
15.060.459 18.072.551 21.084.643
98 E-1-20-II
SEDANG
20.161.597 24.193.916 28.226.235
99 E-1-20-III
BERAT
36.767.408 44.120.889 51.474.371
100 E-4-10-I
RINGAN
6.186.817 7.424.180 8.661.544
101 E-4-10-II
SEDANG
9.482.205 11.378.646 13.275.087
102 E-4-10-III
BERAT
13.070.860 15.685.032 18.299.204
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
166 G-4-11-I TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF RINGAN 10.486.448 12.583.737 14.681.027
167 G-4-11-II TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF SEDANG 15.290.834 18.349.001 21.407.167
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
178 G-4-15-I
6.654.917 7.985.901 9.316.884
179 G-4-15-II
8.433.513 10.120.216 11.806.918
180 G-4-15-III
10.358.257 12.429.909 14.501.560
190 G-4-19-I
6.645.217 7.974.260 9.303.304
191 G-4-19-II
11.403.476 13.684.171 15.964.866
192 G-4-19-III
14.335.177 17.202.212 20.069.247
235 I-1-03-I
ANOMALI RINGAN
40.586.421 48.703.705 56.820.989
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
236 I-1-03-II
ANOMALI SEDANG
49.287.555 59.145.066 69.002.577
237 I-1-03-III
ANOMALI BERAT
76.557.696 91.869.235 107.180.774
238 I-1-04-I
RINGAN
47.894.985 57.473.982 67.052.979
239 I-1-04-II
SEDANG
75.591.150 90.709.380 105.827.610
240 I-1-04-III PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG BERAT 120.756.420 144.907.704 169.058.988
241 I-1-05-I
70.118.809 84.142.570 98.166.332
242 I-1-05-II
84.142.570 100.971.084 117.799.598
243 I-1-05-III
127.201.853 152.642.223 178.082.594
247 I-1-07-I
57.494.732 68.993.678 80.492.624
248 I-1-07-II
70.931.431 85.117.717 99.304.004
249 I-1-07-III
107.431.657 128.917.989 150.404.320
250 I-1-11-I
7.406.479 8.887.774 10.369.070
251 I-1-11-II
8.235.263 9.882.316 11.529.369
252 I-1-11-III
10.958.626 13.150.351 15.342.076
259 I-1-14-I
RINGAN
54.536.851 65.444.221 76.351.591
260 I-1-14-II
SEDANG
67.781.515 81.337.818 94.894.121
261 I-1-14-III PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN BERAT 88.817.157 106.580.589 124.344.020
265 I-1-16-I
23.372.936 28.047.523 32.722.111
266 I-1-16-II
60.769.634 72.923.561 85.077.488
267 I-1-16-III
70.096.282 84.115.538 98.134.794
268 I-1-17-I PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA RINGAN 34.952.758 41.943.310 48.933.861
269 I-1-17-II PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA SEDANG 43.764.132 52.516.959 61.269.785
274 I-1-30-I
JANTUNG RINGAN
72.831.791 87.398.150 101.964.508
275 I-1-30-II
JANTUNG SEDANG
87.810.968 105.373.162 122.935.356
276 I-1-30-III
JANTUNG BERAT
95.827.541 114.993.049 134.158.557
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
319 I-4-23-I
5.448.923 6.538.707 7.628.492
320 I-4-23-II
6.690.021 8.028.026 9.366.030
321 I-4-23-III
13.071.692 15.686.030 18.300.368
325 J-1-01-I
TRAKEOSTOMI RINGAN
81.248.945 97.498.734 113.748.523
326 J-1-01-II
TRAKEOSTOMI SEDANG
90.276.606 108.331.927 126.387.248
327 J-1-01-III
TRAKEOSTOMI BERAT
100.307.340 120.368.808 140.430.276
328 J-1-02-I
RINGAN
43.115.926 51.739.111 60.362.296
329 J-1-02-II
SEDANG
58.942.904 70.731.485 82.520.066
330 J-1-02-III
BERAT
95.596.715 114.716.058 133.835.401
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
373 J-4-21-I
(RINGAN)
4.781.912 5.738.294 6.694.676
374 J-4-21-II
(SEDANG)
8.857.395 10.628.874 12.400.353
375 J-4-21-III
(BERAT)
12.675.694 15.210.833 17.745.971
382 K-1-12-I
(RINGAN)
6.628.115 7.953.738 9.279.361
383 K-1-12-II
(SEDANG)
8.660.202 10.392.242 12.124.283
384 K-1-12-III PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (BERAT) 17.230.402 20.676.483 24.122.563
394 K-1-30-I
(RINGAN)
15.538.226 18.645.871 21.753.517
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
395 K-1-30-II
(SEDANG)
23.845.875 28.615.050 33.384.225
396 K-1-30-III
(BERAT)
44.714.439 53.657.327 62.600.215
412 K-4-13-I
BESAR (RINGAN)
6.639.912 7.967.894 9.295.877
413 K-4-13-II
BESAR (SEDANG)
8.602.357 10.322.828 12.043.299
414 K-4-13-III
BESAR (BERAT)
14.086.804 16.904.164 19.721.525
436 L-1-40-I
RINGAN
9.982.853 11.979.424 13.975.994
437 L-1-40-II
SEDANG
18.230.143 21.876.172 25.522.200
438 L-1-40-III
BERAT
34.303.283 41.163.940 48.024.596
451 L-4-13-I
RINGAN
4.976.689 5.972.027 6.967.365
452 L-4-13-II
SEDANG
5.790.863 6.949.036 8.107.208
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
453 L-4-13-III
BERAT
8.674.614 10.409.537 12.144.460
457 M-1-01-I
21.580.009 25.896.011 30.212.013
458 M-1-01-II
24.086.781 28.904.138 33.721.494
459 M-1-01-III
BAWAH MAYOR (BERAT)
33.835.402 40.602.482 47.369.563
463 M-1-03-I
BELAKANG RINGAN
38.666.478 46.399.774 54.133.070
464 M-1-03-II
BELAKANG SEDANG
45.313.537 54.376.245 63.438.952
465 M-1-03-III
BELAKANG BERAT
52.804.780 63.365.736 73.926.693
466 M-1-04-I
MAYOR (RINGAN)
12.100.048 14.520.058 16.940.068
467 M-1-04-II
MAYOR (SEDANG)
15.548.462 18.658.154 21.767.847
468 M-1-04-III
MAYOR (BERAT)
19.455.969 23.347.163 27.238.357
469 M-1-05-I
MAYOR (RINGAN)
15.344.215 18.413.058 21.481.901
