GROUP

NO DIAGNOSIS PROSEDUR DRUG

KELAS 1 KELAS 3
Thorax Foto (87.4)
1 HIV (B24) + GEA (A09.9) + Anemia (D50) - - Rp 3,107,100
Transfusi PRC (99.04)
2 Difteri (A36.2) + Dehidrasi Berat (P74.1) - - - Rp 2,792,000
3 Anemia Aplastik (D61.9) Transfusi PRC (99.04) - - Rp 1,977,800
Leukemia (ALL) (C91.0)+ Anemia Berat Transfusi PRC (99.04)
4 (D50) - - Rp 3,868,300
Nefrotik Syndrom (N04) + Hipoalbumin - Human Albumin - Rp 0
5 (R77.0)
Hipoalbumin (R77.0) + Nefrotik Syndrom - Human Albumin - Rp 3,232,500
6 (N04)
7 CKD (N18.2) + Nefrotik Syndrom (N04) - - - Rp 3,028,400
USG (88.76)
CKD (N18.3) + Nefrotik Syndrom (N04) +
8 Thorax Foto (87.4) Human Albumin - Rp 7,141,100
Hipoalbumin (R77.0) + Efusi Pleura (J90)

9 CKD (N18.4) + HT Renal Failure (I13.1) + Hemodialisis (39.95) - - Rp 4,081,800

Anemi (D50)
An. Def Iron (D50) + CRF (N18.9) + HT Transfusi PRC (99.04) - - Rp 0
10 (I10)
11 CRF (N18.9) + Anemia (D50) Transfusi PRC (99.04) - - Rp 3,028,400
12 CRF (N18.9) + Anemia (D50) + HT (I10) Transfusi PRC (99.04) - - Rp 4,081,800
13 Dyspepsia (K30) + Gastritis (K29.1) USG Abdomen (88.76) - - Rp 4,627,500
X-Ray Ankle & Foot
14 Gangren (A48.0) + DM Dependen Syndrom - - Rp 3,079,100
(E10) (88.28) + Kultur (90.53)
X-Ray Ankle & Foot Human Albumin
15 Gangren (A48.0) + DM Dependen Syndrom - Rp 3,079,100
(E10) + Hipoalbumin (R77.0) (88.28) (DD05)
Hipoalbumin (R77.0) + Insulin Dependen X-Ray Ankle & Foot Human Albumin
16 - Rp 6,103,000
DM (E10) + Gangren (A48.0) (88.28) (DD05)
 Hipoalbumin (R77.0) + Insulin Dependen X-Ray Ankle & Foot Human Albumin
16 - Rp 6,103,000
DM (E10) + Gangren (A48.0) (88.28) (DD05)
Hipoalbumin (R77.0) + Insulin Dependen
X-Ray Ankle & Foot Human Albumin
17 DM (E10) + Gangren (A48.0) + Sepsis - Rp 6,103,000
(88.28) + Kultur (90.53) (DD05)
(A41.9)

Hipoalbumin (R77.0) + Insulin Dependen

Skeletal X-Ray (88.28) + Human Albumin
18 (E10) + Gangren (A48.0) + Sepsis (A41.9) + Rp 8,468,000 Rp 6,048,600
Kultur (90.53) (DD05)
Secondary Thrombositopeni (D69.5)

Transfusi PRC (99.04)

19 CRF (N18.9) + Anemi (D50) - Rp 4,202,400 Rp 3,001,700
Hemodialisis (39.95)
CRF (N18.9) + Anemi (D50) + Secondary Tranfusi PRC ((99.04)
20 - Rp 9,908,400 Rp 7,077,400
Thrombositopeni (D69.5) Hemodialisis (39.95)

DHF (A91) + Secondary Thrombositopeni

21 - - Rp 4,484,300 Rp 3,736,800
(D69.5) + Dyspepsia (K30)

Typhoid Fever (A10.0) + Dyspepsia (K30) +

22 USG Abdomen (88.76) - Rp 4,272,700 Rp 3,051,900
Hepatitis (B17.9)
23 Ulcerative Colitis (K51.9) Colonoscopy (45.23) - Rp 4,340,900 Rp 3,100,600
Insulin Dependen DM With Neurologi
24 - - Rp 5,342,400 Rp 3,816,000
Complication (E10.4)

