PMK No. 64 2016 TTG Standar Tarif Pelayanan Kesehatan

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
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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.
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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.
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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.
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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

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-1-
LAMPIRAN
PERATURAN MENTERI KESEHATAN
NOMOR 64 TAHUN 2016
TENTANG
PERUBAHAN ATAS PERATURAN MENTERI KESEHATAN
NOMOR 52 TAHUN 2016
TENTANG
STANDAR TARIF PELAYANAN KESEHATAN DALAM
PENYELENGGARAAN PROGRAM JAMINAN
STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN

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

REGIONAL 1
RUMAH SAKIT KELAS A PEMERINTAH
RAWAT INAP
KOD TARI TARI TARI

NO DESKRIPSI KODE INA-CBG
E INA- F F F
1 A-4-10-I SEPTIKEMIA (RINGAN) 3,516,500 4,219,800 4,923,100
2 A-4-10-II SEPTIKEMIA (SEDANG) 6,007,600 7,209,200 8,410,700
3 A-4-10-III SEPTIKEMIA (BERAT) 8,100,200 9,720,200 11,340,300
4 A-4-11-I INFEKSI SESUDAH OPERASI & TRAUMA (RINGAN) 4,263,700 5,116,500 5,969,200
5 A-4-11-II INFEKSI SESUDAH OPERASI & TRAUMA (SEDANG) 6,068,500 7,282,200 8,495,900
6 A-4-11-III INFEKSI SESUDAH OPERASI & TRAUMA (BERAT) 8,399,400 10,079,200 11,759,100
7 A-4-12-I DEMAM YANG TIDAK DITENTUKAN (RINGAN) 2,780,700 3,336,800 3,893,000
8 A-4-12-II DEMAM YANG TIDAK DITENTUKAN (SEDANG) 4,800,000 5,760,000 6,719,900
9 A-4-12-III DEMAM YANG TIDAK DITENTUKAN (BERAT) 6,915,900 8,299,000 9,682,200
10 A-4-13-I INFEKSI VIRAL & NON-BAKTERIAL LAIN (RINGAN) 2,069,600 2,483,500 2,897,500
11 A-4-13-II INFEKSI VIRAL & NON-BAKTERIAL LAIN (SEDANG) 3,657,500 4,389,000 5,120,600
12 A-4-13-III INFEKSI VIRAL & NON-BAKTERIAL LAIN (BERAT) 4,389,000 5,266,900 6,144,700
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN
13 A-4-14-I 2,318,600 2,782,300 3,246,000
(RINGAN)
14 A-4-14-II 3,901,100 4,681,300 5,461,500
(SEDANG)
15 A-4-14-III 4,681,300 5,617,600 6,553,800
(BERAT)
16 A-4-15-I INFEKSI HIV (RINGAN) 18,100,900 21,721,100 25,341,300
17 A-4-15-II INFEKSI HIV (SEDANG) 22,541,700 27,050,000 31,558,300
18 A-4-15-III INFEKSI HIV (BERAT) 25,465,800 30,558,900 35,652,100
19 B-1-01-I PENCANGKOKAN HATI (RINGAN) 49,908,000 59,889,600 69,871,200
20 B-1-01-II PENCANGKOKAN HATI (SEDANG) 55,061,700 66,074,000 77,086,400
21 B-1-01-III PENCANGKOKAN HATI (BERAT) 121,370,800 145,644,900 169,919,100
22 B-1-10-I PROSEDUR HATI DAN PANKREAS (RINGAN) 8,067,400 9,680,800 11,294,300
23 B-1-10-II PROSEDUR HATI DAN PANKREAS (SEDANG) 17,906,000 21,487,200 25,068,400
24 B-1-10-III PROSEDUR HATI DAN PANKREAS (BERAT) 35,348,800 42,418,600 49,488,400
25 B-1-11-I PROSEDUR SALURAN EMPEDU KOMPLEK (RINGAN) 32,192,200 38,630,700 45,069,100
26 B-1-11-II PROSEDUR SALURAN EMPEDU KOMPLEK (SEDANG) 38,358,700 46,030,500 53,702,200
27 B-1-11-III PROSEDUR SALURAN EMPEDU KOMPLEK (BERAT) 59,275,000 71,130,000 82,985,000
28 B-1-12-I CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN) 9,473,000 11,367,600 13,262,200
29 B-1-12-II CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG) 10,535,700 12,642,800 14,750,000
30 B-1-12-III CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT) 16,481,900 19,778,300 23,074,700
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-

31 B-1-13-I 7,545,400 9,054,500 10,563,500
LAIN (RINGAN)
32 B-1-13-II 12,415,000 14,898,000 17,381,000
LAIN (SEDANG)
33 B-1-13-III 16,063,900 19,276,700 22,489,500
LAIN (BERAT)
CHOLESISTEKTOMI DENGAN LAPAROSKOPIK
34 B-1-14-I 19,768,800 23,722,600 27,676,300
(RINGAN)
35 B-1-14-II 20,762,800 24,915,400 29,067,900
(SEDANG)
36 B-1-14-III CHOLESISTEKTOMI DENGAN LAPAROSKOPIK (BERAT) 36,753,800 44,104,500 51,455,300
37 B-4-10-I SIROSIS HATI DAN HEPATITIS ALKOHOLIK (RINGAN) 3,207,700 3,849,300 4,490,800
38 B-4-10-II SIROSIS HATI DAN HEPATITIS ALKOHOLIK (SEDANG) 5,120,500 6,144,600 7,168,700
39 B-4-10-III SIROSIS HATI DAN HEPATITIS ALKOHOLIK (BERAT) 7,063,900 8,476,700 9,889,400
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REGIONAL 1
RAWAT INAP
KODE TARIF TARIF TARIF

INA-CBG KELAS 3 KELAS 2 KELAS 1
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS
40 B-4-11-I 6,763,200 8,115,800 9,468,400
(RINGAN)
41 B-4-11-II 9,468,500 11,362,200 13,255,900
(SEDANG)
42 B-4-11-III 11,470,900 13,765,100 16,059,300
(BERAT)
43 B-4-12-I GANGGUAN PANKREAS SELAIN TUMOR (RINGAN) 6,114,600 7,337,600 8,560,500
44 B-4-12-II GANGGUAN PANKREAS SELAIN TUMOR (SEDANG) 8,707,000 10,448,400 12,189,800
45 B-4-12-III GANGGUAN PANKREAS SELAIN TUMOR (BERAT) 12,954,100 15,544,900 18,135,800
46 B-4-13-I GANGGUAN HATI LAIN-LAIN (RINGAN) 5,832,900 6,999,400 8,166,000
47 B-4-13-II GANGGUAN HATI LAIN-LAIN (SEDANG) 6,795,000 8,154,000 9,513,100
48 B-4-13-III GANGGUAN HATI LAIN-LAIN (BERAT) 9,360,800 11,232,900 13,105,100
49 B-4-14-I GANGGUAN SALURAN EMPEDU LAIN-LAIN (RINGAN) 5,826,600 6,992,000 8,157,300
50 B-4-14-II GANGGUAN SALURAN EMPEDU LAIN-LAIN (SEDANG) 6,797,500 8,157,000 9,516,500
51 B-4-14-III GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT) 9,105,400 10,926,500 12,747,600

52 C-4-10-I LEUKEMIA AKUT (RINGAN) 11,801,200 14,161,500 16,521,700
53 C-4-10-II LEUKEMIA AKUT (SEDANG) 18,979,600 22,775,600 26,571,500
54 C-4-10-III LEUKEMIA AKUT (BERAT) 35,561,700 42,674,000 49,786,300
55 C-4-11-I LIMFOMA & LEUKEMIA NON AKUT (RINGAN) 6,142,900 7,371,500 8,600,100
56 C-4-11-II LIMFOMA & LEUKEMIA NON AKUT (SEDANG) 8,220,100 9,864,100 11,508,200
57 C-4-11-III LIMFOMA & LEUKEMIA NON AKUT (BERAT) 12,638,500 15,166,200 17,694,000
58 C-4-12-I RADIOTERAPI (RINGAN) 4,090,100 4,908,200 5,726,200
59 C-4-12-II RADIOTERAPI (SEDANG) 8,056,000 9,667,200 11,278,400
60 C-4-12-III RADIOTERAPI (BERAT) 20,690,100 24,828,100 28,966,100
61 C-4-13-I KEMOTERAPI (RINGAN) 3,075,000 3,690,000 4,304,900
62 C-4-13-II KEMOTERAPI (SEDANG) 5,787,100 6,944,500 8,101,900
63 C-4-13-III KEMOTERAPI (BERAT) 7,833,800 9,400,500 10,967,300
64 C-4-14-I TUMOR MYELOPROLIFERATIF LAIN-LAIN (RINGAN) 5,109,200 6,131,000 7,152,900
65 C-4-14-II TUMOR MYELOPROLIFERATIF LAIN-LAIN (SEDANG) 7,167,100 8,600,600 10,034,000
66 C-4-14-III TUMOR MYELOPROLIFERATIF LAIN-LAIN (BERAT) 10,678,900 12,814,700 14,950,500
67 D-1-10-I PENCANGKOKAN SUMSUM TULANG (RINGAN) 30,868,200 37,041,900 43,215,500
68 D-1-10-II PENCANGKOKAN SUMSUM TULANG (SEDANG) 47,014,500 56,417,300 65,820,200
69 D-1-10-III PENCANGKOKAN SUMSUM TULANG (BERAT) 67,376,800 80,852,200 94,327,500
70 D-1-11-I PROSEDUR LIMPA (RINGAN) 8,264,700 9,917,600 11,570,500
71 D-1-11-II PROSEDUR LIMPA (SEDANG) 21,103,600 25,324,300 29,545,000
72 D-1-11-III PROSEDUR LIMPA (BERAT) 27,424,900 32,909,900 38,394,900
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK
73 D-1-20-I 7,164,500 8,597,400 10,030,300
DARAH LAIN-LAIN (RINGAN)
74 D-1-20-II 19,744,300 23,693,200 27,642,100
DARAH LAIN-LAIN (SEDANG)
75 D-1-20-III 31,320,300 37,584,400 43,848,400
DARAH LAIN-LAIN (BERAT)
76 D-4-10-I AGRANULOSITOSIS (RINGAN) 2,831,200 3,397,400 3,963,700
77 D-4-10-II AGRANULOSITOSIS (SEDANG) 4,646,300 5,575,600 6,504,800
78 D-4-10-III AGRANULOSITOSIS (BERAT) 7,309,700 8,771,700 10,233,600
79 D-4-11-I GANGGUAN PEMBEKUAN DARAH (RINGAN) 5,608,800 6,730,600 7,852,400
80 D-4-11-II GANGGUAN PEMBEKUAN DARAH (SEDANG) 10,078,900 12,094,600 14,110,400
81 D-4-11-III GANGGUAN PEMBEKUAN DARAH (BERAT) 13,845,900 16,615,000 19,384,200
82 D-4-12-I KRISIS ANEMIA SEL SICKLE (RINGAN) 4,835,600 5,802,700 6,769,800
83 D-4-12-II KRISIS ANEMIA SEL SICKLE (SEDANG) 6,707,100 8,048,500 9,389,900
84 D-4-12-III KRISIS ANEMIA SEL SICKLE (BERAT) 10,299,000 12,358,800 14,418,600
GANGGUAN SEL DARAH MERAH SELAIN KRISIS
85 D-4-13-I 4,144,000 4,972,800 5,801,600
ANEMIA SEL SICKLE (RINGAN)
86 D-4-13-II 5,865,100 7,038,200 8,211,200
ANEMIA SEL SICKLE (SEDANG)
87 D-4-13-III 7,501,700 9,002,000 10,502,400
ANEMIA SEL SICKLE (BERAT)
GANGGUAN PADA DARAH & ORGAN PEMBENTUK
88 D-4-14-I 4,444,600 5,333,500 6,222,400
89 D-4-14-II 7,276,900 8,732,300 10,187,700
90 D-4-14-III 8,900,400 10,680,500 12,460,600
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REGIONAL 1
RAWAT INAP

PROSEDUR KELENJAR PITUITARI DAN PINEAL
91 E-1-01-I 8,859,800 10,631,800 12,403,700
(RINGAN)
92 E-1-01-II 12,094,900 14,513,900 16,932,900
(SEDANG)
93 E-1-01-III PROSEDUR KELENJAR PITUITARI DAN PINEAL (BERAT) 29,162,200 34,994,600 40,827,000
94 E-1-10-I PROSEDUR KELENJAR ADRENAL (RINGAN) 9,211,300 11,053,600 12,895,800

95 E-1-10-II PROSEDUR KELENJAR ADRENAL (SEDANG) 12,786,400 15,343,700 17,901,000
96 E-1-10-III PROSEDUR KELENJAR ADRENAL (BERAT) 24,157,700 28,989,300 33,820,800
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN
97 E-1-20-I 10,427,900 12,513,500 14,599,100
TIROGLOSAL (RINGAN)
98 E-1-20-II 14,035,700 16,842,900 19,650,000
TIROGLOSAL (SEDANG)
99 E-1-20-III 19,344,100 23,212,900 27,081,700
TIROGLOSAL (BERAT)
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/
100 E-4-10-I 3,690,400 4,428,500 5,166,600
METABOLIK (RINGAN)
101 E-4-10-II 7,147,700 8,577,200 10,006,800
METABOLIK (SEDANG)
102 E-4-10-III 11,976,800 14,372,200 16,767,500
METABOLIK (BERAT)
103 E-4-11-I HIPOVOLEMIA & GANGGUAN ELEKROLIT (RINGAN) 4,099,400 4,919,300 5,739,200
104 E-4-11-II HIPOVOLEMIA & GANGGUAN ELEKROLIT (SEDANG) 6,249,900 7,499,900 8,749,900
105 E-4-11-III HIPOVOLEMIA & GANGGUAN ELEKROLIT (BERAT) 8,469,100 10,162,900 11,856,700
106 E-4-12-I GANGGUAN METABOLIK BAWAAN (RINGAN) 4,710,200 5,652,200 6,594,200
107 E-4-12-II GANGGUAN METABOLIK BAWAAN (SEDANG) 8,156,900 9,788,300 11,419,600
108 E-4-12-III GANGGUAN METABOLIK BAWAAN (BERAT) 9,668,900 11,602,700 13,536,400
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN
109 E-4-13-I 5,129,200 6,155,000 7,180,900
(RINGAN)
110 E-4-13-II 7,513,400 9,016,100 10,518,700
(SEDANG)
111 E-4-13-III GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN (BERAT) 9,821,500 11,785,800 13,750,100
112 F-4-10-I SCHIZOFRENIA (RINGAN) 5,460,700 6,552,800 7,645,000

113 F-4-10-II SCHIZOFRENIA (SEDANG) 6,276,000 7,531,100 8,786,300
114 F-4-10-III SCHIZOFRENIA (BERAT) 7,531,100 9,037,400 10,543,600
115 F-4-11-I DEPRESI MAYOR (RINGAN) 5,281,400 6,337,600 7,393,900
116 F-4-11-II DEPRESI MAYOR (SEDANG) 6,153,300 7,384,000 8,614,700
117 F-4-11-III DEPRESI MAYOR (BERAT) 7,890,800 9,469,000 11,047,200
GANGGUAN PERSONALITI & KONTROL IMPULSE
118 F-4-12-I 2,895,000 3,474,000 4,053,100
(RINGAN)
119 F-4-12-II 4,115,800 4,939,000 5,762,200
(SEDANG)
120 F-4-12-III 8,941,400 10,729,700 12,518,000
(BERAT)
121 F-4-13-I GANGGUAN BIPOLAR (RINGAN) 4,254,300 5,105,100 5,956,000
122 F-4-13-II GANGGUAN BIPOLAR (SEDANG) 5,613,600 6,736,300 7,859,000
123 F-4-13-III GANGGUAN BIPOLAR (BERAT) 7,267,500 8,721,000 10,174,500
124 F-4-14-I DEPRESI (RINGAN) 2,427,300 2,912,700 3,398,200
125 F-4-14-II DEPRESI (SEDANG) 3,113,300 3,736,000 4,358,600
126 F-4-14-III DEPRESI (BERAT) 4,189,200 5,027,000 5,864,900
127 F-4-15-I FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (RINGAN) 3,865,600 4,638,700 5,411,800
128 F-4-15-II FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (SEDANG) 5,760,200 6,912,200 8,064,300
129 F-4-15-III FOBIA,ANXIETAS DAN NEUROSIS LAIN-LAIN (BERAT) 7,605,300 9,126,300 10,647,400
GANGGUAN ORGANIK LAIN-LAIN TERMASUK
130 F-4-16-I 7,605,700 9,126,800 10,648,000
KETERBELAKANGAN MENTAL (RINGAN)
131 F-4-16-II 8,842,900 10,611,500 12,380,000
KETERBELAKANGAN MENTAL (SEDANG)
132 F-4-16-III 11,803,700 14,164,500 16,525,200
KETERBELAKANGAN MENTAL (BERAT)
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN) 1,796,200 2,155,400 2,514,600
134 F-4-17-II GANGGUAN MENTAL PADA KANAK-KANAK (SEDANG) 5,264,400 6,317,200 7,370,100
-4-

REGIONAL 1
RAWAT INAP

135 F-4-17-III GANGGUAN MENTAL PADA KANAK-KANAK (BERAT) 5,616,600 6,739,900 7,863,200
136 F-4-18-I GANGGUAN NUTRISI KOMPULSIF (RINGAN) 6,608,800 7,930,600 9,252,300
137 F-4-18-II GANGGUAN NUTRISI KOMPULSIF (SEDANG) 7,271,600 8,725,900 10,180,200
138 F-4-18-III GANGGUAN NUTRISI KOMPULSIF (BERAT) 11,209,600 13,451,600 15,693,500
139 F-4-19-I GANGGUAN MENTAL LAIN-LAIN (RINGAN) 5,050,700 6,060,800 7,070,900
140 F-4-19-II GANGGUAN MENTAL LAIN-LAIN (SEDANG) 6,467,600 7,761,100 9,054,700
141 F-4-19-III GANGGUAN MENTAL LAIN-LAIN (BERAT) 8,052,100 9,662,500 11,273,000
PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL
142 G-1-01-I 21,425,500 25,710,500 29,995,600
(RINGAN)
143 G-1-01-II 30,729,300 36,875,100 43,021,000
(SEDANG)
144 G-1-01-III 50,275,600 60,330,800 70,385,900
(BERAT)
145 G-1-10-I KRANIOTOMI (RINGAN) 33,312,800 39,975,400 46,637,900
146 G-1-10-II KRANIOTOMI (SEDANG) 40,799,900 48,959,900 57,119,800
147 G-1-10-III KRANIOTOMI (BERAT) 50,137,500 60,165,000 70,192,500
148 G-1-11-I PROSEDUR VENTRICULAR SHUNT (RINGAN) 16,396,900 19,676,300 22,955,700
149 G-1-11-II PROSEDUR VENTRICULAR SHUNT (SEDANG) 29,977,400 35,972,800 41,968,300
150 G-1-11-III PROSEDUR VENTRICULAR SHUNT (BERAT) 48,172,300 57,806,800 67,441,300
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL
151 G-1-12-I 6,846,300 8,215,500 9,584,800
(RINGAN)
152 G-1-12-II 12,833,700 15,400,400 17,967,100
(SEDANG)
153 G-1-12-III 17,489,800 20,987,800 24,485,700
(BERAT)
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE (RINGAN) 2,065,300 2,478,400 2,891,400
155 G-1-13-II PROSEDUR CARPAL TUNNEL RELEASE (SEDANG) 5,546,400 6,655,700 7,765,000
156 G-1-13-III PROSEDUR CARPAL TUNNEL RELEASE (BERAT) 12,515,200 15,018,200 17,521,300
157 G-1-20-I PROSEDUR SARAF KRANIAL DAN PERIFER (RINGAN) 11,594,600 13,913,500 16,232,400
158 G-1-20-II PROSEDUR SARAF KRANIAL DAN PERIFER (SEDANG) 17,544,400 21,053,300 24,562,200
159 G-1-20-III PROSEDUR SARAF KRANIAL DAN PERIFER (BERAT) 29,916,400 35,899,700 41,883,000
160 G-1-30-I PROSEDUR TULANG BELAKANG (RINGAN) 28,885,100 34,662,100 40,439,200
161 G-1-30-II PROSEDUR TULANG BELAKANG (SEDANG) 38,944,200 46,733,000 54,521,900
162 G-1-30-III PROSEDUR TULANG BELAKANG (BERAT) 58,481,500 70,177,800 81,874,100
KECEDERAAN & GANGGUAN TULANG BELAKANG
163 G-4-10-I 5,876,800 7,052,100 8,227,500
(RINGAN)
164 G-4-10-II 7,183,400 8,620,100 10,056,800
(SEDANG)
165 G-4-10-III 9,856,900 11,828,300 13,799,600
(BERAT)
TUMOR SISTEM PERSARAFAN & GANGGUAN
166 G-4-11-I 6,152,100 7,382,500 8,612,900
DEGENERATIF (RINGAN)
167 G-4-11-II 8,172,300 9,806,700 11,441,200
DEGENERATIF (SEDANG)
168 G-4-11-III 12,007,800 14,409,400 16,811,000
DEGENERATIF (BERAT)
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR
169 G-4-12-I 6,825,000 8,190,000 9,555,000
(RINGAN)
170 G-4-12-II 8,620,500 10,344,600 12,068,700
(SEDANG)
171 G-4-12-III SKLEROSIS MULTIPLE & ATAXIA CEREBELAR (BERAT) 12,520,200 15,024,200 17,528,200
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK

172 G-4-13-I 4,099,900 4,919,900 5,739,800
(RINGAN)
173 G-4-13-II 7,149,400 8,579,300 10,009,100
(SEDANG)
174 G-4-13-III 8,479,300 10,175,200 11,871,100
(BERAT)
KECEDERAAN PEMBULUH DARAH OTAK DENGAN
175 G-4-14-I 6,955,000 8,346,000 9,737,000
INFARK (RINGAN)
176 G-4-14-II 9,298,300 11,157,900 13,017,600
INFARK (SEDANG)
177 G-4-14-III 11,670,400 14,004,500 16,338,600
INFARK (BERAT)
-5-

REGIONAL 1
RAWAT INAP

KECEDERAAN PEMBULUH DARAH OTAK NON
178 G-4-15-I SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 5,682,800 6,819,400 7,956,000
INFARK (RINGAN)
179 G-4-15-II SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 6,782,200 8,138,600 9,495,000
INFARK (SEDANG)
180 G-4-15-III SPESIFIK & PENYUMBATAN PRE-CEREBRAL TANPA 9,572,400 11,486,900 13,401,400
INFARK (BERAT)
181 G-4-16-I ISKEMIK TRANSIENT (RINGAN) 4,684,700 5,621,700 6,558,600
182 G-4-16-II ISKEMIK TRANSIENT (SEDANG) 6,219,600 7,463,500 8,707,400
183 G-4-16-III ISKEMIK TRANSIENT (BERAT) 8,857,200 10,628,700 12,400,100
GANGUAN PERSARAFAN KRANIAL DAN PERIFER
184 G-4-17-I 6,239,700 7,487,700 8,735,600
(RINGAN)
185 G-4-17-II 8,181,700 9,818,000 11,454,300
(SEDANG)
186 G-4-17-III 10,280,600 12,336,700 14,392,900
(BERAT)
187 G-4-18-I INFEKSI BAKTERI SISTEM PERSARAFAN (RINGAN) 6,145,200 7,374,200 8,603,200
188 G-4-18-II INFEKSI BAKTERI SISTEM PERSARAFAN (SEDANG) 8,214,200 9,857,100 11,499,900
189 G-4-18-III INFEKSI BAKTERI SISTEM PERSARAFAN (BERAT) 9,191,100 11,029,300 12,867,500
INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK
190 G-4-19-I 5,127,000 6,152,500 7,177,900
TERMASUK MENINGITIS VIRUS) (RINGAN)
191 G-4-19-II 8,665,900 10,399,100 12,132,300
TERMASUK MENINGITIS VIRUS) (SEDANG)
192 G-4-19-III 11,378,000 13,653,600 15,929,200
TERMASUK MENINGITIS VIRUS) (BERAT)
193 G-4-20-I MENINGITIS VIRUS (RINGAN) 3,586,600 4,304,000 5,021,300
194 G-4-20-II MENINGITIS VIRUS (SEDANG) 5,070,400 6,084,500 7,098,500
195 G-4-20-III MENINGITIS VIRUS (BERAT) 8,375,100 10,050,100 11,725,100
196 G-4-21-I KOMA & STUPOR NON TRAUMA (RINGAN) 3,734,900 4,481,900 5,228,900
197 G-4-21-II KOMA & STUPOR NON TRAUMA (SEDANG) 6,321,400 7,585,700 8,849,900
198 G-4-21-III KOMA & STUPOR NON TRAUMA (BERAT) 7,429,100 8,914,900 10,400,700
199 G-4-22-I SERANGAN KEJANG (RINGAN) 2,798,200 3,357,800 3,917,400
200 G-4-22-II SERANGAN KEJANG (SEDANG) 4,955,600 5,946,700 6,937,800
201 G-4-22-III SERANGAN KEJANG (BERAT) 7,817,000 9,380,400 10,943,800
202 G-4-23-I MIGREN DAN SAKIT KEPALA LAIN (RINGAN) 3,676,700 4,412,000 5,147,300
203 G-4-23-II MIGREN DAN SAKIT KEPALA LAIN ((SEDANG) 4,612,900 5,535,500 6,458,100
204 G-4-23-III MIGREN DAN SAKIT KEPALA LAIN (BERAT) 6,567,700 7,881,200 9,194,800
205 G-4-24-I TRAUMA KEPALA (RINGAN) 4,095,200 4,914,300 5,733,300
206 G-4-24-II TRAUMA KEPALA (SEDANG) 5,116,400 6,139,700 7,163,000
207 G-4-24-III TRAUMA KEPALA (BERAT) 8,523,800 10,228,500 11,933,300
208 G-4-25-I GEGAR OTAK (RINGAN) 3,499,300 4,199,200 4,899,000
209 G-4-25-II GEGAR OTAK (SEDANG) 4,425,300 5,310,300 6,195,400
210 G-4-25-III GEGAR OTAK (BERAT) 5,864,300 7,037,200 8,210,100
GANGGUAN - PENYAKIT SISTEM PERSARAFAN LAIN-
211 G-4-26-I 3,989,500 4,787,400 5,585,300
LAIN (RINGAN)
212 G-4-26-II 4,641,000 5,569,200 6,497,400
LAIN (SEDANG)
213 G-4-26-III 6,939,700 8,327,700 9,715,600
LAIN (BERAT)
214 H-1-20-I PROSEDUR EKSTRAOKULER DAN ORBITA (RINGAN) 11,801,000 14,161,200 16,521,400
215 H-1-20-II PROSEDUR EKSTRAOKULER DAN ORBITA (SEDANG) 13,041,900 15,650,300 18,258,700
216 H-1-20-III PROSEDUR EKSTRAOKULER DAN ORBITA (BERAT) 17,736,300 21,283,500 24,830,800
217 H-1-30-I PROSEDUR LENSA DAN INTRA OKULER (RINGAN) 8,041,400 9,649,600 11,257,900
218 H-1-30-II PROSEDUR LENSA DAN INTRA OKULER (SEDANG) 9,990,600 11,988,700 13,986,800
219 H-1-30-III PROSEDUR LENSA DAN INTRA OKULER (BERAT) 13,993,300 16,791,900 19,590,600
220 H-4-10-I INFEKSI MATA AKUT MAYOR (RINGAN) 4,263,700 5,116,400 5,969,100
221 H-4-10-II INFEKSI MATA AKUT MAYOR (SEDANG) 5,784,900 6,941,900 8,098,900
222 H-4-10-III INFEKSI MATA AKUT MAYOR (BERAT) 11,370,600 13,644,700 15,918,800
223 H-4-11-I GANGGUAN PERSARAFAN MATA (RINGAN) 4,088,500 4,906,100 5,723,800
224 H-4-11-II GANGGUAN PERSARAFAN MATA (SEDANG) 4,663,700 5,596,400 6,529,100
225 H-4-11-III GANGGUAN PERSARAFAN MATA (BERAT) 6,678,100 8,013,700 9,349,300
226 H-4-12-I GANGGUAN MATA LAIN-LAIN (RINGAN) 4,820,300 5,784,400 6,748,500
227 H-4-12-II GANGGUAN MATA LAIN-LAIN (SEDANG) 5,759,400 6,911,300 8,063,100
-6-

REGIONAL 1
RAWAT INAP

228 H-4-12-III GANGGUAN MATA LAIN-LAIN (BERAT) 9,651,700 11,582,100 13,512,400
229 I-1-01-I TRANPLANTASI PARU ATAU/DAN JANTUNG (RINGAN) 64,745,400 77,694,500 90,643,600
230 I-1-01-II TRANPLANTASI PARU ATAU/DAN JANTUNG (SEDANG) 66,169,800 79,403,800 92,637,700
231 I-1-01-III TRANPLANTASI PARU ATAU/DAN JANTUNG (BERAT) 104,448,100 125,337,800 146,227,400
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI
232 I-1-02-I 35,920,500 43,104,600 50,288,700
(RINGAN)
233 I-1-02-II 46,337,000 55,604,400 64,871,800
(SEDANG)
234 I-1-02-III 57,113,200 68,535,900 79,958,500
(BERAT)
OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG
235 I-1-03-I 33,876,900 40,652,300 47,427,600
ANOMALI (RINGAN)
236 I-1-03-II 46,960,400 56,352,500 65,744,500
ANOMALI (SEDANG)
237 I-1-03-III 59,596,300 71,515,600 83,434,900
ANOMALI (BERAT)
PROSEDUR KATUP JANTUNG TANPA KATETERISASI
238 I-1-04-I 51,050,600 61,260,700 71,470,900
JANTUNG (RINGAN)
239 I-1-04-II 80,571,700 96,686,000 112,800,300
JANTUNG (SEDANG)
240 I-1-04-III 128,712,700 154,455,200 180,197,800
JANTUNG (BERAT)
PEMBEDAHAN BYPASS PEMBULUH KORONER
241 I-1-05-I 84,564,000 101,476,800 118,389,600
DENGAN KATETERISASI JANTUNG (RINGAN)
242 I-1-05-II 103,356,000 124,027,200 144,698,400
DENGAN KATETERISASI JANTUNG (SEDANG)
243 I-1-05-III 140,940,000 169,128,000 197,316,000
DENGAN KATETERISASI JANTUNG (BERAT)
244 I-1-06-I PROSEDUR KARDIOTORASIK LAIN (RINGAN) 48,292,200 57,950,600 67,609,100
245 I-1-06-II PROSEDUR KARDIOTORASIK LAIN (SEDANG) 69,955,200 83,946,200 97,937,300
246 I-1-06-III PROSEDUR KARDIOTORASIK LAIN (BERAT) 83,469,500 100,163,400 116,857,300
PROSEDUR BYPASS KORONER TANPA KATETERISASI
247 I-1-07-I 75,168,000 90,201,600 105,235,200
JANTUNG (RINGAN)
248 I-1-07-II 93,960,000 112,752,000 131,544,000
JANTUNG (SEDANG)
249 I-1-07-III 140,940,000 169,128,000 197,316,000
JANTUNG (BERAT)
DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM
250 I-1-11-I 5,628,900 6,754,600 7,880,400
BANTUAN JANTUNG (RINGAN)
251 I-1-11-II 6,258,700 7,510,500 8,762,200
BANTUAN JANTUNG (SEDANG)
252 I-1-11-III 8,328,500 9,994,100 11,659,800
BANTUAN JANTUNG (BERAT)
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS
253 I-1-12-I 16,202,500 19,443,000 22,683,600
(RINGAN)
254 I-1-12-II 26,462,000 31,754,400 37,046,800
(SEDANG)
255 I-1-12-III 34,814,800 41,777,700 48,740,700
(BERAT)
PROSEDUR PEMBULUH DARAH ABDOMINAL
256 I-1-13-I 15,716,200 18,859,500 22,002,700
KOMPLEK (RINGAN)
257 I-1-13-II 20,929,400 25,115,300 29,301,100
KOMPLEK (SEDANG)
258 I-1-13-III 25,811,700 30,974,100 36,136,400
KOMPLEK (BERAT)
PEMASANGAN PACEMAKER JANTUNG PERMANEN
259 I-1-14-I 32,167,300 38,600,700 45,034,200
(RINGAN)
260 I-1-14-II 39,979,200 47,975,000 55,970,900
(SEDANG)
261 I-1-14-III 52,386,500 62,863,800 73,341,200
(BERAT)
262 I-1-15-I KATETERISASI JANTUNG (RINGAN) 6,110,900 7,333,000 8,555,200
263 I-1-15-II KATETERISASI JANTUNG (SEDANG) 8,533,700 10,240,400 11,947,200
264 I-1-15-III KATETERISASI JANTUNG (BERAT) 16,432,500 19,719,000 23,005,500
REVISI DEFIBRILATOR & PACEMAKER JANTUNG
265 I-1-16-I 15,841,600 19,009,900 22,178,200
TIDAK TERMASUK PENGGANTIAN ALAT (RINGAN)
-7-

REGIONAL 1
RAWAT INAP

266 I-1-16-II 35,843,100 43,011,700 50,180,300
TIDAK TERMASUK PENGGANTIAN ALAT (SEDANG)
267 I-1-16-III 41,344,400 49,613,300 57,882,200
TIDAK TERMASUK PENGGANTIAN ALAT (BERAT)
LIGASI DAN STRIPPING PEMBULUH DARAH VENA
268 I-1-17-I 18,343,000 22,011,600 25,680,200
(RINGAN)
269 I-1-17-II 22,967,200 27,560,600 32,154,100
(SEDANG)
270 I-1-17-III 28,410,100 34,092,100 39,774,100
(BERAT)
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN
271 I-1-20-I 20,675,700 24,810,900 28,946,000
(RINGAN)
272 I-1-20-II 25,829,700 30,995,600 36,161,600
(SEDANG)
273 I-1-20-III 27,152,300 32,582,800 38,013,300
(BERAT)
PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER
274 I-1-30-I 15,640,000 18,768,000 21,896,000
JANTUNG (RINGAN)
275 I-1-30-II 32,534,700 39,041,700 45,548,600
JANTUNG (SEDANG)
276 I-1-30-III 50,417,100 60,500,600 70,584,000
JANTUNG (BERAT)
277 I-1-40-I PROSEDUR KARDIOVASKULAR PERKUTAN (RINGAN) 14,434,100 17,320,900 20,207,700
278 I-1-40-II PROSEDUR KARDIOVASKULAR PERKUTAN (SEDANG) 35,683,500 42,820,200 49,956,900
279 I-1-40-III PROSEDUR KARDIOVASKULAR PERKUTAN (BERAT) 47,661,100 57,193,300 66,725,500

280 I-4-10-I INFARK MYOKARD AKUT (RINGAN) 5,440,800 6,528,900 7,617,100
281 I-4-10-II INFARK MYOKARD AKUT (SEDANG) 9,715,200 11,658,200 13,601,200
282 I-4-10-III INFARK MYOKARD AKUT (BERAT) 13,998,200 16,797,800 19,597,500
283 I-4-11-I ENDOKARDITIS AKUT DAN SUBAKUT (RINGAN) 8,370,600 10,044,800 11,718,900
284 I-4-11-II ENDOKARDITIS AKUT DAN SUBAKUT (SEDANG) 10,358,700 12,430,500 14,502,200
285 I-4-11-III ENDOKARDITIS AKUT DAN SUBAKUT (BERAT) 19,162,500 22,995,000 26,827,500
286 I-4-12-I KEGAGALAN JANTUNG (RINGAN) 4,811,900 5,774,300 6,736,700
287 I-4-12-II KEGAGALAN JANTUNG (SEDANG) 5,577,700 6,693,200 7,808,800
288 I-4-12-III KEGAGALAN JANTUNG (BERAT) 6,693,200 8,031,900 9,370,500
THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA
289 I-4-13-I 4,896,700 5,876,100 6,855,400
(RINGAN)
290 I-4-13-II 8,743,700 10,492,400 12,241,100
(SEDANG)
291 I-4-13-III 12,598,400 15,118,100 17,637,700
(BERAT)
292 I-4-14-I CARDIAC ARREST DAN LAIN-LAIN (RINGAN) 4,624,100 5,548,900 6,473,700
293 I-4-14-II CARDIAC ARREST DAN LAIN-LAIN (SEDANG) 4,783,200 5,739,900 6,696,500
294 I-4-14-III CARDIAC ARREST DAN LAIN-LAIN (BERAT) 8,385,000 10,062,000 11,739,000
PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN
295 I-4-15-I 4,722,500 5,667,000 6,611,500
(RINGAN)
296 I-4-15-II 8,905,200 10,686,300 12,467,300
(SEDANG)
297 I-4-15-III PENYAKIT PEMBULUH DARAH DAN LAIN-LAIN (BERAT) 10,686,300 12,823,500 14,960,800
298 I-4-16-I ATHEROSKLEROSIS (RINGAN) 2,918,500 3,502,200 4,085,900

299 I-4-16-II ATHEROSKLEROSIS (SEDANG) 4,686,400 5,623,700 6,560,900
300 I-4-16-III ATHEROSKLEROSIS (BERAT) 5,623,700 6,748,400 7,873,100
301 I-4-17-I HIPERTENSI (RINGAN) 1,948,600 2,338,300 2,728,000
302 I-4-17-II HIPERTENSI (SEDANG) 3,144,400 3,773,300 4,402,200
303 I-4-17-III HIPERTENSI (BERAT) 4,402,200 5,282,600 6,163,000
PENYAKIT JANTUNG KONGENITAL DAN KATUP
304 I-4-18-I 5,629,400 6,755,300 7,881,200
JANTUNG (RINGAN)
305 I-4-18-II 8,571,100 10,285,300 11,999,500
JANTUNG (SEDANG)
306 I-4-18-III 11,636,600 13,964,000 16,291,300
JANTUNG (BERAT)
307 I-4-19-I GANGGUAN KONDUKSI & ARITMIA JANTUNG (RINGAN) 5,431,300 6,517,500 7,603,800
GANGGUAN KONDUKSI & ARITMIA JANTUNG

308 I-4-19-II 8,478,500 10,174,200 11,870,000
(SEDANG)
-8-

REGIONAL 1
RAWAT INAP

309 I-4-19-III GANGGUAN KONDUKSI & ARITMIA JANTUNG (BERAT) 10,121,800 12,146,100 14,170,500
310 I-4-20-I ANGINA PEKTORIS DAN NYERI DADA (RINGAN) 5,655,600 6,786,700 7,917,800
311 I-4-20-II ANGINA PEKTORIS DAN NYERI DADA (SEDANG) 6,532,200 7,838,600 9,145,100
312 I-4-20-III ANGINA PEKTORIS DAN NYERI DADA (BERAT) 9,767,000 11,720,400 13,673,800
313 I-4-21-I SYNCOPE & COLLAPSE (RINGAN) 3,808,800 4,570,600 5,332,400
314 I-4-21-II SYNCOPE & COLLAPSE (SEDANG) 4,825,800 5,791,000 6,756,200
315 I-4-21-III SYNCOPE & COLLAPSE (BERAT) 6,965,600 8,358,700 9,751,800
316 I-4-22-I KARDIOMIOPATHI (RINGAN) 3,422,100 4,106,500 4,791,000
317 I-4-22-II KARDIOMIOPATHI (SEDANG) 4,260,000 5,112,000 5,964,000
318 I-4-22-III KARDIOMIOPATHI (BERAT) 6,226,800 7,472,200 8,717,500
MALFUNGSI, REAKSI DAN KOMPLIKASI DARI ALAT
319 I-4-23-I 4,642,400 5,570,900 6,499,400
ATAU PROSEDUR KARDIOVASKULER (RINGAN)
320 I-4-23-II 5,699,600 6,839,500 7,979,400
ATAU PROSEDUR KARDIOVASKULER (SEDANG)
321 I-4-23-III 11,136,600 13,363,900 15,591,300
ATAU PROSEDUR KARDIOVASKULER (BERAT)
GANGGUAN SISTEM PEMBULUH DARAH LAIN-LAIN
322 I-4-24-I 3,016,000 3,619,200 4,222,400
(RINGAN)
323 I-4-24-II 6,945,100 8,334,100 9,723,100
(SEDANG)
324 I-4-24-III 8,780,800 10,537,000 12,293,200
(BERAT)
VENTILASI MEKANIKAL LONG TERM DENGAN
325 J-1-01-I 95,561,100 114,673,400 133,785,600
TRAKEOSTOMI (RINGAN)
326 J-1-01-II 108,145,200 129,774,200 151,403,300
TRAKEOSTOMI (SEDANG)
327 J-1-01-III 148,339,800 178,007,700 207,675,700
TRAKEOSTOMI (BERAT)
VENTILASI MEKANIKAL LONG TERM TANPA
328 J-1-02-I 62,342,100 74,810,500 87,278,900
329 J-1-02-II 78,663,600 94,396,300 110,129,000
330 J-1-02-III 92,025,200 110,430,300 128,835,300
TRAKEOSTOMI (BERAT)
PROSEDUR SISTEM PERNAFASAN SANGAT KOMPLEKS
331 J-1-10-I 12,153,800 14,584,600 17,015,400
(RINGAN)
332 J-1-10-II 24,593,400 29,512,000 34,430,700
(SEDANG)
333 J-1-10-III 25,558,600 30,670,300 35,782,000
(BERAT)
PROSEDUR SISTEM PERNAFASAN NON-KOMPLEKS
334 J-1-20-I 33,481,700 40,178,000 46,874,300
(RINGAN)
335 J-1-20-II 35,059,800 42,071,800 49,083,700
(SEDANG)
336 J-1-20-III 39,455,200 47,346,300 55,237,300
(BERAT)
PROSEDUR SISTEM PERNAFASAN KOMPLEKS
337 J-1-30-I 10,142,700 12,171,200 14,199,800
(RINGAN)
338 J-1-30-II 18,373,400 22,048,000 25,722,700
(SEDANG)
339 J-1-30-III PROSEDUR SISTEM PERNAFASAN KOMPLEKS (BERAT) 53,034,100 63,640,900 74,247,700
340 J-4-10-I KISTA FIBROSIS (RINGAN) 2,989,800 3,587,800 4,185,700

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

REGIONAL 1
RAWAT INAP

353 J-4-14-II TUMOR PARU (SEDANG) 9,966,500 11,959,800 13,953,100
354 J-4-14-III TUMOR PARU (BERAT) 11,791,400 14,149,600 16,507,900
355 J-4-15-I PERADANGAN DAN INFEKSI PERNAFASAN (RINGAN) 4,431,800 5,318,100 6,204,500
356 J-4-15-II PERADANGAN DAN INFEKSI PERNAFASAN (SEDANG) 7,339,100 8,806,900 10,274,700
357 J-4-15-III PERADANGAN DAN INFEKSI PERNAFASAN (BERAT) 13,329,900 15,995,900 18,661,900
358 J-4-16-I SIMPLE PNEUMONIA & WHOOPING COUGH (RINGAN) 3,692,600 4,431,100 5,169,700
359 J-4-16-II SIMPLE PNEUMONIA & WHOOPING COUGH (SEDANG) 7,192,600 8,631,100 10,069,600
360 J-4-16-III SIMPLE PNEUMONIA & WHOOPING COUGH (BERAT) 12,276,800 14,732,200 17,187,500
361 J-4-17-I PENYAKIT PARU OBSTRUKTIF KRONIS (RINGAN) 5,117,700 6,141,200 7,164,700
362 J-4-17-II PENYAKIT PARU OBSTRUKTIF KRONIS (SEDANG) 6,128,500 7,354,300 8,580,000
363 J-4-17-III PENYAKIT PARU OBSTRUKTIF KRONIS (BERAT) 8,042,500 9,651,000 11,259,500
364 J-4-18-I ASTHMA & BRONKIOLITIS (RINGAN) 2,274,800 2,729,800 3,184,700
365 J-4-18-II ASTHMA & BRONKIOLITIS (SEDANG) 4,336,800 5,204,200 6,071,500
366 J-4-18-III ASTHMA & BRONKIOLITIS (BERAT) 6,162,800 7,395,400 8,628,000
367 J-4-19-I PENYAKIT PARU INTERSTITIAL (RINGAN) 6,487,500 7,785,000 9,082,600
368 J-4-19-II PENYAKIT PARU INTERSTITIAL (SEDANG) 7,357,300 8,828,700 10,300,200
369 J-4-19-III PENYAKIT PARU INTERSTITIAL (BERAT) 8,125,200 9,750,300 11,375,300
370 J-4-20-I PLEURAL EFUSI DAN PNEUMOTORAK (RINGAN) 5,160,800 6,192,900 7,225,100
371 J-4-20-II PLEURAL EFUSI DAN PNEUMOTORAK (SEDANG) 7,150,800 8,580,900 10,011,100
372 J-4-20-III PLEURAL EFUSI DAN PNEUMOTORAK (BERAT) 8,382,900 10,059,500 11,736,100
GEJALA, TANDA DAN DIAGNOSIS SISTEM
373 J-4-21-I 2,948,500 3,538,200 4,127,800
PERNAFASAN LAIN-LAIN (RINGAN)
374 J-4-21-II 6,583,800 7,900,600 9,217,400
PERNAFASAN LAIN-LAIN (SEDANG)
375 J-4-21-III 12,402,800 14,883,300 17,363,900
PERNAFASAN LAIN-LAIN (BERAT)
PROSEDUR NON KOMPLEKS USUS HALUS & USUS
376 K-1-10-I 11,018,200 13,221,800 15,425,500
BESAR (RINGAN)
377 K-1-10-II 13,846,700 16,616,100 19,385,400
BESAR (SEDANG)
378 K-1-10-III 16,228,800 19,474,600 22,720,400
BESAR (BERAT)
379 K-1-11-I ADHESIOLISIS PERITONEAL (RINGAN) 10,347,500 12,416,900 14,486,400
380 K-1-11-II ADHESIOLISIS PERITONEAL (SEDANG) 13,584,900 16,301,900 19,018,900
381 K-1-11-III ADHESIOLISIS PERITONEAL (BERAT) 26,851,900 32,222,200 37,592,600
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL &
382 K-1-12-I 4,623,100 5,547,700 6,472,300
FEMORAL (RINGAN)
383 K-1-12-II 6,012,800 7,215,400 8,418,000
FEMORAL (SEDANG)
384 K-1-12-III 11,912,400 14,294,800 16,677,300
FEMORAL (BERAT)
385 K-1-13-I PROSEDUR APPENDIK (RINGAN) 5,213,900 6,256,700 7,299,500
386 K-1-13-II PROSEDUR APPENDIK (SEDANG) 5,735,300 6,882,400 8,029,400
387 K-1-13-III PROSEDUR APPENDIK (BERAT) 9,166,200 10,999,500 12,832,700
PROSEDUR HERNIA INGUINAL DAN FEMORAL
388 K-1-14-I 7,615,100 9,138,100 10,661,200
(RINGAN)
389 K-1-14-II 8,924,700 10,709,700 12,494,600
(SEDANG)
390 K-1-14-III PROSEDUR HERNIA INGUINAL DAN FEMORAL (BERAT) 15,580,000 18,696,000 21,812,000
391 K-1-20-I PROSEDUR INTESTINAL KOMPLEKS (RINGAN) 16,383,700 19,660,400 22,937,100

392 K-1-20-II PROSEDUR INTESTINAL KOMPLEKS (SEDANG) 22,884,300 27,461,200 32,038,000
393 K-1-20-III PROSEDUR INTESTINAL KOMPLEKS (BERAT) 33,413,500 40,096,200 46,778,900
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG
394 K-1-30-I 9,689,200 11,627,000 13,564,900
NON KOMPLEKS (RINGAN)
395 K-1-30-II 17,207,800 20,649,300 24,090,900
NON KOMPLEKS (SEDANG)
396 K-1-30-III 23,678,100 28,413,800 33,149,400
NON KOMPLEKS (BERAT)
397 K-1-40-I PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (RINGAN) 10,810,900 12,973,100 15,135,200
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN

398 K-1-40-II 11,919,400 14,303,300 16,687,100
(SEDANG)
- 10 -

REGIONAL 1
RAWAT INAP

399 K-1-40-III PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (BERAT) 20,199,100 24,238,900 28,278,700
400 K-1-50-I PROSEDUR ANAL (RINGAN) 8,260,600 9,912,700 11,564,800

401 K-1-50-II PROSEDUR ANAL (SEDANG) 10,727,400 12,872,900 15,018,400
402 K-1-50-III PROSEDUR ANAL (BERAT) 15,159,800 18,191,800 21,223,700
403 K-4-10-I TUMOR PENCERNAAN (RINGAN) 6,819,600 8,183,500 9,547,400
404 K-4-10-II TUMOR PENCERNAAN (SEDANG) 9,798,700 11,758,400 13,718,200
405 K-4-10-III TUMOR PENCERNAAN (BERAT) 14,937,600 17,925,100 20,912,600
406 K-4-11-I GASTRITIS & ULKUS PEPTIKUM (RINGAN) 2,370,600 2,844,800 3,318,900
407 K-4-11-II GASTRITIS & ULKUS PEPTIKUM (SEDANG) 4,669,500 5,603,400 6,537,300
408 K-4-11-III GASTRITIS & ULKUS PEPTIKUM (BERAT) 5,603,400 6,724,100 7,844,700
409 K-4-12-I GANGGUAN ESOFAGUS (RINGAN) 4,099,400 4,919,300 5,739,200
410 K-4-12-II GANGGUAN ESOFAGUS (SEDANG) 5,516,600 6,619,900 7,723,200
411 K-4-12-III GANGGUAN ESOFAGUS (BERAT) 9,126,200 10,951,400 12,776,700
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT
412 K-4-13-I 5,526,300 6,631,500 7,736,800
PERADANGAN USUS BESAR (RINGAN)
413 K-4-13-II 7,148,600 8,578,300 10,008,100
PERADANGAN USUS BESAR (SEDANG)
414 K-4-13-III 11,011,100 13,213,400 15,415,600
PERADANGAN USUS BESAR (BERAT)
GANGGUAN PEMBULUH DARAH GASTROINTERTINAL
415 K-4-14-I 3,153,300 3,784,000 4,414,700
(RINGAN)
416 K-4-14-II 4,232,800 5,079,400 5,925,900
(SEDANG)
417 K-4-14-III 6,792,000 8,150,400 9,508,800
(BERAT)
418 K-4-15-I OBSTRUKSI SALURAN GASTROINTESTINAL (RINGAN) 4,494,700 5,393,600 6,292,600
419 K-4-15-II OBSTRUKSI SALURAN GASTROINTESTINAL (SEDANG) 6,922,300 8,306,800 9,691,200
420 K-4-15-III OBSTRUKSI SALURAN GASTROINTESTINAL (BERAT) 9,853,000 11,823,600 13,794,200

421 K-4-16-I INFEKSI-INFEKSI GASTROINTESTINAL (RINGAN) 4,070,500 4,884,600 5,698,700
422 K-4-16-II INFEKSI-INFEKSI GASTROINTESTINAL (SEDANG) 4,881,700 5,858,000 6,834,400
423 K-4-16-III INFEKSI-INFEKSI GASTROINTESTINAL (BERAT) 5,696,200 6,835,400 7,974,700
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN
424 K-4-17-I 1,996,600 2,396,000 2,795,300
(RINGAN)
425 K-4-17-II 2,458,900 2,950,600 3,442,400
(SEDANG)
426 K-4-17-III 2,950,600 3,540,800 4,130,900
(BERAT)
GANGGUAN SISTEM PENCERNAAN LAIN-LAIN
427 K-4-18-I 1,759,500 2,111,400 2,463,300
(RINGAN)
428 K-4-18-II 2,969,200 3,563,000 4,156,900
(SEDANG)
429 K-4-18-III GANGGUAN SISTEM PENCERNAAN LAIN-LAIN (BERAT) 3,563,000 4,275,600 4,988,200
430 L-1-20-I PEMINDAHAN KULIT PADA LUKA BAKAR (RINGAN) 26,121,700 31,346,100 36,570,400
431 L-1-20-II PEMINDAHAN KULIT PADA LUKA BAKAR (SEDANG) 39,430,100 47,316,100 55,202,100
432 L-1-20-III PEMINDAHAN KULIT PADA LUKA BAKAR (BERAT) 52,685,000 63,222,000 73,759,000
433 L-1-30-I PEMINDAHAN KULIT TANPA LUKA BAKAR (RINGAN) 12,324,500 14,789,400 17,254,300
434 L-1-30-II PEMINDAHAN KULIT TANPA LUKA BAKAR (SEDANG) 21,148,000 25,377,600 29,607,200
435 L-1-30-III PEMINDAHAN KULIT TANPA LUKA BAKAR (BERAT) 26,255,600 31,506,700 36,757,800
PROSEDUR PADA KULIT, JARINGAN) BAWAH KULIT
436 L-1-40-I 6,906,900 8,288,300 9,669,700
(RINGAN)
437 L-1-40-II 13,853,700 16,624,500 19,395,200
(SEDANG)
438 L-1-40-III 23,318,900 27,982,700 32,646,500
(BERAT)
439 L-1-50-I PROSEDUR PADA PAYUDARA (RINGAN) 9,067,400 10,880,900 12,694,400
440 L-1-50-II PROSEDUR PADA PAYUDARA (SEDANG) 14,593,000 17,511,600 20,430,200
441 L-1-50-III PROSEDUR PADA PAYUDARA (BERAT) 20,873,900 25,048,600 29,223,400
442 L-4-10-I PENYAKIT KULIT MAYOR (RINGAN) 2,371,600 2,845,900 3,320,300
443 L-4-10-II PENYAKIT KULIT MAYOR (SEDANG) 2,752,800 3,303,400 3,853,900
444 L-4-10-III PENYAKIT KULIT MAYOR (BERAT) 3,195,300 3,834,300 4,473,400
445 L-4-11-I TUMOR PAYUDARA (RINGAN) 4,966,500 5,959,800 6,953,200
- 11 -

REGIONAL 1
RAWAT INAP

446 L-4-11-II TUMOR PAYUDARA (SEDANG) 6,826,100 8,191,300 9,556,500
447 L-4-11-III TUMOR PAYUDARA (BERAT) 15,511,000 18,613,200 21,715,400
448 L-4-12-I PERADANGAN KULIT/CELLULITIS (RINGAN) 2,358,700 2,830,400 3,302,100
449 L-4-12-II PERADANGAN KULIT/CELLULITIS (SEDANG) 3,119,600 3,743,600 4,367,500
450 L-4-12-III PERADANGAN KULIT/CELLULITIS (BERAT) 10,315,400 12,378,500 14,441,600
TRAUMA PADA KULIT, JA(RINGAN) BAWAH KULIT DAN
451 L-4-13-I 2,511,500 3,013,800 3,516,100
PAYUDARA (RINGAN)
452 L-4-13-II 4,091,400 4,909,700 5,727,900
PAYUDARA (SEDANG)
453 L-4-13-III 8,127,700 9,753,300 11,378,800
PAYUDARA (BERAT)
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN
454 L-4-14-I 4,084,400 4,901,300 5,718,100
(RINGAN)
455 L-4-14-II 6,134,900 7,361,900 8,588,800
(SEDANG)
456 L-4-14-III 8,647,900 10,377,400 12,107,000
(BERAT)
PROSEDUR BILATERAL DAN MULTIPLE PADA SENDI
457 M-1-01-I 14,437,900 17,325,500 20,213,000
TUNGKAI BAWAH (RINGAN)
458 M-1-01-II 20,521,400 24,625,700 28,730,000
TUNGKAI BAWAH (SEDANG)
459 M-1-01-III 28,826,500 34,591,800 40,357,100
TUNGKAI BAWAH (BERAT)
460 M-1-02-I AMPUTASI (RINGAN) 12,796,500 15,355,800 17,915,100
461 M-1-02-II AMPUTASI (SEDANG) 20,992,200 25,190,600 29,389,000
462 M-1-02-III AMPUTASI (BERAT) 35,665,200 42,798,200 49,931,200
PROSEDUR FUSI TULANG BELAKANG PADA
463 M-1-03-I 51,152,200 61,382,600 71,613,100
LENGKUNGAN TULANG BELAKANG (RINGAN)
464 M-1-03-II 59,830,000 71,795,900 83,761,900
LENGKUNGAN TULANG BELAKANG (SEDANG)
465 M-1-03-III 74,049,500 88,859,500 103,669,400
LENGKUNGAN TULANG BELAKANG (BERAT)
466 M-1-04-I PROSEDUR PADA SENDI TUNGKAI BAWAH (RINGAN) 26,197,900 31,437,500 36,677,100
467 M-1-04-II PROSEDUR PADA SENDI TUNGKAI BAWAH (SEDANG) 33,656,700 40,388,100 47,119,400
468 M-1-04-III PROSEDUR PADA SENDI TUNGKAI BAWAH (BERAT) 40,271,100 48,325,300 56,379,500
469 M-1-05-I PROSEDUR PADA SENDI TUNGKAI ATAS (RINGAN) 10,186,700 12,224,100 14,261,400
470 M-1-05-II PROSEDUR PADA SENDI TUNGKAI ATAS (SEDANG) 16,477,400 19,772,900 23,068,400
471 M-1-05-III PROSEDUR PADA SENDI TUNGKAI ATAS (BERAT) 21,047,800 25,257,400 29,466,900
PROSEDUR FUSI TULANG BELAKANG SELAIN
472 M-1-07-I 18,618,600 22,342,300 26,066,000
473 M-1-07-II 24,942,400 29,930,900 34,919,400
474 M-1-07-III 50,810,100 60,972,100 71,134,100
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG
475 M-1-10-I 22,002,200 26,402,600 30,803,100
WAJAH (RINGAN)
476 M-1-10-II 52,606,300 63,127,600 73,648,800
WAJAH (SEDANG)
477 M-1-10-III 113,466,900 136,160,300 158,853,700
WAJAH (BERAT)
PROSEDUR PADA PAHA DAN SENDI PANGGUL
478 M-1-20-I 17,145,100 20,574,100 24,003,100
(RINGAN)
479 M-1-20-II 21,904,600 26,285,500 30,666,400
(SEDANG)
480 M-1-20-III PROSEDUR PADA PAHA DAN SENDI PANGGUL (BERAT) 54,535,700 65,442,800 76,350,000
481 M-1-30-I PROSEDUR KAKI (RINGAN) 11,762,000 14,114,300 16,466,700

