Lampiran Permenkes 64 THN 2016

PERATURAN MENTERl KESEHATAN REPUBLIK INDONESIA
NOMOR 64 TAHUN 2016

TENTANG
PERUBAHAN ATAS PERATURAN MENTERI KESEHATAN
NOMOR 52 TAHUN 2016 TENTANG STANDAR TARIF PELAYANAN
KESEHATAN DALAM PENYELENGGARAAN PROGRAM JAMINAN KESEHATAN
DENGAN RAHMAT TUHAN YANG MAHA ESA
MENTERI KESEHATAN REPUBLIK INDONESIA,
Menimbang : a. bahwa standar tarif pelayanan kesehatan dalam

penyelenggaraan program jaminan kesehatan disusun
bersama antara Menteri Kesehatan, Badan Penyelenggara
Jaminan Sosial (BPJS) Kesehatan, Dewan Jaminan Sosial
Nasional (DJSN), dan menteri yang menyelenggarakan
urusan pemerintahan di bidang keuangan, dengan
memperhatikan kecukupan anggaran;
b. bahwa standar tarif pelayanan kesehatan dalam
penyelenggaraan program jaminan kesehatan telah
ditetapkan melalui Peraturan Menteri Kesehatan Nomor
52 Tahun 2016 Tentang Standar Tarif Pelayanan
Kesehatan dalam Penyelenggaraan Program Jaminan
Kesehatan, namun belum memenuhi ketentuan
sebagaimana dimaksud dalam huruf a;
c. bahwa berdasarkan pertimbangan sebagaimana
dimaksud dalam huruf a dan huruf b, perlu menetapkan
Peraturan Menteri Kesehatan tentang Perubahan atas
Peraturan Menteri Kesehatan Nomor 52 Tahun 2016
-2-
tentang Standar Tarif Pelayanan Kesehatan Dalam

Penyelenggaraan Program Jaminan Kesehatan;
Mengingat : 1. Undang-Undang Nomor 40 Tahun 2004 tentang Sistem

Jaminan Sosial Nasional (Lembaran Negara Republik
Indonesia Nomor 2004 Tahun 150, Tambahan Lembaran
Negara Republik Indonesia Nomor 4456);
2. Undang-Undang Nomor 36 Tahun 2009 tentang
Kesehatan (Lembaran Negara Republik Indonesia 2009
Nomor 144, Tambahan Lembaran Negara Republik
Indonesi Nomor 5063);
3. Undang-UndangNomor 24 Tahun 2011 tentang Badan
Penyelenggara Jaminan Sosial (Lembaran Negar Republik
Indonesia Tahun 2011 Nomor 116, Tambahan Lembaran
Negara Republik Indonesia Nomor 5256);
4. Peraturan Presiden Nomor 12 Tahun 2013 tentang
Jaminan Kesehatan (Lembaran Negara Republik
Indonesia Tahun 2013 Nomor 29) sebagaimana telah
diubah beberapa kali terakhir dengan Peraturan Presiden
Nomor 19 Tahun 2016 (Lembaran Negara Republik
Indonesia Tahun 2016 Nomor 42);
5. Peraturan Menteri Kesehatan Nomor 9 Tahun 2014
tentang Klinik (Berita Negara Republik Indonesia Tahun
2014 Nomor 232);
6. Peraturan Menteri Kesehatan Nomor 52 Tahun 2016
tentang Standar Tarif Pelayanan Kesehatan Dalam
Penyelenggaraan Program Jaminan Kesehatan (Berita
Negara Republik Indonesia Tahun 2016 Nomor 1601);
MEMUTUSKAN:
Menetapkan : PERATURAN MENTERI KESEHATAN TENTANG PERUBAHAN
ATAS PERATURAN MENTERI KESEHATAN NOMOR 52 TAHUN
2016 TENTANG STANDAR TARIF PELAYANAN KESEHATAN
DALAM PENYELENGGARAAN PROGRAM JAMINAN
KESEHATAN.
-3-
Pasal I
Beberapa Ketentuan dalam Peraturan Menteri Kesehatan

Nomor 52 Tahun 2016 tentang Standar Tarif Pelayanan
Kesehatan Dalam Penyelenggaraan Program Jaminan
Kesehatan (Berita Negara Republik Indonesia Tahun 2016
Nomor 1601), diubah sebagai berikut:
1. Ketentuan Pasal 25 diubah, sehingga berbunyi sebagai

berikut:
Pasal 25
(1) Besaran tambahan pembayaran pelayanan rawat
jalan eksekutif paling banyak sebesar Rp 250.000
untuk setiap episode rawat jalan.
(2) Peserta yang menginginkan kelas pelayanan rawat
inap yang lebih tinggi dari haknya, harus membayar
tambahan biaya dengan ketentuan:
a. untuk kenaikan kelas pelayanan rawat inap ke
kelas 2 atau kelas 1, tambahan pembayaran
adalah sebesar selisih antara tarif INA-CBG
pada kelas rawat inap yang lebih tinggi
terhadap tarif INA CBG pada kelas rawat inap
yang sesuai hak peserta; dan
b. untuk kenaikan kelas pelayanan rawat inap ke
kelas VIP, tambahan pembayaran adalah
sebesar selisih antara tarif kamar rawat inap
kelas VIP terhadap tarif kamar rawat inap pada
kelas yang menjadi hak peserta, sesuai lama
waktu rawat.
(3) Pembayaran besaran selisih biaya sebagaimana
dimaksud pada ayat (2) dapat dilakukan oleh:
a. peserta;
b. pemberi kerja; dan/atau
c. asuransi kesehatan tambahan.
-4-
2. Diantara Pasal 26 dan Pasal 27 disisipkan satu pasal,

yakni Pasal 26A, sehingga berbunyi sebagai berikut:
Pasal 26A
Pada saat Peraturan Menteri ini mulai berlaku:
a. Pembayaran atas pasien yang mendapat pelayanan
rawat jalan mulai tanggal 26 Oktober 2016
menggunakan tarif dalam ketentuan Peraturan
Menteri ini;
b. Pembayaran atas pasien yang mendapat pelayanan
rawat inap yang masuk mulai tanggal 26 Oktober
2016 menggunakan tarif dalam ketentuan Peraturan
Menteri ini;
c. Pembayaran atas pasien yang mendapat pelayanan
rawat inap yang masuk sebelum tanggal 26 Oktober
2016 dan pulang setelah tanggal 26 Oktober 2016
menggunakan tarif Peraturan Menteri Kesehatan
Nomor 59 Tahun 2014 tentang Standar Tarif
Pelayanan Kesehatan Dalam Penyelenggaraan
Program Jaminan Kesehatan;
d. Pembayaran atas selisih tarif pelayanan rawat inap
akibat naik kelas bagi pasien yang dirawat sebelum
tanggal 26 Oktober 2016 sampai dengan Peraturan
Menteri ini berlaku, menggunakan tarif sesuai
ketentuan dalam Peraturan Menteri Kesehatan
Nomor 59 Tahun 2014 tentang Standar Tarif
Pelayanan Kesehatan Dalam Penyelenggaraan
Program Jaminan Kesehatan.
3. Ketentuan dalam Lampiran diubah, sehingga berbunyi

sebagaimana tercantum dalam Lampiran yang
merupakan bagian tidak terpisahkan dari Peraturan
Menteri ini.
Pasal II
Peraturan Menteri ini mulai berlaku pada tanggal
diundangkan.
-5-
Agar setiap orang mengetahuinya, memerintahkan

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

dan Organisasi Kesehatan
Tanggal Tanggal
Paraf Paraf
kretaris Jenderal
Kementerian Ke
-246 -
LAMPIRAN
PERATURAN MENTERI KESEHATAN
NOMOR 64 TAHUN 2016
TENTANG
PERUBAHAN ATAS PERATURAN MENTERI KESEHATAN
NOMOR 52 TAHUN 2016
TENTANG
STANDAR TARIF PELAYANAN KESEHATAN DALAM
PENYELENGGARAAN PROGRAM JAMINAN
STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN

TINGKAT LANJUTAN (INA-CBG)
TARIF INA-CBG TAHUN 2016

REGIONAL 2
RUMAH SAKIT KELAS B PEMERINTAH
RAWAT INAP
KODE TARIF TARIF TARIF

NO DESKRIPSI KODE INA-CBG
INA-CBG KELAS 3 KELAS 2 KELAS 1
1 A-4-10-I SEPTIKEMIA (RINGAN) 2,483,000 2,979,600 3,476,200
2 A-4-10-II SEPTIKEMIA (SEDANG) 4,242,000 5,090,400 5,938,800
3 A-4-10-III SEPTIKEMIA (BERAT) 5,719,600 6,863,500 8,007,400
4 A-4-11-I INFEKSI SESUDAH OPERASI & TRAUMA (RINGAN) 3,226,600 3,871,900 4,517,200
5 A-4-11-II INFEKSI SESUDAH OPERASI & TRAUMA (SEDANG) 4,592,300 5,510,800 6,429,300
6 A-4-11-III INFEKSI SESUDAH OPERASI & TRAUMA (BERAT) 6,356,200 7,627,500 8,898,700
7 A-4-12-I DEMAM YANG TIDAK DITENTUKAN (RINGAN) 2,585,500 3,102,600 3,619,700
8 A-4-12-II DEMAM YANG TIDAK DITENTUKAN (SEDANG) 3,219,800 3,863,800 4,507,700
9 A-4-12-III DEMAM YANG TIDAK DITENTUKAN (BERAT) 3,542,700 4,251,200 4,959,800
10 A-4-13-I INFEKSI VIRAL & NON-BAKTERIAL LAIN (RINGAN) 2,047,300 2,456,800 2,866,300
11 A-4-13-II INFEKSI VIRAL & NON-BAKTERIAL LAIN (SEDANG) 2,613,000 3,135,700 3,658,300
12 A-4-13-III INFEKSI VIRAL & NON-BAKTERIAL LAIN (BERAT) 3,135,700 3,762,800 4,389,900
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN
13 A-4-14-I 2,222,500 2,667,000 3,111,400
(RINGAN)
14 A-4-14-II 2,697,800 3,237,400 3,776,900
(SEDANG)
15 A-4-14-III 3,237,400 3,884,800 4,532,300
(BERAT)
16 A-4-15-I INFEKSI HIV (RINGAN) 14,172,700 17,007,300 19,841,800
17 A-4-15-II INFEKSI HIV (SEDANG) 17,649,800 21,179,700 24,709,700
18 A-4-15-III INFEKSI HIV (BERAT) 19,939,300 23,927,100 27,915,000
19 B-1-01-I PENCANGKOKAN HATI (RINGAN) 38,764,200 46,517,000 54,269,800
20 B-1-01-II PENCANGKOKAN HATI (SEDANG) 42,767,100 51,320,500 59,873,900
21 B-1-01-III PENCANGKOKAN HATI (BERAT) 94,270,100 113,124,200 131,978,200
22 B-1-10-I PROSEDUR HATI DAN PANKREAS (RINGAN) 6,266,000 7,519,200 8,772,400
23 B-1-10-II PROSEDUR HATI DAN PANKREAS (SEDANG) 13,907,800 16,689,400 19,470,900
24 B-1-10-III PROSEDUR HATI DAN PANKREAS (BERAT) 27,455,900 32,947,000 38,438,200
25 B-1-11-I PROSEDUR SALURAN EMPEDU KOMPLEK (RINGAN) 6,850,300 8,220,300 9,590,400
26 B-1-11-II PROSEDUR SALURAN EMPEDU KOMPLEK (SEDANG) 9,152,000 10,982,400 12,812,800
27 B-1-11-III PROSEDUR SALURAN EMPEDU KOMPLEK (BERAT) 11,824,200 14,189,100 16,553,900
28 B-1-12-I CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN) 6,895,800 8,275,000 9,654,100
29 B-1-12-II CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG) 7,669,300 9,203,200 10,737,100
30 B-1-12-III CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT) 11,997,800 14,397,400 16,797,000
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-

31 B-1-13-I 5,492,600 6,591,100 7,689,600
LAIN (RINGAN)
32 B-1-13-II 9,037,400 10,844,800 12,652,300
LAIN (SEDANG)
33 B-1-13-III 11,693,600 14,032,300 16,371,000
LAIN (BERAT)
CHOLESISTEKTOMI DENGAN LAPAROSKOPIK
34 B-1-14-I 7,547,000 9,056,400 10,565,800
(RINGAN)
35 B-1-14-II 8,393,600 10,072,400 11,751,100
(SEDANG)
36 B-1-14-III CHOLESISTEKTOMI DENGAN LAPAROSKOPIK (BERAT) 13,130,900 15,757,100 18,383,300
37 B-4-10-I SIROSIS HATI DAN HEPATITIS ALKOHOLIK (RINGAN) 2,265,000 2,718,000 3,171,000
38 B-4-10-II SIROSIS HATI DAN HEPATITIS ALKOHOLIK (SEDANG) 3,615,600 4,338,700 5,061,800
39 B-4-10-III SIROSIS HATI DAN HEPATITIS ALKOHOLIK (BERAT) 4,987,800 5,985,400 6,983,000
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS
40 B-4-11-I 4,775,500 5,730,600 6,685,700
(RINGAN)
41 B-4-11-II 6,685,700 8,022,900 9,360,000
(SEDANG)
42 B-4-11-III 8,099,700 9,719,600 11,339,500
(BERAT)
43 B-4-12-I GANGGUAN PANKREAS SELAIN TUMOR (RINGAN) 4,317,600 5,181,100 6,044,600
44 B-4-12-II GANGGUAN PANKREAS SELAIN TUMOR (SEDANG) 6,338,200 7,605,800 8,873,400
45 B-4-12-III GANGGUAN PANKREAS SELAIN TUMOR (BERAT) 9,429,800 11,315,800 13,201,700
46 B-4-13-I GANGGUAN HATI LAIN-LAIN (RINGAN) 4,118,600 4,942,300 5,766,000
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REGIONAL 2
RAWAT INAP

47 B-4-13-II GANGGUAN HATI LAIN-LAIN (SEDANG) 4,798,000 5,757,600 6,717,200
48 B-4-13-III GANGGUAN HATI LAIN-LAIN (BERAT) 6,609,600 7,931,600 9,253,500
49 B-4-14-I GANGGUAN SALURAN EMPEDU LAIN-LAIN (RINGAN) 4,114,200 4,937,000 5,759,900
50 B-4-14-II GANGGUAN SALURAN EMPEDU LAIN-LAIN (SEDANG) 4,799,700 5,759,700 6,719,600
51 B-4-14-III GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT) 6,429,400 7,715,200 9,001,100

52 C-4-10-I LEUKEMIA AKUT (RINGAN) 3,924,100 4,708,900 5,493,700
53 C-4-10-II LEUKEMIA AKUT (SEDANG) 7,529,400 9,035,200 10,541,100
54 C-4-10-III LEUKEMIA AKUT (BERAT) 12,891,300 15,469,500 18,047,800
55 C-4-11-I LIMFOMA & LEUKEMIA NON AKUT (RINGAN) 4,337,500 5,205,000 6,072,500
56 C-4-11-II LIMFOMA & LEUKEMIA NON AKUT (SEDANG) 5,804,200 6,965,100 8,125,900
57 C-4-11-III LIMFOMA & LEUKEMIA NON AKUT (BERAT) 9,200,100 11,040,100 12,880,100
58 C-4-12-I RADIOTERAPI (RINGAN) 2,888,100 3,465,700 4,043,300
59 C-4-12-II RADIOTERAPI (SEDANG) 5,864,300 7,037,100 8,210,000
60 C-4-12-III RADIOTERAPI (BERAT) 15,061,100 18,073,300 21,085,600
61 C-4-13-I KEMOTERAPI (RINGAN) 2,171,200 2,605,500 3,039,700
62 C-4-13-II KEMOTERAPI (SEDANG) 4,086,300 4,903,500 5,720,800
63 C-4-13-III KEMOTERAPI (BERAT) 5,531,400 6,637,700 7,744,000
64 C-4-14-I TUMOR MYELOPROLIFERATIF LAIN-LAIN (RINGAN) 3,607,600 4,329,100 5,050,600
65 C-4-14-II TUMOR MYELOPROLIFERATIF LAIN-LAIN (SEDANG) 5,060,700 6,072,900 7,085,000
66 C-4-14-III TUMOR MYELOPROLIFERATIF LAIN-LAIN (BERAT) 7,773,600 9,328,300 10,883,000
67 D-1-10-I PENCANGKOKAN SUMSUM TULANG (RINGAN) 21,578,100 25,893,800 30,209,400
68 D-1-10-II PENCANGKOKAN SUMSUM TULANG (SEDANG) 32,865,000 39,438,000 46,011,000
69 D-1-10-III PENCANGKOKAN SUMSUM TULANG (BERAT) 52,332,400 62,798,800 73,265,300
70 D-1-11-I PROSEDUR LIMPA (RINGAN) 5,835,700 7,002,800 8,170,000
71 D-1-11-II PROSEDUR LIMPA (SEDANG) 14,901,300 17,881,500 20,861,800
72 D-1-11-III PROSEDUR LIMPA (BERAT) 19,963,700 23,956,400 27,949,200
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK
73 D-1-20-I 5,058,900 6,070,700 7,082,400
DARAH LAIN-LAIN (RINGAN)
74 D-1-20-II 13,941,500 16,729,800 19,518,100
DARAH LAIN-LAIN (SEDANG)
75 D-1-20-III 22,115,300 26,538,400 30,961,500
DARAH LAIN-LAIN (BERAT)
76 D-4-10-I AGRANULOSITOSIS (RINGAN) 2,493,900 2,992,700 3,491,400
77 D-4-10-II AGRANULOSITOSIS (SEDANG) 4,092,700 4,911,300 5,729,800
78 D-4-10-III AGRANULOSITOSIS (BERAT) 6,438,800 7,726,600 9,014,400
79 D-4-11-I GANGGUAN PEMBEKUAN DARAH (RINGAN) 3,960,400 4,752,500 5,544,600
80 D-4-11-II GANGGUAN PEMBEKUAN DARAH (SEDANG) 7,116,700 8,540,000 9,963,400
81 D-4-11-III GANGGUAN PEMBEKUAN DARAH (BERAT) 10,079,000 12,094,800 14,110,500
82 D-4-12-I KRISIS ANEMIA SEL SICKLE (RINGAN) 3,414,400 4,097,300 4,780,200
83 D-4-12-II KRISIS ANEMIA SEL SICKLE (SEDANG) 4,735,900 5,683,000 6,630,200
84 D-4-12-III KRISIS ANEMIA SEL SICKLE (BERAT) 7,272,100 8,726,600 10,181,000
GANGGUAN SEL DARAH MERAH SELAIN KRISIS
85 D-4-13-I 2,926,100 3,511,300 4,096,500
ANEMIA SEL SICKLE (RINGAN)
86 D-4-13-II 4,141,400 4,969,700 5,797,900
ANEMIA SEL SICKLE (SEDANG)
87 D-4-13-III 5,297,000 6,356,400 7,415,700
ANEMIA SEL SICKLE (BERAT)
GANGGUAN PADA DARAH & ORGAN PEMBENTUK
88 D-4-14-I 3,138,300 3,766,000 4,393,700
89 D-4-14-II 5,138,300 6,165,900 7,193,600
90 D-4-14-III 6,284,600 7,541,500 8,798,500
PROSEDUR KELENJAR PITUITARI DAN PINEAL
91 E-1-01-I 6,881,500 8,257,800 9,634,100
(RINGAN)
92 E-1-01-II 9,394,300 11,273,100 13,152,000
(SEDANG)
93 E-1-01-III PROSEDUR KELENJAR PITUITARI DAN PINEAL (BERAT) 22,650,600 27,180,700 31,710,800
94 E-1-10-I PROSEDUR KELENJAR ADRENAL (RINGAN) 7,154,500 8,585,400 10,016,400

95 E-1-10-II PROSEDUR KELENJAR ADRENAL (SEDANG) 9,931,400 11,917,600 13,903,900
96 E-1-10-III PROSEDUR KELENJAR ADRENAL (BERAT) 18,763,600 22,516,300 26,269,000
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN
97 E-1-20-I 7,363,200 8,835,800 10,308,500
TIROGLOSAL (RINGAN)
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REGIONAL 2
RAWAT INAP

98 E-1-20-II 9,910,600 11,892,800 13,874,900
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,081,300 16,897,600 19,713,900
TIROGLOSAL (BERAT)
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/
100 E-4-10-I 3,431,300 4,117,600 4,803,800
METABOLIK (RINGAN)
101 E-4-10-II 4,794,600 5,753,600 6,712,500
METABOLIK (SEDANG)
102 E-4-10-III 6,135,200 7,362,200 8,589,200
METABOLIK (BERAT)
103 E-4-11-I HIPOVOLEMIA & GANGGUAN ELEKROLIT (RINGAN) 2,894,600 3,473,500 4,052,500
104 E-4-11-II HIPOVOLEMIA & GANGGUAN ELEKROLIT (SEDANG) 4,413,100 5,295,700 6,178,300
105 E-4-11-III HIPOVOLEMIA & GANGGUAN ELEKROLIT (BERAT) 6,165,000 7,398,000 8,631,000
106 E-4-12-I GANGGUAN METABOLIK BAWAAN (RINGAN) 3,325,900 3,991,000 4,656,200
107 E-4-12-II GANGGUAN METABOLIK BAWAAN (SEDANG) 5,759,600 6,911,500 8,063,400
108 E-4-12-III GANGGUAN METABOLIK BAWAAN (BERAT) 6,827,200 8,192,700 9,558,100
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN
109 E-4-13-I 3,621,700 4,346,100 5,070,400
(RINGAN)
110 E-4-13-II 5,305,200 6,366,300 7,427,300
(SEDANG)
111 E-4-13-III GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN (BERAT) 7,149,400 8,579,300 10,009,200
112 F-4-10-I SCHIZOFRENIA (RINGAN) 3,975,000 4,770,000 5,565,000

113 F-4-10-II SCHIZOFRENIA (SEDANG) 4,568,500 5,482,200 6,395,900
114 F-4-10-III SCHIZOFRENIA (BERAT) 5,482,200 6,578,600 7,675,100
115 F-4-11-I DEPRESI MAYOR (RINGAN) 3,844,500 4,613,400 5,382,300
116 F-4-11-II DEPRESI MAYOR (SEDANG) 4,479,300 5,375,100 6,271,000
117 F-4-11-III DEPRESI MAYOR (BERAT) 5,744,100 6,892,900 8,041,700
GANGGUAN PERSONALITI & KONTROL IMPULSE
118 F-4-12-I 2,044,200 2,453,000 2,861,900
(RINGAN)
119 F-4-12-II 2,906,200 3,487,400 4,068,700
(SEDANG)
120 F-4-12-III 6,313,600 7,576,300 8,839,000
(BERAT)
121 F-4-13-I GANGGUAN BIPOLAR (RINGAN) 3,096,800 3,716,200 4,335,600
122 F-4-13-II GANGGUAN BIPOLAR (SEDANG) 4,086,400 4,903,600 5,720,900
123 F-4-13-III GANGGUAN BIPOLAR (BERAT) 5,290,300 6,348,400 7,406,400
124 F-4-14-I DEPRESI (RINGAN) 1,766,900 2,120,300 2,473,700
125 F-4-14-II DEPRESI (SEDANG) 2,266,300 2,719,600 3,172,800
126 F-4-14-III DEPRESI (BERAT) 3,049,500 3,659,400 4,269,300
127 F-4-15-I FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (RINGAN) 2,729,500 3,275,400 3,821,300
128 F-4-15-II FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (SEDANG) 4,067,300 4,880,700 5,694,200
129 F-4-15-III FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (BERAT) 5,370,100 6,444,100 7,518,100
GANGGUAN ORGANIK LAIN-LAIN TERMASUK
130 F-4-16-I 5,536,500 6,643,800 7,751,100
KETERBELAKANGAN MENTAL (RINGAN)
131 F-4-16-II 6,437,100 7,724,500 9,011,900
KETERBELAKANGAN MENTAL (SEDANG)
132 F-4-16-III 8,592,400 10,310,900 12,029,400
KETERBELAKANGAN MENTAL (BERAT)
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN) 1,268,300 1,521,900 1,775,600
134 F-4-17-II GANGGUAN MENTAL PADA KANAK-KANAK (SEDANG) 3,717,200 4,460,600 5,204,000
135 F-4-17-III GANGGUAN MENTAL PADA KANAK-KANAK (BERAT) 3,965,900 4,759,000 5,552,200
136 F-4-18-I GANGGUAN NUTRISI KOMPULSIF (RINGAN) 4,810,800 5,773,000 6,735,100
137 F-4-18-II GANGGUAN NUTRISI KOMPULSIF (SEDANG) 5,293,300 6,351,900 7,410,600
138 F-4-18-III GANGGUAN NUTRISI KOMPULSIF (BERAT) 8,159,900 9,791,900 11,423,900
139 F-4-19-I GANGGUAN MENTAL LAIN-LAIN (RINGAN) 3,676,600 4,411,900 5,147,200
140 F-4-19-II GANGGUAN MENTAL LAIN-LAIN (SEDANG) 4,708,000 5,649,600 6,591,200
141 F-4-19-III GANGGUAN MENTAL LAIN-LAIN (BERAT) 5,861,500 7,033,700 8,206,000
PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL
142 G-1-01-I 16,641,400 19,969,700 23,298,000
(RINGAN)
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RAWAT INAP

143 G-1-01-II 23,867,800 28,641,400 33,414,900
(SEDANG)
144 G-1-01-III 36,231,700 43,478,000 50,724,400
(BERAT)
145 G-1-10-I KRANIOTOMI (RINGAN) 17,038,900 20,446,700 23,854,500
146 G-1-10-II KRANIOTOMI (SEDANG) 20,061,600 24,073,900 28,086,200
147 G-1-10-III KRANIOTOMI (BERAT) 22,103,700 26,524,400 30,945,100
148 G-1-11-I PROSEDUR VENTRICULAR SHUNT (RINGAN) 11,577,900 13,893,500 16,209,000
149 G-1-11-II PROSEDUR VENTRICULAR SHUNT (SEDANG) 21,167,100 25,400,500 29,633,900
150 G-1-11-III PROSEDUR VENTRICULAR SHUNT (BERAT) 35,117,800 42,141,300 49,164,900
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL
151 G-1-12-I 4,834,200 5,801,000 6,767,800
(RINGAN)
152 G-1-12-II 9,342,100 11,210,600 13,079,000
(SEDANG)
153 G-1-12-III 12,731,500 15,277,800 17,824,100
(BERAT)
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE (RINGAN) 1,458,300 1,750,000 2,041,700
155 G-1-13-II PROSEDUR CARPAL TUNNEL RELEASE (SEDANG) 3,916,300 4,699,600 5,482,900
156 G-1-13-III PROSEDUR CARPAL TUNNEL RELEASE (BERAT) 8,837,000 10,604,400 12,371,800
157 G-1-20-I PROSEDUR SARAF KRANIAL DAN PERIFER (RINGAN) 8,629,600 10,355,600 12,081,500
158 G-1-20-II PROSEDUR SARAF KRANIAL DAN PERIFER (SEDANG) 14,048,400 16,858,100 19,667,800
159 G-1-20-III PROSEDUR SARAF KRANIAL DAN PERIFER (BERAT) 21,559,600 25,871,500 30,183,400
160 G-1-30-I PROSEDUR TULANG BELAKANG (RINGAN) 10,980,200 13,176,300 15,372,300
161 G-1-30-II PROSEDUR TULANG BELAKANG (SEDANG) 22,927,100 27,512,500 32,097,900
162 G-1-30-III PROSEDUR TULANG BELAKANG (BERAT) 31,234,500 37,481,400 43,728,300
KECEDERAAN & GANGGUAN TULANG BELAKANG
163 G-4-10-I 4,149,600 4,979,500 5,809,500
(RINGAN)
164 G-4-10-II 5,072,200 6,086,700 7,101,100
(SEDANG)
165 G-4-10-III 7,175,200 8,610,300 10,045,300
(BERAT)
TUMOR SISTEM PERSARAFAN & GANGGUAN
166 G-4-11-I 4,478,300 5,374,000 6,269,700
DEGENERATIF (RINGAN)
167 G-4-11-II 5,948,900 7,138,700 8,328,500
DEGENERATIF (SEDANG)
168 G-4-11-III 8,741,000 10,489,200 12,237,400
DEGENERATIF (BERAT)
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR
169 G-4-12-I 4,968,200 5,961,800 6,955,500
(RINGAN)
170 G-4-12-II 6,086,900 7,304,300 8,521,700
(SEDANG)
171 G-4-12-III SKLEROSIS MULTIPLE & ATAXIA CEREBELAR (BERAT) 8,840,500 10,608,600 12,376,700
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK

172 G-4-13-I 2,894,900 3,473,900 4,052,900
(RINGAN)
173 G-4-13-II 5,048,200 6,057,800 7,067,500
(SEDANG)
174 G-4-13-III 5,987,300 7,184,700 8,382,200
(BERAT)
KECEDERAAN PEMBULUH DARAH OTAK DENGAN
175 G-4-14-I 4,910,900 5,893,100 6,875,300
INFARK (RINGAN)
176 G-4-14-II 6,768,600 8,122,300 9,476,000
INFARK (SEDANG)
177 G-4-14-III 8,495,400 10,194,500 11,893,500
INFARK (BERAT)
KECEDERAAN PEMBULUH DARAH OTAK NON
178 G-4-15-I SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 4,012,700 4,815,200 5,617,700
INFARK (RINGAN)
179 G-4-15-II SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 4,788,900 5,746,700 6,704,400
INFARK (SEDANG)
180 G-4-15-III SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 6,759,100 8,110,900 9,462,800
INFARK (BERAT)
181 G-4-16-I ISKEMIK TRANSIENT (RINGAN) 3,307,900 3,969,500 4,631,000
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RAWAT INAP

182 G-4-16-II ISKEMIK TRANSIENT (SEDANG) 4,391,700 5,270,000 6,148,300
183 G-4-16-III ISKEMIK TRANSIENT (BERAT) 6,254,100 7,504,900 8,755,700
GANGUAN PERSARAFAN KRANIAL DAN PERIFER
184 G-4-17-I 4,405,900 5,287,100 6,168,200
(RINGAN)
185 G-4-17-II 5,777,100 6,932,500 8,087,900
(SEDANG)
186 G-4-17-III 7,483,700 8,980,400 10,477,100
(BERAT)
187 G-4-18-I INFEKSI BAKTERI SISTEM PERSARAFAN (RINGAN) 4,339,100 5,206,900 6,074,800
188 G-4-18-II INFEKSI BAKTERI SISTEM PERSARAFAN (SEDANG) 5,800,100 6,960,100 8,120,100
189 G-4-18-III INFEKSI BAKTERI SISTEM PERSARAFAN (BERAT) 6,489,800 7,787,800 9,085,800
INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK
190 G-4-19-I 3,620,200 4,344,300 5,068,300
TERMASUK MENINGITIS VIRUS) (RINGAN)
191 G-4-19-II 6,119,000 7,342,900 8,566,700
TERMASUK MENINGITIS VIRUS) (SEDANG)
192 G-4-19-III 8,034,000 9,640,800 11,247,600
TERMASUK MENINGITIS VIRUS) (BERAT)
193 G-4-20-I MENINGITIS VIRUS (RINGAN) 2,532,500 3,039,000 3,545,500
194 G-4-20-II MENINGITIS VIRUS (SEDANG) 3,580,200 4,296,300 5,012,300
195 G-4-20-III MENINGITIS VIRUS (BERAT) 5,913,600 7,096,400 8,279,100
196 G-4-21-I KOMA & STUPOR NON TRAUMA (RINGAN) 2,637,200 3,164,700 3,692,100
197 G-4-21-II KOMA & STUPOR NON TRAUMA (SEDANG) 4,463,500 5,356,300 6,249,000
198 G-4-21-III KOMA & STUPOR NON TRAUMA (BERAT) 5,407,900 6,489,500 7,571,100
199 G-4-22-I SERANGAN KEJANG (RINGAN) 2,601,700 3,122,100 3,642,400
200 G-4-22-II SERANGAN KEJANG (SEDANG) 3,324,200 3,989,000 4,653,900
201 G-4-22-III SERANGAN KEJANG (BERAT) 3,884,200 4,661,000 5,437,800
202 G-4-23-I MIGREN DAN SAKIT KEPALA LAIN (RINGAN) 2,596,100 3,115,300 3,634,500
203 G-4-23-II MIGREN DAN SAKIT KEPALA LAIN ((SEDANG) 3,257,200 3,908,600 4,560,100
204 G-4-23-III MIGREN DAN SAKIT KEPALA LAIN (BERAT) 4,637,500 5,565,000 6,492,400
205 G-4-24-I TRAUMA KEPALA (RINGAN) 2,981,100 3,577,300 4,173,500
206 G-4-24-II TRAUMA KEPALA (SEDANG) 3,724,400 4,469,300 5,214,200
207 G-4-24-III TRAUMA KEPALA (BERAT) 6,204,800 7,445,800 8,686,700
208 G-4-25-I GEGAR OTAK (RINGAN) 2,470,900 2,965,000 3,459,200
209 G-4-25-II GEGAR OTAK (SEDANG) 3,124,700 3,749,600 4,374,600
210 G-4-25-III GEGAR OTAK (BERAT) 4,140,800 4,969,000 5,797,200
GANGGUAN - PENYAKIT SISTEM PERSARAFAN LAIN-
211 G-4-26-I 3,514,200 4,217,000 4,919,800
LAIN (RINGAN)
212 G-4-26-II 4,214,500 5,057,400 5,900,300
LAIN (SEDANG)
213 G-4-26-III 6,112,900 7,335,500 8,558,100
LAIN (BERAT)
214 H-1-20-I PROSEDUR EKSTRAOKULER DAN ORBITA (RINGAN) 9,974,600 11,969,500 13,964,400
215 H-1-20-II PROSEDUR EKSTRAOKULER DAN ORBITA (SEDANG) 11,023,500 13,228,300 15,433,000
216 H-1-20-III PROSEDUR EKSTRAOKULER DAN ORBITA (BERAT) 14,991,200 17,989,500 20,987,700
217 H-1-30-I PROSEDUR LENSA DAN INTRA OKULER (RINGAN) 7,302,300 8,762,800 10,223,300
218 H-1-30-II PROSEDUR LENSA DAN INTRA OKULER (SEDANG) 9,072,400 10,886,900 12,701,400
219 H-1-30-III PROSEDUR LENSA DAN INTRA OKULER (BERAT) 12,707,300 15,248,700 17,790,200
220 H-4-10-I INFEKSI MATA AKUT MAYOR (RINGAN) 3,345,100 4,014,100 4,683,100
221 H-4-10-II INFEKSI MATA AKUT MAYOR (SEDANG) 4,538,600 5,446,300 6,354,100
222 H-4-10-III INFEKSI MATA AKUT MAYOR (BERAT) 8,920,900 10,705,000 12,489,200
223 H-4-11-I GANGGUAN PERSARAFAN MATA (RINGAN) 2,886,900 3,464,200 4,041,600
224 H-4-11-II GANGGUAN PERSARAFAN MATA (SEDANG) 3,293,000 3,951,600 4,610,200
225 H-4-11-III GANGGUAN PERSARAFAN MATA (BERAT) 4,715,400 5,658,500 6,601,600
226 H-4-12-I GANGGUAN MATA LAIN-LAIN (RINGAN) 3,403,600 4,084,400 4,765,100
227 H-4-12-II GANGGUAN MATA LAIN-LAIN (SEDANG) 4,192,500 5,031,000 5,869,500
228 H-4-12-III GANGGUAN MATA LAIN-LAIN (BERAT) 7,025,900 8,431,100 9,836,200
229 I-1-01-I TRANPLANTASI PARU ATAU/DAN JANTUNG (RINGAN) 45,716,900 54,860,200 64,003,600
230 I-1-01-II TRANPLANTASI PARU ATAU/DAN JANTUNG (SEDANG) 46,722,600 56,067,100 65,411,700
231 I-1-01-III TRANPLANTASI PARU ATAU/DAN JANTUNG (BERAT) 73,751,000 88,501,200 103,251,400
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI
232 I-1-02-I 25,363,500 30,436,200 35,508,900
(RINGAN)
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RAWAT INAP

233 I-1-02-II 32,718,600 39,262,400 45,806,100
(SEDANG)
234 I-1-02-III 40,327,800 48,393,300 56,458,900
(BERAT)
OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG
235 I-1-03-I 14,650,000 17,580,100 20,510,100
ANOMALI (RINGAN)
236 I-1-03-II 20,308,000 24,369,600 28,431,200
ANOMALI (SEDANG)
237 I-1-03-III 26,569,500 31,883,400 37,197,300
ANOMALI (BERAT)
PROSEDUR KATUP JANTUNG TANPA KATETERISASI
238 I-1-04-I 22,759,600 27,311,500 31,863,400
JANTUNG (RINGAN)
239 I-1-04-II 35,920,800 43,105,000 50,289,100
JANTUNG (SEDANG)
240 I-1-04-III 57,383,200 68,859,900 80,336,500
JANTUNG (BERAT)
PEMBEDAHAN BYPASS PEMBULUH KORONER
241 I-1-05-I 53,521,600 64,225,900 74,930,200
DENGAN KATETERISASI JANTUNG (RINGAN)
242 I-1-05-II 65,415,300 78,498,300 91,581,400
DENGAN KATETERISASI JANTUNG (SEDANG)
243 I-1-05-III 89,202,600 107,043,200 124,883,700
DENGAN KATETERISASI JANTUNG (BERAT)
244 I-1-06-I PROSEDUR KARDIOTORASIK LAIN (RINGAN) 21,529,800 25,835,800 30,141,800
245 I-1-06-II PROSEDUR KARDIOTORASIK LAIN (SEDANG) 31,187,700 37,425,300 43,662,800
246 I-1-06-III PROSEDUR KARDIOTORASIK LAIN (BERAT) 37,212,700 44,655,300 52,097,800
PROSEDUR BYPASS KORONER TANPA KATETERISASI
247 I-1-07-I 47,574,700 57,089,700 66,604,600
JANTUNG (RINGAN)
248 I-1-07-II 59,468,400 71,362,100 83,255,800
JANTUNG (SEDANG)
249 I-1-07-III 89,202,600 107,043,200 124,883,700
JANTUNG (BERAT)
DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM
250 I-1-11-I 4,097,500 4,917,000 5,736,500
BANTUAN JANTUNG (RINGAN)
251 I-1-11-II 4,556,000 5,467,200 6,378,400
BANTUAN JANTUNG (SEDANG)
252 I-1-11-III 6,062,600 7,275,100 8,487,700
BANTUAN JANTUNG (BERAT)
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS
253 I-1-12-I 11,794,500 14,153,400 16,512,300
(RINGAN)
254 I-1-12-II 18,684,900 22,421,800 26,158,800
(SEDANG)
255 I-1-12-III 24,582,800 29,499,300 34,415,900
(BERAT)
PROSEDUR PEMBULUH DARAH ABDOMINAL
256 I-1-13-I 11,440,500 13,728,600 16,016,700
KOMPLEK (RINGAN)
257 I-1-13-II 15,235,300 18,282,400 21,329,500
KOMPLEK (SEDANG)
258 I-1-13-III 18,789,400 22,547,300 26,305,100
KOMPLEK (BERAT)
PEMASANGAN PACEMAKER JANTUNG PERMANEN
259 I-1-14-I 23,415,900 28,099,000 32,782,200
(RINGAN)
260 I-1-14-II 29,102,500 34,923,000 40,743,400
(SEDANG)
261 I-1-14-III 38,134,300 45,761,100 53,388,000
(BERAT)
262 I-1-15-I KATETERISASI JANTUNG (RINGAN) 4,448,300 5,338,000 6,227,700
263 I-1-15-II KATETERISASI JANTUNG (SEDANG) 6,212,000 7,454,400 8,696,800
264 I-1-15-III KATETERISASI JANTUNG (BERAT) 11,961,900 14,354,300 16,746,600
REVISI DEFIBRILATOR & PACEMAKER JANTUNG
265 I-1-16-I 11,185,800 13,422,900 15,660,100
TIDAK TERMASUK PENGGANTIAN ALAT (RINGAN)
266 I-1-16-II 26,091,600 31,309,900 36,528,300
TIDAK TERMASUK PENGGANTIAN ALAT (SEDANG)
267 I-1-16-III 30,096,300 36,115,500 42,134,800
TIDAK TERMASUK PENGGANTIAN ALAT (BERAT)
LIGASI DAN STRIPPING PEMBULUH DARAH VENA
268 I-1-17-I 13,352,600 16,023,200 18,693,700
(RINGAN)
269 I-1-17-II 16,718,700 20,062,500 23,406,200
(SEDANG)
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RAWAT INAP