Insulin Dependen DM With Neurologi

25 Thorax Foto (87.4) - Rp 6,635,000 Rp 4,739,500
Complication (E10.4) + Pneumonia (J12.9)

CRF (N18.9) + HT Renal Failure (I13.1) + USG Abdomen (88.76)

26 - Rp 5,663,500 Rp 4,045,400
Hiperkalemi (E87.5) + Asidosis (E87.2) Thorax Foto (87.4)
27 Hipokalemi (E87.6) + Gastritis (K29.1) Thorax Foto (87.4) - - Rp 4,327,900
28 GEA (A09.0) + Ileus Paralitik (K56.0) BOF (87.6) - - Rp 3,561,900
29 TF (A01.0) + Ileus Obstruksi (K56.7) BOF (87.6) - - Rp 3,925,500
30 HT Heart Failure (I11.0) + CRF (N18.9) + Hemodialisis (39.95) - - Rp 7,688,300
Anemia (D50)
31 DM With Coma (E10.0) + Hiponatremi - - Rp 9,046,100 -
(E87.1) + Sepsis (A41.9)
32 Cholesistitis (K81.0) + Cholelithiasis USG Abdomen (88.76) - Rp 4,860,200 Rp 3,471,600
(K80.8) +Anemia (D50)
33 Cholesistitis (K81.0) + Dyspepsia (K30) USG Abdomen (88.76) - Rp 4,860,200 Rp 3,471,600
34 Hepatitis B (B16.9) USG Abdomen (88.76) - Rp 4,117,500 Rp 2,941,000
35 Lympoma Hodgkin (C81.7) FNAB (26.11) - Rp 5,425,900 Rp 3,875,600
36 Hepatitis Virus Akut (B17.9) USG Abdomen (88.76) - Rp 4,117,500 Rp 2,941,000
USG Abdomen (88.76)
CKD (N18.5) + Pneumonia (J12.9) + HT
37 Heart Failure (I11.0) + Batu Ginjal (N20.0) - Rp 9,908,400 Rp 7,077,400
Hemodialisis (39.95)
+ Anemia (D50)
38 Cholangitis (K83.0) + Koma Hepatikum Peritoneal Lavage (54.25) - Rp 7,642,200 Rp 5,458,700
(R40.2) + HM (K25.0)
39 GEA (A09.0) + DHF (A91) + TF (A01.0) + Thorax Foto (87.4) - Rp 4,865,000 Rp 4,054,000
Skizofrenia (F20.1)

ENDOKRIN
Thorax Foto (87.4)
USG Abdomen (88.76) Human Albumin
40 DM Insulin Dependent Ketoacidosis (E10.1) Rp 5,929,300 Rp 4,235,200
+ CRF (N18.9) + HT Renal Disease (I13) + ECG (89.52) (DD05)
Hipoalbumin (R77.0) + Anemia (D50) Transfusi PRC (99.04)
DM Insulin Dependent Ketoacidosis (E10.1) Thorax Foto (87.4)
Human Albumin
41 + HT Esensial (I10) + Pneumonia (J12.9) + ECG (89.52) Rp 5,929,300 Rp 4,235,200
(DD05)
Hipoalbumin (R77.0)
Thorax Foto (87.4)
42 DM Insulin Dependent Ketoacidosis (E10.1) Transfusi PRC (99.04) - Rp 4,283,200 Rp 3,059,500
+ Hipertensi Esensial (I10) + Anemia (D50)
42 DM Insulin Dependent Ketoacidosis (E10.1) - Rp 4,283,200 Rp 3,059,500
+ Hipertensi Esensial (I10) + Anemia (D50)
43 Coma Hipoglikemi (E10.0) + Hipertensi Thorax Foto (87.4) - Rp 4,283,200 Rp 3,059,500
Esensial (I10)
USG Abdomen (88.76)
DM Insulin Dependent Ketoacidosis (E10.1)
Thorax Foto (87.4) Human Albumin
44 + ALO (I27.2) + CRF (N18.9) + HT Renal Rp 5,929,300 Rp 4,235,200
Failure (I13.1) + Hipoalbumin (R77.0) + Hemodialisis (39.95) (DD05)
Anemia (D50) Transfusi PRC (99.04)
Hemodialisis (39.95)
DM Insulin Dependent Ketoacidosis (E10.1) Thorax Foto (87.4)
45 + CRF (N18.9) + ALO (I27.2) + HT Renal - Rp 5,929,300 Rp 4,273,300
Failure (I13.1) + Anemia (D50) USG Abdomen (88.76)
Transfusi PRC (99.04)
DM Dependent Ketoacidosis (E10.1) + CRF
46 (N18.9) + HT Renal Failure (I13.1) + CVA Thorax Foto (87.4) - Rp 6,519,600 Rp 6,519,600
(G46.8)
Thorax Foto (87.4)
CRF (N18.9) + Anemia (D50) + HT Renal
47 Failure (I13.1) + DM Dependent USG Abdomen (88.76) - Rp 4,240,200 Rp 3,028,400
Ketoacidosis (E10.1) Hemodialisis (39.95)