482 M-1-30-II PROSEDUR KAKI (SEDANG) 19,059,200 22,871,000 26,682,800
483 M-1-30-III PROSEDUR KAKI (BERAT) 27,252,900 32,703,500 38,154,100
EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI
484 M-1-40-I 7,184,700 8,621,700 10,058,600
INTERNAL (RINGAN)
485 M-1-40-II 10,618,200 12,741,800 14,865,500
INTERNAL (SEDANG)
486 M-1-40-III 15,160,700 18,192,900 21,225,000
INTERNAL (BERAT)
487 M-1-50-I PROSEDUR JARINGAN LUNAK (RINGAN) 7,174,800 8,609,800 10,044,800
488 M-1-50-II PROSEDUR JARINGAN LUNAK (SEDANG) 11,906,600 14,287,900 16,669,200
- 12 -

REGIONAL 1
RAWAT INAP

489 M-1-50-III PROSEDUR JARINGAN LUNAK (BERAT) 19,555,800 23,466,900 27,378,100
PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN
490 M-1-60-I 11,081,000 13,297,100 15,513,300
PENGHUBUNG LAIN-LAIN (RINGAN)
491 M-1-60-II 13,931,300 16,717,600 19,503,800
PENGHUBUNG LAIN-LAIN (SEDANG)
492 M-1-60-III 21,044,900 25,253,900 29,462,900
PENGHUBUNG LAIN-LAIN (BERAT)
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN
493 M-1-70-I 20,529,500 24,635,400 28,741,300
KAKI (RINGAN)
494 M-1-70-II 22,582,400 27,098,900 31,615,400
KAKI (SEDANG)
495 M-1-70-III 25,853,900 31,024,700 36,195,400
KAKI (BERAT)
496 M-1-80-I PROSEDUR ANGGOTA TUBUH ATAS (RINGAN) 11,670,100 14,004,200 16,338,200
497 M-1-80-II PROSEDUR ANGGOTA TUBUH ATAS (SEDANG) 13,859,400 16,631,300 19,403,100
498 M-1-80-III PROSEDUR ANGGOTA TUBUH ATAS (BERAT) 31,194,500 37,433,400 43,672,300
499 M-4-10-I FRAKTUR FEMUR (RINGAN) 4,111,000 4,933,200 5,755,300
500 M-4-10-II FRAKTUR FEMUR (SEDANG) 6,130,800 7,357,000 8,583,100
501 M-4-10-III FRAKTUR FEMUR (BERAT) 11,599,500 13,919,400 16,239,400
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL
502 M-4-11-I 5,122,600 6,147,200 7,171,700
(RINGAN)
503 M-4-11-II 11,231,200 13,477,400 15,723,600
(SEDANG)
504 M-4-11-III 16,238,300 19,486,000 22,733,700
(BERAT)
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS
505 M-4-12-I 4,089,000 4,906,800 5,724,600
(RINGAN)
506 M-4-12-II 6,801,200 8,161,400 9,521,600
(SEDANG)
507 M-4-12-III 9,097,300 10,916,700 12,736,200
(BERAT)
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN
508 M-4-13-I 6,808,600 8,170,300 9,532,100
FRAKTUR PATOLOGIS (RINGAN)
509 M-4-13-II 10,229,700 12,275,600 14,321,500
FRAKTUR PATOLOGIS (SEDANG)
510 M-4-13-III 19,957,800 23,949,400 27,941,000
FRAKTUR PATOLOGIS (BERAT)
511 M-4-14-I OSTEOMIELITIS (RINGAN) 7,765,000 9,318,000 10,871,000
512 M-4-14-II OSTEOMIELITIS (SEDANG) 9,577,000 11,492,400 13,407,800
513 M-4-14-III OSTEOMIELITIS (BERAT) 14,391,400 17,269,700 20,148,000
514 M-4-15-I ARTRITIS SEPSIS (RINGAN) 4,604,400 5,525,300 6,446,200
515 M-4-15-II ARTRITIS SEPSIS (SEDANG) 6,137,400 7,364,800 8,592,300
516 M-4-15-III ARTRITIS SEPSIS (BERAT) 13,927,500 16,713,000 19,498,500
517 M-4-16-I GANGGUAN JARINGAN KONEKTIF (RINGAN) 3,942,100 4,730,500 5,518,900
518 M-4-16-II GANGGUAN JARINGAN KONEKTIF (SEDANG) 6,312,800 7,575,300 8,837,900
519 M-4-16-III GANGGUAN JARINGAN KONEKTIF (BERAT) 10,605,000 12,726,100 14,847,100
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG
520 M-4-17-I 4,604,700 5,525,600 6,446,500
(RINGAN)
521 M-4-17-II 6,440,200 7,728,200 9,016,200
(SEDANG)
522 M-4-17-III 8,993,200 10,791,900 12,590,500
(BERAT)
523 M-4-18-I PENYAKIT TULANG DAN SENDI LAIN-LAIN (RINGAN) 3,867,100 4,640,500 5,414,000
524 M-4-18-II PENYAKIT TULANG DAN SENDI LAIN-LAIN (SEDANG) 5,827,900 6,993,500 8,159,100
525 M-4-18-III PENYAKIT TULANG DAN SENDI LAIN-LAIN (BERAT) 7,017,100 8,420,500 9,823,900
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI
526 M-4-19-I PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 4,032,800 4,839,400 5,645,900
(RINGAN)
527 M-4-19-II PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 6,792,800 8,151,300 9,509,900
(SEDANG)
528 M-4-19-III PROSEDUR ATAU PEMASANGAN ALAT ORTOPEDIK 13,266,700 15,920,100 18,573,400
(BERAT)
TANDA, GEJALA & PERADANGAN MUSKULOSKELETAL
529 M-4-20-I 3,661,200 4,393,400 5,125,700
(RINGAN)
- 13 -

REGIONAL 1
RAWAT INAP

530 M-4-20-II 5,361,200 6,433,400 7,505,600
(SEDANG)
531 M-4-20-III 5,991,800 7,190,100 8,388,500
(BERAT)
GANGGUAN SISTEM MUSKULOSKELETAL &
532 M-4-21-I 3,686,500 4,423,800 5,161,100
JA(RINGAN) PENYAMBUNG LAIN-LAIN (RINGAN)
533 M-4-21-II 4,610,800 5,532,900 6,455,100
JA(RINGAN) PENYAMBUNG LAIN-LAIN (SEDANG)
534 M-4-21-III 10,337,300 12,404,700 14,472,200
JA(RINGAN) PENYAMBUNG LAIN-LAIN (BERAT)
535 N-1-01-I TRANSPLANTASI GINJAL (RINGAN) 283,523,900 340,228,700 396,933,400
536 N-1-01-II TRANSPLANTASI GINJAL (SEDANG) 283,523,900 340,228,700 396,933,400
537 N-1-01-III TRANSPLANTASI GINJAL (BERAT) 283,523,900 340,228,700 396,933,400
538 N-1-11-I PROSEDUR KANDUNG KEMIH KOMPLEK (RINGAN) 11,815,200 14,178,300 16,541,300
539 N-1-11-II PROSEDUR KANDUNG KEMIH KOMPLEK (SEDANG) 18,682,800 22,419,300 26,155,900
540 N-1-11-III PROSEDUR KANDUNG KEMIH KOMPLEK (BERAT) 29,126,400 34,951,700 40,777,000
MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN
541 N-1-12-I 6,021,800 7,226,200 8,430,600
ALAT DIALISIS (RINGAN)
542 N-1-12-II 11,988,800 14,386,600 16,784,400
ALAT DIALISIS (SEDANG)
543 N-1-12-III 26,016,200 31,219,400 36,422,700
ALAT DIALISIS (BERAT)
544 N-1-20-I PROSEDUR SALURAN URIN ATAS (RINGAN) 13,166,000 15,799,200 18,432,400
545 N-1-20-II PROSEDUR SALURAN URIN ATAS (SEDANG) 18,425,100 22,110,100 25,795,200
546 N-1-20-III PROSEDUR SALURAN URIN ATAS (BERAT) 25,783,700 30,940,500 36,097,200
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN
547 N-1-30-I 12,049,200 14,459,100 16,868,900
BAWAH (RINGAN)
548 N-1-30-II 18,228,100 21,873,700 25,519,300
BAWAH (SEDANG)
549 N-1-30-III 20,978,800 25,174,600 29,370,300
BAWAH (BERAT)
PROSEDUR PADA URETRA DAN TRANSURETRA
550 N-1-40-I 10,821,100 12,985,300 15,149,500
(RINGAN)
551 N-1-40-II 14,694,700 17,633,700 20,572,600
(SEDANG)
552 N-1-40-III 17,102,800 20,523,300 23,943,900
(BERAT)
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL
553 N-4-10-I 4,597,400 5,516,900 6,436,400
(RINGAN)
554 N-4-10-II 5,560,700 6,672,800 7,785,000
(SEDANG)
555 N-4-10-III 8,179,000 9,814,800 11,450,500
(BERAT)
556 N-4-11-I PERADANGAN GINJAL (RINGAN) 3,529,300 4,235,100 4,941,000
557 N-4-11-II PERADANGAN GINJAL (SEDANG) 6,166,100 7,399,300 8,632,500
558 N-4-11-III PERADANGAN GINJAL (BERAT) 7,671,900 9,206,300 10,740,700
559 N-4-12-I INFEKSI GINJAL DAN SALURAN URIN (RINGAN) 2,661,000 3,193,100 3,725,300
560 N-4-12-II INFEKSI GINJAL DAN SALURAN URIN (SEDANG) 5,528,100 6,633,700 7,739,400
561 N-4-12-III INFEKSI GINJAL DAN SALURAN URIN (BERAT) 8,982,800 10,779,400 12,576,000
562 N-4-13-I BATU URIN (RINGAN) 3,600,700 4,320,900 5,041,000
563 N-4-13-II BATU URIN (SEDANG) 6,019,700 7,223,600 8,427,500
564 N-4-13-III BATU URIN (BERAT) 12,453,400 14,944,100 17,434,800
565 N-4-14-I PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 3,544,600 4,253,500 4,962,400
KULIT ATAU PENCAKOKAN (RINGAN)
566 N-4-14-II PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 5,029,600 6,035,500 7,041,400
KULIT ATAU PENCAKOKAN (SEDANG)
567 N-4-14-III PEMASANGAN ALAT SALURAN URIN, PEMINDAHAN 8,062,300 9,674,800 11,287,300
KULIT ATAU PENCAKOKAN (BERAT)
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN
568 N-4-15-I 4,187,400 5,024,900 5,862,400
URIN (RINGAN)
569 N-4-15-II 5,195,900 6,235,000 7,274,200
URIN (SEDANG)
570 N-4-15-III 5,929,400 7,115,200 8,301,100
URIN (BERAT)
- 14 -

REGIONAL 1
RAWAT INAP

PENYAKIT GINJAL DAN SALURAN URIN LAIN-LAIN
571 N-4-16-I 5,127,500 6,153,000 7,178,500
(RINGAN)
572 N-4-16-II 7,318,600 8,782,300 10,246,000
(SEDANG)
573 N-4-16-III 9,741,600 11,689,900 13,638,200
(BERAT)
574 O-6-10-I OPERASI PEMBEDAHAN CAESAR (RINGAN) 5,253,900 6,304,700 7,355,500
575 O-6-10-II OPERASI PEMBEDAHAN CAESAR (SEDANG) 6,762,600 8,115,100 9,467,600
576 O-6-10-III OPERASI PEMBEDAHAN CAESAR (BERAT) 10,660,100 12,792,100 14,924,100
PERSALINAN VAGINAL DENGAN STERILISASI &/
577 O-6-11-I 4,766,300 5,719,500 6,672,800
DILATASI & KURET (RINGAN)
578 O-6-11-II 5,297,200 6,356,600 7,416,000
DILATASI & KURET (SEDANG)
579 O-6-11-III 6,589,700 7,907,700 9,225,600
DILATASI & KURET (BERAT)
PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN
580 O-6-12-I 3,376,800 4,052,200 4,727,600
STERILISASI &/ DILATASI &KURET (RINGAN)
581 O-6-12-II 4,055,500 4,866,600 5,677,800
STERILISASI &/ DILATASI & KURET (SEDANG)
582 O-6-12-III 5,095,900 6,115,100 7,134,300
STERILISASI &/ DILATASI & KURET (BERAT)
583 O-6-13-I PERSALINAN VAGINAL (RINGAN) 1,711,800 2,054,100 2,396,500
584 O-6-13-II PERSALINAN VAGINAL (SEDANG) 2,808,200 3,369,900 3,931,500
585 O-6-13-III PERSALINAN VAGINAL (BERAT) 3,369,900 4,043,900 4,717,800
NEONATAL DENGAN PENCANGKOKAN ORGAN ATAU
586 P-8-01-I 75,405,000 90,486,000 105,567,000
OKSIGENASI SELAPUT EKSTRAKORPORAL (RINGAN)
587 P-8-01-II 93,302,400 111,962,900 130,623,400
OKSIGENASI SELAPUT EKSTRAKORPORAL (SEDANG)
588 P-8-01-III 109,510,800 131,412,900 153,315,100
OKSIGENASI SELAPUT EKSTRAKORPORAL (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 DENGAN
589 P-8-02-I 102,924,300 123,509,200 144,094,000
PROSEDUR MAYOR (RINGAN)
590 P-8-02-II 118,064,500 141,677,400 165,290,300
PROSEDUR MAYOR (SEDANG)
591 P-8-02-III 134,897,100 161,876,500 188,855,900
PROSEDUR MAYOR (BERAT)
NEONATAL, BERAT BADAN LAHIR GROUP-1 TANPA
592 P-8-03-I 15,438,500 18,526,200 21,613,900
593 P-8-03-II 20,435,000 24,522,000 28,609,000
594 P-8-03-III 28,732,600 34,479,100 40,225,600
595 P-8-04-I 49,751,400 59,701,600 69,651,900
596 P-8-04-II 64,566,500 77,479,800 90,393,100
597 P-8-04-III 92,572,200 111,086,600 129,601,000
598 P-8-05-I 27,053,200 32,463,800 37,874,500
599 P-8-05-II 41,734,300 50,081,100 58,428,000
600 P-8-05-III 56,495,000 67,794,000 79,093,000
601 P-8-06-I 7,303,500 8,764,200 10,224,900
602 P-8-06-II 20,477,300 24,572,800 28,668,300
603 P-8-06-III 27,127,400 32,552,900 37,978,400
604 P-8-07-I 8,646,200 10,375,500 12,104,700
605 P-8-07-II 24,242,000 29,090,400 33,938,800
606 P-8-07-III 32,114,700 38,537,700 44,960,600
607 P-8-08-I 5,002,800 6,003,400 7,003,900
SINDROMA DISTRES PERNAFASAN (RINGAN)
- 15 -

REGIONAL 1
RAWAT INAP

608 P-8-08-II 7,098,700 8,518,500 9,938,200
SINDROMA DISTRES PERNAFASAN (SEDANG)
609 P-8-08-III 13,809,800 16,571,800 19,333,800
SINDROMA DISTRES PERNAFASAN (BERAT)
NEONATAL, BBL 1000 - 1499 GR TANPA PROSEDUR
610 P-8-11-I 12,865,400 15,438,500 18,011,600
MAYOR (RINGAN)
611 P-8-11-II 17,029,200 20,435,000 23,840,800
MAYOR (SEDANG)
612 P-8-11-III 23,943,800 28,732,600 33,521,300
MAYOR (BERAT)
613 P-8-12-I 11,695,900 14,035,000 16,374,200
MAYOR (RINGAN)
614 P-8-12-II 14,191,000 17,029,200 19,867,400
MAYOR (SEDANG)
615 P-8-12-III 20,820,700 24,984,800 29,149,000
MAYOR (BERAT)
616 P-8-13-I 6,497,700 7,797,200 9,096,800
MAYOR (RINGAN)
617 P-8-13-II 10,136,400 12,163,700 14,191,000
MAYOR (SEDANG)
618 P-8-13-III 16,015,900 19,219,100 22,422,300
MAYOR (BERAT)
NEONATAL, BBL > 2499 GR DENGAN ANOMALI MAYOR
619 P-8-14-I 4,918,300 5,901,900 6,885,600
ATAU KONDISI HEREDITER (RINGAN)
620 P-8-14-II 10,011,600 12,013,900 14,016,300
ATAU KONDISI HEREDITER (SEDANG)
621 P-8-14-III 39,146,200 46,975,400 54,804,700
ATAU KONDISI HEREDITER (BERAT)
NEONATAL, BBL > 2499 GR DENGAN SINDROMA
622 P-8-15-I 3,688,800 4,426,500 5,164,300
ASPIRASI (RINGAN)
623 P-8-15-II 7,386,900 8,864,300 10,341,700
ASPIRASI (SEDANG)
624 P-8-15-III 8,667,200 10,400,600 12,134,100
ASPIRASI (BERAT)
NEONATAL, BBL > 2499 GR DENGAN
625 P-8-16-I 3,338,400 4,006,000 4,673,700
KONGENITAL/INFEKSI PERINATAL (RINGAN)
626 P-8-16-II 6,415,200 7,698,300 8,981,300
KONGENITAL/INFEKSI PERINATAL (SEDANG)
627 P-8-16-III 15,044,700 18,053,700 21,062,600
KONGENITAL/INFEKSI PERINATAL (BERAT)
NEONATAL, BBL > 2499 GR TANPA PROSEDUR MAYOR
628 P-8-17-I 4,331,800 5,198,200 6,064,500
(RINGAN)
629 P-8-17-II 7,797,200 9,356,700 10,916,100
(SEDANG)
630 P-8-17-III 13,346,600 16,015,900 18,685,200
(BERAT)
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK
631 S-4-10-I 3,764,000 4,516,800 5,269,600
ATAU BANYAK TEMPAT (RINGAN)
632 S-4-10-II 4,637,800 5,565,300 6,492,900
ATAU BANYAK TEMPAT (SEDANG)
633 S-4-10-III 6,348,600 7,618,400 8,888,100
ATAU BANYAK TEMPAT (BERAT)
634 S-4-11-I REAKSI ALLERGI (RINGAN) 1,729,700 2,075,700 2,421,600
635 S-4-11-II REAKSI ALLERGI (SEDANG) 3,515,800 4,219,000 4,922,200
636 S-4-11-III REAKSI ALLERGI (BERAT) 8,112,200 9,734,600 11,357,000
637 S-4-12-I EFEK TOKSIK DAN KERACUNAN OBAT (RINGAN) 2,767,300 3,320,700 3,874,200
638 S-4-12-II EFEK TOKSIK DAN KERACUNAN OBAT (SEDANG) 3,683,200 4,419,800 5,156,400
639 S-4-12-III EFEK TOKSIK DAN KERACUNAN OBAT (BERAT) 6,384,800 7,661,700 8,938,700
KOMPLIKASI DARI PENATALAKSANAAN PASIEN
640 S-4-13-I 4,086,500 4,903,800 5,721,100
(RINGAN)
641 S-4-13-II 7,249,800 8,699,800 10,149,800
(SEDANG)
642 S-4-13-III 11,767,400 14,120,800 16,474,300
(BERAT)
SINDROMA MALTREATMENT PADA DEWASA ATAU
643 S-4-14-I 2,068,100 2,481,700 2,895,300
KANAK-KANAK (RINGAN)
644 S-4-14-II 4,392,700 5,271,300 6,149,800
KANAK-KANAK (SEDANG)
- 16 -

REGIONAL 1
RAWAT INAP

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

REGIONAL 1
RAWAT INAP

686 U-1-20-II 12,396,900 14,876,300 17,355,700
TELINGA LAIN-LAIN (SEDANG)
687 U-1-20-III 31,825,200 38,190,200 44,555,300
TELINGA LAIN-LAIN (BERAT)
688 U-1-30-I PROSEDUR MULUT (RINGAN) 7,143,600 8,572,300 10,001,100
689 U-1-30-II PROSEDUR MULUT (SEDANG) 9,686,400 11,623,700 13,561,000
690 U-1-30-III PROSEDUR MULUT (BERAT) 18,942,200 22,730,700 26,519,100
NEOPLASMA TELIGA, HIDUNG, MULUT DAN
691 U-4-10-I 5,140,800 6,169,000 7,197,200
TENGGOROKAN (RINGAN)
692 U-4-10-II 11,769,000 14,122,800 16,476,500
TENGGOROKAN (SEDANG)
693 U-4-10-III 18,069,000 21,682,800 25,296,600
TENGGOROKAN (BERAT)
694 U-4-11-I DYSEQUILIBRIUM (RINGAN) 1,625,100 1,950,100 2,275,100
695 U-4-11-II DYSEQUILIBRIUM (SEDANG) 2,363,400 2,836,100 3,308,800
696 U-4-11-III DYSEQUILIBRIUM (BERAT) 2,486,300 2,983,600 3,480,900
697 U-4-12-I EPISTAKSIS/PERDARAHAN HIDUNG (RINGAN) 2,670,200 3,204,300 3,738,300
698 U-4-12-II EPISTAKSIS/PERDARAHAN HIDUNG (SEDANG) 4,305,300 5,166,300 6,027,400
699 U-4-12-III EPISTAKSIS/PERDARAHAN HIDUNG (BERAT) 7,539,900 9,047,900 10,555,800
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA
700 U-4-13-I 2,023,700 2,428,400 2,833,100
DAN LARINGOTRAKEITIS (RINGAN)
701 U-4-13-II 3,306,800 3,968,200 4,629,500
DAN LARINGOTRAKEITIS (SEDANG)
702 U-4-13-III 5,339,400 6,407,300 7,475,200
DAN LARINGOTRAKEITIS (BERAT)
703 U-4-14-I PENYAKIT MULUT DAN GIGI (RINGAN) 5,116,900 6,140,200 7,163,600
704 U-4-14-II PENYAKIT MULUT DAN GIGI (SEDANG) 6,127,300 7,352,800 8,578,200
705 U-4-14-III PENYAKIT MULUT DAN GIGI (BERAT) 10,289,600 12,347,500 14,405,500
PENYAKIT TELINGA, HIDUNG, MULUT DAN
706 U-4-15-I 4,108,700 4,930,400 5,752,200
TENGGOROKAN LAIN-LAIN (RINGAN)
707 U-4-15-II 5,118,900 6,142,700 7,166,500
TENGGOROKAN LAIN-LAIN (SEDANG)
708 U-4-15-III 7,164,000 8,596,800 10,029,600
TENGGOROKAN LAIN-LAIN (BERAT)
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK
709 V-1-10-I 6,701,600 8,042,000 9,382,300
(RINGAN)
710 V-1-10-II 13,805,100 16,566,100 19,327,100
(SEDANG)
711 V-1-10-III 16,930,000 20,316,000 23,702,000
(BERAT)
712 V-1-11-I PROSEDUR PADA PENIS (RINGAN) 12,749,500 15,299,400 17,849,400
713 V-1-11-II PROSEDUR PADA PENIS (SEDANG) 14,558,500 17,470,100 20,381,800
714 V-1-11-III PROSEDUR PADA PENIS (BERAT) 22,799,200 27,359,000 31,918,800
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-
715 V-1-12-I 11,987,000 14,384,400 16,781,800
MODERAT (RINGAN)
716 V-1-12-II 16,369,200 19,643,100 22,916,900
MODERAT (SEDANG)
717 V-1-12-III 20,748,200 24,897,800 29,047,500
MODERAT (BERAT)
PROSEDUR PADA SKROTUM DAN PROSTAT NON
718 V-1-13-I 6,252,600 7,503,100 8,753,600
KOMPLEK (RINGAN)
719 V-1-13-II 11,946,600 14,336,000 16,725,300
KOMPLEK (SEDANG)
720 V-1-13-III 18,742,800 22,491,400 26,239,900
KOMPLEK (BERAT)
PENGANGKATAN PROSTAT MELALUI URETRA
721 V-1-14-I 12,261,300 14,713,500 17,165,800
(RINGAN)
722 V-1-14-II 17,815,300 21,378,300 24,941,400
(SEDANG)
723 V-1-14-III PENGANGKATAN PROSTAT MELALUI URETRA (BERAT) 22,245,600 26,694,700 31,143,800
724 V-1-15-I SIRKUMSISI (RINGAN) 1,974,700 2,369,600 2,764,600

725 V-1-15-II SIRKUMSISI (SEDANG) 2,179,100 2,614,900 3,050,700
726 V-1-15-III SIRKUMSISI (BERAT) 2,410,500 2,892,600 3,374,700
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI
727 V-4-10-I 5,336,400 6,403,700 7,471,000
(RINGAN)
- 18 -

REGIONAL 1
RAWAT INAP

728 V-4-10-II 8,864,100 10,636,900 12,409,700
(SEDANG)
729 V-4-10-III 14,613,700 17,536,500 20,459,200
(BERAT)
PENYAKIT SISTEM REPRODUKSI LAKI-LAKI SELAIN
730 V-4-11-I 5,123,300 6,148,000 7,172,600
TUMOR (RINGAN)
731 V-4-11-II 6,874,200 8,249,000 9,623,800
TUMOR (SEDANG)
732 V-4-11-III 9,208,000 11,049,600 12,891,200
TUMOR (BERAT)
OPERASI PENGANGKATAN RAHIM DAN VULVA
733 W-1-01-I 13,964,300 16,757,200 19,550,100
RADIKAL & EVISCERASI (RINGAN)
734 W-1-01-II 16,737,200 20,084,700 23,432,100
RADIKAL & EVISCERASI (SEDANG)
735 W-1-01-III 23,883,600 28,660,300 33,437,000
RADIKAL & EVISCERASI (BERAT)
736 W-1-10-I PROSEDUR ABORSI (RINGAN) 2,962,000 3,554,400 4,146,800
737 W-1-10-II PROSEDUR ABORSI (SEDANG) 3,268,600 3,922,300 4,576,000
738 W-1-10-III PROSEDUR ABORSI (BERAT) 3,615,700 4,338,900 5,062,000
PROSEDUR DILATASI, KURET, INTRAUTERIN &
739 W-1-11-I 3,096,000 3,715,200 4,334,400
SERVIK (RINGAN)
740 W-1-11-II 3,416,400 4,099,700 4,783,000
SERVIK (SEDANG)
741 W-1-11-III 3,779,200 4,535,100 5,290,900
SERVIK (BERAT)
742 W-1-12-I PROSEDUR PADAA TUBA FALOPII (RINGAN) 3,330,600 3,996,800 4,662,900
743 W-1-12-II PROSEDUR PADAA TUBA FALOPII (SEDANG) 4,157,200 4,988,700 5,820,100
744 W-1-12-III PROSEDUR PADAA TUBA FALOPII (BERAT) 7,361,500 8,833,800 10,306,100
745 W-1-13-I INTERUPSI TUBA DENGAN ENDOSKOP (RINGAN) 3,423,600 4,108,300 4,793,100
746 W-1-13-II INTERUPSI TUBA DENGAN ENDOSKOP (SEDANG) 3,716,900 4,460,300 5,203,700
747 W-1-13-III INTERUPSI TUBA DENGAN ENDOSKOP (BERAT) 4,992,800 5,991,300 6,989,900
748 W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA (RINGAN) 11,465,400 13,758,500 16,051,600
749 W-1-20-II PROSEDUR PADA RAHIM & ADNEKSA (SEDANG) 14,326,100 17,191,400 20,056,600
750 W-1-20-III PROSEDUR PADA RAHIM & ADNEKSA (BERAT) 16,607,700 19,929,200 23,250,700
751 W-1-30-I PROSEDUR PADA VAGINA, SERVIK & VULVA (RINGAN) 6,472,400 7,766,800 9,061,300
752 W-1-30-II PROSEDUR PADA VAGINA, SERVIK & VULVA (SEDANG) 10,323,400 12,388,100 14,452,800
753 W-1-30-III PROSEDUR PADA VAGINA, SERVIK & VULVA (BERAT) 25,329,100 30,394,900 35,460,700
754 W-4-10-I TUMOR SISTEM REPRODUKSI WANITA (RINGAN) 4,822,600 5,787,100 6,751,600
755 W-4-10-II TUMOR SISTEM REPRODUKSI WANITA (SEDANG) 7,149,300 8,579,100 10,009,000
756 W-4-10-III TUMOR SISTEM REPRODUKSI WANITA (BERAT) 14,128,400 16,954,100 19,779,800
757 W-4-11-I INFEKSI SISTEM REPRODUKSI WANITA (RINGAN) 3,947,200 4,736,700 5,526,100
758 W-4-11-II INFEKSI SISTEM REPRODUKSI WANITA (SEDANG) 5,992,500 7,191,000 8,389,500
759 W-4-11-III INFEKSI SISTEM REPRODUKSI WANITA (BERAT) 7,294,000 8,752,800 10,211,600
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI
760 W-4-12-I 2,959,900 3,551,900 4,143,800
WANITA LAIN-LAIN (RINGAN)
761 W-4-12-II 5,632,700 6,759,300 7,885,800
WANITA LAIN-LAIN (SEDANG)
762 W-4-12-III 8,289,000 9,946,800 11,604,500
WANITA LAIN-LAIN (BERAT)
763 W-4-13-I ABORTUS (RINGAN) 1,725,600 2,070,700 2,415,800
764 W-4-13-II ABORTUS (SEDANG) 2,357,200 2,828,600 3,300,000
765 W-4-13-III ABORTUS (BERAT) 2,931,300 3,517,500 4,103,800
766 W-4-14-I ABORTUS MENGANCAM (RINGAN) 2,306,000 2,767,200 3,228,400
767 W-4-14-II ABORTUS MENGANCAM (SEDANG) 2,744,800 3,293,700 3,842,700
768 W-4-14-III ABORTUS MENGANCAM (BERAT) 3,511,600 4,213,900 4,916,200
769 W-4-15-I PERSALINAN FALSE LABOR (RINGAN) 1,665,400 1,998,500 2,331,600
770 W-4-15-II PERSALINAN FALSE LABOR (SEDANG) 2,563,800 3,076,500 3,589,300
771 W-4-15-III PERSALINAN FALSE LABOR (BERAT) 4,792,000 5,750,400 6,708,800
772 W-4-16-I GANGGUAN ANTEPARTUM (RINGAN) 2,215,900 2,659,100 3,102,300
773 W-4-16-II GANGGUAN ANTEPARTUM (SEDANG) 4,107,300 4,928,800 5,750,300
774 W-4-16-III GANGGUAN ANTEPARTUM (BERAT) 7,515,200 9,018,200 10,521,200
775 W-4-17-I GANGGUAN POSTPARTUM (RINGAN) 1,635,100 1,962,100 2,289,100
- 19 -

REGIONAL 1
RAWAT INAP

776 W-4-17-II GANGGUAN POSTPARTUM (SEDANG) 4,092,100 4,910,500 5,728,900
777 W-4-17-III GANGGUAN POSTPARTUM (BERAT) 8,167,600 9,801,100 11,434,600
778 Z-4-10-I REHABILITASI (RINGAN) 4,863,200 5,835,800 6,808,500
779 Z-4-10-II REHABILITASI (SEDANG) 6,454,800 7,745,800 9,036,700
780 Z-4-10-III REHABILITASI (BERAT) 9,170,200 11,004,300 12,838,300
781 Z-4-11-I GEJALA-GEJALA DAN TANDA-TANDA (RINGAN) 3,165,900 3,799,100 4,432,300
782 Z-4-11-II GEJALA-GEJALA DAN TANDA-TANDA (SEDANG) 3,802,500 4,562,900 5,323,400
783 Z-4-11-III GEJALA-GEJALA DAN TANDA-TANDA (BERAT) 5,226,700 6,272,000 7,317,400
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS
784 Z-4-12-I 2,092,500 2,511,000 2,929,500
KESEHATAN LAIN-LAIN (RINGAN)
785 Z-4-12-II 4,201,500 5,041,800 5,882,100
KESEHATAN LAIN-LAIN (SEDANG)
786 Z-4-12-III 8,864,100 10,636,900 12,409,700
KESEHATAN LAIN-LAIN (BERAT)
- 20 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS A PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
1 B-2-10-0 PROSEDUR PADA HATI DAN PANKREAS 1,390,000
2 B-2-11-0 PROSEDUR BESAR PADA SALURAN EMPEDU 1,803,000
3 B-2-12-0 PROSEDUR KOLESISTEKTOMI TANPA LAPAROSKOPI 3,352,900
4 B-2-13-0 PROSEDUR LAIN-LAIN PADA HEPATOBILIARI & PANKREAS 2,770,800
5 B-2-14-0 PROSEDUR KOLESISTEKTOMI DENGAN LAPAROSKOPI 3,600,800
6 B-3-10-0 PROSEDUR PERKUTAN PADA HATI DAN SALURAN EMPEDU 662,300
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 1,471,600
8 B-3-12-0 PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN PANKREAS 517,900
9 C-3-10-0 PROSEDUR RADIOTERAPI 1,144,400
10 C-3-11-0 KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH 981,300
11 C-3-12-0 KEMOTERAPI PADA TUMOR KOLON 1,114,000
12 C-3-13-0 KEMOTERAPI PADA TUMOR PAYUDARA ATAU OVARIUM 1,674,900
13 C-3-14-0 KEMOTERAPI PADA TUMOR GASTROINTESTINAL 2,284,500
14 C-3-15-0 KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU PROSTAT 2,093,800
15 C-3-16-0 KEMOTERAPI PADA TUMOR OTAK 678,300
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 1,565,600
17 C-3-18-0 KEMOTERAPI PADA LEUKEMIA AKUT 567,900
18 C-3-19-0 KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS 975,000
19 C-3-20-0 KEMOTERAPI PADA TUMOR KULIT 2,969,800
20 C-3-21-0 KEMOTERAPI PADA TUMOR GINEKOLOGI 1,063,600
21 C-3-22-0 KEMOTERAPI PADA TUMOR METASTASE 2,511,700
22 C-3-23-0 KEMOTERAPI PADA TUMOR LAIN-LAIN 612,800
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 1,787,000
24 D-2-11-0 PROSEDUR LIMPA 2,237,600
25 D-2-21-0 PROSEDUR BESAR PADA NODUL LIMPA DAN TYMUS 1,876,700
26 D-2-22-0 PROSEDUR KECIL PADA NODUL LIMPA DAN TYMUS 460,300
27 D-3-10-0 PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG 1,394,900
28 D-3-11-0 PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH 775,600
29 E-2-10-0 PROSEDUR PADA KELENJAR ADRENAL 498,500
30 E-2-21-0 PROSEDUR BESAR PADA KELENJAR TIROID DAN PARATIROID 431,200
31 E-2-22-0 PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN THYROGLOSSAL 380,600
32 E-3-10-0 PROSEDUR DIAGNOSTIK PADA KELENJAR ENDOKRIN 455,100

33 F-3-10-0 TERAPI SHOCK 633,700
34 F-5-10-0 PELAYANAN KESEHATAN MENTAL EKSTENSIF 466,700
35 F-5-11-0 TERAPI KELOMPOK 512,600
36 F-5-12-0 PROSEDUR TES DIAGNOSTIK KESEHATAN JIWA 394,800
37 F-5-13-0 PSIKOTERAPI INDIVIDU DEWASA AKUT 683,500
38 F-5-14-0 PSIKOTHERAPI INDIVIDU DEWASA BUKAN AKUT 354,400
39 F-5-15-0 PENGOBATAN INDIVIDU KETERBELAKANGAN MENTAL 351,700
40 F-5-16-0 PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN MENTAL 358,500
41 G-2-10-0 PROSEDUR KRANIOTOMI 8,183,600
42 G-2-11-0 PROSEDUR SHUNT VENTRIKEL 3,270,600
43 G-2-12-0 PROSEDUR PADA PEMBULUH DARAH EKSTRAKRANIAL 3,281,600
44 G-2-13-0 PROSEDUR CARPAL TUNNEL RELEASE 844,100
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 1,727,800
46 G-2-22-0 PROSEDUR KECIL PADA SARAF PERIFER 1,081,800
47 G-2-31-0 PROSEDUR BESAR PADA TULANG BELAKANG 2,198,800
48 G-2-32-0 PROSEDUR KECIL PADA TULANG BELAKANG 1,127,100
49 G-3-10-0 PROSEDUR TAP & INJEKSI PADA SPINAL 645,500
50 G-3-11-0 PROSEDUR INJEKSI PADA SARAF PERIFER 487,400
51 G-3-12-0 PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN 786,100
52 G-3-13-0 PROSEDUR ELEKROENSEFALOGRAFI (EEG) 557,800
53 G-5-17-0 PENYAKIT SARAF KRANIAL DAN SARAF PERIFER LAIN-LAIN 371,500
54 H-2-21-0 PROSEDUR BESAR PADA MATA EKSTERNAL 3,623,600
55 H-2-22-0 PROSEDUR SEDANG PADA MATA EKSTERNAL 1,449,400
56 H-2-23-0 PROSEDUR KECIL PADA MATA EKSTERNAL 966,300
57 H-2-31-0 PROSEDUR BESAR PADA SEGMEN ANTERIOR MATA 3,772,100
58 H-2-32-0 PROSEDUR SEDANG PADA SEGMEN ANTERIOR MATA 2,514,700
59 H-2-33-0 PROSEDUR KECIL PADA SEGMEN ANTERIOR MATA 391,800
60 H-2-34-0 PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA 4,086,400
61 H-2-35-0 PROSEDUR KECIL PADA SEGMEN POSTERIOR MATA 2,829,100
62 H-2-36-0 PROSEDUR OPERASI KATARAK 4,410,000
63 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 1,469,700
64 H-3-10-0 PROSEDUR LASER SEDANG PADA MATA 904,000
65 H-3-11-0 PROSEDUR KECIL PADA EKTRAOKULER 389,000
66 H-3-12-0 PROSEDUR LAIN-LAIN PADA MATA 384,800
67 H-3-13-0 PROSEDUR DIAGNOSTIK & IMAGING PADA MATA 365,300
68 I-2-11-0 PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTUNG 5,570,300
69 I-2-12-0 PROSEDUR BESAR PADA PEMBULUH DARAH TORASIK 2,711,500
- 21 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
70 I-2-13-0 PROSEDUR BESAR PADA PEMBULUH DARAH ABDOMEN 3,446,100
71 I-2-14-0 PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUNG 6,098,800
72 I-2-15-0 PROSEDUR KATETERISASI JANTUNG 5,056,600
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK
73 I-2-16-0 3,852,100
PENGGANTIAN ALAT
74 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA 1,269,900
75 I-2-21-0 ANGIOGRAFI ARTERI BUKAN JANTUNG 4,287,500
76 I-2-22-0 PROSEDUR SEDANG PADA PEMBULUH DARAH 2,799,500
77 I-2-23-0 PROSEDUR KECIL PADA PEMBULUH DARAH 688,200
78 I-2-31-0 PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR JANTUNG 6,437,000
79 I-2-32-0 PEMASANGAN ATAU PENGGANTIAN ALAT PACU JANTUNG 5,827,300
80 I-2-41-0 PROSEDUR ELEKTROFISIOLOGIK 3,907,200
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR
81 I-2-42-0 3,701,600
PERKUTAN LAIN
82 I-3-10-0 PROSEDUR RESUSITASI 457,500
83 I-3-11-0 PROSEDUR KARDIOVERSI 439,600
84 I-3-12-0 PROSEDUR KECIL LAIN-LAIN PADA JANTUNG 1,768,900
85 I-3-13-0 PROSEDUR EKOKARDIOGRAFI 483,400
86 I-3-14-0 PROSEDUR STRESS TESTING 430,700
87 I-3-15-0 PROSEDUR PENGAWASAN FUNGSI KARDIOVASKULAR 476,000
88 J-2-10-0 PROSEDUR BESAR PADA SISTEM SALURAN PERNAFASAN 2,042,400
89 J-2-21-0 PROSEDUR VENTILASI MEKANIKAL JANGKA PENDEK 2,231,800
90 J-2-22-0 PROSEDUR PADA LARING DAN TRAKEA 1,949,400
91 J-2-31-0 PROSEDUR THORAKOSKOPI/MEDIASTINOSKOPI 2,152,000
92 J-2-32-0 PROSEDUR DADA INTERMEDIATE 1,303,300
93 J-3-10-0 PROSEDUR PADA DINDING DADA 433,200
94 J-3-11-0 PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA 763,700
95 J-3-12-0 PROSEDUR THORACENTESIS 524,200
96 J-3-13-0 PROSEDUR TERAPI SALURAN PERNAFASAN 473,300
97 J-3-14-0 PROSEDUR BIOPSI PERKUTAN DAN ASPIRASI 461,200
98 J-3-15-0 PROSEDUR BRONKOSKOPI 585,500
99 J-3-16-0 PROSEDUR UJI FUNGSI PARU 667,700
100 J-3-17-0 PROSEDUR LAIN-LAIN PADA SISTEM SALURAN PERNAFASAN 391,400
101 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL 1,123,400
102 K-2-11-0 PROSEDUR ADHESIOLYSIS PADA PERITONEUM 2,047,400
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 1,571,600
104 K-2-13-0 PROSEDUR PADA USUS BUNTU 3,694,800
105 K-2-14-0 PROSEDUR PADA HERNIA INGUINALIS DAN FEMORALIS 481,100
106 K-2-21-0 PROSEDUR BESAR PADA USUS HALUS DAN USUS BESAR 481,100
107 K-2-22-0 PROSEDUR BESAR PADA GASTROINTESTINAL ATAS 4,267,700
108 K-2-31-0 PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS 1,985,300
109 K-2-32-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL ATAS 380,800
110 K-2-41-0 PROSEDUR LAPAROSKOPI 1,761,800
111 K-2-42-0 PROSEDUR LAPAROTOMI & GASTROINTESTINAL LAINNYA 4,576,800
112 K-2-51-0 PROSEDUR UNTUK WASIR 1,050,800
113 K-2-52-0 PROSEDUR SEDANG PADA ANUS & REKTUM 827,700
114 K-2-53-0 PROSEDUR KECIL PADA ANUS & REKTUM 405,500
115 K-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL 273,600
116 K-3-11-0 PROSEDUR LAIN-LAIN PADA ANUS & REKTUM 549,000
117 K-3-12-0 PROSEDUR SIGMOIDOSKOPI DAN ANOSKOPI 765,600
118 K-3-13-0 PROSEDUR KOLONOSKOPI 1,833,100
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 1,615,700
120 K-3-15-0 PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS 1,131,000
121 K-3-16-0 PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL 675,000
122 K-5-18-0 PENYAKIT SISTEM PENCERNAAN LAIN-LAIN 371,500
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 1,963,900
124 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR 1,258,900
125 L-2-31-0 PROSEDUR BESAR PEMINDAHAN KULIT TANPA LUKA BAKAR 672,400
126 L-2-32-0 PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR 613,800
127 L-2-41-0 PROSEDUR BEDAH PLASTIK 2,011,400
128 L-2-42-0 PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH KULIT 528,100
129 L-2-51-0 PROSEDUR PENGANGKATAN PAYUDARA 2,568,700
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 1,965,200
131 L-2-53-0 PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 479,400
132 L-3-10-0 PROSEDUR KECIL LAIN-LAIN PADA PAYUDARA 531,500
133 L-3-11-0 PROSEDUR BESAR PADA KULIT 519,100
134 L-3-12-0 PROSEDUR KECIL PADA KULIT 373,100
135 M-2-10-0 PROSEDUR REKONTRUKSI TULANG KRANIAL DAN WAJAH 2,141,200
136 M-2-21-0 PROSEDUR BESAR PADA SENDI PANGGUL DAN PAHA 2,353,500
137 M-2-22-0 PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA 466,400
- 22 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
138 M-2-31-0 PROSEDUR BUNION 1,429,500
139 M-2-32-0 PROSEDUR LAIN-LAIN PADA KAKI 533,600
140 M-2-41-0 PROSEDUR EKSISI, INSISI DAN ARTHROTOMI TULANG 576,900
141 M-2-42-0 PROSEDUR PEMINDAHAN ALAT IMPLAN 534,200
142 M-2-51-0 PROSEDUR BESAR PADA JARINGAN LUNAK 847,500
143 M-2-52-0 PROSEDUR KECIL PADA JARINGAN LUNAK 651,900
144 M-2-61-0 PROSEDUR ARTROSKOPI 1,632,700
145 M-2-62-0 PROSEDUR LAIN-LAIN PADA SENDI & TULANG 481,700
146 M-2-63-0 PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG 1,340,300
147 M-2-64-0 PROSEDUR BESAR PADA TULANG KEPALA & WAJAH 2,238,700
148 M-2-65-0 PROSEDUR KECIL PADA TULANG KEPALA & WAJAH 392,200
149 M-2-71-0 PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH 2,387,300
150 M-2-72-0 PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH 1,293,700
151 M-2-81-0 PROSEDUR BESAR PADA LENGAN, SIKU & BAHU 2,795,700
152 M-2-82-0 PROSEDUR KECIL PADA LENGAN, SIKU & BAHU 1,411,300
153 M-2-83-0 PROSEDUR BESAR PADA TANGAN & PERGELANGAN TANGAN 623,300
154 M-2-84-0 PROSEDUR KECIL PADA TANGAN & PERGELANGAN TANGAN 479,400
155 M-3-10-0 PROSEDUR MANIPULATIVE OSTEOPATHIC 79,000
156 M-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK MUSKULOSKELETAL 621,400
157 M-3-12-0 PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL 1,404,100
158 M-3-13-0 PROSEDUR REDUKSI FRAKTUR TERTUTUP 547,200
159 M-3-14-0 PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP 739,100
160 M-3-15-0 PROSEDUR APLIKASI CASTS DAN SPLINTS 422,700
161 M-3-16-0 PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL 201,000
162 M-3-17-0 PROSEDUR PEMASANGAN ALAT PROSTETIK 426,800
163 N-2-11-0 PROSEDUR BESAR PADA KANDUNG KEMIH 6,356,400
164 N-2-12-0 PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS 3,613,100
165 N-2-21-0 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN KEMIH 6,030,300
166 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 1,851,700
167 N-2-23-0 PROSEDUR SEDANG PADA GINJAL DAN URETER 827,700
168 N-2-24-0 PROSEDUR KECIL PADA GINJAL DAN URETER 564,000
169 N-2-31-0 PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA 1,275,500
170 N-2-32-0 PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA 674,600
171 N-2-41-0 PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA 1,357,700
172 N-2-42-0 PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA 786,100
173 N-3-10-0 PROSEDUR PADA GINJAL DAN URETER 468,000
174 N-3-11-0 PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH 783,300
175 N-3-12-0 PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN KEMIH 440,800
176 N-3-13-0 PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH 672,800
177 N-3-14-0 PROSEDUR KECIL ENDOSKOPI PADA SALURAN KEMIH 515,800
178 N-3-15-0 PROSEDUR DIALISIS 982,400
179 O-7-10-0 PROSEDUR PERSALINAN DENGAN BEDAH CAESAR 2,460,700
180 O-7-11-0 PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN KURETASE 1,979,800
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN ATAU
181 O-7-12-0 1,745,600
PELEBARAN DAN KURETASE
182 O-7-13-0 PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR 1,232,000
183 P-9-11-0 NEONATAL, BBL GROUP-2 453,200
186 P-9-14-0 NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDITER 370,200
187 P-9-15-0 NEONATAL, BBL GROUP-5 DENGAN SINDROM ASPIRASI 234,800
188 P-9-16-0 NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL 369,200
190 Q-5-10-0 PENYALAHGUNAAN ZAT KIMIA AKUT 488,100
191 Q-5-11-0 PENYALAHGUNAAN ZAT KIMIA BUKAN AKUT 359,500
192 Q-5-12-0 GIGI 317,100
193 Q-5-13-0 MEDICAL CHECK-UP 110,700
194 Q-5-14-0 RONGENT (PLAIN FILM) 121,700
195 Q-5-15-0 ELEKTROKARDIOGRAM (ECG) 90,000
196 Q-5-16-0 VAKSINASI 105,600
197 Q-5-17-0 PROSEDUR CAIRAN INTRA VENA 100,700
198 Q-5-18-0 KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN 153,800
199 Q-5-19-0 KONTAK PELAYANAN KESEHATAN LAIN-LAIN 163,800
200 Q-5-20-0 ABORSI MENGANCAM 252,000
201 Q-5-21-0 ABORSI 276,800
202 Q-5-22-0 PERSALINAN YANG SUKAR (FALSE LABOR) 122,400
203 Q-5-23-0 PEMERIKSAAN ANTEPARTUM 148,600
204 Q-5-24-0 PEMERIKSAAN POSTPARTUM 101,600
205 Q-5-25-0 GASTROINTESTINAL AKUT 158,500
206 Q-5-26-0 BRONKIAL AKUT 224,900
- 23 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
207 Q-5-27-0 SISTEM PERSARAFAN PUSAT AKUT 160,100
208 Q-5-28-0 KECEDERAAN SISTEM PERSARAFAN PUSAT 282,900
209 Q-5-29-0 GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN 799,600
210 Q-5-30-0 INFARK MIOKARD AKUT DAN ARITMIA 927,000
211 Q-5-31-0 FRAKTUR 151,400
212 Q-5-32-0 SALURAN KEMIH AKUT 384,800
213 Q-5-33-0 HEMATOLOGI AKUT 184,300
214 Q-5-34-0 INFEKSI VIRUS HIV 263,100
215 Q-5-35-0 INFEKSI AKUT 647,300
216 Q-5-36-0 KEKACAUAN METABOLIK AKUT 554,100
217 Q-5-37-0 CARDIAC ARREST, RESPIRATORY ARREST & SHOCK 398,300
218 Q-5-38-0 PARU AKUT 377,200
219 Q-5-39-0 KECEDERAAN BESAR PADA JARINGAN LUNAK 150,600
220 Q-5-40-0 INFEKSI SALURAN KEMIH AKUT 147,900
221 Q-5-41-0 PENYAKIT AKUT BESAR LAIN-LAIN 444,100
222 Q-5-42-0 PENYAKIT AKUT KECIL LAIN-LAIN 332,900
223 Q-5-43-0 PENYAKIT KRONIS BESAR LAIN-LAIN 477,500
224 Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN 377,100
225 T-2-10-0 PEMULIHAN ALKOHOL, OBAT DAN ATAU TERAPI DETOKSIKASI 217,800
226 U-2-10-0 PROSEDUR BESAR PADA LARING 3,492,100
227 U-2-11-0 PROSEDUR BESAR LAIN-LAIN PADA KEPALA & LEHER 2,873,600
228 U-2-12-0 PROSEDUR PADA SINUS & MASTOID 456,600
229 U-2-13-0 PROSEDUR KELENJAR LUDAH 472,900
230 U-2-14-0 PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT 904,300
231 U-2-15-0 PROSEDUR OPERASI TONSIL & AMANDEL 888,000
232 U-2-21-0 PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 1,157,600
233 U-2-22-0 PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 598,000
234 U-2-23-0 RHINOPLASTY 1,863,500
235 U-2-24-0 PROSEDUR KECIL PADA HIDUNG 314,900
236 U-2-25-0 PROSEDUR PADA TELINGA TENGAH 486,000
237 U-2-31-0 PROSEDUR BESAR PADA MULUT DAN LIDAH 487,600
238 U-2-32-0 PROSEDUR KECIL PADA MULUT DAN LIDAH 390,400
239 U-3-10-0 PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 493,100
240 U-3-11-0 PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 466,700
241 U-3-12-0 PROSEDUR KAUTERISASI & PACKING PADA RONGGA HIDUNG 218,600
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
242 U-3-13-0 480,300
TENGGOROKAN
243 U-3-14-0 PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 425,800
244 U-3-15-0 PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 385,100
245 U-3-16-0 PROSEDUR PADA GIGI 435,500
246 V-2-10-0 PROSEDUR BESAR PADA PENGANGKATAN PROSTAT 3,605,600
247 V-2-11-0 PROSEDUR PADA PENIS 585,200
248 V-2-12-0 PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM 1,297,600
249 V-2-13-0 PROSEDUR KECIL PADA PROSTAT DAN SKROTUM 465,400
250 V-2-14-0 PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL 827,700
251 V-2-15-0 SIRKUMSISI/SUNAT 543,500
252 V-3-10-0 PROSEDUR STERILISASI PADA LAKI-LAKI 433,500
253 V-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI 1,126,800
254 V-3-12-0 PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI 1,154,000
255 W-2-10-0 PROSEDUR ABORSI 1,230,400
256 W-2-11-0 PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM 1,076,300
257 W-2-12-0 PROSEDUR TERBUKA PADA TUBA FALOPII 1,586,700
258 W-2-13-0 PROSEDUR ENDOSKOPI PADA TUBA FALOPII 320,600
259 W-2-21-0 PROSEDUR BESAR TERBUKA PADA PANGGUL 2,782,800
260 W-2-22-0 PROSEDUR KECIL TERBUKA PADA PANGGUL 422,700
261 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 1,410,600
262 W-2-31-0 PROSEDUR PEMBUANGAN RAHIM MELALUI JALAN LAHIR 3,205,800
263 W-2-32-0 PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL INTERMEDIATE 2,965,400
264 W-2-33-0 PROSEDUR KECIL VULVOVAGINAL 1,295,500
265 W-2-34-0 PROSEDUR GINEKOLOGI LAIN-LAIN 469,500
266 W-3-10-0 PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI 915,600
267 W-3-11-0 PROSEDUR SEDANG GINEKOLOGI 912,000
268 W-3-12-0 PROSEDUR KECIL GINEKOLOGI 422,700
269 Z-3-10-0 PROSEDUR RADIOSURGICAL 3,313,100
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN SALURAN
270 Z-3-11-0 2,606,000
EMPEDU
271 Z-3-12-0 PROSEDUR REHABILITASI 241,200
272 Z-3-13-0 PROSEDUR KECIL PELAYANAN PENUNJANG LAIN-LAIN 180,100
273 Z-3-14-0 DIAGNOSTIK TIDUR 234,000
274 Z-3-15-0 IMAGING NUKLIR JANTUNG 503,900
- 24 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
275 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 1,243,900
276 Z-3-17-0 PELAYANAN KEDOKTERAN NUKLIR 1,487,500
277 Z-3-18-0 CT-SCAN KEPALA 1,373,100
278 Z-3-19-0 CT SCAN LAIN-LAIN 1,656,600
279 Z-3-20-0 IMAGING KONTRAS SALURAN URINARI 793,800
280 Z-3-21-0 IMAGING KONTRAS PEMBULUH DARAH 1,104,300
281 Z-3-22-0 IMAGING KONTRAS LAIN-LAIN 763,300
282 Z-3-23-0 PROSEDUR ULTRASOUND LAIN-LAIN 642,100
283 Z-3-24-0 PROSEDUR ULTRASOUND PEMBULUH DARAH 785,600
284 Z-3-25-0 PROSEDUR ULTRASOUND GINEKOLOGIK 454,900
285 Z-3-26-0 PROSEDUR BESAR RADIOGRAFI 1,075,400
286 Z-3-27-0 PERAWATAN LUKA 215,000
287 Z-3-28-0 IMAGING PAYUDARA 796,400
288 Z-3-29-0 IMAGING LAIN-LAIN 1,339,200
289 Z-3-30-0 FOTOTERAPI 87,300
- 25 -


REGIONAL 1
RUMAH SAKIT KELAS A SWASTA
RAWAT INAP

13 A-4-14-I 2,388,100 2,865,700 3,343,400
(RINGAN)
14 A-4-14-II 4,018,100 4,821,700 5,625,400
(SEDANG)
15 A-4-14-III 4,821,700 5,786,100 6,750,400
(BERAT)

31 B-1-13-I 7,771,700 9,326,100 10,880,400
LAIN (RINGAN)
32 B-1-13-II 12,787,400 15,344,900 17,902,400
LAIN (SEDANG)
33 B-1-13-III 16,545,800 19,855,000 23,164,100
LAIN (BERAT)
34 B-1-14-I 20,361,900 24,434,200 28,506,600
(RINGAN)
35 B-1-14-II 21,385,700 25,662,800 29,940,000
(SEDANG)
40 B-4-11-I 6,966,000 8,359,300 9,752,500
(RINGAN)
41 B-4-11-II 9,752,500 11,703,100 13,653,600
(SEDANG)
42 B-4-11-III 11,815,100 14,178,100 16,541,100
(BERAT)
- 26 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 7,379,400 8,855,300 10,331,200
74 D-1-20-II 20,336,700 24,404,000 28,471,300
75 D-1-20-III 32,259,900 38,711,900 45,163,900
85 D-4-13-I 4,268,300 5,122,000 5,975,600
86 D-4-13-II 6,041,100 7,249,300 8,457,500
87 D-4-13-III 7,726,700 9,272,100 10,817,400
88 D-4-14-I 4,577,900 5,493,500 6,409,100
89 D-4-14-II 7,495,200 8,994,300 10,493,300
90 D-4-14-III 9,167,400 11,000,900 12,834,400
91 E-1-01-I 9,125,600 10,950,700 12,775,800
(RINGAN)
92 E-1-01-II 12,457,800 14,949,300 17,440,900
(SEDANG)

97 E-1-20-I 10,740,800 12,888,900 15,037,100
TIROGLOSAL (RINGAN)
- 27 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 14,456,800 17,348,100 20,239,500
TIROGLOSAL (SEDANG)
99 E-1-20-III 19,924,400 23,909,300 27,894,200
TIROGLOSAL (BERAT)
100 E-4-10-I 3,801,100 4,561,300 5,321,600
METABOLIK (RINGAN)
101 E-4-10-II 7,362,100 8,834,500 10,307,000
METABOLIK (SEDANG)
102 E-4-10-III 12,336,100 14,803,300 17,270,500
METABOLIK (BERAT)
109 E-4-13-I 5,283,100 6,339,700 7,396,300
(RINGAN)
110 E-4-13-II 7,738,800 9,286,500 10,834,300
(SEDANG)

118 F-4-12-I 2,981,900 3,578,300 4,174,600
(RINGAN)
119 F-4-12-II 4,239,300 5,087,200 5,935,000
(SEDANG)
120 F-4-12-III 9,209,700 11,051,600 12,893,500
(BERAT)
130 F-4-16-I 7,833,900 9,400,600 10,967,400
131 F-4-16-II 9,108,200 10,929,800 12,751,400
132 F-4-16-III 12,157,800 14,589,400 17,021,000
142 G-1-01-I 22,068,200 26,481,900 30,895,500
(RINGAN)
- 28 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 31,651,200 37,981,400 44,311,600
(SEDANG)
144 G-1-01-III 51,783,900 62,140,700 72,497,500
(BERAT)
151 G-1-12-I 7,051,700 8,462,000 9,872,300
(RINGAN)
152 G-1-12-II 13,218,700 15,862,400 18,506,200
(SEDANG)
153 G-1-12-III 18,014,500 21,617,400 25,220,300
(BERAT)
163 G-4-10-I 6,053,100 7,263,700 8,474,300
(RINGAN)
164 G-4-10-II 7,398,900 8,878,700 10,358,500
(SEDANG)
165 G-4-10-III 10,152,600 12,183,100 14,213,600
(BERAT)
166 G-4-11-I 6,336,600 7,604,000 8,871,300
167 G-4-11-II 8,417,400 10,100,900 11,784,400
168 G-4-11-III 12,368,100 14,841,700 17,315,300
DEGENERATIF (BERAT)
169 G-4-12-I 7,029,800 8,435,700 9,841,700
(RINGAN)
170 G-4-12-II 8,879,100 10,654,900 12,430,700
(SEDANG)