270 I-1-17-III 20,680,800 24,817,000 28,953,100
(BERAT)
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN
271 I-1-20-I 15,050,700 18,060,800 21,071,000
(RINGAN)
272 I-1-20-II 18,802,500 22,563,000 26,323,400
(SEDANG)
273 I-1-20-III 19,765,300 23,718,300 27,671,400
(BERAT)
PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER
274 I-1-30-I 11,385,000 13,662,000 15,939,000
JANTUNG (RINGAN)
275 I-1-30-II 23,683,300 28,420,000 33,156,700
JANTUNG (SEDANG)
276 I-1-30-III 36,700,700 44,040,800 51,380,900
JANTUNG (BERAT)
277 I-1-40-I PROSEDUR KARDIOVASKULAR PERKUTAN (RINGAN) 10,507,100 12,608,600 14,710,000
278 I-1-40-II PROSEDUR KARDIOVASKULAR PERKUTAN (SEDANG) 25,196,200 30,235,400 35,274,700
279 I-1-40-III PROSEDUR KARDIOVASKULAR PERKUTAN (BERAT) 33,653,600 40,384,300 47,115,000

280 I-4-10-I INFARK MYOKARD AKUT (RINGAN) 3,960,600 4,752,700 5,544,800
281 I-4-10-II INFARK MYOKARD AKUT (SEDANG) 7,072,100 8,486,500 9,900,900
282 I-4-10-III INFARK MYOKARD AKUT (BERAT) 10,189,900 12,227,800 14,265,800
283 I-4-11-I ENDOKARDITIS AKUT DAN SUBAKUT (RINGAN) 5,910,500 7,092,600 8,274,700
284 I-4-11-II ENDOKARDITIS AKUT DAN SUBAKUT (SEDANG) 7,314,300 8,777,200 10,240,000
285 I-4-11-III ENDOKARDITIS AKUT DAN SUBAKUT (BERAT) 13,530,700 16,236,800 18,943,000
286 I-4-12-I KEGAGALAN JANTUNG (RINGAN) 3,502,700 4,203,300 4,903,800
287 I-4-12-II KEGAGALAN JANTUNG (SEDANG) 4,060,200 4,872,200 5,684,300
288 I-4-12-III KEGAGALAN JANTUNG (BERAT) 4,872,200 5,846,700 6,821,100
THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA
289 I-4-13-I 3,564,500 4,277,400 4,990,300
(RINGAN)
290 I-4-13-II 6,364,900 7,637,800 8,910,800
(SEDANG)
291 I-4-13-III 9,170,900 11,005,000 12,839,200
(BERAT)
292 I-4-14-I CARDIAC ARREST DAN LAIN-LAIN (RINGAN) 3,265,100 3,918,100 4,571,100
293 I-4-14-II CARDIAC ARREST DAN LAIN-LAIN (SEDANG) 3,481,900 4,178,300 4,874,700
294 I-4-14-III CARDIAC ARREST DAN LAIN-LAIN (BERAT) 5,920,700 7,104,800 8,288,900
PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN
295 I-4-15-I 4,390,900 5,269,100 6,147,300
(RINGAN)
296 I-4-15-II 5,973,600 7,168,300 8,363,000
(SEDANG)
297 I-4-15-III PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN (BERAT) 7,168,300 8,602,000 10,035,600
298 I-4-16-I ATHEROSKLEROSIS (RINGAN) 2,124,500 2,549,400 2,974,300

299 I-4-16-II ATHEROSKLEROSIS (SEDANG) 3,411,400 4,093,700 4,776,000
300 I-4-16-III ATHEROSKLEROSIS (BERAT) 4,093,700 4,912,400 5,731,200
301 I-4-17-I HIPERTENSI (RINGAN) 1,867,800 2,241,400 2,614,900
302 I-4-17-II HIPERTENSI (SEDANG) 2,174,500 2,609,400 3,044,300
303 I-4-17-III HIPERTENSI (BERAT) 2,609,400 3,131,300 3,653,100
PENYAKIT JANTUNG KONGENITAL DAN KATUP
304 I-4-18-I 3,975,000 4,769,900 5,564,900
JANTUNG (RINGAN)
305 I-4-18-II 6,239,200 7,487,100 8,734,900
JANTUNG (SEDANG)
306 I-4-18-III 8,216,600 9,860,000 11,503,300
JANTUNG (BERAT)
307 I-4-19-I GANGGUAN KONDUKSI & ARITMIA JANTUNG (RINGAN) 3,835,000 4,602,100 5,369,100
GANGGUAN KONDUKSI & ARITMIA JANTUNG

308 I-4-19-II 5,986,700 7,184,100 8,381,400
(SEDANG)
309 I-4-19-III GANGGUAN KONDUKSI & ARITMIA JANTUNG (BERAT) 7,147,000 8,576,400 10,005,800
310 I-4-20-I ANGINA PEKTORIS DAN NYERI DADA (RINGAN) 4,116,900 4,940,300 5,763,700
311 I-4-20-II ANGINA PEKTORIS DAN NYERI DADA (SEDANG) 4,755,100 5,706,100 6,657,100
312 I-4-20-III ANGINA PEKTORIS DAN NYERI DADA (BERAT) 6,896,500 8,275,800 9,655,100
313 I-4-21-I SYNCOPE & COLLAPSE (RINGAN) 3,080,700 3,696,800 4,312,900
314 I-4-21-II SYNCOPE & COLLAPSE (SEDANG) 3,903,200 4,683,900 5,464,500
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REGIONAL 2
RAWAT INAP

315 I-4-21-III SYNCOPE & COLLAPSE (BERAT) 5,633,900 6,760,700 7,887,500
316 I-4-22-I KARDIOMIOPATHI (RINGAN) 3,107,600 3,729,200 4,350,700
317 I-4-22-II KARDIOMIOPATHI (SEDANG) 3,868,500 4,642,200 5,415,900
318 I-4-22-III KARDIOMIOPATHI (BERAT) 5,654,600 6,785,500 7,916,400
MALFUNGSI, REAKSI DAN KOMPLIKASI DARI ALAT
319 I-4-23-I 3,278,000 3,933,600 4,589,200
ATAU PROSEDUR KARDIOVASKULER (RINGAN)
320 I-4-23-II 4,024,500 4,829,400 5,634,300
ATAU PROSEDUR KARDIOVASKULER (SEDANG)
321 I-4-23-III 7,863,600 9,436,300 11,009,000
ATAU PROSEDUR KARDIOVASKULER (BERAT)
GANGGUAN SISTEM PEMBULUH DARAH LAIN-LAIN
322 I-4-24-I 2,738,800 3,286,600 3,834,400
(RINGAN)
323 I-4-24-II 6,306,800 7,568,200 8,829,600
(SEDANG)
324 I-4-24-III 7,973,900 9,568,700 11,163,400
(BERAT)
VENTILASI MEKANIKAL LONG TERM DENGAN
325 J-1-01-I 53,254,300 63,905,200 74,556,100
TRAKEOSTOMI (RINGAN)
326 J-1-01-II 60,267,200 72,320,600 84,374,100
TRAKEOSTOMI (SEDANG)
327 J-1-01-III 68,181,100 81,817,400 95,453,600
TRAKEOSTOMI (BERAT)
VENTILASI MEKANIKAL LONG TERM TANPA
328 J-1-02-I 28,260,100 33,912,200 39,564,200
329 J-1-02-II 39,349,300 47,219,200 55,089,000
330 J-1-02-III 64,979,200 77,975,000 90,970,900
TRAKEOSTOMI (BERAT)
PROSEDUR SISTEM PERNAFASAN SANGAT KOMPLEKS
331 J-1-10-I 8,581,900 10,298,200 12,014,600
(RINGAN)
332 J-1-10-II 17,365,400 20,838,500 24,311,600
(SEDANG)
333 J-1-10-III 18,605,100 22,326,100 26,047,200
(BERAT)
PROSEDUR SISTEM PERNAFASAN NON-KOMPLEKS
334 J-1-20-I 14,675,100 17,610,100 20,545,100
(RINGAN)
335 J-1-20-II 18,483,700 22,180,400 25,877,100
(SEDANG)
336 J-1-20-III 28,541,800 34,250,100 39,958,500
(BERAT)
PROSEDUR SISTEM PERNAFASAN KOMPLEKS
337 J-1-30-I 7,161,800 8,594,100 10,026,500
(RINGAN)
338 J-1-30-II 12,973,500 15,568,200 18,162,900
(SEDANG)
339 J-1-30-III PROSEDUR SISTEM PERNAFASAN KOMPLEKS (BERAT) 37,447,500 44,937,000 52,426,400
340 J-4-10-I KISTA FIBROSIS (RINGAN) 2,715,000 3,258,100 3,801,100

341 J-4-10-II KISTA FIBROSIS (SEDANG) 5,439,100 6,526,900 7,614,700
342 J-4-10-III KISTA FIBROSIS (BERAT) 8,228,500 9,874,200 11,519,900
343 J-4-11-I KEGAGALAN PERNAFASAN (RINGAN) 2,692,700 3,231,200 3,769,800
344 J-4-11-II KEGAGALAN PERNAFASAN (SEDANG) 3,637,900 4,365,400 5,093,000
345 J-4-11-III KEGAGALAN PERNAFASAN (BERAT) 5,027,000 6,032,400 7,037,800
346 J-4-12-I EMBOLI PARU (RINGAN) 4,436,300 5,323,600 6,210,800
347 J-4-12-II EMBOLI PARU (SEDANG) 5,050,100 6,060,100 7,070,100
348 J-4-12-III EMBOLI PARU (BERAT) 7,051,300 8,461,600 9,871,900
349 J-4-13-I TRAUMA DADA (RINGAN) 4,043,800 4,852,500 5,661,300
350 J-4-13-II TRAUMA DADA (SEDANG) 5,628,800 6,754,600 7,880,300
351 J-4-13-III TRAUMA DADA (BERAT) 10,501,500 12,601,800 14,702,100
352 J-4-14-I TUMOR PARU (RINGAN) 4,324,600 5,189,500 6,054,400
353 J-4-14-II TUMOR PARU (SEDANG) 7,255,000 8,706,000 10,157,000
354 J-4-14-III TUMOR PARU (BERAT) 8,583,400 10,300,100 12,016,800
355 J-4-15-I PERADANGAN DAN INFEKSI PERNAFASAN (RINGAN) 4,248,100 5,097,700 5,947,300
356 J-4-15-II PERADANGAN DAN INFEKSI PERNAFASAN (SEDANG) 5,075,300 6,090,300 7,105,400
357 J-4-15-III PERADANGAN DAN INFEKSI PERNAFASAN (BERAT) 6,828,300 8,194,000 9,559,600
358 J-4-16-I SIMPLE PNEUMONIA & WHOOPING COUGH (RINGAN) 3,539,600 4,247,500 4,955,400
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REGIONAL 2
RAWAT INAP

359 J-4-16-II SIMPLE PNEUMONIA & WHOOPING COUGH (SEDANG) 4,974,000 5,968,800 6,963,600
360 J-4-16-III SIMPLE PNEUMONIA & WHOOPING COUGH (BERAT) 6,288,900 7,546,600 8,804,400
361 J-4-17-I PENYAKIT PARU OBSTRUKTIF KRONIS (RINGAN) 3,613,600 4,336,300 5,059,000
362 J-4-17-II PENYAKIT PARU OBSTRUKTIF KRONIS (SEDANG) 4,327,400 5,192,900 6,058,300
363 J-4-17-III PENYAKIT PARU OBSTRUKTIF KRONIS (BERAT) 5,678,800 6,814,600 7,950,300
364 J-4-18-I ASTHMA & BRONKIOLITIS (RINGAN) 2,180,500 2,616,600 3,052,700
365 J-4-18-II ASTHMA & BRONKIOLITIS (SEDANG) 2,909,100 3,490,900 4,072,800
366 J-4-18-III ASTHMA & BRONKIOLITIS (BERAT) 3,062,200 3,674,700 4,287,100
367 J-4-19-I PENYAKIT PARU INTERSTITIAL (RINGAN) 5,089,800 6,107,800 7,125,800
368 J-4-19-II PENYAKIT PARU INTERSTITIAL (SEDANG) 5,772,200 6,926,700 8,081,100
369 J-4-19-III PENYAKIT PARU INTERSTITIAL (BERAT) 6,374,700 7,649,600 8,924,600
370 J-4-20-I PLEURAL EFUSI DAN PNEUMOTORAK (RINGAN) 4,545,900 5,455,100 6,364,300
371 J-4-20-II PLEURAL EFUSI DAN PNEUMOTORAK (SEDANG) 6,298,800 7,558,600 8,818,300
372 J-4-20-III PLEURAL EFUSI DAN PNEUMOTORAK (BERAT) 7,612,500 9,135,000 10,657,500
GEJALA, TANDA DAN DIAGNOSIS SISTEM
373 J-4-21-I 2,741,500 3,289,700 3,838,000
PERNAFASAN LAIN-LAIN (RINGAN)
374 J-4-21-II 4,416,400 5,299,700 6,183,000
PERNAFASAN LAIN-LAIN (SEDANG)
375 J-4-21-III 6,162,800 7,395,300 8,627,900
PERNAFASAN LAIN-LAIN (BERAT)
PROSEDUR NON KOMPLEKS USUS HALUS & USUS
376 K-1-10-I 7,780,000 9,336,000 10,892,000
BESAR (RINGAN)
377 K-1-10-II 10,079,600 12,095,500 14,111,400
BESAR (SEDANG)
378 K-1-10-III 11,813,600 14,176,300 16,539,100
BESAR (BERAT)
379 K-1-11-I ADHESIOLISIS PERITONEAL (RINGAN) 8,101,900 9,722,300 11,342,600
380 K-1-11-II ADHESIOLISIS PERITONEAL (SEDANG) 10,636,800 12,764,200 14,891,500
381 K-1-11-III ADHESIOLISIS PERITONEAL (BERAT) 18,965,500 22,758,600 26,551,700
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL &
382 K-1-12-I 3,365,300 4,038,400 4,711,500
FEMORAL (RINGAN)
383 K-1-12-II 4,377,000 5,252,400 6,127,800
FEMORAL (SEDANG)
384 K-1-12-III 8,671,500 10,405,800 12,140,100
FEMORAL (BERAT)
385 K-1-13-I PROSEDUR APPENDIK (RINGAN) 3,795,400 4,554,500 5,313,600
386 K-1-13-II PROSEDUR APPENDIK (SEDANG) 4,175,000 5,009,900 5,844,900
387 K-1-13-III PROSEDUR APPENDIK (BERAT) 4,212,900 5,055,500 5,898,100
PROSEDUR HERNIA INGUINAL DAN FEMORAL
388 K-1-14-I 5,377,000 6,452,500 7,527,900
(RINGAN)
389 K-1-14-II 6,301,800 7,562,100 8,822,500
(SEDANG)
390 K-1-14-III PROSEDUR HERNIA INGUINAL DAN FEMORAL (BERAT) 11,341,300 13,609,500 15,877,800
391 K-1-20-I PROSEDUR INTESTINAL KOMPLEKS (RINGAN) 11,926,300 14,311,600 16,696,900

392 K-1-20-II PROSEDUR INTESTINAL KOMPLEKS (SEDANG) 16,658,400 19,990,100 23,321,800
393 K-1-20-III PROSEDUR INTESTINAL KOMPLEKS (BERAT) 24,323,000 29,187,700 34,052,300
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG
394 K-1-30-I 7,053,100 8,463,800 9,874,400
NON KOMPLEKS (RINGAN)
395 K-1-30-II 12,150,400 14,580,500 17,010,600
NON KOMPLEKS (SEDANG)
396 K-1-30-III 17,236,300 20,683,500 24,130,800
NON KOMPLEKS (BERAT)
397 K-1-40-I PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (RINGAN) 7,633,600 9,160,300 10,687,000
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN

398 K-1-40-II 8,676,600 10,411,900 12,147,200
(SEDANG)
399 K-1-40-III PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (BERAT) 14,703,700 17,644,400 20,585,200
400 K-1-50-I PROSEDUR ANAL (RINGAN) 5,832,800 6,999,400 8,166,000

401 K-1-50-II PROSEDUR ANAL (SEDANG) 7,808,900 9,370,700 10,932,500
402 K-1-50-III PROSEDUR ANAL (BERAT) 10,704,400 12,845,200 14,986,100
403 K-4-10-I TUMOR PENCERNAAN (RINGAN) 4,815,300 5,778,400 6,741,400
404 K-4-10-II TUMOR PENCERNAAN (SEDANG) 6,918,900 8,302,600 9,686,400
- 255 -

REGIONAL 2
RAWAT INAP

405 K-4-10-III TUMOR PENCERNAAN (BERAT) 10,873,700 13,048,400 15,223,200
406 K-4-11-I GASTRITIS & ULKUS PEPTIKUM (RINGAN) 2,272,300 2,726,800 3,181,300
407 K-4-11-II GASTRITIS & ULKUS PEPTIKUM (SEDANG) 3,229,200 3,875,000 4,520,900
408 K-4-11-III GASTRITIS & ULKUS PEPTIKUM (BERAT) 3,875,000 4,650,100 5,425,100
409 K-4-12-I GANGGUAN ESOFAGUS (RINGAN) 2,894,600 3,473,500 4,052,500
410 K-4-12-II GANGGUAN ESOFAGUS (SEDANG) 4,015,700 4,818,900 5,622,000
411 K-4-12-III GANGGUAN ESOFAGUS (BERAT) 6,643,300 7,972,000 9,300,700
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT
412 K-4-13-I 3,902,100 4,682,500 5,463,000
PERADANGAN USUS BESAR (RINGAN)
413 K-4-13-II 5,047,600 6,057,200 7,066,700
PERADANGAN USUS BESAR (SEDANG)
414 K-4-13-III 7,775,000 9,330,000 10,885,000
PERADANGAN USUS BESAR (BERAT)
GANGGUAN PEMBULUH DARAH GASTROINTERTINAL
415 K-4-14-I 2,550,500 3,060,600 3,570,700
(RINGAN)
416 K-4-14-II 3,423,600 4,108,300 4,793,000
(SEDANG)
417 K-4-14-III 5,493,500 6,592,200 7,690,900
(BERAT)
418 K-4-15-I OBSTRUKSI SALURAN GASTROINTESTINAL (RINGAN) 2,592,600 3,111,200 3,629,700
419 K-4-15-II OBSTRUKSI SALURAN GASTROINTESTINAL (SEDANG) 3,996,300 4,795,600 5,594,900
420 K-4-15-III OBSTRUKSI SALURAN GASTROINTESTINAL (BERAT) 5,608,700 6,730,500 7,852,200

421 K-4-16-I INFEKSI-INFEKSI GASTROINTESTINAL (RINGAN) 3,611,900 4,334,300 5,056,700
422 K-4-16-II INFEKSI-INFEKSI GASTROINTESTINAL (SEDANG) 4,331,700 5,198,000 6,064,400
423 K-4-16-III INFEKSI-INFEKSI GASTROINTESTINAL (BERAT) 5,054,400 6,065,300 7,076,200
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN
424 K-4-17-I 1,682,900 2,019,500 2,356,100
(RINGAN)
425 K-4-17-II 2,072,500 2,487,000 2,901,500
(SEDANG)
426 K-4-17-III 2,487,000 2,984,400 3,481,800
(BERAT)
GANGGUAN SISTEM PENCERNAAN LAIN-LAIN
427 K-4-18-I 1,423,200 1,707,800 1,992,400
(RINGAN)
428 K-4-18-II 2,401,600 2,881,900 3,362,200
(SEDANG)
429 K-4-18-III GANGGUAN SISTEM PENCERNAAN LAIN-LAIN (BERAT) 2,881,900 3,458,200 4,034,600
430 L-1-20-I PEMINDAHAN KULIT PADA LUKA BAKAR (RINGAN) 19,015,100 22,818,100 26,621,100
431 L-1-20-II PEMINDAHAN KULIT PADA LUKA BAKAR (SEDANG) 28,702,700 34,443,300 40,183,800
432 L-1-20-III PEMINDAHAN KULIT PADA LUKA BAKAR (BERAT) 38,351,500 46,021,800 53,692,100
433 L-1-30-I PEMINDAHAN KULIT TANPA LUKA BAKAR (RINGAN) 8,702,300 10,442,800 12,183,300
434 L-1-30-II PEMINDAHAN KULIT TANPA LUKA BAKAR (SEDANG) 15,394,500 18,473,400 21,552,300
435 L-1-30-III PEMINDAHAN KULIT TANPA LUKA BAKAR (BERAT) 19,112,500 22,935,000 26,757,500
PROSEDUR PADA KULIT, JARINGAN) BAWAH KULIT
436 L-1-40-I 4,877,000 5,852,400 6,827,800
(RINGAN)
437 L-1-40-II 9,782,100 11,738,600 13,695,000
(SEDANG)
438 L-1-40-III 16,465,500 19,758,600 23,051,700
(BERAT)
439 L-1-50-I PROSEDUR PADA PAYUDARA (RINGAN) 6,402,500 7,683,000 8,963,500
440 L-1-50-II PROSEDUR PADA PAYUDARA (SEDANG) 10,304,200 12,365,000 14,425,800
441 L-1-50-III PROSEDUR PADA PAYUDARA (BERAT) 14,739,100 17,686,900 20,634,700
442 L-4-10-I PENYAKIT KULIT MAYOR (RINGAN) 1,726,400 2,071,700 2,417,000
443 L-4-10-II PENYAKIT KULIT MAYOR (SEDANG) 2,003,900 2,404,700 2,805,400
444 L-4-10-III PENYAKIT KULIT MAYOR (BERAT) 2,326,000 2,791,200 3,256,400
445 L-4-11-I TUMOR PAYUDARA (RINGAN) 3,506,900 4,208,300 4,909,600
446 L-4-11-II TUMOR PAYUDARA (SEDANG) 4,819,900 5,783,900 6,747,900
447 L-4-11-III TUMOR PAYUDARA (BERAT) 11,291,100 13,549,300 15,807,500
448 L-4-12-I PERADANGAN KULIT/CELLULITIS (RINGAN) 1,717,000 2,060,400 2,403,700
449 L-4-12-II PERADANGAN KULIT/CELLULITIS (SEDANG) 2,270,900 2,725,100 3,179,300
450 L-4-12-III PERADANGAN KULIT/CELLULITIS (BERAT) 7,509,000 9,010,800 10,512,600
TRAUMA PADA KULIT, JA(RINGAN) BAWAH KULIT DAN
451 L-4-13-I 2,335,200 2,802,200 3,269,300
PAYUDARA (RINGAN)
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REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,744,500 3,293,400 3,842,300
PAYUDARA (SEDANG)
453 L-4-13-III 4,038,600 4,846,300 5,654,000
PAYUDARA (BERAT)
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN
454 L-4-14-I 2,884,000 3,460,800 4,037,600
(RINGAN)
455 L-4-14-II 4,331,900 5,198,200 6,064,600
(SEDANG)
456 L-4-14-III 6,106,300 7,327,500 8,548,800
(BERAT)
PROSEDUR BILATERAL DAN MULTIPLE PADA SENDI
457 M-1-01-I 10,194,600 12,233,500 14,272,500
TUNGKAI BAWAH (RINGAN)
458 M-1-01-II 14,490,200 17,388,300 20,286,300
TUNGKAI BAWAH (SEDANG)
459 M-1-01-III 20,354,400 24,425,300 28,496,200
TUNGKAI BAWAH (BERAT)
460 M-1-02-I AMPUTASI (RINGAN) 9,315,100 11,178,100 13,041,100
461 M-1-02-II AMPUTASI (SEDANG) 15,281,000 18,337,200 21,393,400
462 M-1-02-III AMPUTASI (BERAT) 25,183,200 30,219,900 35,256,500
PROSEDUR FUSI TULANG BELAKANG PADA
463 M-1-03-I 22,804,900 27,365,900 31,926,800
LENGKUNGAN TULANG BELAKANG (RINGAN)
464 M-1-03-II 26,673,600 32,008,400 37,343,100
LENGKUNGAN TULANG BELAKANG (SEDANG)
465 M-1-03-III 33,013,100 39,615,700 46,218,300
LENGKUNGAN TULANG BELAKANG (BERAT)
466 M-1-04-I PROSEDUR PADA SENDI TUNGKAI BAWAH (RINGAN) 11,329,300 13,595,100 15,861,000
467 M-1-04-II PROSEDUR PADA SENDI TUNGKAI BAWAH (SEDANG) 14,554,800 17,465,800 20,376,800
468 M-1-04-III PROSEDUR PADA SENDI TUNGKAI BAWAH (BERAT) 17,953,800 21,544,600 25,135,400
469 M-1-05-I PROSEDUR PADA SENDI TUNGKAI ATAS (RINGAN) 7,415,300 8,898,400 10,381,500
470 M-1-05-II PROSEDUR PADA SENDI TUNGKAI ATAS (SEDANG) 11,634,700 13,961,700 16,288,600
471 M-1-05-III PROSEDUR PADA SENDI TUNGKAI ATAS (BERAT) 15,321,500 18,385,800 21,450,100
PROSEDUR FUSI TULANG BELAKANG SELAIN
472 M-1-07-I 8,051,600 9,661,900 11,272,200
473 M-1-07-II 10,786,300 12,943,600 15,100,900
474 M-1-07-III 21,972,800 26,367,300 30,761,900
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG
475 M-1-10-I 18,597,000 22,316,400 26,035,800
WAJAH (RINGAN)
476 M-1-10-II 44,464,700 53,357,700 62,250,600
WAJAH (SEDANG)
477 M-1-10-III 95,906,300 115,087,500 134,268,800
WAJAH (BERAT)
PROSEDUR PADA PAHA DAN SENDI PANGGUL
478 M-1-20-I 12,106,200 14,527,400 16,948,600
(RINGAN)
479 M-1-20-II 15,945,200 19,134,300 22,323,300
(SEDANG)
480 M-1-20-III PROSEDUR PADA PAHA DAN SENDI PANGGUL (BERAT) 39,756,700 47,708,000 55,659,300
481 M-1-30-I PROSEDUR KAKI (RINGAN) 8,562,000 10,274,400 11,986,800

482 M-1-30-II PROSEDUR KAKI (SEDANG) 13,873,900 16,648,700 19,423,500
483 M-1-30-III PROSEDUR KAKI (BERAT) 19,838,500 23,806,200 27,773,900
EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI
484 M-1-40-I 4,227,600 5,073,200 5,918,700
INTERNAL (RINGAN)
485 M-1-40-II 7,497,500 8,997,000 10,496,500
INTERNAL (SEDANG)
486 M-1-40-III 10,705,000 12,846,000 14,987,000
INTERNAL (BERAT)
487 M-1-50-I PROSEDUR JARINGAN LUNAK (RINGAN) 5,222,900 6,267,400 7,312,000
488 M-1-50-II PROSEDUR JARINGAN LUNAK (SEDANG) 8,667,300 10,400,700 12,134,200
489 M-1-50-III PROSEDUR JARINGAN LUNAK (BERAT) 14,235,400 17,082,500 19,929,600
PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN
490 M-1-60-I 7,824,300 9,389,100 10,954,000
PENGHUBUNG LAIN-LAIN (RINGAN)
491 M-1-60-II 9,836,900 11,804,300 13,771,700
PENGHUBUNG LAIN-LAIN (SEDANG)
492 M-1-60-III 15,319,500 18,383,300 21,447,200
PENGHUBUNG LAIN-LAIN (BERAT)
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REGIONAL 2
RAWAT INAP

PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN
493 M-1-70-I 14,944,200 17,933,100 20,921,900
KAKI (RINGAN)
494 M-1-70-II 16,438,700 19,726,400 23,014,100
KAKI (SEDANG)
495 M-1-70-III 18,820,100 22,584,100 26,348,100
KAKI (BERAT)
496 M-1-80-I PROSEDUR ANGGOTA TUBUH ATAS (RINGAN) 8,495,200 10,194,200 11,893,200
497 M-1-80-II PROSEDUR ANGGOTA TUBUH ATAS (SEDANG) 10,088,800 12,106,600 14,124,300
498 M-1-80-III PROSEDUR ANGGOTA TUBUH ATAS (BERAT) 22,707,700 27,249,300 31,790,800
499 M-4-10-I FRAKTUR FEMUR (RINGAN) 2,902,800 3,483,300 4,063,900
500 M-4-10-II FRAKTUR FEMUR (SEDANG) 4,329,000 5,194,800 6,060,600
501 M-4-10-III FRAKTUR FEMUR (BERAT) 8,190,500 9,828,500 11,466,600
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL
502 M-4-11-I 3,617,100 4,340,500 5,063,900
(RINGAN)
503 M-4-11-II 7,930,300 9,516,400 11,102,500
(SEDANG)
504 M-4-11-III 11,820,500 14,184,600 16,548,700
(BERAT)
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS
505 M-4-12-I 2,887,300 3,464,700 4,042,200
(RINGAN)
506 M-4-12-II 4,802,300 5,762,800 6,723,200
(SEDANG)
507 M-4-12-III 6,622,300 7,946,700 9,271,200
(BERAT)
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN
508 M-4-13-I 4,807,600 5,769,100 6,730,600
FRAKTUR PATOLOGIS (RINGAN)
509 M-4-13-II 7,223,200 8,667,800 10,112,500
FRAKTUR PATOLOGIS (SEDANG)
510 M-4-13-III 14,092,300 16,910,700 19,729,200
FRAKTUR PATOLOGIS (BERAT)
511 M-4-14-I OSTEOMIELITIS (RINGAN) 5,482,900 6,579,500 7,676,000
512 M-4-14-II OSTEOMIELITIS (SEDANG) 6,762,300 8,114,800 9,467,200
513 M-4-14-III OSTEOMIELITIS (BERAT) 10,161,800 12,194,200 14,226,500
514 M-4-15-I ARTRITIS SEPSIS (RINGAN) 3,351,700 4,022,100 4,692,400
515 M-4-15-II ARTRITIS SEPSIS (SEDANG) 4,333,600 5,200,300 6,067,100
516 M-4-15-III ARTRITIS SEPSIS (BERAT) 9,834,200 11,801,100 13,767,900
517 M-4-16-I GANGGUAN JARINGAN KONEKTIF (RINGAN) 2,783,500 3,340,200 3,896,900
518 M-4-16-II GANGGUAN JARINGAN KONEKTIF (SEDANG) 4,595,300 5,514,400 6,433,500
519 M-4-16-III GANGGUAN JARINGAN KONEKTIF (BERAT) 7,719,800 9,263,800 10,807,800
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG
520 M-4-17-I 3,612,600 4,335,200 5,057,700
(RINGAN)
521 M-4-17-II 5,052,700 6,063,200 7,073,700
(SEDANG)
522 M-4-17-III 7,055,700 8,466,900 9,878,000
(BERAT)
523 M-4-18-I PENYAKIT TULANG DAN SENDI LAIN-LAIN (RINGAN) 2,730,600 3,276,700 3,822,800
524 M-4-18-II PENYAKIT TULANG DAN SENDI LAIN-LAIN (SEDANG) 4,115,100 4,938,100 5,761,200
525 M-4-18-III PENYAKIT TULANG DAN SENDI LAIN-LAIN (BERAT) 4,954,800 5,945,700 6,936,700
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI
526 M-4-19-I PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 2,935,600 3,522,800 4,109,900
(RINGAN)
527 M-4-19-II PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 4,796,400 5,755,700 6,715,000
(SEDANG)
528 M-4-19-III PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 9,367,700 11,241,200 13,114,700
(BERAT)
TANDA, GEJALA & PERADANGAN MUSKULOSKELETAL
529 M-4-20-I 2,872,400 3,446,900 4,021,400
(RINGAN)
530 M-4-20-II 4,206,200 5,047,400 5,888,600
(SEDANG)
531 M-4-20-III 4,700,900 5,641,100 6,581,200
(BERAT)
GANGGUAN SISTEM MUSKULOSKELETAL &
532 M-4-21-I 2,892,300 3,470,800 4,049,200
JA(RINGAN) PENYAMBUNG LAIN-LAIN (RINGAN)
533 M-4-21-II 3,617,400 4,340,900 5,064,400
JA(RINGAN) PENYAMBUNG LAIN-LAIN (SEDANG)
- 258 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 8,110,200 9,732,200 11,354,300
JA(RINGAN) PENYAMBUNG LAIN-LAIN (BERAT)
535 N-1-01-I TRANSPLANTASI GINJAL (RINGAN) 171,645,400 205,974,400 240,303,500
536 N-1-01-II TRANSPLANTASI GINJAL (SEDANG) 171,645,400 205,974,400 240,303,500
537 N-1-01-III TRANSPLANTASI GINJAL (BERAT) 171,645,400 205,974,400 240,303,500
538 N-1-11-I PROSEDUR KANDUNG KEMIH KOMPLEK (RINGAN) 8,342,800 10,011,300 11,679,900
539 N-1-11-II PROSEDUR KANDUNG KEMIH KOMPLEK (SEDANG) 13,191,900 15,830,300 18,468,700
540 N-1-11-III PROSEDUR KANDUNG KEMIH KOMPLEK (BERAT) 20,566,200 24,679,500 28,792,700
MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN
541 N-1-12-I 4,252,000 5,102,400 5,952,800
ALAT DIALISIS (RINGAN)
542 N-1-12-II 8,727,100 10,472,600 12,218,000
ALAT DIALISIS (SEDANG)
543 N-1-12-III 18,938,200 22,725,900 26,513,500
ALAT DIALISIS (BERAT)
544 N-1-20-I PROSEDUR SALURAN URIN ATAS (RINGAN) 9,584,100 11,500,900 13,417,700
545 N-1-20-II PROSEDUR SALURAN URIN ATAS (SEDANG) 13,412,400 16,094,900 18,777,300
546 N-1-20-III PROSEDUR SALURAN URIN ATAS (BERAT) 18,206,000 21,847,100 25,488,300
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN
547 N-1-30-I 8,508,000 10,209,600 11,911,200
BAWAH (RINGAN)
548 N-1-30-II 12,870,900 15,445,100 18,019,300
BAWAH (SEDANG)
549 N-1-30-III 14,813,200 17,775,800 20,738,400
BAWAH (BERAT)
PROSEDUR PADA URETRA DAN TRANSURETRA
550 N-1-40-I 7,877,100 9,452,500 11,027,900
(RINGAN)
551 N-1-40-II 10,696,900 12,836,300 14,975,600
(SEDANG)
552 N-1-40-III 12,449,800 14,939,700 17,429,700
(BERAT)
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL
553 N-4-10-I 3,246,300 3,895,500 4,544,800
(RINGAN)
554 N-4-10-II 4,047,800 4,857,400 5,667,000
(SEDANG)
555 N-4-10-III 5,953,800 7,144,600 8,335,300
(BERAT)
556 N-4-11-I PERADANGAN GINJAL (RINGAN) 2,569,100 3,082,900 3,596,800
557 N-4-11-II PERADANGAN GINJAL (SEDANG) 4,353,900 5,224,700 6,095,500
558 N-4-11-III PERADANGAN GINJAL (BERAT) 5,417,200 6,500,600 7,584,000
559 N-4-12-I INFEKSI GINJAL DAN SALURAN URIN (RINGAN) 2,343,900 2,812,700 3,281,500
560 N-4-12-II INFEKSI GINJAL DAN SALURAN URIN (SEDANG) 4,120,300 4,944,300 5,768,400
561 N-4-12-III INFEKSI GINJAL DAN SALURAN URIN (BERAT) 4,959,400 5,951,300 6,943,200
562 N-4-13-I BATU URIN (RINGAN) 3,347,900 4,017,500 4,687,100
563 N-4-13-II BATU URIN (SEDANG) 4,038,000 4,845,600 5,653,200
564 N-4-13-III BATU URIN (BERAT) 6,379,300 7,655,200 8,931,000
565 N-4-14-I PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 2,502,800 3,003,400 3,503,900
KULIT ATAU PENCAKOKAN (RINGAN)
566 N-4-14-II PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 3,551,400 4,261,700 4,971,900
KULIT ATAU PENCAKOKAN (SEDANG)
567 N-4-14-III PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 5,692,800 6,831,400 7,970,000
KULIT ATAU PENCAKOKAN (BERAT)
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN
568 N-4-15-I 2,956,800 3,548,100 4,139,500
URIN (RINGAN)
569 N-4-15-II 3,782,300 4,538,700 5,295,200
URIN (SEDANG)
570 N-4-15-III 4,316,200 5,179,500 6,042,700
URIN (BERAT)
PENYAKIT GINJAL DAN SALURAN URIN LAIN-LAIN
571 N-4-16-I 3,620,500 4,344,600 5,068,800
(RINGAN)
572 N-4-16-II 5,167,700 6,201,200 7,234,700
(SEDANG)
573 N-4-16-III 7,091,300 8,509,500 9,927,800
(BERAT)
574 O-6-10-I OPERASI PEMBEDAHAN CAESAR (RINGAN) 4,885,100 5,862,100 6,839,100
575 O-6-10-II OPERASI PEMBEDAHAN CAESAR (SEDANG) 5,295,000 6,354,000 7,413,000