48 HT Esensial (I10) + GEA (A09.9) + DM Thorax Foto (87.4) - Rp 4,947,000 Rp 3,533,500

Dependent Insulin (E10)
Endoscopy (44.43)
Gastric Ulcer With Hemorrhage (K25.0) +
49 Hipertensi Esensial (I10) + TF (A01.0) + - - Rp 4,933,900
Transfusi PRC (99.04)
DM Dependent Insulin (E10)
USG Abdomen (88.76)
CRF (N18.9) + DM (E10) + HT Renal
50 Transfusi PRC (99.04) - Rp 9,997,600 Rp 7,141,100
Failure (I13) + DHF (A91)
Thorax Foto (87.4)
Gastric Ulcer With Hemorrhage (K25.0) +
51 Dyspepsia (K30) + HT Esensial (I10) + DM USG Abdomen (88.76) - Rp 3,090,300 Rp 2,207,600
(E10)
52 HT Esensial (I10) + DM Dependent Insulin - - Rp 4,947,000 Rp 3,533,500
(E10) + Dyspepsia (K30)
X-Ray Ankle & Foot
53 MH (A30.5) + Gangren Pedis (A48.0) + DM - Rp 6,353,500 Rp 4,537,800
(E10) (88.28)
X-Ray Ankle & Foot
(88.28)
Gangren Pedis (A48.0) + DM (E10) + CRF Thorax Foto (87.4) Human Albumin
54 (N18.9) + HT Renal Failure (I13) + Anemia Rp 21,120,500 Rp 15,087,600
ECG (89.52) (DD05)
(D50) + Hipoalbumin (R77.0)
Transfusi PRC (99.04)
Amputasi (84.12)
X-Ray Ankle & Foot
Ostemielitis (M86.07) + DM (E10) + CRF (88.28)
55 (N18.9) + HT Renal Failure (I13) + Anemia ECG (89.52) - Rp 21,120,500 Rp 15,087,600
(D50) Transfusi PRC (99.04)
Amputasi (84.12)
X-Ray Ankle & Foot
56 Gangren Pedis (A48.0) + DM (E10) + CRF - - Rp 3,079,100
(N18.9) + HT Esensial (I10) (88.28)
X-Ray Ankle & Foot
Gangren Pedis (A48.0) + DM (E10) + HT (88.28)
57 - Rp 4,310,700 Rp 3,079,100
Esensial (I10) + Anemia (D50)
Transfusi PRC (99.04)

X-Ray Ankle & Foot

58 Gangren Pedis (A48.0) + Anemia (D50) (88.28) - - Rp 3,079,100
Transfusi PRC (99.04)

Human Albumin
59 Hipoalbumin (R77.0) + DM (E10) + Selulitis Transfusi PRC (99.04) Rp 4,525,000 Rp 3,232,500
(DD05)
(L03.1) + Anemia (D50) + HT Esensial (I10)
Thorax Foto (87.4)
60 HT Esensial (I10) + DM (E10) + Anemia - Rp 4,947,000 Rp 3,533,500
(D50)
60 HT Esensial (I10) + DM (E10) + Anemia - Rp 4,947,000 Rp 3,533,500
(D50) Transfusi PRC (99.04)