172 G-4-13-I 4,222,900 5,067,400 5,912,000
(RINGAN)
173 G-4-13-II 7,363,900 8,836,600 10,309,400
(SEDANG)
174 G-4-13-III 8,733,700 10,480,500 12,227,200
(BERAT)
175 G-4-14-I 7,163,600 8,596,300 10,029,100
INFARK (RINGAN)
176 G-4-14-II 9,577,200 11,492,700 13,408,100
INFARK (SEDANG)
177 G-4-14-III 12,020,600 14,424,700 16,828,800
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 29 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 6,426,900 7,712,300 8,997,700
(RINGAN)
185 G-4-17-II 8,427,100 10,112,500 11,797,900
(SEDANG)
186 G-4-17-III 10,589,000 12,706,800 14,824,700
(BERAT)
190 G-4-19-I 5,280,900 6,337,000 7,393,200
191 G-4-19-II 8,925,900 10,711,100 12,496,300
192 G-4-19-III 11,719,300 14,063,200 16,407,100
211 G-4-26-I 4,109,200 4,931,000 5,752,800
LAIN (RINGAN)
212 G-4-26-II 4,780,200 5,736,300 6,692,300
LAIN (SEDANG)
213 G-4-26-III 7,147,900 8,577,500 10,007,100
LAIN (BERAT)
232 I-1-02-I 36,998,100 44,397,700 51,797,400
(RINGAN)
- 30 -

REGIONAL 1
RAWAT INAP

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

REGIONAL 1
RAWAT INAP

270 I-1-17-III 29,262,400 35,114,800 40,967,300
(BERAT)
271 I-1-20-I 21,296,000 25,555,200 29,814,400
(RINGAN)
272 I-1-20-II 26,604,600 31,925,500 37,246,400
(SEDANG)
273 I-1-20-III 27,966,900 33,560,300 39,153,700
(BERAT)
274 I-1-30-I 16,109,200 19,331,100 22,552,900
JANTUNG (RINGAN)
275 I-1-30-II 33,510,800 40,212,900 46,915,100
JANTUNG (SEDANG)
276 I-1-30-III 51,929,600 62,315,600 72,701,500
JANTUNG (BERAT)

289 I-4-13-I 5,043,600 6,052,300 7,061,100
(RINGAN)
290 I-4-13-II 9,006,000 10,807,200 12,608,400
(SEDANG)
291 I-4-13-III 12,976,300 15,571,600 18,166,900
(BERAT)
295 I-4-15-I 4,864,200 5,837,000 6,809,800
(RINGAN)
296 I-4-15-II 9,172,400 11,006,900 12,841,300
(SEDANG)

304 I-4-18-I 5,798,300 6,958,000 8,117,700
JANTUNG (RINGAN)
305 I-4-18-II 8,828,200 10,593,800 12,359,500
JANTUNG (SEDANG)
306 I-4-18-III 11,985,700 14,382,900 16,780,000
JANTUNG (BERAT)

308 I-4-19-II 8,732,900 10,479,500 12,226,100
(SEDANG)
- 32 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 4,781,700 5,738,000 6,694,400
320 I-4-23-II 5,870,500 7,044,700 8,218,800
321 I-4-23-III 11,470,700 13,764,900 16,059,000
322 I-4-24-I 3,106,500 3,727,800 4,349,100
(RINGAN)
323 I-4-24-II 7,153,400 8,584,100 10,014,800
(SEDANG)
324 I-4-24-III 9,044,300 10,853,100 12,662,000
(BERAT)
325 J-1-01-I 98,428,000 118,113,600 137,799,200
326 J-1-01-II 111,389,600 133,667,500 155,945,400
327 J-1-01-III 152,790,000 183,348,000 213,906,000
TRAKEOSTOMI (BERAT)
328 J-1-02-I 64,212,300 77,054,800 89,897,300
329 J-1-02-II 81,023,500 97,228,200 113,432,900
330 J-1-02-III 94,786,000 113,743,200 132,700,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,518,500 15,022,100 17,525,800
(RINGAN)
332 J-1-10-II 25,331,200 30,397,400 35,463,600
(SEDANG)
333 J-1-10-III 26,325,300 31,590,400 36,855,500
(BERAT)
334 J-1-20-I 34,486,100 41,383,300 48,280,600
(RINGAN)
335 J-1-20-II 36,111,600 43,333,900 50,556,200
(SEDANG)
336 J-1-20-III 40,638,900 48,766,700 56,894,400
(BERAT)
337 J-1-30-I 10,447,000 12,536,400 14,625,800
(RINGAN)
338 J-1-30-II 18,924,600 22,709,500 26,494,400
(SEDANG)

- 33 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 3,036,900 3,644,300 4,251,700
374 J-4-21-II 6,781,400 8,137,600 9,493,900
375 J-4-21-III 12,774,900 15,329,800 17,884,800
376 K-1-10-I 11,348,700 13,618,500 15,888,200
BESAR (RINGAN)
377 K-1-10-II 14,262,100 17,114,500 19,967,000
BESAR (SEDANG)
378 K-1-10-III 16,715,700 20,058,800 23,402,000
BESAR (BERAT)
382 K-1-12-I 4,761,800 5,714,100 6,666,500
FEMORAL (RINGAN)
383 K-1-12-II 6,193,200 7,431,900 8,670,500
FEMORAL (SEDANG)
384 K-1-12-III 12,269,700 14,723,700 17,177,600
FEMORAL (BERAT)
388 K-1-14-I 7,843,600 9,412,300 10,981,000
(RINGAN)
389 K-1-14-II 9,192,500 11,031,000 12,869,500
(SEDANG)

394 K-1-30-I 9,979,900 11,975,800 13,971,800
395 K-1-30-II 17,724,000 21,268,800 24,813,600
396 K-1-30-III 24,388,500 29,266,200 34,143,900

398 K-1-40-II 12,277,000 14,732,400 17,187,700
(SEDANG)

- 34 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 5,692,100 6,830,500 7,968,900
413 K-4-13-II 7,363,100 8,835,700 10,308,300
414 K-4-13-III 11,341,500 13,609,800 15,878,100
415 K-4-14-I 3,247,900 3,897,500 4,547,100
(RINGAN)
416 K-4-14-II 4,359,800 5,231,700 6,103,700
(SEDANG)
417 K-4-14-III 6,995,700 8,394,900 9,794,000
(BERAT)

424 K-4-17-I 2,056,500 2,467,800 2,879,200
(RINGAN)
425 K-4-17-II 2,532,600 3,039,200 3,545,700
(SEDANG)
426 K-4-17-III 3,039,200 3,647,000 4,254,800
(BERAT)
427 K-4-18-I 1,812,300 2,174,800 2,537,200
(RINGAN)
428 K-4-18-II 3,058,300 3,669,900 4,281,600
(SEDANG)
436 L-1-40-I 7,114,100 8,536,900 9,959,800
(RINGAN)
437 L-1-40-II 14,269,300 17,123,200 19,977,100
(SEDANG)
438 L-1-40-III 24,018,500 28,822,200 33,625,900
(BERAT)
451 L-4-13-I 2,586,900 3,104,200 3,621,600
PAYUDARA (RINGAN)
- 35 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 4,214,100 5,057,000 5,899,800
PAYUDARA (SEDANG)
453 L-4-13-III 8,371,600 10,045,900 11,720,200
PAYUDARA (BERAT)
454 L-4-14-I 4,206,900 5,048,300 5,889,700
(RINGAN)
455 L-4-14-II 6,318,900 7,582,700 8,846,500
(SEDANG)
456 L-4-14-III 8,907,300 10,688,700 12,470,200
(BERAT)
457 M-1-01-I 14,871,000 17,845,200 20,819,400
458 M-1-01-II 21,137,100 25,364,500 29,591,900
459 M-1-01-III 29,691,300 35,629,500 41,567,800
463 M-1-03-I 52,686,800 63,224,100 73,761,500
464 M-1-03-II 61,624,900 73,949,800 86,274,800
465 M-1-03-III 76,271,000 91,525,200 106,779,400
472 M-1-07-I 19,177,100 23,012,500 26,848,000
473 M-1-07-II 25,690,700 30,828,900 35,967,000
474 M-1-07-III 52,334,400 62,801,200 73,268,100
475 M-1-10-I 22,662,300 27,194,700 31,727,200
WAJAH (RINGAN)
476 M-1-10-II 54,184,500 65,021,400 75,858,300
WAJAH (SEDANG)
477 M-1-10-III 116,870,900 140,245,100 163,619,300
WAJAH (BERAT)
478 M-1-20-I 17,659,400 21,191,300 24,723,200
(RINGAN)
479 M-1-20-II 22,561,700 27,074,000 31,586,400
(SEDANG)

484 M-1-40-I 7,400,300 8,880,300 10,360,400
INTERNAL (RINGAN)
485 M-1-40-II 10,936,700 13,124,100 15,311,400
INTERNAL (SEDANG)
486 M-1-40-III 15,615,600 18,738,700 21,861,800
INTERNAL (BERAT)
490 M-1-60-I 11,413,400 13,696,100 15,978,700
491 M-1-60-II 14,349,300 17,219,100 20,089,000
492 M-1-60-III 21,676,300 26,011,500 30,346,800
- 36 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 21,145,400 25,374,400 29,603,500
KAKI (RINGAN)
494 M-1-70-II 23,259,900 27,911,900 32,563,900
KAKI (SEDANG)
495 M-1-70-III 26,629,500 31,955,400 37,281,300
KAKI (BERAT)
502 M-4-11-I 5,276,300 6,331,600 7,386,800
(RINGAN)
503 M-4-11-II 11,568,100 13,881,700 16,195,300
(SEDANG)
504 M-4-11-III 16,725,500 20,070,600 23,415,700
(BERAT)
505 M-4-12-I 4,211,700 5,054,000 5,896,400
(RINGAN)
506 M-4-12-II 7,005,200 8,406,200 9,807,300
(SEDANG)
507 M-4-12-III 9,370,200 11,244,200 13,118,200
(BERAT)
508 M-4-13-I 7,012,900 8,415,500 9,818,000
509 M-4-13-II 10,536,600 12,643,900 14,751,200
510 M-4-13-III 20,556,600 24,667,900 28,779,200
520 M-4-17-I 4,742,800 5,691,400 6,639,900
(RINGAN)
521 M-4-17-II 6,633,400 7,960,000 9,286,700
(SEDANG)
522 M-4-17-III 9,263,000 11,115,700 12,968,300
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,771,000 4,525,200 5,279,400
(RINGAN)
530 M-4-20-II 5,522,000 6,626,400 7,730,800
(SEDANG)
531 M-4-20-III 6,171,500 7,405,800 8,640,100
(BERAT)
532 M-4-21-I 3,797,100 4,556,500 5,316,000
533 M-4-21-II 4,749,100 5,698,900 6,648,700
- 37 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 10,647,400 12,776,900 14,906,400
541 N-1-12-I 6,202,500 7,443,000 8,683,500
542 N-1-12-II 12,348,500 14,818,200 17,287,900
543 N-1-12-III 26,796,700 32,156,000 37,515,300
547 N-1-30-I 12,410,700 14,892,800 17,375,000
BAWAH (RINGAN)
548 N-1-30-II 18,774,900 22,529,900 26,284,900
BAWAH (SEDANG)
549 N-1-30-III 21,608,200 25,929,800 30,251,400
BAWAH (BERAT)
550 N-1-40-I 11,145,700 13,374,800 15,604,000
(RINGAN)
551 N-1-40-II 15,135,600 18,162,700 21,189,800
(SEDANG)
552 N-1-40-III 17,615,800 21,139,000 24,662,200
(BERAT)
553 N-4-10-I 4,735,400 5,682,400 6,629,500
(RINGAN)
554 N-4-10-II 5,727,500 6,873,000 8,018,500
(SEDANG)
555 N-4-10-III 8,424,300 10,109,200 11,794,100
(BERAT)
568 N-4-15-I 4,313,100 5,175,700 6,038,300
URIN (RINGAN)
569 N-4-15-II 5,351,700 6,422,100 7,492,400
URIN (SEDANG)
570 N-4-15-III 6,107,300 7,328,700 8,550,200
URIN (BERAT)
571 N-4-16-I 5,281,300 6,337,600 7,393,900
(RINGAN)
572 N-4-16-II 7,538,100 9,045,800 10,553,400
(SEDANG)
573 N-4-16-III 10,033,800 12,040,600 14,047,300
(BERAT)
- 38 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 4,909,200 5,891,100 6,872,900
578 O-6-11-II 5,456,100 6,547,300 7,638,500
579 O-6-11-III 6,787,400 8,144,900 9,502,400
580 O-6-12-I 3,478,100 4,173,800 4,869,400
581 O-6-12-II 4,177,200 5,012,600 5,848,100
582 O-6-12-III 5,248,800 6,298,600 7,348,400
586 P-8-01-I 77,667,200 93,200,600 108,734,000
587 P-8-01-II 96,101,500 115,321,800 134,542,100
588 P-8-01-III 112,796,100 135,355,300 157,914,600
589 P-8-02-I 106,012,000 127,214,400 148,416,800
590 P-8-02-II 121,606,400 145,927,700 170,249,000
591 P-8-02-III 138,944,000 166,732,800 194,521,600
592 P-8-03-I 15,901,700 19,082,000 22,262,400
593 P-8-03-II 21,048,100 25,257,700 29,467,300
594 P-8-03-III 29,594,500 35,513,400 41,432,400
595 P-8-04-I 51,243,900 61,492,700 71,741,400
596 P-8-04-II 66,503,500 79,804,200 93,104,900
597 P-8-04-III 95,349,300 114,419,200 133,489,000
598 P-8-05-I 27,864,800 33,437,700 39,010,700
599 P-8-05-II 42,986,300 51,583,500 60,180,800
600 P-8-05-III 58,189,900 69,827,800 81,465,800
601 P-8-06-I 7,522,600 9,027,100 10,531,600
602 P-8-06-II 21,091,700 25,310,000 29,528,300
603 P-8-06-III 27,941,300 33,529,500 39,117,800
604 P-8-07-I 8,905,600 10,686,700 12,467,800
605 P-8-07-II 24,969,300 29,963,100 34,957,000
606 P-8-07-III 33,078,200 39,693,800 46,309,400
607 P-8-08-I 5,152,900 6,183,500 7,214,000
608 P-8-08-II 7,311,700 8,774,000 10,236,400
609 P-8-08-III 14,224,100 17,069,000 19,913,800
610 P-8-11-I 13,251,400 15,901,700 18,552,000
MAYOR (RINGAN)
611 P-8-11-II 17,540,000 21,048,100 24,556,100
MAYOR (SEDANG)
- 39 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 24,662,100 29,594,500 34,527,000
MAYOR (BERAT)
613 P-8-12-I 12,046,700 14,456,100 16,865,400
MAYOR (RINGAN)
614 P-8-12-II 14,616,700 17,540,000 20,463,400
MAYOR (SEDANG)
615 P-8-12-III 21,445,300 25,734,400 30,023,400
MAYOR (BERAT)
616 P-8-13-I 6,692,600 8,031,200 9,369,700
MAYOR (RINGAN)
617 P-8-13-II 10,440,500 12,528,600 14,616,700
MAYOR (SEDANG)
618 P-8-13-III 16,496,400 19,795,700 23,095,000
MAYOR (BERAT)
619 P-8-14-I 5,065,800 6,079,000 7,092,100
620 P-8-14-II 10,312,000 12,374,400 14,436,700
621 P-8-14-III 40,320,600 48,384,700 56,448,800
622 P-8-15-I 3,799,400 4,559,300 5,319,200
ASPIRASI (RINGAN)
623 P-8-15-II 7,608,500 9,130,200 10,651,900
ASPIRASI (SEDANG)
624 P-8-15-III 8,927,200 10,712,600 12,498,100
ASPIRASI (BERAT)
625 P-8-16-I 3,438,500 4,126,200 4,813,900
626 P-8-16-II 6,607,700 7,929,200 9,250,700
627 P-8-16-III 15,496,100 18,595,300 21,694,500
628 P-8-17-I 4,461,800 5,354,100 6,246,500
(RINGAN)
629 P-8-17-II 8,031,200 9,637,400 11,243,600
(SEDANG)
630 P-8-17-III 13,747,000 16,496,400 19,245,800
(BERAT)
631 S-4-10-I 3,876,900 4,652,300 5,427,600
632 S-4-10-II 4,776,900 5,732,300 6,687,700
633 S-4-10-III 6,539,100 7,846,900 9,154,700
640 S-4-13-I 4,209,100 5,051,000 5,892,800
(RINGAN)
641 S-4-13-II 7,467,300 8,960,800 10,454,200
(SEDANG)
642 S-4-13-III 12,120,400 14,544,500 16,968,500
(BERAT)
643 S-4-14-I 2,130,100 2,556,100 2,982,200
644 S-4-14-II 4,524,500 5,429,400 6,334,300
645 S-4-14-III 8,580,100 10,296,100 12,012,100
KANAK-KANAK (BERAT)
646 S-4-15-I 1,424,600 1,709,600 1,994,500
647 S-4-15-II 2,688,500 3,226,200 3,763,900
648 S-4-15-III 3,482,100 4,178,500 4,874,900
- 40 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 3,555,600 4,266,700 4,977,800
653 S-4-17-II 5,276,900 6,332,300 7,387,700
654 S-4-17-III 6,346,600 7,616,000 8,885,300
655 T-1-10-I 2,379,000 2,854,800 3,330,600
OBAT (RINGAN)
656 T-1-10-II 3,195,300 3,834,300 4,473,400
OBAT (SEDANG)
657 T-1-10-III 5,812,700 6,975,200 8,137,800
OBAT (BERAT)
658 T-4-10-I 1,302,600 1,563,100 1,823,700
659 T-4-10-II 2,482,100 2,978,600 3,475,000
660 T-4-10-III 3,607,900 4,329,500 5,051,000
661 T-4-11-I 1,258,000 1,509,600 1,761,200
662 T-4-11-II 1,979,800 2,375,800 2,771,700
663 T-4-11-III 3,188,900 3,826,700 4,464,400
664 T-4-12-I 2,947,700 3,537,200 4,126,700
LAIN (RINGAN)
665 T-4-12-II 4,449,800 5,339,700 6,229,700
LAIN (SEDANG)
666 T-4-12-III 6,887,600 8,265,100 9,642,700
LAIN (BERAT)
670 U-1-11-I 12,268,800 14,722,600 17,176,400
(RINGAN)
671 U-1-11-II 18,505,300 22,206,300 25,907,400
(SEDANG)
672 U-1-11-III 21,936,800 26,324,100 30,711,500
(BERAT)
679 U-1-14-I 5,651,300 6,781,600 7,911,800
(RINGAN)
680 U-1-14-II 6,935,500 8,322,600 9,709,700
(SEDANG)
681 U-1-14-III 8,218,600 9,862,300 11,506,000
(BERAT)
685 U-1-20-I 8,579,600 10,295,500 12,011,400
686 U-1-20-II 12,768,800 15,322,600 17,876,300
687 U-1-20-III 32,780,000 39,335,900 45,891,900
691 U-4-10-I 5,295,100 6,354,100 7,413,100
- 41 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 12,122,000 14,546,400 16,970,800
693 U-4-10-III 18,611,000 22,333,200 26,055,500
TENGGOROKAN (BERAT)
700 U-4-13-I 2,084,400 2,501,200 2,918,100
701 U-4-13-II 3,406,000 4,087,200 4,768,400
702 U-4-13-III 5,499,600 6,599,500 7,699,400
706 U-4-15-I 4,232,000 5,078,300 5,924,700
707 U-4-15-II 5,272,500 6,327,000 7,381,500
708 U-4-15-III 7,378,900 8,854,700 10,330,500
709 V-1-10-I 6,902,700 8,283,200 9,663,700
(RINGAN)
710 V-1-10-II 14,219,300 17,063,100 19,907,000
(SEDANG)
711 V-1-10-III 17,437,900 20,925,500 24,413,100
(BERAT)
715 V-1-12-I 12,346,600 14,816,000 17,285,300
MODERAT (RINGAN)
716 V-1-12-II 16,860,300 20,232,400 23,604,400
MODERAT (SEDANG)
717 V-1-12-III 21,370,600 25,644,800 29,918,900
MODERAT (BERAT)
718 V-1-13-I 6,440,200 7,728,200 9,016,200
KOMPLEK (RINGAN)
719 V-1-13-II 12,305,000 14,766,000 17,227,000
KOMPLEK (SEDANG)
720 V-1-13-III 19,305,100 23,166,100 27,027,100
KOMPLEK (BERAT)
721 V-1-14-I 12,629,100 15,154,900 17,680,800
(RINGAN)
722 V-1-14-II 18,349,700 22,019,700 25,689,600
(SEDANG)

727 V-4-10-I 5,496,500 6,595,800 7,695,100
(RINGAN)
728 V-4-10-II 9,130,000 10,956,000 12,782,000
(SEDANG)
729 V-4-10-III 15,052,100 18,062,600 21,073,000
(BERAT)
730 V-4-11-I 5,277,000 6,332,400 7,387,800
TUMOR (RINGAN)
731 V-4-11-II 7,080,400 8,496,500 9,912,500
TUMOR (SEDANG)
732 V-4-11-III 9,484,300 11,381,100 13,278,000
TUMOR (BERAT)
- 42 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 14,383,300 17,259,900 20,136,600
734 W-1-01-II 17,239,300 20,687,200 24,135,100
735 W-1-01-III 24,600,100 29,520,100 34,440,100
739 W-1-11-I 3,188,900 3,826,600 4,464,400
SERVIK (RINGAN)
740 W-1-11-II 3,518,900 4,222,700 4,926,500
SERVIK (SEDANG)
741 W-1-11-III 3,892,600 4,671,100 5,449,600
SERVIK (BERAT)
760 W-4-12-I 3,048,700 3,658,400 4,268,200
761 W-4-12-II 5,801,700 6,962,000 8,122,400
762 W-4-12-III 8,537,600 10,245,200 11,952,700
- 43 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 2,155,300 2,586,300 3,017,400
785 Z-4-12-II 4,327,500 5,193,100 6,058,600
786 Z-4-12-III 9,130,000 10,956,000 12,782,000
- 44 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS A SWASTA
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
10 C-3-11-0 KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH 1,030,300
18 C-3-19-0 KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS 1,023,700
24 D-2-11-0 PROSEDUR LIMPA 2,349,500

33 F-3-10-0 TERAPI SHOCK 665,400
56 H-2-23-0 PROSEDUR KECIL PADA MATA EKSTERNAL 1,014,600
- 45 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 4,044,700
PENGGANTIAN ALAT
81 I-2-42-0 3,886,700
PERKUTAN LAIN
- 46 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
178 N-3-15-0 PROSEDUR DIALISIS 1,031,500
181 O-7-12-0 1,832,900
192 Q-5-12-0 GIGI 333,000
196 Q-5-16-0 VAKSINASI 110,900
201 Q-5-21-0 ABORSI 290,600
206 Q-5-26-0 BRONKIAL AKUT 236,200
- 47 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 159,000
215 Q-5-35-0 INFEKSI AKUT 679,600
218 Q-5-38-0 PARU AKUT 396,000
234 U-2-23-0 RHINOPLASTY 1,956,700
242 U-3-13-0 504,400
TENGGOROKAN
270 Z-3-11-0 2,736,300
EMPEDU
- 48 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,441,800
289 Z-3-30-0 FOTOTERAPI 91,700
- 49 -


REGIONAL 1
RUMAH SAKIT KELAS B PEMERINTAH
RAWAT INAP

13 A-4-14-I 2,202,600 2,643,200 3,083,700
(RINGAN)
14 A-4-14-II 2,673,700 3,208,500 3,743,200
(SEDANG)
15 A-4-14-III 3,208,500 3,850,200 4,491,900
(BERAT)

31 B-1-13-I 5,443,600 6,532,300 7,621,000
LAIN (RINGAN)
32 B-1-13-II 8,956,800 10,748,100 12,539,500
LAIN (SEDANG)
33 B-1-13-III 11,589,300 13,907,100 16,225,000
LAIN (BERAT)
34 B-1-14-I 7,479,700 8,975,700 10,471,600
(RINGAN)
35 B-1-14-II 8,318,800 9,982,500 11,646,300
(SEDANG)
40 B-4-11-I 4,732,900 5,679,500 6,626,000
(RINGAN)
41 B-4-11-II 6,626,100 7,951,300 9,276,500
(SEDANG)
42 B-4-11-III 8,027,400 9,632,900 11,238,400
(BERAT)
- 50 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 5,013,800 6,016,500 7,019,300
74 D-1-20-II 13,817,200 16,580,600 19,344,000
75 D-1-20-III 21,918,100 26,301,700 30,685,300
85 D-4-13-I 2,900,000 3,480,000 4,060,000
86 D-4-13-II 4,104,400 4,925,300 5,746,200
87 D-4-13-III 5,249,700 6,299,700 7,349,600
88 D-4-14-I 3,110,300 3,732,400 4,354,500
89 D-4-14-II 5,092,400 6,110,900 7,129,400
90 D-4-14-III 6,228,600 7,474,300 8,720,000
91 E-1-01-I 6,820,100 8,184,200 9,548,200
(RINGAN)
92 E-1-01-II 9,310,500 11,172,600 13,034,700
(SEDANG)

97 E-1-20-I 7,297,500 8,757,000 10,216,500
TIROGLOSAL (RINGAN)
- 51 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 9,822,200 11,786,700 13,751,100
TIROGLOSAL (SEDANG)
99 E-1-20-III 13,955,700 16,746,900 19,538,000
TIROGLOSAL (BERAT)
100 E-4-10-I 3,400,700 4,080,900 4,761,000
METABOLIK (RINGAN)
101 E-4-10-II 4,751,900 5,702,300 6,652,600
METABOLIK (SEDANG)
102 E-4-10-III 6,080,400 7,296,500 8,512,600
METABOLIK (BERAT)
109 E-4-13-I 3,589,400 4,307,300 5,025,200
(RINGAN)
110 E-4-13-II 5,257,900 6,309,500 7,361,000
(SEDANG)

118 F-4-12-I 2,026,000 2,431,100 2,836,300
(RINGAN)
119 F-4-12-II 2,880,300 3,456,300 4,032,400
(SEDANG)
120 F-4-12-III 6,257,200 7,508,700 8,760,100
(BERAT)
130 F-4-16-I 5,487,100 6,584,500 7,682,000
131 F-4-16-II 6,379,700 7,655,600 8,931,500
132 F-4-16-III 8,515,800 10,218,900 11,922,100
142 G-1-01-I 16,493,000 19,791,600 23,090,200
(RINGAN)
- 52 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 23,654,900 28,385,900 33,116,900
(SEDANG)
144 G-1-01-III 35,908,500 43,090,200 50,271,900
(BERAT)
151 G-1-12-I 4,791,100 5,749,300 6,707,500
(RINGAN)
152 G-1-12-II 9,258,800 11,110,600 12,962,300
(SEDANG)
153 G-1-12-III 12,618,000 15,141,600 17,665,100
(BERAT)
163 G-4-10-I 4,112,600 4,935,100 5,757,600
(RINGAN)
164 G-4-10-II 5,027,000 6,032,400 7,037,800
(SEDANG)
165 G-4-10-III 7,111,200 8,533,500 9,955,700
(BERAT)
166 G-4-11-I 4,438,400 5,326,100 6,213,800
167 G-4-11-II 5,895,900 7,075,000 8,254,200
168 G-4-11-III 8,663,000 10,395,600 12,128,200
DEGENERATIF (BERAT)
169 G-4-12-I 4,923,900 5,908,700 6,893,400
(RINGAN)
170 G-4-12-II 6,032,600 7,239,200 8,445,700
(SEDANG)

172 G-4-13-I 2,869,100 3,442,900 4,016,800
(RINGAN)
173 G-4-13-II 5,003,200 6,003,800 7,004,400
(SEDANG)
174 G-4-13-III 5,933,900 7,120,600 8,307,400
(BERAT)
175 G-4-14-I 4,867,100 5,840,500 6,814,000
INFARK (RINGAN)
176 G-4-14-II 6,708,200 8,049,900 9,391,500
INFARK (SEDANG)
177 G-4-14-III 8,419,600 10,103,500 11,787,500
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 53 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 4,366,600 5,239,900 6,113,200
(RINGAN)
185 G-4-17-II 5,725,600 6,870,700 8,015,800
(SEDANG)
186 G-4-17-III 7,416,900 8,900,300 10,383,700
(BERAT)
190 G-4-19-I 3,587,900 4,305,500 5,023,100
191 G-4-19-II 6,064,500 7,277,400 8,490,200
192 G-4-19-III 7,962,400 9,554,800 11,147,300
211 G-4-26-I 3,482,800 4,179,400 4,876,000
LAIN (RINGAN)
212 G-4-26-II 4,176,900 5,012,300 5,847,700
LAIN (SEDANG)
213 G-4-26-III 6,058,400 7,270,100 8,481,700
LAIN (BERAT)
232 I-1-02-I 25,137,300 30,164,800 35,192,200
(RINGAN)
- 54 -

REGIONAL 1
RAWAT INAP

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

REGIONAL 1
RAWAT INAP

270 I-1-17-III 20,496,400 24,595,600 28,694,900
(BERAT)
271 I-1-20-I 14,916,500 17,899,700 20,883,000
(RINGAN)
272 I-1-20-II 18,634,700 22,361,700 26,088,600
(SEDANG)
273 I-1-20-III 19,589,000 23,506,800 27,424,600
(BERAT)
274 I-1-30-I 11,283,500 13,540,100 15,796,800
JANTUNG (RINGAN)
275 I-1-30-II 23,472,100 28,166,500 32,860,900
JANTUNG (SEDANG)
276 I-1-30-III 36,373,300 43,648,000 50,922,600
JANTUNG (BERAT)

289 I-4-13-I 3,532,700 4,239,300 4,945,800
(RINGAN)
290 I-4-13-II 6,308,100 7,569,700 8,831,300
(SEDANG)
291 I-4-13-III 9,089,100 10,906,900 12,724,700
(BERAT)
295 I-4-15-I 4,351,800 5,222,100 6,092,500
(RINGAN)
296 I-4-15-II 5,920,300 7,104,400 8,288,400
(SEDANG)

304 I-4-18-I 3,939,500 4,727,400 5,515,300
JANTUNG (RINGAN)
305 I-4-18-II 6,183,600 7,420,300 8,657,000
JANTUNG (SEDANG)
306 I-4-18-III 8,143,400 9,772,000 11,400,700
JANTUNG (BERAT)

308 I-4-19-II 5,933,300 7,120,000 8,306,600
(SEDANG)
- 56 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 3,248,800 3,898,500 4,548,300
320 I-4-23-II 3,988,600 4,786,300 5,584,000
321 I-4-23-III 7,793,400 9,352,100 10,910,800
322 I-4-24-I 2,714,400 3,257,300 3,800,200
(RINGAN)
323 I-4-24-II 6,250,600 7,500,700 8,750,800
(SEDANG)
324 I-4-24-III 7,902,800 9,483,300 11,063,900
(BERAT)
325 J-1-01-I 52,779,300 63,335,200 73,891,000
326 J-1-01-II 59,729,600 71,675,500 83,621,500
327 J-1-01-III 67,573,000 81,087,600 94,602,200
TRAKEOSTOMI (BERAT)
328 J-1-02-I 28,008,100 33,609,700 39,211,300
329 J-1-02-II 38,998,300 46,798,000 54,597,700
330 J-1-02-III 64,399,600 77,279,500 90,159,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,505,300 10,206,400 11,907,400
(RINGAN)
332 J-1-10-II 17,210,500 20,652,600 24,094,700
(SEDANG)
333 J-1-10-III 18,439,200 22,127,000 25,814,800
(BERAT)
334 J-1-20-I 14,544,200 17,453,000 20,361,900
(RINGAN)
335 J-1-20-II 18,318,800 21,982,600 25,646,300
(SEDANG)
336 J-1-20-III 28,287,200 33,944,600 39,602,100
(BERAT)
337 J-1-30-I 7,097,900 8,517,500 9,937,100
(RINGAN)
338 J-1-30-II 12,857,800 15,429,300 18,000,900
(SEDANG)

- 57 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,717,000 3,260,400 3,803,800
374 J-4-21-II 4,377,000 5,252,400 6,127,800
375 J-4-21-III 6,107,800 7,329,400 8,550,900
376 K-1-10-I 7,710,600 9,252,700 10,794,800
BESAR (RINGAN)
377 K-1-10-II 9,989,700 11,987,600 13,985,500
BESAR (SEDANG)
378 K-1-10-III 11,708,200 14,049,900 16,391,500
BESAR (BERAT)
382 K-1-12-I 3,335,300 4,002,400 4,669,400
FEMORAL (RINGAN)
383 K-1-12-II 4,338,000 5,205,500 6,073,100
FEMORAL (SEDANG)
384 K-1-12-III 8,594,100 10,313,000 12,031,800
FEMORAL (BERAT)
388 K-1-14-I 5,329,100 6,394,900 7,460,700
(RINGAN)
389 K-1-14-II 6,245,600 7,494,700 8,743,800
(SEDANG)

394 K-1-30-I 6,990,200 8,388,300 9,786,300
395 K-1-30-II 12,042,100 14,450,500 16,858,900
396 K-1-30-III 17,082,500 20,499,000 23,915,500

398 K-1-40-II 8,599,200 10,319,000 12,038,900
(SEDANG)

- 58 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 3,867,300 4,640,800 5,414,200
413 K-4-13-II 5,002,600 6,003,100 7,003,700
414 K-4-13-III 7,705,600 9,246,800 10,787,900
415 K-4-14-I 2,527,700 3,033,300 3,538,800
(RINGAN)
416 K-4-14-II 3,393,000 4,071,600 4,750,300
(SEDANG)
417 K-4-14-III 5,444,500 6,533,400 7,622,300
(BERAT)

424 K-4-17-I 1,667,900 2,001,500 2,335,100
(RINGAN)
425 K-4-17-II 2,054,000 2,464,800 2,875,600
(SEDANG)
426 K-4-17-III 2,464,800 2,957,800 3,450,700
(BERAT)
427 K-4-18-I 1,410,500 1,692,600 1,974,700
(RINGAN)
428 K-4-18-II 2,380,100 2,856,200 3,332,200
(SEDANG)
436 L-1-40-I 4,833,500 5,800,200 6,766,900
(RINGAN)
437 L-1-40-II 9,694,900 11,633,900 13,572,800
(SEDANG)
438 L-1-40-III 16,318,700 19,582,400 22,846,100
(BERAT)
451 L-4-13-I 2,314,400 2,777,200 3,240,100
PAYUDARA (RINGAN)
- 59 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,720,000 3,264,000 3,808,000
PAYUDARA (SEDANG)
453 L-4-13-III 4,002,500 4,803,000 5,603,500
PAYUDARA (BERAT)
454 L-4-14-I 2,858,300 3,429,900 4,001,600
(RINGAN)
455 L-4-14-II 4,293,200 5,151,900 6,010,500
(SEDANG)
456 L-4-14-III 6,051,800 7,262,200 8,472,500
(BERAT)
457 M-1-01-I 10,103,700 12,124,400 14,145,200
458 M-1-01-II 14,361,000 17,233,200 20,105,400
459 M-1-01-III 20,172,900 24,207,400 28,242,000
463 M-1-03-I 22,601,500 27,121,800 31,642,100
464 M-1-03-II 26,435,700 31,722,900 37,010,000
465 M-1-03-III 32,718,600 39,262,300 45,806,100
472 M-1-07-I 7,979,800 9,575,700 11,171,700
473 M-1-07-II 10,690,100 12,828,200 14,966,200
474 M-1-07-III 21,776,800 26,132,200 30,487,500
475 M-1-10-I 18,431,100 22,117,300 25,803,500
WAJAH (RINGAN)
476 M-1-10-II 44,068,100 52,881,700 61,695,300
WAJAH (SEDANG)
477 M-1-10-III 95,050,800 114,061,000 133,071,100
WAJAH (BERAT)
478 M-1-20-I 11,998,200 14,397,800 16,797,400
(RINGAN)
479 M-1-20-II 15,803,000 18,963,600 22,124,200
(SEDANG)

484 M-1-40-I 4,189,900 5,027,900 5,865,900
INTERNAL (RINGAN)
485 M-1-40-II 7,430,700 8,916,800 10,402,900
INTERNAL (SEDANG)
486 M-1-40-III 10,609,500 12,731,400 14,853,300
INTERNAL (BERAT)
490 M-1-60-I 7,754,500 9,305,400 10,856,300
491 M-1-60-II 9,749,200 11,699,000 13,648,900
492 M-1-60-III 15,182,800 18,219,400 21,255,900
- 60 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 14,810,900 17,773,100 20,735,300
KAKI (RINGAN)
494 M-1-70-II 16,292,000 19,550,400 22,808,800
KAKI (SEDANG)
495 M-1-70-III 18,652,200 22,382,700 26,113,100
KAKI (BERAT)
502 M-4-11-I 3,584,800 4,301,800 5,018,800
(RINGAN)
503 M-4-11-II 7,859,600 9,431,500 11,003,500
(SEDANG)
504 M-4-11-III 11,715,100 14,058,100 16,401,100
(BERAT)
505 M-4-12-I 2,861,500 3,433,800 4,006,100
(RINGAN)
506 M-4-12-II 4,759,500 5,711,400 6,663,300
(SEDANG)
507 M-4-12-III 6,563,200 7,875,800 9,188,500
(BERAT)
508 M-4-13-I 4,764,700 5,717,600 6,670,600
509 M-4-13-II 7,158,800 8,590,500 10,022,300
510 M-4-13-III 13,966,600 16,759,900 19,553,200
520 M-4-17-I 3,580,400 4,296,500 5,012,600
(RINGAN)
521 M-4-17-II 5,007,600 6,009,100 7,010,600
(SEDANG)
522 M-4-17-III 6,992,800 8,391,300 9,789,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,846,800 3,416,100 3,985,500
(RINGAN)
530 M-4-20-II 4,168,600 5,002,400 5,836,100
(SEDANG)
531 M-4-20-III 4,659,000 5,590,700 6,522,500
(BERAT)
532 M-4-21-I 2,866,500 3,439,800 4,013,100
533 M-4-21-II 3,585,200 4,302,200 5,019,200
- 61 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 8,037,900 9,645,400 11,253,000
541 N-1-12-I 4,214,100 5,056,900 5,899,700
542 N-1-12-II 8,649,300 10,379,200 12,109,000
543 N-1-12-III 18,769,300 22,523,200 26,277,000
547 N-1-30-I 8,432,100 10,118,500 11,804,900
BAWAH (RINGAN)
548 N-1-30-II 12,756,100 15,307,300 17,858,500
BAWAH (SEDANG)
549 N-1-30-III 14,681,000 17,617,300 20,553,500
BAWAH (BERAT)
550 N-1-40-I 7,806,800 9,368,200 10,929,600
(RINGAN)
551 N-1-40-II 10,601,500 12,721,800 14,842,100
(SEDANG)
552 N-1-40-III 12,338,700 14,806,500 17,274,200
(BERAT)
553 N-4-10-I 3,217,300 3,860,800 4,504,200
(RINGAN)
554 N-4-10-II 4,011,700 4,814,100 5,616,400
(SEDANG)
555 N-4-10-III 5,900,700 7,080,800 8,261,000
(BERAT)
568 N-4-15-I 2,930,400 3,516,500 4,102,500
URIN (RINGAN)
569 N-4-15-II 3,748,500 4,498,300 5,248,000
URIN (SEDANG)
570 N-4-15-III 4,277,700 5,133,300 5,988,800
URIN (BERAT)
571 N-4-16-I 3,588,200 4,305,900 5,023,500
(RINGAN)
572 N-4-16-II 5,121,600 6,145,900 7,170,200
(SEDANG)
573 N-4-16-III 7,028,000 8,433,600 9,839,200
(BERAT)
- 62 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 3,335,400 4,002,500 4,669,600
578 O-6-11-II 3,707,000 4,448,400 5,189,800
579 O-6-11-III 4,754,100 5,705,000 6,655,800
580 O-6-12-I 2,436,200 2,923,400 3,410,700
581 O-6-12-II 2,925,900 3,511,000 4,096,200
582 O-6-12-III 3,676,500 4,411,700 5,147,000
586 P-8-01-I 52,768,700 63,322,500 73,876,200
587 P-8-01-II 65,293,400 78,352,000 91,410,700
588 P-8-01-III 76,636,000 91,963,300 107,290,500
589 P-8-02-I 82,448,400 98,938,000 115,427,700
590 P-8-02-II 94,576,700 113,492,100 132,407,400
591 P-8-02-III 108,060,700 129,672,900 151,285,000
592 P-8-03-I 11,928,200 14,313,800 16,699,400
593 P-8-03-II 16,842,900 20,211,500 23,580,100
594 P-8-03-III 23,575,000 28,290,100 33,005,100
595 P-8-04-I 34,404,100 41,285,000 48,165,800
596 P-8-04-II 44,475,300 53,370,400 62,265,500
597 P-8-04-III 63,766,500 76,519,800 89,273,100
598 P-8-05-I 18,681,600 22,417,900 26,154,200
599 P-8-05-II 29,205,800 35,046,900 40,888,100
600 P-8-05-III 38,868,400 46,642,000 54,415,700
601 P-8-06-I 5,111,000 6,133,200 7,155,400
602 P-8-06-II 14,330,100 17,196,100 20,062,200
603 P-8-06-III 18,983,900 22,780,700 26,577,400
604 P-8-07-I 4,950,500 5,940,600 6,930,800
605 P-8-07-II 13,880,200 16,656,200 19,432,200
606 P-8-07-III 18,387,800 22,065,400 25,742,900
607 P-8-08-I 4,099,000 4,918,800 5,738,600
608 P-8-08-II 5,816,200 6,979,500 8,142,700
609 P-8-08-III 9,417,800 11,301,300 13,184,900
610 P-8-11-I 9,940,100 11,928,200 13,916,200
MAYOR (RINGAN)
611 P-8-11-II 14,035,800 16,842,900 19,650,100
MAYOR (SEDANG)
- 63 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 19,645,900 23,575,000 27,504,200
MAYOR (BERAT)
613 P-8-12-I 9,390,800 11,269,000 13,147,100
MAYOR (RINGAN)
614 P-8-12-II 10,796,800 12,956,100 15,115,500
MAYOR (SEDANG)
615 P-8-12-III 15,112,200 18,134,600 21,157,100
MAYOR (BERAT)
616 P-8-13-I 5,323,800 6,388,600 7,453,400
MAYOR (RINGAN)
617 P-8-13-II 8,305,200 9,966,200 11,627,300
MAYOR (SEDANG)
618 P-8-13-III 12,902,400 15,482,900 18,063,400
MAYOR (BERAT)
619 P-8-14-I 3,548,300 4,257,900 4,967,600
620 P-8-14-II 7,222,800 8,667,400 10,112,000
621 P-8-14-III 12,999,100 15,598,900 18,198,700
622 P-8-15-I 2,661,200 3,193,500 3,725,700
ASPIRASI (RINGAN)
623 P-8-15-II 5,329,300 6,395,100 7,461,000
ASPIRASI (SEDANG)
624 P-8-15-III 6,252,900 7,503,500 8,754,100
ASPIRASI (BERAT)
625 P-8-16-I 2,408,500 2,890,200 3,371,800
626 P-8-16-II 4,628,200 5,553,900 6,479,500
627 P-8-16-III 11,325,900 13,591,100 15,856,200
628 P-8-17-I 3,549,200 4,259,100 4,968,900
(RINGAN)
629 P-8-17-II 6,388,600 7,666,300 8,944,100
(SEDANG)
630 P-8-17-III 8,989,900 10,787,900 12,585,900
(BERAT)
631 S-4-10-I 2,634,000 3,160,800 3,687,700
632 S-4-10-II 3,245,500 3,894,600 4,543,700
633 S-4-10-III 4,442,800 5,331,400 6,219,900
640 S-4-13-I 2,859,800 3,431,700 4,003,700
(RINGAN)
641 S-4-13-II 5,073,500 6,088,100 7,102,800
(SEDANG)
642 S-4-13-III 8,234,800 9,881,800 11,528,800
(BERAT)
643 S-4-14-I 1,447,200 1,736,700 2,026,100
644 S-4-14-II 3,074,100 3,688,900 4,303,700
645 S-4-14-III 5,829,500 6,995,400 8,161,300
KANAK-KANAK (BERAT)
646 S-4-15-I 967,900 1,161,500 1,355,100
647 S-4-15-II 1,826,600 2,192,000 2,557,300
648 S-4-15-III 2,365,800 2,839,000 3,312,100
- 64 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 2,415,700 2,898,900 3,382,000
653 S-4-17-II 3,585,200 4,302,300 5,019,300
654 S-4-17-III 4,312,000 5,174,500 6,036,900
655 T-1-10-I 1,666,300 1,999,600 2,332,800
OBAT (RINGAN)
656 T-1-10-II 2,238,100 2,685,700 3,133,300
OBAT (SEDANG)
657 T-1-10-III 4,071,400 4,885,700 5,700,000
OBAT (BERAT)
658 T-4-10-I 722,800 867,300 1,011,900
659 T-4-10-II 1,377,500 1,653,000 1,928,600
660 T-4-10-III 2,002,600 2,403,100 2,803,600
661 T-4-11-I 986,500 1,183,800 1,381,100
662 T-4-11-II 1,552,400 1,862,900 2,173,400
663 T-4-11-III 2,500,500 3,000,600 3,500,700
664 T-4-12-I 1,625,200 1,950,300 2,275,300
LAIN (RINGAN)
665 T-4-12-II 2,421,600 2,906,000 3,390,300
LAIN (SEDANG)
666 T-4-12-III 3,715,400 4,458,500 5,201,500
LAIN (BERAT)
670 U-1-11-I 8,171,500 9,805,800 11,440,000
(RINGAN)
671 U-1-11-II 10,358,600 12,430,300 14,502,000
(SEDANG)
672 U-1-11-III 15,365,300 18,438,300 21,511,400
(BERAT)
679 U-1-14-I 3,958,400 4,750,000 5,541,700
(RINGAN)
680 U-1-14-II 4,857,900 5,829,500 6,801,000
(SEDANG)
681 U-1-14-III 5,756,600 6,907,900 8,059,200
(BERAT)
685 U-1-20-I 6,009,400 7,211,300 8,413,200
686 U-1-20-II 8,943,700 10,732,400 12,521,200
687 U-1-20-III 22,271,400 26,725,700 31,179,900
691 U-4-10-I 3,708,800 4,450,600 5,192,400
- 65 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 8,236,000 9,883,200 11,530,300
693 U-4-10-III 12,644,700 15,173,700 17,702,600
TENGGOROKAN (BERAT)
700 U-4-13-I 1,922,500 2,307,000 2,691,500
701 U-4-13-II 2,266,400 2,719,700 3,173,000
702 U-4-13-III 2,710,700 3,252,900 3,795,000
706 U-4-15-I 2,875,300 3,450,300 4,025,400
707 U-4-15-II 3,582,200 4,298,700 5,015,100
708 U-4-15-III 5,013,400 6,016,100 7,018,700
709 V-1-10-I 4,834,900 5,801,800 6,768,800
(RINGAN)
710 V-1-10-II 9,660,900 11,593,000 13,525,200
(SEDANG)
711 V-1-10-III 11,847,700 14,217,200 16,586,800
(BERAT)
715 V-1-12-I 8,388,600 10,066,300 11,744,000
MODERAT (RINGAN)
716 V-1-12-II 11,809,500 14,171,400 16,533,400
MODERAT (SEDANG)
717 V-1-12-III 14,519,700 17,423,600 20,327,500
MODERAT (BERAT)
718 V-1-13-I 4,510,900 5,413,100 6,315,300
KOMPLEK (RINGAN)
719 V-1-13-II 8,618,900 10,342,600 12,066,400
KOMPLEK (SEDANG)
720 V-1-13-III 13,116,300 15,739,500 18,362,800
KOMPLEK (BERAT)
721 V-1-14-I 8,580,500 10,296,600 12,012,700
(RINGAN)
722 V-1-14-II 12,467,200 14,960,600 17,454,100
(SEDANG)

727 V-4-10-I 4,277,700 5,133,300 5,988,800
(RINGAN)
728 V-4-10-II 7,105,500 8,526,600 9,947,700
(SEDANG)
729 V-4-10-III 11,714,500 14,057,400 16,400,300
(BERAT)
730 V-4-11-I 3,585,300 4,302,400 5,019,400
TUMOR (RINGAN)
731 V-4-11-II 4,810,600 5,772,700 6,734,800
TUMOR (SEDANG)
732 V-4-11-III 6,643,100 7,971,700 9,300,300
TUMOR (BERAT)
- 66 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 10,074,500 12,089,400 14,104,300
734 W-1-01-II 11,712,800 14,055,300 16,397,900
735 W-1-01-III 17,230,700 20,676,900 24,123,000
739 W-1-11-I 2,233,600 2,680,300 3,127,000
SERVIK (RINGAN)
740 W-1-11-II 2,464,800 2,957,700 3,450,700
SERVIK (SEDANG)
741 W-1-11-III 2,726,500 3,271,800 3,817,100
SERVIK (BERAT)
760 W-4-12-I 2,727,500 3,273,000 3,818,500
761 W-4-12-II 3,744,700 4,493,600 5,242,600
762 W-4-12-III 4,081,900 4,898,300 5,714,700
- 67 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 1,822,000 2,186,400 2,550,800
785 Z-4-12-II 3,823,300 4,588,000 5,352,600
786 Z-4-12-III 5,885,400 7,062,500 8,239,600
- 68 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS B PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
1 B-2-10-0 PROSEDUR PADA HATI DAN PANKREAS 915,400
9 C-3-10-0 PROSEDUR RADIOTERAPI 915,500
11 C-3-12-0 KEMOTERAPI PADA TUMOR KOLON 772,200
20 C-3-21-0 KEMOTERAPI PADA TUMOR GINEKOLOGI 737,300
24 D-2-11-0 PROSEDUR LIMPA 1,473,600
27 D-3-10-0 PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG 967,000

33 F-3-10-0 TERAPI SHOCK 417,300
46 G-2-22-0 PROSEDUR KECIL PADA SARAF PERIFER 783,700
48 G-2-32-0 PROSEDUR KECIL PADA TULANG BELAKANG 742,300
- 69 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,536,800
PENGGANTIAN ALAT
74 I-2-17-0 PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA 836,300
81 I-2-42-0 2,437,700
PERKUTAN LAIN
92 J-2-32-0 PROSEDUR DADA INTERMEDIATE 944,100
101 K-2-10-0 PROSEDUR KECIL PADA USUS BESAR DAN KECIL 739,800
112 K-2-51-0 PROSEDUR UNTUK WASIR 692,000
120 K-3-15-0 PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS 819,300
124 L-2-22-0 PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR 829,100
- 70 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
138 M-2-31-0 PROSEDUR BUNION 941,400
146 M-2-63-0 PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG 882,600
150 M-2-72-0 PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH 851,900
152 M-2-82-0 PROSEDUR KECIL PADA LENGAN, SIKU & BAHU 929,400
157 M-3-12-0 PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL 924,700
169 N-2-31-0 PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA 840,000
171 N-2-41-0 PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA 894,100
181 O-7-12-0 1,210,100
182 O-7-13-0 PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR 854,000
192 Q-5-12-0 GIGI 208,800
196 Q-5-16-0 VAKSINASI 97,700
201 Q-5-21-0 ABORSI 182,300
206 Q-5-26-0 BRONKIAL AKUT 208,100
- 71 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 140,100
215 Q-5-35-0 INFEKSI AKUT 426,300
218 Q-5-38-0 PARU AKUT 248,400
232 U-2-21-0 PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN 762,300
234 U-2-23-0 RHINOPLASTY 1,227,200
242 U-3-13-0 316,300
TENGGOROKAN
248 V-2-12-0 PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM 854,500
253 V-3-11-0 PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI 742,100
254 V-3-12-0 PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI 759,900
255 W-2-10-0 PROSEDUR ABORSI 810,300
256 W-2-11-0 PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM 708,800
264 W-2-33-0 PROSEDUR KECIL VULVOVAGINAL 853,100
270 Z-3-11-0 1,716,200
EMPEDU
- 72 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
276 Z-3-17-0 PELAYANAN KEDOKTERAN NUKLIR 603,300
277 Z-3-18-0 CT-SCAN KEPALA 951,900
280 Z-3-21-0 IMAGING KONTRAS PEMBULUH DARAH 727,300
285 Z-3-26-0 PROSEDUR BESAR RADIOGRAFI 708,200
289 Z-3-30-0 FOTOTERAPI 80,800
- 73 -


REGIONAL 1
RUMAH SAKIT KELAS B SWASTA
RAWAT INAP

13 A-4-14-I 2,268,700 2,722,500 3,176,200
(RINGAN)
14 A-4-14-II 2,753,900 3,304,700 3,855,500
(SEDANG)
15 A-4-14-III 3,304,700 3,965,700 4,626,600
(BERAT)

31 B-1-13-I 5,606,900 6,728,300 7,849,700
LAIN (RINGAN)
32 B-1-13-II 9,225,500 11,070,600 12,915,600
LAIN (SEDANG)
33 B-1-13-III 11,936,900 14,324,300 16,711,700
LAIN (BERAT)
34 B-1-14-I 7,704,100 9,244,900 10,785,700
(RINGAN)
35 B-1-14-II 8,568,300 10,282,000 11,995,700
(SEDANG)
40 B-4-11-I 4,874,900 5,849,800 6,824,800
(RINGAN)
41 B-4-11-II 6,824,900 8,189,800 9,554,800
(SEDANG)
42 B-4-11-III 8,268,200 9,921,900 11,575,500
(BERAT)
- 74 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 5,164,200 6,197,000 7,229,800
74 D-1-20-II 14,231,700 17,078,000 19,924,300
75 D-1-20-III 22,575,600 27,090,700 31,605,800
85 D-4-13-I 2,987,000 3,584,400 4,181,800
86 D-4-13-II 4,227,600 5,073,100 5,918,600
87 D-4-13-III 5,407,200 6,488,600 7,570,100
88 D-4-14-I 3,203,700 3,844,400 4,485,100
89 D-4-14-II 5,245,200 6,294,200 7,343,300
90 D-4-14-III 6,415,400 7,698,500 8,981,600
91 E-1-01-I 7,024,700 8,429,700 9,834,600
(RINGAN)
92 E-1-01-II 9,589,800 11,507,800 13,425,700
(SEDANG)

97 E-1-20-I 7,516,400 9,019,700 10,523,000
TIROGLOSAL (RINGAN)
- 75 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 10,116,900 12,140,300 14,163,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,374,400 17,249,300 20,124,200
TIROGLOSAL (BERAT)
100 E-4-10-I 3,502,700 4,203,300 4,903,800
METABOLIK (RINGAN)
101 E-4-10-II 4,894,400 5,873,300 6,852,200
METABOLIK (SEDANG)
102 E-4-10-III 6,262,900 7,515,400 8,768,000
METABOLIK (BERAT)
109 E-4-13-I 3,697,100 4,436,500 5,176,000
(RINGAN)
110 E-4-13-II 5,415,600 6,498,800 7,581,900
(SEDANG)

118 F-4-12-I 2,086,700 2,504,100 2,921,400
(RINGAN)
119 F-4-12-II 2,966,700 3,560,000 4,153,400
(SEDANG)
120 F-4-12-III 6,445,000 7,734,000 9,023,000
(BERAT)
130 F-4-16-I 5,651,700 6,782,100 7,912,400
131 F-4-16-II 6,571,100 7,885,300 9,199,500
132 F-4-16-III 8,771,200 10,525,500 12,279,700
142 G-1-01-I 16,987,800 20,385,300 23,782,900
(RINGAN)
- 76 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 24,364,600 29,237,500 34,110,400
(SEDANG)
144 G-1-01-III 36,985,800 44,382,900 51,780,100
(BERAT)
151 G-1-12-I 4,934,800 5,921,700 6,908,700
(RINGAN)
152 G-1-12-II 9,536,600 11,443,900 13,351,200
(SEDANG)
153 G-1-12-III 12,996,500 15,595,800 18,195,100
(BERAT)
163 G-4-10-I 4,236,000 5,083,200 5,930,400
(RINGAN)
164 G-4-10-II 5,177,800 6,213,400 7,248,900
(SEDANG)
165 G-4-10-III 7,324,600 8,789,500 10,254,400
(BERAT)
166 G-4-11-I 4,571,500 5,485,900 6,400,200
167 G-4-11-II 6,072,700 7,287,300 8,501,800
168 G-4-11-III 8,922,900 10,707,500 12,492,100
DEGENERATIF (BERAT)
169 G-4-12-I 5,071,600 6,085,900 7,100,200
(RINGAN)
170 G-4-12-II 6,213,600 7,456,300 8,699,100
(SEDANG)

172 G-4-13-I 2,955,200 3,546,200 4,137,300
(RINGAN)
173 G-4-13-II 5,153,300 6,183,900 7,214,600
(SEDANG)
174 G-4-13-III 6,111,900 7,334,300 8,556,600
(BERAT)
175 G-4-14-I 5,013,100 6,015,800 7,018,400
INFARK (RINGAN)
176 G-4-14-II 6,909,500 8,291,400 9,673,300
INFARK (SEDANG)
177 G-4-14-III 8,672,200 10,406,600 12,141,100
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 77 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 4,497,600 5,397,100 6,296,600
(RINGAN)
185 G-4-17-II 5,897,300 7,076,800 8,256,200
(SEDANG)
186 G-4-17-III 7,639,400 9,167,300 10,695,200
(BERAT)
190 G-4-19-I 3,695,600 4,434,700 5,173,800
191 G-4-19-II 6,246,400 7,495,700 8,745,000
192 G-4-19-III 8,201,200 9,841,500 11,481,700
211 G-4-26-I 3,587,300 4,304,800 5,022,200
LAIN (RINGAN)
212 G-4-26-II 4,302,200 5,162,700 6,023,100
LAIN (SEDANG)
213 G-4-26-III 6,240,100 7,488,200 8,736,200
LAIN (BERAT)
232 I-1-02-I 25,891,400 31,069,700 36,248,000
(RINGAN)
- 78 -