- 259 -

REGIONAL 2
RAWAT INAP

576 O-6-10-III OPERASI PEMBEDAHAN CAESAR (BERAT) 8,868,400 10,642,000 12,415,700
PERSALINAN VAGINAL DENGAN STERILISASI &/
577 O-6-11-I 3,365,500 4,038,600 4,711,700
DILATASI & KURET (RINGAN)
578 O-6-11-II 3,740,300 4,488,400 5,236,500
DILATASI & KURET (SEDANG)
579 O-6-11-III 4,796,900 5,756,300 6,715,700
DILATASI & KURET (BERAT)
PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN
580 O-6-12-I 2,458,100 2,949,800 3,441,400
STERILISASI &/ DILATASI &KURET (RINGAN)
581 O-6-12-II 2,952,200 3,542,600 4,133,100
STERILISASI &/ DILATASI & KURET (SEDANG)
582 O-6-12-III 3,709,500 4,451,500 5,193,400
STERILISASI &/ DILATASI & KURET (BERAT)
583 O-6-13-I PERSALINAN VAGINAL (RINGAN) 1,640,800 1,969,000 2,297,100
584 O-6-13-II PERSALINAN VAGINAL (SEDANG) 1,942,000 2,330,500 2,718,900
585 O-6-13-III PERSALINAN VAGINAL (BERAT) 2,330,500 2,796,500 3,262,600
NEONATAL DENGAN PENCANGKOKAN ORGAN ATAU
586 P-8-01-I 53,243,600 63,892,400 74,541,100
OKSIGENASI SELAPUT EKSTRAKORPORAL (RINGAN)
587 P-8-01-II 65,881,000 79,057,200 92,233,400
OKSIGENASI SELAPUT EKSTRAKORPORAL (SEDANG)
588 P-8-01-III 77,325,800 92,790,900 108,256,100
OKSIGENASI SELAPUT EKSTRAKORPORAL (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 DENGAN
589 P-8-02-I 83,190,400 99,828,500 116,466,600
PROSEDUR MAYOR (RINGAN)
590 P-8-02-II 95,427,900 114,513,500 133,599,100
PROSEDUR MAYOR (SEDANG)
591 P-8-02-III 109,033,300 130,840,000 152,646,600
PROSEDUR MAYOR (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 TANPA
592 P-8-03-I 12,035,500 14,442,600 16,849,700
593 P-8-03-II 16,994,500 20,393,400 23,792,300
594 P-8-03-III 23,787,200 28,544,700 33,302,100
595 P-8-04-I 34,713,800 41,656,500 48,599,300
596 P-8-04-II 44,875,600 53,850,700 62,825,900
597 P-8-04-III 64,340,400 77,208,500 90,076,500
598 P-8-05-I 18,849,700 22,619,600 26,389,600
599 P-8-05-II 29,468,600 35,362,400 41,256,100
600 P-8-05-III 39,218,200 47,061,800 54,905,400
601 P-8-06-I 5,157,000 6,188,400 7,219,800
602 P-8-06-II 14,459,100 17,350,900 20,242,700
603 P-8-06-III 19,154,700 22,985,700 26,816,600
604 P-8-07-I 4,995,100 5,994,100 6,993,100
605 P-8-07-II 14,005,100 16,806,100 19,607,100
606 P-8-07-III 18,553,300 22,264,000 25,974,600
607 P-8-08-I 4,135,900 4,963,100 5,790,200
SINDROMA DISTRES PERNAFASAN (RINGAN)
608 P-8-08-II 5,868,600 7,042,300 8,216,000
SINDROMA DISTRES PERNAFASAN (SEDANG)
609 P-8-08-III 9,502,500 11,403,000 13,303,500
SINDROMA DISTRES PERNAFASAN (BERAT)
NEONATAL, BBL 1000 - 1499 GR TANPA PROSEDUR
610 P-8-11-I 10,029,600 12,035,500 14,041,500
MAYOR (RINGAN)
611 P-8-11-II 14,162,100 16,994,500 19,826,900
MAYOR (SEDANG)
- 260 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 19,822,700 23,787,200 27,751,800
MAYOR (BERAT)
613 P-8-12-I 9,475,300 11,370,400 13,265,400
MAYOR (RINGAN)
614 P-8-12-II 10,893,900 13,072,700 15,251,500
MAYOR (SEDANG)
615 P-8-12-III 15,248,200 18,297,900 21,347,500
MAYOR (BERAT)
616 P-8-13-I 5,371,800 6,446,100 7,520,500
MAYOR (RINGAN)
617 P-8-13-II 8,379,900 10,055,900 11,731,900
MAYOR (SEDANG)
618 P-8-13-III 13,018,500 15,622,200 18,225,900
MAYOR (BERAT)
NEONATAL, BBL > 2499 GR DENGAN ANOMALI MAYOR
619 P-8-14-I 3,580,200 4,296,200 5,012,300
ATAU KONDISI HEREDITER (RINGAN)
620 P-8-14-II 7,287,900 8,745,400 10,203,000
ATAU KONDISI HEREDITER (SEDANG)
621 P-8-14-III 13,116,100 15,739,300 18,362,500
ATAU KONDISI HEREDITER (BERAT)
NEONATAL, BBL > 2499 GR DENGAN SINDROMA
622 P-8-15-I 2,685,200 3,222,200 3,759,300
ASPIRASI (RINGAN)
623 P-8-15-II 5,377,200 6,452,700 7,528,100
ASPIRASI (SEDANG)
624 P-8-15-III 6,309,200 7,571,000 8,832,900
ASPIRASI (BERAT)
NEONATAL, BBL > 2499 GR DENGAN
625 P-8-16-I 2,430,100 2,916,200 3,402,200
KONGENITAL/INFEKSI PERINATAL (RINGAN)
626 P-8-16-II 4,669,900 5,603,900 6,537,800
KONGENITAL/INFEKSI PERINATAL (SEDANG)
627 P-8-16-III 11,427,800 13,713,400 15,998,900
KONGENITAL/INFEKSI PERINATAL (BERAT)
NEONATAL, BBL > 2499 GR TANPA PROSEDUR MAYOR
628 P-8-17-I 3,581,200 4,297,400 5,013,600
(RINGAN)
629 P-8-17-II 6,446,100 7,735,300 9,024,600
(SEDANG)
630 P-8-17-III 9,070,800 10,885,000 12,699,100
(BERAT)
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK
631 S-4-10-I 2,657,700 3,189,300 3,720,800
ATAU BANYAK TEMPAT (RINGAN)
632 S-4-10-II 3,274,700 3,929,700 4,584,600
ATAU BANYAK TEMPAT (SEDANG)
633 S-4-10-III 4,482,800 5,379,300 6,275,900
ATAU BANYAK TEMPAT (BERAT)
634 S-4-11-I REAKSI ALLERGI (RINGAN) 1,608,300 1,930,000 2,251,600
635 S-4-11-II REAKSI ALLERGI (SEDANG) 2,358,400 2,830,100 3,301,800
636 S-4-11-III REAKSI ALLERGI (BERAT) 4,030,800 4,837,000 5,643,100
637 S-4-12-I EFEK TOKSIK DAN KERACUNAN OBAT (RINGAN) 1,954,000 2,344,800 2,735,600
638 S-4-12-II EFEK TOKSIK DAN KERACUNAN OBAT (SEDANG) 2,600,700 3,120,800 3,641,000
639 S-4-12-III EFEK TOKSIK DAN KERACUNAN OBAT (BERAT) 4,508,300 5,410,000 6,311,600
KOMPLIKASI DARI PENATALAKSANAAN PASIEN
640 S-4-13-I 2,885,500 3,462,600 4,039,700
(RINGAN)
641 S-4-13-II 5,119,100 6,142,900 7,166,800
(SEDANG)
642 S-4-13-III 8,309,000 9,970,700 11,632,500
(BERAT)
SINDROMA MALTREATMENT PADA DEWASA ATAU
643 S-4-14-I 1,460,300 1,752,300 2,044,400
KANAK-KANAK (RINGAN)
644 S-4-14-II 3,101,700 3,722,100 4,342,400
KANAK-KANAK (SEDANG)
645 S-4-14-III 5,882,000 7,058,400 8,234,700
KANAK-KANAK (BERAT)
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN
646 S-4-15-I 976,600 1,172,000 1,367,300
AKUT YANG LAIN (RINGAN)
647 S-4-15-II 1,843,100 2,211,700 2,580,300
AKUT YANG LAIN (SEDANG)
648 S-4-15-III 2,387,100 2,864,500 3,342,000
AKUT YANG LAIN (BERAT)
649 S-4-16-I LUKA BAKAR (RINGAN) 5,057,200 6,068,700 7,080,100
- 261 -

REGIONAL 2
RAWAT INAP

650 S-4-16-II LUKA BAKAR (SEDANG) 6,630,500 7,956,600 9,282,700
651 S-4-16-III LUKA BAKAR (BERAT) 9,493,500 11,392,300 13,291,000
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK
652 S-4-17-I 2,437,500 2,925,000 3,412,500
TOKSIK LAIN-LAIN (RINGAN)
653 S-4-17-II 3,617,500 4,341,000 5,064,500
TOKSIK LAIN-LAIN (SEDANG)
654 S-4-17-III 4,350,900 5,221,000 6,091,200
TOKSIK LAIN-LAIN (BERAT)
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL &
655 T-1-10-I 1,681,300 2,017,600 2,353,800
OBAT (RINGAN)
656 T-1-10-II 2,258,200 2,709,900 3,161,500
OBAT (SEDANG)
657 T-1-10-III 4,108,000 4,929,700 5,751,300
OBAT (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT DAN
658 T-4-10-I 729,300 875,200 1,021,000
ALKOHOL, MENOLAK NASEHAT DOKTER (RINGAN)
659 T-4-10-II 1,389,900 1,667,900 1,945,900
ALKOHOL, MENOLAK NASEHAT DOKTER (SEDANG)
660 T-4-10-III 2,020,600 2,424,700 2,828,900
ALKOHOL, MENOLAK NASEHAT DOKTER (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN
661 T-4-11-I 995,400 1,194,400 1,393,500
ALKOHOL,OPIUM DAN KOKAIN (RINGAN)
662 T-4-11-II 1,566,400 1,879,700 2,192,900
ALKOHOL,OPIUM DAN KOKAIN (SEDANG)
663 T-4-11-III 2,523,000 3,027,600 3,532,200
ALKOHOL,OPIUM DAN KOKAIN (BERAT)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-
664 T-4-12-I 1,639,800 1,967,800 2,295,800
LAIN (RINGAN)
665 T-4-12-II 2,443,400 2,932,100 3,420,800
LAIN (SEDANG)
666 T-4-12-III 3,748,800 4,498,600 5,248,300
LAIN (BERAT)
667 U-1-10-I PROSEDUR KOMPLEKS LARING (RINGAN) 5,329,500 6,395,400 7,461,300
668 U-1-10-II PROSEDUR KOMPLEKS LARING (SEDANG) 8,273,500 9,928,200 11,582,900
669 U-1-10-III PROSEDUR KOMPLEKS LARING (BERAT) 21,852,500 26,223,000 30,593,500
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN
670 U-1-11-I 8,245,000 9,894,000 11,543,000
(RINGAN)
671 U-1-11-II 10,451,800 12,542,100 14,632,500
(SEDANG)
672 U-1-11-III 15,503,500 18,604,300 21,705,000
(BERAT)
673 U-1-12-I PROSEDUR MASTOID DAN SINUS (RINGAN) 6,442,600 7,731,100 9,019,600
674 U-1-12-II PROSEDUR MASTOID DAN SINUS (SEDANG) 9,879,300 11,855,200 13,831,000
675 U-1-12-III PROSEDUR MASTOID DAN SINUS (BERAT) 14,510,700 17,412,800 20,314,900
676 U-1-13-I PROSEDUR KELENJAR LUDAH (RINGAN) 6,447,000 7,736,400 9,025,800
677 U-1-13-II PROSEDUR KELENJAR LUDAH (SEDANG) 7,511,800 9,014,100 10,516,500
678 U-1-13-III PROSEDUR KELENJAR LUDAH (BERAT) 12,452,100 14,942,600 17,433,000
OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT
679 U-1-14-I 3,994,000 4,792,800 5,591,600
(RINGAN)
680 U-1-14-II 4,901,600 5,881,900 6,862,200
(SEDANG)
681 U-1-14-III 5,808,400 6,970,100 8,131,700
(BERAT)
682 U-1-15-I PROSEDUR TONSIL & ADENOID (RINGAN) 3,821,200 4,585,400 5,349,700
683 U-1-15-II PROSEDUR TONSIL & ADENOID (SEDANG) 5,432,600 6,519,100 7,605,700
684 U-1-15-III PROSEDUR TONSIL & ADENOID (BERAT) 7,002,400 8,402,900 9,803,300
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN
685 U-1-20-I 6,063,500 7,276,200 8,488,900
TELINGA LAIN-LAIN (RINGAN)
686 U-1-20-II 9,024,200 10,829,000 12,633,900
TELINGA LAIN-LAIN (SEDANG)
687 U-1-20-III 22,471,800 26,966,200 31,460,600
TELINGA LAIN-LAIN (BERAT)
688 U-1-30-I PROSEDUR MULUT (RINGAN) 5,200,100 6,240,200 7,280,200
689 U-1-30-II PROSEDUR MULUT (SEDANG) 7,051,200 8,461,400 9,871,600
690 U-1-30-III PROSEDUR MULUT (BERAT) 13,375,100 16,050,200 18,725,200
NEOPLASMA TELIGA, HIDUNG, MULUT DAN
691 U-4-10-I 3,742,200 4,490,700 5,239,100
TENGGOROKAN (RINGAN)
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REGIONAL 2
RAWAT INAP

692 U-4-10-II 8,310,100 9,972,100 11,634,100
TENGGOROKAN (SEDANG)
693 U-4-10-III 12,758,500 15,310,200 17,861,900
TENGGOROKAN (BERAT)
694 U-4-11-I DYSEQUILIBRIUM (RINGAN) 1,486,600 1,783,900 2,081,200
695 U-4-11-II DYSEQUILIBRIUM (SEDANG) 2,162,000 2,594,400 3,026,800
696 U-4-11-III DYSEQUILIBRIUM (BERAT) 2,274,400 2,729,300 3,184,200
697 U-4-12-I EPISTAKSIS/PERDARAHAN HIDUNG (RINGAN) 2,482,800 2,979,300 3,475,900
698 U-4-12-II EPISTAKSIS/PERDARAHAN HIDUNG (SEDANG) 2,888,000 3,465,500 4,043,100
699 U-4-12-III EPISTAKSIS/PERDARAHAN HIDUNG (BERAT) 3,862,300 4,634,800 5,407,300
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA
700 U-4-13-I 1,939,800 2,327,700 2,715,700
DAN LARINGOTRAKEITIS (RINGAN)
701 U-4-13-II 2,286,800 2,744,200 3,201,500
DAN LARINGOTRAKEITIS (SEDANG)
702 U-4-13-III 2,735,100 3,282,200 3,829,200
DAN LARINGOTRAKEITIS (BERAT)
703 U-4-14-I PENYAKIT MULUT DAN GIGI (RINGAN) 3,613,000 4,335,600 5,058,200
704 U-4-14-II PENYAKIT MULUT DAN GIGI (SEDANG) 4,326,500 5,191,800 6,057,100
705 U-4-14-III PENYAKIT MULUT DAN GIGI (BERAT) 7,265,500 8,718,600 10,171,700
PENYAKIT TELINGA, HIDUNG, MULUT DAN
706 U-4-15-I 2,901,200 3,481,400 4,061,600
TENGGOROKAN LAIN-LAIN (RINGAN)
707 U-4-15-II 3,614,500 4,337,400 5,060,300
TENGGOROKAN LAIN-LAIN (SEDANG)
708 U-4-15-III 5,058,500 6,070,200 7,081,900
TENGGOROKAN LAIN-LAIN (BERAT)
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK
709 V-1-10-I 4,878,400 5,854,100 6,829,700
(RINGAN)
710 V-1-10-II 9,747,800 11,697,400 13,646,900
(SEDANG)
711 V-1-10-III 11,954,300 14,345,200 16,736,100
(BERAT)
712 V-1-11-I PROSEDUR PADA PENIS (RINGAN) 9,002,500 10,803,000 12,603,500
713 V-1-11-II PROSEDUR PADA PENIS (SEDANG) 10,279,800 12,335,700 14,391,700
714 V-1-11-III PROSEDUR PADA PENIS (BERAT) 16,098,500 19,318,200 22,537,900
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-
715 V-1-12-I 8,464,100 10,156,900 11,849,700
MODERAT (RINGAN)
716 V-1-12-II 11,915,800 14,299,000 16,682,200
MODERAT (SEDANG)
717 V-1-12-III 14,650,300 17,580,400 20,510,500
MODERAT (BERAT)
PROSEDUR PADA SKROTUM DAN PROSTAT NON
718 V-1-13-I 4,551,500 5,461,800 6,372,100
KOMPLEK (RINGAN)
719 V-1-13-II 8,696,400 10,435,700 12,175,000
KOMPLEK (SEDANG)
720 V-1-13-III 13,234,300 15,881,200 18,528,000
KOMPLEK (BERAT)
PENGANGKATAN PROSTAT MELALUI URETRA
721 V-1-14-I 8,657,700 10,389,300 12,120,800
(RINGAN)
722 V-1-14-II 12,579,400 15,095,300 17,611,200
(SEDANG)
723 V-1-14-III PENGANGKATAN PROSTAT MELALUI URETRA (BERAT) 15,707,700 18,849,200 21,990,700
724 V-1-15-I SIRKUMSISI (RINGAN) 1,437,500 1,724,900 2,012,400

725 V-1-15-II SIRKUMSISI (SEDANG) 1,586,200 1,903,500 2,220,700
726 V-1-15-III SIRKUMSISI (BERAT) 1,754,700 2,105,600 2,456,600
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI
727 V-4-10-I 4,316,200 5,179,500 6,042,700
(RINGAN)
728 V-4-10-II 7,169,400 8,603,300 10,037,200
(SEDANG)
729 V-4-10-III 11,819,900 14,183,900 16,547,900
(BERAT)
PENYAKIT SISTEM REPRODUKSI LAKI-LAKI SELAIN
730 V-4-11-I 3,617,600 4,341,100 5,064,600
TUMOR (RINGAN)
731 V-4-11-II 4,853,900 5,824,600 6,795,400
TUMOR (SEDANG)
732 V-4-11-III 6,702,900 8,043,500 9,384,000
TUMOR (BERAT)
- 263 -

REGIONAL 2
RAWAT INAP

OPERASI PENGANGKATAN RAHIM DAN VULVA
733 W-1-01-I 10,165,200 12,198,200 14,231,300
RADIKAL & EVISCERASI (RINGAN)
734 W-1-01-II 11,818,200 14,181,800 16,545,500
RADIKAL & EVISCERASI (SEDANG)
735 W-1-01-III 17,385,800 20,863,000 24,340,100
RADIKAL & EVISCERASI (BERAT)
736 W-1-10-I PROSEDUR ABORSI (RINGAN) 2,156,200 2,587,400 3,018,700
737 W-1-10-II PROSEDUR ABORSI (SEDANG) 2,379,300 2,855,200 3,331,100
738 W-1-10-III PROSEDUR ABORSI (BERAT) 2,632,000 3,158,400 3,684,800
PROSEDUR DILATASI, KURET, INTRAUTERIN &
739 W-1-11-I 2,253,700 2,704,400 3,155,200
SERVIK (RINGAN)
740 W-1-11-II 2,486,900 2,984,300 3,481,700
SERVIK (SEDANG)
741 W-1-11-III 2,751,000 3,301,300 3,851,500
SERVIK (BERAT)
742 W-1-12-I PROSEDUR PADAA TUBA FALOPII (RINGAN) 2,424,500 2,909,400 3,394,300
743 W-1-12-II PROSEDUR PADAA TUBA FALOPII (SEDANG) 3,026,200 3,631,400 4,236,700
744 W-1-12-III PROSEDUR PADAA TUBA FALOPII (BERAT) 5,198,000 6,237,600 7,277,200
745 W-1-13-I INTERUPSI TUBA DENGAN ENDOSKOP (RINGAN) 2,417,400 2,900,900 3,384,400
746 W-1-13-II INTERUPSI TUBA DENGAN ENDOSKOP (SEDANG) 2,624,500 3,149,400 3,674,300
747 W-1-13-III INTERUPSI TUBA DENGAN ENDOSKOP (BERAT) 3,525,400 4,230,500 4,935,600
748 W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA (RINGAN) 8,095,700 9,714,900 11,334,000
749 W-1-20-II PROSEDUR PADA RAHIM & ADNEKSA (SEDANG) 10,115,700 12,138,800 14,162,000
750 W-1-20-III PROSEDUR PADA RAHIM & ADNEKSA (BERAT) 11,726,700 14,072,000 16,417,400
751 W-1-30-I PROSEDUR PADA VAGINA, SERVIK & VULVA (RINGAN) 4,570,200 5,484,200 6,398,200
752 W-1-30-II PROSEDUR PADA VAGINA, SERVIK & VULVA (SEDANG) 7,289,400 8,747,300 10,205,100
753 W-1-30-III PROSEDUR PADA VAGINA, SERVIK & VULVA (BERAT) 17,884,900 21,461,900 25,038,900
754 W-4-10-I TUMOR SISTEM REPRODUKSI WANITA (RINGAN) 3,405,200 4,086,300 4,767,300
755 W-4-10-II TUMOR SISTEM REPRODUKSI WANITA (SEDANG) 5,048,100 6,057,700 7,067,400
756 W-4-10-III TUMOR SISTEM REPRODUKSI WANITA (BERAT) 9,976,100 11,971,300 13,966,500
757 W-4-11-I INFEKSI SISTEM REPRODUKSI WANITA (RINGAN) 3,096,800 3,716,200 4,335,500
758 W-4-11-II INFEKSI SISTEM REPRODUKSI WANITA (SEDANG) 4,701,400 5,641,700 6,582,000
759 W-4-11-III INFEKSI SISTEM REPRODUKSI WANITA (BERAT) 5,722,500 6,867,000 8,011,600
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI
760 W-4-12-I 2,752,100 3,302,500 3,852,900
WANITA LAIN-LAIN (RINGAN)
761 W-4-12-II 3,778,400 4,534,100 5,289,800
WANITA LAIN-LAIN (SEDANG)
762 W-4-12-III 4,118,700 4,942,400 5,766,100
WANITA LAIN-LAIN (BERAT)
763 W-4-13-I ABORTUS (RINGAN) 1,218,400 1,462,100 1,705,800
764 W-4-13-II ABORTUS (SEDANG) 1,664,400 1,997,300 2,330,200
765 W-4-13-III ABORTUS (BERAT) 2,069,800 2,483,700 2,897,700
766 W-4-14-I ABORTUS MENGANCAM (RINGAN) 1,628,300 1,953,900 2,279,600
767 W-4-14-II ABORTUS MENGANCAM (SEDANG) 1,998,000 2,397,600 2,797,200
768 W-4-14-III ABORTUS MENGANCAM (BERAT) 2,479,500 2,975,400 3,471,300
769 W-4-15-I PERSALINAN FALSE LABOR (RINGAN) 1,548,500 1,858,200 2,167,900
770 W-4-15-II PERSALINAN FALSE LABOR (SEDANG) 1,719,800 2,063,700 2,407,700
771 W-4-15-III PERSALINAN FALSE LABOR (BERAT) 2,381,100 2,857,300 3,333,500
772 W-4-16-I GANGGUAN ANTEPARTUM (RINGAN) 2,124,000 2,548,900 2,973,700
773 W-4-16-II GANGGUAN ANTEPARTUM (SEDANG) 2,840,400 3,408,500 3,976,600
774 W-4-16-III GANGGUAN ANTEPARTUM (BERAT) 3,849,700 4,619,600 5,389,500
775 W-4-17-I GANGGUAN POSTPARTUM (RINGAN) 1,520,300 1,824,400 2,128,400
776 W-4-17-II GANGGUAN POSTPARTUM (SEDANG) 2,744,900 3,293,900 3,842,900
777 W-4-17-III GANGGUAN POSTPARTUM (BERAT) 4,058,400 4,870,000 5,681,700
778 Z-4-10-I REHABILITASI (RINGAN) 2,805,000 3,366,000 3,927,000
779 Z-4-10-II REHABILITASI (SEDANG) 3,723,300 4,468,000 5,212,600
780 Z-4-10-III REHABILITASI (BERAT) 5,289,300 6,347,200 7,405,000
781 Z-4-11-I GEJALA-GEJALA DAN TANDA-TANDA (RINGAN) 2,555,500 3,066,600 3,577,800
782 Z-4-11-II GEJALA-GEJALA DAN TANDA-TANDA (SEDANG) 3,069,300 3,683,200 4,297,100
783 Z-4-11-III GEJALA-GEJALA DAN TANDA-TANDA (BERAT) 4,219,000 5,062,800 5,906,600
- 264 -

REGIONAL 2
RAWAT INAP

FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS
784 Z-4-12-I 1,838,400 2,206,100 2,573,800
KESEHATAN LAIN-LAIN (RINGAN)
785 Z-4-12-II 3,857,700 4,629,300 5,400,800
KESEHATAN LAIN-LAIN (SEDANG)
786 Z-4-12-III 5,938,400 7,126,000 8,313,700
KESEHATAN LAIN-LAIN (BERAT)
- 265 -

REGIONAL 2
RUMAH SAKIT UMUM KELAS B PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
1 B-2-10-0 PROSEDUR PADA HATI DAN PANKREAS 923,600
2 B-2-11-0 PROSEDUR BESAR PADA SALURAN EMPEDU 1,198,100
3 B-2-12-0 PROSEDUR KOLESISTEKTOMI TANPA LAPAROSKOPI 2,227,900
4 B-2-13-0 PROSEDUR LAIN-LAIN PADA HEPATOBILIARI & PANKREAS 1,841,100
5 B-2-14-0 PROSEDUR KOLESISTEKTOMI DENGAN LAPAROSKOPI 2,392,600
6 B-3-10-0 PROSEDUR PERKUTAN PADA HATI DAN SALURAN EMPEDU 440,100
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 1,075,700
8 B-3-12-0 PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN PANKREAS 344,100
9 C-3-10-0 PROSEDUR RADIOTERAPI 923,700
10 C-3-11-0 KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH 686,300
11 C-3-12-0 KEMOTERAPI PADA TUMOR KOLON 779,200
12 C-3-13-0 KEMOTERAPI PADA TUMOR PAYUDARA ATAU OVARIUM 1,171,500
13 C-3-14-0 KEMOTERAPI PADA TUMOR GASTROINTESTINAL 1,597,900
14 C-3-15-0 KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU PROSTAT 1,464,500
15 C-3-16-0 KEMOTERAPI PADA TUMOR OTAK 474,400
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 1,095,000
17 C-3-18-0 KEMOTERAPI PADA LEUKEMIA AKUT 397,200
18 C-3-19-0 KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS 681,900
19 C-3-20-0 KEMOTERAPI PADA TUMOR KULIT 2,077,200
20 C-3-21-0 KEMOTERAPI PADA TUMOR GINEKOLOGI 743,900
21 C-3-22-0 KEMOTERAPI PADA TUMOR METASTASE 1,756,800
22 C-3-23-0 KEMOTERAPI PADA TUMOR LAIN-LAIN 428,600
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 1,306,100
24 D-2-11-0 PROSEDUR LIMPA 1,486,800
25 D-2-21-0 PROSEDUR BESAR PADA NODUL LIMPA DAN TYMUS 1,247,000
26 D-2-22-0 PROSEDUR KECIL PADA NODUL LIMPA DAN TYMUS 305,800
27 D-3-10-0 PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG 975,700
28 D-3-11-0 PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH 515,300
29 E-2-10-0 PROSEDUR PADA KELENJAR ADRENAL 364,300
30 E-2-21-0 PROSEDUR BESAR PADA KELENJAR TIROID DAN PARATIROID 286,500
31 E-2-22-0 PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL 252,900
32 E-3-10-0 PROSEDUR DIAGNOSTIK PADA KELENJAR ENDOKRIN 302,400

33 F-3-10-0 TERAPI SHOCK 421,100
34 F-5-10-0 PELAYANAN KESEHATAN MENTAL EKSTENSIF 361,800
35 F-5-11-0 TERAPI KELOMPOK 340,600
36 F-5-12-0 PROSEDUR TES DIAGNOSTIK KESEHATAN JIWA 306,000
37 F-5-13-0 PSIKOTERAPI INDIVIDU DEWASA AKUT 454,100
38 F-5-14-0 PSIKOTHERAPI INDIVIDU DEWASA BUKAN AKUT 198,300
39 F-5-15-0 PENGOBATAN INDIVIDU KETERBELAKANGAN MENTAL 233,700
40 F-5-16-0 PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN MENTAL 268,000
41 G-2-10-0 PROSEDUR KRANIOTOMI 5,437,800
42 G-2-11-0 PROSEDUR SHUNT VENTRIKEL 2,173,200
43 G-2-12-0 PROSEDUR PADA PEMBULUH DARAH EKSTRAKRANIAL 2,180,500
44 G-2-13-0 PROSEDUR CARPAL TUNNEL RELEASE 560,900
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 1,262,900
46 G-2-22-0 PROSEDUR KECIL PADA SARAF PERIFER 790,700
47 G-2-31-0 PROSEDUR BESAR PADA TULANG BELAKANG 1,607,200
48 G-2-32-0 PROSEDUR KECIL PADA TULANG BELAKANG 748,900
49 G-3-10-0 PROSEDUR TAP & INJEKSI PADA SPINAL 428,900
50 G-3-11-0 PROSEDUR INJEKSI PADA SARAF PERIFER 323,900
51 G-3-12-0 PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN 522,400
52 G-3-13-0 PROSEDUR ELEKROENSEFALOGRAFI (EEG) 346,900
53 G-5-17-0 PENYAKIT SARAF KRANIAL DAN SARAF PERIFER LAIN-LAIN 259,800
54 H-2-21-0 PROSEDUR BESAR PADA MATA EKSTERNAL 2,648,600
55 H-2-22-0 PROSEDUR SEDANG PADA MATA EKSTERNAL 1,236,000
56 H-2-23-0 PROSEDUR KECIL PADA MATA EKSTERNAL 706,300
57 H-2-31-0 PROSEDUR BESAR PADA SEGMEN ANTERIOR MATA 2,757,100
58 H-2-32-0 PROSEDUR SEDANG PADA SEGMEN ANTERIOR MATA 1,838,100
59 H-2-33-0 PROSEDUR KECIL PADA SEGMEN ANTERIOR MATA 260,300
60 H-2-34-0 PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA 2,986,800
61 H-2-35-0 PROSEDUR KECIL PADA SEGMEN POSTERIOR MATA 2,067,800
62 H-2-36-0 PROSEDUR OPERASI KATARAK 3,814,000
63 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 1,074,200
64 H-3-10-0 PROSEDUR LASER SEDANG PADA MATA 660,800
65 H-3-11-0 PROSEDUR KECIL PADA EKTRAOKULER 258,400
66 H-3-12-0 PROSEDUR LAIN-LAIN PADA MATA 215,300
67 H-3-13-0 PROSEDUR DIAGNOSTIK & IMAGING PADA MATA 242,700
68 I-2-11-0 PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTUNG 3,701,300
69 I-2-12-0 PROSEDUR BESAR PADA PEMBULUH DARAH TORASIK 1,801,700
- 266 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
70 I-2-13-0 PROSEDUR BESAR PADA PEMBULUH DARAH ABDOMEN 2,289,800
71 I-2-14-0 PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUNG 4,052,500
72 I-2-15-0 PROSEDUR KATETERISASI JANTUNG 3,536,800
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK
73 I-2-16-0 2,559,600
PENGGANTIAN ALAT
74 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA 843,800
75 I-2-21-0 ANGIOGRAFI ARTERI BUKAN JANTUNG 2,848,900
76 I-2-22-0 PROSEDUR SEDANG PADA PEMBULUH DARAH 1,860,200
77 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH 457,300
78 I-2-31-0 PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR JANTUNG 4,277,200
79 I-2-32-0 PEMASANGAN ATAU PENGGANTIAN ALAT PACU JANTUNG 3,872,100
80 I-2-41-0 PROSEDUR ELEKTROFISIOLOGIK 2,596,300
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR
81 I-2-42-0 2,459,600
PERKUTAN LAIN
82 I-3-10-0 PROSEDUR RESUSITASI 320,000
83 I-3-11-0 PROSEDUR KARDIOVERSI 292,100
84 I-3-12-0 PROSEDUR KECIL LAIN-LAIN PADA JANTUNG 1,175,400
85 I-3-13-0 PROSEDUR EKOKARDIOGRAFI 338,100
86 I-3-14-0 PROSEDUR STRESS TESTING 286,200
87 I-3-15-0 PROSEDUR PENGAWASAN FUNGSI KARDIOVASKULAR 316,300
88 J-2-10-0 PROSEDUR BESAR PADA SISTEM SALURAN PERNAFASAN 1,492,800
89 J-2-21-0 PROSEDUR VENTILASI MEKANIKAL JANGKA PENDEK 1,483,000
90 J-2-22-0 PROSEDUR PADA LARING DAN TRAKEA 1,295,300
91 J-2-31-0 PROSEDUR THORAKOSKOPI/MEDIASTINOSKOPI 1,572,900
92 J-2-32-0 PROSEDUR DADA INTERMEDIATE 952,600
93 J-3-10-0 PROSEDUR PADA DINDING DADA 287,900
94 J-3-11-0 PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA 507,400
95 J-3-12-0 PROSEDUR THORACENTESIS 348,300
96 J-3-13-0 PROSEDUR TERAPI SALURAN PERNAFASAN 314,500
97 J-3-14-0 PROSEDUR BIOPSI PERKUTAN DAN ASPIRASI 306,400
98 J-3-15-0 PROSEDUR BRONKOSKOPI 389,100
99 J-3-16-0 PROSEDUR UJI FUNGSI PARU 443,700
100 J-3-17-0 PROSEDUR LAIN-LAIN PADA SISTEM SALURAN PERNAFASAN 260,100
101 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL 746,500
102 K-2-11-0 PROSEDUR ADHESIOLYSIS PADA PERITONEUM 1,360,400
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 1,044,300
104 K-2-13-0 PROSEDUR PADA USUS BUNTU 2,455,100
105 K-2-14-0 PROSEDUR PADA HERNIA INGUINALIS DAN FEMORALIS 319,700
106 K-2-21-0 PROSEDUR BESAR PADA USUS HALUS DAN USUS BESAR 319,700
107 K-2-22-0 PROSEDUR BESAR PADA GASTROINTESTINAL ATAS 3,119,400
108 K-2-31-0 PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS 1,319,200
109 K-2-32-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL ATAS 253,100
110 K-2-41-0 PROSEDUR LAPAROSKOPI 1,170,700
111 K-2-42-0 PROSEDUR LAPAROTOMI & GASTROINTESTINAL LAINNYA 3,201,200
112 K-2-51-0 PROSEDUR UNTUK WASIR 698,200
113 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM 550,000
114 K-2-53-0 PROSEDUR KECIL PADA ANUS & REKTUM 269,400
115 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL 255,400
116 K-3-11-0 PROSEDUR LAIN-LAIN PADA ANUS & REKTUM 401,300
117 K-3-12-0 PROSEDUR SIGMOIDOSKOPI DAN ANOSKOPI 559,600
118 K-3-13-0 PROSEDUR KOLONOSKOPI 1,339,900
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 1,181,000
120 K-3-15-0 PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS 826,700
121 K-3-16-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL 448,500
122 K-5-18-0 PENYAKIT SISTEM PENCERNAAN LAIN-LAIN 259,800
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 1,435,500
124 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR 836,500
125 L-2-31-0 PROSEDUR BESAR PEMINDAHAN KULIT TANPA LUKA BAKAR 491,500
126 L-2-32-0 PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR 407,800
127 L-2-41-0 PROSEDUR BEDAH PLASTIK 1,336,500
128 L-2-42-0 PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH KULIT 295,500
129 L-2-51-0 PROSEDUR PENGANGKATAN PAYUDARA 1,877,500
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 1,436,400
131 L-2-53-0 PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 318,600
132 L-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA PAYUDARA 353,100
133 L-3-11-0 PROSEDUR BESAR PADA KULIT 344,900
134 L-3-12-0 PROSEDUR KECIL PADA KULIT 208,700
135 M-2-10-0 PROSEDUR REKONTRUKSI TULANG KRANIAL DAN WAJAH 1,565,000
136 M-2-21-0 PROSEDUR BESAR PADA SENDI PANGGUL DAN PAHA 1,563,900
137 M-2-22-0 PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA 309,900
- 267 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
138 M-2-31-0 PROSEDUR BUNION 949,900
139 M-2-32-0 PROSEDUR LAIN-LAIN PADA KAKI 354,600
140 M-2-41-0 PROSEDUR EKSISI, INSISI DAN ARTHROTOMI TULANG 383,400
141 M-2-42-0 PROSEDUR PEMINDAHAN ALAT IMPLAN 355,000
142 M-2-51-0 PROSEDUR BESAR PADA JARINGAN LUNAK 563,100
143 M-2-52-0 PROSEDUR KECIL PADA JARINGAN LUNAK 433,200
144 M-2-61-0 PROSEDUR ARTROSKOPI 1,084,900
145 M-2-62-0 PROSEDUR LAIN-LAIN PADA SENDI & TULANG 320,100
146 M-2-63-0 PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG 890,600
147 M-2-64-0 PROSEDUR BESAR PADA TULANG KEPALA & WAJAH 1,636,300
148 M-2-65-0 PROSEDUR KECIL PADA TULANG KEPALA & WAJAH 260,600
149 M-2-71-0 PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH 1,586,300
150 M-2-72-0 PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH 859,600
151 M-2-81-0 PROSEDUR BESAR PADA LENGAN, SIKU & BAHU 1,857,700
152 M-2-82-0 PROSEDUR KECIL PADA LENGAN, SIKU & BAHU 937,800
153 M-2-83-0 PROSEDUR BESAR PADA TANGAN & PERGELANGAN TANGAN 414,100
154 M-2-84-0 PROSEDUR KECIL PADA TANGAN & PERGELANGAN TANGAN 318,600
155 M-3-10-0 PROSEDUR MANIPULATIVE OSTEOPATHIC 73,700
156 M-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK MUSKULOSKELETAL 412,900
157 M-3-12-0 PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL 933,000
158 M-3-13-0 PROSEDUR REDUKSI FRAKTUR TERTUTUP 363,600
159 M-3-14-0 PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP 491,100
160 M-3-15-0 PROSEDUR APLIKASI CASTS DAN SPLINTS 280,800
161 M-3-16-0 PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL 114,100
162 M-3-17-0 PROSEDUR PEMASANGAN ALAT PROSTETIK 283,600
163 N-2-11-0 PROSEDUR BESAR PADA KANDUNG KEMIH 4,223,700
164 N-2-12-0 PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS 2,400,800
165 N-2-21-0 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN KEMIH 4,007,000
166 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 1,353,500
167 N-2-23-0 PROSEDUR SEDANG PADA GINJAL DAN URETER 550,000
168 N-2-24-0 PROSEDUR KECIL PADA GINJAL DAN URETER 374,700
169 N-2-31-0 PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA 847,500
170 N-2-32-0 PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA 448,300
171 N-2-41-0 PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA 902,200
172 N-2-42-0 PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA 522,400
173 N-3-10-0 PROSEDUR PADA GINJAL DAN URETER 311,000
174 N-3-11-0 PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH 520,500
175 N-3-12-0 PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN KEMIH 322,200
176 N-3-13-0 PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH 491,800
177 N-3-14-0 PROSEDUR KECIL ENDOSKOPI PADA SALURAN KEMIH 342,700
178 N-3-15-0 PROSEDUR DIALISIS 887,100
179 O-7-10-0 PROSEDUR PERSALINAN DENGAN BEDAH CAESAR 1,721,200
180 O-7-11-0 PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN KURETASE 1,384,800
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU
181 O-7-12-0 1,221,000
PELEBARAN DAN KURETASE
182 O-7-13-0 PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR 861,700
183 P-9-11-0 NEONATAL, BBL GROUP-2 301,100
186 P-9-14-0 NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDITER 246,000
187 P-9-15-0 NEONATAL, BBL GROUP-5 DENGAN SINDROM ASPIRASI 156,000
188 P-9-16-0 NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL 245,300
190 Q-5-10-0 PENYALAHGUNAAN ZAT KIMIA AKUT 324,400
191 Q-5-11-0 PENYALAHGUNAAN ZAT KIMIA BUKAN AKUT 238,900
192 Q-5-12-0 GIGI 210,700
193 Q-5-13-0 MEDICAL CHECK-UP 103,300
194 Q-5-14-0 RONGENT (PLAIN FILM) 113,600
195 Q-5-15-0 ELEKTROKARDIOGRAM (ECG) 84,000
196 Q-5-16-0 VAKSINASI 98,600
197 Q-5-17-0 PROSEDUR CAIRAN INTRA VENA 94,000
198 Q-5-18-0 KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN 143,500
199 Q-5-19-0 KONTAK PELAYANAN KESEHATAN LAIN-LAIN 128,700
200 Q-5-20-0 ABORSI MENGANCAM 167,400
201 Q-5-21-0 ABORSI 183,900
202 Q-5-22-0 PERSALINAN YANG SUKAR (FALSE LABOR) 108,600
203 Q-5-23-0 PEMERIKSAAN ANTEPARTUM 138,700
204 Q-5-24-0 PEMERIKSAAN POSTPARTUM 94,800
205 Q-5-25-0 GASTROINTESTINAL AKUT 148,000
206 Q-5-26-0 BRONKIAL AKUT 209,900
- 268 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
207 Q-5-27-0 SISTEM PERSARAFAN PUSAT AKUT 149,500
208 Q-5-28-0 KECEDERAAN SISTEM PERSARAFAN PUSAT 188,000
209 Q-5-29-0 GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN 531,300
210 Q-5-30-0 INFARK MIOKARD AKUT DAN ARITMIA 615,900
211 Q-5-31-0 FRAKTUR 141,300
212 Q-5-32-0 SALURAN KEMIH AKUT 255,700
213 Q-5-33-0 HEMATOLOGI AKUT 172,000
214 Q-5-34-0 INFEKSI VIRUS HIV 245,500
215 Q-5-35-0 INFEKSI AKUT 430,100
216 Q-5-36-0 KEKACAUAN METABOLIK AKUT 368,200
217 Q-5-37-0 CARDIAC ARREST, RESPIRATORY ARREST & SHOCK 264,700
218 Q-5-38-0 PARU AKUT 250,600
219 Q-5-39-0 KECEDERAAN BESAR PADA JARINGAN LUNAK 140,500
220 Q-5-40-0 INFEKSI SALURAN KEMIH AKUT 131,100
221 Q-5-41-0 PENYAKIT AKUT BESAR LAIN-LAIN 295,100
222 Q-5-42-0 PENYAKIT AKUT KECIL LAIN-LAIN 186,300
223 Q-5-43-0 PENYAKIT KRONIS BESAR LAIN-LAIN 267,200
224 Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN 184,900
225 T-2-10-0 PEMULIHAN ALKOHOL, OBAT DAN ATAU TERAPI DETOKSIKASI 144,700
226 U-2-10-0 PROSEDUR BESAR PADA LARING 2,552,400
227 U-2-11-0 PROSEDUR BESAR LAIN-LAIN PADA KEPALA & LEHER 1,909,400
228 U-2-12-0 PROSEDUR PADA SINUS & MASTOID 303,400
229 U-2-13-0 PROSEDUR KELENJAR LUDAH 314,200
230 U-2-14-0 PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT 600,900
231 U-2-15-0 PROSEDUR OPERASI TONSIL & AMANDEL 787,400
232 U-2-21-0 PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 769,200
233 U-2-22-0 PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 397,300
234 U-2-23-0 RHINOPLASTY 1,238,300
235 U-2-24-0 PROSEDUR KECIL PADA HIDUNG 293,900
236 U-2-25-0 PROSEDUR PADA TELINGA TENGAH 322,900
237 U-2-31-0 PROSEDUR BESAR PADA MULUT DAN LIDAH 324,000
238 U-2-32-0 PROSEDUR KECIL PADA MULUT DAN LIDAH 259,400
239 U-3-10-0 PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 327,700
240 U-3-11-0 PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 310,100
241 U-3-12-0 PROSEDUR KAUTERISASI & PACKING PADA RONGGA HIDUNG 145,300
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
242 U-3-13-0 319,200
TENGGOROKAN
243 U-3-14-0 PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 282,900
244 U-3-15-0 PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 255,900
245 U-3-16-0 PROSEDUR PADA GIGI 289,400
246 V-2-10-0 PROSEDUR BESAR PADA PENGANGKATAN PROSTAT 2,395,800
247 V-2-11-0 PROSEDUR PADA PENIS 427,700
248 V-2-12-0 PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM 862,200
249 V-2-13-0 PROSEDUR KECIL PADA PROSTAT DAN SKROTUM 309,300
250 V-2-14-0 PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL 605,000
251 V-2-15-0 SIRKUMSISI/SUNAT 481,900
252 V-3-10-0 PROSEDUR STERILISASI PADA LAKI-LAKI 404,600
253 V-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI 748,700
254 V-3-12-0 PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI 766,800
255 W-2-10-0 PROSEDUR ABORSI 817,500
256 W-2-11-0 PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM 715,100
257 W-2-12-0 PROSEDUR TERBUKA PADA TUBA FALOPII 1,368,900
258 W-2-13-0 PROSEDUR ENDOSKOPI PADA TUBA FALOPII 213,100
259 W-2-21-0 PROSEDUR BESAR TERBUKA PADA PANGGUL 2,034,000
260 W-2-22-0 PROSEDUR KECIL TERBUKA PADA PANGGUL 280,800
261 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 1,031,000
262 W-2-31-0 PROSEDUR PEMBUANGAN RAHIM MELALUI JALAN LAHIR 2,343,200
263 W-2-32-0 PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL INTERMEDIATE 1,970,400
264 W-2-33-0 PROSEDUR KECIL VULVOVAGINAL 860,800
265 W-2-34-0 PROSEDUR GINEKOLOGI LAIN-LAIN 312,000
266 W-3-10-0 PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI 608,400
267 W-3-11-0 PROSEDUR SEDANG GINEKOLOGI 606,000
268 W-3-12-0 PROSEDUR KECIL GINEKOLOGI 280,800
269 Z-3-10-0 PROSEDUR RADIOSURGICAL 2,201,500
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN
270 Z-3-11-0 1,731,600
EMPEDU
271 Z-3-12-0 PROSEDUR REHABILITASI 155,100
272 Z-3-13-0 PROSEDUR KECIL PELAYANAN PENUNJANG LAIN-LAIN 168,100
273 Z-3-14-0 DIAGNOSTIK TIDUR 218,400
274 Z-3-15-0 IMAGING NUKLIR JANTUNG 387,700
- 269 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
275 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 1,129,600
276 Z-3-17-0 PELAYANAN KEDOKTERAN NUKLIR 608,700
277 Z-3-18-0 CT-SCAN KEPALA 960,400
278 Z-3-19-0 CT SCAN LAIN-LAIN 1,100,800
279 Z-3-20-0 IMAGING KONTRAS SALURAN URINARI 555,300
280 Z-3-21-0 IMAGING KONTRAS PEMBULUH DARAH 733,800
281 Z-3-22-0 IMAGING KONTRAS LAIN-LAIN 533,900
282 Z-3-23-0 PROSEDUR ULTRASOUND LAIN-LAIN 569,300
283 Z-3-24-0 PROSEDUR ULTRASOUND PEMBULUH DARAH 713,400
284 Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK 318,200
285 Z-3-26-0 PROSEDUR BESAR RADIOGRAFI 714,600
286 Z-3-27-0 PERAWATAN LUKA 200,700
287 Z-3-28-0 IMAGING PAYUDARA 706,100
288 Z-3-29-0 IMAGING LAIN-LAIN 1,216,100
289 Z-3-30-0 FOTOTERAPI 81,500
- 294 -