61 CRF (N18.9) + HT Renal Failure (I13.1) + Transfusi PRC (99.04) - - Rp 3,028,400

Anemia (D50) + DM (E10)
62 USG Abdomen (88.76) - Rp 3,258,600 Rp 2,327,500
ISK (N39.0) + DM (E10) + Dyspepsia (K30)
TROPIC INFECTION
Transfusi PRC (99.04)
63 Anemia Aplastik (D61.3) + Anemia (D50) - Rp 2,768,900 Rp 1,977,800
Transfusi TC (99.05)
USG Abdomen (88.76)
64 CML (C92.1) + Hepatosplenomegali (R16.2) - Rp 6,270,900 Rp 4,478,800
+ Anemia Berat (D50.8) Transfusi PRC (99.04)
USG Abdomen (88.76)
65 Cirrosis Hepatis (K74.6) + Efusi Pleura (J90) Human Albumin Rp 7,567,400 Rp 5,405,300
+ Hipoalbumin (R77.0) Thorax Foto (87.4) (DD05)
66 Cirrosis Hepatis (K74.6) + Hipoalbumin USG Abdomen (88.76) Human Albumin Rp 2,913,800 Rp 2,081,500
(R77.0) (DD05)
67 Hepatoma (C22.2) + Dyspepsia (K30) USG Abdomen (88.76) - Rp 5,698,400 Rp 4,070,300
USG Abdomen (88.76)
68 Hepatoma (C22.2) + Anemia (D50) - Rp 5,698,400 Rp 4,070,300
Transfusi PRC (99.04)

69 Hepatitis Virus Akut (B17.9) + TF (A01.0) + Transfusi PRC (99.04) - Rp 7,567,400 Rp 5,405,300
Anemia Berat (D50.8)
70 Hepatitis Virus Akut (B17.9) + TF (A01.0) USG Abdomen (88.76) - Rp 7,567,400 Rp 5,405,300
71 DHF (A91) + Hepatosplenomegali (R16.2) + Transfusi TC (99.05) - Rp 3,619,300 Rp 3,015,700
Dyspepsia (K30)
72 Transfusi TC (99.05) - Rp 4,524,200 Rp 3,770,100
DHF (A91) + TF (A01.0) + Dyspepsia (K30)
73 DHF (A91) + Hepatitis Virus (B17.9) + Transfusi TC (99.05) - Rp 3,048,300 Rp 2,540,200
Dyspepsia (K30)
74 GEA (A09.9) + TF (A01.0) - - Rp 4,865,000 Rp 4,054,000
75 Dyspepsia (K30) + Gastritis (K29.1) USG Abdomen (88.76) - Rp 6,477,900 Rp 4,627,500
76 GEA (A09.9) + Sepsis (A41.9) + TF (A01.0) Transfusi PRC (99.04) - Rp 4,865,000 Rp 4,054,000
+ Anemia (D50)
77 GEA (A09.9) + Hepatitis Virus (B17.9) USG Abdomen (88.76) - Rp 3,154,700 Rp 2,605,600
78 Hepatitis Virus (B17.9) + GEA (A09.9) USG Abdomen (88.76) - Rp 4,154,500 Rp 2,941,000
79 Difteri Laring (A36.2) + DM (E10) + Transfusi PRC (99.04) - Rp 2,982,300 Rp 2,130,000
Anemia (D50)
80 Difteri Laring (A36.2) + Sepsis (A41.9) - - Rp 5,316,900 Rp 3,797,400
81 Thorax Foto (87.4) - Rp 4,310,700 Rp 3,079,100
TF (A01.0) + DM (E10) + HT Esensial (I10)
82 TBC Paru (A15.3) + Hepatitis (B17.9) Thorax Foto (87.4) - Rp 6,480,700 Rp 4,628,600
83 DHF (A91) Transfusi TC (99.05) - Rp 3,048,300 Rp 2,540,200
84 TF (A09.9) + DHF (A91) + Anemia (D50) Transfusi PRC (99.04) - Rp 6,353,500 Rp 4,537,800
GASTROENTEROLOGI
Endoscopy (44.43)
Gastric Ulcer (K25.0) + Anemia (D50) +
85 Thorax Foto (87.4) - Rp 5,546,300 Rp 3,183,400
CRF(N18.9) + HT Renal Failure (I13)
Transfusi PRC (99.04)
USG Abdomen (88.76)
86 Gastric Ulcer (K25.0) + Anemia (D50) - Rp 3,090,300 Rp 2,207,600
Transfusi PRC (99.04)
Endoscopy (44.43)
87 Gastric Ulcer (K25.0) + Anemia (D50) - Rp 3,090,300 Rp 2,207,600
Transfusi PRC (99.04)
Endoscopy (44.43)
88 Varises Oesofagus (I85.0) + CRF (N18.9) + - Rp 5,546,300 Rp 3,962,000
HT Renal Failure (I13) + Anemia (D50) Transfusi PRC (99.04)
USG Abdomen (88.76)
89 Gastric Ulcer (K25.0) + Anemia (D50) - Rp 3,090,300 Rp 2,207,600
Transfusi PRC (99.04)
Transfusi PRC (99.04)
90 Gastric Ulcer (K25.0) + CRF (N18.9) + HT - Rp 9,997,600 Rp 7,141,100
Renal Failure (I13) + Anemia (D50) Hemodialisis (39.95)
91 Gastric Ulcer (K25.0) + Anemia (D50) Transfusi PRC (99.04) - Rp 3,063,000 Rp 2,207,600