REGIONAL 1
RAWAT INAP

233 I-1-02-II 33,399,600 40,079,500 46,759,400
(SEDANG)
234 I-1-02-III 41,167,100 49,400,500 57,633,900
(BERAT)
235 I-1-03-I 14,954,900 17,945,900 20,936,900
ANOMALI (RINGAN)
236 I-1-03-II 20,730,700 24,876,800 29,022,900
ANOMALI (SEDANG)
237 I-1-03-III 27,122,500 32,547,000 37,971,500
ANOMALI (BERAT)
238 I-1-04-I 23,233,300 27,879,900 32,526,600
JANTUNG (RINGAN)
239 I-1-04-II 36,668,400 44,002,100 51,335,800
JANTUNG (SEDANG)
240 I-1-04-III 58,577,500 70,293,000 82,008,600
JANTUNG (BERAT)
241 I-1-05-I 54,635,500 65,562,600 76,489,700
242 I-1-05-II 66,776,700 80,132,100 93,487,400
243 I-1-05-III 91,059,200 109,271,000 127,482,800
247 I-1-07-I 48,564,900 58,277,900 67,990,800
JANTUNG (RINGAN)
248 I-1-07-II 60,706,100 72,847,300 84,988,600
JANTUNG (SEDANG)
249 I-1-07-III 91,059,200 109,271,000 127,482,800
JANTUNG (BERAT)
250 I-1-11-I 4,182,800 5,019,300 5,855,900
251 I-1-11-II 4,650,800 5,581,000 6,511,100
252 I-1-11-III 6,188,800 7,426,600 8,664,300
253 I-1-12-I 12,040,000 14,447,900 16,855,900
(RINGAN)
254 I-1-12-II 19,073,800 22,888,500 26,703,300
(SEDANG)
255 I-1-12-III 25,094,400 30,113,300 35,132,200
(BERAT)
256 I-1-13-I 11,678,600 14,014,300 16,350,000
KOMPLEK (RINGAN)
257 I-1-13-II 15,552,400 18,662,900 21,773,400
KOMPLEK (SEDANG)
258 I-1-13-III 19,180,400 23,016,500 26,852,600
KOMPLEK (BERAT)
259 I-1-14-I 23,903,200 28,683,800 33,464,500
(RINGAN)
260 I-1-14-II 29,708,200 35,649,800 41,591,400
(SEDANG)
261 I-1-14-III 38,927,900 46,713,500 54,499,100
(BERAT)
265 I-1-16-I 11,418,600 13,702,300 15,986,000
266 I-1-16-II 26,634,600 31,961,600 37,288,500
267 I-1-16-III 30,722,700 36,867,200 43,011,700
268 I-1-17-I 13,630,500 16,356,600 19,082,700
(RINGAN)
269 I-1-17-II 17,066,700 20,480,000 23,893,400
(SEDANG)
- 79 -

REGIONAL 1
RAWAT INAP

270 I-1-17-III 21,111,200 25,333,500 29,555,700
(BERAT)
271 I-1-20-I 15,363,900 18,436,700 21,509,500
(RINGAN)
272 I-1-20-II 19,193,800 23,032,500 26,871,300
(SEDANG)
273 I-1-20-III 20,176,600 24,212,000 28,247,300
(BERAT)
274 I-1-30-I 11,622,000 13,946,400 16,270,700
JANTUNG (RINGAN)
275 I-1-30-II 24,176,300 29,011,500 33,846,800
JANTUNG (SEDANG)
276 I-1-30-III 37,464,500 44,957,400 52,450,300
JANTUNG (BERAT)

289 I-4-13-I 3,638,700 4,366,400 5,094,200
(RINGAN)
290 I-4-13-II 6,497,300 7,796,800 9,096,300
(SEDANG)
291 I-4-13-III 9,361,700 11,234,100 13,106,400
(BERAT)
295 I-4-15-I 4,482,300 5,378,800 6,275,300
(RINGAN)
296 I-4-15-II 6,097,900 7,317,500 8,537,100
(SEDANG)

304 I-4-18-I 4,057,700 4,869,200 5,680,800
JANTUNG (RINGAN)
305 I-4-18-II 6,369,100 7,642,900 8,916,700
JANTUNG (SEDANG)
306 I-4-18-III 8,387,700 10,065,200 11,742,700
JANTUNG (BERAT)

308 I-4-19-II 6,111,300 7,333,600 8,555,800
(SEDANG)
- 80 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 3,346,200 4,015,500 4,684,700
320 I-4-23-II 4,108,200 4,929,900 5,751,500
321 I-4-23-III 8,027,200 9,632,700 11,238,100
322 I-4-24-I 2,795,900 3,355,000 3,914,200
(RINGAN)
323 I-4-24-II 6,438,100 7,725,700 9,013,300
(SEDANG)
324 I-4-24-III 8,139,800 9,767,800 11,395,800
(BERAT)
325 J-1-01-I 54,362,700 65,235,200 76,107,800
326 J-1-01-II 61,521,500 73,825,800 86,130,100
327 J-1-01-III 69,600,200 83,520,200 97,440,200
TRAKEOSTOMI (BERAT)
328 J-1-02-I 28,848,300 34,618,000 40,387,600
329 J-1-02-II 40,168,300 48,201,900 56,235,600
330 J-1-02-III 66,331,600 79,597,900 92,864,200
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,760,500 10,512,600 12,264,600
(RINGAN)
332 J-1-10-II 17,726,800 21,272,200 24,817,600
(SEDANG)
333 J-1-10-III 18,992,300 22,790,800 26,589,300
(BERAT)
334 J-1-20-I 14,980,500 17,976,600 20,972,700
(RINGAN)
335 J-1-20-II 18,868,400 22,642,000 26,415,700
(SEDANG)
336 J-1-20-III 29,135,800 34,963,000 40,790,100
(BERAT)
337 J-1-30-I 7,310,800 8,773,000 10,235,200
(RINGAN)
338 J-1-30-II 13,243,500 15,892,200 18,540,900
(SEDANG)

- 81 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,798,500 3,358,200 3,917,900
374 J-4-21-II 4,508,300 5,410,000 6,311,700
375 J-4-21-III 6,291,000 7,549,300 8,807,500
376 K-1-10-I 7,941,900 9,530,300 11,118,700
BESAR (RINGAN)
377 K-1-10-II 10,289,400 12,347,200 14,405,100
BESAR (SEDANG)
378 K-1-10-III 12,059,500 14,471,400 16,883,300
BESAR (BERAT)
382 K-1-12-I 3,435,400 4,122,400 4,809,500
FEMORAL (RINGAN)
383 K-1-12-II 4,468,100 5,361,700 6,255,300
FEMORAL (SEDANG)
384 K-1-12-III 8,852,000 10,622,400 12,392,800
FEMORAL (BERAT)
388 K-1-14-I 5,489,000 6,586,700 7,684,500
(RINGAN)
389 K-1-14-II 6,432,900 7,719,500 9,006,100
(SEDANG)

394 K-1-30-I 7,199,900 8,639,900 10,079,900
395 K-1-30-II 12,403,300 14,884,000 17,364,600
396 K-1-30-III 17,595,000 21,114,000 24,633,000

398 K-1-40-II 8,857,200 10,628,600 12,400,100
(SEDANG)

- 82 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 3,983,300 4,780,000 5,576,700
413 K-4-13-II 5,152,700 6,183,200 7,213,800
414 K-4-13-III 7,936,800 9,524,200 11,111,500
415 K-4-14-I 2,603,600 3,124,300 3,645,000
(RINGAN)
416 K-4-14-II 3,494,800 4,193,800 4,892,800
(SEDANG)
417 K-4-14-III 5,607,800 6,729,400 7,851,000
(BERAT)

424 K-4-17-I 1,718,000 2,061,500 2,405,100
(RINGAN)
425 K-4-17-II 2,115,600 2,538,800 2,961,900
(SEDANG)
426 K-4-17-III 2,538,800 3,046,500 3,554,300
(BERAT)
427 K-4-18-I 1,452,800 1,743,400 2,033,900
(RINGAN)
428 K-4-18-II 2,451,500 2,941,900 3,432,200
(SEDANG)
436 L-1-40-I 4,978,500 5,974,200 6,969,900
(RINGAN)
437 L-1-40-II 9,985,700 11,982,900 13,980,000
(SEDANG)
438 L-1-40-III 16,808,200 20,169,900 23,531,500
(BERAT)
451 L-4-13-I 2,383,800 2,860,500 3,337,300
PAYUDARA (RINGAN)
- 83 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,801,600 3,361,900 3,922,300
PAYUDARA (SEDANG)
453 L-4-13-III 4,122,600 4,947,100 5,771,700
PAYUDARA (BERAT)
454 L-4-14-I 2,944,000 3,532,800 4,121,600
(RINGAN)
455 L-4-14-II 4,422,000 5,306,400 6,190,800
(SEDANG)
456 L-4-14-III 6,233,400 7,480,000 8,726,700
(BERAT)
457 M-1-01-I 10,406,800 12,488,200 14,569,500
458 M-1-01-II 14,791,800 17,750,200 20,708,500
459 M-1-01-III 20,778,100 24,933,700 29,089,300
463 M-1-03-I 23,279,500 27,935,400 32,591,300
464 M-1-03-II 27,228,800 32,674,600 38,120,300
465 M-1-03-III 33,700,200 40,440,200 47,180,200
472 M-1-07-I 8,219,200 9,863,000 11,506,800
473 M-1-07-II 11,010,800 13,213,000 15,415,200
474 M-1-07-III 22,430,100 26,916,100 31,402,100
475 M-1-10-I 18,984,000 22,780,800 26,577,600
WAJAH (RINGAN)
476 M-1-10-II 45,390,100 54,468,200 63,546,200
WAJAH (SEDANG)
477 M-1-10-III 97,902,300 117,482,800 137,063,300
WAJAH (BERAT)
478 M-1-20-I 12,358,100 14,829,700 17,301,400
(RINGAN)
479 M-1-20-II 16,277,100 19,532,500 22,787,900
(SEDANG)

484 M-1-40-I 4,315,600 5,178,700 6,041,900
INTERNAL (RINGAN)
485 M-1-40-II 7,653,600 9,184,300 10,715,000
INTERNAL (SEDANG)
486 M-1-40-III 10,927,800 13,113,400 15,298,900
INTERNAL (BERAT)
490 M-1-60-I 7,987,100 9,584,600 11,182,000
491 M-1-60-II 10,041,700 12,050,000 14,058,300
492 M-1-60-III 15,638,300 18,765,900 21,893,600
- 84 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 15,255,300 18,306,300 21,357,400
KAKI (RINGAN)
494 M-1-70-II 16,780,800 20,136,900 23,493,100
KAKI (SEDANG)
495 M-1-70-III 19,211,800 23,054,100 26,896,500
KAKI (BERAT)
502 M-4-11-I 3,692,400 4,430,900 5,169,300
(RINGAN)
503 M-4-11-II 8,095,400 9,714,500 11,333,600
(SEDANG)
504 M-4-11-III 12,066,500 14,479,900 16,893,200
(BERAT)
505 M-4-12-I 2,947,400 3,536,800 4,126,300
(RINGAN)
506 M-4-12-II 4,902,300 5,882,700 6,863,200
(SEDANG)
507 M-4-12-III 6,760,100 8,112,100 9,464,100
(BERAT)
508 M-4-13-I 4,907,600 5,889,200 6,870,700
509 M-4-13-II 7,373,500 8,848,200 10,322,900
510 M-4-13-III 14,385,600 17,262,700 20,139,800
520 M-4-17-I 3,687,800 4,425,400 5,162,900
(RINGAN)
521 M-4-17-II 5,157,800 6,189,400 7,221,000
(SEDANG)
522 M-4-17-III 7,202,600 8,643,100 10,083,600
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,932,200 3,518,600 4,105,100
(RINGAN)
530 M-4-20-II 4,293,700 5,152,400 6,011,200
(SEDANG)
531 M-4-20-III 4,798,700 5,758,500 6,718,200
(BERAT)
532 M-4-21-I 2,952,500 3,543,000 4,133,500
533 M-4-21-II 3,692,700 4,431,300 5,169,800
- 85 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 8,279,000 9,934,800 11,590,600
541 N-1-12-I 4,340,500 5,208,600 6,076,700
542 N-1-12-II 8,908,800 10,690,500 12,472,300
543 N-1-12-III 19,332,400 23,198,900 27,065,300
547 N-1-30-I 8,685,100 10,422,100 12,159,100
BAWAH (RINGAN)
548 N-1-30-II 13,138,800 15,766,500 18,394,300
BAWAH (SEDANG)
549 N-1-30-III 15,121,500 18,145,800 21,170,100
BAWAH (BERAT)
550 N-1-40-I 8,041,000 9,649,200 11,257,400
(RINGAN)
551 N-1-40-II 10,919,500 13,103,400 15,287,300
(SEDANG)
552 N-1-40-III 12,708,900 15,250,700 17,792,500
(BERAT)
553 N-4-10-I 3,313,800 3,976,600 4,639,400
(RINGAN)
554 N-4-10-II 4,132,100 4,958,500 5,784,900
(SEDANG)
555 N-4-10-III 6,077,700 7,293,200 8,508,800
(BERAT)
568 N-4-15-I 3,018,300 3,622,000 4,225,600
URIN (RINGAN)
569 N-4-15-II 3,861,000 4,633,200 5,405,400
URIN (SEDANG)
570 N-4-15-III 4,406,100 5,287,300 6,168,500
URIN (BERAT)
571 N-4-16-I 3,695,900 4,435,100 5,174,200
(RINGAN)
572 N-4-16-II 5,275,200 6,330,300 7,385,300
(SEDANG)
573 N-4-16-III 7,238,900 8,686,600 10,134,400
(BERAT)
- 86 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 3,435,500 4,122,600 4,809,700
578 O-6-11-II 3,818,200 4,581,800 5,345,400
579 O-6-11-III 4,896,800 5,876,100 6,855,500
580 O-6-12-I 2,509,300 3,011,100 3,513,000
581 O-6-12-II 3,013,600 3,616,400 4,219,100
582 O-6-12-III 3,786,700 4,544,100 5,301,400
586 P-8-01-I 54,351,800 65,222,100 76,092,500
587 P-8-01-II 67,252,200 80,702,600 94,153,000
588 P-8-01-III 78,935,100 94,722,200 110,509,200
589 P-8-02-I 84,921,800 101,906,200 118,890,600
590 P-8-02-II 97,414,000 116,896,900 136,379,700
591 P-8-02-III 111,302,600 133,563,100 155,823,600
592 P-8-03-I 12,286,000 14,743,200 17,200,400
593 P-8-03-II 17,348,200 20,817,900 24,287,500
594 P-8-03-III 24,282,300 29,138,800 33,995,200
595 P-8-04-I 35,436,300 42,523,500 49,610,800
596 P-8-04-II 45,809,600 54,971,500 64,133,400
597 P-8-04-III 65,679,500 78,815,400 91,951,300
598 P-8-05-I 19,242,000 23,090,400 26,938,800
599 P-8-05-II 30,082,000 36,098,300 42,114,700
600 P-8-05-III 40,034,400 48,041,300 56,048,200
601 P-8-06-I 5,264,300 6,317,200 7,370,100
602 P-8-06-II 14,760,000 17,712,000 20,664,000
603 P-8-06-III 19,553,400 23,464,100 27,374,800
604 P-8-07-I 5,099,100 6,118,900 7,138,700
605 P-8-07-II 14,296,600 17,155,900 20,015,200
606 P-8-07-III 18,939,500 22,727,300 26,515,200
607 P-8-08-I 4,222,000 5,066,300 5,910,700
608 P-8-08-II 5,990,700 7,188,800 8,387,000
609 P-8-08-III 9,700,300 11,640,400 13,580,400
610 P-8-11-I 10,238,400 12,286,000 14,333,700
MAYOR (RINGAN)
611 P-8-11-II 14,456,900 17,348,200 20,239,600
MAYOR (SEDANG)
- 87 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 20,235,200 24,282,300 28,329,300
MAYOR (BERAT)
613 P-8-12-I 9,672,500 11,607,000 13,541,500
MAYOR (RINGAN)
614 P-8-12-II 11,120,700 13,344,800 15,568,900
MAYOR (SEDANG)
615 P-8-12-III 15,565,600 18,678,700 21,791,800
MAYOR (BERAT)
616 P-8-13-I 5,483,600 6,580,300 7,677,000
MAYOR (RINGAN)
617 P-8-13-II 8,554,400 10,265,200 11,976,100
MAYOR (SEDANG)
618 P-8-13-III 13,289,500 15,947,400 18,605,300
MAYOR (BERAT)
619 P-8-14-I 3,654,700 4,385,700 5,116,600
620 P-8-14-II 7,439,500 8,927,400 10,415,300
621 P-8-14-III 13,389,100 16,066,900 18,744,700
622 P-8-15-I 2,741,100 3,289,300 3,837,500
ASPIRASI (RINGAN)
623 P-8-15-II 5,489,100 6,587,000 7,684,800
ASPIRASI (SEDANG)
624 P-8-15-III 6,440,500 7,728,600 9,016,700
ASPIRASI (BERAT)
625 P-8-16-I 2,480,700 2,976,900 3,473,000
626 P-8-16-II 4,767,100 5,720,500 6,673,900
627 P-8-16-III 11,665,700 13,998,800 16,331,900
628 P-8-17-I 3,655,700 4,386,800 5,118,000
(RINGAN)
629 P-8-17-II 6,580,300 7,896,300 9,212,400
(SEDANG)
630 P-8-17-III 9,259,600 11,111,500 12,963,400
(BERAT)
631 S-4-10-I 2,713,100 3,255,700 3,798,300
632 S-4-10-II 3,342,900 4,011,500 4,680,100
633 S-4-10-III 4,576,100 5,491,300 6,406,500
640 S-4-13-I 2,945,600 3,534,700 4,123,800
(RINGAN)
641 S-4-13-II 5,225,700 6,270,800 7,315,900
(SEDANG)
642 S-4-13-III 8,481,900 10,178,300 11,874,600
(BERAT)
643 S-4-14-I 1,490,700 1,788,800 2,086,900
644 S-4-14-II 3,166,300 3,799,500 4,432,800
645 S-4-14-III 6,004,400 7,205,300 8,406,100
KANAK-KANAK (BERAT)
646 S-4-15-I 997,000 1,196,400 1,395,800
647 S-4-15-II 1,881,400 2,257,700 2,634,000
648 S-4-15-III 2,436,800 2,924,100 3,411,500
- 88 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 2,488,200 2,985,900 3,483,500
653 S-4-17-II 3,692,800 4,431,400 5,169,900
654 S-4-17-III 4,441,400 5,329,700 6,218,000
655 T-1-10-I 1,716,300 2,059,600 2,402,800
OBAT (RINGAN)
656 T-1-10-II 2,305,200 2,766,300 3,227,300
OBAT (SEDANG)
657 T-1-10-III 4,193,500 5,032,300 5,871,000
OBAT (BERAT)
658 T-4-10-I 744,500 893,400 1,042,300
659 T-4-10-II 1,418,900 1,702,600 1,986,400
660 T-4-10-III 2,062,700 2,475,200 2,887,700
661 T-4-11-I 1,016,100 1,219,300 1,422,500
662 T-4-11-II 1,599,000 1,918,800 2,238,600
663 T-4-11-III 2,575,500 3,090,600 3,605,700
664 T-4-12-I 1,674,000 2,008,800 2,343,600
LAIN (RINGAN)
665 T-4-12-II 2,494,300 2,993,100 3,492,000
LAIN (SEDANG)
666 T-4-12-III 3,826,800 4,592,200 5,357,600
LAIN (BERAT)
670 U-1-11-I 8,416,600 10,099,900 11,783,200
(RINGAN)
671 U-1-11-II 10,669,300 12,803,200 14,937,000
(SEDANG)
672 U-1-11-III 15,826,200 18,991,500 22,156,700
(BERAT)
679 U-1-14-I 4,077,100 4,892,500 5,708,000
(RINGAN)
680 U-1-14-II 5,003,600 6,004,300 7,005,100
(SEDANG)
681 U-1-14-III 5,929,300 7,115,100 8,301,000
(BERAT)
685 U-1-20-I 6,189,700 7,427,700 8,665,600
686 U-1-20-II 9,212,000 11,054,400 12,896,800
687 U-1-20-III 22,939,500 27,527,400 32,115,300
691 U-4-10-I 3,820,100 4,584,100 5,348,200
- 89 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 8,483,000 10,179,600 11,876,300
693 U-4-10-III 13,024,100 15,628,900 18,233,700
TENGGOROKAN (BERAT)
700 U-4-13-I 1,980,100 2,376,200 2,772,200
701 U-4-13-II 2,334,400 2,801,300 3,268,200
702 U-4-13-III 2,792,100 3,350,500 3,908,900
706 U-4-15-I 2,961,500 3,553,800 4,146,200
707 U-4-15-II 3,689,700 4,427,600 5,165,600
708 U-4-15-III 5,163,800 6,196,500 7,229,300
709 V-1-10-I 4,979,900 5,975,900 6,971,900
(RINGAN)
710 V-1-10-II 9,950,700 11,940,800 13,931,000
(SEDANG)
711 V-1-10-III 12,203,100 14,643,700 17,084,400
(BERAT)
715 V-1-12-I 8,640,200 10,368,300 12,096,300
MODERAT (RINGAN)
716 V-1-12-II 12,163,800 14,596,600 17,029,400
MODERAT (SEDANG)
717 V-1-12-III 14,955,300 17,946,300 20,937,400
MODERAT (BERAT)
718 V-1-13-I 4,646,200 5,575,500 6,504,700
KOMPLEK (RINGAN)
719 V-1-13-II 8,877,400 10,652,900 12,428,400
KOMPLEK (SEDANG)
720 V-1-13-III 13,509,800 16,211,700 18,913,700
KOMPLEK (BERAT)
721 V-1-14-I 8,837,900 10,605,500 12,373,100
(RINGAN)
722 V-1-14-II 12,841,200 15,409,500 17,977,700
(SEDANG)

727 V-4-10-I 4,406,000 5,287,200 6,168,500
(RINGAN)
728 V-4-10-II 7,318,700 8,782,400 10,246,100
(SEDANG)
729 V-4-10-III 12,065,900 14,479,100 16,892,300
(BERAT)
730 V-4-11-I 3,692,900 4,431,500 5,170,000
TUMOR (RINGAN)
731 V-4-11-II 4,954,900 5,945,900 6,936,800
TUMOR (SEDANG)
732 V-4-11-III 6,842,400 8,210,900 9,579,300
TUMOR (BERAT)
- 90 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 10,376,800 12,452,100 14,527,500
734 W-1-01-II 12,064,100 14,477,000 16,889,800
735 W-1-01-III 17,747,700 21,297,200 24,846,700
739 W-1-11-I 2,300,600 2,760,700 3,220,800
SERVIK (RINGAN)
740 W-1-11-II 2,538,700 3,046,400 3,554,200
SERVIK (SEDANG)
741 W-1-11-III 2,808,300 3,370,000 3,931,600
SERVIK (BERAT)
760 W-4-12-I 2,809,400 3,371,200 3,933,100
761 W-4-12-II 3,857,000 4,628,500 5,399,900
762 W-4-12-III 4,204,400 5,045,300 5,886,200
- 91 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 1,876,700 2,252,000 2,627,300
785 Z-4-12-II 3,938,000 4,725,600 5,513,200
786 Z-4-12-III 6,062,000 7,274,400 8,486,700
- 92 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS B SWASTA
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,547,200

33 F-3-10-0 TERAPI SHOCK 438,200
- 93 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,663,700
PENGGANTIAN ALAT
81 I-2-42-0 2,559,600
PERKUTAN LAIN
- 94 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,270,600
192 Q-5-12-0 GIGI 219,300
196 Q-5-16-0 VAKSINASI 102,600
201 Q-5-21-0 ABORSI 191,400
206 Q-5-26-0 BRONKIAL AKUT 218,500
- 95 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 147,100
215 Q-5-35-0 INFEKSI AKUT 447,600
218 Q-5-38-0 PARU AKUT 260,800
234 U-2-23-0 RHINOPLASTY 1,288,600
242 U-3-13-0 332,100
TENGGOROKAN
270 Z-3-11-0 1,802,000
EMPEDU
- 96 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 999,500
289 Z-3-30-0 FOTOTERAPI 84,800
- 97 -


REGIONAL 1
RUMAH SAKIT KELAS C PEMERINTAH
RAWAT INAP

13 A-4-14-I 2,092,500 2,511,000 2,929,500
(RINGAN)
14 A-4-14-II 2,540,000 3,048,000 3,556,000
(SEDANG)
15 A-4-14-III 3,048,000 3,657,600 4,267,200
(BERAT)

31 B-1-13-I 4,038,700 4,846,400 5,654,100
LAIN (RINGAN)
32 B-1-13-II 6,645,100 7,974,200 9,303,200
LAIN (SEDANG)
33 B-1-13-III 8,598,200 10,317,900 12,037,500
LAIN (BERAT)
34 B-1-14-I 5,549,300 6,659,200 7,769,000
(RINGAN)
35 B-1-14-II 6,171,800 7,406,200 8,640,500
(SEDANG)
40 B-4-11-I 3,620,000 4,344,000 5,068,000
(RINGAN)
41 B-4-11-II 5,068,000 6,081,600 7,095,200
(SEDANG)
42 B-4-11-III 6,139,800 7,367,800 8,595,800
(BERAT)
- 98 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 3,834,800 4,601,800 5,368,700
74 D-1-20-II 10,568,200 12,681,800 14,795,500
75 D-1-20-III 16,764,200 20,117,100 23,469,900
85 D-4-13-I 2,218,100 2,661,700 3,105,300
86 D-4-13-II 3,139,300 3,767,200 4,395,100
87 D-4-13-III 4,015,300 4,818,400 5,621,400
88 D-4-14-I 2,379,000 2,854,800 3,330,600
89 D-4-14-II 3,895,000 4,674,000 5,453,000
90 D-4-14-III 4,764,000 5,716,800 6,669,600
91 E-1-01-I 4,234,900 5,081,900 5,928,900
(RINGAN)
92 E-1-01-II 5,547,300 6,656,800 7,766,200
(SEDANG)

97 E-1-20-I 5,581,600 6,697,900 7,814,200
TIROGLOSAL (RINGAN)
- 99 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 7,512,600 9,015,200 10,517,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,354,000 12,424,700 14,495,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,330,600 3,996,700 4,662,800
METABOLIK (RINGAN)
101 E-4-10-II 4,653,900 5,584,700 6,515,500
METABOLIK (SEDANG)
102 E-4-10-III 5,776,400 6,931,700 8,087,000
METABOLIK (BERAT)
109 E-4-13-I 2,745,400 3,294,500 3,843,600
(RINGAN)
110 E-4-13-II 4,021,500 4,825,900 5,630,200
(SEDANG)

118 F-4-12-I 1,549,600 1,859,500 2,169,400
(RINGAN)
119 F-4-12-II 2,203,000 2,643,600 3,084,200
(SEDANG)
120 F-4-12-III 4,785,900 5,743,100 6,700,300
(BERAT)
130 F-4-16-I 4,071,000 4,885,200 5,699,400
131 F-4-16-II 4,733,200 5,679,800 6,626,400
132 F-4-16-III 6,318,000 7,581,600 8,845,100
133 F-4-17-I GANGGUAN MENTAL PADA KANAK-KANAK (RINGAN) 961,400 1,153,700 1,346,000
142 G-1-01-I 10,309,700 12,371,600 14,433,500
(RINGAN)
- 100 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 16,054,400 19,265,200 22,476,100
(SEDANG)
144 G-1-01-III 30,875,500 37,050,600 43,225,700
(BERAT)
151 G-1-12-I 3,664,500 4,397,400 5,130,300
(RINGAN)
152 G-1-12-II 6,869,200 8,243,100 9,616,900
(SEDANG)
153 G-1-12-III 9,361,400 11,233,700 13,106,000
(BERAT)
163 G-4-10-I 3,145,600 3,774,700 4,403,800
(RINGAN)
164 G-4-10-II 3,844,900 4,613,900 5,382,900
(SEDANG)
165 G-4-10-III 5,275,900 6,331,100 7,386,300
(BERAT)
166 G-4-11-I 3,292,900 3,951,500 4,610,100
167 G-4-11-II 4,374,200 5,249,100 6,123,900
168 G-4-11-III 6,427,200 7,712,700 8,998,100
DEGENERATIF (BERAT)
169 G-4-12-I 3,653,100 4,383,700 5,114,300
(RINGAN)
170 G-4-12-II 4,614,100 5,537,000 6,459,800
(SEDANG)

172 G-4-13-I 2,194,500 2,633,400 3,072,300
(RINGAN)
173 G-4-13-II 3,826,700 4,592,100 5,357,400
(SEDANG)
174 G-4-13-III 4,538,600 5,446,300 6,354,000
(BERAT)
175 G-4-14-I 3,722,700 4,467,200 5,211,700
INFARK (RINGAN)
176 G-4-14-II 4,976,900 5,972,300 6,967,700
INFARK (SEDANG)
177 G-4-14-III 6,246,600 7,496,000 8,745,300
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 101 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 3,339,800 4,007,800 4,675,800
(RINGAN)
185 G-4-17-II 4,379,200 5,255,100 6,130,900
(SEDANG)
186 G-4-17-III 5,502,700 6,603,300 7,703,800
(BERAT)
190 G-4-19-I 2,744,300 3,293,100 3,842,000
191 G-4-19-II 4,638,500 5,566,200 6,493,800
192 G-4-19-III 6,090,100 7,308,100 8,526,100
211 G-4-26-I 2,959,900 3,551,800 4,143,800
LAIN (RINGAN)
212 G-4-26-II 3,443,200 4,131,900 4,820,500
LAIN (SEDANG)
213 G-4-26-III 5,148,700 6,178,400 7,208,200
LAIN (BERAT)
232 I-1-02-I 19,226,500 23,071,800 26,917,100
(RINGAN)
- 102 -

REGIONAL 1
RAWAT INAP

233 I-1-02-II 24,801,900 29,762,300 34,722,700
(SEDANG)
234 I-1-02-III 30,570,000 36,683,900 42,797,900
(BERAT)
235 I-1-03-I 11,105,300 13,326,300 15,547,400
ANOMALI (RINGAN)
236 I-1-03-II 15,394,200 18,473,100 21,551,900
ANOMALI (SEDANG)
237 I-1-03-III 19,536,400 23,443,700 27,351,000
ANOMALI (BERAT)
238 I-1-04-I 16,735,000 20,082,100 23,429,100
JANTUNG (RINGAN)
239 I-1-04-II 26,412,400 31,694,900 36,977,400
JANTUNG (SEDANG)
240 I-1-04-III 42,193,700 50,632,400 59,071,200
JANTUNG (BERAT)
241 I-1-05-I 21,472,600 25,767,100 30,061,700
242 I-1-05-II 25,767,200 30,920,700 36,074,100
243 I-1-05-III 35,455,500 42,546,600 49,637,700
247 I-1-07-I 18,844,600 22,613,600 26,382,500
JANTUNG (RINGAN)
248 I-1-07-II 23,248,700 27,898,400 32,548,200
JANTUNG (SEDANG)
249 I-1-07-III 25,364,200 30,437,100 35,509,900
JANTUNG (BERAT)
250 I-1-11-I 3,012,900 3,615,400 4,218,000
251 I-1-11-II 3,350,000 4,020,000 4,690,000
252 I-1-11-III 4,457,800 5,349,400 6,240,900
253 I-1-12-I 8,672,400 10,406,900 12,141,400
(RINGAN)
254 I-1-12-II 14,163,800 16,996,600 19,829,400
(SEDANG)
255 I-1-12-III 18,634,700 22,361,600 26,088,500
(BERAT)
256 I-1-13-I 8,412,100 10,094,600 11,777,000
KOMPLEK (RINGAN)
257 I-1-13-II 11,202,500 13,443,000 15,683,500
KOMPLEK (SEDANG)
258 I-1-13-III 13,815,800 16,578,900 19,342,100
KOMPLEK (BERAT)
259 I-1-14-I 17,217,600 20,661,100 24,104,600
(RINGAN)
260 I-1-14-II 21,398,900 25,678,700 29,958,500
(SEDANG)
261 I-1-14-III 28,040,000 33,648,000 39,256,000
(BERAT)
265 I-1-16-I 8,479,200 10,175,100 11,870,900
266 I-1-16-II 19,185,100 23,022,100 26,859,100
267 I-1-16-III 22,129,700 26,555,600 30,981,500
268 I-1-17-I 9,818,100 11,781,800 13,745,400
(RINGAN)
269 I-1-17-II 12,293,200 14,751,900 17,210,500
(SEDANG)
- 103 -

REGIONAL 1
RAWAT INAP

270 I-1-17-III 15,206,500 18,247,800 21,289,100
(BERAT)
271 I-1-20-I 11,066,700 13,280,100 15,493,400
(RINGAN)
272 I-1-20-II 13,825,400 16,590,500 19,355,500
(SEDANG)
273 I-1-20-III 14,533,300 17,440,000 20,346,700
(BERAT)
274 I-1-30-I 8,371,400 10,045,600 11,719,900
JANTUNG (RINGAN)
275 I-1-30-II 17,414,300 20,897,100 24,380,000
JANTUNG (SEDANG)
276 I-1-30-III 26,985,900 32,383,000 37,780,200
JANTUNG (BERAT)

289 I-4-13-I 2,621,000 3,145,200 3,669,400
(RINGAN)
290 I-4-13-II 4,680,100 5,616,100 6,552,100
(SEDANG)
291 I-4-13-III 6,743,300 8,092,000 9,440,600
(BERAT)
295 I-4-15-I 4,262,100 5,114,500 5,966,900
(RINGAN)
296 I-4-15-II 5,798,200 6,957,900 8,117,500
(SEDANG)

304 I-4-18-I 3,013,200 3,615,800 4,218,400
JANTUNG (RINGAN)
305 I-4-18-II 4,587,700 5,505,200 6,422,700
JANTUNG (SEDANG)
306 I-4-18-III 6,228,500 7,474,200 8,719,900
JANTUNG (BERAT)

308 I-4-19-II 4,538,200 5,445,800 6,353,400
(SEDANG)
- 104 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 2,484,900 2,981,800 3,478,800
320 I-4-23-II 3,050,700 3,660,800 4,271,000
321 I-4-23-III 5,960,900 7,153,100 8,345,300
322 I-4-24-I 2,237,600 2,685,200 3,132,700
(RINGAN)
323 I-4-24-II 5,152,700 6,183,200 7,213,700
(SEDANG)
324 I-4-24-III 6,514,600 7,817,500 9,120,500
(BERAT)
325 J-1-01-I 40,368,800 48,442,500 56,516,300
326 J-1-01-II 45,684,800 54,821,700 63,958,700
327 J-1-01-III 51,683,800 62,020,600 72,357,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 21,422,200 25,706,700 29,991,100
329 J-1-02-II 29,828,300 35,793,900 41,759,600
330 J-1-02-III 49,256,700 59,108,000 68,959,300
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,505,400 7,806,400 9,107,500
(RINGAN)
332 J-1-10-II 13,163,600 15,796,400 18,429,100
(SEDANG)
333 J-1-10-III 13,680,300 16,416,300 19,152,400
(BERAT)
334 J-1-20-I 9,217,400 11,060,900 12,904,400
(RINGAN)
335 J-1-20-II 12,179,400 14,615,200 17,051,100
(SEDANG)
336 J-1-20-III 18,651,400 22,381,600 26,111,900
(BERAT)
337 J-1-30-I 5,428,900 6,514,700 7,600,500
(RINGAN)
338 J-1-30-II 9,834,400 11,801,300 13,768,100
(SEDANG)

- 105 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,661,000 3,193,200 3,725,400
374 J-4-21-II 4,286,800 5,144,100 6,001,500
375 J-4-21-III 5,981,900 7,178,200 8,374,600
376 K-1-10-I 5,897,500 7,077,000 8,256,500
BESAR (RINGAN)
377 K-1-10-II 7,411,500 8,893,800 10,376,100
BESAR (SEDANG)
378 K-1-10-III 8,686,500 10,423,800 12,161,100
BESAR (BERAT)
382 K-1-12-I 2,474,500 2,969,400 3,464,300
FEMORAL (RINGAN)
383 K-1-12-II 3,218,400 3,862,100 4,505,700
FEMORAL (SEDANG)
384 K-1-12-III 6,376,100 7,651,300 8,926,600
FEMORAL (BERAT)
388 K-1-14-I 4,528,900 5,434,700 6,340,400
(RINGAN)
389 K-1-14-II 5,307,800 6,369,300 7,430,900
(SEDANG)

394 K-1-30-I 5,186,200 6,223,400 7,260,600
395 K-1-30-II 9,210,500 11,052,600 12,894,700
396 K-1-30-III 12,673,800 15,208,500 17,743,300

398 K-1-40-II 6,379,900 7,655,800 8,931,800
(SEDANG)

- 106 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 2,958,000 3,549,500 4,141,100
413 K-4-13-II 3,826,300 4,591,600 5,356,800
414 K-4-13-III 5,893,700 7,072,500 8,251,200
415 K-4-14-I 1,875,400 2,250,400 2,625,500
(RINGAN)
416 K-4-14-II 2,517,300 3,020,800 3,524,300
(SEDANG)
417 K-4-14-III 4,039,300 4,847,200 5,655,100
(BERAT)

424 K-4-17-I 1,406,200 1,687,500 1,968,700
(RINGAN)
425 K-4-17-II 1,923,400 2,308,000 2,692,700
(SEDANG)
426 K-4-17-III 2,308,000 2,769,600 3,231,200
(BERAT)
427 K-4-18-I 1,242,600 1,491,100 1,739,600
(RINGAN)
428 K-4-18-II 1,765,800 2,119,000 2,472,100
(SEDANG)
436 L-1-40-I 3,696,900 4,436,300 5,175,700
(RINGAN)
437 L-1-40-II 7,415,200 8,898,300 10,381,300
(SEDANG)
438 L-1-40-III 12,481,500 14,977,800 17,474,100
(BERAT)
451 L-4-13-I 2,266,600 2,720,000 3,173,300
PAYUDARA (RINGAN)
- 107 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,663,900 3,196,700 3,729,500
PAYUDARA (SEDANG)
453 L-4-13-III 3,920,000 4,704,000 5,488,000
PAYUDARA (BERAT)
454 L-4-14-I 2,186,200 2,623,400 3,060,600
(RINGAN)
455 L-4-14-II 3,283,700 3,940,400 4,597,200
(SEDANG)
456 L-4-14-III 4,628,800 5,554,500 6,480,300
(BERAT)
457 M-1-01-I 7,727,900 9,273,500 10,819,100
458 M-1-01-II 10,984,100 13,181,000 15,377,800
459 M-1-01-III 15,429,400 18,515,300 21,601,200
463 M-1-03-I 18,596,400 22,315,700 26,035,000
464 M-1-03-II 21,751,200 26,101,400 30,451,700
465 M-1-03-III 26,920,700 32,304,900 37,689,000
472 M-1-07-I 6,103,400 7,324,100 8,544,800
473 M-1-07-II 8,176,500 9,811,700 11,447,000
474 M-1-07-III 16,656,200 19,987,400 23,318,700
475 M-1-10-I 10,047,200 12,056,700 14,066,100
WAJAH (RINGAN)
476 M-1-10-II 22,047,400 26,456,900 30,866,400
WAJAH (SEDANG)
477 M-1-10-III 47,554,200 57,065,100 66,575,900
WAJAH (BERAT)
478 M-1-20-I 9,176,900 11,012,300 12,847,700
(RINGAN)
479 M-1-20-II 11,724,500 14,069,300 16,414,200
(SEDANG)

484 M-1-40-I 3,204,700 3,845,600 4,486,600
INTERNAL (RINGAN)
485 M-1-40-II 5,683,400 6,820,100 7,956,800
INTERNAL (SEDANG)
486 M-1-40-III 8,114,800 9,737,800 11,360,700
INTERNAL (BERAT)
490 M-1-60-I 5,931,100 7,117,300 8,303,500
491 M-1-60-II 7,456,800 8,948,100 10,439,500
492 M-1-60-III 11,264,300 13,517,200 15,770,100
- 108 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 10,988,400 13,186,100 15,383,800
KAKI (RINGAN)
494 M-1-70-II 12,087,300 14,504,700 16,922,200
KAKI (SEDANG)
495 M-1-70-III 13,838,300 16,606,000 19,373,700
KAKI (BERAT)
502 M-4-11-I 2,741,900 3,290,300 3,838,700
(RINGAN)
503 M-4-11-II 6,011,500 7,213,800 8,416,100
(SEDANG)
504 M-4-11-III 8,691,600 10,429,900 12,168,200
(BERAT)
505 M-4-12-I 2,188,700 2,626,400 3,064,100
(RINGAN)
506 M-4-12-II 3,640,300 4,368,400 5,096,500
(SEDANG)
507 M-4-12-III 4,869,300 5,843,200 6,817,000
(BERAT)
508 M-4-13-I 3,644,300 4,373,200 5,102,100
509 M-4-13-II 5,475,400 6,570,500 7,665,600
510 M-4-13-III 10,682,500 12,819,000 14,955,500
520 M-4-17-I 2,738,500 3,286,200 3,833,900
(RINGAN)
521 M-4-17-II 3,830,100 4,596,100 5,362,200
(SEDANG)
522 M-4-17-III 5,348,500 6,418,200 7,487,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,177,400 2,612,900 3,048,400
(RINGAN)
530 M-4-20-II 3,188,400 3,826,100 4,463,800
(SEDANG)
531 M-4-20-III 3,563,400 4,276,100 4,988,800
(BERAT)
532 M-4-21-I 2,192,500 2,631,000 3,069,500
533 M-4-21-II 2,742,100 3,290,600 3,839,000
- 109 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 6,147,800 7,377,400 8,607,000
541 N-1-12-I 3,223,200 3,867,800 4,512,500
542 N-1-12-II 6,417,000 7,700,400 8,983,900
543 N-1-12-III 13,925,200 16,710,200 19,495,300
547 N-1-30-I 6,449,400 7,739,200 9,029,100
BAWAH (RINGAN)
548 N-1-30-II 9,756,600 11,707,900 13,659,300
BAWAH (SEDANG)
549 N-1-30-III 11,228,900 13,474,700 15,720,500
BAWAH (BERAT)
550 N-1-40-I 5,792,000 6,950,400 8,108,800
(RINGAN)
551 N-1-40-II 7,865,400 9,438,500 11,011,500
(SEDANG)
552 N-1-40-III 9,154,300 10,985,100 12,816,000
(BERAT)
553 N-4-10-I 2,460,800 2,952,900 3,445,100
(RINGAN)
554 N-4-10-II 2,976,400 3,571,600 4,166,900
(SEDANG)
555 N-4-10-III 4,377,800 5,253,400 6,128,900
(BERAT)
568 N-4-15-I 2,241,300 2,689,600 3,137,900
URIN (RINGAN)
569 N-4-15-II 2,781,100 3,337,300 3,893,500
URIN (SEDANG)
570 N-4-15-III 3,173,700 3,808,400 4,443,200
URIN (BERAT)
571 N-4-16-I 2,744,500 3,293,400 3,842,300
(RINGAN)
572 N-4-16-II 3,917,300 4,700,700 5,484,200
(SEDANG)
573 N-4-16-III 5,214,200 6,257,000 7,299,900
(BERAT)
- 110 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 2,551,100 3,061,400 3,571,600
578 O-6-11-II 2,835,300 3,402,400 3,969,400
579 O-6-11-III 3,527,200 4,232,600 4,938,000
580 O-6-12-I 1,807,500 2,168,900 2,530,400
581 O-6-12-II 2,170,700 2,604,900 3,039,000
582 O-6-12-III 2,727,600 3,273,100 3,818,700
586 P-8-01-I 40,360,700 48,432,800 56,504,900
587 P-8-01-II 49,940,300 59,928,300 69,916,400
588 P-8-01-III 58,615,800 70,339,000 82,062,200
589 P-8-02-I 67,998,700 81,598,400 95,198,200
590 P-8-02-II 78,001,400 93,601,700 109,202,000
591 P-8-02-III 89,122,200 106,946,700 124,771,100
592 P-8-03-I 7,348,100 8,817,700 10,287,300
593 P-8-03-II 10,902,100 13,082,600 15,263,000
594 P-8-03-III 12,339,000 14,806,800 17,274,700
595 P-8-04-I 21,787,800 26,145,300 30,502,900
596 P-8-04-II 36,680,700 44,016,900 51,353,000
597 P-8-04-III 52,590,900 63,109,100 73,627,200
598 P-8-05-I 15,407,500 18,489,000 21,570,500
599 P-8-05-II 22,338,300 26,806,000 31,273,700
600 P-8-05-III 32,056,400 38,467,700 44,879,000
601 P-8-06-I 3,909,200 4,691,100 5,472,900
602 P-8-06-II 10,960,500 13,152,600 15,344,700
603 P-8-06-III 14,520,000 17,424,000 20,328,000
604 P-8-07-I 3,786,500 4,543,800 5,301,100
605 P-8-07-II 10,616,400 12,739,700 14,862,900
606 P-8-07-III 14,064,100 16,876,900 19,689,700
607 P-8-08-I 3,841,500 4,609,800 5,378,100
608 P-8-08-II 5,451,100 6,541,300 7,631,500
609 P-8-08-III 8,826,400 10,591,700 12,357,000
610 P-8-11-I 6,680,100 8,016,100 9,352,100
MAYOR (RINGAN)
611 P-8-11-II 9,911,000 11,893,200 13,875,400
MAYOR (SEDANG)
- 111 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 11,217,300 13,460,800 15,704,200
MAYOR (BERAT)
613 P-8-12-I 5,808,700 6,970,500 8,132,200
MAYOR (RINGAN)
614 P-8-12-II 8,259,200 9,911,000 11,562,900
MAYOR (SEDANG)
615 P-8-12-III 9,347,800 11,217,300 13,086,900
MAYOR (BERAT)
616 P-8-13-I 4,989,600 5,987,500 6,985,400
MAYOR (RINGAN)
617 P-8-13-II 7,783,800 9,340,500 10,897,300
MAYOR (SEDANG)
618 P-8-13-III 10,624,500 12,749,400 14,874,300
MAYOR (BERAT)
619 P-8-14-I 2,632,500 3,159,000 3,685,500
620 P-8-14-II 5,358,700 6,430,500 7,502,200
621 P-8-14-III 9,942,500 11,931,000 13,919,500
622 P-8-15-I 1,974,400 2,369,300 2,764,200
ASPIRASI (RINGAN)
623 P-8-15-II 3,953,900 4,744,600 5,535,400
ASPIRASI (SEDANG)
624 P-8-15-III 4,639,100 5,567,000 6,494,800
ASPIRASI (BERAT)
625 P-8-16-I 1,786,900 2,144,200 2,501,600
626 P-8-16-II 3,433,800 4,120,500 4,807,300
627 P-8-16-III 7,002,400 8,402,800 9,803,300
628 P-8-17-I 3,326,400 3,991,700 4,657,000
(RINGAN)
629 P-8-17-II 5,987,500 7,185,000 8,382,500
(SEDANG)
630 P-8-17-III 8,172,700 9,807,200 11,441,800
(BERAT)
631 S-4-10-I 2,014,700 2,417,600 2,820,500
632 S-4-10-II 2,482,400 2,978,900 3,475,300
633 S-4-10-III 3,398,100 4,077,700 4,757,400
640 S-4-13-I 2,187,300 2,624,800 3,062,300
(RINGAN)
641 S-4-13-II 3,880,500 4,656,600 5,432,700
(SEDANG)
642 S-4-13-III 6,298,500 7,558,200 8,817,900
(BERAT)
643 S-4-14-I 1,106,900 1,328,300 1,549,700
644 S-4-14-II 2,351,200 2,821,500 3,291,700
645 S-4-14-III 4,458,700 5,350,500 6,242,200
KANAK-KANAK (BERAT)
646 S-4-15-I 740,300 888,400 1,036,500
647 S-4-15-II 1,397,100 1,676,500 1,956,000
648 S-4-15-III 1,809,500 2,171,400 2,533,300
- 112 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 1,847,700 2,217,300 2,586,800
653 S-4-17-II 2,742,200 3,290,600 3,839,100
654 S-4-17-III 3,298,100 3,957,700 4,617,400
655 T-1-10-I 1,236,300 1,483,500 1,730,800
OBAT (RINGAN)
656 T-1-10-II 1,660,500 1,992,600 2,324,600
OBAT (SEDANG)
657 T-1-10-III 3,020,600 3,624,800 4,228,900
OBAT (BERAT)
658 T-4-10-I 589,500 707,400 825,300
659 T-4-10-II 1,123,600 1,348,300 1,573,000
660 T-4-10-III 1,633,300 1,960,000 2,286,600
661 T-4-11-I 789,200 947,100 1,104,900
662 T-4-11-II 1,241,900 1,490,300 1,738,700
663 T-4-11-III 2,000,400 2,400,500 2,800,600
664 T-4-12-I 1,226,300 1,471,600 1,716,900
LAIN (RINGAN)
665 T-4-12-II 1,853,600 2,224,300 2,595,000
LAIN (SEDANG)
666 T-4-12-III 2,869,500 3,443,400 4,017,300
LAIN (BERAT)
670 U-1-11-I 6,250,000 7,500,000 8,750,000
(RINGAN)
671 U-1-11-II 7,922,800 9,507,400 11,092,000
(SEDANG)
672 U-1-11-III 11,399,700 13,679,600 15,959,600
(BERAT)
679 U-1-14-I 2,936,800 3,524,100 4,111,500
(RINGAN)
680 U-1-14-II 3,604,100 4,325,000 5,045,800
(SEDANG)
681 U-1-14-III 4,270,900 5,125,100 5,979,200
(BERAT)
685 U-1-20-I 4,458,500 5,350,200 6,241,900
686 U-1-20-II 6,635,500 7,962,500 9,289,600
687 U-1-20-III 17,034,500 20,441,400 23,848,300
691 U-4-10-I 2,751,600 3,302,000 3,852,300
- 113 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 6,299,400 7,559,200 8,819,100
693 U-4-10-III 9,671,400 11,605,700 13,540,000
TENGGOROKAN (BERAT)
700 U-4-13-I 1,826,300 2,191,600 2,556,900
701 U-4-13-II 2,153,100 2,583,700 3,014,300
702 U-4-13-III 2,575,200 3,090,200 3,605,300
706 U-4-15-I 2,199,200 2,639,000 3,078,900
707 U-4-15-II 2,739,900 3,287,900 3,835,900
708 U-4-15-III 3,834,500 4,601,400 5,368,300
709 V-1-10-I 3,587,100 4,304,500 5,021,900
(RINGAN)
710 V-1-10-II 7,389,200 8,867,000 10,344,900
(SEDANG)
711 V-1-10-III 9,061,800 10,874,200 12,686,600
(BERAT)
715 V-1-12-I 6,416,100 7,699,300 8,982,500
MODERAT (RINGAN)
716 V-1-12-II 8,761,700 10,514,000 12,266,300
MODERAT (SEDANG)
717 V-1-12-III 11,105,500 13,326,600 15,547,700
MODERAT (BERAT)
718 V-1-13-I 3,346,700 4,016,000 4,685,400
KOMPLEK (RINGAN)
719 V-1-13-II 6,394,500 7,673,300 8,952,200
KOMPLEK (SEDANG)
720 V-1-13-III 10,032,100 12,038,500 14,045,000
KOMPLEK (BERAT)
721 V-1-14-I 6,562,900 7,875,400 9,188,000
(RINGAN)
722 V-1-14-II 9,535,700 11,442,800 13,349,900
(SEDANG)

727 V-4-10-I 3,173,700 3,808,400 4,443,200
(RINGAN)
728 V-4-10-II 5,271,700 6,326,000 7,380,300
(SEDANG)
729 V-4-10-III 8,691,100 10,429,400 12,167,600
(BERAT)
730 V-4-11-I 2,742,300 3,290,700 3,839,200
TUMOR (RINGAN)
731 V-4-11-II 3,679,400 4,415,300 5,151,200
TUMOR (SEDANG)
732 V-4-11-III 4,928,600 5,914,300 6,900,100
TUMOR (BERAT)
- 114 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 7,474,400 8,969,300 10,464,200
734 W-1-01-II 8,958,600 10,750,300 12,542,100
735 W-1-01-III 12,783,700 15,340,500 17,897,200
739 W-1-11-I 1,657,100 1,988,600 2,320,000
SERVIK (RINGAN)
740 W-1-11-II 1,828,600 2,194,400 2,560,100
SERVIK (SEDANG)
741 W-1-11-III 2,022,800 2,427,400 2,832,000
SERVIK (BERAT)
760 W-4-12-I 2,671,300 3,205,600 3,739,800
761 W-4-12-II 3,667,500 4,401,000 5,134,500
762 W-4-12-III 3,997,800 4,797,300 5,596,900
763 W-4-13-I ABORTUS (RINGAN) 923,600 1,108,300 1,293,100
- 115 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 1,166,200 1,399,400 1,632,700
785 Z-4-12-II 2,860,900 3,433,100 4,005,300
786 Z-4-12-III 4,092,700 4,911,200 5,729,800
- 116 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS C PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
7 B-3-11-0 PROSEDUR ENDOSKOPI SALURAN EMPEDU 767,200
23 D-2-10-0 PROSEDUR PENCANGKOKAN SUMSUM TULANG 931,600
24 D-2-11-0 PROSEDUR LIMPA 1,458,200

33 F-3-10-0 TERAPI SHOCK 413,000
45 G-2-21-0 PROSEDUR BESAR PADA SARAF PERIFER 900,800
55 H-2-22-0 PROSEDUR SEDANG PADA MATA EKSTERNAL 881,600
63 H-2-37-0 PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA 766,200
- 117 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,510,300
PENGGANTIAN ALAT
81 I-2-42-0 2,412,200
PERKUTAN LAIN
118 K-3-13-0 PROSEDUR KOLONOSKOPI 955,700
119 K-3-14-0 PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS 842,300
- 118 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
166 N-2-22-0 PROSEDUR BESAR PADA GINJAL DAN URETER 965,400
181 O-7-12-0 1,137,600
192 Q-5-12-0 GIGI 206,700
196 Q-5-16-0 VAKSINASI 90,400
201 Q-5-21-0 ABORSI 180,400
206 Q-5-26-0 BRONKIAL AKUT 192,500
- 119 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 129,600
215 Q-5-35-0 INFEKSI AKUT 421,800
218 Q-5-38-0 PARU AKUT 245,800
234 U-2-23-0 RHINOPLASTY 1,214,400
242 U-3-13-0 313,000
TENGGOROKAN
261 W-2-23-0 PROSEDUR LAPAROSKOPI GINEKOLOGI 735,400
270 Z-3-11-0 1,698,200
EMPEDU
- 120 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
275 Z-3-16-0 PROSEDUR MAGNETIC RESONANCE IMAGING (MRI) 995,100
277 Z-3-18-0 CT-SCAN KEPALA 894,800
289 Z-3-30-0 FOTOTERAPI 74,700
- 121 -


REGIONAL 1
RUMAH SAKIT KELAS C SWASTA
RAWAT INAP

13 A-4-14-I 2,155,300 2,586,400 3,017,400
(RINGAN)
14 A-4-14-II 2,616,200 3,139,400 3,662,700
(SEDANG)
15 A-4-14-III 3,139,400 3,767,300 4,395,200
(BERAT)

31 B-1-13-I 4,159,800 4,991,800 5,823,800
LAIN (RINGAN)
32 B-1-13-II 6,844,500 8,213,400 9,582,300
LAIN (SEDANG)
33 B-1-13-III 8,856,200 10,627,400 12,398,600
LAIN (BERAT)
34 B-1-14-I 5,715,800 6,858,900 8,002,100
(RINGAN)
35 B-1-14-II 6,357,000 7,628,300 8,899,700
(SEDANG)
40 B-4-11-I 3,728,600 4,474,300 5,220,000
(RINGAN)
41 B-4-11-II 5,220,100 6,264,100 7,308,100
(SEDANG)
42 B-4-11-III 6,324,000 7,588,800 8,853,600
(BERAT)
- 122 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 3,949,900 4,739,800 5,529,800
74 D-1-20-II 10,885,200 13,062,300 15,239,300
75 D-1-20-III 17,267,200 20,720,600 24,174,000
85 D-4-13-I 2,284,600 2,741,500 3,198,500
86 D-4-13-II 3,233,500 3,880,200 4,526,900
87 D-4-13-III 4,135,800 4,962,900 5,790,100
88 D-4-14-I 2,450,400 2,940,400 3,430,500
89 D-4-14-II 4,011,800 4,814,200 5,616,600
90 D-4-14-III 4,906,900 5,888,300 6,869,600
91 E-1-01-I 4,361,900 5,234,300 6,106,700
(RINGAN)
92 E-1-01-II 5,713,700 6,856,500 7,999,200
(SEDANG)

97 E-1-20-I 5,749,000 6,898,800 8,048,600
TIROGLOSAL (RINGAN)
- 123 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 7,738,000 9,285,600 10,833,200
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,664,600 12,797,500 14,930,400
TIROGLOSAL (BERAT)
100 E-4-10-I 3,430,500 4,116,600 4,802,700
METABOLIK (RINGAN)
101 E-4-10-II 4,793,500 5,752,200 6,710,900
METABOLIK (SEDANG)
102 E-4-10-III 5,949,700 7,139,700 8,329,600
METABOLIK (BERAT)
109 E-4-13-I 2,827,800 3,393,300 3,958,900
(RINGAN)
110 E-4-13-II 4,142,200 4,970,600 5,799,100
(SEDANG)