REGIONAL 2
RUMAH SAKIT KELAS C PEMERINTAH
RAWAT INAP

13 A-4-14-I 2,111,400 2,533,600 2,955,900
(RINGAN)
14 A-4-14-II 2,562,900 3,075,400 3,588,000
(SEDANG)
15 A-4-14-III 3,075,400 3,690,500 4,305,600
(BERAT)

31 B-1-13-I 4,075,000 4,890,000 5,705,000
LAIN (RINGAN)
32 B-1-13-II 6,704,900 8,045,900 9,386,900
LAIN (SEDANG)
33 B-1-13-III 8,675,600 10,410,700 12,145,900
LAIN (BERAT)
34 B-1-14-I 5,599,200 6,719,100 7,838,900
(RINGAN)
35 B-1-14-II 6,227,300 7,472,800 8,718,300
(SEDANG)
40 B-4-11-I 3,652,600 4,383,100 5,113,600
(RINGAN)
41 B-4-11-II 5,113,600 6,136,400 7,159,100
(SEDANG)
42 B-4-11-III 6,195,100 7,434,100 8,673,100
(BERAT)
- 295 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 3,869,300 4,643,200 5,417,100
74 D-1-20-II 10,663,300 12,796,000 14,928,600
75 D-1-20-III 16,915,100 20,298,100 23,681,200
85 D-4-13-I 2,238,000 2,685,600 3,133,300
86 D-4-13-II 3,167,600 3,801,100 4,434,600
87 D-4-13-III 4,051,400 4,861,700 5,672,000
88 D-4-14-I 2,400,400 2,880,500 3,360,500
89 D-4-14-II 3,930,000 4,716,100 5,502,100
90 D-4-14-III 4,806,800 5,768,200 6,729,600
91 E-1-01-I 4,273,000 5,127,600 5,982,200
(RINGAN)
92 E-1-01-II 5,597,200 6,716,700 7,836,100
(SEDANG)

97 E-1-20-I 5,631,800 6,758,200 7,884,500
TIROGLOSAL (RINGAN)
- 296 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 7,580,300 9,096,300 10,612,400
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,447,100 12,536,600 14,626,000
TIROGLOSAL (BERAT)
100 E-4-10-I 3,360,600 4,032,700 4,704,800
METABOLIK (RINGAN)
101 E-4-10-II 4,695,800 5,634,900 6,574,100
METABOLIK (SEDANG)
102 E-4-10-III 5,828,400 6,994,100 8,159,800
METABOLIK (BERAT)
109 E-4-13-I 2,770,100 3,324,100 3,878,200
(RINGAN)
110 E-4-13-II 4,057,700 4,869,300 5,680,800
(SEDANG)

118 F-4-12-I 1,563,500 1,876,200 2,188,900
(RINGAN)
119 F-4-12-II 2,222,800 2,667,400 3,112,000
(SEDANG)
120 F-4-12-III 4,829,000 5,794,800 6,760,600
(BERAT)
130 F-4-16-I 4,107,600 4,929,100 5,750,600
131 F-4-16-II 4,775,800 5,730,900 6,686,100
132 F-4-16-III 6,374,800 7,649,800 8,924,800
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN) 970,100 1,164,100 1,358,100
142 G-1-01-I 10,402,500 12,483,000 14,563,400
(RINGAN)
- 297 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 16,198,900 19,438,600 22,678,400
(SEDANG)
144 G-1-01-III 31,153,400 37,384,100 43,614,800
(BERAT)
151 G-1-12-I 3,697,500 4,437,000 5,176,400
(RINGAN)
152 G-1-12-II 6,931,100 8,317,300 9,703,500
(SEDANG)
153 G-1-12-III 9,445,700 11,334,800 13,224,000
(BERAT)
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE (RINGAN) 1,115,400 1,338,500 1,561,600
163 G-4-10-I 3,173,900 3,808,600 4,443,400
(RINGAN)
164 G-4-10-II 3,879,500 4,655,500 5,431,400
(SEDANG)
165 G-4-10-III 5,323,400 6,388,100 7,452,800
(BERAT)
166 G-4-11-I 3,322,500 3,987,100 4,651,600
167 G-4-11-II 4,413,600 5,296,300 6,179,000
168 G-4-11-III 6,485,100 7,782,100 9,079,100
DEGENERATIF (BERAT)
169 G-4-12-I 3,686,000 4,423,200 5,160,400
(RINGAN)
170 G-4-12-II 4,655,700 5,586,800 6,517,900
(SEDANG)

172 G-4-13-I 2,214,200 2,657,100 3,099,900
(RINGAN)
173 G-4-13-II 3,861,200 4,633,400 5,405,600
(SEDANG)
174 G-4-13-III 4,579,400 5,495,300 6,411,200
(BERAT)
175 G-4-14-I 3,756,200 4,507,400 5,258,600
INFARK (RINGAN)
176 G-4-14-II 5,021,700 6,026,100 7,030,400
INFARK (SEDANG)
177 G-4-14-III 6,302,800 7,563,400 8,824,000
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 298 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 3,369,900 4,043,900 4,717,800
(RINGAN)
185 G-4-17-II 4,418,700 5,302,400 6,186,100
(SEDANG)
186 G-4-17-III 5,552,200 6,662,700 7,773,100
(BERAT)
190 G-4-19-I 2,769,000 3,322,800 3,876,500
191 G-4-19-II 4,680,200 5,616,300 6,552,300
192 G-4-19-III 6,144,900 7,373,900 8,602,900
211 G-4-26-I 2,986,500 3,583,800 4,181,100
LAIN (RINGAN)
212 G-4-26-II 3,474,200 4,169,100 4,863,900
LAIN (SEDANG)
213 G-4-26-III 5,195,000 6,234,000 7,273,000
LAIN (BERAT)
232 I-1-02-I 19,399,500 23,279,500 27,159,400
(RINGAN)
- 299 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 25,025,200 30,030,200 35,035,200
(SEDANG)
234 I-1-02-III 30,845,100 37,014,100 43,183,100
(BERAT)
235 I-1-03-I 11,205,200 13,446,300 15,687,300
ANOMALI (RINGAN)
236 I-1-03-II 15,532,800 18,639,300 21,745,900
ANOMALI (SEDANG)
237 I-1-03-III 19,712,300 23,654,700 27,597,200
ANOMALI (BERAT)
238 I-1-04-I 16,885,700 20,262,800 23,639,900
JANTUNG (RINGAN)
239 I-1-04-II 26,650,100 31,980,200 37,310,200
JANTUNG (SEDANG)
240 I-1-04-III 42,573,400 51,088,100 59,602,800
JANTUNG (BERAT)
241 I-1-05-I 21,665,900 25,999,000 30,332,200
242 I-1-05-II 25,999,100 31,199,000 36,398,800
243 I-1-05-III 35,774,600 42,929,500 50,084,400
247 I-1-07-I 19,014,200 22,817,100 26,619,900
JANTUNG (RINGAN)
248 I-1-07-II 23,457,900 28,149,500 32,841,100
JANTUNG (SEDANG)
249 I-1-07-III 25,592,500 30,711,000 35,829,500
JANTUNG (BERAT)
250 I-1-11-I 3,040,000 3,648,000 4,256,000
251 I-1-11-II 3,380,100 4,056,200 4,732,200
252 I-1-11-III 4,497,900 5,397,500 6,297,100
253 I-1-12-I 8,750,500 10,500,600 12,250,700
(RINGAN)
254 I-1-12-II 14,291,300 17,149,600 20,007,800
(SEDANG)
255 I-1-12-III 18,802,400 22,562,800 26,323,300
(BERAT)
256 I-1-13-I 8,487,900 10,185,400 11,883,000
KOMPLEK (RINGAN)
257 I-1-13-II 11,303,300 13,564,000 15,824,600
KOMPLEK (SEDANG)
258 I-1-13-III 13,940,100 16,728,100 19,516,100
KOMPLEK (BERAT)
259 I-1-14-I 17,372,600 20,847,100 24,321,600
(RINGAN)
260 I-1-14-II 21,591,500 25,909,800 30,228,100
(SEDANG)
261 I-1-14-III 28,292,300 33,950,800 39,609,300
(BERAT)
265 I-1-16-I 8,555,500 10,266,600 11,977,800
266 I-1-16-II 19,357,700 23,229,300 27,100,800
267 I-1-16-III 22,328,800 26,794,600 31,260,400
268 I-1-17-I 9,906,500 11,887,800 13,869,100
(RINGAN)
269 I-1-17-II 12,403,900 14,884,600 17,365,400
(SEDANG)
- 300 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 15,343,400 18,412,100 21,480,700
(BERAT)
271 I-1-20-I 11,166,300 13,399,600 15,632,900
(RINGAN)
272 I-1-20-II 13,949,800 16,739,800 19,529,700
(SEDANG)
273 I-1-20-III 14,664,100 17,597,000 20,529,800
(BERAT)
274 I-1-30-I 8,446,700 10,136,000 11,825,400
JANTUNG (RINGAN)
275 I-1-30-II 17,571,000 21,085,200 24,599,400
JANTUNG (SEDANG)
276 I-1-30-III 27,228,700 32,674,500 38,120,200
JANTUNG (BERAT)

289 I-4-13-I 2,644,600 3,173,500 3,702,400
(RINGAN)
290 I-4-13-II 4,722,200 5,666,600 6,611,000
(SEDANG)
291 I-4-13-III 6,804,000 8,164,800 9,525,600
(BERAT)
295 I-4-15-I 4,300,400 5,160,500 6,020,600
(RINGAN)
296 I-4-15-II 5,850,400 7,020,500 8,190,600
(SEDANG)

304 I-4-18-I 3,040,300 3,648,300 4,256,400
JANTUNG (RINGAN)
305 I-4-18-II 4,629,000 5,554,800 6,480,500
JANTUNG (SEDANG)
306 I-4-18-III 6,284,600 7,541,500 8,798,400
JANTUNG (BERAT)

308 I-4-19-II 4,579,000 5,494,800 6,410,600
(SEDANG)
- 301 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 2,507,200 3,008,700 3,510,100
320 I-4-23-II 3,078,200 3,693,800 4,309,400
321 I-4-23-III 6,014,500 7,217,400 8,420,400
322 I-4-24-I 2,257,800 2,709,300 3,160,900
(RINGAN)
323 I-4-24-II 5,199,000 6,238,800 7,278,700
(SEDANG)
324 I-4-24-III 6,573,300 7,887,900 9,202,600
(BERAT)
325 J-1-01-I 40,732,100 48,878,500 57,024,900
326 J-1-01-II 46,095,900 55,315,100 64,534,300
327 J-1-01-III 52,149,000 62,578,800 73,008,600
TRAKEOSTOMI (BERAT)
328 J-1-02-I 21,615,000 25,938,100 30,261,100
329 J-1-02-II 30,096,700 36,116,100 42,135,400
330 J-1-02-III 49,700,000 59,640,000 69,580,000
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,563,900 7,876,700 9,189,500
(RINGAN)
332 J-1-10-II 13,282,100 15,938,500 18,595,000
(SEDANG)
333 J-1-10-III 13,803,400 16,564,100 19,324,700
(BERAT)
334 J-1-20-I 9,300,400 11,160,500 13,020,600
(RINGAN)
335 J-1-20-II 12,289,000 14,746,800 17,204,600
(SEDANG)
336 J-1-20-III 18,819,200 22,583,100 26,346,900
(BERAT)
337 J-1-30-I 5,477,800 6,573,300 7,668,900
(RINGAN)
338 J-1-30-II 9,922,900 11,907,500 13,892,000
(SEDANG)

- 302 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,684,900 3,221,900 3,758,900
374 J-4-21-II 4,325,400 5,190,400 6,055,500
375 J-4-21-III 6,035,700 7,242,900 8,450,000
376 K-1-10-I 5,950,600 7,140,700 8,330,800
BESAR (RINGAN)
377 K-1-10-II 7,478,200 8,973,800 10,469,500
BESAR (SEDANG)
378 K-1-10-III 8,764,700 10,517,600 12,270,600
BESAR (BERAT)
382 K-1-12-I 2,496,800 2,996,100 3,495,500
FEMORAL (RINGAN)
383 K-1-12-II 3,247,400 3,896,800 4,546,300
FEMORAL (SEDANG)
384 K-1-12-III 6,433,500 7,720,200 9,006,900
FEMORAL (BERAT)
388 K-1-14-I 4,569,700 5,483,600 6,397,500
(RINGAN)
389 K-1-14-II 5,355,500 6,426,600 7,497,700
(SEDANG)

394 K-1-30-I 5,232,800 6,279,400 7,326,000
395 K-1-30-II 9,293,400 11,152,100 13,010,700
396 K-1-30-III 12,787,800 15,345,400 17,903,000

398 K-1-40-II 6,437,300 7,724,700 9,012,200
(SEDANG)

- 303 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 2,984,600 3,581,500 4,178,400
413 K-4-13-II 3,860,700 4,632,900 5,405,000
414 K-4-13-III 5,946,800 7,136,100 8,325,500
415 K-4-14-I 1,892,200 2,270,700 2,649,100
(RINGAN)
416 K-4-14-II 2,540,000 3,048,000 3,556,000
(SEDANG)
417 K-4-14-III 4,075,700 4,890,800 5,706,000
(BERAT)

424 K-4-17-I 1,418,900 1,702,700 1,986,500
(RINGAN)
425 K-4-17-II 1,940,700 2,328,800 2,716,900
(SEDANG)
426 K-4-17-III 2,328,800 2,794,600 3,260,300
(BERAT)
427 K-4-18-I 1,253,800 1,504,500 1,755,300
(RINGAN)
428 K-4-18-II 1,781,700 2,138,000 2,494,400
(SEDANG)
436 L-1-40-I 3,730,200 4,476,200 5,222,300
(RINGAN)
437 L-1-40-II 7,482,000 8,978,400 10,474,800
(SEDANG)
438 L-1-40-III 12,593,800 15,112,600 17,631,300
(BERAT)
451 L-4-13-I 2,287,000 2,744,400 3,201,900
PAYUDARA (RINGAN)
- 304 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,687,900 3,225,500 3,763,100
PAYUDARA (SEDANG)
453 L-4-13-III 3,955,300 4,746,300 5,537,400
PAYUDARA (BERAT)
454 L-4-14-I 2,205,800 2,647,000 3,088,200
(RINGAN)
455 L-4-14-II 3,313,300 3,975,900 4,638,600
(SEDANG)
456 L-4-14-III 4,670,400 5,604,500 6,538,600
(BERAT)
457 M-1-01-I 7,797,500 9,356,900 10,916,400
458 M-1-01-II 11,083,000 13,299,600 15,516,200
459 M-1-01-III 15,568,300 18,681,900 21,795,600
463 M-1-03-I 18,763,800 22,516,600 26,269,300
464 M-1-03-II 21,946,900 26,336,300 30,725,700
465 M-1-03-III 27,163,000 32,595,600 38,028,200
472 M-1-07-I 6,158,300 7,390,000 8,621,700
473 M-1-07-II 8,250,000 9,900,100 11,550,100
474 M-1-07-III 16,806,100 20,167,300 23,528,500
475 M-1-10-I 10,137,600 12,165,200 14,192,700
WAJAH (RINGAN)
476 M-1-10-II 22,245,800 26,695,000 31,144,200
WAJAH (SEDANG)
477 M-1-10-III 47,982,200 57,578,600 67,175,100
WAJAH (BERAT)
478 M-1-20-I 9,259,500 11,111,400 12,963,300
(RINGAN)
479 M-1-20-II 11,830,000 14,196,000 16,562,000
(SEDANG)

484 M-1-40-I 3,233,500 3,880,300 4,527,000
INTERNAL (RINGAN)
485 M-1-40-II 5,734,600 6,881,500 8,028,400
INTERNAL (SEDANG)
486 M-1-40-III 8,187,800 9,825,400 11,463,000
INTERNAL (BERAT)
490 M-1-60-I 5,984,500 7,181,400 8,378,300
491 M-1-60-II 7,523,900 9,028,600 10,533,400
492 M-1-60-III 11,365,700 13,638,900 15,912,000
- 305 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 11,087,300 13,304,800 15,522,300
KAKI (RINGAN)
494 M-1-70-II 12,196,100 14,635,300 17,074,500
KAKI (SEDANG)
495 M-1-70-III 13,962,900 16,755,500 19,548,000
KAKI (BERAT)
502 M-4-11-I 2,766,600 3,319,900 3,873,200
(RINGAN)
503 M-4-11-II 6,065,600 7,278,700 8,491,800
(SEDANG)
504 M-4-11-III 8,769,800 10,523,800 12,277,700
(BERAT)
505 M-4-12-I 2,208,400 2,650,000 3,091,700
(RINGAN)
506 M-4-12-II 3,673,100 4,407,700 5,142,300
(SEDANG)
507 M-4-12-III 4,913,100 5,895,800 6,878,400
(BERAT)
508 M-4-13-I 3,677,100 4,412,500 5,148,000
509 M-4-13-II 5,524,700 6,629,700 7,734,600
510 M-4-13-III 10,778,600 12,934,300 15,090,100
520 M-4-17-I 2,763,200 3,315,800 3,868,400
(RINGAN)
521 M-4-17-II 3,864,600 4,637,500 5,410,400
(SEDANG)
522 M-4-17-III 5,396,600 6,476,000 7,555,300
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,197,000 2,636,400 3,075,800
(RINGAN)
530 M-4-20-II 3,217,100 3,860,500 4,504,000
(SEDANG)
531 M-4-20-III 3,595,500 4,314,600 5,033,700
(BERAT)
532 M-4-21-I 2,212,200 2,654,600 3,097,100
533 M-4-21-II 2,766,800 3,320,200 3,873,600
- 306 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 6,203,200 7,443,800 8,684,400
541 N-1-12-I 3,252,200 3,902,600 4,553,100
542 N-1-12-II 6,474,800 7,769,800 9,064,700
543 N-1-12-III 14,050,500 16,860,600 19,670,700
547 N-1-30-I 6,507,400 7,808,900 9,110,400
BAWAH (RINGAN)
548 N-1-30-II 9,844,400 11,813,300 13,782,200
BAWAH (SEDANG)
549 N-1-30-III 11,330,000 13,596,000 15,862,000
BAWAH (BERAT)
550 N-1-40-I 5,844,100 7,012,900 8,181,800
(RINGAN)
551 N-1-40-II 7,936,200 9,523,400 11,110,600
(SEDANG)
552 N-1-40-III 9,236,700 11,084,000 12,931,300
(BERAT)
553 N-4-10-I 2,482,900 2,979,500 3,476,100
(RINGAN)
554 N-4-10-II 3,003,200 3,603,800 4,204,400
(SEDANG)
555 N-4-10-III 4,417,200 5,300,600 6,184,100
(BERAT)
568 N-4-15-I 2,261,500 2,713,800 3,166,100
URIN (RINGAN)
569 N-4-15-II 2,806,100 3,367,400 3,928,600
URIN (SEDANG)
570 N-4-15-III 3,202,300 3,842,700 4,483,200
URIN (BERAT)
571 N-4-16-I 2,769,200 3,323,000 3,876,900
(RINGAN)
572 N-4-16-II 3,952,500 4,743,000 5,533,600
(SEDANG)
573 N-4-16-III 5,261,100 6,313,300 7,365,600
(BERAT)
- 307 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 2,574,100 3,088,900 3,603,800
578 O-6-11-II 2,860,800 3,433,000 4,005,200
579 O-6-11-III 3,558,900 4,270,700 4,982,500
580 O-6-12-I 1,823,700 2,188,500 2,553,200
581 O-6-12-II 2,190,300 2,628,300 3,066,400
582 O-6-12-III 2,752,200 3,302,600 3,853,000
586 P-8-01-I 40,723,900 48,868,700 57,013,500
587 P-8-01-II 50,389,700 60,467,700 70,545,600
588 P-8-01-III 59,143,400 70,972,000 82,800,700
589 P-8-02-I 68,610,700 82,332,800 96,055,000
590 P-8-02-II 78,703,500 94,444,100 110,184,800
591 P-8-02-III 89,924,300 107,909,200 125,894,000
592 P-8-03-I 7,414,200 8,897,000 10,379,900
593 P-8-03-II 11,000,300 13,200,300 15,400,400
594 P-8-03-III 12,450,100 14,940,100 17,430,100
595 P-8-04-I 21,983,900 26,380,600 30,777,400
596 P-8-04-II 37,010,800 44,413,000 51,815,200
597 P-8-04-III 53,064,200 63,677,000 74,289,900
598 P-8-05-I 15,546,100 18,655,400 21,764,600
599 P-8-05-II 22,539,400 27,047,200 31,555,100
600 P-8-05-III 32,344,900 38,813,900 45,282,900
601 P-8-06-I 3,944,400 4,733,300 5,522,200
602 P-8-06-II 11,059,200 13,271,000 15,482,800
603 P-8-06-III 14,650,700 17,580,800 20,511,000
604 P-8-07-I 3,820,500 4,584,700 5,348,800
605 P-8-07-II 10,711,900 12,854,300 14,996,700
606 P-8-07-III 14,190,700 17,028,800 19,866,900
607 P-8-08-I 3,876,100 4,651,300 5,426,500
608 P-8-08-II 5,500,100 6,600,100 7,700,200
609 P-8-08-III 8,905,800 10,687,000 12,468,200
610 P-8-11-I 6,740,200 8,088,200 9,436,200
MAYOR (RINGAN)
611 P-8-11-II 10,000,200 12,000,300 14,000,300
MAYOR (SEDANG)
- 308 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 11,318,300 13,581,900 15,845,600
MAYOR (BERAT)
613 P-8-12-I 5,861,000 7,033,200 8,205,400
MAYOR (RINGAN)
614 P-8-12-II 8,333,500 10,000,200 11,666,900
MAYOR (SEDANG)
615 P-8-12-III 9,431,900 11,318,300 13,204,600
MAYOR (BERAT)
616 P-8-13-I 5,034,500 6,041,400 7,048,300
MAYOR (RINGAN)
617 P-8-13-II 7,853,800 9,424,600 10,995,400
MAYOR (SEDANG)
618 P-8-13-III 10,720,100 12,864,200 15,008,200
MAYOR (BERAT)
619 P-8-14-I 2,656,200 3,187,400 3,718,700
620 P-8-14-II 5,407,000 6,488,400 7,569,700
621 P-8-14-III 10,032,000 12,038,300 14,044,700
622 P-8-15-I 1,992,200 2,390,600 2,789,100
ASPIRASI (RINGAN)
623 P-8-15-II 3,989,400 4,787,300 5,585,200
ASPIRASI (SEDANG)
624 P-8-15-III 4,680,900 5,617,100 6,553,200
ASPIRASI (BERAT)
625 P-8-16-I 1,803,000 2,163,500 2,524,100
626 P-8-16-II 3,464,700 4,157,600 4,850,500
627 P-8-16-III 7,065,400 8,478,500 9,891,500
628 P-8-17-I 3,356,300 4,027,600 4,698,900
(RINGAN)
629 P-8-17-II 6,041,400 7,249,700 8,458,000
(SEDANG)
630 P-8-17-III 8,246,300 9,895,500 11,544,800
(BERAT)
631 S-4-10-I 2,032,800 2,439,400 2,845,900
632 S-4-10-II 2,504,700 3,005,700 3,506,600
633 S-4-10-III 3,428,700 4,114,400 4,800,200
640 S-4-13-I 2,207,000 2,648,400 3,089,800
(RINGAN)
641 S-4-13-II 3,915,400 4,698,500 5,481,600
(SEDANG)
642 S-4-13-III 6,355,200 7,626,200 8,897,300
(BERAT)
643 S-4-14-I 1,116,900 1,340,300 1,563,700
644 S-4-14-II 2,372,400 2,846,900 3,321,300
645 S-4-14-III 4,498,900 5,398,700 6,298,400
KANAK-KANAK (BERAT)
646 S-4-15-I 747,000 896,400 1,045,800
647 S-4-15-II 1,409,700 1,691,600 1,973,600
648 S-4-15-III 1,825,800 2,191,000 2,556,100
- 309 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 1,864,300 2,237,200 2,610,100
653 S-4-17-II 2,766,900 3,320,300 3,873,600
654 S-4-17-III 3,327,800 3,993,400 4,658,900
655 T-1-10-I 1,247,400 1,496,900 1,746,300
OBAT (RINGAN)
656 T-1-10-II 1,675,400 2,010,500 2,345,600
OBAT (SEDANG)
657 T-1-10-III 3,047,800 3,657,400 4,266,900
OBAT (BERAT)
658 T-4-10-I 594,800 713,800 832,700
659 T-4-10-II 1,133,700 1,360,400 1,587,100
660 T-4-10-III 1,648,000 1,977,600 2,307,200
661 T-4-11-I 796,300 955,600 1,114,800
662 T-4-11-II 1,253,100 1,503,700 1,754,300
663 T-4-11-III 2,018,400 2,422,100 2,825,800
664 T-4-12-I 1,237,400 1,484,900 1,732,300
LAIN (RINGAN)
665 T-4-12-II 1,870,200 2,244,300 2,618,300
LAIN (SEDANG)
666 T-4-12-III 2,895,300 3,474,400 4,053,400
LAIN (BERAT)
670 U-1-11-I 6,306,300 7,567,500 8,828,800
(RINGAN)
671 U-1-11-II 7,994,100 9,593,000 11,191,800
(SEDANG)
672 U-1-11-III 11,502,300 13,802,800 16,103,200
(BERAT)
679 U-1-14-I 2,963,200 3,555,800 4,148,500
(RINGAN)
680 U-1-14-II 3,636,600 4,363,900 5,091,200
(SEDANG)
681 U-1-14-III 4,309,300 5,171,200 6,033,000
(BERAT)
685 U-1-20-I 4,498,600 5,398,300 6,298,100
686 U-1-20-II 6,695,200 8,034,200 9,373,200
687 U-1-20-III 17,187,800 20,625,400 24,062,900
691 U-4-10-I 2,776,400 3,331,700 3,887,000
- 310 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 6,356,000 7,627,300 8,898,500
693 U-4-10-III 9,758,500 11,710,200 13,661,900
TENGGOROKAN (BERAT)
700 U-4-13-I 1,842,800 2,211,300 2,579,900
701 U-4-13-II 2,172,500 2,607,000 3,041,500
702 U-4-13-III 2,598,400 3,118,000 3,637,700
706 U-4-15-I 2,219,000 2,662,800 3,106,600
707 U-4-15-II 2,764,600 3,317,500 3,870,400
708 U-4-15-III 3,869,000 4,642,900 5,416,700
709 V-1-10-I 3,619,300 4,343,200 5,067,100
(RINGAN)
710 V-1-10-II 7,455,700 8,946,800 10,438,000
(SEDANG)
711 V-1-10-III 9,143,400 10,972,100 12,800,700
(BERAT)
715 V-1-12-I 6,473,800 7,768,600 9,063,300
MODERAT (RINGAN)
716 V-1-12-II 8,840,500 10,608,600 12,376,700
MODERAT (SEDANG)
717 V-1-12-III 11,205,500 13,446,500 15,687,600
MODERAT (BERAT)
718 V-1-13-I 3,376,800 4,052,200 4,727,600
KOMPLEK (RINGAN)
719 V-1-13-II 6,452,000 7,742,400 9,032,800
KOMPLEK (SEDANG)
720 V-1-13-III 10,122,400 12,146,900 14,171,400
KOMPLEK (BERAT)
721 V-1-14-I 6,621,900 7,946,300 9,270,700
(RINGAN)
722 V-1-14-II 9,621,500 11,545,800 13,470,100
(SEDANG)
724 V-1-15-I SIRKUMSISI (RINGAN) 1,066,500 1,279,800 1,493,100

727 V-4-10-I 3,202,300 3,842,700 4,483,200
(RINGAN)
728 V-4-10-II 5,319,100 6,382,900 7,446,800
(SEDANG)
729 V-4-10-III 8,769,400 10,523,200 12,277,100
(BERAT)
730 V-4-11-I 2,766,900 3,320,300 3,873,700
TUMOR (RINGAN)
731 V-4-11-II 3,712,500 4,455,000 5,197,500
TUMOR (SEDANG)
732 V-4-11-III 4,973,000 5,967,600 6,962,200
TUMOR (BERAT)
- 311 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 7,541,700 9,050,000 10,558,400
734 W-1-01-II 9,039,300 10,847,100 12,655,000
735 W-1-01-III 12,898,800 15,478,500 18,058,300
739 W-1-11-I 1,672,000 2,006,500 2,340,900
SERVIK (RINGAN)
740 W-1-11-II 1,845,100 2,214,100 2,583,100
SERVIK (SEDANG)
741 W-1-11-III 2,041,000 2,449,200 2,857,500
SERVIK (BERAT)
760 W-4-12-I 2,695,300 3,234,400 3,773,500
761 W-4-12-II 3,700,500 4,440,600 5,180,700
762 W-4-12-III 4,033,800 4,840,500 5,647,300
763 W-4-13-I ABORTUS (RINGAN) 931,900 1,118,300 1,304,700
- 312 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 1,176,700 1,412,000 1,647,400
785 Z-4-12-II 2,886,600 3,464,000 4,041,300
786 Z-4-12-III 4,129,500 4,955,400 5,781,300
- 313 -

REGIONAL 2
RUMAH SAKIT UMUM KELAS C PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 774,100
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 1,029,400
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 940,000
24 D-2-11-0 PROSEDUR LIMPA 1,471,300

33 F-3-10-0 TERAPI SHOCK 416,700
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 908,900
55 H-2-22-0 PROSEDUR SEDANG PADA MATA EKSTERNAL 889,500
63 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 773,100
- 314 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,532,900
PENGGANTIAN ALAT
81 I-2-42-0 2,434,000
PERKUTAN LAIN
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 1,033,400
118 K-3-13-0 PROSEDUR KOLONOSKOPI 964,300
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 849,900
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 1,033,100
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 1,033,700
- 315 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
166 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 974,100
181 O-7-12-0 1,147,800
192 Q-5-12-0 GIGI 208,500
196 Q-5-16-0 VAKSINASI 91,200
201 Q-5-21-0 ABORSI 182,000
206 Q-5-26-0 BRONKIAL AKUT 194,200
- 316 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 130,700
215 Q-5-35-0 INFEKSI AKUT 425,600
218 Q-5-38-0 PARU AKUT 248,000
234 U-2-23-0 RHINOPLASTY 1,225,300
242 U-3-13-0 315,800
TENGGOROKAN
261 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 742,000
270 Z-3-11-0 1,713,500
EMPEDU
- 317 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
275 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 1,004,100
277 Z-3-18-0 CT-SCAN KEPALA 902,900
288 Z-3-29-0 IMAGING LAIN-LAIN 1,081,000
289 Z-3-30-0 FOTOTERAPI 75,400
- 342 -


REGIONAL 2
RUMAH SAKIT KELAS D PEMERINTAH
RAWAT INAP

13 A-4-14-I 2,111,400 2,533,600 2,955,900
(RINGAN)
14 A-4-14-II 2,562,900 3,075,400 3,588,000
(SEDANG)
15 A-4-14-III 3,075,400 3,690,500 4,305,600
(BERAT)

31 B-1-13-I 3,555,100 4,266,100 4,977,100
LAIN (RINGAN)
32 B-1-13-II 5,849,400 7,019,300 8,189,200
LAIN (SEDANG)
33 B-1-13-III 7,568,600 9,082,400 10,596,100
LAIN (BERAT)
34 B-1-14-I 4,884,800 5,861,800 6,838,700
(RINGAN)
35 B-1-14-II 5,432,800 6,519,300 7,605,900
(SEDANG)
40 B-4-11-I 3,186,500 3,823,800 4,461,100
(RINGAN)
41 B-4-11-II 4,461,200 5,353,400 6,245,600
(SEDANG)
42 B-4-11-III 5,404,600 6,485,600 7,566,500
(BERAT)
- 343 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 3,375,600 4,050,700 4,725,900
74 D-1-20-II 9,302,700 11,163,200 13,023,800
75 D-1-20-III 14,756,800 17,708,200 20,659,500
85 D-4-13-I 1,952,500 2,343,000 2,733,500
86 D-4-13-II 2,763,400 3,316,100 3,868,800
87 D-4-13-III 3,534,500 4,241,400 4,948,300
88 D-4-14-I 2,094,100 2,512,900 2,931,800
89 D-4-14-II 3,428,600 4,114,300 4,800,000
90 D-4-14-III 4,193,500 5,032,200 5,870,900
91 E-1-01-I 3,265,800 3,918,900 4,572,100
(RINGAN)
92 E-1-01-II 4,277,800 5,133,400 5,989,000
(SEDANG)