470 M-1-05-II
MAYOR (SEDANG)
16.260.365 19.512.437 22.764.510
471 M-1-05-III
MAYOR (BERAT)
27.695.829 33.234.995 38.774.161
472 M-1-07-I
BELAKANG RINGAN
17.337.880 20.805.456 24.273.032
473 M-1-07-II
BELAKANG SEDANG
23.227.341 27.872.809 32.518.277
474 M-1-07-III
BELAKANG BERAT
47.316.295 56.779.555 66.242.814
478 M-1-20-I
RINGAN
12.878.500 15.454.200 18.029.900
479 M-1-20-II
SEDANG
14.596.115 17.515.338 20.434.561
480 M-1-20-III PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR BERAT 35.805.661 42.966.794 50.127.926
484 M-1-40-I
INTERNAL RINGAN
7.630.398 9.156.478 10.682.557
485 M-1-40-II
INTERNAL SEDANG
12.557.372 15.068.847 17.580.321
486 M-1-40-III
INTERNAL BERAT
20.826.665 24.991.998 29.157.331
490 M-1-60-I
LAIN-LAIN (RINGAN)
7.800.717 9.360.861 10.921.004
491 M-1-60-II
LAIN-LAIN (SEDANG)
15.613.396 18.736.075 21.858.754
492 M-1-60-III
LAIN-LAIN (BERAT)
27.168.664 32.602.397 38.036.130
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
508 M-4-13-I
PATOLOGIS RINGAN
9.848.197 11.817.837 13.787.476
509 M-4-13-II
PATOLOGIS SEDANG
11.048.335 13.258.002 15.467.669
510 M-4-13-III
PATOLOGIS BERAT
28.984.686 34.781.623 40.578.560
526 M-4-19-I
5.780.253 6.936.303 8.092.354
527 M-4-19-II
9.735.797 11.682.956 13.630.116
528 M-4-19-III
16.581.106 19.897.327 23.213.548
529 M-4-20-I
4.432.157 5.318.588 6.205.020
530 M-4-20-II
6.646.833 7.976.200 9.305.567
531 M-4-20-III
7.358.548 8.830.257 10.301.967
532 M-4-21-I
LAIN-LAIN (RINGAN)
4.433.486 5.320.183 6.206.881
533 M-4-21-II
LAIN-LAIN (SEDANG)
6.962.069 8.354.483 9.746.897
534 M-4-21-III
LAIN-LAIN (BERAT)
15.113.702 18.136.443 21.159.183
541 N-1-12-I
DIALISIS RINGAN
8.960.374 10.752.449 12.544.524
542 N-1-12-II
DIALISIS SEDANG
25.078.857 30.094.628 35.110.399
543 N-1-12-III
DIALISIS BERAT
45.695.397 54.834.476 63.973.555
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
565 N-4-14-I
3.834.050 4.600.860 5.367.669
566 N-4-14-II
5.903.892 7.084.670 8.265.448
567 N-4-14-III
9.574.230 11.489.076 13.403.922
577 O-6-11-I
& KURET RINGAN
5.406.142 6.487.371 7.568.599
578 O-6-11-II
& KURET SEDANG
6.970.033 8.364.040 9.758.046
579 O-6-11-III
& KURET BERAT
12.152.115 14.582.538 17.012.961
580 O-6-12-I
4.443.764 5.332.516 6.221.269
581 O-6-12-II
5.336.949 6.404.339 7.471.729
582 O-6-12-III
6.705.112 8.046.134 9.387.156
586 P-8-01-I
111.214.872 133.457.846 155.700.821
587 P-8-01-II
137.611.007 165.133.209 192.655.410
588 P-8-01-III
161.516.746 193.820.095 226.123.445
589 P-8-02-I
162.139.639 194.567.567 226.995.494
590 P-8-02-II
185.990.855 223.189.026 260.387.197
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
591 P-8-02-III
212.507.850 255.009.421 297.510.991
592 P-8-03-I
6.061.843 7.274.212 8.486.581
593 P-8-03-II
8.494.477 10.193.373 11.892.268
594 P-8-03-III
14.672.162 17.606.595 20.541.027
595 P-8-04-I
65.249.536 78.299.443 91.349.350
596 P-8-04-II
84.907.065 101.888.478 118.869.891
597 P-8-04-III
121.735.360 146.082.431 170.429.503
598 P-8-05-I
35.436.584 42.523.900 49.611.217
599 P-8-05-II
50.326.619 60.391.942 70.457.266
600 P-8-05-III
74.149.517 88.979.420 103.809.323
601 P-8-06-I
6.102.992 7.323.591 8.544.189
602 P-8-06-II
14.563.261 17.475.913 20.388.565
603 P-8-06-III
26.181.280 31.417.536 36.653.792
604 P-8-07-I
9.448.512 11.338.215 13.227.917
605 P-8-07-II
23.782.721 28.539.265 33.295.810
606 P-8-07-III
31.679.843 38.015.812 44.351.781
607 P-8-08-I
7.378.595 8.854.314 10.330.033
608 P-8-08-II
10.482.303 12.578.764 14.675.224
609 P-8-08-III
15.551.627 18.661.953 21.772.278
610 P-8-10-I
4.578.756 5.494.507 6.410.259
611 P-8-10-II
8.177.706 9.813.247 11.448.788
612 P-8-10-III
16.055.246 19.266.296 22.477.345
622 P-8-14-I
HEREDITER RINGAN
7.076.723 8.492.067 9.907.412
623 P-8-14-II
HEREDITER SEDANG
14.460.309 17.352.371 20.244.433
624 P-8-14-III
HEREDITER BERAT
15.871.317 19.045.580 22.219.844
628 P-8-16-I
RINGAN
4.828.411 5.794.093 6.759.775
629 P-8-16-II
SEDANG
6.843.670 8.212.404 9.581.138
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
630 P-8-16-III
BERAT
18.462.957 22.155.548 25.848.139
634 S-4-10-I
TEMPAT (RINGAN)
4.432.732 5.319.278 6.205.824
635 S-4-10-II
TEMPAT (SEDANG)
5.540.945 6.649.134 7.757.322
636 S-4-10-III
TEMPAT (BERAT)
7.207.647 8.649.176 10.090.705
646 S-4-14-I
RINGAN
2.696.872 3.236.247 3.775.621
647 S-4-14-II
SEDANG
5.729.061 6.874.873 8.020.686
648 S-4-14-III
BERAT
10.864.341 13.037.210 15.210.078
649 S-4-15-I
(RINGAN)
2.039.669 2.447.603 2.855.537
650 S-4-15-II
(SEDANG)
3.849.551 4.619.461 5.389.371
651 S-4-15-III
(BERAT)
4.986.063 5.983.275 6.980.488
655 S-4-17-I
RINGAN
4.971.188 5.965.426 6.959.664
656 S-4-17-II
SEDANG
5.787.136 6.944.563 8.101.990
657 S-4-17-III
BERAT
9.024.614 10.829.537 12.634.459
661 T-4-10-I
1.865.045 2.238.054 2.611.063
662 T-4-10-II
3.554.363 4.265.235 4.976.108
663 T-4-10-III
5.167.079 6.200.494 7.233.910
664 T-4-11-I
KOKAIN RINGAN
2.212.397 2.654.876 3.097.355
665 T-4-11-II
KOKAIN SEDANG