118 F-4-12-I 1,596,100 1,915,300 2,234,500
(RINGAN)
119 F-4-12-II 2,269,100 2,722,900 3,176,700
(SEDANG)
120 F-4-12-III 4,929,500 5,915,400 6,901,300
(BERAT)
130 F-4-16-I 4,193,100 5,031,700 5,870,300
131 F-4-16-II 4,875,200 5,850,200 6,825,200
132 F-4-16-III 6,507,500 7,809,000 9,110,500
142 G-1-01-I 10,619,000 12,742,800 14,866,500
(RINGAN)
- 124 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 16,536,000 19,843,200 23,150,400
(SEDANG)
144 G-1-01-III 31,801,800 38,162,100 44,522,500
(BERAT)
151 G-1-12-I 3,774,400 4,529,300 5,284,200
(RINGAN)
152 G-1-12-II 7,075,300 8,490,400 9,905,500
(SEDANG)
153 G-1-12-III 9,642,300 11,570,700 13,499,200
(BERAT)
163 G-4-10-I 3,239,900 3,887,900 4,535,900
(RINGAN)
164 G-4-10-II 3,960,300 4,752,400 5,544,400
(SEDANG)
165 G-4-10-III 5,434,200 6,521,000 7,607,900
(BERAT)
166 G-4-11-I 3,391,700 4,070,000 4,748,400
167 G-4-11-II 4,505,400 5,406,500 6,307,600
168 G-4-11-III 6,620,000 7,944,000 9,268,000
DEGENERATIF (BERAT)
169 G-4-12-I 3,762,700 4,515,200 5,267,800
(RINGAN)
170 G-4-12-II 4,752,600 5,703,100 6,653,600
(SEDANG)

172 G-4-13-I 2,260,300 2,712,400 3,164,400
(RINGAN)
173 G-4-13-II 3,941,500 4,729,800 5,518,100
(SEDANG)
174 G-4-13-III 4,674,700 5,609,700 6,544,600
(BERAT)
175 G-4-14-I 3,834,300 4,601,200 5,368,100
INFARK (RINGAN)
176 G-4-14-II 5,126,200 6,151,500 7,176,700
INFARK (SEDANG)
177 G-4-14-III 6,434,000 7,720,800 9,007,600
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 125 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 3,440,000 4,128,000 4,816,000
(RINGAN)
185 G-4-17-II 4,510,600 5,412,700 6,314,900
(SEDANG)
186 G-4-17-III 5,667,800 6,801,400 7,934,900
(BERAT)
190 G-4-19-I 2,826,600 3,391,900 3,957,200
191 G-4-19-II 4,777,600 5,733,100 6,688,700
192 G-4-19-III 6,272,800 7,527,400 8,781,900
211 G-4-26-I 3,048,700 3,658,400 4,268,100
LAIN (RINGAN)
212 G-4-26-II 3,546,500 4,255,800 4,965,100
LAIN (SEDANG)
213 G-4-26-III 5,303,100 6,363,800 7,424,400
LAIN (BERAT)
232 I-1-02-I 19,803,300 23,764,000 27,724,600
(RINGAN)
- 126 -

REGIONAL 1
RAWAT INAP

233 I-1-02-II 25,546,000 30,655,200 35,764,400
(SEDANG)
234 I-1-02-III 31,487,000 37,784,500 44,081,900
(BERAT)
235 I-1-03-I 11,438,400 13,726,100 16,013,800
ANOMALI (RINGAN)
236 I-1-03-II 15,856,000 19,027,300 22,198,500
ANOMALI (SEDANG)
237 I-1-03-III 20,122,500 24,147,000 28,171,600
ANOMALI (BERAT)
238 I-1-04-I 17,237,100 20,684,500 24,131,900
JANTUNG (RINGAN)
239 I-1-04-II 27,204,800 32,645,800 38,086,700
JANTUNG (SEDANG)
240 I-1-04-III 43,459,500 52,151,400 60,843,300
JANTUNG (BERAT)
241 I-1-05-I 22,116,800 26,540,200 30,963,500
242 I-1-05-II 26,540,200 31,848,300 37,156,300
243 I-1-05-III 36,519,200 43,823,000 51,126,800
247 I-1-07-I 19,410,000 23,292,000 27,174,000
JANTUNG (RINGAN)
248 I-1-07-II 23,946,200 28,735,400 33,524,600
JANTUNG (SEDANG)
249 I-1-07-III 26,125,200 31,350,200 36,575,200
JANTUNG (BERAT)
250 I-1-11-I 3,103,200 3,723,900 4,344,500
251 I-1-11-II 3,450,500 4,140,600 4,830,700
252 I-1-11-III 4,591,600 5,509,900 6,428,200
253 I-1-12-I 8,932,600 10,719,100 12,505,700
(RINGAN)
254 I-1-12-II 14,588,700 17,506,500 20,424,200
(SEDANG)
255 I-1-12-III 19,193,700 23,032,400 26,871,200
(BERAT)
256 I-1-13-I 8,664,500 10,397,400 12,130,300
KOMPLEK (RINGAN)
257 I-1-13-II 11,538,600 13,846,300 16,154,000
KOMPLEK (SEDANG)
258 I-1-13-III 14,230,200 17,076,300 19,922,300
KOMPLEK (BERAT)
259 I-1-14-I 17,734,100 21,280,900 24,827,800
(RINGAN)
260 I-1-14-II 22,040,900 26,449,100 30,857,300
(SEDANG)
261 I-1-14-III 28,881,200 34,657,400 40,433,700
(BERAT)
265 I-1-16-I 8,733,600 10,480,300 12,227,000
266 I-1-16-II 19,760,600 23,712,700 27,664,900
267 I-1-16-III 22,793,600 27,352,300 31,911,000
268 I-1-17-I 10,112,700 12,135,200 14,157,800
(RINGAN)
269 I-1-17-II 12,662,000 15,194,400 17,726,800
(SEDANG)
- 127 -

REGIONAL 1
RAWAT INAP

270 I-1-17-III 15,662,700 18,795,300 21,927,800
(BERAT)
271 I-1-20-I 11,398,700 13,678,500 15,958,200
(RINGAN)
272 I-1-20-II 14,240,100 17,088,200 19,936,200
(SEDANG)
273 I-1-20-III 14,969,300 17,963,200 20,957,100
(BERAT)
274 I-1-30-I 8,622,500 10,347,000 12,071,500
JANTUNG (RINGAN)
275 I-1-30-II 17,936,700 21,524,000 25,111,400
JANTUNG (SEDANG)
276 I-1-30-III 27,795,400 33,354,500 38,913,600
JANTUNG (BERAT)

289 I-4-13-I 2,699,600 3,239,500 3,779,400
(RINGAN)
290 I-4-13-II 4,820,500 5,784,600 6,748,600
(SEDANG)
291 I-4-13-III 6,945,600 8,334,700 9,723,800
(BERAT)
295 I-4-15-I 4,389,900 5,267,900 6,145,900
(RINGAN)
296 I-4-15-II 5,972,200 7,166,600 8,361,100
(SEDANG)

304 I-4-18-I 3,103,600 3,724,300 4,345,000
JANTUNG (RINGAN)
305 I-4-18-II 4,725,300 5,670,400 6,615,400
JANTUNG (SEDANG)
306 I-4-18-III 6,415,400 7,698,500 8,981,500
JANTUNG (BERAT)

308 I-4-19-II 4,674,300 5,609,200 6,544,000
(SEDANG)
- 128 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 2,559,400 3,071,300 3,583,200
320 I-4-23-II 3,142,200 3,770,700 4,399,100
321 I-4-23-III 6,139,700 7,367,700 8,595,600
322 I-4-24-I 2,304,800 2,765,700 3,226,700
(RINGAN)
323 I-4-24-II 5,307,200 6,368,700 7,430,100
(SEDANG)
324 I-4-24-III 6,710,100 8,052,100 9,394,100
(BERAT)
325 J-1-01-I 41,579,800 49,895,800 58,211,800
326 J-1-01-II 47,055,300 56,466,400 65,877,500
327 J-1-01-III 53,234,400 63,881,200 74,528,100
TRAKEOSTOMI (BERAT)
328 J-1-02-I 22,064,900 26,477,900 30,890,900
329 J-1-02-II 30,723,100 36,867,700 43,012,300
330 J-1-02-III 50,734,400 60,881,200 71,028,100
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,700,500 8,040,600 9,380,700
(RINGAN)
332 J-1-10-II 13,558,500 16,270,300 18,982,000
(SEDANG)
333 J-1-10-III 14,090,700 16,908,800 19,726,900
(BERAT)
334 J-1-20-I 9,494,000 11,392,800 13,291,500
(RINGAN)
335 J-1-20-II 12,544,700 15,053,700 17,562,600
(SEDANG)
336 J-1-20-III 19,210,900 23,053,100 26,895,300
(BERAT)
337 J-1-30-I 5,591,800 6,710,100 7,828,500
(RINGAN)
338 J-1-30-II 10,129,400 12,155,300 14,181,200
(SEDANG)

- 129 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,740,800 3,289,000 3,837,100
374 J-4-21-II 4,415,400 5,298,500 6,181,500
375 J-4-21-III 6,161,300 7,393,600 8,625,900
376 K-1-10-I 6,074,400 7,289,300 8,504,200
BESAR (RINGAN)
377 K-1-10-II 7,633,800 9,160,600 10,687,400
BESAR (SEDANG)
378 K-1-10-III 8,947,100 10,736,500 12,525,900
BESAR (BERAT)
382 K-1-12-I 2,548,700 3,058,500 3,568,200
FEMORAL (RINGAN)
383 K-1-12-II 3,314,900 3,977,900 4,640,900
FEMORAL (SEDANG)
384 K-1-12-III 6,567,400 7,880,900 9,194,400
FEMORAL (BERAT)
388 K-1-14-I 4,664,800 5,597,700 6,530,700
(RINGAN)
389 K-1-14-II 5,467,000 6,560,400 7,653,800
(SEDANG)

394 K-1-30-I 5,341,700 6,410,100 7,478,400
395 K-1-30-II 9,486,800 11,384,200 13,281,500
396 K-1-30-III 13,054,000 15,664,800 18,275,600

398 K-1-40-II 6,571,300 7,885,500 9,199,800
(SEDANG)

- 130 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 3,046,700 3,656,000 4,265,400
413 K-4-13-II 3,941,100 4,729,300 5,517,500
414 K-4-13-III 6,070,500 7,284,600 8,498,800
415 K-4-14-I 1,931,600 2,317,900 2,704,300
(RINGAN)
416 K-4-14-II 2,592,900 3,111,400 3,630,000
(SEDANG)
417 K-4-14-III 4,160,500 4,992,600 5,824,700
(BERAT)

424 K-4-17-I 1,448,400 1,738,100 2,027,800
(RINGAN)
425 K-4-17-II 1,981,100 2,377,300 2,773,500
(SEDANG)
426 K-4-17-III 2,377,300 2,852,700 3,328,200
(BERAT)
427 K-4-18-I 1,279,900 1,535,900 1,791,800
(RINGAN)
428 K-4-18-II 1,818,800 2,182,500 2,546,300
(SEDANG)
436 L-1-40-I 3,807,800 4,569,400 5,331,000
(RINGAN)
437 L-1-40-II 7,637,700 9,165,200 10,692,800
(SEDANG)
438 L-1-40-III 12,855,900 15,427,100 17,998,300
(BERAT)
451 L-4-13-I 2,334,600 2,801,600 3,268,500
PAYUDARA (RINGAN)
- 131 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,743,800 3,292,600 3,841,400
PAYUDARA (SEDANG)
453 L-4-13-III 4,037,600 4,845,100 5,652,700
PAYUDARA (BERAT)
454 L-4-14-I 2,251,800 2,702,100 3,152,500
(RINGAN)
455 L-4-14-II 3,382,200 4,058,700 4,735,100
(SEDANG)
456 L-4-14-III 4,767,600 5,721,200 6,674,700
(BERAT)
457 M-1-01-I 7,959,700 9,551,700 11,143,600
458 M-1-01-II 11,313,700 13,576,400 15,839,100
459 M-1-01-III 15,892,300 19,070,800 22,249,200
463 M-1-03-I 19,154,300 22,985,200 26,816,100
464 M-1-03-II 22,403,700 26,884,500 31,365,200
465 M-1-03-III 27,728,400 33,274,000 38,819,700
472 M-1-07-I 6,286,500 7,543,800 8,801,100
473 M-1-07-II 8,421,700 10,106,100 11,790,400
474 M-1-07-III 17,155,900 20,587,100 24,018,200
475 M-1-10-I 10,348,600 12,418,400 14,488,100
WAJAH (RINGAN)
476 M-1-10-II 22,708,800 27,250,600 31,792,400
WAJAH (SEDANG)
477 M-1-10-III 48,980,800 58,777,000 68,573,200
WAJAH (BERAT)
478 M-1-20-I 9,452,200 11,342,700 13,233,100
(RINGAN)
479 M-1-20-II 12,076,200 14,491,400 16,906,700
(SEDANG)

484 M-1-40-I 3,300,800 3,961,000 4,621,200
INTERNAL (RINGAN)
485 M-1-40-II 5,853,900 7,024,700 8,195,500
INTERNAL (SEDANG)
486 M-1-40-III 8,358,300 10,029,900 11,701,600
INTERNAL (BERAT)
490 M-1-60-I 6,109,000 7,330,800 8,552,600
491 M-1-60-II 7,680,500 9,216,600 10,752,600
492 M-1-60-III 11,602,300 13,922,700 16,243,200
- 132 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 11,318,100 13,581,700 15,845,300
KAKI (RINGAN)
494 M-1-70-II 12,449,900 14,939,900 17,429,900
KAKI (SEDANG)
495 M-1-70-III 14,253,500 17,104,200 19,954,900
KAKI (BERAT)
502 M-4-11-I 2,824,200 3,389,000 3,953,800
(RINGAN)
503 M-4-11-II 6,191,800 7,430,200 8,668,600
(SEDANG)
504 M-4-11-III 8,952,300 10,742,800 12,533,300
(BERAT)
505 M-4-12-I 2,254,300 2,705,200 3,156,000
(RINGAN)
506 M-4-12-II 3,749,500 4,499,400 5,249,400
(SEDANG)
507 M-4-12-III 5,015,400 6,018,500 7,021,600
(BERAT)
508 M-4-13-I 3,753,700 4,504,400 5,255,100
509 M-4-13-II 5,639,700 6,767,700 7,895,600
510 M-4-13-III 11,002,900 13,203,500 15,404,100
520 M-4-17-I 2,820,700 3,384,800 3,948,900
(RINGAN)
521 M-4-17-II 3,945,000 4,734,000 5,523,000
(SEDANG)
522 M-4-17-III 5,509,000 6,610,700 7,712,500
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,242,700 2,691,300 3,139,800
(RINGAN)
530 M-4-20-II 3,284,100 3,940,900 4,597,700
(SEDANG)
531 M-4-20-III 3,670,400 4,404,400 5,138,500
(BERAT)
532 M-4-21-I 2,258,200 2,709,900 3,161,500
533 M-4-21-II 2,824,400 3,389,300 3,954,200
- 133 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 6,332,300 7,598,700 8,865,200
541 N-1-12-I 3,319,900 3,983,900 4,647,900
542 N-1-12-II 6,609,600 7,931,500 9,253,400
543 N-1-12-III 14,343,000 17,211,600 20,080,100
547 N-1-30-I 6,642,800 7,971,400 9,300,000
BAWAH (RINGAN)
548 N-1-30-II 10,049,300 12,059,200 14,069,000
BAWAH (SEDANG)
549 N-1-30-III 11,565,800 13,879,000 16,192,100
BAWAH (BERAT)
550 N-1-40-I 5,965,800 7,158,900 8,352,100
(RINGAN)
551 N-1-40-II 8,101,300 9,721,600 11,341,900
(SEDANG)
552 N-1-40-III 9,428,900 11,314,700 13,200,500
(BERAT)
553 N-4-10-I 2,534,600 3,041,500 3,548,500
(RINGAN)
554 N-4-10-II 3,065,700 3,678,800 4,291,900
(SEDANG)
555 N-4-10-III 4,509,100 5,411,000 6,312,800
(BERAT)
568 N-4-15-I 2,308,600 2,770,300 3,232,000
URIN (RINGAN)
569 N-4-15-II 2,864,500 3,437,400 4,010,300
URIN (SEDANG)
570 N-4-15-III 3,268,900 3,922,700 4,576,500
URIN (BERAT)
571 N-4-16-I 2,826,800 3,392,200 3,957,600
(RINGAN)
572 N-4-16-II 4,034,800 4,841,800 5,648,700
(SEDANG)
573 N-4-16-III 5,370,600 6,444,700 7,518,900
(BERAT)
- 134 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 2,627,700 3,153,200 3,678,800
578 O-6-11-II 2,920,400 3,504,400 4,088,500
579 O-6-11-III 3,633,000 4,359,600 5,086,200
580 O-6-12-I 1,861,700 2,234,000 2,606,300
581 O-6-12-II 2,235,900 2,683,000 3,130,200
582 O-6-12-III 2,809,400 3,371,300 3,933,200
586 P-8-01-I 41,571,500 49,885,800 58,200,100
587 P-8-01-II 51,438,500 61,726,200 72,013,900
588 P-8-01-III 60,374,300 72,449,200 84,524,000
589 P-8-02-I 70,038,700 84,046,400 98,054,100
590 P-8-02-II 80,341,500 96,409,800 112,478,100
591 P-8-02-III 91,795,900 110,155,100 128,514,200
592 P-8-03-I 7,568,500 9,082,200 10,595,900
593 P-8-03-II 11,229,200 13,475,000 15,720,900
594 P-8-03-III 12,709,200 15,251,100 17,792,900
595 P-8-04-I 22,441,400 26,929,700 31,418,000
596 P-8-04-II 37,781,100 45,337,400 52,893,600
597 P-8-04-III 54,168,600 65,002,300 75,836,100
598 P-8-05-I 15,869,700 19,043,600 22,217,600
599 P-8-05-II 23,008,500 27,610,200 32,211,900
600 P-8-05-III 33,018,100 39,621,700 46,225,400
601 P-8-06-I 4,026,500 4,831,800 5,637,100
602 P-8-06-II 11,289,300 13,547,200 15,805,100
603 P-8-06-III 14,955,600 17,946,700 20,937,900
604 P-8-07-I 3,900,100 4,680,100 5,460,100
605 P-8-07-II 10,934,900 13,121,900 15,308,800
606 P-8-07-III 14,486,000 17,383,200 20,280,400
607 P-8-08-I 3,956,800 4,748,100 5,539,500
608 P-8-08-II 5,614,600 6,737,500 7,860,400
609 P-8-08-III 9,091,200 10,909,400 12,727,700
610 P-8-11-I 6,880,500 8,256,500 9,632,600
MAYOR (RINGAN)
611 P-8-11-II 10,208,400 12,250,000 14,291,700
MAYOR (SEDANG)
- 135 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 11,553,800 13,864,600 16,175,400
MAYOR (BERAT)
613 P-8-12-I 5,983,000 7,179,600 8,376,200
MAYOR (RINGAN)
614 P-8-12-II 8,507,000 10,208,400 11,909,800
MAYOR (SEDANG)
615 P-8-12-III 9,628,200 11,553,800 13,479,500
MAYOR (BERAT)
616 P-8-13-I 5,139,300 6,167,100 7,195,000
MAYOR (RINGAN)
617 P-8-13-II 8,017,300 9,620,700 11,224,200
MAYOR (SEDANG)
618 P-8-13-III 10,943,200 13,131,900 15,320,500
MAYOR (BERAT)
619 P-8-14-I 2,711,500 3,253,800 3,796,100
620 P-8-14-II 5,519,500 6,623,400 7,727,300
621 P-8-14-III 10,240,700 12,288,900 14,337,000
622 P-8-15-I 2,033,600 2,440,400 2,847,100
ASPIRASI (RINGAN)
623 P-8-15-II 4,072,500 4,887,000 5,701,500
ASPIRASI (SEDANG)
624 P-8-15-III 4,778,300 5,734,000 6,689,600
ASPIRASI (BERAT)
625 P-8-16-I 1,840,500 2,208,600 2,576,700
626 P-8-16-II 3,536,800 4,244,100 4,951,500
627 P-8-16-III 7,212,400 8,654,900 10,097,400
628 P-8-17-I 3,426,200 4,111,400 4,796,700
(RINGAN)
629 P-8-17-II 6,167,100 7,400,600 8,634,000
(SEDANG)
630 P-8-17-III 8,417,900 10,101,500 11,785,000
(BERAT)
631 S-4-10-I 2,075,100 2,490,100 2,905,200
632 S-4-10-II 2,556,800 3,068,200 3,579,600
633 S-4-10-III 3,500,100 4,200,100 4,900,100
640 S-4-13-I 2,252,900 2,703,500 3,154,100
(RINGAN)
641 S-4-13-II 3,996,900 4,796,300 5,595,700
(SEDANG)
642 S-4-13-III 6,487,500 7,784,900 9,082,400
(BERAT)
643 S-4-14-I 1,140,100 1,368,200 1,596,200
644 S-4-14-II 2,421,800 2,906,100 3,390,500
645 S-4-14-III 4,592,500 5,511,000 6,429,500
KANAK-KANAK (BERAT)
646 S-4-15-I 762,500 915,000 1,067,600
647 S-4-15-II 1,439,000 1,726,800 2,014,700
648 S-4-15-III 1,863,800 2,236,600 2,609,300
- 136 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 1,903,100 2,283,800 2,664,400
653 S-4-17-II 2,824,500 3,389,400 3,954,300
654 S-4-17-III 3,397,100 4,076,500 4,755,900
655 T-1-10-I 1,273,400 1,528,000 1,782,700
OBAT (RINGAN)
656 T-1-10-II 1,710,300 2,052,300 2,394,400
OBAT (SEDANG)
657 T-1-10-III 3,111,300 3,733,500 4,355,800
OBAT (BERAT)
658 T-4-10-I 607,200 728,600 850,100
659 T-4-10-II 1,157,300 1,388,700 1,620,200
660 T-4-10-III 1,682,300 2,018,800 2,355,200
661 T-4-11-I 812,900 975,500 1,138,000
662 T-4-11-II 1,279,200 1,535,000 1,790,800
663 T-4-11-III 2,060,400 2,472,500 2,884,600
664 T-4-12-I 1,263,100 1,515,800 1,768,400
LAIN (RINGAN)
665 T-4-12-II 1,909,200 2,291,000 2,672,800
LAIN (SEDANG)
666 T-4-12-III 2,955,600 3,546,700 4,137,800
LAIN (BERAT)
670 U-1-11-I 6,437,500 7,725,000 9,012,500
(RINGAN)
671 U-1-11-II 8,160,500 9,792,600 11,424,700
(SEDANG)
672 U-1-11-III 11,741,700 14,090,000 16,438,400
(BERAT)
679 U-1-14-I 3,024,900 3,629,800 4,234,800
(RINGAN)
680 U-1-14-II 3,712,300 4,454,700 5,197,200
(SEDANG)
681 U-1-14-III 4,399,000 5,278,800 6,158,600
(BERAT)
685 U-1-20-I 4,592,200 5,510,700 6,429,100
686 U-1-20-II 6,834,500 8,201,400 9,568,300
687 U-1-20-III 17,545,500 21,054,600 24,563,700
691 U-4-10-I 2,834,200 3,401,000 3,967,900
- 137 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 6,488,300 7,786,000 9,083,700
693 U-4-10-III 9,961,600 11,953,900 13,946,200
TENGGOROKAN (BERAT)
700 U-4-13-I 1,881,100 2,257,400 2,633,600
701 U-4-13-II 2,217,700 2,661,200 3,104,800
702 U-4-13-III 2,652,400 3,182,900 3,713,400
706 U-4-15-I 2,265,200 2,718,200 3,171,200
707 U-4-15-II 2,822,100 3,386,500 3,950,900
708 U-4-15-III 3,949,600 4,739,500 5,529,400
709 V-1-10-I 3,694,700 4,433,600 5,172,500
(RINGAN)
710 V-1-10-II 7,610,900 9,133,100 10,655,200
(SEDANG)
711 V-1-10-III 9,333,700 11,200,400 13,067,200
(BERAT)
715 V-1-12-I 6,608,600 7,930,300 9,252,000
MODERAT (RINGAN)
716 V-1-12-II 9,024,500 10,829,400 12,634,300
MODERAT (SEDANG)
717 V-1-12-III 11,438,700 13,726,400 16,014,100
MODERAT (BERAT)
718 V-1-13-I 3,447,100 4,136,500 4,826,000
KOMPLEK (RINGAN)
719 V-1-13-II 6,586,300 7,903,500 9,220,800
KOMPLEK (SEDANG)
720 V-1-13-III 10,333,100 12,399,700 14,466,300
KOMPLEK (BERAT)
721 V-1-14-I 6,759,800 8,111,700 9,463,700
(RINGAN)
722 V-1-14-II 9,821,700 11,786,100 13,750,400
(SEDANG)

727 V-4-10-I 3,268,900 3,922,700 4,576,500
(RINGAN)
728 V-4-10-II 5,429,800 6,515,800 7,601,700
(SEDANG)
729 V-4-10-III 8,951,900 10,742,200 12,532,600
(BERAT)
730 V-4-11-I 2,824,500 3,389,400 3,954,300
TUMOR (RINGAN)
731 V-4-11-II 3,789,800 4,547,700 5,305,700
TUMOR (SEDANG)
732 V-4-11-III 5,076,500 6,091,800 7,107,100
TUMOR (BERAT)
- 138 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 7,698,700 9,238,400 10,778,100
734 W-1-01-II 9,227,400 11,072,900 12,918,300
735 W-1-01-III 13,167,200 15,800,700 18,434,100
739 W-1-11-I 1,706,800 2,048,200 2,389,600
SERVIK (RINGAN)
740 W-1-11-II 1,883,500 2,260,200 2,636,900
SERVIK (SEDANG)
741 W-1-11-III 2,083,500 2,500,200 2,916,900
SERVIK (BERAT)
760 W-4-12-I 2,751,400 3,301,700 3,852,000
761 W-4-12-II 3,777,500 4,533,000 5,288,500
762 W-4-12-III 4,117,700 4,941,200 5,764,800
- 139 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 1,201,200 1,441,400 1,681,700
785 Z-4-12-II 2,946,700 3,536,100 4,125,400
786 Z-4-12-III 4,215,500 5,058,600 5,901,700
- 140 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS C SWASTA
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,531,100

33 F-3-10-0 TERAPI SHOCK 433,600
- 141 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,635,800
PENGGANTIAN ALAT
81 I-2-42-0 2,532,900
PERKUTAN LAIN
- 142 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,194,500
192 Q-5-12-0 GIGI 217,000
196 Q-5-16-0 VAKSINASI 94,900
201 Q-5-21-0 ABORSI 189,400
206 Q-5-26-0 BRONKIAL AKUT 202,100
- 143 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 136,000
215 Q-5-35-0 INFEKSI AKUT 442,900
218 Q-5-38-0 PARU AKUT 258,100
234 U-2-23-0 RHINOPLASTY 1,275,100
242 U-3-13-0 328,700
TENGGOROKAN
270 Z-3-11-0 1,783,100
EMPEDU
- 144 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 939,600
289 Z-3-30-0 FOTOTERAPI 78,400
- 145 -


REGIONAL 1
RUMAH SAKIT KELAS D PEMERINTAH
RAWAT INAP

13 A-4-14-I 2,092,500 2,511,000 2,929,500
(RINGAN)
14 A-4-14-II 2,540,000 3,048,000 3,556,000
(SEDANG)
15 A-4-14-III 3,048,000 3,657,600 4,267,200
(BERAT)

31 B-1-13-I 3,523,400 4,228,000 4,932,700
LAIN (RINGAN)
32 B-1-13-II 5,797,200 6,956,700 8,116,100
LAIN (SEDANG)
33 B-1-13-III 7,501,100 9,001,400 10,501,600
LAIN (BERAT)
34 B-1-14-I 4,841,200 5,809,500 6,777,700
(RINGAN)
35 B-1-14-II 5,384,300 6,461,200 7,538,000
(SEDANG)
40 B-4-11-I 3,158,100 3,789,700 4,421,300
(RINGAN)
41 B-4-11-II 4,421,400 5,305,600 6,189,900
(SEDANG)
42 B-4-11-III 5,356,400 6,427,700 7,499,000
(BERAT)
- 146 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 3,345,500 4,014,600 4,683,700
74 D-1-20-II 9,219,700 11,063,700 12,907,600
75 D-1-20-III 14,625,200 17,550,200 20,475,300
85 D-4-13-I 1,935,100 2,322,100 2,709,100
86 D-4-13-II 2,738,800 3,286,500 3,834,300
87 D-4-13-III 3,503,000 4,203,500 4,904,100
88 D-4-14-I 2,075,400 2,490,500 2,905,600
89 D-4-14-II 3,398,000 4,077,600 4,757,200
90 D-4-14-III 4,156,100 4,987,300 5,818,600
91 E-1-01-I 3,236,700 3,884,000 4,531,300
(RINGAN)
92 E-1-01-II 4,239,700 5,087,600 5,935,600
(SEDANG)

97 E-1-20-I 4,869,400 5,843,300 6,817,100
TIROGLOSAL (RINGAN)
- 147 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 6,554,100 7,864,900 9,175,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,032,800 10,839,400 12,646,000
TIROGLOSAL (BERAT)
100 E-4-10-I 3,164,100 3,796,900 4,429,700
METABOLIK (RINGAN)
101 E-4-10-II 4,421,200 5,305,500 6,189,700
METABOLIK (SEDANG)
102 E-4-10-III 5,487,600 6,585,100 7,682,600
METABOLIK (BERAT)
109 E-4-13-I 2,395,100 2,874,100 3,353,100
(RINGAN)
110 E-4-13-II 3,508,400 4,210,100 4,911,800
(SEDANG)

118 F-4-12-I 1,351,900 1,622,200 1,892,600
(RINGAN)
119 F-4-12-II 1,921,900 2,306,300 2,690,700
(SEDANG)
120 F-4-12-III 4,175,300 5,010,300 5,845,400
(BERAT)
130 F-4-16-I 3,551,500 4,261,800 4,972,100
131 F-4-16-II 4,129,200 4,955,100 5,780,900
132 F-4-16-III 5,511,800 6,614,200 7,716,500
142 G-1-01-I 5,233,700 6,280,400 7,327,100
(RINGAN)
- 148 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 7,211,600 8,653,900 10,096,200
(SEDANG)
144 G-1-01-III 14,019,400 16,823,200 19,627,100
(BERAT)
151 G-1-12-I 3,196,900 3,836,300 4,475,700
(RINGAN)
152 G-1-12-II 5,992,800 7,191,300 8,389,900
(SEDANG)
153 G-1-12-III 8,167,000 9,800,300 11,433,700
(BERAT)
154 G-1-13-I PROSEDUR CARPAL TUNNEL RELEASE (RINGAN) 964,400 1,157,300 1,350,200
163 G-4-10-I 2,744,200 3,293,000 3,841,900
(RINGAN)
164 G-4-10-II 3,354,300 4,025,200 4,696,100
(SEDANG)
165 G-4-10-III 4,602,700 5,523,300 6,443,800
(BERAT)
166 G-4-11-I 2,872,700 3,447,300 4,021,800
167 G-4-11-II 3,816,100 4,579,300 5,342,500
168 G-4-11-III 5,607,100 6,728,500 7,850,000
DEGENERATIF (BERAT)
169 G-4-12-I 3,187,000 3,824,400 4,461,800
(RINGAN)
170 G-4-12-II 4,025,400 4,830,500 5,635,500
(SEDANG)

172 G-4-13-I 1,914,500 2,297,400 2,680,200
(RINGAN)
173 G-4-13-II 3,338,400 4,006,100 4,673,800
(SEDANG)
174 G-4-13-III 3,959,500 4,751,400 5,543,300
(BERAT)
175 G-4-14-I 3,247,700 3,897,200 4,546,700
INFARK (RINGAN)
176 G-4-14-II 4,341,900 5,210,300 6,078,600
INFARK (SEDANG)
177 G-4-14-III 5,449,600 6,539,500 7,629,400
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 149 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 2,913,700 3,496,400 4,079,100
(RINGAN)
185 G-4-17-II 3,820,500 4,584,600 5,348,700
(SEDANG)
186 G-4-17-III 4,800,600 5,760,700 6,720,800
(BERAT)
190 G-4-19-I 2,394,100 2,872,900 3,351,700
191 G-4-19-II 4,046,600 4,855,900 5,665,300
192 G-4-19-III 5,313,000 6,375,600 7,438,200
211 G-4-26-I 2,582,200 3,098,600 3,615,100
LAIN (RINGAN)
212 G-4-26-II 3,003,900 3,604,700 4,205,400
LAIN (SEDANG)
213 G-4-26-III 4,491,700 5,390,100 6,288,400
LAIN (BERAT)
232 I-1-02-I 16,773,300 20,127,900 23,482,600
(RINGAN)
- 150 -

REGIONAL 1
RAWAT INAP

233 I-1-02-II 21,637,300 25,964,800 30,292,200
(SEDANG)
234 I-1-02-III 26,669,300 32,003,200 37,337,100
(BERAT)
235 I-1-03-I 9,688,300 11,625,900 13,563,600
ANOMALI (RINGAN)
236 I-1-03-II 13,430,000 16,116,000 18,802,000
ANOMALI (SEDANG)
237 I-1-03-III 17,043,700 20,452,400 23,861,100
ANOMALI (BERAT)
238 I-1-04-I 14,599,700 17,519,700 20,439,600
JANTUNG (RINGAN)
239 I-1-04-II 23,042,300 27,650,800 32,259,200
JANTUNG (SEDANG)
240 I-1-04-III 36,809,900 44,171,900 51,533,900
JANTUNG (BERAT)
241 I-1-05-I 18,732,800 22,479,300 26,225,900
242 I-1-05-II 22,479,400 26,975,300 31,471,200
243 I-1-05-III 30,931,500 37,117,800 43,304,100
247 I-1-07-I 16,440,100 19,728,200 23,016,200
JANTUNG (RINGAN)
248 I-1-07-II 20,282,200 24,338,700 28,395,100
JANTUNG (SEDANG)
249 I-1-07-III 22,127,900 26,553,400 30,979,000
JANTUNG (BERAT)
250 I-1-11-I 2,628,400 3,154,100 3,679,800
251 I-1-11-II 2,922,500 3,507,100 4,091,600
252 I-1-11-III 3,889,000 4,666,800 5,444,600
253 I-1-12-I 7,565,900 9,079,000 10,592,200
(RINGAN)
254 I-1-12-II 12,356,600 14,827,900 17,299,200
(SEDANG)
255 I-1-12-III 16,256,900 19,508,300 22,759,700
(BERAT)
256 I-1-13-I 7,338,800 8,806,500 10,274,300
KOMPLEK (RINGAN)
257 I-1-13-II 9,773,100 11,727,700 13,682,300
KOMPLEK (SEDANG)
258 I-1-13-III 12,052,900 14,463,500 16,874,100
KOMPLEK (BERAT)
259 I-1-14-I 15,020,700 18,024,800 21,029,000
(RINGAN)
260 I-1-14-II 18,668,500 22,402,200 26,135,900
(SEDANG)
261 I-1-14-III 24,462,200 29,354,600 34,247,100
(BERAT)
265 I-1-16-I 7,397,300 8,876,800 10,356,200
266 I-1-16-II 16,737,100 20,084,500 23,432,000
267 I-1-16-III 19,306,000 23,167,200 27,028,400
268 I-1-17-I 8,565,400 10,278,500 11,991,500
(RINGAN)
269 I-1-17-II 10,724,700 12,869,600 15,014,500
(SEDANG)
- 151 -

REGIONAL 1
RAWAT INAP

270 I-1-17-III 13,266,200 15,919,500 18,572,700
(BERAT)
271 I-1-20-I 9,654,700 11,585,600 13,516,500
(RINGAN)
272 I-1-20-II 12,061,300 14,473,600 16,885,800
(SEDANG)
273 I-1-20-III 12,678,900 15,214,700 17,750,500
(BERAT)
274 I-1-30-I 7,303,200 8,763,800 10,224,500
JANTUNG (RINGAN)
275 I-1-30-II 15,192,300 18,230,700 21,269,200
JANTUNG (SEDANG)
276 I-1-30-III 23,542,600 28,251,100 32,959,600
JANTUNG (BERAT)

289 I-4-13-I 2,286,500 2,743,900 3,201,200
(RINGAN)
290 I-4-13-II 4,082,900 4,899,500 5,716,100
(SEDANG)
291 I-4-13-III 5,882,900 7,059,500 8,236,000
(BERAT)
295 I-4-15-I 4,048,900 4,858,700 5,668,500
(RINGAN)
296 I-4-15-II 5,508,300 6,610,000 7,711,700
(SEDANG)

304 I-4-18-I 2,628,700 3,154,400 3,680,200
JANTUNG (RINGAN)
305 I-4-18-II 4,002,300 4,802,800 5,603,200
JANTUNG (SEDANG)
306 I-4-18-III 5,433,800 6,520,500 7,607,300
JANTUNG (BERAT)

308 I-4-19-II 3,959,100 4,750,900 5,542,700
(SEDANG)
- 152 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 2,167,800 2,601,400 3,034,900
320 I-4-23-II 2,661,400 3,193,700 3,726,000
321 I-4-23-III 5,200,300 6,240,400 7,280,400
322 I-4-24-I 1,952,100 2,342,500 2,733,000
(RINGAN)
323 I-4-24-II 4,495,200 5,394,200 6,293,300
(SEDANG)
324 I-4-24-III 5,683,400 6,820,100 7,956,700
(BERAT)
325 J-1-01-I 35,217,900 42,261,400 49,305,000
326 J-1-01-II 39,855,600 47,826,700 55,797,800
327 J-1-01-III 45,089,200 54,107,000 63,124,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 18,688,800 22,426,600 26,164,400
329 J-1-02-II 26,022,300 31,226,700 36,431,200
330 J-1-02-III 42,971,700 51,566,000 60,160,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,675,300 6,810,400 7,945,400
(RINGAN)
332 J-1-10-II 11,484,000 13,780,800 16,077,600
(SEDANG)
333 J-1-10-III 11,934,700 14,321,700 16,708,600
(BERAT)
334 J-1-20-I 6,669,100 8,002,900 9,336,700
(RINGAN)
335 J-1-20-II 7,895,400 9,474,500 11,053,600
(SEDANG)
336 J-1-20-III 12,191,800 14,630,200 17,068,600
(BERAT)
337 J-1-30-I 4,736,200 5,683,400 6,630,700
(RINGAN)
338 J-1-30-II 8,579,500 10,295,500 12,011,400
(SEDANG)

- 153 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,527,900 3,033,500 3,539,100
374 J-4-21-II 4,072,400 4,886,900 5,701,400
375 J-4-21-III 5,682,800 6,819,300 7,955,900
376 K-1-10-I 5,145,000 6,174,000 7,203,000
BESAR (RINGAN)
377 K-1-10-II 6,465,800 7,759,000 9,052,100
BESAR (SEDANG)
378 K-1-10-III 7,578,100 9,093,800 10,609,400
BESAR (BERAT)
382 K-1-12-I 2,158,800 2,590,500 3,022,300
FEMORAL (RINGAN)
383 K-1-12-II 2,807,700 3,369,300 3,930,800
FEMORAL (SEDANG)
384 K-1-12-III 5,562,500 6,675,100 7,787,600
FEMORAL (BERAT)
388 K-1-14-I 3,951,000 4,741,200 5,531,400
(RINGAN)
389 K-1-14-II 4,630,500 5,556,600 6,482,700
(SEDANG)

394 K-1-30-I 4,524,400 5,429,300 6,334,200
395 K-1-30-II 8,035,300 9,642,300 11,249,400
396 K-1-30-III 11,056,600 13,268,000 15,479,300

398 K-1-40-II 5,565,800 6,679,000 7,792,100
(SEDANG)

- 154 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 2,580,500 3,096,600 3,612,700
413 K-4-13-II 3,338,100 4,005,700 4,673,300
414 K-4-13-III 5,141,700 6,170,100 7,198,400
415 K-4-14-I 1,636,100 1,963,300 2,290,500
(RINGAN)
416 K-4-14-II 2,196,100 2,635,400 3,074,600
(SEDANG)
417 K-4-14-III 3,523,900 4,228,700 4,933,500
(BERAT)

424 K-4-17-I 1,079,600 1,295,500 1,511,400
(RINGAN)
425 K-4-17-II 1,618,800 1,942,600 2,266,400
(SEDANG)
426 K-4-17-III 1,942,600 2,331,100 2,719,600
(BERAT)
427 K-4-18-I 1,084,000 1,300,900 1,517,700
(RINGAN)
428 K-4-18-II 1,540,500 1,848,600 2,156,700
(SEDANG)
436 L-1-40-I 3,225,200 3,870,300 4,515,300
(RINGAN)
437 L-1-40-II 6,469,100 7,762,900 9,056,700
(SEDANG)
438 L-1-40-III 10,888,900 13,066,700 15,244,500
(BERAT)
451 L-4-13-I 2,153,300 2,584,000 3,014,600
PAYUDARA (RINGAN)
- 155 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,530,700 3,036,900 3,543,000
PAYUDARA (SEDANG)
453 L-4-13-III 3,724,000 4,468,800 5,213,600
PAYUDARA (BERAT)
454 L-4-14-I 1,907,200 2,288,700 2,670,100
(RINGAN)
455 L-4-14-II 2,864,700 3,437,700 4,010,600
(SEDANG)
456 L-4-14-III 4,038,200 4,845,800 5,653,400
(BERAT)
457 M-1-01-I 6,741,800 8,090,200 9,438,600
458 M-1-01-II 9,582,600 11,499,100 13,415,600
459 M-1-01-III 13,460,700 16,152,800 18,845,000
463 M-1-03-I 14,628,800 17,554,500 20,480,300
464 M-1-03-II 17,110,500 20,532,600 23,954,700
465 M-1-03-III 21,177,100 25,412,500 29,647,900
472 M-1-07-I 5,324,600 6,389,600 7,454,500
473 M-1-07-II 7,133,200 8,559,800 9,986,400
474 M-1-07-III 14,530,900 17,437,100 20,343,300
475 M-1-10-I 8,765,200 10,518,300 12,271,300
WAJAH (RINGAN)
476 M-1-10-II 19,234,200 23,081,100 26,927,900
WAJAH (SEDANG)
477 M-1-10-III 41,486,500 49,783,800 58,081,000
WAJAH (BERAT)
478 M-1-20-I 8,006,000 9,607,200 11,208,400
(RINGAN)
479 M-1-20-II 10,228,500 12,274,100 14,319,800
(SEDANG)

484 M-1-40-I 2,795,800 3,355,000 3,914,100
INTERNAL (RINGAN)
485 M-1-40-II 4,958,200 5,949,900 6,941,500
INTERNAL (SEDANG)
486 M-1-40-III 7,079,400 8,495,300 9,911,100
INTERNAL (BERAT)
490 M-1-60-I 5,174,300 6,209,200 7,244,000
491 M-1-60-II 6,505,300 7,806,400 9,107,400
492 M-1-60-III 9,827,000 11,792,500 13,757,900
- 156 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 9,586,400 11,503,600 13,420,900
KAKI (RINGAN)
494 M-1-70-II 10,545,000 12,654,000 14,763,000
KAKI (SEDANG)
495 M-1-70-III 12,072,600 14,487,100 16,901,700
KAKI (BERAT)
502 M-4-11-I 2,392,000 2,870,500 3,348,900
(RINGAN)
503 M-4-11-II 5,244,500 6,293,300 7,342,200
(SEDANG)
504 M-4-11-III 7,582,600 9,099,100 10,615,600
(BERAT)
505 M-4-12-I 1,909,400 2,291,300 2,673,100
(RINGAN)
506 M-4-12-II 3,175,800 3,811,000 4,446,200
(SEDANG)
507 M-4-12-III 4,248,000 5,097,600 5,947,200
(BERAT)
508 M-4-13-I 3,179,300 3,815,200 4,451,100
509 M-4-13-II 4,776,800 5,732,200 6,687,500
510 M-4-13-III 9,319,400 11,183,300 13,047,200
520 M-4-17-I 2,389,100 2,866,900 3,344,700
(RINGAN)
521 M-4-17-II 3,341,400 4,009,700 4,678,000
(SEDANG)
522 M-4-17-III 4,666,100 5,599,300 6,532,500
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,899,600 2,279,500 2,659,400
(RINGAN)
530 M-4-20-II 2,781,600 3,337,900 3,894,200
(SEDANG)
531 M-4-20-III 3,108,800 3,730,500 4,352,300
(BERAT)
532 M-4-21-I 1,912,700 2,295,300 2,677,800
533 M-4-21-II 2,392,300 2,870,700 3,349,200
- 157 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 5,363,400 6,436,100 7,508,700
541 N-1-12-I 2,811,900 3,374,300 3,936,700
542 N-1-12-II 5,598,200 6,717,900 7,837,500
543 N-1-12-III 12,148,400 14,578,100 17,007,800
547 N-1-30-I 5,626,400 6,751,700 7,877,000
BAWAH (RINGAN)
548 N-1-30-II 8,511,700 10,214,100 11,916,400
BAWAH (SEDANG)
549 N-1-30-III 9,796,200 11,755,400 13,714,600
BAWAH (BERAT)
550 N-1-40-I 5,053,000 6,063,500 7,074,100
(RINGAN)
551 N-1-40-II 6,861,800 8,234,100 9,606,500
(SEDANG)
552 N-1-40-III 7,986,200 9,583,500 11,180,700
(BERAT)
553 N-4-10-I 2,146,800 2,576,200 3,005,500
(RINGAN)
554 N-4-10-II 2,596,600 3,115,900 3,635,200
(SEDANG)
555 N-4-10-III 3,819,200 4,583,100 5,346,900
(BERAT)
568 N-4-15-I 1,955,300 2,346,400 2,737,500
URIN (RINGAN)
569 N-4-15-II 2,426,200 2,911,500 3,396,700
URIN (SEDANG)
570 N-4-15-III 2,768,800 3,322,500 3,876,300
URIN (BERAT)
571 N-4-16-I 2,394,300 2,873,200 3,352,000
(RINGAN)
572 N-4-16-II 3,417,500 4,100,900 4,784,400
(SEDANG)
573 N-4-16-III 4,548,900 5,458,700 6,368,400
(BERAT)
- 158 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 2,225,600 2,670,800 3,115,900
578 O-6-11-II 2,473,500 2,968,200 3,462,900
579 O-6-11-III 3,077,100 3,692,500 4,308,000
580 O-6-12-I 1,576,800 1,892,200 2,207,600
581 O-6-12-II 1,893,800 2,272,500 2,651,300
582 O-6-12-III 2,379,600 2,855,500 3,331,400
586 P-8-01-I 35,210,800 42,252,900 49,295,100
587 P-8-01-II 43,568,100 52,281,700 60,995,300
588 P-8-01-III 51,136,700 61,364,000 71,591,300
589 P-8-02-I 48,061,100 57,673,300 67,285,500
590 P-8-02-II 55,130,900 66,157,000 77,183,200
591 P-8-02-III 62,990,900 75,589,100 88,187,300
592 P-8-03-I 5,857,400 7,028,900 8,200,400
593 P-8-03-II 8,317,500 9,981,000 11,644,500
594 P-8-03-III 9,398,800 11,278,500 13,158,300
595 P-8-04-I 19,007,700 22,809,300 26,610,800
596 P-8-04-II 24,667,900 29,601,500 34,535,100
597 P-8-04-III 35,367,600 42,441,100 49,514,600
598 P-8-05-I 10,335,800 12,402,900 14,470,100
599 P-8-05-II 19,488,000 23,385,600 27,283,200
600 P-8-05-III 23,782,000 28,538,400 33,294,800
601 P-8-06-I 3,410,400 4,092,500 4,774,600
602 P-8-06-II 9,562,000 11,474,400 13,386,800
603 P-8-06-III 12,667,300 15,200,800 17,734,200
604 P-8-07-I 3,303,300 3,964,000 4,624,700
605 P-8-07-II 9,261,800 11,114,100 12,966,500
606 P-8-07-III 12,269,600 14,723,500 17,177,400
607 P-8-08-I 3,492,300 4,190,700 4,889,200
608 P-8-08-II 4,955,500 5,946,600 6,937,700
609 P-8-08-III 8,024,000 9,628,700 11,233,500
610 P-8-11-I 5,533,700 6,640,400 7,747,200
MAYOR (RINGAN)
611 P-8-11-II 7,857,800 9,429,400 11,001,000
MAYOR (SEDANG)
- 159 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 8,879,400 10,655,200 12,431,100
MAYOR (BERAT)
613 P-8-12-I 5,227,900 6,273,400 7,319,000
MAYOR (RINGAN)
614 P-8-12-II 7,433,300 8,919,900 10,406,600
MAYOR (SEDANG)
615 P-8-12-III 8,413,000 10,095,600 11,778,200
MAYOR (BERAT)
616 P-8-13-I 4,536,000 5,443,200 6,350,400
MAYOR (RINGAN)
617 P-8-13-II 5,987,500 7,185,000 8,382,500
MAYOR (SEDANG)
618 P-8-13-III 8,915,600 10,698,800 12,481,900
MAYOR (BERAT)
619 P-8-14-I 2,296,600 2,755,900 3,215,300
620 P-8-14-II 4,675,000 5,610,000 6,545,000
621 P-8-14-III 8,673,800 10,408,600 12,143,400
622 P-8-15-I 1,722,500 2,067,000 2,411,500
ASPIRASI (RINGAN)
623 P-8-15-II 3,449,400 4,139,200 4,829,100
ASPIRASI (SEDANG)
624 P-8-15-III 4,047,200 4,856,600 5,666,100
ASPIRASI (BERAT)
625 P-8-16-I 1,558,900 1,870,600 2,182,400
626 P-8-16-II 2,995,600 3,594,700 4,193,900
627 P-8-16-III 6,108,900 7,330,700 8,552,400
628 P-8-17-I 3,024,000 3,628,800 4,233,600
(RINGAN)
629 P-8-17-II 5,443,200 6,531,800 7,620,500
(SEDANG)
630 P-8-17-III 7,429,700 8,915,600 10,401,600
(BERAT)
631 S-4-10-I 1,757,600 2,109,100 2,460,600
632 S-4-10-II 2,165,600 2,598,800 3,031,900
633 S-4-10-III 2,964,500 3,557,400 4,150,300
640 S-4-13-I 1,908,200 2,289,900 2,671,500
(RINGAN)
641 S-4-13-II 3,385,300 4,062,400 4,739,500
(SEDANG)
642 S-4-13-III 5,494,800 6,593,800 7,692,800
(BERAT)
643 S-4-14-I 965,700 1,158,800 1,352,000
644 S-4-14-II 2,051,200 2,461,500 2,871,700
645 S-4-14-III 3,889,800 4,667,800 5,445,800
KANAK-KANAK (BERAT)
646 S-4-15-I 645,900 775,000 904,200
647 S-4-15-II 1,218,900 1,462,600 1,706,400
648 S-4-15-III 1,578,600 1,894,400 2,210,100
- 160 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 1,611,900 1,934,300 2,256,700
653 S-4-17-II 2,392,300 2,870,800 3,349,200
654 S-4-17-III 2,877,300 3,452,700 4,028,200
655 T-1-10-I 1,078,500 1,294,200 1,509,900
OBAT (RINGAN)
656 T-1-10-II 1,448,600 1,738,300 2,028,000
OBAT (SEDANG)
657 T-1-10-III 2,635,200 3,162,300 3,689,300
OBAT (BERAT)
658 T-4-10-I 491,900 590,200 688,600
659 T-4-10-II 937,400 1,124,900 1,312,400
660 T-4-10-III 1,362,800 1,635,300 1,907,900
661 T-4-11-I 582,500 699,000 815,500
662 T-4-11-II 916,700 1,100,000 1,283,300
663 T-4-11-III 1,476,400 1,771,600 2,066,900
664 T-4-12-I 1,018,700 1,222,500 1,426,200
LAIN (RINGAN)
665 T-4-12-II 1,540,100 1,848,100 2,156,100
LAIN (SEDANG)
666 T-4-12-III 2,403,600 2,884,400 3,365,100
LAIN (BERAT)
670 U-1-11-I 5,452,500 6,543,100 7,633,600
(RINGAN)
671 U-1-11-II 6,911,900 8,294,300 9,676,700
(SEDANG)
672 U-1-11-III 9,945,100 11,934,200 13,923,200
(BERAT)
679 U-1-14-I 2,562,000 3,074,500 3,586,900
(RINGAN)
680 U-1-14-II 3,144,300 3,773,100 4,402,000
(SEDANG)
681 U-1-14-III 3,725,900 4,471,100 5,216,300
(BERAT)
685 U-1-20-I 3,889,600 4,667,500 5,445,400
686 U-1-20-II 5,788,800 6,946,600 8,104,300
687 U-1-20-III 14,861,000 17,833,100 20,805,300
691 U-4-10-I 2,400,500 2,880,700 3,360,800
- 161 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 5,495,600 6,594,700 7,693,800
693 U-4-10-III 8,437,400 10,124,900 11,812,400
TENGGOROKAN (BERAT)
700 U-4-13-I 1,735,000 2,082,000 2,429,000
701 U-4-13-II 2,045,400 2,454,500 2,863,600
702 U-4-13-III 2,446,400 2,935,700 3,425,000
706 U-4-15-I 1,918,600 2,302,300 2,686,000
707 U-4-15-II 2,390,300 2,868,400 3,346,400
708 U-4-15-III 3,345,300 4,014,300 4,683,400
709 V-1-10-I 3,129,400 3,755,200 4,381,100
(RINGAN)
710 V-1-10-II 6,446,400 7,735,600 9,024,900
(SEDANG)
711 V-1-10-III 7,905,600 9,486,700 11,067,800
(BERAT)
715 V-1-12-I 5,597,400 6,716,900 7,836,400
MODERAT (RINGAN)
716 V-1-12-II 7,643,700 9,172,400 10,701,200
MODERAT (SEDANG)
717 V-1-12-III 9,688,500 11,626,200 13,563,900
MODERAT (BERAT)
718 V-1-13-I 2,919,700 3,503,600 4,087,600
KOMPLEK (RINGAN)
719 V-1-13-II 5,578,500 6,694,300 7,810,000
KOMPLEK (SEDANG)
720 V-1-13-III 8,752,000 10,502,500 12,252,900
KOMPLEK (BERAT)
721 V-1-14-I 5,725,500 6,870,600 8,015,700
(RINGAN)
722 V-1-14-II 8,318,900 9,982,700 11,646,500
(SEDANG)
724 V-1-15-I SIRKUMSISI (RINGAN) 922,100 1,106,500 1,290,900

727 V-4-10-I 2,768,700 3,322,500 3,876,200
(RINGAN)
728 V-4-10-II 4,599,000 5,518,800 6,438,600
(SEDANG)
729 V-4-10-III 7,582,200 9,098,600 10,615,000
(BERAT)
730 V-4-11-I 2,392,400 2,870,800 3,349,300
TUMOR (RINGAN)
731 V-4-11-II 3,209,900 3,851,900 4,493,900
TUMOR (SEDANG)
732 V-4-11-III 4,299,700 5,159,700 6,019,600
TUMOR (BERAT)
- 162 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 6,520,700 7,824,900 9,129,000
734 W-1-01-II 7,815,500 9,378,600 10,941,700
735 W-1-01-III 11,152,600 13,383,100 15,613,600
739 W-1-11-I 1,445,700 1,734,800 2,024,000
SERVIK (RINGAN)
740 W-1-11-II 1,595,300 1,914,400 2,233,400
SERVIK (SEDANG)
741 W-1-11-III 1,764,700 2,117,700 2,470,600
SERVIK (BERAT)
760 W-4-12-I 2,537,700 3,045,300 3,552,800
761 W-4-12-II 3,484,100 4,180,900 4,877,800
762 W-4-12-III 3,797,900 4,557,500 5,317,000
763 W-4-13-I ABORTUS (RINGAN) 805,800 966,900 1,128,100
- 163 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 753,800 904,600 1,055,300
785 Z-4-12-II 1,836,700 2,204,000 2,571,400
786 Z-4-12-III 2,329,300 2,795,200 3,261,000
- 164 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS D PEMERINTAH
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
16 C-3-17-0 KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER 968,700
24 D-2-11-0 PROSEDUR LIMPA 1,384,500

33 F-3-10-0 TERAPI SHOCK 392,100
- 165 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,383,500
PENGGANTIAN ALAT
81 I-2-42-0 2,290,400
PERKUTAN LAIN
103 K-2-12-0 PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS 972,500
123 L-2-21-0 PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR 972,200
130 L-2-52-0 PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA 972,800
- 166 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,080,100
192 Q-5-12-0 GIGI 196,200
196 Q-5-16-0 VAKSINASI 83,600
201 Q-5-21-0 ABORSI 171,300
206 Q-5-26-0 BRONKIAL AKUT 178,000
- 167 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 119,900
215 Q-5-35-0 INFEKSI AKUT 400,500
218 Q-5-38-0 PARU AKUT 233,400
234 U-2-23-0 RHINOPLASTY 1,153,100
242 U-3-13-0 297,200
TENGGOROKAN
270 Z-3-11-0 1,612,500
EMPEDU
- 168 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 849,600
288 Z-3-29-0 IMAGING LAIN-LAIN 937,400
289 Z-3-30-0 FOTOTERAPI 69,100
- 169 -


REGIONAL 1
RUMAH SAKIT KELAS D SWASTA
RAWAT INAP

13 A-4-14-I 2,155,300 2,586,400 3,017,400
(RINGAN)
14 A-4-14-II 2,616,200 3,139,400 3,662,700
(SEDANG)
15 A-4-14-III 3,139,400 3,767,300 4,395,200
(BERAT)

31 B-1-13-I 3,629,100 4,354,900 5,080,700
LAIN (RINGAN)
32 B-1-13-II 5,971,200 7,165,400 8,359,600
LAIN (SEDANG)
33 B-1-13-III 7,726,200 9,271,400 10,816,600
LAIN (BERAT)
34 B-1-14-I 4,986,500 5,983,800 6,981,100
(RINGAN)
35 B-1-14-II 5,545,800 6,655,000 7,764,200
(SEDANG)
40 B-4-11-I 3,252,800 3,903,400 4,554,000
(RINGAN)
41 B-4-11-II 4,554,000 5,464,800 6,375,600
(SEDANG)
42 B-4-11-III 5,517,100 6,620,500 7,724,000
(BERAT)
- 170 -