NEFROLOGI
NEFROLOGI
USG Abdomen (88.76)
CRF (N18.9) + Anemia (D50) + HT Renal Thorax Foto (87.4) Human Albumin
92 Failure (I13.1) + ALO (I27.2) + Rp 5,714,500 Rp 4,081,800
Transfusi PRC (99.04) (DD05)
Hipoalbumin (R77.0)
Hemodialisis (39.95)
USG Abdomen (88.76)
CRF (N18.9) + Anemia (D50) + HT Renal
93 Transfusi PRC (99.04) - Rp 5,714,500 Rp 4,081,800
Failure (I13.1) + ISK (N39.0)
Hemodialisis (39.95)

94 CRF (N18.9) + HT Renal Failure (I13.1) + USG Abdomen (88.76) - Rp 9,997,600 Rp 7,141,100
TF (A01.0)
CRF (N18.9) + HT Renal Failure (I13.1) + USG Abdomen (88.76)
95 - Rp 4,240,200 Rp 3,028,400
GEA (A09.9) + Anemia (D50) Transfusi PRC (99.04)
USG Abdomen (88.76)
96 CRF (N18.9) + HT Renal Failure (I13.1) + Human Albumin Rp 4,240,200 Rp 3,028,400
Hipoalbumin (R77.0) + Anemia (D50) Transfusi PRC (99.04) (DD05)
USG Abdomen (88.76)
Human Albumin
97 CRF (N18.9) + Sindroma Nefrotik (N04) + Thorax Foto (87.4) Rp 9,997,600 Rp 7,141,100
(DD05)
Hipoalbumin (R77.0) + Efusi Pleura (J90)
USG Abdomen (88.76)
98 CRF (N18.9) + Sindroma Nefrotik (N04) + - Rp 4,240,200 Rp 3,028,400
Anemia (D50) Transfusi PRC (99.04)

99 Hipoalbumin (R77.0) + Sindroma Nefrotik USG Abdomen (88.76) Human Albumin Rp 4,525,000 Rp 3,232,500
(N04) (DD05)
100 CRF (N18.9) + Sindroma Nefrotik (N04) + USG Abdomen (88.76) Human Albumin Rp 4,240,200 Rp 3,028,400
Hipoalbumin (R77.0) (DD05)
101 Glomerulonefritis (N00.2) + Dyspepsia USG Abdomen (88.76) - Rp 6,887,100 Rp 4,919,800
(K30) + TF (A01.0)
102 Glomerulonefritis (N00.2) +DHF (A91) + BOF (87.6) - Rp 6,887,100 Rp 4,919,800
Dyspepsia (K30)
103 Glomerulonefritis (N00.2) + Hepatitis Virus USG Abdomen (88.76) - Rp 3,557,300 Rp 2,540,900
(B17.9)
104 TBC Paru (A15.3) + DM (E10) Thorax Foto (87.4) - Rp 6,480,700 Rp 4,628,600
USG Abdomen (88.76)
CRF (N18.9) + HT Renal Failure (I13.1) + Thorax Foto (87.4)
105 TBC Paru (A15.3) + Hepatitis (B17.9) + - Rp 5,714,500 Rp 4,081,800
Anemia (D50) Transfusi PRC (99.04)