97 E-1-20-I 4,913,200 5,895,800 6,878,500
TIROGLOSAL (RINGAN)
- 344 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 6,613,000 7,935,600 9,258,300
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,114,100 10,937,000 12,759,800
TIROGLOSAL (BERAT)
100 E-4-10-I 3,192,500 3,831,000 4,469,600
METABOLIK (RINGAN)
101 E-4-10-II 4,461,000 5,353,200 6,245,400
METABOLIK (SEDANG)
102 E-4-10-III 5,537,000 6,644,400 7,751,800
METABOLIK (BERAT)
109 E-4-13-I 2,416,700 2,900,000 3,383,300
(RINGAN)
110 E-4-13-II 3,540,000 4,248,000 4,956,000
(SEDANG)

118 F-4-12-I 1,364,000 1,636,800 1,909,600
(RINGAN)
119 F-4-12-II 1,939,200 2,327,100 2,714,900
(SEDANG)
120 F-4-12-III 4,212,800 5,055,400 5,898,000
(BERAT)
130 F-4-16-I 3,583,500 4,300,200 5,016,900
131 F-4-16-II 4,166,400 4,999,700 5,833,000
132 F-4-16-III 5,561,400 6,673,700 7,786,000
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN) 846,300 1,015,500 1,184,800
142 G-1-01-I 5,280,800 6,336,900 7,393,100
(RINGAN)
- 345 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 7,276,500 8,731,800 10,187,100
(SEDANG)
144 G-1-01-III 14,145,500 16,974,600 19,803,700
(BERAT)
151 G-1-12-I 3,225,700 3,870,800 4,516,000
(RINGAN)
152 G-1-12-II 6,046,700 7,256,000 8,465,400
(SEDANG)
153 G-1-12-III 8,240,500 9,888,500 11,536,600
(BERAT)
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE (RINGAN) 973,100 1,167,700 1,362,300
163 G-4-10-I 2,768,900 3,322,700 3,876,500
(RINGAN)
164 G-4-10-II 3,384,500 4,061,400 4,738,300
(SEDANG)
165 G-4-10-III 4,644,200 5,573,000 6,501,800
(BERAT)
166 G-4-11-I 2,898,600 3,478,300 4,058,000
167 G-4-11-II 3,850,400 4,620,500 5,390,600
168 G-4-11-III 5,657,600 6,789,100 7,920,600
DEGENERATIF (BERAT)
169 G-4-12-I 3,215,700 3,858,800 4,501,900
(RINGAN)
170 G-4-12-II 4,061,600 4,873,900 5,686,300
(SEDANG)

172 G-4-13-I 1,931,700 2,318,000 2,704,400
(RINGAN)
173 G-4-13-II 3,368,500 4,042,200 4,715,900
(SEDANG)
174 G-4-13-III 3,995,100 4,794,100 5,593,100
(BERAT)
175 G-4-14-I 3,276,900 3,932,300 4,587,600
INFARK (RINGAN)
176 G-4-14-II 4,381,000 5,257,200 6,133,300
INFARK (SEDANG)
177 G-4-14-III 5,498,600 6,598,400 7,698,100
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 346 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 2,939,900 3,527,900 4,115,900
(RINGAN)
185 G-4-17-II 3,854,900 4,625,800 5,396,800
(SEDANG)
186 G-4-17-III 4,843,800 5,812,600 6,781,300
(BERAT)
190 G-4-19-I 2,415,700 2,898,800 3,381,900
191 G-4-19-II 4,083,000 4,899,600 5,716,200
192 G-4-19-III 5,360,800 6,433,000 7,505,200
211 G-4-26-I 2,605,400 3,126,500 3,647,600
LAIN (RINGAN)
212 G-4-26-II 3,030,900 3,637,100 4,243,300
LAIN (SEDANG)
213 G-4-26-III 4,532,200 5,438,600 6,345,000
LAIN (BERAT)
232 I-1-02-I 16,924,200 20,309,100 23,693,900
(RINGAN)
- 347 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 21,832,000 26,198,500 30,564,900
(SEDANG)
234 I-1-02-III 26,909,400 32,291,200 37,673,100
(BERAT)
235 I-1-03-I 9,775,500 11,730,600 13,685,700
ANOMALI (RINGAN)
236 I-1-03-II 13,550,800 16,261,000 18,971,200
ANOMALI (SEDANG)
237 I-1-03-III 17,197,100 20,636,500 24,075,900
ANOMALI (BERAT)
238 I-1-04-I 14,731,100 17,677,300 20,623,600
JANTUNG (RINGAN)
239 I-1-04-II 23,249,700 27,899,600 32,549,600
JANTUNG (SEDANG)
240 I-1-04-III 37,141,200 44,569,500 51,997,700
JANTUNG (BERAT)
241 I-1-05-I 18,901,400 22,681,700 26,461,900
242 I-1-05-II 22,681,700 27,218,100 31,754,400
243 I-1-05-III 31,209,900 37,451,900 43,693,900
247 I-1-07-I 16,588,100 19,905,700 23,223,300
JANTUNG (RINGAN)
248 I-1-07-II 20,464,800 24,557,700 28,650,700
JANTUNG (SEDANG)
249 I-1-07-III 22,327,000 26,792,400 31,257,800
JANTUNG (BERAT)
250 I-1-11-I 2,652,100 3,182,500 3,712,900
251 I-1-11-II 2,948,800 3,538,600 4,128,400
252 I-1-11-III 3,924,000 4,708,800 5,493,600
253 I-1-12-I 7,634,000 9,160,700 10,687,500
(RINGAN)
254 I-1-12-II 12,467,800 14,961,300 17,454,900
(SEDANG)
255 I-1-12-III 16,403,300 19,683,900 22,964,600
(BERAT)
256 I-1-13-I 7,404,800 8,885,800 10,366,800
KOMPLEK (RINGAN)
257 I-1-13-II 9,861,000 11,833,300 13,805,500
KOMPLEK (SEDANG)
258 I-1-13-III 12,161,400 14,593,700 17,026,000
KOMPLEK (BERAT)
259 I-1-14-I 15,155,900 18,187,000 21,218,200
(RINGAN)
260 I-1-14-II 18,836,500 22,603,800 26,371,100
(SEDANG)
261 I-1-14-III 24,682,300 29,618,800 34,555,300
(BERAT)
265 I-1-16-I 7,463,900 8,956,700 10,449,400
266 I-1-16-II 16,887,800 20,265,300 23,642,900
267 I-1-16-III 19,479,800 23,375,700 27,271,700
268 I-1-17-I 8,642,500 10,371,000 12,099,500
(RINGAN)
269 I-1-17-II 10,821,200 12,985,400 15,149,600
(SEDANG)
- 348 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 13,385,600 16,062,800 18,739,900
(BERAT)
271 I-1-20-I 9,741,500 11,689,900 13,638,200
(RINGAN)
272 I-1-20-II 12,169,900 14,603,800 17,037,800
(SEDANG)
273 I-1-20-III 12,793,000 15,351,600 17,910,300
(BERAT)
274 I-1-30-I 7,368,900 8,842,700 10,316,500
JANTUNG (RINGAN)
275 I-1-30-II 15,329,000 18,394,800 21,460,600
JANTUNG (SEDANG)
276 I-1-30-III 23,754,400 28,505,300 33,256,200
JANTUNG (BERAT)

289 I-4-13-I 2,307,100 2,768,500 3,230,000
(RINGAN)
290 I-4-13-II 4,119,600 4,943,600 5,767,500
(SEDANG)
291 I-4-13-III 5,935,800 7,123,000 8,310,200
(BERAT)
295 I-4-15-I 4,085,400 4,902,500 5,719,500
(RINGAN)
296 I-4-15-II 5,557,900 6,669,500 7,781,100
(SEDANG)

304 I-4-18-I 2,652,400 3,182,800 3,713,300
JANTUNG (RINGAN)
305 I-4-18-II 4,038,300 4,846,000 5,653,700
JANTUNG (SEDANG)
306 I-4-18-III 5,482,700 6,579,200 7,675,800
JANTUNG (BERAT)

308 I-4-19-II 3,994,700 4,793,700 5,592,600
(SEDANG)
- 349 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 2,187,300 2,624,800 3,062,200
320 I-4-23-II 2,685,400 3,222,500 3,759,600
321 I-4-23-III 5,247,100 6,296,500 7,345,900
322 I-4-24-I 1,969,700 2,363,600 2,757,600
(RINGAN)
323 I-4-24-II 4,535,700 5,442,800 6,349,900
(SEDANG)
324 I-4-24-III 5,734,500 6,881,400 8,028,300
(BERAT)
325 J-1-01-I 35,534,800 42,641,800 49,748,800
326 J-1-01-II 40,214,300 48,257,100 56,300,000
327 J-1-01-III 45,495,000 54,594,000 63,693,000
TRAKEOSTOMI (BERAT)
328 J-1-02-I 18,857,000 22,628,400 26,399,900
329 J-1-02-II 26,256,500 31,507,800 36,759,100
330 J-1-02-III 43,358,400 52,030,100 60,701,800
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,726,400 6,871,700 8,016,900
(RINGAN)
332 J-1-10-II 11,587,400 13,904,800 16,222,300
(SEDANG)
333 J-1-10-III 12,042,100 14,450,600 16,859,000
(BERAT)
334 J-1-20-I 6,729,100 8,074,900 9,420,800
(RINGAN)
335 J-1-20-II 7,966,500 9,559,800 11,153,100
(SEDANG)
336 J-1-20-III 12,301,600 14,761,900 17,222,200
(BERAT)
337 J-1-30-I 4,778,800 5,734,600 6,690,300
(RINGAN)
338 J-1-30-II 8,656,800 10,388,100 12,119,500
(SEDANG)

- 350 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,550,700 3,060,800 3,571,000
374 J-4-21-II 4,109,100 4,930,900 5,752,700
375 J-4-21-III 5,733,900 6,880,700 8,027,500
376 K-1-10-I 5,191,300 6,229,600 7,267,800
BESAR (RINGAN)
377 K-1-10-II 6,524,000 7,828,800 9,133,600
BESAR (SEDANG)
378 K-1-10-III 7,646,300 9,175,600 10,704,900
BESAR (BERAT)
382 K-1-12-I 2,178,200 2,613,800 3,049,500
FEMORAL (RINGAN)
383 K-1-12-II 2,833,000 3,399,600 3,966,200
FEMORAL (SEDANG)
384 K-1-12-III 5,612,600 6,735,100 7,857,700
FEMORAL (BERAT)
388 K-1-14-I 3,986,600 4,783,900 5,581,200
(RINGAN)
389 K-1-14-II 4,672,200 5,606,600 6,541,100
(SEDANG)

394 K-1-30-I 4,565,100 5,478,200 6,391,200
395 K-1-30-II 8,107,600 9,729,100 11,350,600
396 K-1-30-III 11,156,100 13,387,400 15,618,600

398 K-1-40-II 5,615,900 6,739,100 7,862,300
(SEDANG)

- 351 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 2,603,800 3,124,500 3,645,300
413 K-4-13-II 3,368,100 4,041,800 4,715,400
414 K-4-13-III 5,188,000 6,225,600 7,263,200
415 K-4-14-I 1,650,800 1,981,000 2,311,100
(RINGAN)
416 K-4-14-II 2,215,900 2,659,100 3,102,300
(SEDANG)
417 K-4-14-III 3,555,700 4,266,800 4,977,900
(BERAT)

424 K-4-17-I 1,089,300 1,307,200 1,525,000
(RINGAN)
425 K-4-17-II 1,633,400 1,960,100 2,286,800
(SEDANG)
426 K-4-17-III 1,960,100 2,352,100 2,744,100
(BERAT)
427 K-4-18-I 1,093,800 1,312,600 1,531,300
(RINGAN)
428 K-4-18-II 1,554,400 1,865,300 2,176,200
(SEDANG)
436 L-1-40-I 3,254,200 3,905,100 4,555,900
(RINGAN)
437 L-1-40-II 6,527,300 7,832,800 9,138,200
(SEDANG)
438 L-1-40-III 10,986,900 13,184,300 15,381,700
(BERAT)
451 L-4-13-I 2,172,700 2,607,200 3,041,800
PAYUDARA (RINGAN)
- 352 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,553,500 3,064,200 3,574,900
PAYUDARA (SEDANG)
453 L-4-13-III 3,757,500 4,509,000 5,260,500
PAYUDARA (BERAT)
454 L-4-14-I 1,924,400 2,309,300 2,694,100
(RINGAN)
455 L-4-14-II 2,890,500 3,468,600 4,046,700
(SEDANG)
456 L-4-14-III 4,074,500 4,889,400 5,704,300
(BERAT)
457 M-1-01-I 6,802,500 8,163,000 9,523,500
458 M-1-01-II 9,668,800 11,602,600 13,536,400
459 M-1-01-III 13,581,800 16,298,200 19,014,600
463 M-1-03-I 14,760,400 17,712,500 20,664,600
464 M-1-03-II 17,264,500 20,717,400 24,170,300
465 M-1-03-III 21,367,700 25,641,200 29,914,700
472 M-1-07-I 5,372,600 6,447,100 7,521,600
473 M-1-07-II 7,197,400 8,636,800 10,076,300
474 M-1-07-III 14,661,700 17,594,000 20,526,400
475 M-1-10-I 8,844,100 10,612,900 12,381,800
WAJAH (RINGAN)
476 M-1-10-II 19,407,300 23,288,800 27,170,300
WAJAH (SEDANG)
477 M-1-10-III 41,859,800 50,231,800 58,603,800
WAJAH (BERAT)
478 M-1-20-I 8,078,000 9,693,600 11,309,200
(RINGAN)
479 M-1-20-II 10,320,500 12,384,600 14,448,700
(SEDANG)

484 M-1-40-I 2,821,000 3,385,200 3,949,300
INTERNAL (RINGAN)
485 M-1-40-II 5,002,800 6,003,400 7,004,000
INTERNAL (SEDANG)
486 M-1-40-III 7,143,100 8,571,700 10,000,300
INTERNAL (BERAT)
490 M-1-60-I 5,220,900 6,265,100 7,309,200
491 M-1-60-II 6,563,900 7,876,600 9,189,400
492 M-1-60-III 9,915,500 11,898,600 13,881,700
- 353 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 9,672,600 11,607,200 13,541,700
KAKI (RINGAN)
494 M-1-70-II 10,639,900 12,767,900 14,895,800
KAKI (SEDANG)
495 M-1-70-III 12,181,300 14,617,500 17,053,800
KAKI (BERAT)
502 M-4-11-I 2,413,600 2,896,300 3,379,000
(RINGAN)
503 M-4-11-II 5,291,700 6,350,000 7,408,300
(SEDANG)
504 M-4-11-III 7,650,800 9,181,000 10,711,100
(BERAT)
505 M-4-12-I 1,926,600 2,311,900 2,697,200
(RINGAN)
506 M-4-12-II 3,204,400 3,845,300 4,486,200
(SEDANG)
507 M-4-12-III 4,286,200 5,143,500 6,000,700
(BERAT)
508 M-4-13-I 3,207,900 3,849,500 4,491,100
509 M-4-13-II 4,819,800 5,783,700 6,747,700
510 M-4-13-III 9,403,300 11,284,000 13,164,600
520 M-4-17-I 2,410,600 2,892,700 3,374,800
(RINGAN)
521 M-4-17-II 3,371,500 4,045,800 4,720,100
(SEDANG)
522 M-4-17-III 4,708,000 5,649,700 6,591,300
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,916,700 2,300,000 2,683,300
(RINGAN)
530 M-4-20-II 2,806,600 3,367,900 3,929,300
(SEDANG)
531 M-4-20-III 3,136,700 3,764,100 4,391,400
(BERAT)
532 M-4-21-I 1,929,900 2,315,900 2,701,900
533 M-4-21-II 2,413,800 2,896,500 3,379,300
- 354 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 5,411,700 6,494,000 7,576,300
541 N-1-12-I 2,837,200 3,404,700 3,972,100
542 N-1-12-II 5,648,600 6,778,400 7,908,100
543 N-1-12-III 12,257,700 14,709,300 17,160,800
547 N-1-30-I 5,677,100 6,812,500 7,947,900
BAWAH (RINGAN)
548 N-1-30-II 8,588,300 10,306,000 12,023,600
BAWAH (SEDANG)
549 N-1-30-III 9,884,300 11,861,200 13,838,100
BAWAH (BERAT)
550 N-1-40-I 5,098,400 6,118,100 7,137,800
(RINGAN)
551 N-1-40-II 6,923,500 8,308,300 9,693,000
(SEDANG)
552 N-1-40-III 8,058,100 9,669,700 11,281,300
(BERAT)
553 N-4-10-I 2,166,100 2,599,300 3,032,600
(RINGAN)
554 N-4-10-II 2,620,000 3,144,000 3,667,900
(SEDANG)
555 N-4-10-III 3,853,600 4,624,300 5,395,000
(BERAT)
568 N-4-15-I 1,972,900 2,367,500 2,762,100
URIN (RINGAN)
569 N-4-15-II 2,448,100 2,937,700 3,427,300
URIN (SEDANG)
570 N-4-15-III 2,793,700 3,352,400 3,911,100
URIN (BERAT)
571 N-4-16-I 2,415,900 2,899,000 3,382,200
(RINGAN)
572 N-4-16-II 3,448,200 4,137,900 4,827,500
(SEDANG)
573 N-4-16-III 4,589,800 5,507,800 6,425,700
(BERAT)
- 355 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 2,245,700 2,694,800 3,143,900
578 O-6-11-II 2,495,800 2,995,000 3,494,100
579 O-6-11-III 3,104,800 3,725,800 4,346,700
580 O-6-12-I 1,591,000 1,909,200 2,227,400
581 O-6-12-II 1,910,800 2,293,000 2,675,100
582 O-6-12-III 2,401,000 2,881,200 3,361,400
586 P-8-01-I 35,527,700 42,633,200 49,738,800
587 P-8-01-II 43,960,200 52,752,200 61,544,200
588 P-8-01-III 51,596,900 61,916,300 72,235,600
589 P-8-02-I 48,493,600 58,192,300 67,891,100
590 P-8-02-II 55,627,000 66,752,400 77,877,900
591 P-8-02-III 63,557,800 76,269,400 88,981,000
592 P-8-03-I 5,910,100 7,092,100 8,274,200
593 P-8-03-II 8,392,400 10,070,800 11,749,300
594 P-8-03-III 9,483,400 11,380,100 13,276,700
595 P-8-04-I 19,178,800 23,014,600 26,850,300
596 P-8-04-II 24,889,900 29,867,900 34,845,900
597 P-8-04-III 35,685,900 42,823,100 49,960,300
598 P-8-05-I 10,428,800 12,514,600 14,600,300
599 P-8-05-II 19,663,400 23,596,100 27,528,800
600 P-8-05-III 23,996,000 28,795,200 33,594,500
601 P-8-06-I 3,441,100 4,129,300 4,817,500
602 P-8-06-II 9,648,100 11,577,700 13,507,300
603 P-8-06-III 12,781,300 15,337,600 17,893,800
604 P-8-07-I 3,333,100 3,999,700 4,666,300
605 P-8-07-II 9,345,100 11,214,200 13,083,200
606 P-8-07-III 12,380,000 14,856,000 17,332,000
607 P-8-08-I 3,523,700 4,228,500 4,933,200
608 P-8-08-II 5,000,100 6,000,100 7,000,100
609 P-8-08-III 8,096,200 9,715,400 11,334,600
610 P-8-11-I 5,583,500 6,700,200 7,816,900
MAYOR (RINGAN)
611 P-8-11-II 7,928,600 9,514,300 11,100,000
MAYOR (SEDANG)
- 356 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 8,959,300 10,751,100 12,543,000
MAYOR (BERAT)
613 P-8-12-I 5,274,900 6,329,900 7,384,900
MAYOR (RINGAN)
614 P-8-12-II 7,500,200 9,000,200 10,500,200
MAYOR (SEDANG)
615 P-8-12-III 8,488,700 10,186,400 11,884,200
MAYOR (BERAT)
616 P-8-13-I 4,576,800 5,492,200 6,407,600
MAYOR (RINGAN)
617 P-8-13-II 6,041,400 7,249,700 8,458,000
MAYOR (SEDANG)
618 P-8-13-III 8,995,900 10,795,100 12,594,200
MAYOR (BERAT)
619 P-8-14-I 2,317,300 2,780,700 3,244,200
620 P-8-14-II 4,717,100 5,660,500 6,603,900
621 P-8-14-III 8,751,900 10,502,300 12,252,700
622 P-8-15-I 1,738,000 2,085,600 2,433,200
ASPIRASI (RINGAN)
623 P-8-15-II 3,480,400 4,176,500 4,872,600
ASPIRASI (SEDANG)
624 P-8-15-III 4,083,600 4,900,300 5,717,100
ASPIRASI (BERAT)
625 P-8-16-I 1,572,900 1,887,500 2,202,100
626 P-8-16-II 3,022,600 3,627,100 4,231,600
627 P-8-16-III 6,163,900 7,396,600 8,629,400
628 P-8-17-I 3,051,200 3,661,500 4,271,700
(RINGAN)
629 P-8-17-II 5,492,200 6,590,600 7,689,100
(SEDANG)
630 P-8-17-III 7,496,600 8,995,900 10,495,200
(BERAT)
631 S-4-10-I 1,773,400 2,128,100 2,482,800
632 S-4-10-II 2,185,100 2,622,200 3,059,200
633 S-4-10-III 2,991,200 3,589,500 4,187,700
640 S-4-13-I 1,925,400 2,310,500 2,695,600
(RINGAN)
641 S-4-13-II 3,415,800 4,099,000 4,782,100
(SEDANG)
642 S-4-13-III 5,544,300 6,653,100 7,762,000
(BERAT)
643 S-4-14-I 974,400 1,169,300 1,364,100
644 S-4-14-II 2,069,700 2,483,600 2,897,500
645 S-4-14-III 3,924,800 4,709,800 5,494,800
KANAK-KANAK (BERAT)
646 S-4-15-I 651,700 782,000 912,400
647 S-4-15-II 1,229,800 1,475,800 1,721,800
648 S-4-15-III 1,592,800 1,911,400 2,230,000
- 357 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 1,626,500 1,951,700 2,277,000
653 S-4-17-II 2,413,800 2,896,600 3,379,400
654 S-4-17-III 2,903,200 3,483,800 4,064,400
655 T-1-10-I 1,088,200 1,305,900 1,523,500
OBAT (RINGAN)
656 T-1-10-II 1,461,600 1,754,000 2,046,300
OBAT (SEDANG)
657 T-1-10-III 2,658,900 3,190,700 3,722,500
OBAT (BERAT)
658 T-4-10-I 496,300 595,500 694,800
659 T-4-10-II 945,900 1,135,100 1,324,200
660 T-4-10-III 1,375,000 1,650,100 1,925,100
661 T-4-11-I 587,700 705,300 822,800
662 T-4-11-II 924,900 1,109,900 1,294,900
663 T-4-11-III 1,489,600 1,787,600 2,085,500
664 T-4-12-I 1,027,900 1,233,500 1,439,000
LAIN (RINGAN)
665 T-4-12-II 1,553,900 1,864,700 2,175,500
LAIN (SEDANG)
666 T-4-12-III 2,425,300 2,910,300 3,395,400
LAIN (BERAT)
670 U-1-11-I 5,501,600 6,601,900 7,702,300
(RINGAN)
671 U-1-11-II 6,974,100 8,368,900 9,763,800
(SEDANG)
672 U-1-11-III 10,034,600 12,041,600 14,048,500
(BERAT)
679 U-1-14-I 2,585,100 3,102,100 3,619,100
(RINGAN)
680 U-1-14-II 3,172,600 3,807,100 4,441,600
(SEDANG)
681 U-1-14-III 3,759,500 4,511,400 5,263,300
(BERAT)
685 U-1-20-I 3,924,600 4,709,500 5,494,400
686 U-1-20-II 5,840,900 7,009,100 8,177,300
687 U-1-20-III 14,994,700 17,993,600 20,992,600
691 U-4-10-I 2,422,200 2,906,600 3,391,000
- 358 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 5,545,000 6,654,000 7,763,100
693 U-4-10-III 8,513,300 10,216,000 11,918,700
TENGGOROKAN (BERAT)
700 U-4-13-I 1,750,600 2,100,800 2,450,900
701 U-4-13-II 2,063,800 2,476,600 2,889,400
702 U-4-13-III 2,468,500 2,962,100 3,455,800
706 U-4-15-I 1,935,800 2,323,000 2,710,200
707 U-4-15-II 2,411,800 2,894,200 3,376,500
708 U-4-15-III 3,375,400 4,050,400 4,725,500
709 V-1-10-I 3,157,500 3,789,000 4,420,500
(RINGAN)
710 V-1-10-II 6,504,400 7,805,300 9,106,100
(SEDANG)
711 V-1-10-III 7,976,700 9,572,100 11,167,400
(BERAT)
715 V-1-12-I 5,647,800 6,777,300 7,906,900
MODERAT (RINGAN)
716 V-1-12-II 7,712,500 9,255,000 10,797,500
MODERAT (SEDANG)
717 V-1-12-III 9,775,700 11,730,800 13,686,000
MODERAT (BERAT)
718 V-1-13-I 2,946,000 3,535,100 4,124,300
KOMPLEK (RINGAN)
719 V-1-13-II 5,628,800 6,754,500 7,880,300
KOMPLEK (SEDANG)
720 V-1-13-III 8,830,800 10,597,000 12,363,100
KOMPLEK (BERAT)
721 V-1-14-I 5,777,000 6,932,400 8,087,800
(RINGAN)
722 V-1-14-II 8,393,800 10,072,600 11,751,300
(SEDANG)
724 V-1-15-I SIRKUMSISI (RINGAN) 930,400 1,116,500 1,302,500

727 V-4-10-I 2,793,700 3,352,400 3,911,100
(RINGAN)
728 V-4-10-II 4,640,400 5,568,500 6,496,600
(SEDANG)
729 V-4-10-III 7,650,400 9,180,500 10,710,600
(BERAT)
730 V-4-11-I 2,413,900 2,896,700 3,379,400
TUMOR (RINGAN)
731 V-4-11-II 3,238,800 3,886,600 4,534,300
TUMOR (SEDANG)
732 V-4-11-III 4,338,400 5,206,100 6,073,800
TUMOR (BERAT)
- 359 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 6,579,400 7,895,300 9,211,200
734 W-1-01-II 7,885,900 9,463,000 11,040,200
735 W-1-01-III 11,252,900 13,503,500 15,754,100
739 W-1-11-I 1,458,700 1,750,400 2,042,200
SERVIK (RINGAN)
740 W-1-11-II 1,609,700 1,931,600 2,253,500
SERVIK (SEDANG)
741 W-1-11-III 1,780,600 2,136,700 2,492,900
SERVIK (BERAT)
760 W-4-12-I 2,560,600 3,072,700 3,584,800
761 W-4-12-II 3,515,500 4,218,600 4,921,700
762 W-4-12-III 3,832,100 4,598,500 5,364,900
763 W-4-13-I ABORTUS (RINGAN) 813,000 975,600 1,138,200
- 360 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 760,600 912,700 1,064,800
785 Z-4-12-II 1,853,200 2,223,900 2,594,500
786 Z-4-12-III 2,350,300 2,820,300 3,290,400
- 361 -

REGIONAL 2
RUMAH SAKIT UMUM KELAS D PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 735,000
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 977,400
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 892,500
24 D-2-11-0 PROSEDUR LIMPA 1,397,000

33 F-3-10-0 TERAPI SHOCK 395,600
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 863,000
55 H-2-22-0 PROSEDUR SEDANG PADA MATA EKSTERNAL 844,600
63 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 734,100
- 362 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,405,000
PENGGANTIAN ALAT
81 I-2-42-0 2,311,000
PERKUTAN LAIN
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 981,200
118 K-3-13-0 PROSEDUR KOLONOSKOPI 915,600
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 807,000
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 980,900
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 981,500
- 363 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
166 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 924,900
181 O-7-12-0 1,089,800
192 Q-5-12-0 GIGI 198,000
196 Q-5-16-0 VAKSINASI 84,300
201 Q-5-21-0 ABORSI 172,800
206 Q-5-26-0 BRONKIAL AKUT 179,600
- 364 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 120,900
215 Q-5-35-0 INFEKSI AKUT 404,100
218 Q-5-38-0 PARU AKUT 235,500
234 U-2-23-0 RHINOPLASTY 1,163,500
242 U-3-13-0 299,900
TENGGOROKAN
261 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 704,500
270 Z-3-11-0 1,627,000
EMPEDU
- 365 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
275 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 878,600
277 Z-3-18-0 CT-SCAN KEPALA 857,300
288 Z-3-29-0 IMAGING LAIN-LAIN 945,900
289 Z-3-30-0 FOTOTERAPI 69,700
- 1062 -
REGIONAL 1
TOP UP SPESIAL CMG
KODE DESKRIPSI KELAS A B C D

NO KODE CBG
SPECIAL SPECIAL CMG RAWAT PEMERINTAH PEMERINTAH PEMERINTAH PEMERINTAH
1 3,264,500 3,140,200 2,912,200 2,540,600
1 DD-01-I Streptokinase I-4-10-I 2 3,264,500 3,140,200 2,912,200 2,540,600
3 3,264,500 3,140,200 2,912,200 2,540,600
1 3,264,500 3,140,200 2,912,200 2,540,600
2 DD-01-I Streptokinase I-4-10-II 2 3,264,500 3,140,200 2,912,200 2,540,600
3 3,264,500 3,140,200 2,912,200 2,540,600
1 3,264,500 3,140,200 2,912,200 2,540,600
3 DD-01-I Streptokinase I-4-10-III 2 3,264,500 3,140,200 2,912,200 2,540,600
3 3,264,500 3,140,200 2,912,200 2,540,600
1 6,216,000 5,800,000 5,545,300 5,805,300
4 DD-02-II Deferiprone (IP) D-4-13-I 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
5 DD-02-II Deferiprone (IP) D-4-13-II 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
6 DD-02-II Deferiprone (IP) D-4-13-III 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
7 DD-03-II Deferoksamin (IP) D-4-13-I 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
8 DD-03-II Deferoksamin (IP) D-4-13-II 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
9 DD-03-II Deferoksamin (IP) D-4-13-III 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
10 DD-04-II Deferasirox (IP) D-4-13-I 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
11 DD-04-II Deferasirox (IP) D-4-13-II 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 6,216,000 5,800,000 5,545,300 5,805,300
12 DD-04-II Deferasirox (IP) D-4-13-III 2 6,216,000 5,800,000 5,545,300 5,805,300
3 6,216,000 5,800,000 5,545,300 5,805,300
1 2,109,900 1,968,700 1,694,000 1,642,100
Human Albumin for
13 DD-05-II A-4-10-I 2 2,109,900 1,968,700 1,694,000 1,642,100
Septicaemia
3 2,109,900 1,968,700 1,694,000 1,642,100
1 2,109,900 1,968,700 1,694,000 1,642,100
Human Albumin for
14 DD-05-II A-4-10-II 2 2,109,900 1,968,700 1,694,000 1,642,100
Septicaemia
3 2,109,900 1,968,700 1,694,000 1,642,100
1 2,109,900 1,968,700 1,694,000 1,642,100
Human Albumin for
15 DD-05-II A-4-10-III 2 2,109,900 1,968,700 1,694,000 1,642,100
Septicaemia
3 2,109,900 1,968,700 1,694,000 1,642,100
1 11,217,600 7,850,200 6,754,700 5,893,000
Anti Hemofilia Factor
16 DD-06-II D-4-11-I 2 11,217,600 7,850,200 6,754,700 5,893,000
(IP)
3 11,217,600 7,850,200 6,754,700 5,893,000
1 11,217,600 7,850,200 6,754,700 5,893,000
17 DD-06-II D-4-11-II 2 11,217,600 7,850,200 6,754,700 5,893,000
(IP)
3 11,217,600 7,850,200 6,754,700 5,893,000
1 11,217,600 7,850,200 6,754,700 5,893,000
18 DD-06-II D-4-11-III 2 11,217,600 7,850,200 6,754,700 5,893,000
(IP)
3 11,217,600 7,850,200 6,754,700 5,893,000
1 4,297,300 4,009,700 3,450,200 3,344,400
Human Albumin for
19 DD-11-II S-4-16-I 2 4,297,300 4,009,700 3,450,200 3,344,400
Burn
3 4,297,300 4,009,700 3,450,200 3,344,400
1 4,297,300 4,009,700 3,450,200 3,344,400
Human Albumin for
20 DD-11-II S-4-16-II 2 4,297,300 4,009,700 3,450,200 3,344,400
Burn
3 4,297,300 4,009,700 3,450,200 3,344,400
1 4,297,300 4,009,700 3,450,200 3,344,400
Human Albumin for
21 DD-11-II S-4-16-III 2 4,297,300 4,009,700 3,450,200 3,344,400
Burn
3 4,297,300 4,009,700 3,450,200 3,344,400
1 15,673,000 15,076,400 12,583,500 12,197,700
Human Albumin for
22 DD-11-II L-1-20-I 2 15,673,000 15,076,400 12,583,500 12,197,700
Burn
3 15,673,000 15,076,400 12,583,500 12,197,700
1 15,673,000 15,076,400 12,583,500 12,197,700
Human Albumin for
23 DD-11-II L-1-20-II 2 15,673,000 15,076,400 12,583,500 12,197,700
Burn
3 15,673,000 15,076,400 12,583,500 12,197,700
1 15,673,000 15,076,400 12,583,500 12,197,700
Human Albumin for
24 DD-11-II L-1-20-III 2 15,673,000 15,076,400 12,583,500 12,197,700
Burn
3 15,673,000 15,076,400 12,583,500 12,197,700
- 1063 -
REGIONAL 1
TOP UP SPESIAL CMG

NO KODE CBG
1 16,656,400 8,443,500 5,283,900 1,565,200
Subdural Grid
25 RR-01-II G-1-10-I 2 16,656,400 8,443,500 5,283,900 1,565,200
Electrode
3 16,656,400 8,443,500 5,283,900 1,565,200
1 16,656,400 8,443,500 5,283,900 1,565,200
Subdural Grid
26 RR-01-II G-1-10-II 2 16,656,400 8,443,500 5,283,900 1,565,200
Electrode
3 16,656,400 8,443,500 5,283,900 1,565,200
1 16,656,400 8,443,500 5,283,900 1,565,200
Subdural Grid
27 RR-01-II G-1-10-III 2 16,656,400 8,443,500 5,283,900 1,565,200
Electrode
3 16,656,400 8,443,500 5,283,900 1,565,200
1 16,938,500 7,259,700 5,552,700 4,844,200
28 RR-02-II Cote Graft I-1-03-I 2 16,938,500 7,259,700 5,552,700 4,844,200
3 16,938,500 7,259,700 5,552,700 4,844,200
1 16,938,500 7,259,700 5,552,700 4,844,200
29 RR-02-II Cote Graft I-1-03-II 2 16,938,500 7,259,700 5,552,700 4,844,200
3 16,938,500 7,259,700 5,552,700 4,844,200
1 16,938,500 7,259,700 5,552,700 4,844,200
30 RR-02-II Cote Graft I-1-03-III 2 16,938,500 7,259,700 5,552,700 4,844,200
3 16,938,500 7,259,700 5,552,700 4,844,200
1 11,081,000 7,754,500 5,931,100 5,174,300
31 RR-03-III TMJ Prothesis M-1-60-I 2 11,081,000 7,754,500 5,931,100 5,174,300
3 11,081,000 7,754,500 5,931,100 5,174,300
1 11,081,000 7,754,500 5,931,100 5,174,300
32 RR-03-III TMJ Prothesis M-1-60-II 2 11,081,000 7,754,500 5,931,100 5,174,300
3 11,081,000 7,754,500 5,931,100 5,174,300
1 11,081,000 7,754,500 5,931,100 5,174,300
33 RR-03-III TMJ Prothesis M-1-60-III 2 11,081,000 7,754,500 5,931,100 5,174,300
3 11,081,000 7,754,500 5,931,100 5,174,300
1 26,197,900 11,228,200 8,588,000 7,492,200
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,197,900 11,228,200 8,588,000 7,492,200
Implant
3 26,197,900 11,228,200 8,588,000 7,492,200
1 26,197,900 11,228,200 8,588,000 7,492,200
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,197,900 11,228,200 8,588,000 7,492,200
Implant
3 26,197,900 11,228,200 8,588,000 7,492,200
1 26,197,900 11,228,200 8,588,000 7,492,200
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,197,900 11,228,200 8,588,000 7,492,200
Implant
3 26,197,900 11,228,200 8,588,000 7,492,200
1 103,378,500 96,957,300 55,333,500 48,273,500
Prostesis
37 RR-05-III I-1-20-I 2 103,378,500 96,957,300 55,333,500 48,273,500
Evar/Tevar/Hevar
3 103,378,500 96,957,300 55,333,500 48,273,500
1 103,378,500 96,957,300 55,333,500 48,273,500
Prostesis
38 RR-05-III I-1-20-II 2 103,378,500 96,957,300 55,333,500 48,273,500
Evar/Tevar/Hevar
3 103,378,500 96,957,300 55,333,500 48,273,500
1 103,378,500 96,957,300 55,333,500 48,273,500
Prostesis
39 RR-05-III I-1-20-III 2 103,378,500 96,957,300 55,333,500 48,273,500
Evar/Tevar/Hevar
3 103,378,500 96,957,300 55,333,500 48,273,500
Hip 1 13,099,000 5,614,100 4,294,000 3,746,100
40 YY-01-II Replacement/Knee M-1-04-I 2 13,099,000 5,614,100 4,294,000 3,746,100
Replacement 3 13,099,000 5,614,100 4,294,000 3,746,100
Hip 1 13,099,000 5,614,100 4,294,000 3,746,100
41 YY-01-II Replacement/Knee M-1-04-II 2 13,099,000 5,614,100 4,294,000 3,746,100
Replacement 3 13,099,000 5,614,100 4,294,000 3,746,100
Hip 1 13,099,000 5,614,100 4,294,000 3,746,100
42 YY-01-II Replacement/Knee M-1-04-III 2 13,099,000 5,614,100 4,294,000 3,746,100
Replacement 3 13,099,000 5,614,100 4,294,000 3,746,100
1 14,434,100 10,413,400 7,725,900 6,740,100
43 YY-02-III PCI I-1-40-I 2 14,434,100 10,413,400 7,725,900 6,740,100
3 14,434,100 10,413,400 7,725,900 6,740,100
1 14,434,100 10,413,400 7,725,900 6,740,100
44 YY-02-III PCI I-1-40-II 2 14,434,100 10,413,400 7,725,900 6,740,100
3 14,434,100 10,413,400 7,725,900 6,740,100
1 14,434,100 10,413,400 7,725,900 6,740,100
45 YY-02-III PCI I-1-40-III 2 14,434,100 10,413,400 7,725,900 6,740,100
3 14,434,100 10,413,400 7,725,900 6,740,100
1 8,041,400 7,237,200 6,433,000 5,629,000
46 YY-03-III Keratoplasty H-1-30-I 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
1 8,041,400 7,237,200 6,433,000 5,629,000
47 YY-03-III Keratoplasty H-1-30-II 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
1 8,041,400 7,237,200 6,433,000 5,629,000
48 YY-03-III Keratoplasty H-1-30-III 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
- 1064 -
REGIONAL 1
TOP UP SPESIAL CMG