REGIONAL 1
RAWAT INAP


73 D-1-20-I 3,445,900 4,135,000 4,824,200
74 D-1-20-II 9,496,300 11,395,600 13,294,800
75 D-1-20-III 15,063,900 18,076,700 21,089,500
85 D-4-13-I 1,993,100 2,391,700 2,790,400
86 D-4-13-II 2,820,900 3,385,100 3,949,300
87 D-4-13-III 3,608,000 4,329,700 5,051,300
88 D-4-14-I 2,137,700 2,565,200 2,992,800
89 D-4-14-II 3,499,900 4,199,900 4,899,900
90 D-4-14-III 4,280,800 5,136,900 5,993,100
91 E-1-01-I 3,333,800 4,000,500 4,667,300
(RINGAN)
92 E-1-01-II 4,366,900 5,240,200 6,113,600
(SEDANG)

97 E-1-20-I 5,015,500 6,018,600 7,021,600
TIROGLOSAL (RINGAN)
- 171 -

REGIONAL 1
RAWAT INAP

98 E-1-20-II 6,750,700 8,100,800 9,450,900
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,303,800 11,164,600 13,025,300
TIROGLOSAL (BERAT)
100 E-4-10-I 3,259,000 3,910,800 4,562,600
METABOLIK (RINGAN)
101 E-4-10-II 4,553,800 5,464,600 6,375,400
METABOLIK (SEDANG)
102 E-4-10-III 5,652,200 6,782,700 7,913,100
METABOLIK (BERAT)
109 E-4-13-I 2,467,000 2,960,400 3,453,700
(RINGAN)
110 E-4-13-II 3,613,700 4,336,400 5,059,100
(SEDANG)

118 F-4-12-I 1,392,400 1,670,900 1,949,400
(RINGAN)
119 F-4-12-II 1,979,600 2,375,500 2,771,400
(SEDANG)
120 F-4-12-III 4,300,500 5,160,600 6,020,700
(BERAT)
130 F-4-16-I 3,658,100 4,389,700 5,121,300
131 F-4-16-II 4,253,100 5,103,700 5,954,400
132 F-4-16-III 5,677,200 6,812,600 7,948,000
142 G-1-01-I 5,390,700 6,468,800 7,546,900
(RINGAN)
- 172 -

REGIONAL 1
RAWAT INAP

143 G-1-01-II 7,428,000 8,913,500 10,399,100
(SEDANG)
144 G-1-01-III 14,439,900 17,327,900 20,215,900
(BERAT)
151 G-1-12-I 3,292,800 3,951,400 4,609,900
(RINGAN)
152 G-1-12-II 6,172,500 7,407,000 8,641,600
(SEDANG)
153 G-1-12-III 8,412,000 10,094,400 11,776,700
(BERAT)
163 G-4-10-I 2,826,500 3,391,800 3,957,100
(RINGAN)
164 G-4-10-II 3,455,000 4,146,000 4,837,000
(SEDANG)
165 G-4-10-III 4,740,800 5,689,000 6,637,100
(BERAT)
166 G-4-11-I 2,958,900 3,550,700 4,142,500
167 G-4-11-II 3,930,600 4,716,700 5,502,800
168 G-4-11-III 5,775,300 6,930,400 8,085,500
DEGENERATIF (BERAT)
169 G-4-12-I 3,282,600 3,939,100 4,595,600
(RINGAN)
170 G-4-12-II 4,146,100 4,975,400 5,804,600
(SEDANG)

172 G-4-13-I 1,971,900 2,366,300 2,760,600
(RINGAN)
173 G-4-13-II 3,438,600 4,126,300 4,814,000
(SEDANG)
174 G-4-13-III 4,078,300 4,893,900 5,709,600
(BERAT)
175 G-4-14-I 3,345,100 4,014,100 4,683,100
INFARK (RINGAN)
176 G-4-14-II 4,472,100 5,366,600 6,261,000
INFARK (SEDANG)
177 G-4-14-III 5,613,100 6,735,700 7,858,300
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 173 -

REGIONAL 1
RAWAT INAP

184 G-4-17-I 3,001,100 3,601,300 4,201,500
(RINGAN)
185 G-4-17-II 3,935,100 4,722,100 5,509,100
(SEDANG)
186 G-4-17-III 4,944,600 5,933,500 6,922,500
(BERAT)
190 G-4-19-I 2,465,900 2,959,100 3,452,300
191 G-4-19-II 4,168,000 5,001,600 5,835,200
192 G-4-19-III 5,472,400 6,566,900 7,661,400
211 G-4-26-I 2,659,700 3,191,600 3,723,500
LAIN (RINGAN)
212 G-4-26-II 3,094,000 3,712,800 4,331,600
LAIN (SEDANG)
213 G-4-26-III 4,626,500 5,551,800 6,477,100
LAIN (BERAT)
232 I-1-02-I 17,276,500 20,731,800 24,187,100
(RINGAN)
- 174 -

REGIONAL 1
RAWAT INAP

233 I-1-02-II 22,286,400 26,743,700 31,201,000
(SEDANG)
234 I-1-02-III 27,469,400 32,963,300 38,457,200
(BERAT)
235 I-1-03-I 9,978,900 11,974,700 13,970,500
ANOMALI (RINGAN)
236 I-1-03-II 13,832,900 16,599,400 19,366,000
ANOMALI (SEDANG)
237 I-1-03-III 17,555,000 21,066,000 24,577,000
ANOMALI (BERAT)
238 I-1-04-I 15,037,700 18,045,300 21,052,800
JANTUNG (RINGAN)
239 I-1-04-II 23,733,600 28,480,300 33,227,000
JANTUNG (SEDANG)
240 I-1-04-III 37,914,200 45,497,100 53,079,900
JANTUNG (BERAT)
241 I-1-05-I 19,294,800 23,153,700 27,012,700
242 I-1-05-II 23,153,800 27,784,600 32,415,300
243 I-1-05-III 31,859,500 38,231,300 44,603,200
247 I-1-07-I 16,933,300 20,320,000 23,706,700
JANTUNG (RINGAN)
248 I-1-07-II 20,890,700 25,068,900 29,247,000
JANTUNG (SEDANG)
249 I-1-07-III 22,791,700 27,350,000 31,908,400
JANTUNG (BERAT)
250 I-1-11-I 2,707,300 3,248,700 3,790,200
251 I-1-11-II 3,010,200 3,612,300 4,214,300
252 I-1-11-III 4,005,700 4,806,800 5,608,000
253 I-1-12-I 7,792,800 9,351,400 10,910,000
(RINGAN)
254 I-1-12-II 12,727,300 15,272,700 17,818,200
(SEDANG)
255 I-1-12-III 16,744,600 20,093,600 23,442,500
(BERAT)
256 I-1-13-I 7,558,900 9,070,700 10,582,500
KOMPLEK (RINGAN)
257 I-1-13-II 10,066,300 12,079,500 14,092,800
KOMPLEK (SEDANG)
258 I-1-13-III 12,414,500 14,897,400 17,380,300
KOMPLEK (BERAT)
259 I-1-14-I 15,471,300 18,565,600 21,659,800
(RINGAN)
260 I-1-14-II 19,228,600 23,074,300 26,920,000
(SEDANG)
261 I-1-14-III 25,196,000 30,235,300 35,274,500
(BERAT)
265 I-1-16-I 7,619,200 9,143,100 10,666,900
266 I-1-16-II 17,239,200 20,687,100 24,134,900
267 I-1-16-III 19,885,200 23,862,200 27,839,300
268 I-1-17-I 8,822,300 10,586,800 12,351,300
(RINGAN)
269 I-1-17-II 11,046,400 13,255,700 15,465,000
(SEDANG)
- 175 -

REGIONAL 1
RAWAT INAP

270 I-1-17-III 13,664,200 16,397,100 19,129,900
(BERAT)
271 I-1-20-I 9,944,300 11,933,100 13,922,000
(RINGAN)
272 I-1-20-II 12,423,200 14,907,800 17,392,400
(SEDANG)
273 I-1-20-III 13,059,300 15,671,200 18,283,000
(BERAT)
274 I-1-30-I 7,522,300 9,026,800 10,531,200
JANTUNG (RINGAN)
275 I-1-30-II 15,648,000 18,777,700 21,907,300
JANTUNG (SEDANG)
276 I-1-30-III 24,248,800 29,098,600 33,948,400
JANTUNG (BERAT)

289 I-4-13-I 2,355,100 2,826,200 3,297,200
(RINGAN)
290 I-4-13-II 4,205,400 5,046,500 5,887,500
(SEDANG)
291 I-4-13-III 6,059,400 7,271,200 8,483,100
(BERAT)
295 I-4-15-I 4,170,400 5,004,500 5,838,600
(RINGAN)
296 I-4-15-II 5,673,600 6,808,300 7,943,000
(SEDANG)

304 I-4-18-I 2,707,600 3,249,100 3,790,600
JANTUNG (RINGAN)
305 I-4-18-II 4,122,400 4,946,800 5,771,300
JANTUNG (SEDANG)
306 I-4-18-III 5,596,800 6,716,200 7,835,500
JANTUNG (BERAT)

308 I-4-19-II 4,077,900 4,893,400 5,709,000
(SEDANG)
- 176 -

REGIONAL 1
RAWAT INAP

319 I-4-23-I 2,232,800 2,679,400 3,126,000
320 I-4-23-II 2,741,300 3,289,500 3,837,800
321 I-4-23-III 5,356,300 6,427,600 7,498,800
322 I-4-24-I 2,010,700 2,412,800 2,814,900
(RINGAN)
323 I-4-24-II 4,630,100 5,556,100 6,482,100
(SEDANG)
324 I-4-24-III 5,853,900 7,024,700 8,195,400
(BERAT)
325 J-1-01-I 36,274,400 43,529,300 50,784,200
326 J-1-01-II 41,051,200 49,261,500 57,471,700
327 J-1-01-III 46,441,800 55,730,200 65,018,600
TRAKEOSTOMI (BERAT)
328 J-1-02-I 19,249,500 23,099,400 26,949,300
329 J-1-02-II 26,802,900 32,163,500 37,524,100
330 J-1-02-III 44,260,800 53,113,000 61,965,200
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,845,600 7,014,700 8,183,800
(RINGAN)
332 J-1-10-II 11,828,500 14,194,200 16,559,900
(SEDANG)
333 J-1-10-III 12,292,800 14,751,300 17,209,900
(BERAT)
334 J-1-20-I 6,869,200 8,243,000 9,616,800
(RINGAN)
335 J-1-20-II 8,132,300 9,758,700 11,385,200
(SEDANG)
336 J-1-20-III 12,557,600 15,069,100 17,580,600
(BERAT)
337 J-1-30-I 4,878,300 5,853,900 6,829,600
(RINGAN)
338 J-1-30-II 8,836,900 10,604,300 12,371,700
(SEDANG)

- 177 -

REGIONAL 1
RAWAT INAP

373 J-4-21-I 2,603,800 3,124,500 3,645,300
374 J-4-21-II 4,194,600 5,033,500 5,872,500
375 J-4-21-III 5,853,300 7,023,900 8,194,600
376 K-1-10-I 5,299,400 6,359,200 7,419,100
BESAR (RINGAN)
377 K-1-10-II 6,659,800 7,991,700 9,323,700
BESAR (SEDANG)
378 K-1-10-III 7,805,500 9,366,600 10,927,700
BESAR (BERAT)
382 K-1-12-I 2,223,500 2,668,200 3,112,900
FEMORAL (RINGAN)
383 K-1-12-II 2,892,000 3,470,400 4,048,700
FEMORAL (SEDANG)
384 K-1-12-III 5,729,400 6,875,300 8,021,200
FEMORAL (BERAT)
388 K-1-14-I 4,069,600 4,883,500 5,697,400
(RINGAN)
389 K-1-14-II 4,769,400 5,723,300 6,677,200
(SEDANG)

394 K-1-30-I 4,660,200 5,592,200 6,524,200
395 K-1-30-II 8,276,300 9,931,600 11,586,800
396 K-1-30-III 11,388,300 13,666,000 15,943,700

398 K-1-40-II 5,732,800 6,879,400 8,025,900
(SEDANG)

- 178 -

REGIONAL 1
RAWAT INAP

412 K-4-13-I 2,657,900 3,189,500 3,721,100
413 K-4-13-II 3,438,200 4,125,900 4,813,500
414 K-4-13-III 5,296,000 6,355,200 7,414,300
415 K-4-14-I 1,685,200 2,022,200 2,359,200
(RINGAN)
416 K-4-14-II 2,262,000 2,714,400 3,166,800
(SEDANG)
417 K-4-14-III 3,629,700 4,355,600 5,081,500
(BERAT)

424 K-4-17-I 1,112,000 1,334,400 1,556,800
(RINGAN)
425 K-4-17-II 1,667,400 2,000,900 2,334,400
(SEDANG)
426 K-4-17-III 2,000,900 2,401,100 2,801,200
(BERAT)
427 K-4-18-I 1,116,600 1,339,900 1,563,200
(RINGAN)
428 K-4-18-II 1,586,700 1,904,100 2,221,400
(SEDANG)
436 L-1-40-I 3,322,000 3,986,400 4,650,800
(RINGAN)
437 L-1-40-II 6,663,100 7,995,800 9,328,400
(SEDANG)
438 L-1-40-III 11,215,600 13,458,700 15,701,800
(BERAT)
451 L-4-13-I 2,217,900 2,661,500 3,105,100
PAYUDARA (RINGAN)
- 179 -

REGIONAL 1
RAWAT INAP

452 L-4-13-II 2,606,700 3,128,000 3,649,300
PAYUDARA (SEDANG)
453 L-4-13-III 3,835,700 4,602,900 5,370,000
PAYUDARA (BERAT)
454 L-4-14-I 1,964,400 2,357,300 2,750,200
(RINGAN)
455 L-4-14-II 2,950,700 3,540,800 4,130,900
(SEDANG)
456 L-4-14-III 4,159,300 4,991,200 5,823,000
(BERAT)
457 M-1-01-I 6,944,100 8,332,900 9,721,700
458 M-1-01-II 9,870,100 11,844,100 13,818,100
459 M-1-01-III 13,864,500 16,637,400 19,410,300
463 M-1-03-I 15,067,600 18,081,200 21,094,700
464 M-1-03-II 17,623,800 21,148,600 24,673,300
465 M-1-03-III 21,812,400 26,174,900 30,537,300
472 M-1-07-I 5,484,400 6,581,200 7,678,100
473 M-1-07-II 7,347,200 8,816,600 10,286,000
474 M-1-07-III 14,966,900 17,960,200 20,953,600
475 M-1-10-I 9,028,200 10,833,800 12,639,500
WAJAH (RINGAN)
476 M-1-10-II 19,811,300 23,773,500 27,735,800
WAJAH (SEDANG)
477 M-1-10-III 42,731,100 51,277,300 59,823,500
WAJAH (BERAT)
478 M-1-20-I 8,246,200 9,895,400 11,544,600
(RINGAN)
479 M-1-20-II 10,535,300 12,642,400 14,749,400
(SEDANG)

484 M-1-40-I 2,879,700 3,455,600 4,031,500
INTERNAL (RINGAN)
485 M-1-40-II 5,107,000 6,128,400 7,149,800
INTERNAL (SEDANG)
486 M-1-40-III 7,291,800 8,750,100 10,208,500
INTERNAL (BERAT)
490 M-1-60-I 5,329,500 6,395,500 7,461,400
491 M-1-60-II 6,700,500 8,040,600 9,380,600
492 M-1-60-III 10,121,900 12,146,200 14,170,600
- 180 -

REGIONAL 1
RAWAT INAP

493 M-1-70-I 9,873,900 11,848,700 13,823,500
KAKI (RINGAN)
494 M-1-70-II 10,861,300 13,033,600 15,205,900
KAKI (SEDANG)
495 M-1-70-III 12,434,800 14,921,800 17,408,700
KAKI (BERAT)
502 M-4-11-I 2,463,800 2,956,600 3,449,300
(RINGAN)
503 M-4-11-II 5,401,800 6,482,100 7,562,500
(SEDANG)
504 M-4-11-III 7,810,100 9,372,100 10,934,100
(BERAT)
505 M-4-12-I 1,966,700 2,360,000 2,753,300
(RINGAN)
506 M-4-12-II 3,271,100 3,925,300 4,579,600
(SEDANG)
507 M-4-12-III 4,375,500 5,250,500 6,125,600
(BERAT)
508 M-4-13-I 3,274,700 3,929,600 4,584,600
509 M-4-13-II 4,920,100 5,904,100 6,888,100
510 M-4-13-III 9,599,000 11,518,800 13,438,600
520 M-4-17-I 2,460,800 2,952,900 3,445,100
(RINGAN)
521 M-4-17-II 3,441,600 4,130,000 4,818,300
(SEDANG)
522 M-4-17-III 4,806,000 5,767,200 6,728,400
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,956,600 2,347,900 2,739,200
(RINGAN)
530 M-4-20-II 2,865,000 3,438,000 4,011,100
(SEDANG)
531 M-4-20-III 3,202,000 3,842,400 4,482,800
(BERAT)
532 M-4-21-I 1,970,100 2,364,100 2,758,100
533 M-4-21-II 2,464,000 2,956,800 3,449,600
- 181 -

REGIONAL 1
RAWAT INAP

534 M-4-21-III 5,524,300 6,629,100 7,734,000
541 N-1-12-I 2,896,300 3,475,500 4,054,800
542 N-1-12-II 5,766,200 6,919,400 8,072,700
543 N-1-12-III 12,512,900 15,015,400 17,518,000
547 N-1-30-I 5,795,200 6,954,300 8,113,300
BAWAH (RINGAN)
548 N-1-30-II 8,767,100 10,520,500 12,273,900
BAWAH (SEDANG)
549 N-1-30-III 10,090,100 12,108,100 14,126,100
BAWAH (BERAT)
550 N-1-40-I 5,204,500 6,245,500 7,286,400
(RINGAN)
551 N-1-40-II 7,067,600 8,481,200 9,894,700
(SEDANG)
552 N-1-40-III 8,225,800 9,871,000 11,516,100
(BERAT)
553 N-4-10-I 2,211,200 2,653,400 3,095,700
(RINGAN)
554 N-4-10-II 2,674,500 3,209,400 3,744,300
(SEDANG)
555 N-4-10-III 3,933,800 4,720,500 5,507,300
(BERAT)
568 N-4-15-I 2,014,000 2,416,800 2,819,600
URIN (RINGAN)
569 N-4-15-II 2,499,000 2,998,800 3,498,600
URIN (SEDANG)
570 N-4-15-III 2,851,800 3,422,200 3,992,500
URIN (BERAT)
571 N-4-16-I 2,466,100 2,959,400 3,452,600
(RINGAN)
572 N-4-16-II 3,520,000 4,224,000 4,928,000
(SEDANG)
573 N-4-16-III 4,685,300 5,622,400 6,559,500
(BERAT)
- 182 -

REGIONAL 1
RAWAT INAP

577 O-6-11-I 2,292,400 2,750,900 3,209,400
578 O-6-11-II 2,547,700 3,057,300 3,566,800
579 O-6-11-III 3,169,400 3,803,300 4,437,200
580 O-6-12-I 1,624,100 1,949,000 2,273,800
581 O-6-12-II 1,950,600 2,340,700 2,730,800
582 O-6-12-III 2,451,000 2,941,200 3,431,400
586 P-8-01-I 36,267,100 43,520,500 50,774,000
587 P-8-01-II 44,875,100 53,850,100 62,825,100
588 P-8-01-III 52,670,800 63,204,900 73,739,100
589 P-8-02-I 49,502,900 59,403,500 69,304,000
590 P-8-02-II 56,784,800 68,141,700 79,498,700
591 P-8-02-III 64,880,600 77,856,800 90,832,900
592 P-8-03-I 6,033,100 7,239,800 8,446,400
593 P-8-03-II 8,567,000 10,280,400 11,993,900
594 P-8-03-III 9,680,800 11,616,900 13,553,100
595 P-8-04-I 19,578,000 23,493,500 27,409,100
596 P-8-04-II 25,407,900 30,489,500 35,571,100
597 P-8-04-III 36,428,600 43,714,400 51,000,100
598 P-8-05-I 10,645,900 12,775,000 14,904,200
599 P-8-05-II 20,072,700 24,087,200 28,101,700
600 P-8-05-III 24,495,500 29,394,600 34,293,600
601 P-8-06-I 3,512,700 4,215,300 4,917,800
602 P-8-06-II 9,848,900 11,818,600 13,788,400
603 P-8-06-III 13,047,300 15,656,800 18,266,300
604 P-8-07-I 3,402,400 4,082,900 4,763,400
605 P-8-07-II 9,539,600 11,447,500 13,355,500
606 P-8-07-III 12,637,700 15,165,200 17,692,700
607 P-8-08-I 3,597,000 4,316,500 5,035,900
608 P-8-08-II 5,104,200 6,125,000 7,145,800
609 P-8-08-III 8,264,700 9,917,600 11,570,500
610 P-8-11-I 5,699,700 6,839,600 7,979,600
MAYOR (RINGAN)
611 P-8-11-II 8,093,600 9,712,300 11,331,000
MAYOR (SEDANG)
- 183 -

REGIONAL 1
RAWAT INAP

612 P-8-11-III 9,145,700 10,974,900 12,804,000
MAYOR (BERAT)
613 P-8-12-I 5,384,700 6,461,600 7,538,600
MAYOR (RINGAN)
614 P-8-12-II 7,656,300 9,187,500 10,718,800
MAYOR (SEDANG)
615 P-8-12-III 8,665,400 10,398,400 12,131,500
MAYOR (BERAT)
616 P-8-13-I 4,672,100 5,606,500 6,540,900
MAYOR (RINGAN)
617 P-8-13-II 6,167,100 7,400,600 8,634,000
MAYOR (SEDANG)
618 P-8-13-III 9,183,100 11,019,700 12,856,400
MAYOR (BERAT)
619 P-8-14-I 2,365,500 2,838,600 3,311,700
620 P-8-14-II 4,815,200 5,778,300 6,741,300
621 P-8-14-III 8,934,100 10,720,900 12,507,700
622 P-8-15-I 1,774,200 2,129,000 2,483,800
ASPIRASI (RINGAN)
623 P-8-15-II 3,552,800 4,263,400 4,974,000
ASPIRASI (SEDANG)
624 P-8-15-III 4,168,600 5,002,300 5,836,100
ASPIRASI (BERAT)
625 P-8-16-I 1,605,600 1,926,800 2,247,900
626 P-8-16-II 3,085,500 3,702,600 4,319,700
627 P-8-16-III 6,292,200 7,550,600 8,809,000
628 P-8-17-I 3,114,700 3,737,700 4,360,600
(RINGAN)
629 P-8-17-II 5,606,500 6,727,800 7,849,100
(SEDANG)
630 P-8-17-III 7,652,600 9,183,100 10,713,600
(BERAT)
631 S-4-10-I 1,810,300 2,172,400 2,534,500
632 S-4-10-II 2,230,600 2,676,700 3,122,800
633 S-4-10-III 3,053,500 3,664,200 4,274,900
640 S-4-13-I 1,965,500 2,358,600 2,751,700
(RINGAN)
641 S-4-13-II 3,486,900 4,184,300 4,881,700
(SEDANG)
642 S-4-13-III 5,659,700 6,791,600 7,923,500
(BERAT)
643 S-4-14-I 994,700 1,193,600 1,392,500
644 S-4-14-II 2,112,800 2,535,300 2,957,900
645 S-4-14-III 4,006,500 4,807,800 5,609,100
KANAK-KANAK (BERAT)
646 S-4-15-I 665,200 798,300 931,300
647 S-4-15-II 1,255,400 1,506,500 1,757,600
648 S-4-15-III 1,626,000 1,951,200 2,276,400
- 184 -

REGIONAL 1
RAWAT INAP

652 S-4-17-I 1,660,300 1,992,400 2,324,400
653 S-4-17-II 2,464,100 2,956,900 3,449,700
654 S-4-17-III 2,963,600 3,556,300 4,149,000
655 T-1-10-I 1,110,900 1,333,100 1,555,200
OBAT (RINGAN)
656 T-1-10-II 1,492,000 1,790,500 2,088,900
OBAT (SEDANG)
657 T-1-10-III 2,714,300 3,257,100 3,800,000
OBAT (BERAT)
658 T-4-10-I 506,600 607,900 709,200
659 T-4-10-II 965,600 1,158,700 1,351,800
660 T-4-10-III 1,403,700 1,684,400 1,965,100
661 T-4-11-I 600,000 719,900 839,900
662 T-4-11-II 944,100 1,133,000 1,321,800
663 T-4-11-III 1,520,700 1,824,800 2,128,900
664 T-4-12-I 1,049,300 1,259,100 1,469,000
LAIN (RINGAN)
665 T-4-12-II 1,586,300 1,903,500 2,220,800
LAIN (SEDANG)
666 T-4-12-III 2,475,700 2,970,900 3,466,000
LAIN (BERAT)
670 U-1-11-I 5,616,100 6,739,300 7,862,600
(RINGAN)
671 U-1-11-II 7,119,300 8,543,100 9,967,000
(SEDANG)
672 U-1-11-III 10,243,500 12,292,200 14,340,900
(BERAT)
679 U-1-14-I 2,638,900 3,166,700 3,694,500
(RINGAN)
680 U-1-14-II 3,238,600 3,886,300 4,534,000
(SEDANG)
681 U-1-14-III 3,837,700 4,605,300 5,372,800
(BERAT)
685 U-1-20-I 4,006,300 4,807,500 5,608,800
686 U-1-20-II 5,962,500 7,155,000 8,347,400
687 U-1-20-III 15,306,800 18,368,100 21,429,500
691 U-4-10-I 2,472,600 2,967,100 3,461,600
- 185 -

REGIONAL 1
RAWAT INAP

692 U-4-10-II 5,660,400 6,792,500 7,924,600
693 U-4-10-III 8,690,500 10,428,600 12,166,700
TENGGOROKAN (BERAT)
700 U-4-13-I 1,787,100 2,144,500 2,501,900
701 U-4-13-II 2,106,800 2,528,200 2,949,500
702 U-4-13-III 2,519,800 3,023,800 3,527,800
706 U-4-15-I 1,976,100 2,371,400 2,766,600
707 U-4-15-II 2,462,000 2,954,400 3,446,800
708 U-4-15-III 3,445,600 4,134,700 4,823,900
709 V-1-10-I 3,223,200 3,867,900 4,512,500
(RINGAN)
710 V-1-10-II 6,639,800 7,967,700 9,295,700
(SEDANG)
711 V-1-10-III 8,142,700 9,771,300 11,399,800
(BERAT)
715 V-1-12-I 5,765,300 6,918,400 8,071,500
MODERAT (RINGAN)
716 V-1-12-II 7,873,000 9,447,600 11,022,200
MODERAT (SEDANG)
717 V-1-12-III 9,979,100 11,975,000 13,970,800
MODERAT (BERAT)
718 V-1-13-I 3,007,300 3,608,700 4,210,200
KOMPLEK (RINGAN)
719 V-1-13-II 5,745,900 6,895,100 8,044,300
KOMPLEK (SEDANG)
720 V-1-13-III 9,014,600 10,817,500 12,620,500
KOMPLEK (BERAT)
721 V-1-14-I 5,897,200 7,076,700 8,256,100
(RINGAN)
722 V-1-14-II 8,568,500 10,282,200 11,995,900
(SEDANG)

727 V-4-10-I 2,851,800 3,422,200 3,992,500
(RINGAN)
728 V-4-10-II 4,737,000 5,684,400 6,631,800
(SEDANG)
729 V-4-10-III 7,809,600 9,371,600 10,933,500
(BERAT)
730 V-4-11-I 2,464,100 2,957,000 3,449,800
TUMOR (RINGAN)
731 V-4-11-II 3,306,200 3,967,500 4,628,700
TUMOR (SEDANG)
732 V-4-11-III 4,428,700 5,314,500 6,200,200
TUMOR (BERAT)
- 186 -

REGIONAL 1
RAWAT INAP

733 W-1-01-I 6,716,300 8,059,600 9,402,900
734 W-1-01-II 8,050,000 9,660,000 11,270,000
735 W-1-01-III 11,487,100 13,784,600 16,082,000
739 W-1-11-I 1,489,100 1,786,900 2,084,700
SERVIK (RINGAN)
740 W-1-11-II 1,643,200 1,971,800 2,300,400
SERVIK (SEDANG)
741 W-1-11-III 1,817,700 2,181,200 2,544,700
SERVIK (BERAT)
760 W-4-12-I 2,613,900 3,136,600 3,659,400
761 W-4-12-II 3,588,600 4,306,400 5,024,100
762 W-4-12-III 3,911,800 4,694,200 5,476,500
- 187 -

REGIONAL 1
RAWAT INAP

784 Z-4-12-I 776,400 931,700 1,087,000
785 Z-4-12-II 1,891,800 2,270,200 2,648,500
786 Z-4-12-III 2,399,200 2,879,000 3,358,900
- 188 -

REGIONAL 1
RUMAH SAKIT UMUM KELAS D SWASTA
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,453,700

33 F-3-10-0 TERAPI SHOCK 411,700
- 189 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,502,700
PENGGANTIAN ALAT
81 I-2-42-0 2,404,900
PERKUTAN LAIN
- 190 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,134,100
192 Q-5-12-0 GIGI 206,000
196 Q-5-16-0 VAKSINASI 87,800
201 Q-5-21-0 ABORSI 179,800
206 Q-5-26-0 BRONKIAL AKUT 186,900
- 191 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 125,800
215 Q-5-35-0 INFEKSI AKUT 420,500
218 Q-5-38-0 PARU AKUT 245,100
234 U-2-23-0 RHINOPLASTY 1,210,700
242 U-3-13-0 312,100
TENGGOROKAN
270 Z-3-11-0 1,693,100
EMPEDU
- 192 -

REGIONAL 1
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 892,100
289 Z-3-30-0 FOTOTERAPI 72,600
- 193 -


REGIONAL 2
RAWAT INAP

13 A-4-14-I 2,339,400 2,807,300 3,275,200
(RINGAN)
14 A-4-14-II 3,936,200 4,723,400 5,510,700
(SEDANG)
15 A-4-14-III 4,723,400 5,668,100 6,612,800
(BERAT)

31 B-1-13-I 7,613,300 9,135,900 10,658,600
LAIN (RINGAN)
32 B-1-13-II 12,526,700 15,032,100 17,537,400
LAIN (SEDANG)
33 B-1-13-III 16,208,500 19,450,200 22,691,900
LAIN (BERAT)
34 B-1-14-I 19,946,700 23,936,100 27,925,400
(RINGAN)
35 B-1-14-II 20,949,700 25,139,600 29,329,500
(SEDANG)
40 B-4-11-I 6,824,000 8,188,800 9,553,600
(RINGAN)
41 B-4-11-II 9,553,700 11,464,400 13,375,200
(SEDANG)
42 B-4-11-III 11,574,200 13,889,000 16,203,900
(BERAT)
- 194 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 7,229,000 8,674,800 10,120,600
74 D-1-20-II 19,922,000 23,906,400 27,890,800
75 D-1-20-III 31,602,200 37,922,600 44,243,100
85 D-4-13-I 4,181,300 5,017,500 5,853,800
86 D-4-13-II 5,917,900 7,101,500 8,285,100
87 D-4-13-III 7,569,200 9,083,100 10,596,900
88 D-4-14-I 4,484,600 5,381,500 6,278,400
89 D-4-14-II 7,342,400 8,810,900 10,279,400
90 D-4-14-III 8,980,500 10,776,600 12,572,800
91 E-1-01-I 8,939,500 10,727,400 12,515,400
(RINGAN)
92 E-1-01-II 12,203,800 14,644,600 17,085,300
(SEDANG)

97 E-1-20-I 10,521,800 12,626,100 14,730,500
TIROGLOSAL (RINGAN)
- 195 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 14,162,000 16,994,400 19,826,800
TIROGLOSAL (SEDANG)
99 E-1-20-III 19,518,200 23,421,800 27,325,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,723,600 4,468,300 5,213,100
METABOLIK (RINGAN)
101 E-4-10-II 7,212,000 8,654,400 10,096,800
METABOLIK (SEDANG)
102 E-4-10-III 12,084,600 14,501,500 16,918,400
METABOLIK (BERAT)
109 E-4-13-I 5,175,400 6,210,400 7,245,500
(RINGAN)
110 E-4-13-II 7,581,000 9,097,200 10,613,400
(SEDANG)

118 F-4-12-I 2,921,100 3,505,300 4,089,500
(RINGAN)
119 F-4-12-II 4,152,900 4,983,500 5,814,000
(SEDANG)
120 F-4-12-III 9,021,900 10,826,300 12,630,700
(BERAT)
130 F-4-16-I 7,674,200 9,209,000 10,743,800
131 F-4-16-II 8,922,500 10,707,000 12,491,500
132 F-4-16-III 11,910,000 14,291,900 16,673,900
142 G-1-01-I 21,618,300 25,941,900 30,265,600
(RINGAN)
- 196 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 31,005,800 37,207,000 43,408,200
(SEDANG)
144 G-1-01-III 50,728,100 60,873,800 71,019,400
(BERAT)
151 G-1-12-I 6,907,900 8,289,500 9,671,100
(RINGAN)
152 G-1-12-II 12,949,200 15,539,000 18,128,900
(SEDANG)
153 G-1-12-III 17,647,200 21,176,600 24,706,100
(BERAT)
163 G-4-10-I 5,929,700 7,115,600 8,301,600
(RINGAN)
164 G-4-10-II 7,248,100 8,697,700 10,147,300
(SEDANG)
165 G-4-10-III 9,945,600 11,934,700 13,923,800
(BERAT)
166 G-4-11-I 6,207,400 7,448,900 8,690,400
167 G-4-11-II 8,245,800 9,895,000 11,544,100
168 G-4-11-III 12,115,900 14,539,100 16,962,300
DEGENERATIF (BERAT)
169 G-4-12-I 6,886,400 8,263,700 9,641,000
(RINGAN)
170 G-4-12-II 8,698,100 10,437,700 12,177,300
(SEDANG)

172 G-4-13-I 4,136,800 4,964,100 5,791,500
(RINGAN)
173 G-4-13-II 7,213,700 8,656,500 10,099,200
(SEDANG)
174 G-4-13-III 8,555,600 10,266,800 11,977,900
(BERAT)
175 G-4-14-I 7,017,600 8,421,100 9,824,600
INFARK (RINGAN)
176 G-4-14-II 9,382,000 11,258,400 13,134,800
INFARK (SEDANG)
177 G-4-14-III 11,775,500 14,130,600 16,485,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 197 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 6,295,900 7,555,100 8,814,200
(RINGAN)
185 G-4-17-II 8,255,300 9,906,300 11,557,400
(SEDANG)
186 G-4-17-III 10,373,100 12,447,800 14,522,400
(BERAT)
190 G-4-19-I 5,173,200 6,207,800 7,242,500
191 G-4-19-II 8,743,900 10,492,700 12,241,500
192 G-4-19-III 11,480,400 13,776,500 16,072,600
211 G-4-26-I 4,025,400 4,830,500 5,635,600
LAIN (RINGAN)
212 G-4-26-II 4,682,800 5,619,300 6,555,900
LAIN (SEDANG)
213 G-4-26-III 7,002,200 8,402,600 9,803,100
LAIN (BERAT)
232 I-1-02-I 36,243,800 43,492,500 50,741,300
(RINGAN)
- 198 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 46,754,000 56,104,800 65,455,600
(SEDANG)
234 I-1-02-III 57,627,300 69,152,700 80,678,200
(BERAT)
235 I-1-03-I 34,181,800 41,018,100 47,854,500
ANOMALI (RINGAN)
236 I-1-03-II 47,383,000 56,859,600 66,336,200
ANOMALI (SEDANG)
237 I-1-03-III 60,132,700 72,159,200 84,185,800
ANOMALI (BERAT)
238 I-1-04-I 51,510,100 61,812,100 72,114,100
JANTUNG (RINGAN)
239 I-1-04-II 81,296,800 97,556,200 113,815,500
JANTUNG (SEDANG)
240 I-1-04-III 129,871,100 155,845,300 181,819,600
JANTUNG (BERAT)
241 I-1-05-I 85,325,100 102,390,100 119,455,100
242 I-1-05-II 104,286,200 125,143,400 146,000,700
243 I-1-05-III 142,208,500 170,650,200 199,091,800
247 I-1-07-I 75,844,500 91,013,400 106,182,300
JANTUNG (RINGAN)
248 I-1-07-II 94,805,600 113,766,800 132,727,900
JANTUNG (SEDANG)
249 I-1-07-III 142,208,500 170,650,200 199,091,800
JANTUNG (BERAT)
250 I-1-11-I 5,679,500 6,815,400 7,951,300
251 I-1-11-II 6,315,100 7,578,100 8,841,100
252 I-1-11-III 8,403,400 10,084,100 11,764,800
253 I-1-12-I 16,348,400 19,618,000 22,887,700
(RINGAN)
254 I-1-12-II 26,700,200 32,040,200 37,380,200
(SEDANG)
255 I-1-12-III 35,128,100 42,153,700 49,179,300
(BERAT)
256 I-1-13-I 15,857,700 19,029,200 22,200,800
KOMPLEK (RINGAN)
257 I-1-13-II 21,117,700 25,341,300 29,564,800
KOMPLEK (SEDANG)
258 I-1-13-III 26,044,000 31,252,800 36,461,600
KOMPLEK (BERAT)
259 I-1-14-I 32,456,800 38,948,100 45,439,500
(RINGAN)
260 I-1-14-II 40,339,000 48,406,800 56,474,600
(SEDANG)
261 I-1-14-III 52,858,000 63,429,600 74,001,200
(BERAT)
265 I-1-16-I 15,984,100 19,181,000 22,377,800
266 I-1-16-II 36,165,700 43,398,800 50,631,900
267 I-1-16-III 41,716,500 50,059,800 58,403,200
268 I-1-17-I 18,508,100 22,209,700 25,911,400
(RINGAN)
269 I-1-17-II 23,173,900 27,808,700 32,443,500
(SEDANG)
- 199 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 28,665,700 34,398,900 40,132,000
(BERAT)
271 I-1-20-I 20,861,800 25,034,200 29,206,600
(RINGAN)
272 I-1-20-II 26,062,100 31,274,600 36,487,000
(SEDANG)
273 I-1-20-III 27,396,700 32,876,000 38,355,400
(BERAT)
274 I-1-30-I 15,780,800 18,937,000 22,093,100
JANTUNG (RINGAN)
275 I-1-30-II 32,827,600 39,393,100 45,958,600
JANTUNG (SEDANG)
276 I-1-30-III 50,870,900 61,045,100 71,219,200
JANTUNG (BERAT)

289 I-4-13-I 4,940,800 5,928,900 6,917,100
(RINGAN)
290 I-4-13-II 8,822,400 10,586,800 12,351,300
(SEDANG)
291 I-4-13-III 12,711,800 15,254,100 17,796,500
(BERAT)
295 I-4-15-I 4,765,000 5,718,000 6,671,000
(RINGAN)
296 I-4-15-II 8,985,400 10,782,400 12,579,500
(SEDANG)

304 I-4-18-I 5,680,100 6,816,100 7,952,100
JANTUNG (RINGAN)
305 I-4-18-II 8,648,200 10,377,800 12,107,500
JANTUNG (SEDANG)
306 I-4-18-III 11,741,400 14,089,600 16,437,900
JANTUNG (BERAT)

308 I-4-19-II 8,554,800 10,265,800 11,976,800
(SEDANG)
- 200 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 4,684,200 5,621,000 6,557,900
320 I-4-23-II 5,750,900 6,901,000 8,051,200
321 I-4-23-III 11,236,800 13,484,200 15,731,600
322 I-4-24-I 3,043,200 3,651,800 4,260,400
(RINGAN)
323 I-4-24-II 7,007,600 8,409,100 9,810,600
(SEDANG)
324 I-4-24-III 8,859,900 10,631,800 12,403,800
(BERAT)
325 J-1-01-I 96,421,200 115,705,400 134,989,700
326 J-1-01-II 109,118,500 130,942,200 152,765,900
327 J-1-01-III 149,674,800 179,609,800 209,544,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 62,903,200 75,483,800 88,064,400
329 J-1-02-II 79,371,600 95,245,900 111,120,200
330 J-1-02-III 92,853,500 111,424,200 129,994,900
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,263,200 14,715,900 17,168,500
(RINGAN)
332 J-1-10-II 24,814,700 29,777,600 34,740,600
(SEDANG)
333 J-1-10-III 25,788,600 30,946,300 36,104,000
(BERAT)
334 J-1-20-I 33,783,000 40,539,600 47,296,200
(RINGAN)
335 J-1-20-II 35,375,300 42,450,400 49,525,500
(SEDANG)
336 J-1-20-III 39,810,300 47,772,400 55,734,500
(BERAT)
337 J-1-30-I 10,234,000 12,280,800 14,327,600
(RINGAN)
338 J-1-30-II 18,538,700 22,246,500 25,954,200
(SEDANG)

- 201 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,975,000 3,570,000 4,165,000
374 J-4-21-II 6,643,100 7,971,700 9,300,300
375 J-4-21-III 12,514,400 15,017,300 17,520,200
376 K-1-10-I 11,117,400 13,340,800 15,564,300
BESAR (RINGAN)
377 K-1-10-II 13,971,300 16,765,600 19,559,900
BESAR (SEDANG)
378 K-1-10-III 16,374,900 19,649,900 22,924,800
BESAR (BERAT)
382 K-1-12-I 4,664,700 5,597,600 6,530,600
FEMORAL (RINGAN)
383 K-1-12-II 6,067,000 7,280,400 8,493,700
FEMORAL (SEDANG)
384 K-1-12-III 12,019,600 14,423,500 16,827,400
FEMORAL (BERAT)
388 K-1-14-I 7,683,600 9,220,400 10,757,100
(RINGAN)
389 K-1-14-II 9,005,100 10,806,100 12,607,100
(SEDANG)

394 K-1-30-I 9,776,400 11,731,700 13,686,900
395 K-1-30-II 17,362,600 20,835,200 24,307,700
396 K-1-30-III 23,891,200 28,669,500 33,447,700

398 K-1-40-II 12,026,700 14,432,000 16,837,300
(SEDANG)

- 202 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 5,576,000 6,691,200 7,806,400
413 K-4-13-II 7,212,900 8,655,500 10,098,100
414 K-4-13-III 11,110,200 13,332,300 15,554,300
415 K-4-14-I 3,181,700 3,818,000 4,454,400
(RINGAN)
416 K-4-14-II 4,270,900 5,125,100 5,979,200
(SEDANG)
417 K-4-14-III 6,853,100 8,223,700 9,594,300
(BERAT)

424 K-4-17-I 2,014,600 2,417,500 2,820,500
(RINGAN)
425 K-4-17-II 2,481,000 2,977,200 3,473,400
(SEDANG)
426 K-4-17-III 2,977,200 3,572,600 4,168,100
(BERAT)
427 K-4-18-I 1,775,400 2,130,400 2,485,500
(RINGAN)
428 K-4-18-II 2,995,900 3,595,100 4,194,300
(SEDANG)
436 L-1-40-I 6,969,100 8,362,900 9,756,700
(RINGAN)
437 L-1-40-II 13,978,400 16,774,100 19,569,800
(SEDANG)
438 L-1-40-III 23,528,800 28,234,500 32,940,300
(BERAT)
451 L-4-13-I 2,534,100 3,040,900 3,547,800
PAYUDARA (RINGAN)
- 203 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 4,128,200 4,953,900 5,779,500
PAYUDARA (SEDANG)
453 L-4-13-III 8,200,900 9,841,100 11,481,200
PAYUDARA (BERAT)
454 L-4-14-I 4,121,100 4,945,400 5,769,600
(RINGAN)
455 L-4-14-II 6,190,100 7,428,100 8,666,100
(SEDANG)
456 L-4-14-III 8,725,700 10,470,800 12,216,000
(BERAT)
457 M-1-01-I 14,567,800 17,481,400 20,395,000
458 M-1-01-II 20,706,100 24,847,300 28,988,600
459 M-1-01-III 29,085,900 34,903,100 40,720,300
463 M-1-03-I 51,612,600 61,935,100 72,257,600
464 M-1-03-II 60,368,400 72,442,100 84,515,800
465 M-1-03-III 74,716,000 89,659,200 104,602,400
472 M-1-07-I 18,786,100 22,543,300 26,300,600
473 M-1-07-II 25,166,900 30,200,300 35,233,700
474 M-1-07-III 51,267,400 61,520,800 71,774,300
475 M-1-10-I 22,200,200 26,640,300 31,080,300
WAJAH (RINGAN)
476 M-1-10-II 53,079,800 63,695,700 74,311,700
WAJAH (SEDANG)
477 M-1-10-III 114,488,100 137,385,700 160,283,300
WAJAH (BERAT)
478 M-1-20-I 17,299,400 20,759,200 24,219,100
(RINGAN)
479 M-1-20-II 22,101,700 26,522,000 30,942,400
(SEDANG)

484 M-1-40-I 7,249,400 8,699,300 10,149,200
INTERNAL (RINGAN)
485 M-1-40-II 10,713,800 12,856,500 14,999,300
INTERNAL (SEDANG)
486 M-1-40-III 15,297,200 18,356,600 21,416,000
INTERNAL (BERAT)
490 M-1-60-I 11,180,700 13,416,800 15,653,000
491 M-1-60-II 14,056,700 16,868,000 19,679,400
492 M-1-60-III 21,234,300 25,481,200 29,728,100
- 204 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 20,714,200 24,857,100 28,999,900
KAKI (RINGAN)
494 M-1-70-II 22,785,700 27,342,800 31,899,900
KAKI (SEDANG)
495 M-1-70-III 26,086,600 31,303,900 36,521,200
KAKI (BERAT)
502 M-4-11-I 5,168,700 6,202,500 7,236,200
(RINGAN)
503 M-4-11-II 11,332,200 13,598,700 15,865,100
(SEDANG)
504 M-4-11-III 16,384,500 19,661,400 22,938,300
(BERAT)
505 M-4-12-I 4,125,800 4,951,000 5,776,100
(RINGAN)
506 M-4-12-II 6,862,400 8,234,800 9,607,300
(SEDANG)
507 M-4-12-III 9,179,100 11,015,000 12,850,800
(BERAT)
508 M-4-13-I 6,869,900 8,243,900 9,617,900
509 M-4-13-II 10,321,700 12,386,100 14,450,400
510 M-4-13-III 20,137,500 24,165,000 28,192,500
520 M-4-17-I 4,646,100 5,575,300 6,504,600
(RINGAN)
521 M-4-17-II 6,498,100 7,797,700 9,097,400
(SEDANG)
522 M-4-17-III 9,074,200 10,889,000 12,703,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,694,100 4,433,000 5,171,800
(RINGAN)
530 M-4-20-II 5,409,400 6,491,300 7,573,200
(SEDANG)
531 M-4-20-III 6,045,700 7,254,800 8,464,000
(BERAT)
532 M-4-21-I 3,719,700 4,463,600 5,207,600
533 M-4-21-II 4,652,300 5,582,700 6,513,200
- 205 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 10,430,300 12,516,400 14,602,400
541 N-1-12-I 6,076,000 7,291,200 8,506,400
542 N-1-12-II 12,096,700 14,516,100 16,935,400
543 N-1-12-III 26,250,300 31,500,400 36,750,500
547 N-1-30-I 12,157,700 14,589,200 17,020,700
BAWAH (RINGAN)
548 N-1-30-II 18,392,200 22,070,600 25,749,000
BAWAH (SEDANG)
549 N-1-30-III 21,167,600 25,401,100 29,634,700
BAWAH (BERAT)
550 N-1-40-I 10,918,500 13,102,100 15,285,800
(RINGAN)
551 N-1-40-II 14,827,000 17,792,400 20,757,800
(SEDANG)
552 N-1-40-III 17,256,700 20,708,000 24,159,400
(BERAT)
553 N-4-10-I 4,638,800 5,566,600 6,494,400
(RINGAN)
554 N-4-10-II 5,610,700 6,732,900 7,855,000
(SEDANG)
555 N-4-10-III 8,252,600 9,903,100 11,553,600
(BERAT)
568 N-4-15-I 4,225,100 5,070,100 5,915,200
URIN (RINGAN)
569 N-4-15-II 5,242,600 6,291,200 7,339,700
URIN (SEDANG)
570 N-4-15-III 5,982,700 7,179,300 8,375,800
URIN (BERAT)
571 N-4-16-I 5,173,600 6,208,400 7,243,100
(RINGAN)
572 N-4-16-II 7,384,400 8,861,300 10,338,200
(SEDANG)
573 N-4-16-III 9,829,200 11,795,100 13,760,900
(BERAT)
- 206 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 4,809,200 5,771,000 6,732,800
578 O-6-11-II 5,344,800 6,413,800 7,482,800
579 O-6-11-III 6,649,000 7,978,800 9,308,600
580 O-6-12-I 3,407,200 4,088,700 4,770,100
581 O-6-12-II 4,092,000 4,910,400 5,728,900
582 O-6-12-III 5,141,800 6,170,200 7,198,500
586 P-8-01-I 76,083,700 91,300,400 106,517,100
587 P-8-01-II 94,142,100 112,970,500 131,799,000
588 P-8-01-III 110,496,400 132,595,700 154,694,900
589 P-8-02-I 103,850,600 124,620,700 145,390,900
590 P-8-02-II 119,127,100 142,952,500 166,777,900
591 P-8-02-III 136,111,100 163,333,400 190,555,600
592 P-8-03-I 15,577,500 18,693,000 21,808,500
593 P-8-03-II 20,618,900 24,742,700 28,866,500
594 P-8-03-III 28,991,200 34,789,400 40,587,600
595 P-8-04-I 50,199,100 60,238,900 70,278,800
596 P-8-04-II 65,147,600 78,177,100 91,206,600
597 P-8-04-III 93,405,300 112,086,400 130,767,400
598 P-8-05-I 27,296,700 32,756,000 38,215,300
599 P-8-05-II 42,109,900 50,531,800 58,953,800
600 P-8-05-III 57,003,500 68,404,200 79,804,900
601 P-8-06-I 7,369,200 8,843,100 10,316,900
602 P-8-06-II 20,661,600 24,794,000 28,926,300
603 P-8-06-III 27,371,600 32,845,900 38,320,200
604 P-8-07-I 8,724,000 10,468,800 12,213,700
605 P-8-07-II 24,460,200 29,352,200 34,244,300
606 P-8-07-III 32,403,800 38,884,500 45,365,300
607 P-8-08-I 5,047,800 6,057,400 7,067,000
608 P-8-08-II 7,162,600 8,595,200 10,027,700
609 P-8-08-III 13,934,100 16,721,000 19,507,800
610 P-8-11-I 12,981,200 15,577,500 18,173,700
MAYOR (RINGAN)
611 P-8-11-II 17,182,400 20,618,900 24,055,400
MAYOR (SEDANG)
- 207 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 24,159,300 28,991,200 33,823,000
MAYOR (BERAT)
613 P-8-12-I 11,801,100 14,161,300 16,521,600
MAYOR (RINGAN)
614 P-8-12-II 14,318,700 17,182,400 20,046,200
MAYOR (SEDANG)
615 P-8-12-III 21,008,100 25,209,700 29,411,300
MAYOR (BERAT)
616 P-8-13-I 6,556,200 7,867,400 9,178,700
MAYOR (RINGAN)
617 P-8-13-II 10,227,600 12,273,200 14,318,700
MAYOR (SEDANG)
618 P-8-13-III 16,160,100 19,392,100 22,624,100
MAYOR (BERAT)
619 P-8-14-I 4,962,500 5,955,000 6,947,500
620 P-8-14-II 10,101,700 12,122,100 14,142,400
621 P-8-14-III 39,498,500 47,398,200 55,297,900
622 P-8-15-I 3,722,000 4,466,300 5,210,700
ASPIRASI (RINGAN)
623 P-8-15-II 7,453,400 8,944,100 10,434,700
ASPIRASI (SEDANG)
624 P-8-15-III 8,745,200 10,494,200 12,243,300
ASPIRASI (BERAT)
625 P-8-16-I 3,368,400 4,042,100 4,715,800
626 P-8-16-II 6,472,900 7,767,500 9,062,100
627 P-8-16-III 15,180,100 18,216,200 21,252,200
628 P-8-17-I 4,370,800 5,244,900 6,119,100
(RINGAN)
629 P-8-17-II 7,867,400 9,440,900 11,014,400
(SEDANG)
630 P-8-17-III 13,466,700 16,160,100 18,853,400
(BERAT)
631 S-4-10-I 3,797,800 4,557,400 5,317,000
632 S-4-10-II 4,679,500 5,615,400 6,551,300
633 S-4-10-III 6,405,800 7,686,900 8,968,100
640 S-4-13-I 4,123,300 4,948,000 5,772,600
(RINGAN)
641 S-4-13-II 7,315,100 8,778,100 10,241,100
(SEDANG)
642 S-4-13-III 11,873,300 14,247,900 16,622,600
(BERAT)
643 S-4-14-I 2,086,700 2,504,000 2,921,400
644 S-4-14-II 4,432,300 5,318,700 6,205,200
645 S-4-14-III 8,405,200 10,086,200 11,767,200
KANAK-KANAK (BERAT)
646 S-4-15-I 1,395,600 1,674,700 1,953,800
647 S-4-15-II 2,633,700 3,160,500 3,687,200
648 S-4-15-III 3,411,100 4,093,300 4,775,600
- 208 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 3,483,100 4,179,700 4,876,300
653 S-4-17-II 5,169,300 6,203,200 7,237,000
654 S-4-17-III 6,217,200 7,460,700 8,704,100
655 T-1-10-I 2,330,500 2,796,600 3,262,700
OBAT (RINGAN)
656 T-1-10-II 3,130,100 3,756,100 4,382,200
OBAT (SEDANG)
657 T-1-10-III 5,694,200 6,833,000 7,971,800
OBAT (BERAT)
658 T-4-10-I 1,276,100 1,531,300 1,786,500
659 T-4-10-II 2,431,500 2,917,800 3,404,100
660 T-4-10-III 3,534,300 4,241,200 4,948,100
661 T-4-11-I 1,232,400 1,478,900 1,725,300
662 T-4-11-II 1,939,400 2,327,300 2,715,200
663 T-4-11-III 3,123,900 3,748,600 4,373,400
664 T-4-12-I 2,887,600 3,465,100 4,042,600
LAIN (RINGAN)
665 T-4-12-II 4,359,100 5,230,900 6,102,700
LAIN (SEDANG)
666 T-4-12-III 6,747,200 8,096,600 9,446,100
LAIN (BERAT)
670 U-1-11-I 12,018,700 14,422,400 16,826,200
(RINGAN)
671 U-1-11-II 18,128,000 21,753,600 25,379,200
(SEDANG)
672 U-1-11-III 21,489,500 25,787,400 30,085,300
(BERAT)
679 U-1-14-I 5,536,100 6,643,300 7,750,500
(RINGAN)
680 U-1-14-II 6,794,100 8,152,900 9,511,800
(SEDANG)
681 U-1-14-III 8,051,000 9,661,200 11,271,400
(BERAT)
685 U-1-20-I 8,404,700 10,085,600 11,766,500
686 U-1-20-II 12,508,500 15,010,200 17,511,900
687 U-1-20-III 32,111,600 38,534,000 44,956,300
691 U-4-10-I 5,187,100 6,224,500 7,262,000
- 209 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 11,874,900 14,249,900 16,624,800
693 U-4-10-III 18,231,600 21,877,900 25,524,200
TENGGOROKAN (BERAT)
700 U-4-13-I 2,041,900 2,450,200 2,858,600
701 U-4-13-II 3,336,600 4,003,900 4,671,200
702 U-4-13-III 5,387,400 6,464,900 7,542,400
706 U-4-15-I 4,145,700 4,974,800 5,803,900
707 U-4-15-II 5,165,000 6,198,000 7,231,000
708 U-4-15-III 7,228,500 8,674,100 10,119,800
709 V-1-10-I 6,761,900 8,114,300 9,466,700
(RINGAN)
710 V-1-10-II 13,929,300 16,715,200 19,501,100
(SEDANG)
711 V-1-10-III 17,082,400 20,498,900 23,915,400
(BERAT)
715 V-1-12-I 12,094,900 14,513,900 16,932,900
MODERAT (RINGAN)
716 V-1-12-II 16,516,600 19,819,900 23,123,200
MODERAT (SEDANG)
717 V-1-12-III 20,934,900 25,121,900 29,308,900
MODERAT (BERAT)
718 V-1-13-I 6,308,900 7,570,600 8,832,400
KOMPLEK (RINGAN)
719 V-1-13-II 12,054,200 14,465,000 16,875,800
KOMPLEK (SEDANG)
720 V-1-13-III 18,911,500 22,693,800 26,476,100
KOMPLEK (BERAT)
721 V-1-14-I 12,371,600 14,846,000 17,320,300
(RINGAN)
722 V-1-14-II 17,975,600 21,570,700 25,165,900
(SEDANG)

727 V-4-10-I 5,384,400 6,461,300 7,538,200
(RINGAN)
728 V-4-10-II 8,943,800 10,732,600 12,521,400
(SEDANG)
729 V-4-10-III 14,745,200 17,694,300 20,643,300
(BERAT)
730 V-4-11-I 5,169,400 6,203,300 7,237,200
TUMOR (RINGAN)
731 V-4-11-II 6,936,000 8,323,200 9,710,400
TUMOR (SEDANG)
732 V-4-11-III 9,290,900 11,149,100 13,007,200
TUMOR (BERAT)
- 210 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 14,090,000 16,908,000 19,726,000
734 W-1-01-II 16,887,900 20,265,400 23,643,000
735 W-1-01-III 24,098,500 28,918,200 33,737,900
739 W-1-11-I 3,123,800 3,748,600 4,373,400
SERVIK (RINGAN)
740 W-1-11-II 3,447,200 4,136,600 4,826,000
SERVIK (SEDANG)
741 W-1-11-III 3,813,200 4,575,900 5,338,500
SERVIK (BERAT)
760 W-4-12-I 2,986,500 3,583,800 4,181,100
761 W-4-12-II 5,683,400 6,820,100 7,956,800
762 W-4-12-III 8,363,600 10,036,300 11,709,000
- 211 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 2,111,300 2,533,600 2,955,900
785 Z-4-12-II 4,239,300 5,087,200 5,935,000
786 Z-4-12-III 8,943,900 10,732,700 12,521,400
- 212 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,257,700