3.481.683 4.178.019 4.874.356
666 T-4-11-III
KOKAIN BERAT
5.607.965 6.729.558 7.851.151
667 T-4-12-I PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (RINGAN) 3.860.515 4.632.618 5.404.721
668 T-4-12-II PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (SEDANG) 5.845.046 7.014.055 8.183.064
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
682 U-1-14-I
(RINGAN)
7.921.391 9.505.669 11.089.948
683 U-1-14-II
(SEDANG)
9.721.140 11.665.368 13.609.596
684 U-1-14-III
(BERAT)
11.519.824 13.823.789 16.127.754
688 U-1-20-I
LAIN (RINGAN)
12.010.827 14.412.992 16.815.158
689 U-1-20-II
LAIN (SEDANG)
21.185.095 25.422.113 29.659.132
690 U-1-20-III
LAIN (BERAT)
35.795.878 42.955.054 50.114.230
703 U-4-13-I
4.432.703 5.319.244 6.205.784
704 U-4-13-II
5.064.979 6.077.975 7.090.971
705 U-4-13-III
6.912.270 8.294.724 9.677.178
709 U-4-15-I
(RINGAN)
4.424.696 5.309.635 6.194.574
710 U-4-15-II
(SEDANG)
5.595.156 6.714.188 7.833.219
711 U-4-15-III
(BERAT)
7.738.048 9.285.657 10.833.267
718 V-1-12-I
(RINGAN)
9.682.824 11.619.389 13.555.954
719 V-1-12-II
(SEDANG)
26.963.187 32.355.824 37.748.461
720 V-1-12-III
(BERAT)
32.178.909 38.614.691 45.050.472
721 V-1-13-I PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (RINGAN) 14.691.029 17.629.235 20.567.441
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
722 V-1-13-II PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (SEDANG) 26.918.005 32.301.607 37.685.208
733 V-4-11-I DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (RINGAN) 6.840.037 8.208.045 9.576.052
734 V-4-11-II DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (SEDANG) 9.869.722 11.843.667 13.817.611
736 W-1-01-I
EVISCERASI RINGAN
20.102.076 24.122.491 28.142.906
737 W-1-01-II
EVISCERASI SEDANG
24.220.689 29.064.826 33.908.964
738 W-1-01-III
EVISCERASI BERAT
39.794.100 47.752.921 55.711.741
745 W-1-12-I
5.288.573 6.346.287 7.404.002
746 W-1-12-II
6.009.288 7.211.145 8.413.003
747 W-1-12-III
9.231.024 11.077.229 12.923.433
763 W-4-12-I
(RINGAN)
4.435.843 5.323.012 6.210.180
764 W-4-12-II
(SEDANG)
6.776.382 8.131.658 9.486.935
765 W-4-12-III
(BERAT)
8.173.655 9.808.387 11.443.118
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Inap
787 Z-4-12-I
LAIN (RINGAN)
3.318.001 3.981.601 4.645.202
788 Z-4-12-II
LAIN (SEDANG)
8.150.897 9.781.076 11.411.255
789 Z-4-12-III
LAIN (BERAT)
13.225.367 15.870.440 18.515.514
No
Kode INA-
CBG
6 B-3-10-0 PROSEDUR PADA PERKUTAN HATI & SALURAN EMPEDU 1.367.005
8 B-3-12-0
PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN
PANKREAS
721.030
14 C-3-15-0
KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU
PROSTAT
4.053.315
24 D-2-11-0 PROSEDUR LIMPA 4.338.996
28 D-3-11-0
PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK
DARAH
1.605.617
31 E-2-22-0
PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN
SALURAN THYROGLOSSAL
564.980
33 F-3-10-0 TERAPI SHOCK 910.775
34 F-5-10-0 PELAYANAN KESEHATAN MENTAL EKSTENSIF 1.117.719
40 F-5-16-0
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH
KESEHATAN MENTAL
524.220
Tarif INA-CBG 2013
Rawat Jalan
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
50 G-3-11-0 PROSEDUR INJEKSI PADA SARAF PERIFER 1.009.904
63 H-3-10-0 PROSEDUR LASER SEDANG PADA MATA 1.305.818
67 I-2-11-0
PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM
BANTU JANTUNG
7.477.872
70 I-2-14-0
PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN
PADA JANTUNG
11.826.242
72 I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG
TIDAK TERMASUK PENGGANTIAN ALAT
7.469.768
76 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH 1.190.512
77 I-2-31-0
PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR
JANTUNG
8.641.356
80 I-2-42-0
7.676.424
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
102 K-2-12-0
PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA
INGUINALIS DAN FEMORALIS
3.047.568
112 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM 1.111.094
114 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL 1.110.380
126 L-2-42-0
PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH
KULIT
767.090
128 L-2-52-0
PAYUDARA
3.810.706
129 L-2-53-0
PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN
PAYUDARA
692.135
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
157 M-3-14-0 PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP 1.123.954
159 M-3-16-0
PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL
MUSKULOSKLETAL
564.454
162 N-2-12-0
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN
ALAT DIALISIS
5.268.029
163 N-2-21-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA
SALURAN KEMIH
5.267.768
164 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 968.436
166 N-2-24-0 PROSEDUR KECIL PADA GINJAL DAN URETER 3.590.684
170 N-2-42-0 PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA 1.639.567
172 N-3-11-0 PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH 1.125.581
173 N-3-12-0
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI
SALURAN KEMIH
868.866
174 N-3-13-0 PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH 1.111.094
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
178 O-7-11-0
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU
3.203.684
179 O-7-12-0
2.269.778
181 P-9-10-0
PERAWATAN PASIEN AKUT LAIN
608.408
185 P-9-14-0
KONDISI HEREDITER
530.457
187 P-9-16-0
PERINATAL
531.157
191 Q-5-12-0 GIGI 457.779
195 Q-5-16-0 VAKSINASI 296.718
196 Q-5-17-0 PASANG INFUS 315.098
200 Q-5-21-0 ABORSI 355.774
205 Q-5-26-0 BRONKIAL AKUT 702.963
208 Q-5-29-0
GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-
LAIN
1.149.965
209 Q-5-30-0 INFARK MIOKARD AKUT DAN ARITMIA 1.335.813
210 Q-5-31-0 FRAKTUR 474.813
214 Q-5-35-0 INFEKSI AKUT 927.686
215 Q-5-36-0 KEKACAUAN METABOLIK AKUT 1.080.224
217 Q-5-38-0 PARU AKUT 737.678
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
229 U-2-14-0 PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT 1.298.560
231 U-2-21-0
TENGGOROKAN
860.157
232 U-2-22-0
TENGGOROKAN
1.659.805
238 U-3-10-0
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG,
MULUT DAN TENGGOROKAN
671.046
239 U-3-11-0
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT
DAN TENGGOROKAN
713.778
241 U-3-13-0
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG,
MULUT DAN TENGGOROKAN
692.685
242 U-3-14-0
TENGGOROKAN
636.421
243 U-3-15-0
TENGGOROKAN
552.453
249 V-2-14-0 PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL 1.111.094
251 V-3-10-0 PROSEDUR STERILISASI PADA LAKI-LAKI 1.268.874
252 V-3-11-0
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL
LAKI-LAKI
2.335.315
255 W-2-11-0
PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER
RAHIM
1.549.733
No
Kode INA-
CBG
Tarif INA-CBG 2013
Rawat Jalan
258 W-2-21-0
PROSEDUR BESAR PADA FRAKTUR RONGGA PANGGUL
TERBUKA
5.396.214
262 W-2-32-0
INTERMEDIATE
4.359.811
266 W-3-11-0 PROSEDUR SEDANG GINEKOLOGI 1.224.400
269 Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN
URINARI DAN SALURAN EMPEDU
4.910.374
276 Z-3-18-0 CT-SCAN KEPALA 838.592
282 Z-3-24-0 PROSEDUR ULTRASOUND PEMBULUH DARAH 1.309.298
288 Z-3-30-0 FOTOTERAPI 275.032
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.631.239
2 1.631.239
1 1.631.239
3 2.747.971
2 2.747.971
1 2.747.971
3 2.747.971
2 2.747.971
1 2.747.971
3 2.747.971
2 2.747.971
1 2.747.971
3 1.627.875
2 1.627.875
1 1.627.875
3 9.120.064
2 9.120.064
1 9.120.064
3 12.847.870
2 12.847.870
1 12.847.870
3 4.988.382
2 4.988.382
1 4.988.382
3 6.338.553
2 6.338.553
1 6.338.553
3 7.807.062
2 7.807.062
1 7.807.062
3 4.101.340
2 4.101.340
1 4.101.340
3 3.903.531
2 3.903.531
1 3.903.531
3 19.302.954
2 19.302.954
1 19.302.954
3 4.670.726
2 4.670.726
1 4.670.726
RR05
YY01
DD01
DD03
DD02
DD04
DD05
PCI
Keratoplasty
Subdural grid electrode
Cote graft
YY02
YY03
YY04
Hip Replacement / knee replacement
TMJ Prothesis
Liquid Embolic (for AVM)
Hip Implant/ knee implant
Streptokinase
Deferiprone
Deferoksamin
Deferasirox
Human Albumin
RS Kelas A
Top Up Special CMG
RR01
RR02
RR03
RR04
Tumor pineal - Endoskopy
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
RS Kelas A
Top Up Special CMG
3 7.527.158
2 7.527.158
1 7.527.158
3 40.776.323
2 40.776.323
1 40.776.323
3 3.786.769
2 3.786.769
1 3.786.769
3 9.390.426
2 9.390.426
1 9.390.426
3 12.125.411
2 12.125.411
1 12.125.411
3 6.622.782
2 6.622.782
1 6.622.782
3 8.334.933
2 8.334.933
1 8.334.933
3 4.670.726
2 4.670.726
1 4.670.726
II01 Other CT Scan 0 902.905
II02 Nuclear Medicine 0 900.388
II03 MRI 0 2.144.692
Torakotomi
Vitrectomy
Pancreatectomy
Repair of septal defect of heart with prosthesis
Lobektomi / bilobektomi
Air plumbage
Timektomi
Stereotactic Surgery & Radiotheraphy
YY10
YY11
YY12
YY13
YY05
YY06
YY09
YY08
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.253.662
2 1.253.662
1 1.253.662
3 1.470.229
2 1.470.229
1 1.470.229
3 1.470.229
2 1.470.229
1 1.470.229
3 1.470.229
2 1.470.229
1 1.470.229
3 1.143.801
2 1.143.801
1 1.143.801
3 3.052.060
2 3.052.060
1 3.052.060
3 7.014.040
2 7.014.040
1 7.014.040
3 3.835.377
2 3.835.377
1 3.835.377
3 4.463.864
2 4.463.864
1 4.463.864
3 5.978.542
2 5.978.542
1 5.978.542
3 3.042.306
2 3.042.306
1 3.042.306
3 2.989.271
2 2.989.271
1 2.989.271
3 15.598.347
2 15.598.347
1 15.598.347
3 3.008.837
2 3.008.837
1 3.008.837
Top Up Special CMG
RS Kelas B
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
YY04 Keratoplasty
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas B
3 4.109.511
2 4.109.511
1 4.109.511
3 32.621.059
2 32.621.059
1 32.621.059
3 1.954.338
2 1.954.338
1 1.954.338
3 3.618.147
2 3.618.147
1 3.618.147
3 6.209.543
2 6.209.543
1 6.209.543
3 4.244.754
2 4.244.754
1 4.244.754
3 4.313.098
2 4.313.098
1 4.313.098
3 3.008.837
2 3.008.837
1 3.008.837
YY15 Microlaringoscopy 0 473.304
II03 MRI 0 937.209
YY05 Pancreatectomy
YY09 Torakotomi
YY13 Vitrectomy
YY11 Air plumbage
YY12 Timektomi
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.002.930