NO KODE CBG
1 8,067,400 6,210,100 3,886,300 3,390,400
49 YY-04-III Pancreatectomy B-1-10-I 2 8,067,400 6,210,100 3,886,300 3,390,400
3 8,067,400 6,210,100 3,886,300 3,390,400
1 8,067,400 6,210,100 3,886,300 3,390,400
50 YY-04-III Pancreatectomy B-1-10-II 2 8,067,400 6,210,100 3,886,300 3,390,400
3 8,067,400 6,210,100 3,886,300 3,390,400
1 8,067,400 6,210,100 3,886,300 3,390,400
51 YY-04-III Pancreatectomy B-1-10-III 2 8,067,400 6,210,100 3,886,300 3,390,400
3 8,067,400 6,210,100 3,886,300 3,390,400
Repair of Septal 1 48,292,200 21,337,800 15,830,800 13,810,900
52 YY-05-III Defect of Heart with I-1-06-I 2 48,292,200 21,337,800 15,830,800 13,810,900
Prosthesis 3 48,292,200 21,337,800 15,830,800 13,810,900
Repair of Septal 1 48,292,200 21,337,800 15,830,800 13,810,900
53 YY-05-III Defect of Heart with I-1-06-II 2 48,292,200 21,337,800 15,830,800 13,810,900
Prosthesis 3 48,292,200 21,337,800 15,830,800 13,810,900
Repair of Septal 1 48,292,200 21,337,800 15,830,800 13,810,900
54 YY-05-III Defect of Heart with I-1-06-III 2 48,292,200 21,337,800 15,830,800 13,810,900
Prosthesis 3 48,292,200 21,337,800 15,830,800 13,810,900
1 4,090,100 2,862,300 2,189,300 1,909,900
Stereotactic Surgery
55 YY-06-III C-4-12-I 2 4,090,100 2,862,300 2,189,300 1,909,900
& Radiotheraphy
3 4,090,100 2,862,300 2,189,300 1,909,900
1 4,090,100 2,862,300 2,189,300 1,909,900
56 YY-06-III C-4-12-II 2 4,090,100 2,862,300 2,189,300 1,909,900
& Radiotheraphy
3 4,090,100 2,862,300 2,189,300 1,909,900
1 4,090,100 2,862,300 2,189,300 1,909,900
57 YY-06-III C-4-12-III 2 4,090,100 2,862,300 2,189,300 1,909,900
& Radiotheraphy
3 4,090,100 2,862,300 2,189,300 1,909,900
1 10,142,700 7,097,900 5,428,900 4,736,200
58 YY-07-III Torakotomi J-1-30-I 2 10,142,700 7,097,900 5,428,900 4,736,200
3 10,142,700 7,097,900 5,428,900 4,736,200
1 10,142,700 7,097,900 5,428,900 4,736,200
59 YY-07-III Torakotomi J-1-30-II 2 10,142,700 7,097,900 5,428,900 4,736,200
3 10,142,700 7,097,900 5,428,900 4,736,200
1 10,142,700 7,097,900 5,428,900 4,736,200
60 YY-07-III Torakotomi J-1-30-III 2 10,142,700 7,097,900 5,428,900 4,736,200
3 10,142,700 7,097,900 5,428,900 4,736,200
1 12,153,800 8,505,300 6,505,400 5,675,300
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,153,800 8,505,300 6,505,400 5,675,300
mi
3 12,153,800 8,505,300 6,505,400 5,675,300
1 12,153,800 8,505,300 6,505,400 5,675,300
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,153,800 8,505,300 6,505,400 5,675,300
mi
3 12,153,800 8,505,300 6,505,400 5,675,300
1 12,153,800 8,505,300 6,505,400 5,675,300
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,153,800 8,505,300 6,505,400 5,675,300
mi
3 12,153,800 8,505,300 6,505,400 5,675,300
1 8,041,400 7,237,200 6,433,000 5,629,000
64 YY-09-III Vitrectomy H-1-30-I 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
1 8,041,400 7,237,200 6,433,000 5,629,000
65 YY-09-III Vitrectomy H-1-30-II 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
1 8,041,400 7,237,200 6,433,000 5,629,000
66 YY-09-III Vitrectomy H-1-30-III 2 8,041,400 7,237,200 6,433,000 5,629,000
3 8,041,400 7,237,200 6,433,000 5,629,000
67 DD-07-II Deferiprone (OP) Q-5-44-0 - 6,033,600 4,032,600 3,990,800 3,876,400
68 DD-08-II Deferoksamin (OP) Q-5-44-0 - 6,033,600 4,032,600 3,990,800 3,876,400
69 DD-09-II Deferasirox (OP) Q-5-44-0 - 6,033,600 4,032,600 3,990,800 3,876,400
70 DD-10-II Q-5-44-0 - 10,181,700 5,499,000 5,442,000 5,286,000
(OP)
71 II-01-III Nuclear Medicine Z-3-17-0 - 2,231,300 905,000 651,200 618,300
72 II-02-III MRI Z-3-16-0 - 1,865,900 1,679,300 1,492,700 1,306,200
Diagnostic and
73 II-03-III Imaging Procedure of H-3-13-0 - 548,000 360,900 357,200 339,000
Eye
74 YY-10-III Phacoemulsification H-2-36-0 - 4,410,000 3,780,000 3,465,000 3,150,000
75 YY-11-III Microlaringoscopy J-3-15-0 - 1,171,000 771,200 763,200 724,600
76 YY-12-III Cholangiograph B-3-11-0 - 2,943,200 2,132,200 1,534,400 1,457,000
- 1065 -
REGIONAL 1
TOP UP SPESIAL CMG

NO KODE CBG
SPECIAL SPECIAL CMG RAWAT SWASTA SWASTA SWASTA SWASTA
1 3,362,400 3,234,400 2,999,600 2,616,800
3 3,362,400 3,234,400 2,999,600 2,616,800
1 3,362,400 3,234,400 2,999,600 2,616,800
3 3,362,400 3,234,400 2,999,600 2,616,800
1 3,362,400 3,234,400 2,999,600 2,616,800
3 3,362,400 3,234,400 2,999,600 2,616,800
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 6,402,500 5,974,000 5,711,500 5,979,300
3 6,402,500 5,974,000 5,711,500 5,979,300
1 2,173,200 2,027,800 1,744,800 1,691,300
Human Albumin for
13 DD-05-II A-4-10-I 2 2,173,200 2,027,800 1,744,800 1,691,300
Septicaemia
3 2,173,200 2,027,800 1,744,800 1,691,300
1 2,173,200 2,027,800 1,744,800 1,691,300
Human Albumin for
14 DD-05-II A-4-10-II 2 2,173,200 2,027,800 1,744,800 1,691,300
Septicaemia
3 2,173,200 2,027,800 1,744,800 1,691,300
1 2,173,200 2,027,800 1,744,800 1,691,300
Human Albumin for
15 DD-05-II A-4-10-III 2 2,173,200 2,027,800 1,744,800 1,691,300
Septicaemia
3 2,173,200 2,027,800 1,744,800 1,691,300
1 11,554,200 8,085,600 6,957,500 6,069,600
16 DD-06-II D-4-11-I 2 11,554,200 8,085,600 6,957,500 6,069,600
(IP)
3 11,554,200 8,085,600 6,957,500 6,069,600
1 11,554,200 8,085,600 6,957,500 6,069,600
17 DD-06-II D-4-11-II 2 11,554,200 8,085,600 6,957,500 6,069,600
(IP)
3 11,554,200 8,085,600 6,957,500 6,069,600
1 11,554,200 8,085,600 6,957,500 6,069,600
18 DD-06-II D-4-11-III 2 11,554,200 8,085,600 6,957,500 6,069,600
(IP)
3 11,554,200 8,085,600 6,957,500 6,069,600
1 4,426,200 4,130,000 3,553,700 3,444,700
Human Albumin for
19 DD-11-II S-4-16-I 2 4,426,200 4,130,000 3,553,700 3,444,700
Burn
3 4,426,200 4,130,000 3,553,700 3,444,700
1 4,426,200 4,130,000 3,553,700 3,444,700
Human Albumin for
20 DD-11-II S-4-16-II 2 4,426,200 4,130,000 3,553,700 3,444,700
Burn
3 4,426,200 4,130,000 3,553,700 3,444,700
1 4,426,200 4,130,000 3,553,700 3,444,700
Human Albumin for
21 DD-11-II S-4-16-III 2 4,426,200 4,130,000 3,553,700 3,444,700
Burn
3 4,426,200 4,130,000 3,553,700 3,444,700
1 16,143,200 15,528,600 12,961,100 12,563,600
Human Albumin for
22 DD-11-II L-1-20-I 2 16,143,200 15,528,600 12,961,100 12,563,600
Burn
3 16,143,200 15,528,600 12,961,100 12,563,600
1 16,143,200 15,528,600 12,961,100 12,563,600
Human Albumin for
23 DD-11-II L-1-20-II 2 16,143,200 15,528,600 12,961,100 12,563,600
Burn
3 16,143,200 15,528,600 12,961,100 12,563,600
1 16,143,200 15,528,600 12,961,100 12,563,600
Human Albumin for
24 DD-11-II L-1-20-III 2 16,143,200 15,528,600 12,961,100 12,563,600
Burn
3 16,143,200 15,528,600 12,961,100 12,563,600
- 1066 -
REGIONAL 1
TOP UP SPESIAL CMG

NO KODE CBG
1 17,156,100 8,696,800 5,442,400 1,612,100
Subdural Grid
25 RR-01-II G-1-10-I 2 17,156,100 8,696,800 5,442,400 1,612,100
Electrode
3 17,156,100 8,696,800 5,442,400 1,612,100
1 17,156,100 8,696,800 5,442,400 1,612,100
Subdural Grid
26 RR-01-II G-1-10-II 2 17,156,100 8,696,800 5,442,400 1,612,100
Electrode
3 17,156,100 8,696,800 5,442,400 1,612,100
1 17,156,100 8,696,800 5,442,400 1,612,100
Subdural Grid
27 RR-01-II G-1-10-III 2 17,156,100 8,696,800 5,442,400 1,612,100
Electrode
3 17,156,100 8,696,800 5,442,400 1,612,100
1 17,446,600 7,477,500 5,719,200 4,989,500
3 17,446,600 7,477,500 5,719,200 4,989,500
1 17,446,600 7,477,500 5,719,200 4,989,500
3 17,446,600 7,477,500 5,719,200 4,989,500
1 17,446,600 7,477,500 5,719,200 4,989,500
3 17,446,600 7,477,500 5,719,200 4,989,500
1 11,413,400 7,987,100 6,109,000 5,329,500
3 11,413,400 7,987,100 6,109,000 5,329,500
1 11,413,400 7,987,100 6,109,000 5,329,500
3 11,413,400 7,987,100 6,109,000 5,329,500
1 11,413,400 7,987,100 6,109,000 5,329,500
3 11,413,400 7,987,100 6,109,000 5,329,500
1 26,983,900 11,565,100 8,845,700 7,717,000
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,983,900 11,565,100 8,845,700 7,717,000
Implant
3 26,983,900 11,565,100 8,845,700 7,717,000
1 26,983,900 11,565,100 8,845,700 7,717,000
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,983,900 11,565,100 8,845,700 7,717,000
Implant
3 26,983,900 11,565,100 8,845,700 7,717,000
1 26,983,900 11,565,100 8,845,700 7,717,000
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,983,900 11,565,100 8,845,700 7,717,000
Implant
3 26,983,900 11,565,100 8,845,700 7,717,000
1 106,480,000 99,865,400 56,993,500 49,721,500
Prostesis
37 RR-05-III I-1-20-I 2 106,480,000 99,865,400 56,993,500 49,721,500
Evar/Tevar/Hevar
3 106,480,000 99,865,400 56,993,500 49,721,500
1 106,480,000 99,865,400 56,993,500 49,721,500
Prostesis
38 RR-05-III I-1-20-II 2 106,480,000 99,865,400 56,993,500 49,721,500
Evar/Tevar/Hevar
3 106,480,000 99,865,400 56,993,500 49,721,500
1 106,480,000 99,865,400 56,993,500 49,721,500
Prostesis
39 RR-05-III I-1-20-III 2 106,480,000 99,865,400 56,993,500 49,721,500
Evar/Tevar/Hevar
3 106,480,000 99,865,400 56,993,500 49,721,500
Hip 1 13,492,000 5,782,600 4,422,900 3,858,500
Replacement 3 13,492,000 5,782,600 4,422,900 3,858,500
Hip 1 13,492,000 5,782,600 4,422,900 3,858,500
Replacement 3 13,492,000 5,782,600 4,422,900 3,858,500
Hip 1 13,492,000 5,782,600 4,422,900 3,858,500
Replacement 3 13,492,000 5,782,600 4,422,900 3,858,500
1 14,867,100 10,725,800 7,957,600 6,942,300
43 YY-02-III PCI I-1-40-I 2 14,867,100 10,725,800 7,957,600 6,942,300
3 14,867,100 10,725,800 7,957,600 6,942,300
1 14,867,100 10,725,800 7,957,600 6,942,300
44 YY-02-III PCI I-1-40-II 2 14,867,100 10,725,800 7,957,600 6,942,300
3 14,867,100 10,725,800 7,957,600 6,942,300
1 14,867,100 10,725,800 7,957,600 6,942,300
45 YY-02-III PCI I-1-40-III 2 14,867,100 10,725,800 7,957,600 6,942,300
3 14,867,100 10,725,800 7,957,600 6,942,300
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
- 1067 -
REGIONAL 1
TOP UP SPESIAL CMG

NO KODE CBG
1 8,309,400 6,396,400 4,002,800 3,492,100
3 8,309,400 6,396,400 4,002,800 3,492,100
1 8,309,400 6,396,400 4,002,800 3,492,100
3 8,309,400 6,396,400 4,002,800 3,492,100
1 8,309,400 6,396,400 4,002,800 3,492,100
3 8,309,400 6,396,400 4,002,800 3,492,100
Repair of Septal 1 49,741,000 21,977,900 16,305,700 14,225,200
Prosthesis 3 49,741,000 21,977,900 16,305,700 14,225,200
Repair of Septal 1 49,741,000 21,977,900 16,305,700 14,225,200
Prosthesis 3 49,741,000 21,977,900 16,305,700 14,225,200
Repair of Septal 1 49,741,000 21,977,900 16,305,700 14,225,200
Prosthesis 3 49,741,000 21,977,900 16,305,700 14,225,200
1 4,212,900 2,948,200 2,254,900 1,967,200
55 YY-06-III C-4-12-I 2 4,212,900 2,948,200 2,254,900 1,967,200
& Radiotheraphy
3 4,212,900 2,948,200 2,254,900 1,967,200
1 4,212,900 2,948,200 2,254,900 1,967,200
56 YY-06-III C-4-12-II 2 4,212,900 2,948,200 2,254,900 1,967,200
& Radiotheraphy
3 4,212,900 2,948,200 2,254,900 1,967,200
1 4,212,900 2,948,200 2,254,900 1,967,200
57 YY-06-III C-4-12-III 2 4,212,900 2,948,200 2,254,900 1,967,200
& Radiotheraphy
3 4,212,900 2,948,200 2,254,900 1,967,200
1 10,447,000 7,310,800 5,591,800 4,878,300
3 10,447,000 7,310,800 5,591,800 4,878,300
1 10,447,000 7,310,800 5,591,800 4,878,300
3 10,447,000 7,310,800 5,591,800 4,878,300
1 10,447,000 7,310,800 5,591,800 4,878,300
3 10,447,000 7,310,800 5,591,800 4,878,300
1 12,518,500 8,760,500 6,700,500 5,845,600
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,518,500 8,760,500 6,700,500 5,845,600
mi
3 12,518,500 8,760,500 6,700,500 5,845,600
1 12,518,500 8,760,500 6,700,500 5,845,600
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,518,500 8,760,500 6,700,500 5,845,600
mi
3 12,518,500 8,760,500 6,700,500 5,845,600
1 12,518,500 8,760,500 6,700,500 5,845,600
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,518,500 8,760,500 6,700,500 5,845,600
mi
3 12,518,500 8,760,500 6,700,500 5,845,600
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
1 8,282,600 7,454,300 6,626,000 5,797,800
3 8,282,600 7,454,300 6,626,000 5,797,800
70 DD-10-II Q-5-44-0 - 10,689,300 5,772,000 5,712,000 5,550,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,959,200 1,763,300 1,567,400 1,371,500
Diagnostic and
Eye
- 1068 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 3,293,900 3,168,500 2,938,400 2,563,500
3 3,293,900 3,168,500 2,938,400 2,563,500
1 3,293,900 3,168,500 2,938,400 2,563,500
3 3,293,900 3,168,500 2,938,400 2,563,500
1 3,293,900 3,168,500 2,938,400 2,563,500
3 3,293,900 3,168,500 2,938,400 2,563,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 6,272,000 5,852,200 5,595,000 5,857,500
3 6,272,000 5,852,200 5,595,000 5,857,500
1 2,128,900 1,986,400 1,709,300 1,656,800
Human Albumin for
13 DD-05-II A-4-10-I 2 2,128,900 1,986,400 1,709,300 1,656,800
Septicaemia
3 2,128,900 1,986,400 1,709,300 1,656,800
1 2,128,900 1,986,400 1,709,300 1,656,800
Human Albumin for
14 DD-05-II A-4-10-II 2 2,128,900 1,986,400 1,709,300 1,656,800
Septicaemia
3 2,128,900 1,986,400 1,709,300 1,656,800
1 2,128,900 1,986,400 1,709,300 1,656,800
Human Albumin for
15 DD-05-II A-4-10-III 2 2,128,900 1,986,400 1,709,300 1,656,800
Septicaemia
3 2,128,900 1,986,400 1,709,300 1,656,800
1 11,318,600 7,920,800 6,815,700 5,945,900
16 DD-06-II D-4-11-I 2 11,318,600 7,920,800 6,815,700 5,945,900
(IP)
3 11,318,600 7,920,800 6,815,700 5,945,900
1 11,318,600 7,920,800 6,815,700 5,945,900
17 DD-06-II D-4-11-II 2 11,318,600 7,920,800 6,815,700 5,945,900
(IP)
3 11,318,600 7,920,800 6,815,700 5,945,900
1 11,318,600 7,920,800 6,815,700 5,945,900
18 DD-06-II D-4-11-III 2 11,318,600 7,920,800 6,815,700 5,945,900
(IP)
3 11,318,600 7,920,800 6,815,700 5,945,900
1 4,336,000 4,045,800 3,481,300 3,374,500
Human Albumin for
19 DD-11-II S-4-16-I 2 4,336,000 4,045,800 3,481,300 3,374,500
Burn
3 4,336,000 4,045,800 3,481,300 3,374,500
1 4,336,000 4,045,800 3,481,300 3,374,500
Human Albumin for
20 DD-11-II S-4-16-II 2 4,336,000 4,045,800 3,481,300 3,374,500
Burn
3 4,336,000 4,045,800 3,481,300 3,374,500
1 4,336,000 4,045,800 3,481,300 3,374,500
Human Albumin for
21 DD-11-II S-4-16-III 2 4,336,000 4,045,800 3,481,300 3,374,500
Burn
3 4,336,000 4,045,800 3,481,300 3,374,500
1 15,814,100 15,212,100 12,696,800 12,307,500
Human Albumin for
22 DD-11-II L-1-20-I 2 15,814,100 15,212,100 12,696,800 12,307,500
Burn
3 15,814,100 15,212,100 12,696,800 12,307,500
1 15,814,100 15,212,100 12,696,800 12,307,500
Human Albumin for
23 DD-11-II L-1-20-II 2 15,814,100 15,212,100 12,696,800 12,307,500
Burn
3 15,814,100 15,212,100 12,696,800 12,307,500
1 15,814,100 15,212,100 12,696,800 12,307,500
Human Albumin for
24 DD-11-II L-1-20-III 2 15,814,100 15,212,100 12,696,800 12,307,500
Burn
3 15,814,100 15,212,100 12,696,800 12,307,500
- 1069 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 16,806,300 8,519,500 5,331,500 1,579,200
Subdural Grid
25 RR-01-II G-1-10-I 2 16,806,300 8,519,500 5,331,500 1,579,200
Electrode
3 16,806,300 8,519,500 5,331,500 1,579,200
1 16,806,300 8,519,500 5,331,500 1,579,200
Subdural Grid
26 RR-01-II G-1-10-II 2 16,806,300 8,519,500 5,331,500 1,579,200
Electrode
3 16,806,300 8,519,500 5,331,500 1,579,200
1 16,806,300 8,519,500 5,331,500 1,579,200
Subdural Grid
27 RR-01-II G-1-10-III 2 16,806,300 8,519,500 5,331,500 1,579,200
Electrode
3 16,806,300 8,519,500 5,331,500 1,579,200
1 17,090,900 7,325,000 5,602,600 4,887,800
3 17,090,900 7,325,000 5,602,600 4,887,800
1 17,090,900 7,325,000 5,602,600 4,887,800
3 17,090,900 7,325,000 5,602,600 4,887,800
1 17,090,900 7,325,000 5,602,600 4,887,800
3 17,090,900 7,325,000 5,602,600 4,887,800
1 11,180,700 7,824,300 5,984,500 5,220,900
3 11,180,700 7,824,300 5,984,500 5,220,900
1 11,180,700 7,824,300 5,984,500 5,220,900
3 11,180,700 7,824,300 5,984,500 5,220,900
1 11,180,700 7,824,300 5,984,500 5,220,900
3 11,180,700 7,824,300 5,984,500 5,220,900
1 26,433,700 11,329,300 8,665,300 7,559,700
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,433,700 11,329,300 8,665,300 7,559,700
Implant
3 26,433,700 11,329,300 8,665,300 7,559,700
1 26,433,700 11,329,300 8,665,300 7,559,700
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,433,700 11,329,300 8,665,300 7,559,700
Implant
3 26,433,700 11,329,300 8,665,300 7,559,700
1 26,433,700 11,329,300 8,665,300 7,559,700
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,433,700 11,329,300 8,665,300 7,559,700
Implant
3 26,433,700 11,329,300 8,665,300 7,559,700
1 104,309,000 97,829,600 55,831,500 48,707,500
Prostesis
37 RR-05-III I-1-20-I 2 104,309,000 97,829,600 55,831,500 48,707,500
Evar/Tevar/Hevar
3 104,309,000 97,829,600 55,831,500 48,707,500
1 104,309,000 97,829,600 55,831,500 48,707,500
Prostesis
38 RR-05-III I-1-20-II 2 104,309,000 97,829,600 55,831,500 48,707,500
Evar/Tevar/Hevar
3 104,309,000 97,829,600 55,831,500 48,707,500
1 104,309,000 97,829,600 55,831,500 48,707,500
Prostesis
39 RR-05-III I-1-20-III 2 104,309,000 97,829,600 55,831,500 48,707,500
Evar/Tevar/Hevar
3 104,309,000 97,829,600 55,831,500 48,707,500
Hip 1 13,216,900 5,664,700 4,332,700 3,779,900
Replacement 3 13,216,900 5,664,700 4,332,700 3,779,900
Hip 1 13,216,900 5,664,700 4,332,700 3,779,900
Replacement 3 13,216,900 5,664,700 4,332,700 3,779,900
Hip 1 13,216,900 5,664,700 4,332,700 3,779,900
Replacement 3 13,216,900 5,664,700 4,332,700 3,779,900
1 14,564,000 10,507,100 7,795,400 6,800,700
43 YY-02-III PCI I-1-40-I 2 14,564,000 10,507,100 7,795,400 6,800,700
3 14,564,000 10,507,100 7,795,400 6,800,700
1 14,564,000 10,507,100 7,795,400 6,800,700
44 YY-02-III PCI I-1-40-II 2 14,564,000 10,507,100 7,795,400 6,800,700
3 14,564,000 10,507,100 7,795,400 6,800,700
1 14,564,000 10,507,100 7,795,400 6,800,700
45 YY-02-III PCI I-1-40-III 2 14,564,000 10,507,100 7,795,400 6,800,700
3 14,564,000 10,507,100 7,795,400 6,800,700
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
- 1070 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 8,140,000 6,266,000 3,921,200 3,420,900
3 8,140,000 6,266,000 3,921,200 3,420,900
1 8,140,000 6,266,000 3,921,200 3,420,900
3 8,140,000 6,266,000 3,921,200 3,420,900
1 8,140,000 6,266,000 3,921,200 3,420,900
3 8,140,000 6,266,000 3,921,200 3,420,900
Repair of Septal 1 48,726,800 21,529,800 15,973,300 13,935,200
Prosthesis 3 48,726,800 21,529,800 15,973,300 13,935,200
Repair of Septal 1 48,726,800 21,529,800 15,973,300 13,935,200
Prosthesis 3 48,726,800 21,529,800 15,973,300 13,935,200
Repair of Septal 1 48,726,800 21,529,800 15,973,300 13,935,200
Prosthesis 3 48,726,800 21,529,800 15,973,300 13,935,200
1 4,127,000 2,888,100 2,209,000 1,927,100
55 YY-06-III C-4-12-I 2 4,127,000 2,888,100 2,209,000 1,927,100
& Radiotheraphy
3 4,127,000 2,888,100 2,209,000 1,927,100
1 4,127,000 2,888,100 2,209,000 1,927,100
56 YY-06-III C-4-12-II 2 4,127,000 2,888,100 2,209,000 1,927,100
& Radiotheraphy
3 4,127,000 2,888,100 2,209,000 1,927,100
1 4,127,000 2,888,100 2,209,000 1,927,100
57 YY-06-III C-4-12-III 2 4,127,000 2,888,100 2,209,000 1,927,100
& Radiotheraphy
3 4,127,000 2,888,100 2,209,000 1,927,100
1 10,234,000 7,161,800 5,477,800 4,778,800
3 10,234,000 7,161,800 5,477,800 4,778,800
1 10,234,000 7,161,800 5,477,800 4,778,800
3 10,234,000 7,161,800 5,477,800 4,778,800
1 10,234,000 7,161,800 5,477,800 4,778,800
3 10,234,000 7,161,800 5,477,800 4,778,800
1 12,263,200 8,581,900 6,563,900 5,726,400
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,263,200 8,581,900 6,563,900 5,726,400
mi
3 12,263,200 8,581,900 6,563,900 5,726,400
1 12,263,200 8,581,900 6,563,900 5,726,400
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,263,200 8,581,900 6,563,900 5,726,400
mi
3 12,263,200 8,581,900 6,563,900 5,726,400
1 12,263,200 8,581,900 6,563,900 5,726,400
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,263,200 8,581,900 6,563,900 5,726,400
mi
3 12,263,200 8,581,900 6,563,900 5,726,400
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
1 8,113,700 7,302,300 6,490,900 5,679,600
3 8,113,700 7,302,300 6,490,900 5,679,600
70 DD-10-II Q-5-44-0 - 10,273,500 5,547,000 5,490,000 5,334,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,882,700 1,694,400 1,506,200 1,317,900
Diagnostic and
Eye
- 1071 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 3,392,600 3,263,500 3,026,600 2,640,400
3 3,392,600 3,263,500 3,026,600 2,640,400
1 3,392,600 3,263,500 3,026,600 2,640,400
3 3,392,600 3,263,500 3,026,600 2,640,400
1 3,392,600 3,263,500 3,026,600 2,640,400
3 3,392,600 3,263,500 3,026,600 2,640,400
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 6,460,100 6,027,800 5,763,000 6,033,000
3 6,460,100 6,027,800 5,763,000 6,033,000
1 2,192,800 2,046,000 1,760,500 1,706,500
Human Albumin for
13 DD-05-II A-4-10-I 2 2,192,800 2,046,000 1,760,500 1,706,500
Septicaemia
3 2,192,800 2,046,000 1,760,500 1,706,500
1 2,192,800 2,046,000 1,760,500 1,706,500
Human Albumin for
14 DD-05-II A-4-10-II 2 2,192,800 2,046,000 1,760,500 1,706,500
Septicaemia
3 2,192,800 2,046,000 1,760,500 1,706,500
1 2,192,800 2,046,000 1,760,500 1,706,500
Human Albumin for
15 DD-05-II A-4-10-III 2 2,192,800 2,046,000 1,760,500 1,706,500
Septicaemia
3 2,192,800 2,046,000 1,760,500 1,706,500
1 11,658,200 8,158,400 7,020,000 6,124,300
16 DD-06-II D-4-11-I 2 11,658,200 8,158,400 7,020,000 6,124,300
(IP)
3 11,658,200 8,158,400 7,020,000 6,124,300
1 11,658,200 8,158,400 7,020,000 6,124,300
17 DD-06-II D-4-11-II 2 11,658,200 8,158,400 7,020,000 6,124,300
(IP)
3 11,658,200 8,158,400 7,020,000 6,124,300
1 11,658,200 8,158,400 7,020,000 6,124,300
18 DD-06-II D-4-11-III 2 11,658,200 8,158,400 7,020,000 6,124,300
(IP)
3 11,658,200 8,158,400 7,020,000 6,124,300
1 4,466,000 4,167,100 3,585,700 3,475,700
Human Albumin for
19 DD-11-II S-4-16-I 2 4,466,000 4,167,100 3,585,700 3,475,700
Burn
3 4,466,000 4,167,100 3,585,700 3,475,700
1 4,466,000 4,167,100 3,585,700 3,475,700
Human Albumin for
20 DD-11-II S-4-16-II 2 4,466,000 4,167,100 3,585,700 3,475,700
Burn
3 4,466,000 4,167,100 3,585,700 3,475,700
1 4,466,000 4,167,100 3,585,700 3,475,700
Human Albumin for
21 DD-11-II S-4-16-III 2 4,466,000 4,167,100 3,585,700 3,475,700
Burn
3 4,466,000 4,167,100 3,585,700 3,475,700
1 16,288,500 15,668,400 13,077,700 12,676,700
Human Albumin for
22 DD-11-II L-1-20-I 2 16,288,500 15,668,400 13,077,700 12,676,700
Burn
3 16,288,500 15,668,400 13,077,700 12,676,700
1 16,288,500 15,668,400 13,077,700 12,676,700
Human Albumin for
23 DD-11-II L-1-20-II 2 16,288,500 15,668,400 13,077,700 12,676,700
Burn
3 16,288,500 15,668,400 13,077,700 12,676,700
1 16,288,500 15,668,400 13,077,700 12,676,700
Human Albumin for
24 DD-11-II L-1-20-III 2 16,288,500 15,668,400 13,077,700 12,676,700
Burn
3 16,288,500 15,668,400 13,077,700 12,676,700
- 1072 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 17,310,500 8,775,100 5,491,400 1,626,600
Subdural Grid
25 RR-01-II G-1-10-I 2 17,310,500 8,775,100 5,491,400 1,626,600
Electrode
3 17,310,500 8,775,100 5,491,400 1,626,600
1 17,310,500 8,775,100 5,491,400 1,626,600
Subdural Grid
26 RR-01-II G-1-10-II 2 17,310,500 8,775,100 5,491,400 1,626,600
Electrode
3 17,310,500 8,775,100 5,491,400 1,626,600
1 17,310,500 8,775,100 5,491,400 1,626,600
Subdural Grid
27 RR-01-II G-1-10-III 2 17,310,500 8,775,100 5,491,400 1,626,600
Electrode
3 17,310,500 8,775,100 5,491,400 1,626,600
1 17,603,600 7,544,800 5,770,700 5,034,400
3 17,603,600 7,544,800 5,770,700 5,034,400
1 17,603,600 7,544,800 5,770,700 5,034,400
3 17,603,600 7,544,800 5,770,700 5,034,400
1 17,603,600 7,544,800 5,770,700 5,034,400
3 17,603,600 7,544,800 5,770,700 5,034,400
1 11,516,100 8,059,000 6,164,000 5,377,500
3 11,516,100 8,059,000 6,164,000 5,377,500
1 11,516,100 8,059,000 6,164,000 5,377,500
3 11,516,100 8,059,000 6,164,000 5,377,500
1 11,516,100 8,059,000 6,164,000 5,377,500
3 11,516,100 8,059,000 6,164,000 5,377,500
1 27,226,700 11,669,200 8,925,300 7,786,400
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 27,226,700 11,669,200 8,925,300 7,786,400
Implant
3 27,226,700 11,669,200 8,925,300 7,786,400
1 27,226,700 11,669,200 8,925,300 7,786,400
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 27,226,700 11,669,200 8,925,300 7,786,400
Implant
3 27,226,700 11,669,200 8,925,300 7,786,400
1 27,226,700 11,669,200 8,925,300 7,786,400
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 27,226,700 11,669,200 8,925,300 7,786,400
Implant
3 27,226,700 11,669,200 8,925,300 7,786,400
1 107,438,500 100,764,300 57,506,500 50,169,000
Prostesis
37 RR-05-III I-1-20-I 2 107,438,500 100,764,300 57,506,500 50,169,000
Evar/Tevar/Hevar
3 107,438,500 100,764,300 57,506,500 50,169,000
1 107,438,500 100,764,300 57,506,500 50,169,000
Prostesis
38 RR-05-III I-1-20-II 2 107,438,500 100,764,300 57,506,500 50,169,000
Evar/Tevar/Hevar
3 107,438,500 100,764,300 57,506,500 50,169,000
1 107,438,500 100,764,300 57,506,500 50,169,000
Prostesis
39 RR-05-III I-1-20-III 2 107,438,500 100,764,300 57,506,500 50,169,000
Evar/Tevar/Hevar
3 107,438,500 100,764,300 57,506,500 50,169,000
Hip 1 13,613,400 5,834,600 4,462,700 3,893,200
Replacement 3 13,613,400 5,834,600 4,462,700 3,893,200
Hip 1 13,613,400 5,834,600 4,462,700 3,893,200
Replacement 3 13,613,400 5,834,600 4,462,700 3,893,200
Hip 1 13,613,400 5,834,600 4,462,700 3,893,200
Replacement 3 13,613,400 5,834,600 4,462,700 3,893,200
1 15,000,900 10,822,300 8,029,200 7,004,700
43 YY-02-III PCI I-1-40-I 2 15,000,900 10,822,300 8,029,200 7,004,700
3 15,000,900 10,822,300 8,029,200 7,004,700
1 15,000,900 10,822,300 8,029,200 7,004,700
44 YY-02-III PCI I-1-40-II 2 15,000,900 10,822,300 8,029,200 7,004,700
3 15,000,900 10,822,300 8,029,200 7,004,700
1 15,000,900 10,822,300 8,029,200 7,004,700
45 YY-02-III PCI I-1-40-III 2 15,000,900 10,822,300 8,029,200 7,004,700
3 15,000,900 10,822,300 8,029,200 7,004,700
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
- 1073 -
REGIONAL 2
TOP UP SPESIAL CMG