STATUS PASIEN
TBC Paru (A15.3) + DM (E10) + HT Thorax Foto (87.4)
106 - Rp 6,480,700 Rp 4,628,600
Esensial (I10) Pmx. Sputum (90.4)
Hemodialisis (39.95)
107 HT Renal Failure (I13.1) + Anemia (D50) + Human Albumin Rp 4,240,200 Rp 3,028,400
Hipoalbumin (R77.0) Transfusi PRC (99.04) (DD05)
Thorax Foto (87.4)
108 DHF (A91) + TF (A01.0) - Rp 4,524,200 Rp 3,770,100
Transfusi TC (99.05)
USG Abdomen (88.76)
109 Gastric Ulcer Kronis (K25.4) Endoscopy (44.43) - Rp 3,090,300 Rp 2,207,600
Transfusi PRC (99.04)
X-Ray Ankle & Foot
Gangren Pedis (A48.0) + DM (E10) + HT (88.28) Human Albumin
110 Rp 12,852,600 Rp 9,181,300
Esensial (I10) + Hipoalbumin (R77.0) Amputasi (84.12) (DD05)
Transfusi PRC (99.04)

111 Gastritis (K29.1) + Dyspepsia (K30) + Infus Elektrolit (99.18) - Rp 4,312,500 Rp 3,594,000
Hipokalemi (E87.6)
Injeksi Insulin (99.17)
112 Gangren Pedis (A48.0) + DM (E10) X-Ray Ankle & Foot - Rp 4,310,700 Rp 3,079,100
(88.28)
113 GEA (A09.9) - - Rp 3,154,700 Rp 2,628,800
114 Gastritis Akut (K29.1) USG Abdomen (88.76) - Rp 3,090,300 Rp 2,207,600
 Varicella (B01.8) + GEA (A09.9) +
115 Thorax Foto (87.4) - Rp 7,587,300 Rp 5,420,100
Pneumonia (J12.9)

116 Gastric Ulcer Kronis (K25.4) + HT Esensial Transfusi PRC (99.04) - Rp 3,090,300 Rp 2,207,600
(110)
117 Dyspepsia (K30) + DM (E10) - - Rp 4,318,700 Rp 3,085,100
USG Abdomen (88.76)
HT Renal Failure (I13.1) + Anemia (D50) + Human Albumin
118 Thorax Foto (87.4) - Rp 7,141,100
Hipoalbumin (R77.0) +ALO (J81) (DD05)
Hemodialisis (39.95)

119 Gastric Ulcer (K25.0) + DHF (A91) + TF USG Abdomen (88.76) - Rp 6,907,400 Rp 4,933,900
(A01.0) + Hepatitis B (B16.1)
120 Coma (R40.2) + Hipoglikemi (E16.2) + HT - - Rp 3,080,500 Rp 2,220,200
Esensial (I10)
121 HT Esensial (I10) + Coma (R40.2) + - - Rp 6,705,600 Rp 4,789,700
Hipoglikemi (E16.2)
122 Gastric Ulcer (K25.0) Transfusi PRC (99.04) - Rp 3,063,000 Rp 2,207,600
123 Cirosis Hepatis (K74.6) + Hepatitis B USG Abdomen (88.76) Human Albumin Rp 6,044,300 Rp 4,317,300
(B16.9) + Hipoalbumin (R77.0) (DD05)
USG Abdomen (88.76)
CRF (N18.9) + Cyst Of Kidney (N28.1) +
124 HT Renal Failure (I13.1) + Oedema - Rp 9,997,600 Rp 7,141,100
Thorax Foto (87.4)
Anasarka (R60.1) + Efusi Pleura (J90)
125 Hepatoma (C22.2) + Dyspepsia (K30) + USG Abdomen (88.76) - Rp 8,686,200 Rp 6,204,400
Hepatitis B (B16.9)
126 HIV (B20.9) + Anemia (D50) Transfusi PRC (99.04) - Rp 4,349,900 Rp 3,107,100
127 Dyspepsia (K30) + ISK (N39.0) BOF (87.6) - Rp 6,477,900 Rp 4,627,500
128 Intoksikasi Organofosfat (A05.8) - - Rp 4,318,700 Rp 3,085,100
129 DHF (A91) - - Rp 3,048,300 Rp 2,540,200
130 TF (A01.0) + Gastritis (K29.1) - - Rp 5,545,200 Rp 3,960,500