2 1.002.930
1 1.002.930
3 1.164.074
2 1.164.074
1 1.164.074
3 1.164.074
2 1.164.074
1 1.164.074
3 1.164.074
2 1.164.074
1 1.164.074
3 937.583
2 937.583
1 937.583
3 2.441.648
2 2.441.648
1 2.441.648
3 5.720.720
2 5.720.720
1 5.720.720
3 2.947.397
2 2.947.397
1 2.947.397
3 2.836.486
2 2.836.486
1 2.836.486
3 4.782.834
2 4.782.834
1 4.782.834
3 2.433.845
2 2.433.845
1 2.433.845
3 2.391.417
2 2.391.417
1 2.391.417
3 10.221.342
2 10.221.342
1 10.221.342
3 2.320.059
2 2.320.059
1 2.320.059
Top Up Special CMG
RS Kelas C
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
YY04 Keratoplasty
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas C
3 3.351.758
2 3.351.758
1 3.351.758
3 12.846.455
2 12.846.455
1 12.846.455
3 1.557.392
2 1.557.392
1 1.557.392
3 2.894.518
2 2.894.518
1 2.894.518
3 4.967.634
2 4.967.634
1 4.967.634
3 2.719.984
2 2.719.984
1 2.719.984
3 3.535.482
2 3.535.482
1 3.535.482
3 2.320.059
2 2.320.059
1 2.320.059
II03 MRI 0 906.521
YY05 Pancreatectomy
YY09 Torakotomi
YY13 Vitrectomy
YY11 Air plumbage
YY12 Timektomi
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
3 739.376
2 739.376
1 739.376
3 975.348
2 975.348
1 975.348
3 975.348
2 975.348
1 975.348
3 975.348
2 975.348
1 975.348
3 738.860
2 738.860
1 738.860
3 1.799.015
2 1.799.015
1 1.799.015
3 4.797.378
2 4.797.378
1 4.797.378
3 2.277.148
2 2.277.148
1 2.277.148
3 2.390.681
2 2.390.681
1 2.390.681
3 3.530.855
2 3.530.855
1 3.530.855
3 1.860.144
2 1.860.144
1 1.860.144
3 1.765.428
2 1.765.428
1 1.765.428
3 7.739.720
2 7.739.720
1 7.739.720
3 1.761.640
2 1.761.640
1 1.761.640
Top Up Special CMG
RS Kelas D
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
YY04 Keratoplasty
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas D
3 2.796.577
2 2.796.577
1 2.796.577
3 9.452.662
2 9.452.662
1 9.452.662
3 1.301.055
2 1.301.055
1 1.301.055
3 2.135.318
2 2.135.318
1 2.135.318
3 3.655.308
2 3.655.308
1 3.655.308
3 2.500.898
2 2.500.898
1 2.500.898
3 2.979.818
2 2.979.818
1 2.979.818
3 1.761.640
2 1.761.640
1 1.761.640
II03 MRI 0 873.982
YY05 Pancreatectomy
YY09 Torakotomi
YY13 Vitrectomy
YY11 Air plumbage
YY12 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.645.920
2 1.645.920
1 1.645.920
3 2.772.703
2 2.772.703
1 2.772.703
3 2.772.703
2 2.772.703
1 2.772.703
3 2.772.703
2 2.772.703
1 2.772.703
3 1.642.526
2 1.642.526
1 1.642.526
3 9.202.145
2 9.202.145
1 9.202.145
3 12.963.501
2 12.963.501
1 12.963.501
3 5.033.278
2 5.033.278
1 5.033.278
3 6.395.600
2 6.395.600
1 6.395.600
3 7.877.326
2 7.877.326
1 7.877.326
3 4.138.252
2 4.138.252
1 4.138.252
3 3.938.663
2 3.938.663
1 3.938.663
3 19.476.681
2 19.476.681
1 19.476.681
YY03 PCI
RR03 TMJ Prothesis
DD05 Human Albumin
RR02 Cote graft
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
Top Up Special CMG
RS Kelas A
DD01 Streptokinase
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas A
3 4.712.762
2 4.712.762
1 4.712.762
3 7.594.902
2 7.594.902
1 7.594.902
3 41.143.310
2 41.143.310
1 41.143.310
3 3.820.850
2 3.820.850
1 3.820.850
3 9.474.940
2 9.474.940
1 9.474.940
3 12.234.539
2 12.234.539
1 12.234.539
3 6.682.387
2 6.682.387
1 6.682.387
3 8.409.948
2 8.409.948
1 8.409.948
3 4.712.762
2 4.712.762
1 4.712.762
II03 MRI 0 2.163.994
YY08 Torakotomi
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
YY04 Keratoplasty
YY05 Pancreatectomy
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.264.945
2 1.264.945
1 1.264.945
3 1.483.461
2 1.483.461
1 1.483.461
3 1.483.461
2 1.483.461
1 1.483.461
3 1.483.461
2 1.483.461
1 1.483.461
3 1.154.095
2 1.154.095
1 1.154.095
3 3.079.529
2 3.079.529
1 3.079.529
3 7.077.167
2 7.077.167
1 7.077.167
3 3.869.895
2 3.869.895
1 3.869.895
3 4.504.039
2 4.504.039
1 4.504.039
3 6.032.349
2 6.032.349
1 6.032.349
3 3.069.687
2 3.069.687
1 3.069.687
3 3.016.175
2 3.016.175
1 3.016.175
3 15.738.732
2 15.738.732
1 15.738.732
YY03 PCI
RR03 TMJ Prothesis
DD05 Human Albumin
RR02 Cote graft
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
Top Up Special CMG
RS Kelas B
DD01 Streptokinase
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas B
3 3.035.916
2 3.035.916
1 3.035.916
3 4.146.497
2 4.146.497
1 4.146.497
3 32.914.648
2 32.914.648
1 32.914.648
3 1.971.927
2 1.971.927
1 1.971.927
3 3.650.710
2 3.650.710
1 3.650.710
3 6.265.429
2 6.265.429
1 6.265.429
3 4.282.957
2 4.282.957
1 4.282.957
3 4.351.916
2 4.351.916
1 4.351.916
3 3.035.916
2 3.035.916
1 3.035.916
II03 MRI 0 945.644
YY08 Torakotomi
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
YY04 Keratoplasty
YY05 Pancreatectomy
Kode Special CMG Item Special CMG
Kelas
Rawat
Top Up
3 1.011.956
2 1.011.956
1 1.011.956
3 1.174.551
2 1.174.551
1 1.174.551
3 1.174.551
2 1.174.551
1 1.174.551
3 1.174.551
2 1.174.551
1 1.174.551
3 946.021
2 946.021
1 946.021
3 2.463.623
2 2.463.623
1 2.463.623
3 5.772.206
2 5.772.206
1 5.772.206
3 2.973.924
2 2.973.924
1 2.973.924
3 2.862.014
2 2.862.014
1 2.862.014
3 4.825.879
2 4.825.879