NO KODE CBG
1 8,384,200 6,454,000 4,038,900 3,523,500
3 8,384,200 6,454,000 4,038,900 3,523,500
1 8,384,200 6,454,000 4,038,900 3,523,500
3 8,384,200 6,454,000 4,038,900 3,523,500
1 8,384,200 6,454,000 4,038,900 3,523,500
3 8,384,200 6,454,000 4,038,900 3,523,500
Repair of Septal 1 50,188,600 22,175,700 16,452,500 14,353,200
Prosthesis 3 50,188,600 22,175,700 16,452,500 14,353,200
Repair of Septal 1 50,188,600 22,175,700 16,452,500 14,353,200
Prosthesis 3 50,188,600 22,175,700 16,452,500 14,353,200
Repair of Septal 1 50,188,600 22,175,700 16,452,500 14,353,200
Prosthesis 3 50,188,600 22,175,700 16,452,500 14,353,200
1 4,250,800 2,974,700 2,275,200 1,984,900
55 YY-06-III C-4-12-I 2 4,250,800 2,974,700 2,275,200 1,984,900
& Radiotheraphy
3 4,250,800 2,974,700 2,275,200 1,984,900
1 4,250,800 2,974,700 2,275,200 1,984,900
56 YY-06-III C-4-12-II 2 4,250,800 2,974,700 2,275,200 1,984,900
& Radiotheraphy
3 4,250,800 2,974,700 2,275,200 1,984,900
1 4,250,800 2,974,700 2,275,200 1,984,900
57 YY-06-III C-4-12-III 2 4,250,800 2,974,700 2,275,200 1,984,900
& Radiotheraphy
3 4,250,800 2,974,700 2,275,200 1,984,900
1 10,541,000 7,376,600 5,642,100 4,922,200
3 10,541,000 7,376,600 5,642,100 4,922,200
1 10,541,000 7,376,600 5,642,100 4,922,200
3 10,541,000 7,376,600 5,642,100 4,922,200
1 10,541,000 7,376,600 5,642,100 4,922,200
3 10,541,000 7,376,600 5,642,100 4,922,200
1 12,631,100 8,839,300 6,760,800 5,898,200
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,631,100 8,839,300 6,760,800 5,898,200
mi
3 12,631,100 8,839,300 6,760,800 5,898,200
1 12,631,100 8,839,300 6,760,800 5,898,200
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,631,100 8,839,300 6,760,800 5,898,200
mi
3 12,631,100 8,839,300 6,760,800 5,898,200
1 12,631,100 8,839,300 6,760,800 5,898,200
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,631,100 8,839,300 6,760,800 5,898,200
mi
3 12,631,100 8,839,300 6,760,800 5,898,200
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
1 8,357,200 7,521,400 6,685,700 5,850,000
3 8,357,200 7,521,400 6,685,700 5,850,000
70 DD-10-II Q-5-44-0 - 10,786,500 5,826,000 5,763,000 5,601,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,976,900 1,779,200 1,581,500 1,383,900
Diagnostic and
Eye
- 1074 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 3,303,700 3,177,800 2,947,100 2,571,100
3 3,303,700 3,177,800 2,947,100 2,571,100
1 3,303,700 3,177,800 2,947,100 2,571,100
3 3,303,700 3,177,800 2,947,100 2,571,100
1 3,303,700 3,177,800 2,947,100 2,571,100
3 3,303,700 3,177,800 2,947,100 2,571,100
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 6,290,600 5,869,600 5,611,800 5,874,900
3 6,290,600 5,869,600 5,611,800 5,874,900
1 2,135,200 1,992,300 1,714,300 1,661,800
Human Albumin for
13 DD-05-II A-4-10-I 2 2,135,200 1,992,300 1,714,300 1,661,800
Septicaemia
3 2,135,200 1,992,300 1,714,300 1,661,800
1 2,135,200 1,992,300 1,714,300 1,661,800
Human Albumin for
14 DD-05-II A-4-10-II 2 2,135,200 1,992,300 1,714,300 1,661,800
Septicaemia
3 2,135,200 1,992,300 1,714,300 1,661,800
1 2,135,200 1,992,300 1,714,300 1,661,800
Human Albumin for
15 DD-05-II A-4-10-III 2 2,135,200 1,992,300 1,714,300 1,661,800
Septicaemia
3 2,135,200 1,992,300 1,714,300 1,661,800
1 11,352,200 7,944,400 6,836,000 5,963,600
16 DD-06-II D-4-11-I 2 11,352,200 7,944,400 6,836,000 5,963,600
(IP)
3 11,352,200 7,944,400 6,836,000 5,963,600
1 11,352,200 7,944,400 6,836,000 5,963,600
17 DD-06-II D-4-11-II 2 11,352,200 7,944,400 6,836,000 5,963,600
(IP)
3 11,352,200 7,944,400 6,836,000 5,963,600
1 11,352,200 7,944,400 6,836,000 5,963,600
18 DD-06-II D-4-11-III 2 11,352,200 7,944,400 6,836,000 5,963,600
(IP)
3 11,352,200 7,944,400 6,836,000 5,963,600
1 4,348,900 4,057,800 3,491,600 3,384,500
Human Albumin for
19 DD-11-II S-4-16-I 2 4,348,900 4,057,800 3,491,600 3,384,500
Burn
3 4,348,900 4,057,800 3,491,600 3,384,500
1 4,348,900 4,057,800 3,491,600 3,384,500
Human Albumin for
20 DD-11-II S-4-16-II 2 4,348,900 4,057,800 3,491,600 3,384,500
Burn
3 4,348,900 4,057,800 3,491,600 3,384,500
1 4,348,900 4,057,800 3,491,600 3,384,500
Human Albumin for
21 DD-11-II S-4-16-III 2 4,348,900 4,057,800 3,491,600 3,384,500
Burn
3 4,348,900 4,057,800 3,491,600 3,384,500
1 15,861,100 15,257,300 12,734,600 12,344,100
Human Albumin for
22 DD-11-II L-1-20-I 2 15,861,100 15,257,300 12,734,600 12,344,100
Burn
3 15,861,100 15,257,300 12,734,600 12,344,100
1 15,861,100 15,257,300 12,734,600 12,344,100
Human Albumin for
23 DD-11-II L-1-20-II 2 15,861,100 15,257,300 12,734,600 12,344,100
Burn
3 15,861,100 15,257,300 12,734,600 12,344,100
1 15,861,100 15,257,300 12,734,600 12,344,100
Human Albumin for
24 DD-11-II L-1-20-III 2 15,861,100 15,257,300 12,734,600 12,344,100
Burn
3 15,861,100 15,257,300 12,734,600 12,344,100
- 1075 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 16,856,300 8,544,800 5,347,300 1,583,900
Subdural Grid
25 RR-01-II G-1-10-I 2 16,856,300 8,544,800 5,347,300 1,583,900
Electrode
3 16,856,300 8,544,800 5,347,300 1,583,900
1 16,856,300 8,544,800 5,347,300 1,583,900
Subdural Grid
26 RR-01-II G-1-10-II 2 16,856,300 8,544,800 5,347,300 1,583,900
Electrode
3 16,856,300 8,544,800 5,347,300 1,583,900
1 16,856,300 8,544,800 5,347,300 1,583,900
Subdural Grid
27 RR-01-II G-1-10-III 2 16,856,300 8,544,800 5,347,300 1,583,900
Electrode
3 16,856,300 8,544,800 5,347,300 1,583,900
1 17,141,700 7,346,800 5,619,300 4,902,300
3 17,141,700 7,346,800 5,619,300 4,902,300
1 17,141,700 7,346,800 5,619,300 4,902,300
3 17,141,700 7,346,800 5,619,300 4,902,300
1 17,141,700 7,346,800 5,619,300 4,902,300
3 17,141,700 7,346,800 5,619,300 4,902,300
1 11,213,900 7,847,500 6,002,300 5,236,400
3 11,213,900 7,847,500 6,002,300 5,236,400
1 11,213,900 7,847,500 6,002,300 5,236,400
3 11,213,900 7,847,500 6,002,300 5,236,400
1 11,213,900 7,847,500 6,002,300 5,236,400
3 11,213,900 7,847,500 6,002,300 5,236,400
1 26,512,300 11,363,000 8,691,100 7,582,100
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,512,300 11,363,000 8,691,100 7,582,100
Implant
3 26,512,300 11,363,000 8,691,100 7,582,100
1 26,512,300 11,363,000 8,691,100 7,582,100
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,512,300 11,363,000 8,691,100 7,582,100
Implant
3 26,512,300 11,363,000 8,691,100 7,582,100
1 26,512,300 11,363,000 8,691,100 7,582,100
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,512,300 11,363,000 8,691,100 7,582,100
Implant
3 26,512,300 11,363,000 8,691,100 7,582,100
1 104,619,500 98,120,800 55,997,500 48,852,500
Prostesis
37 RR-05-III I-1-20-I 2 104,619,500 98,120,800 55,997,500 48,852,500
Evar/Tevar/Hevar
3 104,619,500 98,120,800 55,997,500 48,852,500
1 104,619,500 98,120,800 55,997,500 48,852,500
Prostesis
38 RR-05-III I-1-20-II 2 104,619,500 98,120,800 55,997,500 48,852,500
Evar/Tevar/Hevar
3 104,619,500 98,120,800 55,997,500 48,852,500
1 104,619,500 98,120,800 55,997,500 48,852,500
Prostesis
39 RR-05-III I-1-20-III 2 104,619,500 98,120,800 55,997,500 48,852,500
Evar/Tevar/Hevar
3 104,619,500 98,120,800 55,997,500 48,852,500
Hip 1 13,256,200 5,681,500 4,345,600 3,791,100
Replacement 3 13,256,200 5,681,500 4,345,600 3,791,100
Hip 1 13,256,200 5,681,500 4,345,600 3,791,100
Replacement 3 13,256,200 5,681,500 4,345,600 3,791,100
Hip 1 13,256,200 5,681,500 4,345,600 3,791,100
Replacement 3 13,256,200 5,681,500 4,345,600 3,791,100
1 14,607,300 10,538,400 7,818,600 6,820,900
43 YY-02-III PCI I-1-40-I 2 14,607,300 10,538,400 7,818,600 6,820,900
3 14,607,300 10,538,400 7,818,600 6,820,900
1 14,607,300 10,538,400 7,818,600 6,820,900
44 YY-02-III PCI I-1-40-II 2 14,607,300 10,538,400 7,818,600 6,820,900
3 14,607,300 10,538,400 7,818,600 6,820,900
1 14,607,300 10,538,400 7,818,600 6,820,900
45 YY-02-III PCI I-1-40-III 2 14,607,300 10,538,400 7,818,600 6,820,900
3 14,607,300 10,538,400 7,818,600 6,820,900
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
- 1076 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 8,164,200 6,284,600 3,932,900 3,431,100
3 8,164,200 6,284,600 3,932,900 3,431,100
1 8,164,200 6,284,600 3,932,900 3,431,100
3 8,164,200 6,284,600 3,932,900 3,431,100
1 8,164,200 6,284,600 3,932,900 3,431,100
3 8,164,200 6,284,600 3,932,900 3,431,100
Repair of Septal 1 48,871,700 21,593,800 16,020,800 13,976,600
Prosthesis 3 48,871,700 21,593,800 16,020,800 13,976,600
Repair of Septal 1 48,871,700 21,593,800 16,020,800 13,976,600
Prosthesis 3 48,871,700 21,593,800 16,020,800 13,976,600
Repair of Septal 1 48,871,700 21,593,800 16,020,800 13,976,600
Prosthesis 3 48,871,700 21,593,800 16,020,800 13,976,600
1 4,139,200 2,896,600 2,215,500 1,932,800
55 YY-06-III C-4-12-I 2 4,139,200 2,896,600 2,215,500 1,932,800
& Radiotheraphy
3 4,139,200 2,896,600 2,215,500 1,932,800
1 4,139,200 2,896,600 2,215,500 1,932,800
56 YY-06-III C-4-12-II 2 4,139,200 2,896,600 2,215,500 1,932,800
& Radiotheraphy
3 4,139,200 2,896,600 2,215,500 1,932,800
1 4,139,200 2,896,600 2,215,500 1,932,800
57 YY-06-III C-4-12-III 2 4,139,200 2,896,600 2,215,500 1,932,800
& Radiotheraphy
3 4,139,200 2,896,600 2,215,500 1,932,800
1 10,264,400 7,183,100 5,494,000 4,793,000
3 10,264,400 7,183,100 5,494,000 4,793,000
1 10,264,400 7,183,100 5,494,000 4,793,000
3 10,264,400 7,183,100 5,494,000 4,793,000
1 10,264,400 7,183,100 5,494,000 4,793,000
3 10,264,400 7,183,100 5,494,000 4,793,000
1 12,299,700 8,607,400 6,583,400 5,743,400
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,299,700 8,607,400 6,583,400 5,743,400
mi
3 12,299,700 8,607,400 6,583,400 5,743,400
1 12,299,700 8,607,400 6,583,400 5,743,400
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,299,700 8,607,400 6,583,400 5,743,400
mi
3 12,299,700 8,607,400 6,583,400 5,743,400
1 12,299,700 8,607,400 6,583,400 5,743,400
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,299,700 8,607,400 6,583,400 5,743,400
mi
3 12,299,700 8,607,400 6,583,400 5,743,400
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
1 8,137,900 7,324,100 6,510,200 5,696,500
3 8,137,900 7,324,100 6,510,200 5,696,500
70 DD-10-II Q-5-44-0 - 10,303,200 5,565,000 5,505,000 5,349,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,888,400 1,699,500 1,510,500 1,321,800
Diagnostic and
Eye
- 1077 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 3,402,800 3,273,200 3,035,600 2,648,200
3 3,402,800 3,273,200 3,035,600 2,648,200
1 3,402,800 3,273,200 3,035,600 2,648,200
3 3,402,800 3,273,200 3,035,600 2,648,200
1 3,402,800 3,273,200 3,035,600 2,648,200
3 3,402,800 3,273,200 3,035,600 2,648,200
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 6,479,300 6,045,600 5,780,000 6,051,000
3 6,479,300 6,045,600 5,780,000 6,051,000
1 2,199,300 2,052,100 1,765,700 1,711,600
Human Albumin for
13 DD-05-II A-4-10-I 2 2,199,300 2,052,100 1,765,700 1,711,600
Septicaemia
3 2,199,300 2,052,100 1,765,700 1,711,600
1 2,199,300 2,052,100 1,765,700 1,711,600
Human Albumin for
14 DD-05-II A-4-10-II 2 2,199,300 2,052,100 1,765,700 1,711,600
Septicaemia
3 2,199,300 2,052,100 1,765,700 1,711,600
1 2,199,300 2,052,100 1,765,700 1,711,600
Human Albumin for
15 DD-05-II A-4-10-III 2 2,199,300 2,052,100 1,765,700 1,711,600
Septicaemia
3 2,199,300 2,052,100 1,765,700 1,711,600
1 11,692,800 8,182,600 7,040,900 6,142,500
16 DD-06-II D-4-11-I 2 11,692,800 8,182,600 7,040,900 6,142,500
(IP)
3 11,692,800 8,182,600 7,040,900 6,142,500
1 11,692,800 8,182,600 7,040,900 6,142,500
17 DD-06-II D-4-11-II 2 11,692,800 8,182,600 7,040,900 6,142,500
(IP)
3 11,692,800 8,182,600 7,040,900 6,142,500
1 11,692,800 8,182,600 7,040,900 6,142,500
18 DD-06-II D-4-11-III 2 11,692,800 8,182,600 7,040,900 6,142,500
(IP)
3 11,692,800 8,182,600 7,040,900 6,142,500
1 4,479,400 4,179,500 3,596,400 3,486,100
Human Albumin for
19 DD-11-II S-4-16-I 2 4,479,400 4,179,500 3,596,400 3,486,100
Burn
3 4,479,400 4,179,500 3,596,400 3,486,100
1 4,479,400 4,179,500 3,596,400 3,486,100
Human Albumin for
20 DD-11-II S-4-16-II 2 4,479,400 4,179,500 3,596,400 3,486,100
Burn
3 4,479,400 4,179,500 3,596,400 3,486,100
1 4,479,400 4,179,500 3,596,400 3,486,100
Human Albumin for
21 DD-11-II S-4-16-III 2 4,479,400 4,179,500 3,596,400 3,486,100
Burn
3 4,479,400 4,179,500 3,596,400 3,486,100
1 16,337,000 15,715,000 13,116,600 12,714,400
Human Albumin for
22 DD-11-II L-1-20-I 2 16,337,000 15,715,000 13,116,600 12,714,400
Burn
3 16,337,000 15,715,000 13,116,600 12,714,400
1 16,337,000 15,715,000 13,116,600 12,714,400
Human Albumin for
23 DD-11-II L-1-20-II 2 16,337,000 15,715,000 13,116,600 12,714,400
Burn
3 16,337,000 15,715,000 13,116,600 12,714,400
1 16,337,000 15,715,000 13,116,600 12,714,400
Human Albumin for
24 DD-11-II L-1-20-III 2 16,337,000 15,715,000 13,116,600 12,714,400
Burn
3 16,337,000 15,715,000 13,116,600 12,714,400
- 1078 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 17,362,000 8,801,200 5,507,700 1,631,500
Subdural Grid
25 RR-01-II G-1-10-I 2 17,362,000 8,801,200 5,507,700 1,631,500
Electrode
3 17,362,000 8,801,200 5,507,700 1,631,500
1 17,362,000 8,801,200 5,507,700 1,631,500
Subdural Grid
26 RR-01-II G-1-10-II 2 17,362,000 8,801,200 5,507,700 1,631,500
Electrode
3 17,362,000 8,801,200 5,507,700 1,631,500
1 17,362,000 8,801,200 5,507,700 1,631,500
Subdural Grid
27 RR-01-II G-1-10-III 2 17,362,000 8,801,200 5,507,700 1,631,500
Electrode
3 17,362,000 8,801,200 5,507,700 1,631,500
1 17,656,000 7,567,200 5,787,900 5,049,400
3 17,656,000 7,567,200 5,787,900 5,049,400
1 17,656,000 7,567,200 5,787,900 5,049,400
3 17,656,000 7,567,200 5,787,900 5,049,400
1 17,656,000 7,567,200 5,787,900 5,049,400
3 17,656,000 7,567,200 5,787,900 5,049,400
1 11,550,300 8,083,000 6,182,300 5,393,500
3 11,550,300 8,083,000 6,182,300 5,393,500
1 11,550,300 8,083,000 6,182,300 5,393,500
3 11,550,300 8,083,000 6,182,300 5,393,500
1 11,550,300 8,083,000 6,182,300 5,393,500
3 11,550,300 8,083,000 6,182,300 5,393,500
1 27,307,700 11,703,900 8,951,800 7,809,600
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 27,307,700 11,703,900 8,951,800 7,809,600
Implant
3 27,307,700 11,703,900 8,951,800 7,809,600
1 27,307,700 11,703,900 8,951,800 7,809,600
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 27,307,700 11,703,900 8,951,800 7,809,600
Implant
3 27,307,700 11,703,900 8,951,800 7,809,600
1 27,307,700 11,703,900 8,951,800 7,809,600
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 27,307,700 11,703,900 8,951,800 7,809,600
Implant
3 27,307,700 11,703,900 8,951,800 7,809,600
1 107,758,000 101,064,000 57,677,500 50,318,000
Prostesis
37 RR-05-III I-1-20-I 2 107,758,000 101,064,000 57,677,500 50,318,000
Evar/Tevar/Hevar
3 107,758,000 101,064,000 57,677,500 50,318,000
1 107,758,000 101,064,000 57,677,500 50,318,000
Prostesis
38 RR-05-III I-1-20-II 2 107,758,000 101,064,000 57,677,500 50,318,000
Evar/Tevar/Hevar
3 107,758,000 101,064,000 57,677,500 50,318,000
1 107,758,000 101,064,000 57,677,500 50,318,000
Prostesis
39 RR-05-III I-1-20-III 2 107,758,000 101,064,000 57,677,500 50,318,000
Evar/Tevar/Hevar
3 107,758,000 101,064,000 57,677,500 50,318,000
Hip 1 13,653,900 5,852,000 4,475,900 3,904,800
Replacement 3 13,653,900 5,852,000 4,475,900 3,904,800
Hip 1 13,653,900 5,852,000 4,475,900 3,904,800
Replacement 3 13,653,900 5,852,000 4,475,900 3,904,800
Hip 1 13,653,900 5,852,000 4,475,900 3,904,800
Replacement 3 13,653,900 5,852,000 4,475,900 3,904,800
1 15,045,500 10,854,500 8,053,100 7,025,600
43 YY-02-III PCI I-1-40-I 2 15,045,500 10,854,500 8,053,100 7,025,600
3 15,045,500 10,854,500 8,053,100 7,025,600
1 15,045,500 10,854,500 8,053,100 7,025,600
44 YY-02-III PCI I-1-40-II 2 15,045,500 10,854,500 8,053,100 7,025,600
3 15,045,500 10,854,500 8,053,100 7,025,600
1 15,045,500 10,854,500 8,053,100 7,025,600
45 YY-02-III PCI I-1-40-III 2 15,045,500 10,854,500 8,053,100 7,025,600
3 15,045,500 10,854,500 8,053,100 7,025,600
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
- 1079 -
REGIONAL 3
TOP UP SPESIAL CMG

NO KODE CBG
1 8,409,100 6,473,200 4,050,900 3,534,000
3 8,409,100 6,473,200 4,050,900 3,534,000
1 8,409,100 6,473,200 4,050,900 3,534,000
3 8,409,100 6,473,200 4,050,900 3,534,000
1 8,409,100 6,473,200 4,050,900 3,534,000
3 8,409,100 6,473,200 4,050,900 3,534,000
Repair of Septal 1 50,337,900 22,241,700 16,501,400 14,395,900
Prosthesis 3 50,337,900 22,241,700 16,501,400 14,395,900
Repair of Septal 1 50,337,900 22,241,700 16,501,400 14,395,900
Prosthesis 3 50,337,900 22,241,700 16,501,400 14,395,900
Repair of Septal 1 50,337,900 22,241,700 16,501,400 14,395,900
Prosthesis 3 50,337,900 22,241,700 16,501,400 14,395,900
1 4,263,400 2,983,500 2,282,000 1,990,800
55 YY-06-III C-4-12-I 2 4,263,400 2,983,500 2,282,000 1,990,800
& Radiotheraphy
3 4,263,400 2,983,500 2,282,000 1,990,800
1 4,263,400 2,983,500 2,282,000 1,990,800
56 YY-06-III C-4-12-II 2 4,263,400 2,983,500 2,282,000 1,990,800
& Radiotheraphy
3 4,263,400 2,983,500 2,282,000 1,990,800
1 4,263,400 2,983,500 2,282,000 1,990,800
57 YY-06-III C-4-12-III 2 4,263,400 2,983,500 2,282,000 1,990,800
& Radiotheraphy
3 4,263,400 2,983,500 2,282,000 1,990,800
1 10,572,300 7,398,600 5,658,900 4,936,800
3 10,572,300 7,398,600 5,658,900 4,936,800
1 10,572,300 7,398,600 5,658,900 4,936,800
3 10,572,300 7,398,600 5,658,900 4,936,800
1 10,572,300 7,398,600 5,658,900 4,936,800
3 10,572,300 7,398,600 5,658,900 4,936,800
1 12,668,700 8,865,600 6,780,900 5,915,700
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,668,700 8,865,600 6,780,900 5,915,700
mi
3 12,668,700 8,865,600 6,780,900 5,915,700
1 12,668,700 8,865,600 6,780,900 5,915,700
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,668,700 8,865,600 6,780,900 5,915,700
mi
3 12,668,700 8,865,600 6,780,900 5,915,700
1 12,668,700 8,865,600 6,780,900 5,915,700
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,668,700 8,865,600 6,780,900 5,915,700
mi
3 12,668,700 8,865,600 6,780,900 5,915,700
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
1 8,382,000 7,543,800 6,705,500 5,867,400
3 8,382,000 7,543,800 6,705,500 5,867,400
70 DD-10-II Q-5-44-0 - 10,818,900 5,841,000 5,781,000 5,619,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,982,700 1,784,400 1,586,100 1,388,000
Diagnostic and
Eye
- 1080 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 3,352,600 3,225,000 2,990,800 2,609,200
3 3,352,600 3,225,000 2,990,800 2,609,200
1 3,352,600 3,225,000 2,990,800 2,609,200
3 3,352,600 3,225,000 2,990,800 2,609,200
1 3,352,600 3,225,000 2,990,800 2,609,200
3 3,352,600 3,225,000 2,990,800 2,609,200
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 6,383,900 5,956,600 5,695,000 5,961,900
3 6,383,900 5,956,600 5,695,000 5,961,900
1 2,166,900 2,021,800 1,739,700 1,686,400
Human Albumin for
13 DD-05-II A-4-10-I 2 2,166,900 2,021,800 1,739,700 1,686,400
Septicaemia
3 2,166,900 2,021,800 1,739,700 1,686,400
1 2,166,900 2,021,800 1,739,700 1,686,400
Human Albumin for
14 DD-05-II A-4-10-II 2 2,166,900 2,021,800 1,739,700 1,686,400
Septicaemia
3 2,166,900 2,021,800 1,739,700 1,686,400
1 2,166,900 2,021,800 1,739,700 1,686,400
Human Albumin for
15 DD-05-II A-4-10-III 2 2,166,900 2,021,800 1,739,700 1,686,400
Septicaemia
3 2,166,900 2,021,800 1,739,700 1,686,400
1 11,520,600 8,062,200 6,937,200 6,052,100
16 DD-06-II D-4-11-I 2 11,520,600 8,062,200 6,937,200 6,052,100
(IP)
3 11,520,600 8,062,200 6,937,200 6,052,100
1 11,520,600 8,062,200 6,937,200 6,052,100
17 DD-06-II D-4-11-II 2 11,520,600 8,062,200 6,937,200 6,052,100
(IP)
3 11,520,600 8,062,200 6,937,200 6,052,100
1 11,520,600 8,062,200 6,937,200 6,052,100
18 DD-06-II D-4-11-III 2 11,520,600 8,062,200 6,937,200 6,052,100
(IP)
3 11,520,600 8,062,200 6,937,200 6,052,100
1 4,413,300 4,117,900 3,543,400 3,434,700
Human Albumin for
19 DD-11-II S-4-16-I 2 4,413,300 4,117,900 3,543,400 3,434,700
Burn
3 4,413,300 4,117,900 3,543,400 3,434,700
1 4,413,300 4,117,900 3,543,400 3,434,700
Human Albumin for
20 DD-11-II S-4-16-II 2 4,413,300 4,117,900 3,543,400 3,434,700
Burn
3 4,413,300 4,117,900 3,543,400 3,434,700
1 4,413,300 4,117,900 3,543,400 3,434,700
Human Albumin for
21 DD-11-II S-4-16-III 2 4,413,300 4,117,900 3,543,400 3,434,700
Burn
3 4,413,300 4,117,900 3,543,400 3,434,700
1 16,096,200 15,483,400 12,923,300 12,527,000
Human Albumin for
22 DD-11-II L-1-20-I 2 16,096,200 15,483,400 12,923,300 12,527,000
Burn
3 16,096,200 15,483,400 12,923,300 12,527,000
1 16,096,200 15,483,400 12,923,300 12,527,000
Human Albumin for
23 DD-11-II L-1-20-II 2 16,096,200 15,483,400 12,923,300 12,527,000
Burn
3 16,096,200 15,483,400 12,923,300 12,527,000
1 16,096,200 15,483,400 12,923,300 12,527,000
Human Albumin for
24 DD-11-II L-1-20-III 2 16,096,200 15,483,400 12,923,300 12,527,000
Burn
3 16,096,200 15,483,400 12,923,300 12,527,000
- 1081 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 17,106,200 8,671,500 5,426,600 1,607,400
Subdural Grid
25 RR-01-II G-1-10-I 2 17,106,200 8,671,500 5,426,600 1,607,400
Electrode
3 17,106,200 8,671,500 5,426,600 1,607,400
1 17,106,200 8,671,500 5,426,600 1,607,400
Subdural Grid
26 RR-01-II G-1-10-II 2 17,106,200 8,671,500 5,426,600 1,607,400
Electrode
3 17,106,200 8,671,500 5,426,600 1,607,400
1 17,106,200 8,671,500 5,426,600 1,607,400
Subdural Grid
27 RR-01-II G-1-10-III 2 17,106,200 8,671,500 5,426,600 1,607,400
Electrode
3 17,106,200 8,671,500 5,426,600 1,607,400
1 17,395,800 7,455,700 5,702,600 4,975,000
3 17,395,800 7,455,700 5,702,600 4,975,000
1 17,395,800 7,455,700 5,702,600 4,975,000
3 17,395,800 7,455,700 5,702,600 4,975,000
1 17,395,800 7,455,700 5,702,600 4,975,000
3 17,395,800 7,455,700 5,702,600 4,975,000
1 11,380,100 7,963,900 6,091,200 5,314,000
3 11,380,100 7,963,900 6,091,200 5,314,000
1 11,380,100 7,963,900 6,091,200 5,314,000
3 11,380,100 7,963,900 6,091,200 5,314,000
1 11,380,100 7,963,900 6,091,200 5,314,000
3 11,380,100 7,963,900 6,091,200 5,314,000
1 26,905,300 11,531,400 8,819,900 7,694,500
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,905,300 11,531,400 8,819,900 7,694,500
Implant
3 26,905,300 11,531,400 8,819,900 7,694,500
1 26,905,300 11,531,400 8,819,900 7,694,500
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,905,300 11,531,400 8,819,900 7,694,500
Implant
3 26,905,300 11,531,400 8,819,900 7,694,500
1 26,905,300 11,531,400 8,819,900 7,694,500
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,905,300 11,531,400 8,819,900 7,694,500
Implant
3 26,905,300 11,531,400 8,819,900 7,694,500
1 106,170,000 99,574,800 56,827,500 49,576,500
Prostesis
37 RR-05-III I-1-20-I 2 106,170,000 99,574,800 56,827,500 49,576,500
Evar/Tevar/Hevar
3 106,170,000 99,574,800 56,827,500 49,576,500
1 106,170,000 99,574,800 56,827,500 49,576,500
Prostesis
38 RR-05-III I-1-20-II 2 106,170,000 99,574,800 56,827,500 49,576,500
Evar/Tevar/Hevar
3 106,170,000 99,574,800 56,827,500 49,576,500
1 106,170,000 99,574,800 56,827,500 49,576,500
Prostesis
39 RR-05-III I-1-20-III 2 106,170,000 99,574,800 56,827,500 49,576,500
Evar/Tevar/Hevar
3 106,170,000 99,574,800 56,827,500 49,576,500
Hip 1 13,452,700 5,765,700 4,410,000 3,847,300
Replacement 3 13,452,700 5,765,700 4,410,000 3,847,300
Hip 1 13,452,700 5,765,700 4,410,000 3,847,300
Replacement 3 13,452,700 5,765,700 4,410,000 3,847,300
Hip 1 13,452,700 5,765,700 4,410,000 3,847,300
Replacement 3 13,452,700 5,765,700 4,410,000 3,847,300
1 14,823,800 10,694,600 7,934,500 6,922,000
43 YY-02-III PCI I-1-40-I 2 14,823,800 10,694,600 7,934,500 6,922,000
3 14,823,800 10,694,600 7,934,500 6,922,000
1 14,823,800 10,694,600 7,934,500 6,922,000
44 YY-02-III PCI I-1-40-II 2 14,823,800 10,694,600 7,934,500 6,922,000
3 14,823,800 10,694,600 7,934,500 6,922,000
1 14,823,800 10,694,600 7,934,500 6,922,000
45 YY-02-III PCI I-1-40-III 2 14,823,800 10,694,600 7,934,500 6,922,000
3 14,823,800 10,694,600 7,934,500 6,922,000
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
- 1082 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 8,285,200 6,377,800 3,991,200 3,481,900
3 8,285,200 6,377,800 3,991,200 3,481,900
1 8,285,200 6,377,800 3,991,200 3,481,900
3 8,285,200 6,377,800 3,991,200 3,481,900
1 8,285,200 6,377,800 3,991,200 3,481,900
3 8,285,200 6,377,800 3,991,200 3,481,900
Repair of Septal 1 49,596,100 21,913,900 16,258,200 14,183,700
Prosthesis 3 49,596,100 21,913,900 16,258,200 14,183,700
Repair of Septal 1 49,596,100 21,913,900 16,258,200 14,183,700
Prosthesis 3 49,596,100 21,913,900 16,258,200 14,183,700
Repair of Septal 1 49,596,100 21,913,900 16,258,200 14,183,700
Prosthesis 3 49,596,100 21,913,900 16,258,200 14,183,700
1 4,200,600 2,939,600 2,248,400 1,961,500
55 YY-06-III C-4-12-I 2 4,200,600 2,939,600 2,248,400 1,961,500
& Radiotheraphy
3 4,200,600 2,939,600 2,248,400 1,961,500
1 4,200,600 2,939,600 2,248,400 1,961,500
56 YY-06-III C-4-12-II 2 4,200,600 2,939,600 2,248,400 1,961,500
& Radiotheraphy
3 4,200,600 2,939,600 2,248,400 1,961,500
1 4,200,600 2,939,600 2,248,400 1,961,500
57 YY-06-III C-4-12-III 2 4,200,600 2,939,600 2,248,400 1,961,500
& Radiotheraphy
3 4,200,600 2,939,600 2,248,400 1,961,500
1 10,416,500 7,289,500 5,575,500 4,864,100
3 10,416,500 7,289,500 5,575,500 4,864,100
1 10,416,500 7,289,500 5,575,500 4,864,100
3 10,416,500 7,289,500 5,575,500 4,864,100
1 10,416,500 7,289,500 5,575,500 4,864,100
3 10,416,500 7,289,500 5,575,500 4,864,100
1 12,482,000 8,734,900 6,681,000 5,828,500
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,482,000 8,734,900 6,681,000 5,828,500
mi
3 12,482,000 8,734,900 6,681,000 5,828,500
1 12,482,000 8,734,900 6,681,000 5,828,500
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,482,000 8,734,900 6,681,000 5,828,500
mi
3 12,482,000 8,734,900 6,681,000 5,828,500
1 12,482,000 8,734,900 6,681,000 5,828,500
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,482,000 8,734,900 6,681,000 5,828,500
mi
3 12,482,000 8,734,900 6,681,000 5,828,500
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
1 8,258,500 7,432,600 6,606,700 5,781,000
3 8,258,500 7,432,600 6,606,700 5,781,000
70 DD-10-II Q-5-44-0 - 10,457,100 5,646,000 5,589,000 5,430,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,916,300 1,724,600 1,533,000 1,341,500
Diagnostic and
Eye
- 1083 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 3,453,200 3,321,800 3,080,500 2,687,500
3 3,453,200 3,321,800 3,080,500 2,687,500
1 3,453,200 3,321,800 3,080,500 2,687,500
3 3,453,200 3,321,800 3,080,500 2,687,500
1 3,453,200 3,321,800 3,080,500 2,687,500
3 3,453,200 3,321,800 3,080,500 2,687,500
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 6,575,300 6,135,200 5,865,800 6,140,700
3 6,575,300 6,135,200 5,865,800 6,140,700
1 2,231,900 2,082,500 1,791,900 1,737,000
Human Albumin for
13 DD-05-II A-4-10-I 2 2,231,900 2,082,500 1,791,900 1,737,000
Septicaemia
3 2,231,900 2,082,500 1,791,900 1,737,000
1 2,231,900 2,082,500 1,791,900 1,737,000
Human Albumin for
14 DD-05-II A-4-10-II 2 2,231,900 2,082,500 1,791,900 1,737,000
Septicaemia
3 2,231,900 2,082,500 1,791,900 1,737,000
1 2,231,900 2,082,500 1,791,900 1,737,000
Human Albumin for
15 DD-05-II A-4-10-III 2 2,231,900 2,082,500 1,791,900 1,737,000
Septicaemia
3 2,231,900 2,082,500 1,791,900 1,737,000
1 11,866,200 8,304,000 7,145,300 6,233,600
16 DD-06-II D-4-11-I 2 11,866,200 8,304,000 7,145,300 6,233,600
(IP)
3 11,866,200 8,304,000 7,145,300 6,233,600
1 11,866,200 8,304,000 7,145,300 6,233,600
17 DD-06-II D-4-11-II 2 11,866,200 8,304,000 7,145,300 6,233,600
(IP)
3 11,866,200 8,304,000 7,145,300 6,233,600
1 11,866,200 8,304,000 7,145,300 6,233,600
18 DD-06-II D-4-11-III 2 11,866,200 8,304,000 7,145,300 6,233,600
(IP)
3 11,866,200 8,304,000 7,145,300 6,233,600
1 4,545,700 4,241,500 3,649,700 3,537,800
Human Albumin for
19 DD-11-II S-4-16-I 2 4,545,700 4,241,500 3,649,700 3,537,800
Burn
3 4,545,700 4,241,500 3,649,700 3,537,800
1 4,545,700 4,241,500 3,649,700 3,537,800
Human Albumin for
20 DD-11-II S-4-16-II 2 4,545,700 4,241,500 3,649,700 3,537,800
Burn
3 4,545,700 4,241,500 3,649,700 3,537,800
1 4,545,700 4,241,500 3,649,700 3,537,800
Human Albumin for
21 DD-11-II S-4-16-III 2 4,545,700 4,241,500 3,649,700 3,537,800
Burn
3 4,545,700 4,241,500 3,649,700 3,537,800
1 16,579,100 15,947,900 13,311,000 12,902,800
Human Albumin for
22 DD-11-II L-1-20-I 2 16,579,100 15,947,900 13,311,000 12,902,800
Burn
3 16,579,100 15,947,900 13,311,000 12,902,800
1 16,579,100 15,947,900 13,311,000 12,902,800
Human Albumin for
23 DD-11-II L-1-20-II 2 16,579,100 15,947,900 13,311,000 12,902,800
Burn
3 16,579,100 15,947,900 13,311,000 12,902,800
1 16,579,100 15,947,900 13,311,000 12,902,800
Human Albumin for
24 DD-11-II L-1-20-III 2 16,579,100 15,947,900 13,311,000 12,902,800
Burn
3 16,579,100 15,947,900 13,311,000 12,902,800
- 1084 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 17,619,300 8,931,600 5,589,400 1,655,600
Subdural Grid
25 RR-01-II G-1-10-I 2 17,619,300 8,931,600 5,589,400 1,655,600
Electrode
3 17,619,300 8,931,600 5,589,400 1,655,600
1 17,619,300 8,931,600 5,589,400 1,655,600
Subdural Grid
26 RR-01-II G-1-10-II 2 17,619,300 8,931,600 5,589,400 1,655,600
Electrode
3 17,619,300 8,931,600 5,589,400 1,655,600
1 17,619,300 8,931,600 5,589,400 1,655,600
Subdural Grid
27 RR-01-II G-1-10-III 2 17,619,300 8,931,600 5,589,400 1,655,600
Electrode
3 17,619,300 8,931,600 5,589,400 1,655,600
1 17,917,700 7,679,400 5,873,700 5,124,200
3 17,917,700 7,679,400 5,873,700 5,124,200
1 17,917,700 7,679,400 5,873,700 5,124,200
3 17,917,700 7,679,400 5,873,700 5,124,200
1 17,917,700 7,679,400 5,873,700 5,124,200
3 17,917,700 7,679,400 5,873,700 5,124,200
1 11,721,500 8,202,800 6,274,000 5,473,400
3 11,721,500 8,202,800 6,274,000 5,473,400
1 11,721,500 8,202,800 6,274,000 5,473,400
3 11,721,500 8,202,800 6,274,000 5,473,400
1 11,721,500 8,202,800 6,274,000 5,473,400
3 11,721,500 8,202,800 6,274,000 5,473,400
1 27,712,400 11,877,300 9,084,500 7,925,300
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 27,712,400 11,877,300 9,084,500 7,925,300
Implant
3 27,712,400 11,877,300 9,084,500 7,925,300
1 27,712,400 11,877,300 9,084,500 7,925,300
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 27,712,400 11,877,300 9,084,500 7,925,300
Implant
3 27,712,400 11,877,300 9,084,500 7,925,300
1 27,712,400 11,877,300 9,084,500 7,925,300
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 27,712,400 11,877,300 9,084,500 7,925,300
Implant
3 27,712,400 11,877,300 9,084,500 7,925,300
1 109,355,000 102,562,200 58,532,500 51,064,000
Prostesis
37 RR-05-III I-1-20-I 2 109,355,000 102,562,200 58,532,500 51,064,000
Evar/Tevar/Hevar
3 109,355,000 102,562,200 58,532,500 51,064,000
1 109,355,000 102,562,200 58,532,500 51,064,000
Prostesis
38 RR-05-III I-1-20-II 2 109,355,000 102,562,200 58,532,500 51,064,000
Evar/Tevar/Hevar
3 109,355,000 102,562,200 58,532,500 51,064,000
1 109,355,000 102,562,200 58,532,500 51,064,000
Prostesis
39 RR-05-III I-1-20-III 2 109,355,000 102,562,200 58,532,500 51,064,000
Evar/Tevar/Hevar
3 109,355,000 102,562,200 58,532,500 51,064,000
Hip 1 13,856,200 5,938,700 4,542,300 3,962,700
Replacement 3 13,856,200 5,938,700 4,542,300 3,962,700
Hip 1 13,856,200 5,938,700 4,542,300 3,962,700
Replacement 3 13,856,200 5,938,700 4,542,300 3,962,700
Hip 1 13,856,200 5,938,700 4,542,300 3,962,700
Replacement 3 13,856,200 5,938,700 4,542,300 3,962,700
1 15,268,500 11,015,400 8,172,500 7,129,700
43 YY-02-III PCI I-1-40-I 2 15,268,500 11,015,400 8,172,500 7,129,700
3 15,268,500 11,015,400 8,172,500 7,129,700
1 15,268,500 11,015,400 8,172,500 7,129,700
44 YY-02-III PCI I-1-40-II 2 15,268,500 11,015,400 8,172,500 7,129,700
3 15,268,500 11,015,400 8,172,500 7,129,700
1 15,268,500 11,015,400 8,172,500 7,129,700
45 YY-02-III PCI I-1-40-III 2 15,268,500 11,015,400 8,172,500 7,129,700
3 15,268,500 11,015,400 8,172,500 7,129,700
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
- 1085 -
REGIONAL 4
TOP UP SPESIAL CMG