33 F-3-10-0 TERAPI SHOCK 639,400
- 213 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 3,886,800
PENGGANTIAN ALAT
81 I-2-42-0 3,734,900
PERKUTAN LAIN
- 214 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,761,300
192 Q-5-12-0 GIGI 320,000
196 Q-5-16-0 VAKSINASI 106,600
201 Q-5-21-0 ABORSI 279,300
206 Q-5-26-0 BRONKIAL AKUT 227,000
- 215 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 152,800
215 Q-5-35-0 INFEKSI AKUT 653,100
218 Q-5-38-0 PARU AKUT 380,600
234 U-2-23-0 RHINOPLASTY 1,880,300
242 U-3-13-0 484,700
TENGGOROKAN
270 Z-3-11-0 2,629,400
EMPEDU
- 216 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,385,500
289 Z-3-30-0 FOTOTERAPI 88,100
- 217 -


REGIONAL 2
RAWAT INAP

13 A-4-14-I 2,409,600 2,891,500 3,373,500
(RINGAN)
14 A-4-14-II 4,054,300 4,865,100 5,676,000
(SEDANG)
15 A-4-14-III 4,865,100 5,838,200 6,811,200
(BERAT)

31 B-1-13-I 7,841,700 9,410,000 10,978,400
LAIN (RINGAN)
32 B-1-13-II 12,902,500 15,483,000 18,063,500
LAIN (SEDANG)
33 B-1-13-III 16,694,700 20,033,700 23,372,600
LAIN (BERAT)
34 B-1-14-I 20,545,100 24,654,100 28,763,200
(RINGAN)
35 B-1-14-II 21,578,200 25,893,800 30,209,400
(SEDANG)
40 B-4-11-I 7,028,700 8,434,500 9,840,200
(RINGAN)
41 B-4-11-II 9,840,300 11,808,400 13,776,400
(SEDANG)
42 B-4-11-III 11,921,400 14,305,700 16,690,000
(BERAT)
- 218 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 7,445,900 8,935,000 10,424,200
74 D-1-20-II 20,519,700 24,623,600 28,727,600
75 D-1-20-III 32,550,200 39,060,300 45,570,300
85 D-4-13-I 4,306,700 5,168,100 6,029,400
86 D-4-13-II 6,095,500 7,314,600 8,533,600
87 D-4-13-III 7,796,300 9,355,500 10,914,800
88 D-4-14-I 4,619,100 5,543,000 6,466,800
89 D-4-14-II 7,562,700 9,075,200 10,587,800
90 D-4-14-III 9,250,000 11,099,900 12,949,900
91 E-1-01-I 9,207,700 11,049,300 12,890,800
(RINGAN)
92 E-1-01-II 12,569,900 15,083,900 17,597,900
(SEDANG)

97 E-1-20-I 10,837,400 13,004,900 15,172,400
TIROGLOSAL (RINGAN)
- 219 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 14,586,900 17,504,300 20,421,600
TIROGLOSAL (SEDANG)
99 E-1-20-III 20,103,700 24,124,500 28,145,200
TIROGLOSAL (BERAT)
100 E-4-10-I 3,835,300 4,602,400 5,369,500
METABOLIK (RINGAN)
101 E-4-10-II 7,428,400 8,914,100 10,399,700
METABOLIK (SEDANG)
102 E-4-10-III 12,447,100 14,936,600 17,426,000
METABOLIK (BERAT)
109 E-4-13-I 5,330,600 6,396,700 7,462,900
(RINGAN)
110 E-4-13-II 7,808,400 9,370,100 10,931,800
(SEDANG)

118 F-4-12-I 3,008,700 3,610,500 4,212,200
(RINGAN)
119 F-4-12-II 4,277,500 5,133,000 5,988,500
(SEDANG)
120 F-4-12-III 9,292,600 11,151,100 13,009,600
(BERAT)
130 F-4-16-I 7,904,400 9,485,300 11,066,100
131 F-4-16-II 9,190,100 11,028,200 12,866,200
132 F-4-16-III 12,267,300 14,720,700 17,174,200
142 G-1-01-I 22,266,800 26,720,200 31,173,600
(RINGAN)
- 220 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 31,936,000 38,323,200 44,710,400
(SEDANG)
144 G-1-01-III 52,250,000 62,700,000 73,150,000
(BERAT)
151 G-1-12-I 7,115,100 8,538,200 9,961,200
(RINGAN)
152 G-1-12-II 13,337,700 16,005,200 18,672,700
(SEDANG)
153 G-1-12-III 18,176,600 21,811,900 25,447,300
(BERAT)
163 G-4-10-I 6,107,600 7,329,100 8,550,600
(RINGAN)
164 G-4-10-II 7,465,500 8,958,600 10,451,700
(SEDANG)
165 G-4-10-III 10,244,000 12,292,800 14,341,600
(BERAT)
166 G-4-11-I 6,393,700 7,672,400 8,951,100
167 G-4-11-II 8,493,200 10,191,800 11,890,500
168 G-4-11-III 12,479,400 14,975,200 17,471,100
DEGENERATIF (BERAT)
169 G-4-12-I 7,093,000 8,511,600 9,930,300
(RINGAN)
170 G-4-12-II 8,959,000 10,750,800 12,542,600
(SEDANG)

172 G-4-13-I 4,260,900 5,113,100 5,965,200
(RINGAN)
173 G-4-13-II 7,430,100 8,916,200 10,402,200
(SEDANG)
174 G-4-13-III 8,812,300 10,574,800 12,337,200
(BERAT)
175 G-4-14-I 7,228,100 8,673,700 10,119,300
INFARK (RINGAN)
176 G-4-14-II 9,663,400 11,596,100 13,528,800
INFARK (SEDANG)
177 G-4-14-III 12,128,700 14,554,500 16,980,200
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 221 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 6,484,800 7,781,700 9,078,700
(RINGAN)
185 G-4-17-II 8,502,900 10,203,500 11,904,100
(SEDANG)
186 G-4-17-III 10,684,300 12,821,200 14,958,100
(BERAT)
190 G-4-19-I 5,328,400 6,394,100 7,459,700
191 G-4-19-II 9,006,300 10,807,500 12,608,800
192 G-4-19-III 11,824,800 14,189,800 16,554,700
211 G-4-26-I 4,146,200 4,975,400 5,804,600
LAIN (RINGAN)
212 G-4-26-II 4,823,300 5,787,900 6,752,600
LAIN (SEDANG)
213 G-4-26-III 7,212,300 8,654,700 10,097,200
LAIN (BERAT)
232 I-1-02-I 37,331,100 44,797,300 52,263,500
(RINGAN)
- 222 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 48,156,600 57,788,000 67,419,300
(SEDANG)
234 I-1-02-III 59,356,100 71,227,300 83,098,500
(BERAT)
235 I-1-03-I 35,207,200 42,248,700 49,290,100
ANOMALI (RINGAN)
236 I-1-03-II 48,804,500 58,565,400 68,326,300
ANOMALI (SEDANG)
237 I-1-03-III 61,936,700 74,324,000 86,711,400
ANOMALI (BERAT)
238 I-1-04-I 53,055,400 63,666,500 74,277,500
JANTUNG (RINGAN)
239 I-1-04-II 83,735,700 100,482,900 117,230,000
JANTUNG (SEDANG)
240 I-1-04-III 133,767,300 160,520,700 187,274,200
JANTUNG (BERAT)
241 I-1-05-I 87,884,800 105,461,800 123,038,800
242 I-1-05-II 107,414,800 128,897,700 150,380,700
243 I-1-05-III 146,474,700 175,769,700 205,064,600
247 I-1-07-I 78,119,800 93,743,800 109,367,800
JANTUNG (RINGAN)
248 I-1-07-II 97,649,800 117,179,800 136,709,700
JANTUNG (SEDANG)
249 I-1-07-III 146,474,700 175,769,700 205,064,600
JANTUNG (BERAT)
250 I-1-11-I 5,849,900 7,019,900 8,189,900
251 I-1-11-II 6,504,500 7,805,400 9,106,300
252 I-1-11-III 8,655,500 10,386,600 12,117,700
253 I-1-12-I 16,838,800 20,206,600 23,574,300
(RINGAN)
254 I-1-12-II 27,501,200 33,001,400 38,501,600
(SEDANG)
255 I-1-12-III 36,181,900 43,418,300 50,654,700
(BERAT)
256 I-1-13-I 16,333,400 19,600,100 22,866,800
KOMPLEK (RINGAN)
257 I-1-13-II 21,751,300 26,101,500 30,451,800
KOMPLEK (SEDANG)
258 I-1-13-III 26,825,300 32,190,400 37,555,500
KOMPLEK (BERAT)
259 I-1-14-I 33,430,500 40,116,600 46,802,700
(RINGAN)
260 I-1-14-II 41,549,200 49,859,000 58,168,900
(SEDANG)
261 I-1-14-III 54,443,800 65,332,500 76,221,300
(BERAT)
265 I-1-16-I 16,463,700 19,756,400 23,049,100
266 I-1-16-II 37,250,600 44,700,800 52,150,900
267 I-1-16-III 42,968,000 51,561,600 60,155,200
268 I-1-17-I 19,063,400 22,876,000 26,688,700
(RINGAN)
269 I-1-17-II 23,869,100 28,642,900 33,416,800
(SEDANG)
- 223 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 29,525,700 35,430,900 41,336,000
(BERAT)
271 I-1-20-I 21,487,700 25,785,200 30,082,700
(RINGAN)
272 I-1-20-II 26,844,000 32,212,800 37,581,600
(SEDANG)
273 I-1-20-III 28,218,600 33,862,300 39,506,000
(BERAT)
274 I-1-30-I 16,254,200 19,505,100 22,755,900
JANTUNG (RINGAN)
275 I-1-30-II 33,812,400 40,574,900 47,337,300
JANTUNG (SEDANG)
276 I-1-30-III 52,397,000 62,876,400 73,355,800
JANTUNG (BERAT)

289 I-4-13-I 5,089,000 6,106,800 7,124,600
(RINGAN)
290 I-4-13-II 9,087,000 10,904,400 12,721,800
(SEDANG)
291 I-4-13-III 13,093,100 15,711,700 18,330,400
(BERAT)
295 I-4-15-I 4,907,900 5,889,500 6,871,100
(RINGAN)
296 I-4-15-II 9,254,900 11,105,900 12,956,900
(SEDANG)

304 I-4-18-I 5,850,500 7,020,600 8,190,700
JANTUNG (RINGAN)
305 I-4-18-II 8,907,600 10,689,200 12,470,700
JANTUNG (SEDANG)
306 I-4-18-III 12,093,600 14,512,300 16,931,000
JANTUNG (BERAT)

308 I-4-19-II 8,811,500 10,573,800 12,336,100
(SEDANG)
- 224 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 4,824,700 5,789,700 6,754,600
320 I-4-23-II 5,923,400 7,108,100 8,292,700
321 I-4-23-III 11,574,000 13,888,700 16,203,500
322 I-4-24-I 3,134,500 3,761,400 4,388,200
(RINGAN)
323 I-4-24-II 7,217,800 8,661,400 10,105,000
(SEDANG)
324 I-4-24-III 9,125,700 10,950,800 12,775,900
(BERAT)
325 J-1-01-I 99,313,800 119,176,600 139,039,300
326 J-1-01-II 112,392,100 134,870,500 157,348,900
327 J-1-01-III 154,165,100 184,998,100 215,831,100
TRAKEOSTOMI (BERAT)
328 J-1-02-I 64,790,200 77,748,300 90,706,300
329 J-1-02-II 81,752,700 98,103,200 114,453,800
330 J-1-02-III 95,639,100 114,766,900 133,894,700
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,631,100 15,157,300 17,683,600
(RINGAN)
332 J-1-10-II 25,559,100 30,671,000 35,782,800
(SEDANG)
333 J-1-10-III 26,562,300 31,874,700 37,187,200
(BERAT)
334 J-1-20-I 34,796,500 41,755,800 48,715,100
(RINGAN)
335 J-1-20-II 36,436,600 43,723,900 51,011,200
(SEDANG)
336 J-1-20-III 41,004,600 49,205,600 57,406,500
(BERAT)
337 J-1-30-I 10,541,000 12,649,200 14,757,400
(RINGAN)
338 J-1-30-II 19,094,900 22,913,900 26,732,900
(SEDANG)

- 225 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 3,064,200 3,677,100 4,289,900
374 J-4-21-II 6,842,400 8,210,900 9,579,400
375 J-4-21-III 12,889,800 15,467,800 18,045,800
376 K-1-10-I 11,450,900 13,741,100 16,031,200
BESAR (RINGAN)
377 K-1-10-II 14,390,500 17,268,600 20,146,700
BESAR (SEDANG)
378 K-1-10-III 16,866,100 20,239,400 23,612,600
BESAR (BERAT)
382 K-1-12-I 4,804,600 5,765,500 6,726,500
FEMORAL (RINGAN)
383 K-1-12-II 6,249,000 7,498,800 8,748,600
FEMORAL (SEDANG)
384 K-1-12-III 12,380,200 14,856,200 17,332,200
FEMORAL (BERAT)
388 K-1-14-I 7,914,200 9,497,000 11,079,800
(RINGAN)
389 K-1-14-II 9,275,200 11,130,300 12,985,300
(SEDANG)

394 K-1-30-I 10,069,700 12,083,600 14,097,600
395 K-1-30-II 17,883,500 21,460,200 25,036,900
396 K-1-30-III 24,608,000 29,529,600 34,451,200

398 K-1-40-II 12,387,500 14,864,900 17,342,400
(SEDANG)

- 226 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 5,743,300 6,892,000 8,040,600
413 K-4-13-II 7,429,300 8,915,200 10,401,100
414 K-4-13-III 11,443,500 13,732,200 16,021,000
415 K-4-14-I 3,277,200 3,932,600 4,588,000
(RINGAN)
416 K-4-14-II 4,399,000 5,278,800 6,158,600
(SEDANG)
417 K-4-14-III 7,058,700 8,470,400 9,882,200
(BERAT)

424 K-4-17-I 2,075,000 2,490,100 2,905,100
(RINGAN)
425 K-4-17-II 2,555,400 3,066,500 3,577,600
(SEDANG)
426 K-4-17-III 3,066,500 3,679,800 4,293,100
(BERAT)
427 K-4-18-I 1,828,600 2,194,300 2,560,100
(RINGAN)
428 K-4-18-II 3,085,800 3,702,900 4,320,100
(SEDANG)
436 L-1-40-I 7,178,100 8,613,800 10,049,400
(RINGAN)
437 L-1-40-II 14,397,800 17,277,300 20,156,900
(SEDANG)
438 L-1-40-III 24,234,600 29,081,600 33,928,500
(BERAT)
451 L-4-13-I 2,610,100 3,132,200 3,654,200
PAYUDARA (RINGAN)
- 227 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 4,252,100 5,102,500 5,952,900
PAYUDARA (SEDANG)
453 L-4-13-III 8,446,900 10,136,300 11,825,700
PAYUDARA (BERAT)
454 L-4-14-I 4,244,800 5,093,700 5,942,700
(RINGAN)
455 L-4-14-II 6,375,800 7,651,000 8,926,100
(SEDANG)
456 L-4-14-III 8,987,500 10,784,900 12,582,400
(BERAT)
457 M-1-01-I 15,004,900 18,005,800 21,006,800
458 M-1-01-II 21,327,300 25,592,800 29,858,200
459 M-1-01-III 29,958,500 35,950,200 41,941,900
463 M-1-03-I 53,160,900 63,793,100 74,425,300
464 M-1-03-II 62,179,500 74,615,400 87,051,300
465 M-1-03-III 76,957,500 92,349,000 107,740,500
472 M-1-07-I 19,349,700 23,219,600 27,089,600
473 M-1-07-II 25,921,900 31,106,300 36,290,700
474 M-1-07-III 52,805,400 63,366,500 73,927,500
475 M-1-10-I 22,866,200 27,439,500 32,012,700
WAJAH (RINGAN)
476 M-1-10-II 54,672,100 65,606,600 76,541,000
WAJAH (SEDANG)
477 M-1-10-III 117,922,700 141,507,300 165,091,800
WAJAH (BERAT)
478 M-1-20-I 17,818,300 21,382,000 24,945,700
(RINGAN)
479 M-1-20-II 22,764,800 27,317,700 31,870,700
(SEDANG)

484 M-1-40-I 7,466,900 8,960,300 10,453,600
INTERNAL (RINGAN)
485 M-1-40-II 11,035,200 13,242,200 15,449,200
INTERNAL (SEDANG)
486 M-1-40-III 15,756,100 18,907,300 22,058,500
INTERNAL (BERAT)
490 M-1-60-I 11,516,100 13,819,300 16,122,500
491 M-1-60-II 14,478,400 17,374,100 20,269,800
492 M-1-60-III 21,871,400 26,245,600 30,619,900
- 228 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 21,335,700 25,602,800 29,869,900
KAKI (RINGAN)
494 M-1-70-II 23,469,200 28,163,100 32,856,900
KAKI (SEDANG)
495 M-1-70-III 26,869,200 32,243,000 37,616,800
KAKI (BERAT)
502 M-4-11-I 5,323,800 6,388,600 7,453,300
(RINGAN)
503 M-4-11-II 11,672,200 14,006,700 16,341,100
(SEDANG)
504 M-4-11-III 16,876,000 20,251,200 23,626,400
(BERAT)
505 M-4-12-I 4,249,600 5,099,500 5,949,400
(RINGAN)
506 M-4-12-II 7,068,200 8,481,900 9,895,500
(SEDANG)
507 M-4-12-III 9,454,500 11,345,400 13,236,300
(BERAT)
508 M-4-13-I 7,076,000 8,491,200 9,906,400
509 M-4-13-II 10,631,400 12,757,700 14,883,900
510 M-4-13-III 20,741,600 24,889,900 29,038,200
520 M-4-17-I 4,785,500 5,742,600 6,699,700
(RINGAN)
521 M-4-17-II 6,693,100 8,031,700 9,370,300
(SEDANG)
522 M-4-17-III 9,346,400 11,215,700 13,085,000
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,805,000 4,565,900 5,326,900
(RINGAN)
530 M-4-20-II 5,571,700 6,686,100 7,800,400
(SEDANG)
531 M-4-20-III 6,227,100 7,472,500 8,717,900
(BERAT)
532 M-4-21-I 3,831,300 4,597,600 5,363,800
533 M-4-21-II 4,791,800 5,750,200 6,708,600
- 229 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 10,743,200 12,891,900 15,040,500
541 N-1-12-I 6,258,300 7,510,000 8,761,600
542 N-1-12-II 12,459,600 14,951,600 17,443,500
543 N-1-12-III 27,037,800 32,445,400 37,853,000
547 N-1-30-I 12,522,400 15,026,900 17,531,400
BAWAH (RINGAN)
548 N-1-30-II 18,943,900 22,732,700 26,521,500
BAWAH (SEDANG)
549 N-1-30-III 21,802,600 26,163,200 30,523,700
BAWAH (BERAT)
550 N-1-40-I 11,246,000 13,495,200 15,744,400
(RINGAN)
551 N-1-40-II 15,271,800 18,326,200 21,380,500
(SEDANG)
552 N-1-40-III 17,774,400 21,329,300 24,884,100
(BERAT)
553 N-4-10-I 4,778,000 5,733,600 6,689,200
(RINGAN)
554 N-4-10-II 5,779,100 6,934,900 8,090,700
(SEDANG)
555 N-4-10-III 8,500,100 10,200,200 11,900,200
(BERAT)
568 N-4-15-I 4,351,900 5,222,300 6,092,600
URIN (RINGAN)
569 N-4-15-II 5,399,900 6,479,900 7,559,900
URIN (SEDANG)
570 N-4-15-III 6,162,200 7,394,700 8,627,100
URIN (BERAT)
571 N-4-16-I 5,328,900 6,394,600 7,460,400
(RINGAN)
572 N-4-16-II 7,606,000 9,127,200 10,648,400
(SEDANG)
573 N-4-16-III 10,124,100 12,148,900 14,173,800
(BERAT)
- 230 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 4,953,400 5,944,100 6,934,800
578 O-6-11-II 5,505,200 6,606,200 7,707,200
579 O-6-11-III 6,848,500 8,218,200 9,587,900
580 O-6-12-I 3,509,400 4,211,300 4,913,200
581 O-6-12-II 4,214,800 5,057,800 5,900,700
582 O-6-12-III 5,296,100 6,355,300 7,414,500
586 P-8-01-I 78,366,200 94,039,400 109,712,600
587 P-8-01-II 96,966,400 116,359,700 135,752,900
588 P-8-01-III 113,811,300 136,573,500 159,335,800
589 P-8-02-I 106,966,100 128,359,400 149,752,600
590 P-8-02-II 122,700,900 147,241,100 171,781,200
591 P-8-02-III 140,194,500 168,233,400 196,272,200
592 P-8-03-I 16,044,800 19,253,800 22,462,700
593 P-8-03-II 21,237,500 25,485,000 29,732,500
594 P-8-03-III 29,860,900 35,833,100 41,805,200
595 P-8-04-I 51,705,100 62,046,100 72,387,100
596 P-8-04-II 67,102,000 80,522,400 93,942,800
597 P-8-04-III 96,207,500 115,448,900 134,690,400
598 P-8-05-I 28,115,600 33,738,700 39,361,800
599 P-8-05-II 43,373,200 52,047,800 60,722,400
600 P-8-05-III 58,713,600 70,456,300 82,199,000
601 P-8-06-I 7,590,300 9,108,400 10,626,400
602 P-8-06-II 21,281,500 25,537,800 29,794,100
603 P-8-06-III 28,192,700 33,831,300 39,469,800
604 P-8-07-I 8,985,800 10,782,900 12,580,100
605 P-8-07-II 25,194,000 30,232,800 35,271,600
606 P-8-07-III 33,375,900 40,051,000 46,726,200
607 P-8-08-I 5,199,300 6,239,100 7,279,000
608 P-8-08-II 7,377,500 8,853,000 10,328,500
609 P-8-08-III 14,352,200 17,222,600 20,093,000
610 P-8-11-I 13,370,700 16,044,800 18,718,900
MAYOR (RINGAN)
611 P-8-11-II 17,697,900 21,237,500 24,777,100
MAYOR (SEDANG)
- 231 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 24,884,100 29,860,900 34,837,700
MAYOR (BERAT)
613 P-8-12-I 12,155,200 14,586,200 17,017,200
MAYOR (RINGAN)
614 P-8-12-II 14,748,300 17,697,900 20,647,600
MAYOR (SEDANG)
615 P-8-12-III 21,638,300 25,966,000 30,293,700
MAYOR (BERAT)
616 P-8-13-I 6,752,900 8,103,400 9,454,000
MAYOR (RINGAN)
617 P-8-13-II 10,534,500 12,641,400 14,748,300
MAYOR (SEDANG)
618 P-8-13-III 16,644,900 19,973,800 23,302,800
MAYOR (BERAT)
619 P-8-14-I 5,111,400 6,133,700 7,156,000
620 P-8-14-II 10,404,800 12,485,700 14,566,700
621 P-8-14-III 40,683,500 48,820,200 56,956,800
622 P-8-15-I 3,833,600 4,600,300 5,367,100
ASPIRASI (RINGAN)
623 P-8-15-II 7,677,000 9,212,400 10,747,800
ASPIRASI (SEDANG)
624 P-8-15-III 9,007,600 10,809,100 12,610,600
ASPIRASI (BERAT)
625 P-8-16-I 3,469,500 4,163,400 4,857,300
626 P-8-16-II 6,667,100 8,000,600 9,334,000
627 P-8-16-III 15,635,500 18,762,600 21,889,800
628 P-8-17-I 4,501,900 5,402,300 6,302,700
(RINGAN)
629 P-8-17-II 8,103,400 9,724,100 11,344,800
(SEDANG)
630 P-8-17-III 13,870,700 16,644,900 19,419,000
(BERAT)
631 S-4-10-I 3,911,800 4,694,100 5,476,500
632 S-4-10-II 4,819,900 5,783,900 6,747,900
633 S-4-10-III 6,598,000 7,917,500 9,237,100
640 S-4-13-I 4,247,000 5,096,400 5,945,800
(RINGAN)
641 S-4-13-II 7,534,500 9,041,400 10,548,300
(SEDANG)
642 S-4-13-III 12,229,500 14,675,400 17,121,200
(BERAT)
643 S-4-14-I 2,149,300 2,579,100 3,009,000
644 S-4-14-II 4,565,300 5,478,300 6,391,400
645 S-4-14-III 8,657,300 10,388,800 12,120,200
KANAK-KANAK (BERAT)
646 S-4-15-I 1,437,500 1,725,000 2,012,400
647 S-4-15-II 2,712,700 3,255,300 3,797,800
648 S-4-15-III 3,513,400 4,216,100 4,918,800
- 232 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 3,587,600 4,305,100 5,022,600
653 S-4-17-II 5,324,400 6,389,300 7,454,100
654 S-4-17-III 6,403,800 7,684,500 8,965,300
655 T-1-10-I 2,400,400 2,880,500 3,360,500
OBAT (RINGAN)
656 T-1-10-II 3,224,000 3,868,800 4,513,600
OBAT (SEDANG)
657 T-1-10-III 5,865,000 7,038,000 8,211,000
OBAT (BERAT)
658 T-4-10-I 1,314,300 1,577,200 1,840,100
659 T-4-10-II 2,504,500 3,005,400 3,506,300
660 T-4-10-III 3,640,400 4,368,400 5,096,500
661 T-4-11-I 1,269,400 1,523,200 1,777,100
662 T-4-11-II 1,997,600 2,397,100 2,796,700
663 T-4-11-III 3,217,600 3,861,100 4,504,600
664 T-4-12-I 2,974,200 3,569,000 4,163,900
LAIN (RINGAN)
665 T-4-12-II 4,489,800 5,387,800 6,285,800
LAIN (SEDANG)
666 T-4-12-III 6,949,600 8,339,500 9,729,400
LAIN (BERAT)
670 U-1-11-I 12,379,300 14,855,100 17,331,000
(RINGAN)
671 U-1-11-II 18,671,800 22,406,200 26,140,600
(SEDANG)
672 U-1-11-III 22,134,200 26,561,000 30,987,900
(BERAT)
679 U-1-14-I 5,702,200 6,842,600 7,983,000
(RINGAN)
680 U-1-14-II 6,997,900 8,397,500 9,797,100
(SEDANG)
681 U-1-14-III 8,292,500 9,951,100 11,609,600
(BERAT)
685 U-1-20-I 8,656,800 10,388,200 12,119,500
686 U-1-20-II 12,883,700 15,460,500 18,037,200
687 U-1-20-III 33,075,000 39,690,000 46,305,000
691 U-4-10-I 5,342,700 6,411,300 7,479,800
- 233 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 12,231,100 14,677,400 17,123,600
693 U-4-10-III 18,778,500 22,534,200 26,290,000
TENGGOROKAN (BERAT)
700 U-4-13-I 2,103,100 2,523,700 2,944,400
701 U-4-13-II 3,436,700 4,124,000 4,811,300
702 U-4-13-III 5,549,100 6,658,900 7,768,700
706 U-4-15-I 4,270,000 5,124,100 5,978,100
707 U-4-15-II 5,319,900 6,383,900 7,447,900
708 U-4-15-III 7,445,300 8,934,400 10,423,400
709 V-1-10-I 6,964,800 8,357,800 9,750,700
(RINGAN)
710 V-1-10-II 14,347,200 17,216,700 20,086,100
(SEDANG)
711 V-1-10-III 17,594,900 21,113,800 24,632,800
(BERAT)
715 V-1-12-I 12,457,700 14,949,300 17,440,800
MODERAT (RINGAN)
716 V-1-12-II 17,012,100 20,414,500 23,816,900
MODERAT (SEDANG)
717 V-1-12-III 21,563,000 25,875,600 30,188,200
MODERAT (BERAT)
718 V-1-13-I 6,498,100 7,797,700 9,097,400
KOMPLEK (RINGAN)
719 V-1-13-II 12,415,800 14,898,900 17,382,100
KOMPLEK (SEDANG)
720 V-1-13-III 19,478,800 23,374,600 27,270,400
KOMPLEK (BERAT)
721 V-1-14-I 12,742,800 15,291,300 17,839,900
(RINGAN)
722 V-1-14-II 18,514,900 22,217,900 25,920,800
(SEDANG)

727 V-4-10-I 5,546,000 6,655,200 7,764,400
(RINGAN)
728 V-4-10-II 9,212,100 11,054,600 12,897,000
(SEDANG)
729 V-4-10-III 15,187,600 18,225,100 21,262,600
(BERAT)
730 V-4-11-I 5,324,500 6,389,400 7,454,300
TUMOR (RINGAN)
731 V-4-11-II 7,144,100 8,572,900 10,001,800
TUMOR (SEDANG)
732 V-4-11-III 9,569,600 11,483,500 13,397,500
TUMOR (BERAT)
- 234 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 14,512,700 17,415,300 20,317,800
734 W-1-01-II 17,394,500 20,873,400 24,352,300
735 W-1-01-III 24,821,500 29,785,800 34,750,100
739 W-1-11-I 3,217,600 3,861,100 4,504,600
SERVIK (RINGAN)
740 W-1-11-II 3,550,600 4,260,700 4,970,800
SERVIK (SEDANG)
741 W-1-11-III 3,927,600 4,713,200 5,498,700
SERVIK (BERAT)
760 W-4-12-I 3,076,100 3,691,300 4,306,600
761 W-4-12-II 5,853,900 7,024,700 8,195,500
762 W-4-12-III 8,614,500 10,337,400 12,060,300
- 235 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 2,174,700 2,609,600 3,044,500
785 Z-4-12-II 4,366,500 5,239,800 6,113,100
786 Z-4-12-III 9,212,200 11,054,600 12,897,100
- 236 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,370,600

33 F-3-10-0 TERAPI SHOCK 671,400
- 237 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 4,081,100
PENGGANTIAN ALAT
81 I-2-42-0 3,921,700
PERKUTAN LAIN
- 238 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,849,400
192 Q-5-12-0 GIGI 336,000
196 Q-5-16-0 VAKSINASI 111,900
201 Q-5-21-0 ABORSI 293,200
206 Q-5-26-0 BRONKIAL AKUT 238,300
- 239 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 160,400
215 Q-5-35-0 INFEKSI AKUT 685,800
218 Q-5-38-0 PARU AKUT 399,600
234 U-2-23-0 RHINOPLASTY 1,974,300
242 U-3-13-0 508,900
TENGGOROKAN
270 Z-3-11-0 2,760,900
EMPEDU
- 240 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,454,800
289 Z-3-30-0 FOTOTERAPI 92,500
- 241 -


REGIONAL 2
RAWAT INAP

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)

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)
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)
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)
- 242 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 5,058,900 6,070,700 7,082,400
74 D-1-20-II 13,941,500 16,729,800 19,518,100
75 D-1-20-III 22,115,300 26,538,400 30,961,500
85 D-4-13-I 2,926,100 3,511,300 4,096,500
86 D-4-13-II 4,141,400 4,969,700 5,797,900
87 D-4-13-III 5,297,000 6,356,400 7,415,700
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
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)

97 E-1-20-I 7,363,200 8,835,800 10,308,500
TIROGLOSAL (RINGAN)
- 243 -

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)
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)
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)

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)
130 F-4-16-I 5,536,500 6,643,800 7,751,100
131 F-4-16-II 6,437,100 7,724,500 9,011,900
132 F-4-16-III 8,592,400 10,310,900 12,029,400
142 G-1-01-I 16,641,400 19,969,700 23,298,000
(RINGAN)
- 244 -

REGIONAL 2
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)
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)
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)
166 G-4-11-I 4,478,300 5,374,000 6,269,700
167 G-4-11-II 5,948,900 7,138,700 8,328,500
168 G-4-11-III 8,741,000 10,489,200 12,237,400
DEGENERATIF (BERAT)
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)

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)
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)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 245 -

REGIONAL 2
RAWAT INAP

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)
190 G-4-19-I 3,620,200 4,344,300 5,068,300
191 G-4-19-II 6,119,000 7,342,900 8,566,700
192 G-4-19-III 8,034,000 9,640,800 11,247,600
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)
232 I-1-02-I 25,363,500 30,436,200 35,508,900
(RINGAN)
- 246 -

REGIONAL 2
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)
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)
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)
241 I-1-05-I 53,521,600 64,225,900 74,930,200
242 I-1-05-II 65,415,300 78,498,300 91,581,400
243 I-1-05-III 89,202,600 107,043,200 124,883,700
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)
250 I-1-11-I 4,097,500 4,917,000 5,736,500
251 I-1-11-II 4,556,000 5,467,200 6,378,400
252 I-1-11-III 6,062,600 7,275,100 8,487,700
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)
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)
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)
265 I-1-16-I 11,185,800 13,422,900 15,660,100
266 I-1-16-II 26,091,600 31,309,900 36,528,300
267 I-1-16-III 30,096,300 36,115,500 42,134,800
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)
- 247 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 20,680,800 24,817,000 28,953,100
(BERAT)
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)
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)

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)
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)

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)

308 I-4-19-II 5,986,700 7,184,100 8,381,400
(SEDANG)
- 248 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 3,278,000 3,933,600 4,589,200
320 I-4-23-II 4,024,500 4,829,400 5,634,300
321 I-4-23-III 7,863,600 9,436,300 11,009,000
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)
325 J-1-01-I 53,254,300 63,905,200 74,556,100
326 J-1-01-II 60,267,200 72,320,600 84,374,100
327 J-1-01-III 68,181,100 81,817,400 95,453,600
TRAKEOSTOMI (BERAT)
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)
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)
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)
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)

- 249 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,741,500 3,289,700 3,838,000
374 J-4-21-II 4,416,400 5,299,700 6,183,000
375 J-4-21-III 6,162,800 7,395,300 8,627,900
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)
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)
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)

394 K-1-30-I 7,053,100 8,463,800 9,874,400
395 K-1-30-II 12,150,400 14,580,500 17,010,600
396 K-1-30-III 17,236,300 20,683,500 24,130,800

398 K-1-40-II 8,676,600 10,411,900 12,147,200
(SEDANG)

- 250 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 3,902,100 4,682,500 5,463,000
413 K-4-13-II 5,047,600 6,057,200 7,066,700
414 K-4-13-III 7,775,000 9,330,000 10,885,000
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)

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)
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)
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)
451 L-4-13-I 2,335,200 2,802,200 3,269,300
PAYUDARA (RINGAN)
- 251 -

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)
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)
457 M-1-01-I 10,194,600 12,233,500 14,272,500
458 M-1-01-II 14,490,200 17,388,300 20,286,300
459 M-1-01-III 20,354,400 24,425,300 28,496,200
463 M-1-03-I 22,804,900 27,365,900 31,926,800
464 M-1-03-II 26,673,600 32,008,400 37,343,100
465 M-1-03-III 33,013,100 39,615,700 46,218,300
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
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)
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)

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)
490 M-1-60-I 7,824,300 9,389,100 10,954,000
491 M-1-60-II 9,836,900 11,804,300 13,771,700
492 M-1-60-III 15,319,500 18,383,300 21,447,200
- 252 -

REGIONAL 2
RAWAT INAP

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)
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)
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)
508 M-4-13-I 4,807,600 5,769,100 6,730,600
509 M-4-13-II 7,223,200 8,667,800 10,112,500
510 M-4-13-III 14,092,300 16,910,700 19,729,200
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)
(RINGAN)
(SEDANG)
(BERAT)
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)
532 M-4-21-I 2,892,300 3,470,800 4,049,200
533 M-4-21-II 3,617,400 4,340,900 5,064,400
- 253 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 8,110,200 9,732,200 11,354,300
541 N-1-12-I 4,252,000 5,102,400 5,952,800
542 N-1-12-II 8,727,100 10,472,600 12,218,000
543 N-1-12-III 18,938,200 22,725,900 26,513,500
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)
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)
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)
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)
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)
- 254 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 3,365,500 4,038,600 4,711,700
578 O-6-11-II 3,740,300 4,488,400 5,236,500
579 O-6-11-III 4,796,900 5,756,300 6,715,700
580 O-6-12-I 2,458,100 2,949,800 3,441,400
581 O-6-12-II 2,952,200 3,542,600 4,133,100
582 O-6-12-III 3,709,500 4,451,500 5,193,400
586 P-8-01-I 53,243,600 63,892,400 74,541,100
587 P-8-01-II 65,881,000 79,057,200 92,233,400
588 P-8-01-III 77,325,800 92,790,900 108,256,100
589 P-8-02-I 83,190,400 99,828,500 116,466,600
590 P-8-02-II 95,427,900 114,513,500 133,599,100
591 P-8-02-III 109,033,300 130,840,000 152,646,600
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
608 P-8-08-II 5,868,600 7,042,300 8,216,000
609 P-8-08-III 9,502,500 11,403,000 13,303,500
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)
- 255 -

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)
619 P-8-14-I 3,580,200 4,296,200 5,012,300
620 P-8-14-II 7,287,900 8,745,400 10,203,000
621 P-8-14-III 13,116,100 15,739,300 18,362,500
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)
625 P-8-16-I 2,430,100 2,916,200 3,402,200
626 P-8-16-II 4,669,900 5,603,900 6,537,800
627 P-8-16-III 11,427,800 13,713,400 15,998,900
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)
631 S-4-10-I 2,657,700 3,189,300 3,720,800
632 S-4-10-II 3,274,700 3,929,700 4,584,600
633 S-4-10-III 4,482,800 5,379,300 6,275,900
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)
643 S-4-14-I 1,460,300 1,752,300 2,044,400
644 S-4-14-II 3,101,700 3,722,100 4,342,400
645 S-4-14-III 5,882,000 7,058,400 8,234,700
KANAK-KANAK (BERAT)
646 S-4-15-I 976,600 1,172,000 1,367,300
647 S-4-15-II 1,843,100 2,211,700 2,580,300
648 S-4-15-III 2,387,100 2,864,500 3,342,000
- 256 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 2,437,500 2,925,000 3,412,500
653 S-4-17-II 3,617,500 4,341,000 5,064,500
654 S-4-17-III 4,350,900 5,221,000 6,091,200
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)
658 T-4-10-I 729,300 875,200 1,021,000
659 T-4-10-II 1,389,900 1,667,900 1,945,900
660 T-4-10-III 2,020,600 2,424,700 2,828,900
661 T-4-11-I 995,400 1,194,400 1,393,500
662 T-4-11-II 1,566,400 1,879,700 2,192,900
663 T-4-11-III 2,523,000 3,027,600 3,532,200
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)
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)
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)
685 U-1-20-I 6,063,500 7,276,200 8,488,900
686 U-1-20-II 9,024,200 10,829,000 12,633,900
687 U-1-20-III 22,471,800 26,966,200 31,460,600
691 U-4-10-I 3,742,200 4,490,700 5,239,100
- 257 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 8,310,100 9,972,100 11,634,100
693 U-4-10-III 12,758,500 15,310,200 17,861,900
TENGGOROKAN (BERAT)
700 U-4-13-I 1,939,800 2,327,700 2,715,700
701 U-4-13-II 2,286,800 2,744,200 3,201,500
702 U-4-13-III 2,735,100 3,282,200 3,829,200
706 U-4-15-I 2,901,200 3,481,400 4,061,600
707 U-4-15-II 3,614,500 4,337,400 5,060,300
708 U-4-15-III 5,058,500 6,070,200 7,081,900
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)
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)
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)
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)

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)
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)
- 258 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 10,165,200 12,198,200 14,231,300
734 W-1-01-II 11,818,200 14,181,800 16,545,500
735 W-1-01-III 17,385,800 20,863,000 24,340,100
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)
760 W-4-12-I 2,752,100 3,302,500 3,852,900
761 W-4-12-II 3,778,400 4,534,100 5,289,800
762 W-4-12-III 4,118,700 4,942,400 5,766,100
- 259 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 1,838,400 2,206,100 2,573,800
785 Z-4-12-II 3,857,700 4,629,300 5,400,800
786 Z-4-12-III 5,938,400 7,126,000 8,313,700
- 260 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,486,800

33 F-3-10-0 TERAPI SHOCK 421,100
- 261 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,559,600
PENGGANTIAN ALAT
81 I-2-42-0 2,459,600
PERKUTAN LAIN
- 262 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,221,000
192 Q-5-12-0 GIGI 210,700
196 Q-5-16-0 VAKSINASI 98,600
201 Q-5-21-0 ABORSI 183,900
206 Q-5-26-0 BRONKIAL AKUT 209,900
- 263 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 141,300
215 Q-5-35-0 INFEKSI AKUT 430,100
218 Q-5-38-0 PARU AKUT 250,600
234 U-2-23-0 RHINOPLASTY 1,238,300
242 U-3-13-0 319,200
TENGGOROKAN
270 Z-3-11-0 1,731,600
EMPEDU
- 264 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 960,400
289 Z-3-30-0 FOTOTERAPI 81,500
- 265 -


REGIONAL 2
RAWAT INAP

13 A-4-14-I 2,289,100 2,747,000 3,204,800
(RINGAN)
14 A-4-14-II 2,778,700 3,334,500 3,890,200
(SEDANG)
15 A-4-14-III 3,334,500 4,001,400 4,668,300
(BERAT)

31 B-1-13-I 5,657,400 6,788,800 7,920,300
LAIN (RINGAN)
32 B-1-13-II 9,308,500 11,170,200 13,031,900
LAIN (SEDANG)
33 B-1-13-III 12,044,400 14,453,200 16,862,100
LAIN (BERAT)
34 B-1-14-I 7,773,400 9,328,100 10,882,800
(RINGAN)
35 B-1-14-II 8,645,400 10,374,500 12,103,600
(SEDANG)
40 B-4-11-I 4,918,700 5,902,500 6,886,200
(RINGAN)
41 B-4-11-II 6,886,300 8,263,500 9,640,800
(SEDANG)
42 B-4-11-III 8,342,600 10,011,200 11,679,700
(BERAT)
- 266 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 5,210,600 6,252,800 7,294,900
74 D-1-20-II 14,359,800 17,231,700 20,103,700
75 D-1-20-III 22,778,800 27,334,500 31,890,300
85 D-4-13-I 3,013,900 3,616,600 4,219,400
86 D-4-13-II 4,265,600 5,118,800 5,971,900
87 D-4-13-III 5,455,900 6,547,000 7,638,200
88 D-4-14-I 3,232,500 3,879,000 4,525,500
89 D-4-14-II 5,292,400 6,350,900 7,409,400
90 D-4-14-III 6,473,200 7,767,800 9,062,400
91 E-1-01-I 7,088,000 8,505,600 9,923,100
(RINGAN)
92 E-1-01-II 9,676,100 11,611,300 13,546,600
(SEDANG)

97 E-1-20-I 7,584,100 9,100,900 10,617,700
TIROGLOSAL (RINGAN)
- 267 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 10,208,000 12,249,600 14,291,100
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,503,800 17,404,500 20,305,300
TIROGLOSAL (BERAT)
100 E-4-10-I 3,534,300 4,241,100 4,948,000
METABOLIK (RINGAN)
101 E-4-10-II 4,938,500 5,926,200 6,913,900
METABOLIK (SEDANG)
102 E-4-10-III 6,319,200 7,583,100 8,846,900
METABOLIK (BERAT)
109 E-4-13-I 3,730,400 4,476,500 5,222,500
(RINGAN)
110 E-4-13-II 5,464,400 6,557,200 7,650,100
(SEDANG)

118 F-4-12-I 2,105,500 2,526,600 2,947,700
(RINGAN)
119 F-4-12-II 2,993,400 3,592,100 4,190,700
(SEDANG)
120 F-4-12-III 6,503,000 7,803,600 9,104,200
(BERAT)
130 F-4-16-I 5,702,600 6,843,100 7,983,600
131 F-4-16-II 6,630,200 7,956,200 9,282,300
132 F-4-16-III 8,850,200 10,620,200 12,390,200
142 G-1-01-I 17,140,600 20,568,800 23,996,900
(RINGAN)
- 268 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 24,583,800 29,500,600 34,417,400
(SEDANG)
144 G-1-01-III 37,318,600 44,782,400 52,246,100
(BERAT)
151 G-1-12-I 4,979,200 5,975,000 6,970,900
(RINGAN)
152 G-1-12-II 9,622,400 11,546,900 13,471,400
(SEDANG)
153 G-1-12-III 13,113,500 15,736,200 18,358,900
(BERAT)
163 G-4-10-I 4,274,100 5,128,900 5,983,700
(RINGAN)
164 G-4-10-II 5,224,400 6,269,300 7,314,200
(SEDANG)
165 G-4-10-III 7,390,500 8,868,600 10,346,700
(BERAT)
166 G-4-11-I 4,612,700 5,535,200 6,457,800
167 G-4-11-II 6,127,400 7,352,900 8,578,300
168 G-4-11-III 9,003,200 10,803,800 12,604,500
DEGENERATIF (BERAT)
169 G-4-12-I 5,117,300 6,140,700 7,164,200
(RINGAN)
170 G-4-12-II 6,269,500 7,523,500 8,777,400
(SEDANG)

172 G-4-13-I 2,981,800 3,578,100 4,174,500
(RINGAN)
173 G-4-13-II 5,199,600 6,239,600 7,279,500
(SEDANG)
174 G-4-13-III 6,166,900 7,400,300 8,633,600
(BERAT)
175 G-4-14-I 5,058,200 6,069,900 7,081,500
INFARK (RINGAN)
176 G-4-14-II 6,971,700 8,366,000 9,760,300
INFARK (SEDANG)
177 G-4-14-III 8,750,200 10,500,300 12,250,300
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 269 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 4,538,100 5,445,700 6,353,300
(RINGAN)
185 G-4-17-II 5,950,400 7,140,500 8,330,600
(SEDANG)
186 G-4-17-III 7,708,200 9,249,800 10,791,500
(BERAT)
190 G-4-19-I 3,728,800 4,474,600 5,220,400
191 G-4-19-II 6,302,600 7,563,100 8,823,700
192 G-4-19-III 8,275,000 9,930,100 11,585,100
211 G-4-26-I 3,619,600 4,343,500 5,067,400
LAIN (RINGAN)
212 G-4-26-II 4,340,900 5,209,100 6,077,300
LAIN (SEDANG)
213 G-4-26-III 6,296,300 7,555,600 8,814,800
LAIN (BERAT)
232 I-1-02-I 26,124,400 31,349,300 36,574,200
(RINGAN)
- 270 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 33,700,200 40,440,200 47,180,300
(SEDANG)
234 I-1-02-III 41,537,600 49,845,100 58,152,600
(BERAT)
235 I-1-03-I 15,089,500 18,107,500 21,125,400
ANOMALI (RINGAN)
236 I-1-03-II 20,917,200 25,100,700 29,284,100
ANOMALI (SEDANG)
237 I-1-03-III 27,366,600 32,839,900 38,313,200
ANOMALI (BERAT)
238 I-1-04-I 23,442,400 28,130,900 32,819,300
JANTUNG (RINGAN)
239 I-1-04-II 36,998,400 44,398,100 51,797,800
JANTUNG (SEDANG)
240 I-1-04-III 59,104,700 70,925,700 82,746,600
JANTUNG (BERAT)
241 I-1-05-I 55,127,200 66,152,700 77,178,100
242 I-1-05-II 67,377,700 80,853,300 94,328,800
243 I-1-05-III 91,878,700 110,254,400 128,630,200
247 I-1-07-I 49,002,000 58,802,400 68,602,800
JANTUNG (RINGAN)
248 I-1-07-II 61,252,500 73,503,000 85,753,500
JANTUNG (SEDANG)
249 I-1-07-III 91,878,700 110,254,400 128,630,200
JANTUNG (BERAT)
250 I-1-11-I 4,220,400 5,064,500 5,908,600
251 I-1-11-II 4,692,700 5,631,200 6,569,700
252 I-1-11-III 6,244,500 7,493,400 8,742,300
253 I-1-12-I 12,148,300 14,578,000 17,007,600
(RINGAN)
254 I-1-12-II 19,245,400 23,094,500 26,943,600
(SEDANG)
255 I-1-12-III 25,320,200 30,384,300 35,448,300
(BERAT)
256 I-1-13-I 11,783,700 14,140,400 16,497,200
KOMPLEK (RINGAN)
257 I-1-13-II 15,692,400 18,830,900 21,969,400
KOMPLEK (SEDANG)
258 I-1-13-III 19,353,100 23,223,700 27,094,300
KOMPLEK (BERAT)
259 I-1-14-I 24,118,300 28,942,000 33,765,700
(RINGAN)
260 I-1-14-II 29,975,500 35,970,600 41,965,700
(SEDANG)
261 I-1-14-III 39,278,300 47,133,900 54,989,600
(BERAT)
265 I-1-16-I 11,521,300 13,825,600 16,129,900
266 I-1-16-II 26,874,400 32,249,200 37,624,100
267 I-1-16-III 30,999,200 37,199,000 43,398,800
268 I-1-17-I 13,753,200 16,503,800 19,254,500
(RINGAN)
269 I-1-17-II 17,220,300 20,664,400 24,108,400
(SEDANG)
- 271 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 21,301,200 25,561,500 29,821,700
(BERAT)
271 I-1-20-I 15,502,200 18,602,700 21,703,100
(RINGAN)
272 I-1-20-II 19,366,500 23,239,800 27,113,100
(SEDANG)
273 I-1-20-III 20,358,200 24,429,900 28,501,500
(BERAT)
274 I-1-30-I 11,726,600 14,071,900 16,417,200
JANTUNG (RINGAN)
275 I-1-30-II 24,393,800 29,272,600 34,151,400
JANTUNG (SEDANG)
276 I-1-30-III 37,801,700 45,362,000 52,922,300
JANTUNG (BERAT)

289 I-4-13-I 3,671,400 4,405,700 5,140,000
(RINGAN)
290 I-4-13-II 6,555,800 7,867,000 9,178,100
(SEDANG)
291 I-4-13-III 9,446,000 11,335,200 13,224,400
(BERAT)
295 I-4-15-I 4,522,700 5,427,200 6,331,700
(RINGAN)
296 I-4-15-II 6,152,800 7,383,400 8,613,900
(SEDANG)

304 I-4-18-I 4,094,200 4,913,000 5,731,900
JANTUNG (RINGAN)
305 I-4-18-II 6,426,400 7,711,700 8,996,900
JANTUNG (SEDANG)
306 I-4-18-III 8,463,100 10,155,800 11,848,400
JANTUNG (BERAT)

308 I-4-19-II 6,166,300 7,399,600 8,632,800
(SEDANG)
- 272 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 3,376,400 4,051,600 4,726,900
320 I-4-23-II 4,145,200 4,974,200 5,803,300
321 I-4-23-III 8,099,500 9,719,400 11,339,300
322 I-4-24-I 2,821,000 3,385,200 3,949,400
(RINGAN)
323 I-4-24-II 6,496,000 7,795,300 9,094,500
(SEDANG)
324 I-4-24-III 8,213,100 9,855,700 11,498,300
(BERAT)
325 J-1-01-I 54,852,000 65,822,400 76,792,700
326 J-1-01-II 62,075,200 74,490,200 86,905,300
327 J-1-01-III 70,226,600 84,271,900 98,317,200
TRAKEOSTOMI (BERAT)
328 J-1-02-I 29,107,900 34,929,500 40,751,100
329 J-1-02-II 40,529,800 48,635,800 56,741,700
330 J-1-02-III 66,928,600 80,314,300 93,700,000
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,839,300 10,607,200 12,375,000
(RINGAN)
332 J-1-10-II 17,886,400 21,463,700 25,040,900
(SEDANG)
333 J-1-10-III 19,163,300 22,995,900 26,828,600
(BERAT)
334 J-1-20-I 15,115,300 18,138,400 21,161,500
(RINGAN)
335 J-1-20-II 19,038,200 22,845,800 26,653,400
(SEDANG)
336 J-1-20-III 29,398,000 35,277,600 41,157,200
(BERAT)
337 J-1-30-I 7,376,600 8,852,000 10,327,300
(RINGAN)
338 J-1-30-II 13,362,700 16,035,200 18,707,700
(SEDANG)

- 273 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,823,700 3,388,400 3,953,200
374 J-4-21-II 4,548,900 5,458,700 6,368,500
375 J-4-21-III 6,347,700 7,617,200 8,886,700
376 K-1-10-I 8,013,400 9,616,000 11,218,700
BESAR (RINGAN)
377 K-1-10-II 10,382,000 12,458,400 14,534,800
BESAR (SEDANG)
378 K-1-10-III 12,168,000 14,601,600 17,035,200
BESAR (BERAT)
382 K-1-12-I 3,466,300 4,159,500 4,852,800
FEMORAL (RINGAN)
383 K-1-12-II 4,508,300 5,410,000 6,311,600
FEMORAL (SEDANG)
384 K-1-12-III 8,931,600 10,718,000 12,504,300
FEMORAL (BERAT)
388 K-1-14-I 5,538,400 6,646,000 7,753,700
(RINGAN)
389 K-1-14-II 6,490,800 7,789,000 9,087,200
(SEDANG)

394 K-1-30-I 7,264,700 8,717,700 10,170,600
395 K-1-30-II 12,514,900 15,017,900 17,520,900
396 K-1-30-III 17,753,300 21,304,000 24,854,700

398 K-1-40-II 8,936,900 10,724,300 12,511,700
(SEDANG)

- 274 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 4,019,200 4,823,000 5,626,900
413 K-4-13-II 5,199,100 6,238,900 7,278,700
414 K-4-13-III 8,008,200 9,609,900 11,211,500
415 K-4-14-I 2,627,000 3,152,400 3,677,800
(RINGAN)
416 K-4-14-II 3,526,300 4,231,500 4,936,800
(SEDANG)
417 K-4-14-III 5,658,300 6,790,000 7,921,600
(BERAT)

424 K-4-17-I 1,733,400 2,080,100 2,426,800
(RINGAN)
425 K-4-17-II 2,134,700 2,561,600 2,988,500
(SEDANG)
426 K-4-17-III 2,561,600 3,073,900 3,586,300
(BERAT)
427 K-4-18-I 1,465,900 1,759,000 2,052,200
(RINGAN)
428 K-4-18-II 2,473,600 2,968,300 3,463,100
(SEDANG)
436 L-1-40-I 5,023,300 6,027,900 7,032,600
(RINGAN)
437 L-1-40-II 10,075,600 12,090,700 14,105,900
(SEDANG)
438 L-1-40-III 16,959,500 20,351,400 23,743,300
(BERAT)
451 L-4-13-I 2,405,200 2,886,300 3,367,300
PAYUDARA (RINGAN)
- 275 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,826,800 3,392,200 3,957,600
PAYUDARA (SEDANG)
453 L-4-13-III 4,159,700 4,991,700 5,823,600
PAYUDARA (BERAT)
454 L-4-14-I 2,970,500 3,564,600 4,158,700
(RINGAN)
455 L-4-14-II 4,461,800 5,354,200 6,246,500
(SEDANG)
456 L-4-14-III 6,289,500 7,547,300 8,805,200
(BERAT)
457 M-1-01-I 10,500,500 12,600,500 14,700,600
458 M-1-01-II 14,924,900 17,909,900 20,894,900
459 M-1-01-III 20,965,100 25,158,100 29,351,100
463 M-1-03-I 23,489,000 28,186,800 32,884,600
464 M-1-03-II 27,473,900 32,968,600 38,463,400
465 M-1-03-III 34,003,500 40,804,200 47,604,900
472 M-1-07-I 8,293,100 9,951,800 11,610,400
473 M-1-07-II 11,109,900 13,331,900 15,553,900
474 M-1-07-III 22,632,000 27,158,400 31,684,800
475 M-1-10-I 19,154,900 22,985,900 26,816,800
WAJAH (RINGAN)
476 M-1-10-II 45,798,700 54,958,400 64,118,100
WAJAH (SEDANG)
477 M-1-10-III 98,783,400 118,540,100 138,296,800
WAJAH (BERAT)
478 M-1-20-I 12,469,300 14,963,200 17,457,100
(RINGAN)
479 M-1-20-II 16,423,600 19,708,300 22,993,000
(SEDANG)