1 4.825.879
3 2.455.750
2 2.455.750
1 2.455.750
3 2.412.940
2 2.412.940
1 2.412.940
3 10.313.334
2 10.313.334
1 10.313.334
YY03 PCI
RR03 TMJ Prothesis
DD05 Human Albumin
RR02 Cote graft
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
Top Up Special CMG
RS Kelas C
DD01 Streptokinase
Kode Special CMG Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas C
3 2.340.939
2 2.340.939
1 2.340.939
3 3.381.923
2 3.381.923
1 3.381.923
3 12.962.073
2 12.962.073
1 12.962.073
3 1.571.409
2 1.571.409
1 1.571.409
3 2.920.568
2 2.920.568
1 2.920.568
3 5.012.343
2 5.012.343
1 5.012.343
3 2.744.464
2 2.744.464
1 2.744.464
3 3.567.302
2 3.567.302
1 3.567.302
3 2.340.939
2 2.340.939
1 2.340.939
II03 MRI 0 914.680
YY08 Torakotomi
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
YY04 Keratoplasty
YY05 Pancreatectomy
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 746.030
2 746.030
1 746.030
3 984.126
2 984.126
1 984.126
3 984.126
2 984.126
1 984.126
3 984.126
2 984.126
1 984.126
3 745.510
2 745.510
1 745.510
3 1.815.206
2 1.815.206
1 1.815.206
3 4.840.554
2 4.840.554
1 4.840.554
3 2.297.642
2 2.297.642
1 2.297.642
3 2.412.197
2 2.412.197
1 2.412.197
3 3.562.633
2 3.562.633
1 3.562.633
3 1.876.886
2 1.876.886
1 1.876.886
3 1.781.317
2 1.781.317
1 1.781.317
3 7.809.377
2 7.809.377
1 7.809.377
YY03 PCI
RR03 TMJ Prothesis
DD05 Human Albumin
RR02 Cote graft
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
Top Up Special CMG
RS Kelas D
DD01 Streptokinase
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas D
3 1.777.494
2 1.777.494
1 1.777.494
3 2.821.747
2 2.821.747
1 2.821.747
3 9.537.736
2 9.537.736
1 9.537.736
3 1.312.765
2 1.312.765
1 1.312.765
3 2.154.536
2 2.154.536
1 2.154.536
3 3.688.205
2 3.688.205
1 3.688.205
3 2.523.406
2 2.523.406
1 2.523.406
3 3.006.636
2 3.006.636
1 3.006.636
3 1.777.494
2 1.777.494
1 1.777.494
II03 MRI 0 881.848
YY08 Torakotomi
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
YY04 Keratoplasty
YY05 Pancreatectomy
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.650.814
2 1.650.814
1 1.650.814
3 2.780.947
2 2.780.947
1 2.780.947
3 2.780.947
2 2.780.947
1 2.780.947
3 2.780.947
2 2.780.947
1 2.780.947
3 1.647.409
2 1.647.409
1 1.647.409
3 9.229.505
2 9.229.505
1 9.229.505
3 13.002.044
2 13.002.044
1 13.002.044
3 5.048.243
2 5.048.243
1 5.048.243
3 6.414.615
2 6.414.615
1 6.414.615
3 7.900.747
2 7.900.747
1 7.900.747
3 4.150.556
2 4.150.556
1 4.150.556
3 3.950.374
2 3.950.374
1 3.950.374
3 19.534.590
2 19.534.590
1 19.534.590
Top Up Special CMG
RS Kelas A
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas A
3 4.726.774
2 4.726.774
1 4.726.774
3 7.617.484
2 7.617.484
1 7.617.484
3 41.265.639
2 41.265.639
1 41.265.639
3 3.832.210
2 3.832.210
1 3.832.210
3 9.503.111
2 9.503.111
1 9.503.111
3 12.270.916
2 12.270.916
1 12.270.916
3 6.702.255
2 6.702.255
1 6.702.255
3 8.434.953
2 8.434.953
1 8.434.953
3 4.726.774
2 4.726.774
1 4.726.774
II03 MRI 0 2.170.428
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.268.706
2 1.268.706
1 1.268.706
3 1.487.872
2 1.487.872
1 1.487.872
3 1.487.872
2 1.487.872
1 1.487.872
3 1.487.872
2 1.487.872
1 1.487.872
3 1.157.526
2 1.157.526
1 1.157.526
3 3.088.685
2 3.088.685
1 3.088.685
3 7.098.209
2 7.098.209
1 7.098.209
3 3.881.401
2 3.881.401
1 3.881.401
3 4.517.430
2 4.517.430
1 4.517.430
3 6.050.285
2 6.050.285
1 6.050.285
3 3.078.814
2 3.078.814
1 3.078.814
3 3.025.142
2 3.025.142
1 3.025.142
3 15.785.527
2 15.785.527
1 15.785.527
Top Up Special CMG
RS Kelas B
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas B
3 3.044.943
2 3.044.943
1 3.044.943
3 4.158.825
2 4.158.825
1 4.158.825
3 33.012.511
2 33.012.511
1 33.012.511
3 1.977.790
2 1.977.790
1 1.977.790
3 3.661.565
2 3.661.565
1 3.661.565
3 6.284.058
2 6.284.058
1 6.284.058
3 4.295.691
2 4.295.691
1 4.295.691
3 4.364.855
2 4.364.855
1 4.364.855
3 3.044.943
2 3.044.943
1 3.044.943
II03 MRI 0 948.456
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.014.965
2 1.014.965
1 1.014.965
3 1.178.043
2 1.178.043
1 1.178.043
3 1.178.043
2 1.178.043
1 1.178.043
3 1.178.043
2 1.178.043
1 1.178.043
3 948.834
2 948.834
1 948.834
3 2.470.948
2 2.470.948
1 2.470.948
3 5.789.369
2 5.789.369
1 5.789.369
3 2.982.766
2 2.982.766
1 2.982.766
3 2.870.523
2 2.870.523
1 2.870.523
3 4.840.228
2 4.840.228
1 4.840.228
3 2.463.051
2 2.463.051
1 2.463.051
3 2.420.114
2 2.420.114
1 2.420.114
3 10.343.998
2 10.343.998
1 10.343.998
Top Up Special CMG
RS Kelas C
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas C
3 2.347.899
2 2.347.899
1 2.347.899
3 3.391.979
2 3.391.979
1 3.391.979
3 13.000.612
2 13.000.612
1 13.000.612
3 1.576.081
2 1.576.081
1 1.576.081
3 2.929.252
2 2.929.252
1 2.929.252
3 5.027.246
2 5.027.246
1 5.027.246
3 2.752.624
2 2.752.624
1 2.752.624
3 3.577.908
2 3.577.908
1 3.577.908
3 2.347.899
2 2.347.899
1 2.347.899
II03 MRI 0 917.399
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 748.248