NO KODE CBG
1 8,533,700 6,569,100 4,110,900 3,586,400
3 8,533,700 6,569,100 4,110,900 3,586,400
1 8,533,700 6,569,100 4,110,900 3,586,400
3 8,533,700 6,569,100 4,110,900 3,586,400
1 8,533,700 6,569,100 4,110,900 3,586,400
3 8,533,700 6,569,100 4,110,900 3,586,400
Repair of Septal 1 51,084,000 22,571,300 16,746,000 14,609,300
Prosthesis 3 51,084,000 22,571,300 16,746,000 14,609,300
Repair of Septal 1 51,084,000 22,571,300 16,746,000 14,609,300
Prosthesis 3 51,084,000 22,571,300 16,746,000 14,609,300
Repair of Septal 1 51,084,000 22,571,300 16,746,000 14,609,300
Prosthesis 3 51,084,000 22,571,300 16,746,000 14,609,300
1 4,326,600 3,027,800 2,315,800 2,020,300
55 YY-06-III C-4-12-I 2 4,326,600 3,027,800 2,315,800 2,020,300
& Radiotheraphy
3 4,326,600 3,027,800 2,315,800 2,020,300
1 4,326,600 3,027,800 2,315,800 2,020,300
56 YY-06-III C-4-12-II 2 4,326,600 3,027,800 2,315,800 2,020,300
& Radiotheraphy
3 4,326,600 3,027,800 2,315,800 2,020,300
1 4,326,600 3,027,800 2,315,800 2,020,300
57 YY-06-III C-4-12-III 2 4,326,600 3,027,800 2,315,800 2,020,300
& Radiotheraphy
3 4,326,600 3,027,800 2,315,800 2,020,300
1 10,729,000 7,508,200 5,742,700 5,010,000
3 10,729,000 7,508,200 5,742,700 5,010,000
1 10,729,000 7,508,200 5,742,700 5,010,000
3 10,729,000 7,508,200 5,742,700 5,010,000
1 10,729,000 7,508,200 5,742,700 5,010,000
3 10,729,000 7,508,200 5,742,700 5,010,000
1 12,856,500 8,997,000 6,881,400 6,003,400
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,856,500 8,997,000 6,881,400 6,003,400
mi
3 12,856,500 8,997,000 6,881,400 6,003,400
1 12,856,500 8,997,000 6,881,400 6,003,400
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,856,500 8,997,000 6,881,400 6,003,400
mi
3 12,856,500 8,997,000 6,881,400 6,003,400
1 12,856,500 8,997,000 6,881,400 6,003,400
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,856,500 8,997,000 6,881,400 6,003,400
mi
3 12,856,500 8,997,000 6,881,400 6,003,400
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
1 8,506,200 7,655,600 6,804,900 5,954,400
3 8,506,200 7,655,600 6,804,900 5,954,400
70 DD-10-II Q-5-44-0 - 10,978,200 5,928,000 5,868,000 5,700,000
(OP)
72 II-02-III MRI Z-3-16-0 - 2,012,100 1,810,800 1,609,700 1,408,500
Diagnostic and
Eye
- 1086 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 3,460,300 3,328,600 3,086,900 2,693,000
3 3,460,300 3,328,600 3,086,900 2,693,000
1 3,460,300 3,328,600 3,086,900 2,693,000
3 3,460,300 3,328,600 3,086,900 2,693,000
1 3,460,300 3,328,600 3,086,900 2,693,000
3 3,460,300 3,328,600 3,086,900 2,693,000
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 6,588,900 6,148,000 5,878,000 6,153,600
3 6,588,900 6,148,000 5,878,000 6,153,600
1 2,236,500 2,086,800 1,795,600 1,740,600
Human Albumin for
13 DD-05-II A-4-10-I 2 2,236,500 2,086,800 1,795,600 1,740,600
Septicaemia
3 2,236,500 2,086,800 1,795,600 1,740,600
1 2,236,500 2,086,800 1,795,600 1,740,600
Human Albumin for
14 DD-05-II A-4-10-II 2 2,236,500 2,086,800 1,795,600 1,740,600
Septicaemia
3 2,236,500 2,086,800 1,795,600 1,740,600
1 2,236,500 2,086,800 1,795,600 1,740,600
Human Albumin for
15 DD-05-II A-4-10-III 2 2,236,500 2,086,800 1,795,600 1,740,600
Septicaemia
3 2,236,500 2,086,800 1,795,600 1,740,600
1 11,890,800 8,321,200 7,160,200 6,246,500
16 DD-06-II D-4-11-I 2 11,890,800 8,321,200 7,160,200 6,246,500
(IP)
3 11,890,800 8,321,200 7,160,200 6,246,500
1 11,890,800 8,321,200 7,160,200 6,246,500
17 DD-06-II D-4-11-II 2 11,890,800 8,321,200 7,160,200 6,246,500
(IP)
3 11,890,800 8,321,200 7,160,200 6,246,500
1 11,890,800 8,321,200 7,160,200 6,246,500
18 DD-06-II D-4-11-III 2 11,890,800 8,321,200 7,160,200 6,246,500
(IP)
3 11,890,800 8,321,200 7,160,200 6,246,500
1 4,555,100 4,250,200 3,657,200 3,545,100
Human Albumin for
19 DD-11-II S-4-16-I 2 4,555,100 4,250,200 3,657,200 3,545,100
Burn
3 4,555,100 4,250,200 3,657,200 3,545,100
1 4,555,100 4,250,200 3,657,200 3,545,100
Human Albumin for
20 DD-11-II S-4-16-II 2 4,555,100 4,250,200 3,657,200 3,545,100
Burn
3 4,555,100 4,250,200 3,657,200 3,545,100
1 4,555,100 4,250,200 3,657,200 3,545,100
Human Albumin for
21 DD-11-II S-4-16-III 2 4,555,100 4,250,200 3,657,200 3,545,100
Burn
3 4,555,100 4,250,200 3,657,200 3,545,100
1 16,613,400 15,981,000 13,338,500 12,929,600
Human Albumin for
22 DD-11-II L-1-20-I 2 16,613,400 15,981,000 13,338,500 12,929,600
Burn
3 16,613,400 15,981,000 13,338,500 12,929,600
1 16,613,400 15,981,000 13,338,500 12,929,600
Human Albumin for
23 DD-11-II L-1-20-II 2 16,613,400 15,981,000 13,338,500 12,929,600
Burn
3 16,613,400 15,981,000 13,338,500 12,929,600
1 16,613,400 15,981,000 13,338,500 12,929,600
Human Albumin for
24 DD-11-II L-1-20-III 2 16,613,400 15,981,000 13,338,500 12,929,600
Burn
3 16,613,400 15,981,000 13,338,500 12,929,600
- 1087 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 17,655,800 8,950,100 5,600,900 1,659,100
Subdural Grid
25 RR-01-II G-1-10-I 2 17,655,800 8,950,100 5,600,900 1,659,100
Electrode
3 17,655,800 8,950,100 5,600,900 1,659,100
1 17,655,800 8,950,100 5,600,900 1,659,100
Subdural Grid
26 RR-01-II G-1-10-II 2 17,655,800 8,950,100 5,600,900 1,659,100
Electrode
3 17,655,800 8,950,100 5,600,900 1,659,100
1 17,655,800 8,950,100 5,600,900 1,659,100
Subdural Grid
27 RR-01-II G-1-10-III 2 17,655,800 8,950,100 5,600,900 1,659,100
Electrode
3 17,655,800 8,950,100 5,600,900 1,659,100
1 17,954,800 7,695,300 5,885,800 5,134,800
3 17,954,800 7,695,300 5,885,800 5,134,800
1 17,954,800 7,695,300 5,885,800 5,134,800
3 17,954,800 7,695,300 5,885,800 5,134,800
1 17,954,800 7,695,300 5,885,800 5,134,800
3 17,954,800 7,695,300 5,885,800 5,134,800
1 11,745,800 8,219,800 6,287,000 5,484,800
3 11,745,800 8,219,800 6,287,000 5,484,800
1 11,745,800 8,219,800 6,287,000 5,484,800
3 11,745,800 8,219,800 6,287,000 5,484,800
1 11,745,800 8,219,800 6,287,000 5,484,800
3 11,745,800 8,219,800 6,287,000 5,484,800
1 27,769,800 11,901,900 9,103,300 7,941,800
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 27,769,800 11,901,900 9,103,300 7,941,800
Implant
3 27,769,800 11,901,900 9,103,300 7,941,800
1 27,769,800 11,901,900 9,103,300 7,941,800
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 27,769,800 11,901,900 9,103,300 7,941,800
Implant
3 27,769,800 11,901,900 9,103,300 7,941,800
1 27,769,800 11,901,900 9,103,300 7,941,800
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 27,769,800 11,901,900 9,103,300 7,941,800
Implant
3 27,769,800 11,901,900 9,103,300 7,941,800
1 109,581,500 102,774,100 58,653,500 51,169,500
Prostesis
37 RR-05-III I-1-20-I 2 109,581,500 102,774,100 58,653,500 51,169,500
Evar/Tevar/Hevar
3 109,581,500 102,774,100 58,653,500 51,169,500
1 109,581,500 102,774,100 58,653,500 51,169,500
Prostesis
38 RR-05-III I-1-20-II 2 109,581,500 102,774,100 58,653,500 51,169,500
Evar/Tevar/Hevar
3 109,581,500 102,774,100 58,653,500 51,169,500
1 109,581,500 102,774,100 58,653,500 51,169,500
Prostesis
39 RR-05-III I-1-20-III 2 109,581,500 102,774,100 58,653,500 51,169,500
Evar/Tevar/Hevar
3 109,581,500 102,774,100 58,653,500 51,169,500
Hip 1 13,884,900 5,951,000 4,551,700 3,970,900
Replacement 3 13,884,900 5,951,000 4,551,700 3,970,900
Hip 1 13,884,900 5,951,000 4,551,700 3,970,900
Replacement 3 13,884,900 5,951,000 4,551,700 3,970,900
Hip 1 13,884,900 5,951,000 4,551,700 3,970,900
Replacement 3 13,884,900 5,951,000 4,551,700 3,970,900
1 15,300,100 11,038,200 8,189,400 7,144,500
43 YY-02-III PCI I-1-40-I 2 15,300,100 11,038,200 8,189,400 7,144,500
3 15,300,100 11,038,200 8,189,400 7,144,500
1 15,300,100 11,038,200 8,189,400 7,144,500
44 YY-02-III PCI I-1-40-II 2 15,300,100 11,038,200 8,189,400 7,144,500
3 15,300,100 11,038,200 8,189,400 7,144,500
1 15,300,100 11,038,200 8,189,400 7,144,500
45 YY-02-III PCI I-1-40-III 2 15,300,100 11,038,200 8,189,400 7,144,500
3 15,300,100 11,038,200 8,189,400 7,144,500
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
- 1088 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 8,551,400 6,582,700 4,119,400 3,593,800
3 8,551,400 6,582,700 4,119,400 3,593,800
1 8,551,400 6,582,700 4,119,400 3,593,800
3 8,551,400 6,582,700 4,119,400 3,593,800
1 8,551,400 6,582,700 4,119,400 3,593,800
3 8,551,400 6,582,700 4,119,400 3,593,800
Repair of Septal 1 51,189,700 22,618,100 16,780,700 14,639,500
Prosthesis 3 51,189,700 22,618,100 16,780,700 14,639,500
Repair of Septal 1 51,189,700 22,618,100 16,780,700 14,639,500
Prosthesis 3 51,189,700 22,618,100 16,780,700 14,639,500
Repair of Septal 1 51,189,700 22,618,100 16,780,700 14,639,500
Prosthesis 3 51,189,700 22,618,100 16,780,700 14,639,500
1 4,335,600 3,034,000 2,320,600 2,024,500
55 YY-06-III C-4-12-I 2 4,335,600 3,034,000 2,320,600 2,024,500
& Radiotheraphy
3 4,335,600 3,034,000 2,320,600 2,024,500
1 4,335,600 3,034,000 2,320,600 2,024,500
56 YY-06-III C-4-12-II 2 4,335,600 3,034,000 2,320,600 2,024,500
& Radiotheraphy
3 4,335,600 3,034,000 2,320,600 2,024,500
1 4,335,600 3,034,000 2,320,600 2,024,500
57 YY-06-III C-4-12-III 2 4,335,600 3,034,000 2,320,600 2,024,500
& Radiotheraphy
3 4,335,600 3,034,000 2,320,600 2,024,500
1 10,751,300 7,523,800 5,754,600 5,020,400
3 10,751,300 7,523,800 5,754,600 5,020,400
1 10,751,300 7,523,800 5,754,600 5,020,400
3 10,751,300 7,523,800 5,754,600 5,020,400
1 10,751,300 7,523,800 5,754,600 5,020,400
3 10,751,300 7,523,800 5,754,600 5,020,400
1 12,883,100 9,015,600 6,895,700 6,015,800
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 12,883,100 9,015,600 6,895,700 6,015,800
mi
3 12,883,100 9,015,600 6,895,700 6,015,800
1 12,883,100 9,015,600 6,895,700 6,015,800
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 12,883,100 9,015,600 6,895,700 6,015,800
mi
3 12,883,100 9,015,600 6,895,700 6,015,800
1 12,883,100 9,015,600 6,895,700 6,015,800
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 12,883,100 9,015,600 6,895,700 6,015,800
mi
3 12,883,100 9,015,600 6,895,700 6,015,800
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
1 8,523,900 7,671,400 6,819,000 5,966,700
3 8,523,900 7,671,400 6,819,000 5,966,700
70 DD-10-II Q-5-44-0 - 10,791,900 5,829,000 5,766,000 5,604,000
(OP)
72 II-02-III MRI Z-3-16-0 - 1,977,900 1,780,100 1,582,200 1,384,500
Diagnostic and
Eye
- 1089 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 3,564,200 3,428,500 3,179,500 2,773,800
3 3,564,200 3,428,500 3,179,500 2,773,800
1 3,564,200 3,428,500 3,179,500 2,773,800
3 3,564,200 3,428,500 3,179,500 2,773,800
1 3,564,200 3,428,500 3,179,500 2,773,800
3 3,564,200 3,428,500 3,179,500 2,773,800
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 6,786,600 6,332,400 6,054,300 6,338,100
3 6,786,600 6,332,400 6,054,300 6,338,100
1 2,303,600 2,149,400 1,849,500 1,792,800
Human Albumin for
13 DD-05-II A-4-10-I 2 2,303,600 2,149,400 1,849,500 1,792,800
Septicaemia
3 2,303,600 2,149,400 1,849,500 1,792,800
1 2,303,600 2,149,400 1,849,500 1,792,800
Human Albumin for
14 DD-05-II A-4-10-II 2 2,303,600 2,149,400 1,849,500 1,792,800
Septicaemia
3 2,303,600 2,149,400 1,849,500 1,792,800
1 2,303,600 2,149,400 1,849,500 1,792,800
Human Albumin for
15 DD-05-II A-4-10-III 2 2,303,600 2,149,400 1,849,500 1,792,800
Septicaemia
3 2,303,600 2,149,400 1,849,500 1,792,800
1 12,247,400 8,570,800 7,374,800 6,433,900
16 DD-06-II D-4-11-I 2 12,247,400 8,570,800 7,374,800 6,433,900
(IP)
3 12,247,400 8,570,800 7,374,800 6,433,900
1 12,247,400 8,570,800 7,374,800 6,433,900
17 DD-06-II D-4-11-II 2 12,247,400 8,570,800 7,374,800 6,433,900
(IP)
3 12,247,400 8,570,800 7,374,800 6,433,900
1 12,247,400 8,570,800 7,374,800 6,433,900
18 DD-06-II D-4-11-III 2 12,247,400 8,570,800 7,374,800 6,433,900
(IP)
3 12,247,400 8,570,800 7,374,800 6,433,900
1 4,691,800 4,377,800 3,767,000 3,651,400
Human Albumin for
19 DD-11-II S-4-16-I 2 4,691,800 4,377,800 3,767,000 3,651,400
Burn
3 4,691,800 4,377,800 3,767,000 3,651,400
1 4,691,800 4,377,800 3,767,000 3,651,400
Human Albumin for
20 DD-11-II S-4-16-II 2 4,691,800 4,377,800 3,767,000 3,651,400
Burn
3 4,691,800 4,377,800 3,767,000 3,651,400
1 4,691,800 4,377,800 3,767,000 3,651,400
Human Albumin for
21 DD-11-II S-4-16-III 2 4,691,800 4,377,800 3,767,000 3,651,400
Burn
3 4,691,800 4,377,800 3,767,000 3,651,400
1 17,111,800 16,460,400 13,738,700 13,317,400
Human Albumin for
22 DD-11-II L-1-20-I 2 17,111,800 16,460,400 13,738,700 13,317,400
Burn
3 17,111,800 16,460,400 13,738,700 13,317,400
1 17,111,800 16,460,400 13,738,700 13,317,400
Human Albumin for
23 DD-11-II L-1-20-II 2 17,111,800 16,460,400 13,738,700 13,317,400
Burn
3 17,111,800 16,460,400 13,738,700 13,317,400
1 17,111,800 16,460,400 13,738,700 13,317,400
Human Albumin for
24 DD-11-II L-1-20-III 2 17,111,800 16,460,400 13,738,700 13,317,400
Burn
3 17,111,800 16,460,400 13,738,700 13,317,400
- 1090 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 18,185,500 9,218,600 5,769,000 1,708,800
Subdural Grid
25 RR-01-II G-1-10-I 2 18,185,500 9,218,600 5,769,000 1,708,800
Electrode
3 18,185,500 9,218,600 5,769,000 1,708,800
1 18,185,500 9,218,600 5,769,000 1,708,800
Subdural Grid
26 RR-01-II G-1-10-II 2 18,185,500 9,218,600 5,769,000 1,708,800
Electrode
3 18,185,500 9,218,600 5,769,000 1,708,800
1 18,185,500 9,218,600 5,769,000 1,708,800
Subdural Grid
27 RR-01-II G-1-10-III 2 18,185,500 9,218,600 5,769,000 1,708,800
Electrode
3 18,185,500 9,218,600 5,769,000 1,708,800
1 18,493,400 7,926,100 6,062,400 5,288,900
3 18,493,400 7,926,100 6,062,400 5,288,900
1 18,493,400 7,926,100 6,062,400 5,288,900
3 18,493,400 7,926,100 6,062,400 5,288,900
1 18,493,400 7,926,100 6,062,400 5,288,900
3 18,493,400 7,926,100 6,062,400 5,288,900
1 12,098,200 8,466,400 6,475,600 5,649,300
3 12,098,200 8,466,400 6,475,600 5,649,300
1 12,098,200 8,466,400 6,475,600 5,649,300
3 12,098,200 8,466,400 6,475,600 5,649,300
1 12,098,200 8,466,400 6,475,600 5,649,300
3 12,098,200 8,466,400 6,475,600 5,649,300
1 28,602,900 12,259,000 9,376,400 8,180,000
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 28,602,900 12,259,000 9,376,400 8,180,000
Implant
3 28,602,900 12,259,000 9,376,400 8,180,000
1 28,602,900 12,259,000 9,376,400 8,180,000
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 28,602,900 12,259,000 9,376,400 8,180,000
Implant
3 28,602,900 12,259,000 9,376,400 8,180,000
1 28,602,900 12,259,000 9,376,400 8,180,000
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 28,602,900 12,259,000 9,376,400 8,180,000
Implant
3 28,602,900 12,259,000 9,376,400 8,180,000
1 112,869,000 105,857,700 60,413,000 52,704,500
Prostesis
37 RR-05-III I-1-20-I 2 112,869,000 105,857,700 60,413,000 52,704,500
Evar/Tevar/Hevar
3 112,869,000 105,857,700 60,413,000 52,704,500
1 112,869,000 105,857,700 60,413,000 52,704,500
Prostesis
38 RR-05-III I-1-20-II 2 112,869,000 105,857,700 60,413,000 52,704,500
Evar/Tevar/Hevar
3 112,869,000 105,857,700 60,413,000 52,704,500
1 112,869,000 105,857,700 60,413,000 52,704,500
Prostesis
39 RR-05-III I-1-20-III 2 112,869,000 105,857,700 60,413,000 52,704,500
Evar/Tevar/Hevar
3 112,869,000 105,857,700 60,413,000 52,704,500
Hip 1 14,301,500 6,129,500 4,688,200 4,090,000
Replacement 3 14,301,500 6,129,500 4,688,200 4,090,000
Hip 1 14,301,500 6,129,500 4,688,200 4,090,000
Replacement 3 14,301,500 6,129,500 4,688,200 4,090,000
Hip 1 14,301,500 6,129,500 4,688,200 4,090,000
Replacement 3 14,301,500 6,129,500 4,688,200 4,090,000
1 15,759,100 11,369,400 8,435,100 7,358,800
43 YY-02-III PCI I-1-40-I 2 15,759,100 11,369,400 8,435,100 7,358,800
3 15,759,100 11,369,400 8,435,100 7,358,800
1 15,759,100 11,369,400 8,435,100 7,358,800
44 YY-02-III PCI I-1-40-II 2 15,759,100 11,369,400 8,435,100 7,358,800
3 15,759,100 11,369,400 8,435,100 7,358,800
1 15,759,100 11,369,400 8,435,100 7,358,800
45 YY-02-III PCI I-1-40-III 2 15,759,100 11,369,400 8,435,100 7,358,800
3 15,759,100 11,369,400 8,435,100 7,358,800
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
- 1091 -
REGIONAL 5
TOP UP SPESIAL CMG

NO KODE CBG
1 8,807,900 6,780,200 4,243,000 3,701,600
3 8,807,900 6,780,200 4,243,000 3,701,600
1 8,807,900 6,780,200 4,243,000 3,701,600
3 8,807,900 6,780,200 4,243,000 3,701,600
1 8,807,900 6,780,200 4,243,000 3,701,600
3 8,807,900 6,780,200 4,243,000 3,701,600
Repair of Septal 1 52,725,400 23,296,600 17,284,100 15,078,700
Prosthesis 3 52,725,400 23,296,600 17,284,100 15,078,700
Repair of Septal 1 52,725,400 23,296,600 17,284,100 15,078,700
Prosthesis 3 52,725,400 23,296,600 17,284,100 15,078,700
Repair of Septal 1 52,725,400 23,296,600 17,284,100 15,078,700
Prosthesis 3 52,725,400 23,296,600 17,284,100 15,078,700
1 4,465,600 3,125,100 2,390,200 2,085,200
55 YY-06-III C-4-12-I 2 4,465,600 3,125,100 2,390,200 2,085,200
& Radiotheraphy
3 4,465,600 3,125,100 2,390,200 2,085,200
1 4,465,600 3,125,100 2,390,200 2,085,200
56 YY-06-III C-4-12-II 2 4,465,600 3,125,100 2,390,200 2,085,200
& Radiotheraphy
3 4,465,600 3,125,100 2,390,200 2,085,200
1 4,465,600 3,125,100 2,390,200 2,085,200
57 YY-06-III C-4-12-III 2 4,465,600 3,125,100 2,390,200 2,085,200
& Radiotheraphy
3 4,465,600 3,125,100 2,390,200 2,085,200
1 11,073,800 7,749,500 5,927,300 5,171,000
3 11,073,800 7,749,500 5,927,300 5,171,000
1 11,073,800 7,749,500 5,927,300 5,171,000
3 11,073,800 7,749,500 5,927,300 5,171,000
1 11,073,800 7,749,500 5,927,300 5,171,000
3 11,073,800 7,749,500 5,927,300 5,171,000
1 13,269,600 9,286,100 7,102,600 6,196,300
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 13,269,600 9,286,100 7,102,600 6,196,300
mi
3 13,269,600 9,286,100 7,102,600 6,196,300
1 13,269,600 9,286,100 7,102,600 6,196,300
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 13,269,600 9,286,100 7,102,600 6,196,300
mi
3 13,269,600 9,286,100 7,102,600 6,196,300
1 13,269,600 9,286,100 7,102,600 6,196,300
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 13,269,600 9,286,100 7,102,600 6,196,300
mi
3 13,269,600 9,286,100 7,102,600 6,196,300
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
1 8,779,600 7,901,600 7,023,600 6,145,700
3 8,779,600 7,901,600 7,023,600 6,145,700
70 DD-10-II Q-5-44-0 - 11,331,900 6,120,000 6,054,000 5,883,000
(OP)
71 II-01-III Nuclear Medicine Z-3-17-0 - 2,483,300 1,007,100 724,800 688,200
72 II-02-III MRI Z-3-16-0 - 2,076,800 1,869,000 1,661,400 1,453,800
Diagnostic and
Eye
- 1092 -
REGIONAL 1
TOP UP SPESIAL CMG
KODE DESKRIPSI KELAS RSK

NO KODE CBG RSCM RSJP-HK RSAB-HK
SPECIAL SPECIAL CMG RAWAT DHARMAIS
1 3,446,900 3,288,800 3,288,800 3,288,800
3 3,446,900 3,288,800 3,288,800 3,288,800
1 3,446,900 3,288,800 3,288,800 3,288,800
3 3,446,900 3,288,800 3,288,800 3,288,800
1 3,446,900 3,288,800 3,288,800 3,288,800
3 3,446,900 3,288,800 3,288,800 3,288,800
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 6,563,300 6,262,200 6,262,200 6,262,200
3 6,563,300 6,262,200 6,262,200 6,262,200
1 2,227,800 2,125,600 2,125,600 2,125,600
Human Albumin for
13 DD-05-II A-4-10-I 2 2,227,800 2,125,600 2,125,600 2,125,600
Septicaemia
3 2,227,800 2,125,600 2,125,600 2,125,600
1 2,227,800 2,125,600 2,125,600 2,125,600
Human Albumin for
14 DD-05-II A-4-10-II 2 2,227,800 2,125,600 2,125,600 2,125,600
Septicaemia
3 2,227,800 2,125,600 2,125,600 2,125,600
1 2,227,800 2,125,600 2,125,600 2,125,600
Human Albumin for
15 DD-05-II A-4-10-III 2 2,227,800 2,125,600 2,125,600 2,125,600
Septicaemia
3 2,227,800 2,125,600 2,125,600 2,125,600
1 11,104,100 10,594,900 10,594,900 10,594,900
16 DD-06-II D-4-11-I 2 11,104,100 10,594,900 10,594,900 10,594,900
(IP)
3 11,104,100 10,594,900 10,594,900 10,594,900
1 11,104,100 10,594,900 10,594,900 10,594,900
17 DD-06-II D-4-11-II 2 11,104,100 10,594,900 10,594,900 10,594,900
(IP)
3 11,104,100 10,594,900 10,594,900 10,594,900
1 11,104,100 10,594,900 10,594,900 10,594,900
18 DD-06-II D-4-11-III 2 11,104,100 10,594,900 10,594,900 10,594,900
(IP)
3 11,104,100 10,594,900 10,594,900 10,594,900
1 4,537,400 4,329,300 4,329,300 4,329,300
Human Albumin for
19 DD-11-II S-4-16-I 2 4,537,400 4,329,300 4,329,300 4,329,300
Burn
3 4,537,400 4,329,300 4,329,300 4,329,300
1 4,537,400 4,329,300 4,329,300 4,329,300
Human Albumin for
20 DD-11-II S-4-16-II 2 4,537,400 4,329,300 4,329,300 4,329,300
Burn
3 4,537,400 4,329,300 4,329,300 4,329,300
1 4,537,400 4,329,300 4,329,300 4,329,300
Human Albumin for
21 DD-11-II S-4-16-III 2 4,537,400 4,329,300 4,329,300 4,329,300
Burn
3 4,537,400 4,329,300 4,329,300 4,329,300
1 11,493,600 11,493,600 11,493,600 11,493,600
Human Albumin for
22 DD-11-II L-1-20-I 2 11,493,600 11,493,600 11,493,600 11,493,600
Burn
3 11,493,600 11,493,600 11,493,600 11,493,600
1 11,493,600 11,493,600 11,493,600 11,493,600
Human Albumin for
23 DD-11-II L-1-20-II 2 11,493,600 11,493,600 11,493,600 11,493,600
Burn
3 11,493,600 11,493,600 11,493,600 11,493,600
1 11,493,600 11,493,600 11,493,600 11,493,600
Human Albumin for
24 DD-11-II L-1-20-III 2 11,493,600 11,493,600 11,493,600 11,493,600
Burn
3 11,493,600 11,493,600 11,493,600 11,493,600
- 1093 -
REGIONAL 1
TOP UP SPESIAL CMG

1 16,656,400 16,656,400 16,656,400 16,656,400
Subdural Grid
25 RR-01-II G-1-10-I 2 16,656,400 16,656,400 16,656,400 16,656,400
Electrode
3 16,656,400 16,656,400 16,656,400 16,656,400
1 16,656,400 16,656,400 16,656,400 16,656,400
Subdural Grid
26 RR-01-II G-1-10-II 2 16,656,400 16,656,400 16,656,400 16,656,400
Electrode
3 16,656,400 16,656,400 16,656,400 16,656,400
1 16,656,400 16,656,400 16,656,400 16,656,400
Subdural Grid
27 RR-01-II G-1-10-III 2 16,656,400 16,656,400 16,656,400 16,656,400
Electrode
3 16,656,400 16,656,400 16,656,400 16,656,400
1 16,938,500 16,938,500 16,938,500 16,938,500
3 16,938,500 16,938,500 16,938,500 16,938,500
1 16,938,500 16,938,500 16,938,500 16,938,500
3 16,938,500 16,938,500 16,938,500 16,938,500
1 16,938,500 16,938,500 16,938,500 16,938,500
3 16,938,500 16,938,500 16,938,500 16,938,500
1 17,550,200 16,745,100 16,745,100 16,745,100
3 17,550,200 16,745,100 16,745,100 16,745,100
1 17,550,200 16,745,100 16,745,100 16,745,100
3 17,550,200 16,745,100 16,745,100 16,745,100
1 17,550,200 16,745,100 16,745,100 16,745,100
3 17,550,200 16,745,100 16,745,100 16,745,100
1 26,197,900 26,197,900 26,197,900 26,197,900
Hip Implant/Knee
34 RR-04-III M-1-04-I 2 26,197,900 26,197,900 26,197,900 26,197,900
Implant
3 26,197,900 26,197,900 26,197,900 26,197,900
1 26,197,900 26,197,900 26,197,900 26,197,900
Hip Implant/Knee
35 RR-04-III M-1-04-II 2 26,197,900 26,197,900 26,197,900 26,197,900
Implant
3 26,197,900 26,197,900 26,197,900 26,197,900
1 26,197,900 26,197,900 26,197,900 26,197,900
Hip Implant/Knee
36 RR-04-III M-1-04-III 2 26,197,900 26,197,900 26,197,900 26,197,900
Implant
3 26,197,900 26,197,900 26,197,900 26,197,900
1 106,426,100 109,355,400 109,355,400 109,355,400
Prostesis
37 RR-05-III I-1-20-I 2 106,426,100 109,355,400 109,355,400 109,355,400
Evar/Tevar/Hevar
3 106,426,100 109,355,400 109,355,400 109,355,400
1 106,426,100 109,355,400 109,355,400 109,355,400
Prostesis
38 RR-05-III I-1-20-II 2 106,426,100 109,355,400 109,355,400 109,355,400
Evar/Tevar/Hevar
3 106,426,100 109,355,400 109,355,400 109,355,400
1 106,426,100 109,355,400 109,355,400 109,355,400
Prostesis
39 RR-05-III I-1-20-III 2 106,426,100 109,355,400 109,355,400 109,355,400
Evar/Tevar/Hevar
3 106,426,100 109,355,400 109,355,400 109,355,400
Hip 1 13,099,000 13,099,000 13,099,000 13,099,000
Replacement 3 13,099,000 13,099,000 13,099,000 13,099,000
Hip 1 13,099,000 13,099,000 13,099,000 13,099,000
Replacement 3 13,099,000 13,099,000 13,099,000 13,099,000
Hip 1 13,099,000 13,099,000 13,099,000 13,099,000
Replacement 3 13,099,000 13,099,000 13,099,000 13,099,000
1 22,860,800 21,812,200 21,812,200 21,812,200
43 YY-02-III PCI I-1-40-I 2 22,860,800 21,812,200 21,812,200 21,812,200
3 22,860,800 21,812,200 21,812,200 21,812,200
1 22,860,800 21,812,200 21,812,200 21,812,200
44 YY-02-III PCI I-1-40-II 2 22,860,800 21,812,200 21,812,200 21,812,200
3 22,860,800 21,812,200 21,812,200 21,812,200
1 22,860,800 21,812,200 21,812,200 21,812,200
45 YY-02-III PCI I-1-40-III 2 22,860,800 21,812,200 21,812,200 21,812,200
3 22,860,800 21,812,200 21,812,200 21,812,200
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
- 1094 -
REGIONAL 1
TOP UP SPESIAL CMG

1 12,777,200 12,191,100 12,191,100 12,191,100
3 12,777,200 12,191,100 12,191,100 12,191,100
1 12,777,200 12,191,100 12,191,100 12,191,100
3 12,777,200 12,191,100 12,191,100 12,191,100
1 12,777,200 12,191,100 12,191,100 12,191,100
3 12,777,200 12,191,100 12,191,100 12,191,100
Repair of Septal 1 48,292,200 48,292,200 48,292,200 48,292,200
Prosthesis 3 48,292,200 48,292,200 48,292,200 48,292,200
Repair of Septal 1 48,292,200 48,292,200 48,292,200 48,292,200
Prosthesis 3 48,292,200 48,292,200 48,292,200 48,292,200
Repair of Septal 1 48,292,200 48,292,200 48,292,200 48,292,200
Prosthesis 3 48,292,200 48,292,200 48,292,200 48,292,200
1 6,478,000 6,180,900 6,180,900 6,180,900
55 YY-06-III C-4-12-I 2 6,478,000 6,180,900 6,180,900 6,180,900
& Radiotheraphy
3 6,478,000 6,180,900 6,180,900 6,180,900
1 6,478,000 6,180,900 6,180,900 6,180,900
56 YY-06-III C-4-12-II 2 6,478,000 6,180,900 6,180,900 6,180,900
& Radiotheraphy
3 6,478,000 6,180,900 6,180,900 6,180,900
1 6,478,000 6,180,900 6,180,900 6,180,900
57 YY-06-III C-4-12-III 2 6,478,000 6,180,900 6,180,900 6,180,900
& Radiotheraphy
3 6,478,000 6,180,900 6,180,900 6,180,900
1 16,064,100 15,327,300 15,327,300 15,327,300
3 16,064,100 15,327,300 15,327,300 15,327,300
1 16,064,100 15,327,300 15,327,300 15,327,300
3 16,064,100 15,327,300 15,327,300 15,327,300
1 16,064,100 15,327,300 15,327,300 15,327,300
3 16,064,100 15,327,300 15,327,300 15,327,300
1 19,249,400 18,366,400 18,366,400 18,366,400
Lobektomi/Bilobekto
61 YY-08-III J-1-10-I 2 19,249,400 18,366,400 18,366,400 18,366,400
mi
3 19,249,400 18,366,400 18,366,400 18,366,400
1 19,249,400 18,366,400 18,366,400 18,366,400
Lobektomi/Bilobekto
62 YY-08-III J-1-10-II 2 19,249,400 18,366,400 18,366,400 18,366,400
mi
3 19,249,400 18,366,400 18,366,400 18,366,400
1 19,249,400 18,366,400 18,366,400 18,366,400
Lobektomi/Bilobekto
63 YY-08-III J-1-10-III 2 19,249,400 18,366,400 18,366,400 18,366,400
mi
3 19,249,400 18,366,400 18,366,400 18,366,400
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
1 9,983,400 6,771,000 6,771,000 6,771,000
3 9,983,400 6,771,000 6,771,000 6,771,000
70 DD-10-II Q-5-44-0 - 10,293,400 10,293,400 10,293,400 10,293,400
(OP)
71 II-01-III Nuclear Medicine Z-3-17-0 - 2,231,300 2,231,300 2,231,300 2,231,300
72 II-02-III MRI Z-3-16-0 - 3,332,900 3,166,200 3,166,200 3,166,200
Diagnostic and
Eye
75 YY-11-III Microlaringoscopy J-3-15-0 - 2,091,600 1,987,200 1,987,200 1,987,200
- 1095 -
PERHITUNGAN TARIF
SPECIAL GROUPS UNTUK KASUS SUB-AKUT DAN KRONIS
1. Kasus Sub-Akut
LOS = 43 sampai dengan 103
Total tarif = Tarif Fase Akut + Top up payment Fase Sub Akut.
2. Kasus Kronis
LOS = 104 sampai dengan 180
Total tarif = Tarif Fase Akut + Top up payment Fase Sub Akut + Top up payment
Fase Kronis.
Keterangan
Tarif Fase Akut = Tarif hasil grouping SW INA-CBG versi 4.0.
Top up payment Fase Sub Akut = 0,375 x RIW fase sub akut x UC x LOS.
Top up payment Fase Kronis = 0,25 x RIW fase kronis x UC x LOS.
Resource Intensity Weight (RIW) = ADL Score : 60.
UC (Unit Cost) = Rp. 879.103,00
LOS (Length Of Stay) rawatan = Lama rawat pasien dalam 1 episode.
Rumus LOS :
Fase Akut : Hari 1 sampai dengan 42.
Fase Sub Akut : Rumus : LOS – (LOS-103) - 42.
Bila (LOS-103) hasilnya 0 atau negatif maka, rumus LOS
Fase Akut = LOS-42.
Fase Kronis : Rumus : LOS – 103
Bila hasilnya 0 atau negatif maka LOS Fase Kronis = 0
Karena pasien tersebut dirawat ≤ 103 hari (tidak melalui fase
kronis).
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NILA FARID MOELOEK

Lampiran Permenkes 64 THN 2016

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PERATURAN MENTERl KESEHATAN REPUBLIK INDONESIA

NOMOR 64 TAHUN 2016

DENGAN RAHMAT TUHAN YANG MAHA ESA

MENTERI KESEHATAN REPUBLIK INDONESIA,

Menimbang : a. bahwa standar tarif pelayanan kesehatan dalam

tentang Standar Tarif Pelayanan Kesehatan Dalam

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

Beberapa Ketentuan dalam Peraturan Menteri Kesehatan

1. Ketentuan Pasal 25 diubah, sehingga berbunyi sebagai

2. Diantara Pasal 26 dan Pasal 27 disisipkan satu pasal,

3. Ketentuan dalam Lampiran diubah, sehingga berbunyi

Agar setiap orang mengetahuinya, memerintahkan

NILA FARID MOELOEK

BERITA NEGARA REPUBLIK INDONESIA TAHUN 2016 NOMOR 1790

Telah diperiksa dan disetujui:

Kepala Biro Hukum Kepala Pusat Jaminan

STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

28 B-1-12-I CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN) 6,895,800 8,275,000 9,654,100

29 B-1-12-II CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG) 7,669,300 9,203,200 10,737,100

30 B-1-12-III CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT) 11,997,800 14,397,400 16,797,000

PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

50 B-4-14-II GANGGUAN SALURAN EMPEDU LAIN-LAIN (SEDANG) 4,799,700 5,759,700 6,719,600

51 B-4-14-III GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT) 6,429,400 7,715,200 9,001,100

94 E-1-10-I PROSEDUR KELENJAR ADRENAL (RINGAN) 7,154,500 8,585,400 10,016,400

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

112 F-4-10-I SCHIZOFRENIA (RINGAN) 3,975,000 4,770,000 5,565,000

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

278 I-1-40-II PROSEDUR KARDIOVASKULAR PERKUTAN (SEDANG) 25,196,200 30,235,400 35,274,700

279 I-1-40-III PROSEDUR KARDIOVASKULAR PERKUTAN (BERAT) 33,653,600 40,384,300 47,115,000

298 I-4-16-I ATHEROSKLEROSIS (RINGAN) 2,124,500 2,549,400 2,974,300

GANGGUAN KONDUKSI & ARITMIA JANTUNG

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

340 J-4-10-I KISTA FIBROSIS (RINGAN) 2,715,000 3,258,100 3,801,100

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

391 K-1-20-I PROSEDUR INTESTINAL KOMPLEKS (RINGAN) 11,926,300 14,311,600 16,696,900

PROSEDUR SISTEM PENCERNAAN LAIN-LAIN

400 K-1-50-I PROSEDUR ANAL (RINGAN) 5,832,800 6,999,400 8,166,000

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

418 K-4-15-I OBSTRUKSI SALURAN GASTROINTESTINAL (RINGAN) 2,592,600 3,111,200 3,629,700

419 K-4-15-II OBSTRUKSI SALURAN GASTROINTESTINAL (SEDANG) 3,996,300 4,795,600 5,594,900

420 K-4-15-III OBSTRUKSI SALURAN GASTROINTESTINAL (BERAT) 5,608,700 6,730,500 7,852,200

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

481 M-1-30-I PROSEDUR KAKI (RINGAN) 8,562,000 10,274,400 11,986,800

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

TARIF INA-CBG TAHUN 2016