2 748.248
1 748.248
3 987.052
2 987.052
1 987.052
3 987.052
2 987.052
1 987.052
3 987.052
2 987.052
1 987.052
3 747.727
2 747.727
1 747.727
3 1.820.603
2 1.820.603
1 1.820.603
3 4.854.946
2 4.854.946
1 4.854.946
3 2.304.474
2 2.304.474
1 2.304.474
3 2.419.369
2 2.419.369
1 2.419.369
3 3.573.226
2 3.573.226
1 3.573.226
3 1.882.466
2 1.882.466
1 1.882.466
3 1.786.613
2 1.786.613
1 1.786.613
3 7.832.596
2 7.832.596
1 7.832.596
Top Up Special CMG
RS Kelas D
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas D
3 1.782.779
2 1.782.779
1 1.782.779
3 2.830.136
2 2.830.136
1 2.830.136
3 9.566.094
2 9.566.094
1 9.566.094
3 1.316.668
2 1.316.668
1 1.316.668
3 2.160.941
2 2.160.941
1 2.160.941
3 3.699.171
2 3.699.171
1 3.699.171
3 2.530.909
2 2.530.909
1 2.530.909
3 3.015.576
2 3.015.576
1 3.015.576
3 1.782.779
2 1.782.779
1 1.782.779
II03 MRI 0 884.470
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.675.283
2 1.675.283
1 1.675.283
3 2.822.166
2 2.822.166
1 2.822.166
3 2.822.166
2 2.822.166
1 2.822.166
3 2.822.166
2 2.822.166
1 2.822.166
3 1.671.827
2 1.671.827
1 1.671.827
3 9.366.306
2 9.366.306
1 9.366.306
3 13.194.763
2 13.194.763
1 13.194.763
3 5.123.068
2 5.123.068
1 5.123.068
3 6.509.693
2 6.509.693
1 6.509.693
3 8.017.853
2 8.017.853
1 8.017.853
3 4.212.076
2 4.212.076
1 4.212.076
3 4.008.927
2 4.008.927
1 4.008.927
3 19.824.134
2 19.824.134
1 19.824.134
Top Up Special CMG
RS Kelas A
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas A
3 4.796.835
2 4.796.835
1 4.796.835
3 7.730.391
2 7.730.391
1 7.730.391
3 41.877.284
2 41.877.284
1 41.877.284
3 3.889.012
2 3.889.012
1 3.889.012
3 9.643.968
2 9.643.968
1 9.643.968
3 12.452.797
2 12.452.797
1 12.452.797
3 6.801.597
2 6.801.597
1 6.801.597
3 8.559.977
2 8.559.977
1 8.559.977
3 4.796.835
2 4.796.835
1 4.796.835
II03 MRI 0 2.202.599
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.287.511
2 1.287.511
1 1.287.511
3 1.509.926
2 1.509.926
1 1.509.926
3 1.509.926
2 1.509.926
1 1.509.926
3 1.509.926
2 1.509.926
1 1.509.926
3 1.174.683
2 1.174.683
1 1.174.683
3 3.134.466
2 3.134.466
1 3.134.466
3 7.203.419
2 7.203.419
1 7.203.419
3 3.938.932
2 3.938.932
1 3.938.932
3 4.584.388
2 4.584.388
1 4.584.388
3 6.139.963
2 6.139.963
1 6.139.963
3 3.124.449
2 3.124.449
1 3.124.449
3 3.069.981
2 3.069.981
1 3.069.981
3 16.019.502
2 16.019.502
1 16.019.502
Top Up Special CMG
RS Kelas B
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas B
3 3.090.075
2 3.090.075
1 3.090.075
3 4.220.468
2 4.220.468
1 4.220.468
3 33.501.827
2 33.501.827
1 33.501.827
3 2.007.105
2 2.007.105
1 2.007.105
3 3.715.837
2 3.715.837
1 3.715.837
3 6.377.201
2 6.377.201
1 6.377.201
3 4.359.362
2 4.359.362
1 4.359.362
3 4.429.551
2 4.429.551
1 4.429.551
3 3.090.075
2 3.090.075
1 3.090.075
II03 MRI 0 962.514
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.030.009
2 1.030.009
1 1.030.009
3 1.195.504
2 1.195.504
1 1.195.504
3 1.195.504
2 1.195.504
1 1.195.504
3 1.195.504
2 1.195.504
1 1.195.504
3 962.898
2 962.898
1 962.898
3 2.507.573
2 2.507.573
1 2.507.573
3 5.875.179
2 5.875.179
1 5.875.179
3 3.026.977
2 3.026.977
1 3.026.977
3 2.913.071
2 2.913.071
1 2.913.071
3 4.911.970
2 4.911.970
1 4.911.970
3 2.499.559
2 2.499.559
1 2.499.559
3 2.455.985
2 2.455.985
1 2.455.985
3 10.497.318
2 10.497.318
1 10.497.318
Top Up Special CMG
RS Kelas C
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas C
3 2.382.700
2 2.382.700
1 2.382.700
3 3.442.255
2 3.442.255
1 3.442.255
3 13.193.309
2 13.193.309
1 13.193.309
3 1.599.442
2 1.599.442
1 1.599.442
3 2.972.670
2 2.972.670
1 2.972.670
3 5.101.761
2 5.101.761
1 5.101.761
3 2.793.424
2 2.793.424
1 2.793.424
3 3.630.940
2 3.630.940
1 3.630.940
3 2.382.700
2 2.382.700
1 2.382.700
II03 MRI 0 930.997
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 759.339
2 759.339
1 759.339
3 1.001.682
2 1.001.682
1 1.001.682
3 1.001.682
2 1.001.682
1 1.001.682
3 1.001.682
2 1.001.682
1 1.001.682
3 758.810
2 758.810
1 758.810
3 1.847.588
2 1.847.588
1 1.847.588
3 4.926.907
2 4.926.907
1 4.926.907
3 2.338.631
2 2.338.631
1 2.338.631
3 2.455.230
2 2.455.230
1 2.455.230
3 3.626.188
2 3.626.188
1 3.626.188
3 1.910.368
2 1.910.368
1 1.910.368
3 1.813.094
2 1.813.094
1 1.813.094
3 7.948.692
2 7.948.692
1 7.948.692
Top Up Special CMG
RS Kelas D
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas D
3 1.809.204
2 1.809.204
1 1.809.204
3 2.872.085
2 2.872.085
1 2.872.085
3 9.707.884
2 9.707.884
1 9.707.884
3 1.336.184
2 1.336.184
1 1.336.184
3 2.192.971
2 2.192.971
1 2.192.971
3 3.754.001
2 3.754.001
1 3.754.001
3 2.568.422
2 2.568.422
1 2.568.422
3 3.060.273
2 3.060.273
1 3.060.273
3 1.809.204
2 1.809.204
1 1.809.204
II03 MRI 0 897.580
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.689.964
2 1.689.964
1 1.689.964
3 2.846.898
2 2.846.898
1 2.846.898
3 2.846.898
2 2.846.898
1 2.846.898
3 2.846.898
2 2.846.898
1 2.846.898
3 1.686.478
2 1.686.478
1 1.686.478
3 9.448.386
2 9.448.386
1 9.448.386
3 13.310.393
2 13.310.393
1 13.310.393
3 5.167.964
2 5.167.964
1 5.167.964
3 6.566.740
2 6.566.740
1 6.566.740
3 8.088.117
2 8.088.117
1 8.088.117
3 4.248.988
2 4.248.988
1 4.248.988
3 4.044.058
2 4.044.058
1 4.044.058
3 19.997.861
2 19.997.861
1 19.997.861
YY03 PCI
RR03 TMJ Prothesis
DD05 Human Albumin
RR02 Cote graft
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
Top Up Special CMG
RS Kelas A
DD01 Streptokinase
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas A
3 4.838.872
2 4.838.872
1 4.838.872
3 7.798.135
2 7.798.135
1 7.798.135
3 42.244.271
2 42.244.271
1 42.244.271
3 3.923.093
2 3.923.093
1 3.923.093
3 9.728.482
2 9.728.482
1 9.728.482
3 12.561.925
2 12.561.925
1 12.561.925
3 6.861.202
2 6.861.202
1 6.861.202
3 8.634.991
2 8.634.991
1 8.634.991
3 4.838.872
2 4.838.872
1 4.838.872
II03 MRI 0 2.221.901
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.298.794
2 1.298.794
1 1.298.794
3 1.523.158
2 1.523.158
1 1.523.158
3 1.523.158
2 1.523.158
1 1.523.158
3 1.523.158
2 1.523.158
1 1.523.158
3 1.184.977
2 1.184.977
1 1.184.977
3 3.161.935
2 3.161.935
1 3.161.935
3 7.266.546
2 7.266.546
1 7.266.546
3 3.973.450
2 3.973.450
1 3.973.450
3 4.624.563
2 4.624.563
1 4.624.563
3 6.193.770
2 6.193.770
1 6.193.770
3 3.151.829
2 3.151.829
1 3.151.829
3 3.096.885
2 3.096.885
1 3.096.885
3 16.159.887
2 16.159.887
1 16.159.887
Top Up Special CMG
RS Kelas B
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode Special
CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas B
3 3.117.155
2 3.117.155
1 3.117.155
3 4.257.454
2 4.257.454
1 4.257.454
3 33.795.417
2 33.795.417
1 33.795.417
3 2.024.694
2 2.024.694
1 2.024.694
3 3.748.400
2 3.748.400
1 3.748.400
3 6.433.087
2 6.433.087
1 6.433.087
3 4.397.565
2 4.397.565
1 4.397.565
3 4.468.369
2 4.468.369
1 4.468.369
3 3.117.155
2 3.117.155
1 3.117.155
II03 MRI 0 970.949
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 1.039.035
2 1.039.035
1 1.039.035
3 1.205.981
2 1.205.981
1 1.205.981
3 1.205.981
2 1.205.981
1 1.205.981
3 1.205.981
2 1.205.981
1 1.205.981
3 971.336
2 971.336
1 971.336
3 2.529.548
2 2.529.548
1 2.529.548
3 5.926.666
2 5.926.666
1 5.926.666
3 3.053.504
2 3.053.504
1 3.053.504
3 2.938.599
2 2.938.599
1 2.938.599
3 4.955.016
2 4.955.016
1 4.955.016
3 2.521.463
2 2.521.463
1 2.521.463
3 2.477.508
2 2.477.508
1 2.477.508
3 10.589.310
2 10.589.310
1 10.589.310
Top Up Special CMG
RS Kelas C
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas C
3 2.403.581
2 2.403.581
1 2.403.581
3 3.472.421
2 3.472.421
1 3.472.421
3 13.308.927
2 13.308.927
1 13.308.927
3 1.613.458
2 1.613.458
1 1.613.458
3 2.998.720
2 2.998.720
1 2.998.720
3 5.146.469
2 5.146.469
1 5.146.469
3 2.817.903
2 2.817.903
1 2.817.903
3 3.662.760
2 3.662.760
1 3.662.760
3 2.403.581
2 2.403.581
1 2.403.581
II03 MRI 0 939.156
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
3 765.993
2 765.993
1 765.993
3 1.010.460
2 1.010.460
1 1.010.460
3 1.010.460
2 1.010.460
1 1.010.460
3 1.010.460
2 1.010.460
1 1.010.460
3 765.459
2 765.459
1 765.459
3 1.863.780
2 1.863.780
1 1.863.780
3 4.970.083
2 4.970.083
1 4.970.083
3 2.359.125
2 2.359.125
1 2.359.125
3 2.476.746
2 2.476.746
1 2.476.746
3 3.657.966
2 3.657.966
1 3.657.966
3 1.927.110
2 1.927.110
1 1.927.110
3 1.828.983
2 1.828.983
1 1.828.983
3 8.018.349
2 8.018.349
1 8.018.349
Top Up Special CMG
RS Kelas D
DD01 Streptokinase
DD02 Deferiprone
DD03 Deferoksamin
DD04 Deferasirox
DD05 Human Albumin
RR02 Cote graft
RR03 TMJ Prothesis
YY03 PCI
Kode
Special CMG
Item Special CMG
Kelas
Rawat
Top Up
Top Up Special CMG
RS Kelas D
3 1.825.059
2 1.825.059
1 1.825.059
3 2.897.254
2 2.897.254
1 2.897.254
3 9.792.958
2 9.792.958
1 9.792.958
3 1.347.893
2 1.347.893
1 1.347.893
3 2.212.189
2 2.212.189
1 2.212.189
3 3.786.899
2 3.786.899
1 3.786.899
3 2.590.931
2 2.590.931
1 2.590.931
3 3.087.092
2 3.087.092
1 3.087.092
3 1.825.059
2 1.825.059
1 1.825.059
II03 MRI 0 905.446
YY08 Torakotomi
YY04 Keratoplasty
YY05 Pancreatectomy
YY12 Vitrectomy
YY10 Air plumbage
YY11 Timektomi
PERHITUNGAN TARIF
SPECIAL GROUPS UNTUK KASUS SUB-AKUT DAN KRONIS
Kasus Sub-Akut
LOS = 43 s/d 103 Total tarif = Tarif Fase Akut + Top up payment Fase Sub Akut
Kasus Kronis
LOS = 104 s/d 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 x UC x LOS
Top up payment Fase Kronis = 0,25 x RIW x UC x LOS
Resource Intensity Weight (RIW) = ADL Score : 60
UC (Unit Cost) = Rp 879.103,-
LOS (Length Of Stay) = Lama rawat pasien dalam 1 episode rawatan
Rumus LOS :
Fase Akut : Hari 1 sd 42
Fase Subakut : 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
NAFSIAH MBOI

PMK No. 69 TTG Tarif Pelayanan Kesehatan Program JKN

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

PMK No. 69 TTG Tarif Pelayanan Kesehatan Program JKN

Diunggah oleh

Hak Cipta:

Format Tersedia

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA

NOMOR 69 TAHUN 2013

Anda mungkin juga menyukai