484 M-1-40-I 4,354,500 5,225,400 6,096,200
INTERNAL (RINGAN)
485 M-1-40-II 7,722,500 9,266,900 10,811,400
INTERNAL (SEDANG)
486 M-1-40-III 11,026,200 13,231,400 15,436,600
INTERNAL (BERAT)
490 M-1-60-I 8,059,000 9,670,800 11,282,600
491 M-1-60-II 10,132,000 12,158,400 14,184,900
492 M-1-60-III 15,779,000 18,934,800 22,090,700
- 276 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 15,392,600 18,471,100 21,549,600
KAKI (RINGAN)
494 M-1-70-II 16,931,800 20,318,200 23,704,500
KAKI (SEDANG)
495 M-1-70-III 19,384,700 23,261,600 27,138,600
KAKI (BERAT)
502 M-4-11-I 3,725,600 4,470,700 5,215,900
(RINGAN)
503 M-4-11-II 8,168,300 9,801,900 11,435,600
(SEDANG)
504 M-4-11-III 12,175,100 14,610,200 17,045,200
(BERAT)
505 M-4-12-I 2,973,900 3,568,700 4,163,400
(RINGAN)
506 M-4-12-II 4,946,400 5,935,700 6,924,900
(SEDANG)
507 M-4-12-III 6,820,900 8,185,100 9,549,300
(BERAT)
508 M-4-13-I 4,951,800 5,942,200 6,932,500
509 M-4-13-II 7,439,900 8,927,900 10,415,800
510 M-4-13-III 14,515,000 17,418,000 20,321,100
520 M-4-17-I 3,721,000 4,465,200 5,209,400
(RINGAN)
521 M-4-17-II 5,204,300 6,245,100 7,286,000
(SEDANG)
522 M-4-17-III 7,267,400 8,720,900 10,174,400
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,958,600 3,550,300 4,142,000
(RINGAN)
530 M-4-20-II 4,332,300 5,198,800 6,065,300
(SEDANG)
531 M-4-20-III 4,841,900 5,810,300 6,778,700
(BERAT)
532 M-4-21-I 2,979,100 3,574,900 4,170,700
533 M-4-21-II 3,725,900 4,471,100 5,216,300
- 277 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 8,353,500 10,024,200 11,694,900
541 N-1-12-I 4,379,600 5,255,500 6,131,400
542 N-1-12-II 8,989,000 10,786,800 12,584,500
543 N-1-12-III 19,506,400 23,407,600 27,308,900
547 N-1-30-I 8,763,200 10,515,900 12,268,500
BAWAH (RINGAN)
548 N-1-30-II 13,257,000 15,908,400 18,559,800
BAWAH (SEDANG)
549 N-1-30-III 15,257,600 18,309,100 21,360,600
BAWAH (BERAT)
550 N-1-40-I 8,113,400 9,736,100 11,358,800
(RINGAN)
551 N-1-40-II 11,017,800 13,221,400 15,424,900
(SEDANG)
552 N-1-40-III 12,823,300 15,387,900 17,952,600
(BERAT)
553 N-4-10-I 3,343,700 4,012,400 4,681,100
(RINGAN)
554 N-4-10-II 4,169,300 5,003,100 5,837,000
(SEDANG)
555 N-4-10-III 6,132,400 7,358,900 8,585,400
(BERAT)
568 N-4-15-I 3,045,500 3,654,600 4,263,600
URIN (RINGAN)
569 N-4-15-II 3,895,800 4,674,900 5,454,100
URIN (SEDANG)
570 N-4-15-III 4,445,700 5,334,900 6,224,000
URIN (BERAT)
571 N-4-16-I 3,729,200 4,475,000 5,220,800
(RINGAN)
572 N-4-16-II 5,322,700 6,387,200 7,451,800
(SEDANG)
573 N-4-16-III 7,304,000 8,764,800 10,225,600
(BERAT)
- 278 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 3,466,400 4,159,700 4,853,000
578 O-6-11-II 3,852,500 4,623,000 5,393,600
579 O-6-11-III 4,940,800 5,929,000 6,917,200
580 O-6-12-I 2,531,900 3,038,200 3,544,600
581 O-6-12-II 3,040,800 3,648,900 4,257,100
582 O-6-12-III 3,820,800 4,585,000 5,349,200
586 P-8-01-I 54,840,900 65,809,100 76,777,300
587 P-8-01-II 67,857,400 81,428,900 95,000,400
588 P-8-01-III 79,645,500 95,574,700 111,503,800
589 P-8-02-I 85,686,100 102,823,300 119,960,600
590 P-8-02-II 98,290,800 117,948,900 137,607,100
591 P-8-02-III 112,304,300 134,765,100 157,226,000
592 P-8-03-I 12,396,600 14,875,900 17,355,200
593 P-8-03-II 17,504,400 21,005,200 24,506,100
594 P-8-03-III 24,500,800 29,401,000 34,301,200
595 P-8-04-I 35,755,200 42,906,200 50,057,300
596 P-8-04-II 46,221,900 55,466,300 64,710,600
597 P-8-04-III 66,270,600 79,524,700 92,778,800
598 P-8-05-I 19,415,200 23,298,200 27,181,300
599 P-8-05-II 30,352,700 36,423,200 42,493,800
600 P-8-05-III 40,394,700 48,473,700 56,552,600
601 P-8-06-I 5,311,700 6,374,100 7,436,400
602 P-8-06-II 14,892,900 17,871,400 20,850,000
603 P-8-06-III 19,729,400 23,675,300 27,621,100
604 P-8-07-I 5,144,900 6,173,900 7,202,900
605 P-8-07-II 14,425,200 17,310,300 20,195,300
606 P-8-07-III 19,109,900 22,931,900 26,753,900
607 P-8-08-I 4,260,000 5,111,900 5,963,900
608 P-8-08-II 6,044,600 7,253,500 8,462,500
609 P-8-08-III 9,787,600 11,745,100 13,702,600
610 P-8-11-I 10,330,500 12,396,600 14,462,700
MAYOR (RINGAN)
611 P-8-11-II 14,587,000 17,504,400 20,421,800
MAYOR (SEDANG)
- 279 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 20,417,400 24,500,800 28,584,300
MAYOR (BERAT)
613 P-8-12-I 9,759,600 11,711,500 13,663,400
MAYOR (RINGAN)
614 P-8-12-II 11,220,700 13,464,900 15,709,000
MAYOR (SEDANG)
615 P-8-12-III 15,705,700 18,846,800 21,987,900
MAYOR (BERAT)
616 P-8-13-I 5,532,900 6,639,500 7,746,100
MAYOR (RINGAN)
617 P-8-13-II 8,631,300 10,357,600 12,083,900
MAYOR (SEDANG)
618 P-8-13-III 13,409,100 16,090,900 18,772,700
MAYOR (BERAT)
619 P-8-14-I 3,687,600 4,425,100 5,162,700
620 P-8-14-II 7,506,500 9,007,800 10,509,100
621 P-8-14-III 13,509,600 16,211,500 18,913,400
622 P-8-15-I 2,765,700 3,318,900 3,872,000
ASPIRASI (RINGAN)
623 P-8-15-II 5,538,500 6,646,200 7,754,000
ASPIRASI (SEDANG)
624 P-8-15-III 6,498,500 7,798,200 9,097,900
ASPIRASI (BERAT)
625 P-8-16-I 2,503,000 3,003,600 3,504,300
626 P-8-16-II 4,810,000 5,772,000 6,734,000
627 P-8-16-III 11,770,700 14,124,800 16,478,900
628 P-8-17-I 3,688,600 4,426,300 5,164,100
(RINGAN)
629 P-8-17-II 6,639,500 7,967,400 9,295,300
(SEDANG)
630 P-8-17-III 9,342,900 11,211,500 13,080,100
(BERAT)
631 S-4-10-I 2,737,500 3,285,000 3,832,500
632 S-4-10-II 3,373,000 4,047,600 4,722,200
633 S-4-10-III 4,617,300 5,540,700 6,464,200
640 S-4-13-I 2,972,100 3,566,500 4,160,900
(RINGAN)
641 S-4-13-II 5,272,700 6,327,200 7,381,800
(SEDANG)
642 S-4-13-III 8,558,200 10,269,900 11,981,500
(BERAT)
643 S-4-14-I 1,504,100 1,804,900 2,105,700
644 S-4-14-II 3,194,800 3,833,700 4,472,700
645 S-4-14-III 6,058,400 7,270,100 8,481,800
KANAK-KANAK (BERAT)
646 S-4-15-I 1,005,900 1,207,100 1,408,300
647 S-4-15-II 1,898,400 2,278,000 2,657,700
648 S-4-15-III 2,458,700 2,950,500 3,442,200
- 280 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 2,510,600 3,012,700 3,514,900
653 S-4-17-II 3,726,000 4,471,200 5,216,400
654 S-4-17-III 4,481,400 5,377,700 6,273,900
655 T-1-10-I 1,731,800 2,078,100 2,424,500
OBAT (RINGAN)
656 T-1-10-II 2,326,000 2,791,200 3,256,300
OBAT (SEDANG)
657 T-1-10-III 4,231,300 5,077,500 5,923,800
OBAT (BERAT)
658 T-4-10-I 751,200 901,400 1,051,600
659 T-4-10-II 1,431,600 1,718,000 2,004,300
660 T-4-10-III 2,081,200 2,497,500 2,913,700
661 T-4-11-I 1,025,200 1,230,300 1,435,300
662 T-4-11-II 1,613,400 1,936,000 2,258,700
663 T-4-11-III 2,598,700 3,118,400 3,638,100
664 T-4-12-I 1,689,000 2,026,900 2,364,700
LAIN (RINGAN)
665 T-4-12-II 2,516,700 3,020,100 3,523,400
LAIN (SEDANG)
666 T-4-12-III 3,861,300 4,633,500 5,405,800
LAIN (BERAT)
670 U-1-11-I 8,492,400 10,190,800 11,889,300
(RINGAN)
671 U-1-11-II 10,765,300 12,918,400 15,071,500
(SEDANG)
672 U-1-11-III 15,968,700 19,162,400 22,356,100
(BERAT)
679 U-1-14-I 4,113,800 4,936,600 5,759,300
(RINGAN)
680 U-1-14-II 5,048,600 6,058,400 7,068,100
(SEDANG)
681 U-1-14-III 5,982,600 7,179,200 8,375,700
(BERAT)
685 U-1-20-I 6,245,400 7,494,500 8,743,600
686 U-1-20-II 9,294,900 11,153,900 13,012,900
687 U-1-20-III 23,146,000 27,775,200 32,404,400
691 U-4-10-I 3,854,500 4,625,400 5,396,300
- 281 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 8,559,400 10,271,300 11,983,100
693 U-4-10-III 13,141,300 15,769,500 18,397,800
TENGGOROKAN (BERAT)
700 U-4-13-I 1,998,000 2,397,600 2,797,200
701 U-4-13-II 2,355,400 2,826,500 3,297,600
702 U-4-13-III 2,817,200 3,380,600 3,944,100
706 U-4-15-I 2,988,200 3,585,800 4,183,500
707 U-4-15-II 3,722,900 4,467,500 5,212,100
708 U-4-15-III 5,210,300 6,252,300 7,294,400
709 V-1-10-I 5,024,700 6,029,700 7,034,600
(RINGAN)
710 V-1-10-II 10,040,200 12,048,300 14,056,300
(SEDANG)
711 V-1-10-III 12,313,000 14,775,500 17,238,100
(BERAT)
715 V-1-12-I 8,718,000 10,461,600 12,205,200
MODERAT (RINGAN)
716 V-1-12-II 12,273,300 14,728,000 17,182,600
MODERAT (SEDANG)
717 V-1-12-III 15,089,800 18,107,800 21,125,800
MODERAT (BERAT)
718 V-1-13-I 4,688,100 5,625,700 6,563,300
KOMPLEK (RINGAN)
719 V-1-13-II 8,957,300 10,748,800 12,540,300
KOMPLEK (SEDANG)
720 V-1-13-III 13,631,400 16,357,600 19,083,900
KOMPLEK (BERAT)
721 V-1-14-I 8,917,400 10,700,900 12,484,400
(RINGAN)
722 V-1-14-II 12,956,800 15,548,100 18,139,500
(SEDANG)

727 V-4-10-I 4,445,700 5,334,800 6,224,000
(RINGAN)
728 V-4-10-II 7,384,500 8,861,400 10,338,300
(SEDANG)
729 V-4-10-III 12,174,500 14,609,400 17,044,300
(BERAT)
730 V-4-11-I 3,726,100 4,471,300 5,216,600
TUMOR (RINGAN)
731 V-4-11-II 4,999,500 5,999,400 6,999,300
TUMOR (SEDANG)
732 V-4-11-III 6,904,000 8,284,800 9,665,600
TUMOR (BERAT)
- 282 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 10,470,200 12,564,200 14,658,200
734 W-1-01-II 12,172,700 14,607,300 17,041,800
735 W-1-01-III 17,907,400 21,488,900 25,070,300
739 W-1-11-I 2,321,300 2,785,600 3,249,800
SERVIK (RINGAN)
740 W-1-11-II 2,561,500 3,073,900 3,586,200
SERVIK (SEDANG)
741 W-1-11-III 2,833,600 3,400,300 3,967,000
SERVIK (BERAT)
760 W-4-12-I 2,834,600 3,401,600 3,968,500
761 W-4-12-II 3,891,800 4,670,100 5,448,500
762 W-4-12-III 4,242,200 5,090,700 5,939,100
- 283 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 1,893,500 2,272,300 2,651,000
785 Z-4-12-II 3,973,400 4,768,100 5,562,800
786 Z-4-12-III 6,116,500 7,339,800 8,563,100
- 284 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,561,200

33 F-3-10-0 TERAPI SHOCK 442,100
- 285 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,687,600
PENGGANTIAN ALAT
81 I-2-42-0 2,582,600
PERKUTAN LAIN
- 286 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,282,000
192 Q-5-12-0 GIGI 221,300
196 Q-5-16-0 VAKSINASI 103,500
201 Q-5-21-0 ABORSI 193,100
206 Q-5-26-0 BRONKIAL AKUT 220,400
- 287 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 148,400
215 Q-5-35-0 INFEKSI AKUT 451,600
218 Q-5-38-0 PARU AKUT 263,200
234 U-2-23-0 RHINOPLASTY 1,300,200
242 U-3-13-0 335,100
TENGGOROKAN
270 Z-3-11-0 1,818,200
EMPEDU
- 288 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,008,500
289 Z-3-30-0 FOTOTERAPI 85,600
- 289 -


REGIONAL 2
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)
- 290 -

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)
- 291 -

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
142 G-1-01-I 10,402,500 12,483,000 14,563,400
(RINGAN)
- 292 -

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)
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)
- 293 -

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)
- 294 -

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)
- 295 -

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)
- 296 -

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)

- 297 -

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)

- 298 -

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)
- 299 -

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
- 300 -

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
- 301 -

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)
- 302 -

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)
- 303 -

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
- 304 -

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
- 305 -

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)

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)
- 306 -

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
- 307 -

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
- 308 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,471,300

33 F-3-10-0 TERAPI SHOCK 416,700
- 309 -

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
- 310 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
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
- 311 -

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
270 Z-3-11-0 1,713,500
EMPEDU
- 312 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 902,900
289 Z-3-30-0 FOTOTERAPI 75,400
- 313 -


REGIONAL 2
RAWAT INAP

13 A-4-14-I 2,174,700 2,609,600 3,044,600
(RINGAN)
14 A-4-14-II 2,639,700 3,167,700 3,695,600
(SEDANG)
15 A-4-14-III 3,167,700 3,801,200 4,434,800
(BERAT)

31 B-1-13-I 4,197,300 5,036,700 5,876,200
LAIN (RINGAN)
32 B-1-13-II 6,906,100 8,287,300 9,668,500
LAIN (SEDANG)
33 B-1-13-III 8,935,900 10,723,100 12,510,200
LAIN (BERAT)
34 B-1-14-I 5,767,200 6,920,700 8,074,100
(RINGAN)
35 B-1-14-II 6,414,200 7,697,000 8,979,800
(SEDANG)
40 B-4-11-I 3,762,100 4,514,600 5,267,000
(RINGAN)
41 B-4-11-II 5,267,000 6,320,500 7,373,900
(SEDANG)
42 B-4-11-III 6,381,000 7,657,100 8,933,300
(BERAT)
- 314 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 3,985,400 4,782,500 5,579,600
74 D-1-20-II 10,983,200 13,179,800 15,376,500
75 D-1-20-III 17,422,600 20,907,100 24,391,600
85 D-4-13-I 2,305,200 2,766,200 3,227,200
86 D-4-13-II 3,262,600 3,915,100 4,567,600
87 D-4-13-III 4,173,000 5,007,600 5,842,200
88 D-4-14-I 2,472,400 2,966,900 3,461,400
89 D-4-14-II 4,047,900 4,857,500 5,667,100
90 D-4-14-III 4,951,100 5,941,300 6,931,500
91 E-1-01-I 4,401,200 5,281,400 6,161,700
(RINGAN)
92 E-1-01-II 5,765,100 6,918,200 8,071,200
(SEDANG)

97 E-1-20-I 5,800,800 6,960,900 8,121,100
TIROGLOSAL (RINGAN)
- 315 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 7,807,700 9,369,200 10,930,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,760,600 12,912,700 15,064,800
TIROGLOSAL (BERAT)
100 E-4-10-I 3,461,400 4,153,700 4,845,900
METABOLIK (RINGAN)
101 E-4-10-II 4,836,700 5,804,000 6,771,300
METABOLIK (SEDANG)
102 E-4-10-III 6,003,300 7,203,900 8,404,600
METABOLIK (BERAT)
109 E-4-13-I 2,853,200 3,423,900 3,994,500
(RINGAN)
110 E-4-13-II 4,179,500 5,015,400 5,851,300
(SEDANG)

118 F-4-12-I 1,610,400 1,932,500 2,254,600
(RINGAN)
119 F-4-12-II 2,289,500 2,747,400 3,205,300
(SEDANG)
120 F-4-12-III 4,973,900 5,968,600 6,963,400
(BERAT)
130 F-4-16-I 4,230,800 5,077,000 5,923,200
131 F-4-16-II 4,919,000 5,902,800 6,886,700
132 F-4-16-III 6,566,100 7,879,300 9,192,500
142 G-1-01-I 10,714,500 12,857,400 15,000,300
(RINGAN)
- 316 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 16,684,800 20,021,800 23,358,800
(SEDANG)
144 G-1-01-III 32,088,000 38,505,600 44,923,200
(BERAT)
151 G-1-12-I 3,808,400 4,570,100 5,331,700
(RINGAN)
152 G-1-12-II 7,139,000 8,566,800 9,994,600
(SEDANG)
153 G-1-12-III 9,729,100 11,674,900 13,620,700
(BERAT)
163 G-4-10-I 3,269,100 3,922,900 4,576,700
(RINGAN)
164 G-4-10-II 3,995,900 4,795,100 5,594,300
(SEDANG)
165 G-4-10-III 5,483,100 6,579,700 7,676,300
(BERAT)
166 G-4-11-I 3,422,200 4,106,700 4,791,100
167 G-4-11-II 4,546,000 5,455,200 6,364,400
168 G-4-11-III 6,679,600 8,015,500 9,351,400
DEGENERATIF (BERAT)
169 G-4-12-I 3,796,600 4,555,900 5,315,200
(RINGAN)
170 G-4-12-II 4,795,300 5,754,400 6,713,500
(SEDANG)

172 G-4-13-I 2,280,600 2,736,800 3,192,900
(RINGAN)
173 G-4-13-II 3,977,000 4,772,400 5,567,800
(SEDANG)
174 G-4-13-III 4,716,800 5,660,200 6,603,500
(BERAT)
175 G-4-14-I 3,868,800 4,642,600 5,416,400
INFARK (RINGAN)
176 G-4-14-II 5,172,400 6,206,800 7,241,300
INFARK (SEDANG)
177 G-4-14-III 6,491,900 7,790,300 9,088,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 317 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 3,471,000 4,165,200 4,859,400
(RINGAN)
185 G-4-17-II 4,551,200 5,461,500 6,371,700
(SEDANG)
186 G-4-17-III 5,718,800 6,862,600 8,006,300
(BERAT)
190 G-4-19-I 2,852,000 3,422,400 3,992,800
191 G-4-19-II 4,820,600 5,784,700 6,748,900
192 G-4-19-III 6,329,200 7,595,100 8,860,900
211 G-4-26-I 3,076,100 3,691,300 4,306,500
LAIN (RINGAN)
212 G-4-26-II 3,578,400 4,294,100 5,009,800
LAIN (SEDANG)
213 G-4-26-III 5,350,900 6,421,000 7,491,200
LAIN (BERAT)
232 I-1-02-I 19,981,500 23,977,800 27,974,100
(RINGAN)
- 318 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 25,775,900 30,931,100 36,086,300
(SEDANG)
234 I-1-02-III 31,770,400 38,124,500 44,478,600
(BERAT)
235 I-1-03-I 11,541,400 13,849,700 16,157,900
ANOMALI (RINGAN)
236 I-1-03-II 15,998,700 19,198,500 22,398,200
ANOMALI (SEDANG)
237 I-1-03-III 20,303,600 24,364,400 28,425,100
ANOMALI (BERAT)
238 I-1-04-I 17,392,200 20,870,700 24,349,100
JANTUNG (RINGAN)
239 I-1-04-II 27,449,600 32,939,600 38,429,500
JANTUNG (SEDANG)
240 I-1-04-III 43,850,600 52,620,800 61,390,900
JANTUNG (BERAT)
241 I-1-05-I 22,315,800 26,779,000 31,242,200
242 I-1-05-II 26,779,100 32,134,900 37,490,800
243 I-1-05-III 36,847,800 44,217,400 51,587,000
247 I-1-07-I 19,584,700 23,501,600 27,418,500
JANTUNG (RINGAN)
248 I-1-07-II 24,161,700 28,994,000 33,826,300
JANTUNG (SEDANG)
249 I-1-07-III 26,360,300 31,632,300 36,904,400
JANTUNG (BERAT)
250 I-1-11-I 3,131,200 3,757,400 4,383,700
251 I-1-11-II 3,481,500 4,177,900 4,874,200
252 I-1-11-III 4,632,900 5,559,500 6,486,000
253 I-1-12-I 9,013,000 10,815,600 12,618,200
(RINGAN)
254 I-1-12-II 14,720,000 17,664,100 20,608,100
(SEDANG)
255 I-1-12-III 19,366,400 23,239,700 27,113,000
(BERAT)
256 I-1-13-I 8,742,500 10,491,000 12,239,500
KOMPLEK (RINGAN)
257 I-1-13-II 11,642,400 13,970,900 16,299,400
KOMPLEK (SEDANG)
258 I-1-13-III 14,358,300 17,230,000 20,101,600
KOMPLEK (BERAT)
259 I-1-14-I 17,893,700 21,472,500 25,051,200
(RINGAN)
260 I-1-14-II 22,239,300 26,687,100 31,135,000
(SEDANG)
261 I-1-14-III 29,141,100 34,969,300 40,797,600
(BERAT)
265 I-1-16-I 8,812,200 10,574,600 12,337,100
266 I-1-16-II 19,938,500 23,926,200 27,913,800
267 I-1-16-III 22,998,700 27,598,500 32,198,200
268 I-1-17-I 10,203,700 12,244,400 14,285,200
(RINGAN)
269 I-1-17-II 12,776,000 15,331,200 17,886,400
(SEDANG)
- 319 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 15,803,700 18,964,400 22,125,200
(BERAT)
271 I-1-20-I 11,501,300 13,801,600 16,101,800
(RINGAN)
272 I-1-20-II 14,368,300 17,242,000 20,115,600
(SEDANG)
273 I-1-20-III 15,104,100 18,124,900 21,145,700
(BERAT)
274 I-1-30-I 8,700,100 10,440,100 12,180,100
JANTUNG (RINGAN)
275 I-1-30-II 18,098,100 21,717,800 25,337,400
JANTUNG (SEDANG)
276 I-1-30-III 28,045,600 33,654,700 39,263,800
JANTUNG (BERAT)

289 I-4-13-I 2,723,900 3,268,700 3,813,500
(RINGAN)
290 I-4-13-II 4,863,800 5,836,600 6,809,400
(SEDANG)
291 I-4-13-III 7,008,100 8,409,700 9,811,400
(BERAT)
295 I-4-15-I 4,429,400 5,315,300 6,201,200
(RINGAN)
296 I-4-15-II 6,025,900 7,231,100 8,436,300
(SEDANG)

304 I-4-18-I 3,131,500 3,757,800 4,384,100
JANTUNG (RINGAN)
305 I-4-18-II 4,767,800 5,721,400 6,675,000
JANTUNG (SEDANG)
306 I-4-18-III 6,473,100 7,767,700 9,062,400
JANTUNG (BERAT)

308 I-4-19-II 4,716,400 5,659,600 6,602,900
(SEDANG)
- 320 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 2,582,400 3,098,900 3,615,400
320 I-4-23-II 3,170,500 3,804,600 4,438,700
321 I-4-23-III 6,195,000 7,434,000 8,673,000
322 I-4-24-I 2,325,500 2,790,600 3,255,700
(RINGAN)
323 I-4-24-II 5,355,000 6,426,000 7,497,000
(SEDANG)
324 I-4-24-III 6,770,500 8,124,500 9,478,600
(BERAT)
325 J-1-01-I 41,954,100 50,344,900 58,735,700
326 J-1-01-II 47,478,800 56,974,600 66,470,400
327 J-1-01-III 53,713,500 64,456,200 75,198,900
TRAKEOSTOMI (BERAT)
328 J-1-02-I 22,263,500 26,716,200 31,168,900
329 J-1-02-II 30,999,600 37,199,500 43,399,500
330 J-1-02-III 51,191,000 61,429,200 71,667,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,760,800 8,113,000 9,465,200
(RINGAN)
332 J-1-10-II 13,680,600 16,416,700 19,152,800
(SEDANG)
333 J-1-10-III 14,217,500 17,061,000 19,904,500
(BERAT)
334 J-1-20-I 9,579,400 11,495,300 13,411,200
(RINGAN)
335 J-1-20-II 12,657,600 15,189,200 17,720,700
(SEDANG)
336 J-1-20-III 19,383,800 23,260,600 27,137,300
(BERAT)
337 J-1-30-I 5,642,100 6,770,500 7,898,900
(RINGAN)
338 J-1-30-II 10,220,600 12,264,700 14,308,800
(SEDANG)

- 321 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,765,500 3,318,600 3,871,700
374 J-4-21-II 4,455,100 5,346,100 6,237,200
375 J-4-21-III 6,216,800 7,460,100 8,703,500
376 K-1-10-I 6,129,100 7,354,900 8,580,700
BESAR (RINGAN)
377 K-1-10-II 7,702,500 9,243,000 10,783,500
BESAR (SEDANG)
378 K-1-10-III 9,027,600 10,833,200 12,638,700
BESAR (BERAT)
382 K-1-12-I 2,571,700 3,086,000 3,600,400
FEMORAL (RINGAN)
383 K-1-12-II 3,344,800 4,013,700 4,682,700
FEMORAL (SEDANG)
384 K-1-12-III 6,626,500 7,951,800 9,277,100
FEMORAL (BERAT)
388 K-1-14-I 4,706,700 5,648,100 6,589,400
(RINGAN)
389 K-1-14-II 5,516,200 6,619,400 7,722,700
(SEDANG)

394 K-1-30-I 5,389,800 6,467,800 7,545,700
395 K-1-30-II 9,572,200 11,486,600 13,401,000
396 K-1-30-III 13,171,500 15,805,700 18,440,000

398 K-1-40-II 6,630,400 7,956,500 9,282,600
(SEDANG)

- 322 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 3,074,100 3,688,900 4,303,800
413 K-4-13-II 3,976,600 4,771,900 5,567,200
414 K-4-13-III 6,125,200 7,350,200 8,575,200
415 K-4-14-I 1,949,000 2,338,800 2,728,600
(RINGAN)
416 K-4-14-II 2,616,200 3,139,400 3,662,700
(SEDANG)
417 K-4-14-III 4,198,000 5,037,600 5,877,200
(BERAT)

424 K-4-17-I 1,461,500 1,753,800 2,046,000
(RINGAN)
425 K-4-17-II 1,998,900 2,398,700 2,798,400
(SEDANG)
426 K-4-17-III 2,398,700 2,878,400 3,358,100
(BERAT)
427 K-4-18-I 1,291,400 1,549,700 1,808,000
(RINGAN)
428 K-4-18-II 1,835,100 2,202,200 2,569,200
(SEDANG)
436 L-1-40-I 3,842,100 4,610,500 5,379,000
(RINGAN)
437 L-1-40-II 7,706,400 9,247,700 10,789,000
(SEDANG)
438 L-1-40-III 12,971,600 15,566,000 18,160,300
(BERAT)
451 L-4-13-I 2,355,700 2,826,800 3,297,900
PAYUDARA (RINGAN)
- 323 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,768,500 3,322,300 3,876,000
PAYUDARA (SEDANG)
453 L-4-13-III 4,073,900 4,888,700 5,703,500
PAYUDARA (BERAT)
454 L-4-14-I 2,272,000 2,726,400 3,180,800
(RINGAN)
455 L-4-14-II 3,412,700 4,095,200 4,777,700
(SEDANG)
456 L-4-14-III 4,810,500 5,772,700 6,734,800
(BERAT)
457 M-1-01-I 8,031,400 9,637,700 11,243,900
458 M-1-01-II 11,415,500 13,698,600 15,981,700
459 M-1-01-III 16,035,300 19,242,400 22,449,500
463 M-1-03-I 19,326,700 23,192,100 27,057,400
464 M-1-03-II 22,605,400 27,126,400 31,647,500
465 M-1-03-III 27,977,900 33,573,500 39,169,100
472 M-1-07-I 6,343,100 7,611,700 8,880,300
473 M-1-07-II 8,497,500 10,197,100 11,896,600
474 M-1-07-III 17,310,300 20,772,300 24,234,400
475 M-1-10-I 10,441,800 12,530,100 14,618,500
WAJAH (RINGAN)
476 M-1-10-II 22,913,200 27,495,900 32,078,500
WAJAH (SEDANG)
477 M-1-10-III 49,421,700 59,306,000 69,190,300
WAJAH (BERAT)
478 M-1-20-I 9,537,300 11,444,800 13,352,200
(RINGAN)
479 M-1-20-II 12,184,900 14,621,800 17,058,800
(SEDANG)

484 M-1-40-I 3,330,600 3,996,700 4,662,800
INTERNAL (RINGAN)
485 M-1-40-II 5,906,600 7,087,900 8,269,200
INTERNAL (SEDANG)
486 M-1-40-III 8,433,500 10,120,200 11,806,900
INTERNAL (BERAT)
490 M-1-60-I 6,164,000 7,396,800 8,629,600
491 M-1-60-II 7,749,600 9,299,500 10,849,400
492 M-1-60-III 11,706,700 14,048,000 16,389,400
- 324 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 11,420,000 13,703,900 15,987,900
KAKI (RINGAN)
494 M-1-70-II 12,561,900 15,074,300 17,586,700
KAKI (SEDANG)
495 M-1-70-III 14,381,800 17,258,100 20,134,500
KAKI (BERAT)
502 M-4-11-I 2,849,600 3,419,500 3,989,400
(RINGAN)
503 M-4-11-II 6,247,600 7,497,100 8,746,600
(SEDANG)
504 M-4-11-III 9,032,900 10,839,500 12,646,100
(BERAT)
505 M-4-12-I 2,274,600 2,729,500 3,184,400
(RINGAN)
506 M-4-12-II 3,783,300 4,539,900 5,296,600
(SEDANG)
507 M-4-12-III 5,060,500 6,072,600 7,084,800
(BERAT)
508 M-4-13-I 3,787,400 4,544,900 5,302,400
509 M-4-13-II 5,690,500 6,828,600 7,966,700
510 M-4-13-III 11,102,000 13,322,400 15,542,800
520 M-4-17-I 2,846,100 3,415,300 3,984,500
(RINGAN)
521 M-4-17-II 3,980,500 4,776,600 5,572,700
(SEDANG)
522 M-4-17-III 5,558,500 6,670,200 7,782,000
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,262,900 2,715,500 3,168,100
(RINGAN)
530 M-4-20-II 3,313,600 3,976,400 4,639,100
(SEDANG)
531 M-4-20-III 3,703,400 4,444,100 5,184,700
(BERAT)
532 M-4-21-I 2,278,600 2,734,300 3,190,000
533 M-4-21-II 2,849,800 3,419,800 3,989,800
- 325 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 6,389,300 7,667,100 8,945,000
541 N-1-12-I 3,349,800 4,019,700 4,689,700
542 N-1-12-II 6,669,000 8,002,800 9,336,700
543 N-1-12-III 14,472,100 17,366,500 20,260,900
547 N-1-30-I 6,702,600 8,043,200 9,383,700
BAWAH (RINGAN)
548 N-1-30-II 10,139,800 12,167,700 14,195,700
BAWAH (SEDANG)
549 N-1-30-III 11,669,900 14,003,900 16,337,900
BAWAH (BERAT)
550 N-1-40-I 6,019,400 7,223,300 8,427,200
(RINGAN)
551 N-1-40-II 8,174,300 9,809,100 11,444,000
(SEDANG)
552 N-1-40-III 9,513,800 11,416,500 13,319,300
(BERAT)
553 N-4-10-I 2,557,400 3,068,900 3,580,400
(RINGAN)
554 N-4-10-II 3,093,200 3,711,900 4,330,500
(SEDANG)
555 N-4-10-III 4,549,700 5,459,700 6,369,600
(BERAT)
568 N-4-15-I 2,329,300 2,795,200 3,261,100
URIN (RINGAN)
569 N-4-15-II 2,890,300 3,468,400 4,046,400
URIN (SEDANG)
570 N-4-15-III 3,298,300 3,958,000 4,617,700
URIN (BERAT)
571 N-4-16-I 2,852,300 3,422,700 3,993,200
(RINGAN)
572 N-4-16-II 4,071,100 4,885,300 5,699,600
(SEDANG)
573 N-4-16-III 5,419,000 6,502,700 7,586,500
(BERAT)
- 326 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 2,651,300 3,181,600 3,711,900
578 O-6-11-II 2,946,700 3,536,000 4,125,300
579 O-6-11-III 3,665,700 4,398,800 5,131,900
580 O-6-12-I 1,878,400 2,254,100 2,629,800
581 O-6-12-II 2,256,000 2,707,200 3,158,400
582 O-6-12-III 2,834,700 3,401,700 3,968,600
586 P-8-01-I 41,945,600 50,334,800 58,723,900
587 P-8-01-II 51,901,400 62,281,700 72,662,000
588 P-8-01-III 60,917,700 73,101,200 85,284,700
589 P-8-02-I 70,669,000 84,802,800 98,936,600
590 P-8-02-II 81,064,600 97,277,500 113,490,400
591 P-8-02-III 92,622,000 111,146,500 129,670,900
592 P-8-03-I 7,636,600 9,163,900 10,691,300
593 P-8-03-II 11,330,300 13,596,300 15,862,400
594 P-8-03-III 12,823,600 15,388,300 17,953,000
595 P-8-04-I 22,643,400 27,172,000 31,700,700
596 P-8-04-II 38,121,200 45,745,400 53,369,600
597 P-8-04-III 54,656,100 65,587,400 76,518,600
598 P-8-05-I 16,012,500 19,215,000 22,417,500
599 P-8-05-II 23,215,600 27,858,700 32,501,800
600 P-8-05-III 33,315,300 39,978,300 46,641,400
601 P-8-06-I 4,062,700 4,875,300 5,687,800
602 P-8-06-II 11,391,000 13,669,100 15,947,300
603 P-8-06-III 15,090,200 18,108,300 21,126,300
604 P-8-07-I 3,935,200 4,722,200 5,509,200
605 P-8-07-II 11,033,300 13,239,900 15,446,600
606 P-8-07-III 14,616,400 17,539,700 20,463,000
607 P-8-08-I 3,992,400 4,790,900 5,589,300
608 P-8-08-II 5,665,100 6,798,100 7,931,200
609 P-8-08-III 9,173,000 11,007,600 12,842,200
610 P-8-11-I 6,942,400 8,330,900 9,719,300
MAYOR (RINGAN)
611 P-8-11-II 10,300,200 12,360,300 14,420,300
MAYOR (SEDANG)
- 327 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 11,657,800 13,989,400 16,320,900
MAYOR (BERAT)
613 P-8-12-I 6,036,800 7,244,200 8,451,600
MAYOR (RINGAN)
614 P-8-12-II 8,583,500 10,300,200 12,016,900
MAYOR (SEDANG)
615 P-8-12-III 9,714,800 11,657,800 13,600,800
MAYOR (BERAT)
616 P-8-13-I 5,185,500 6,222,600 7,259,800
MAYOR (RINGAN)
617 P-8-13-II 8,089,400 9,707,300 11,325,200
MAYOR (SEDANG)
618 P-8-13-III 11,041,700 13,250,100 15,458,400
MAYOR (BERAT)
619 P-8-14-I 2,735,900 3,283,100 3,830,200
620 P-8-14-II 5,569,200 6,683,000 7,796,800
621 P-8-14-III 10,332,900 12,399,500 14,466,100
622 P-8-15-I 2,051,900 2,462,300 2,872,700
ASPIRASI (RINGAN)
623 P-8-15-II 4,109,100 4,930,900 5,752,800
ASPIRASI (SEDANG)
624 P-8-15-III 4,821,300 5,785,600 6,749,800
ASPIRASI (BERAT)
625 P-8-16-I 1,857,000 2,228,400 2,599,900
626 P-8-16-II 3,568,600 4,282,300 4,996,000
627 P-8-16-III 7,277,300 8,732,800 10,188,300
628 P-8-17-I 3,457,000 4,148,400 4,839,800
(RINGAN)
629 P-8-17-II 6,222,600 7,467,200 8,711,700
(SEDANG)
630 P-8-17-III 8,493,600 10,192,400 11,891,100
(BERAT)
631 S-4-10-I 2,093,800 2,512,500 2,931,300
632 S-4-10-II 2,579,900 3,095,800 3,611,800
633 S-4-10-III 3,531,600 4,237,900 4,944,200
640 S-4-13-I 2,273,200 2,727,900 3,182,500
(RINGAN)
641 S-4-13-II 4,032,900 4,839,400 5,646,000
(SEDANG)
642 S-4-13-III 6,545,800 7,855,000 9,164,200
(BERAT)
643 S-4-14-I 1,150,400 1,380,500 1,610,600
644 S-4-14-II 2,443,600 2,932,300 3,421,000
645 S-4-14-III 4,633,800 5,560,600 6,487,400
KANAK-KANAK (BERAT)
646 S-4-15-I 769,400 923,300 1,077,200
647 S-4-15-II 1,452,000 1,742,400 2,032,800
648 S-4-15-III 1,880,600 2,256,700 2,632,800
- 328 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 1,920,300 2,304,300 2,688,400
653 S-4-17-II 2,849,900 3,419,900 3,989,800
654 S-4-17-III 3,427,600 4,113,200 4,798,700
655 T-1-10-I 1,284,800 1,541,800 1,798,700
OBAT (RINGAN)
656 T-1-10-II 1,725,700 2,070,800 2,415,900
OBAT (SEDANG)
657 T-1-10-III 3,139,300 3,767,100 4,395,000
OBAT (BERAT)
658 T-4-10-I 612,600 735,200 857,700
659 T-4-10-II 1,167,700 1,401,200 1,634,800
660 T-4-10-III 1,697,500 2,037,000 2,376,400
661 T-4-11-I 820,200 984,200 1,148,300
662 T-4-11-II 1,290,700 1,548,800 1,807,000
663 T-4-11-III 2,079,000 2,494,800 2,910,600
664 T-4-12-I 1,274,500 1,529,400 1,784,300
LAIN (RINGAN)
665 T-4-12-II 1,926,300 2,311,600 2,696,900
LAIN (SEDANG)
666 T-4-12-III 2,982,200 3,578,600 4,175,000
LAIN (BERAT)
670 U-1-11-I 6,495,500 7,794,600 9,093,600
(RINGAN)
671 U-1-11-II 8,234,000 9,880,800 11,527,600
(SEDANG)
672 U-1-11-III 11,847,400 14,216,800 16,586,300
(BERAT)
679 U-1-14-I 3,052,100 3,662,500 4,272,900
(RINGAN)
680 U-1-14-II 3,745,700 4,494,800 5,243,900
(SEDANG)
681 U-1-14-III 4,438,600 5,326,300 6,214,000
(BERAT)
685 U-1-20-I 4,633,600 5,560,300 6,487,000
686 U-1-20-II 6,896,000 8,275,200 9,654,400
687 U-1-20-III 17,703,400 21,244,100 24,784,800
691 U-4-10-I 2,859,700 3,431,600 4,003,600
- 329 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 6,546,700 7,856,100 9,165,400
693 U-4-10-III 10,051,200 12,061,500 14,071,700
TENGGOROKAN (BERAT)
700 U-4-13-I 1,898,100 2,277,700 2,657,300
701 U-4-13-II 2,237,600 2,685,200 3,132,700
702 U-4-13-III 2,676,300 3,211,600 3,746,900
706 U-4-15-I 2,285,500 2,742,700 3,199,800
707 U-4-15-II 2,847,500 3,417,000 3,986,500
708 U-4-15-III 3,985,100 4,782,100 5,579,200
709 V-1-10-I 3,727,900 4,473,500 5,219,100
(RINGAN)
710 V-1-10-II 7,679,400 9,215,300 10,751,100
(SEDANG)
711 V-1-10-III 9,417,700 11,301,200 13,184,800
(BERAT)
715 V-1-12-I 6,668,000 8,001,600 9,335,200
MODERAT (RINGAN)
716 V-1-12-II 9,105,700 10,926,900 12,748,000
MODERAT (SEDANG)
717 V-1-12-III 11,541,600 13,849,900 16,158,300
MODERAT (BERAT)
718 V-1-13-I 3,478,100 4,173,800 4,869,400
KOMPLEK (RINGAN)
719 V-1-13-II 6,645,600 7,974,700 9,303,800
KOMPLEK (SEDANG)
720 V-1-13-III 10,426,100 12,511,300 14,596,500
KOMPLEK (BERAT)
721 V-1-14-I 6,820,600 8,184,700 9,548,800
(RINGAN)
722 V-1-14-II 9,910,100 11,892,200 13,874,200
(SEDANG)

727 V-4-10-I 3,298,300 3,958,000 4,617,700
(RINGAN)
728 V-4-10-II 5,478,700 6,574,400 7,670,200
(SEDANG)
729 V-4-10-III 9,032,400 10,838,900 12,645,400
(BERAT)
730 V-4-11-I 2,850,000 3,419,900 3,989,900
TUMOR (RINGAN)
731 V-4-11-II 3,823,900 4,588,700 5,353,500
TUMOR (SEDANG)
732 V-4-11-III 5,122,200 6,146,600 7,171,000
TUMOR (BERAT)
- 330 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 7,768,000 9,321,600 10,875,100
734 W-1-01-II 9,310,400 11,172,500 13,034,600
735 W-1-01-III 13,285,700 15,942,900 18,600,000
739 W-1-11-I 1,722,200 2,066,600 2,411,100
SERVIK (RINGAN)
740 W-1-11-II 1,900,400 2,280,500 2,660,600
SERVIK (SEDANG)
741 W-1-11-III 2,102,300 2,522,700 2,943,200
SERVIK (BERAT)
760 W-4-12-I 2,776,200 3,331,400 3,886,700
761 W-4-12-II 3,811,500 4,573,800 5,336,100
762 W-4-12-III 4,154,800 4,985,700 5,816,700
- 331 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 1,212,000 1,454,400 1,696,800
785 Z-4-12-II 2,973,200 3,567,900 4,162,500
786 Z-4-12-III 4,253,400 5,104,100 5,954,800
- 332 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,544,800

33 F-3-10-0 TERAPI SHOCK 437,500
- 333 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,659,600
PENGGANTIAN ALAT
81 I-2-42-0 2,555,600
PERKUTAN LAIN
- 334 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,205,200
192 Q-5-12-0 GIGI 219,000
196 Q-5-16-0 VAKSINASI 95,700
201 Q-5-21-0 ABORSI 191,100
206 Q-5-26-0 BRONKIAL AKUT 203,900
- 335 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 137,300
215 Q-5-35-0 INFEKSI AKUT 446,900
218 Q-5-38-0 PARU AKUT 260,400
234 U-2-23-0 RHINOPLASTY 1,286,600
242 U-3-13-0 331,600
TENGGOROKAN
270 Z-3-11-0 1,799,200
EMPEDU
- 336 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 948,000
289 Z-3-30-0 FOTOTERAPI 79,100
- 337 -


REGIONAL 2
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)
- 338 -

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)
- 339 -

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
142 G-1-01-I 5,280,800 6,336,900 7,393,100
(RINGAN)
- 340 -

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)
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)
- 341 -

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)
- 342 -

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)
- 343 -

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)
- 344 -

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)

- 345 -

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)

- 346 -

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)
- 347 -

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
- 348 -

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
- 349 -

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)
- 350 -

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)
- 351 -

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
- 352 -

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
- 353 -

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)

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)
- 354 -

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
- 355 -

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
- 356 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,397,000

33 F-3-10-0 TERAPI SHOCK 395,600
- 357 -

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
- 358 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
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
- 359 -

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
270 Z-3-11-0 1,627,000
EMPEDU
- 360 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 857,300
289 Z-3-30-0 FOTOTERAPI 69,700
- 361 -


REGIONAL 2
RAWAT INAP

13 A-4-14-I 2,174,700 2,609,600 3,044,600
(RINGAN)
14 A-4-14-II 2,639,700 3,167,700 3,695,600
(SEDANG)
15 A-4-14-III 3,167,700 3,801,200 4,434,800
(BERAT)

31 B-1-13-I 3,661,700 4,394,100 5,126,400
LAIN (RINGAN)
32 B-1-13-II 6,024,900 7,229,900 8,434,900
LAIN (SEDANG)
33 B-1-13-III 7,795,700 9,354,800 10,914,000
LAIN (BERAT)
34 B-1-14-I 5,031,300 6,037,600 7,043,900
(RINGAN)
35 B-1-14-II 5,595,700 6,714,900 7,834,000
(SEDANG)
40 B-4-11-I 3,282,100 3,938,500 4,595,000
(RINGAN)
41 B-4-11-II 4,595,000 5,514,000 6,433,000
(SEDANG)
42 B-4-11-III 5,566,800 6,680,100 7,793,500
(BERAT)
- 362 -

REGIONAL 2
RAWAT INAP


73 D-1-20-I 3,476,900 4,172,300 4,867,600
74 D-1-20-II 9,581,800 11,498,100 13,414,500
75 D-1-20-III 15,199,500 18,239,400 21,279,300
85 D-4-13-I 2,011,000 2,413,300 2,815,500
86 D-4-13-II 2,846,300 3,415,600 3,984,800
87 D-4-13-III 3,640,500 4,368,600 5,096,700
88 D-4-14-I 2,156,900 2,588,300 3,019,700
89 D-4-14-II 3,531,400 4,237,700 4,944,000
90 D-4-14-III 4,319,300 5,183,200 6,047,000
91 E-1-01-I 3,363,800 4,036,500 4,709,300
(RINGAN)
92 E-1-01-II 4,406,200 5,287,400 6,168,600
(SEDANG)

97 E-1-20-I 5,060,600 6,072,700 7,084,800
TIROGLOSAL (RINGAN)
- 363 -

REGIONAL 2
RAWAT INAP

98 E-1-20-II 6,811,400 8,173,700 9,536,000
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,387,500 11,265,100 13,142,600
TIROGLOSAL (BERAT)
100 E-4-10-I 3,288,300 3,946,000 4,603,600
METABOLIK (RINGAN)
101 E-4-10-II 4,594,800 5,513,800 6,432,800
METABOLIK (SEDANG)
102 E-4-10-III 5,703,100 6,843,700 7,984,300
METABOLIK (BERAT)
109 E-4-13-I 2,489,200 2,987,000 3,484,800
(RINGAN)
110 E-4-13-II 3,646,200 4,375,400 5,104,700
(SEDANG)

118 F-4-12-I 1,404,900 1,685,900 1,966,900
(RINGAN)
119 F-4-12-II 1,997,400 2,396,900 2,796,300
(SEDANG)
120 F-4-12-III 4,339,200 5,207,100 6,074,900
(BERAT)
130 F-4-16-I 3,691,000 4,429,200 5,167,400
131 F-4-16-II 4,291,400 5,149,700 6,007,900
132 F-4-16-III 5,728,300 6,873,900 8,019,600
142 G-1-01-I 5,439,200 6,527,000 7,614,900
(RINGAN)
- 364 -

REGIONAL 2
RAWAT INAP

143 G-1-01-II 7,494,800 8,993,800 10,492,700
(SEDANG)
144 G-1-01-III 14,569,900 17,483,900 20,397,900
(BERAT)
151 G-1-12-I 3,322,500 3,986,900 4,651,400
(RINGAN)
152 G-1-12-II 6,228,100 7,473,700 8,719,300
(SEDANG)
153 G-1-12-III 8,487,700 10,185,200 11,882,700
(BERAT)
163 G-4-10-I 2,852,000 3,422,400 3,992,700
(RINGAN)
164 G-4-10-II 3,486,100 4,183,300 4,880,500
(SEDANG)
165 G-4-10-III 4,783,500 5,740,200 6,696,900
(BERAT)
166 G-4-11-I 2,985,600 3,582,700 4,179,800
167 G-4-11-II 3,965,900 4,759,100 5,552,300
168 G-4-11-III 5,827,300 6,992,800 8,158,200
DEGENERATIF (BERAT)
169 G-4-12-I 3,312,100 3,974,600 4,637,000
(RINGAN)
170 G-4-12-II 4,183,500 5,020,100 5,856,800
(SEDANG)

172 G-4-13-I 1,989,600 2,387,600 2,785,500
(RINGAN)
173 G-4-13-II 3,469,500 4,163,500 4,857,400
(SEDANG)
174 G-4-13-III 4,115,000 4,938,000 5,760,900
(BERAT)
175 G-4-14-I 3,375,200 4,050,200 4,725,300
INFARK (RINGAN)
176 G-4-14-II 4,512,400 5,414,900 6,317,400
INFARK (SEDANG)
177 G-4-14-III 5,663,600 6,796,300 7,929,000
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 365 -

REGIONAL 2
RAWAT INAP

184 G-4-17-I 3,028,100 3,633,700 4,239,300
(RINGAN)
185 G-4-17-II 3,970,500 4,764,600 5,558,700
(SEDANG)
186 G-4-17-III 4,989,100 5,986,900 6,984,800
(BERAT)
190 G-4-19-I 2,488,100 2,985,700 3,483,400
191 G-4-19-II 4,205,500 5,046,600 5,887,700
192 G-4-19-III 5,521,700 6,626,000 7,730,300
211 G-4-26-I 2,683,600 3,220,300 3,757,000
LAIN (RINGAN)
212 G-4-26-II 3,121,900 3,746,200 4,370,600
LAIN (SEDANG)
213 G-4-26-III 4,668,100 5,601,700 6,535,400
LAIN (BERAT)
232 I-1-02-I 17,432,000 20,918,300 24,404,700
(RINGAN)
- 366 -

REGIONAL 2
RAWAT INAP

233 I-1-02-II 22,487,000 26,984,400 31,481,800
(SEDANG)
234 I-1-02-III 27,716,600 33,260,000 38,803,300
(BERAT)
235 I-1-03-I 10,068,700 12,082,500 14,096,200
ANOMALI (RINGAN)
236 I-1-03-II 13,957,400 16,748,800 19,540,300
ANOMALI (SEDANG)
237 I-1-03-III 17,713,000 21,255,600 24,798,200
ANOMALI (BERAT)
238 I-1-04-I 15,173,000 18,207,700 21,242,300
JANTUNG (RINGAN)
239 I-1-04-II 23,947,200 28,736,600 33,526,000
JANTUNG (SEDANG)
240 I-1-04-III 38,255,400 45,906,500 53,557,600
JANTUNG (BERAT)
241 I-1-05-I 19,468,400 23,362,100 27,255,800
242 I-1-05-II 23,362,200 28,034,600 32,707,100
243 I-1-05-III 32,146,200 38,575,400 45,004,700
247 I-1-07-I 17,085,700 20,502,900 23,920,000
JANTUNG (RINGAN)
248 I-1-07-II 21,078,700 25,294,500 29,510,200
JANTUNG (SEDANG)
249 I-1-07-III 22,996,800 27,596,200 32,195,500
JANTUNG (BERAT)
250 I-1-11-I 2,731,700 3,278,000 3,824,300
251 I-1-11-II 3,037,300 3,644,800 4,252,200
252 I-1-11-III 4,041,700 4,850,100 5,658,400
253 I-1-12-I 7,863,000 9,435,600 11,008,200
(RINGAN)
254 I-1-12-II 12,841,800 15,410,200 17,978,500
(SEDANG)
255 I-1-12-III 16,895,400 20,274,400 23,653,500
(BERAT)
256 I-1-13-I 7,627,000 9,152,400 10,677,800
KOMPLEK (RINGAN)
257 I-1-13-II 10,156,900 12,188,300 14,219,600
KOMPLEK (SEDANG)
258 I-1-13-III 12,526,200 15,031,500 17,536,700
KOMPLEK (BERAT)
259 I-1-14-I 15,610,600 18,732,700 21,854,800
(RINGAN)
260 I-1-14-II 19,401,600 23,281,900 27,162,300
(SEDANG)
261 I-1-14-III 25,422,800 30,507,400 35,591,900
(BERAT)
265 I-1-16-I 7,687,800 9,225,400 10,762,900
266 I-1-16-II 17,394,400 20,873,300 24,352,100
267 I-1-16-III 20,064,200 24,077,000 28,089,800
268 I-1-17-I 8,901,700 10,682,100 12,462,400
(RINGAN)
269 I-1-17-II 11,145,800 13,375,000 15,604,100
(SEDANG)
- 367 -

REGIONAL 2
RAWAT INAP

270 I-1-17-III 13,787,200 16,544,600 19,302,100
(BERAT)
271 I-1-20-I 10,033,800 12,040,500 14,047,300
(RINGAN)
272 I-1-20-II 12,535,000 15,042,000 17,548,900
(SEDANG)
273 I-1-20-III 13,176,800 15,812,200 18,447,600
(BERAT)
274 I-1-30-I 7,590,000 9,108,000 10,626,000
JANTUNG (RINGAN)
275 I-1-30-II 15,788,900 18,946,700 22,104,400
JANTUNG (SEDANG)
276 I-1-30-III 24,467,100 29,360,500 34,253,900
JANTUNG (BERAT)

289 I-4-13-I 2,376,300 2,851,600 3,326,900
(RINGAN)
290 I-4-13-II 4,243,200 5,091,900 5,940,500
(SEDANG)
291 I-4-13-III 6,113,900 7,336,700 8,559,500
(BERAT)
295 I-4-15-I 4,208,000 5,049,500 5,891,100
(RINGAN)
296 I-4-15-II 5,724,600 6,869,600 8,014,500
(SEDANG)

304 I-4-18-I 2,731,900 3,278,300 3,824,700
JANTUNG (RINGAN)
305 I-4-18-II 4,159,500 4,991,400 5,823,300
JANTUNG (SEDANG)
306 I-4-18-III 5,647,200 6,776,600 7,906,000
JANTUNG (BERAT)

308 I-4-19-II 4,114,600 4,937,500 5,760,400
(SEDANG)
- 368 -

REGIONAL 2
RAWAT INAP

319 I-4-23-I 2,252,900 2,703,500 3,154,100
320 I-4-23-II 2,766,000 3,319,100 3,872,300
321 I-4-23-III 5,404,500 6,485,400 7,566,300
322 I-4-24-I 2,028,800 2,434,500 2,840,300
(RINGAN)
323 I-4-24-II 4,671,700 5,606,100 6,540,400
(SEDANG)
324 I-4-24-III 5,906,600 7,087,900 8,269,200
(BERAT)
325 J-1-01-I 36,600,900 43,921,000 51,241,200
326 J-1-01-II 41,420,700 49,704,800 57,989,000
327 J-1-01-III 46,859,800 56,231,800 65,603,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 19,422,800 23,307,300 27,191,900
329 J-1-02-II 27,044,200 32,453,000 37,861,800
330 J-1-02-III 44,659,200 53,591,000 62,522,900
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,898,200 7,077,800 8,257,400
(RINGAN)
332 J-1-10-II 11,935,000 14,322,000 16,709,000
(SEDANG)
333 J-1-10-III 12,403,400 14,884,100 17,364,700
(BERAT)
334 J-1-20-I 6,931,000 8,317,200 9,703,400
(RINGAN)
335 J-1-20-II 8,205,500 9,846,600 11,487,700
(SEDANG)
336 J-1-20-III 12,670,600 15,204,700 17,738,800
(BERAT)
337 J-1-30-I 4,922,200 5,906,600 6,891,000
(RINGAN)
338 J-1-30-II 8,916,500 10,699,800 12,483,100
(SEDANG)

- 369 -

REGIONAL 2
RAWAT INAP

373 J-4-21-I 2,627,200 3,152,600 3,678,100
374 J-4-21-II 4,232,400 5,078,800 5,925,300
375 J-4-21-III 5,905,900 7,087,100 8,268,300
376 K-1-10-I 5,347,100 6,416,500 7,485,900
BESAR (RINGAN)
377 K-1-10-II 6,719,700 8,063,700 9,407,600
BESAR (SEDANG)
378 K-1-10-III 7,875,700 9,450,900 11,026,000
BESAR (BERAT)
382 K-1-12-I 2,243,500 2,692,300 3,141,000
FEMORAL (RINGAN)
383 K-1-12-II 2,918,000 3,501,600 4,085,200
FEMORAL (SEDANG)
384 K-1-12-III 5,781,000 6,937,200 8,093,400
FEMORAL (BERAT)
388 K-1-14-I 4,106,200 4,927,400 5,748,600
(RINGAN)
389 K-1-14-II 4,812,300 5,774,800 6,737,300
(SEDANG)

394 K-1-30-I 4,702,100 5,642,500 6,582,900
395 K-1-30-II 8,350,800 10,021,000 11,691,100
396 K-1-30-III 11,490,800 13,789,000 16,087,200

398 K-1-40-II 5,784,400 6,941,300 8,098,100
(SEDANG)

- 370 -

REGIONAL 2
RAWAT INAP

412 K-4-13-I 2,681,900 3,218,200 3,754,600
413 K-4-13-II 3,469,200 4,163,000 4,856,800
414 K-4-13-III 5,343,600 6,412,300 7,481,100
415 K-4-14-I 1,700,300 2,040,400 2,380,400
(RINGAN)
416 K-4-14-II 2,282,400 2,738,900 3,195,300
(SEDANG)
417 K-4-14-III 3,662,300 4,394,800 5,127,300
(BERAT)

424 K-4-17-I 1,122,000 1,346,400 1,570,800
(RINGAN)
425 K-4-17-II 1,682,400 2,018,900 2,355,400
(SEDANG)
426 K-4-17-III 2,018,900 2,422,700 2,826,400
(BERAT)
427 K-4-18-I 1,126,600 1,351,900 1,577,300
(RINGAN)
428 K-4-18-II 1,601,000 1,921,200 2,241,400
(SEDANG)
436 L-1-40-I 3,351,900 4,022,200 4,692,600
(RINGAN)
437 L-1-40-II 6,723,100 8,067,700 9,412,400
(SEDANG)
438 L-1-40-III 11,316,500 13,579,800 15,843,100
(BERAT)
451 L-4-13-I 2,237,900 2,685,400 3,133,000
PAYUDARA (RINGAN)
- 371 -

REGIONAL 2
RAWAT INAP

452 L-4-13-II 2,630,100 3,156,100 3,682,200
PAYUDARA (SEDANG)
453 L-4-13-III 3,870,300 4,644,300 5,418,400
PAYUDARA (BERAT)
454 L-4-14-I 1,982,100 2,378,500 2,775,000
(RINGAN)
455 L-4-14-II 2,977,200 3,572,700 4,168,100
(SEDANG)
456 L-4-14-III 4,196,700 5,036,100 5,875,400
(BERAT)
457 M-1-01-I 7,006,600 8,407,900 9,809,200
458 M-1-01-II 9,958,900 11,950,700 13,942,500
459 M-1-01-III 13,989,300 16,787,100 19,585,000
463 M-1-03-I 15,203,200 18,243,900 21,284,500
464 M-1-03-II 17,782,400 21,338,900 24,895,400
465 M-1-03-III 22,008,700 26,410,400 30,812,200
472 M-1-07-I 5,533,700 6,640,500 7,747,200
473 M-1-07-II 7,413,300 8,895,900 10,378,600
474 M-1-07-III 15,101,600 18,121,900 21,142,200
475 M-1-10-I 9,109,400 10,931,300 12,753,200
WAJAH (RINGAN)
476 M-1-10-II 19,989,600 23,987,500 27,985,400
WAJAH (SEDANG)
477 M-1-10-III 43,115,600 51,738,800 60,361,900
WAJAH (BERAT)
478 M-1-20-I 8,320,400 9,984,400 11,648,500
(RINGAN)
479 M-1-20-II 10,630,100 12,756,200 14,882,200
(SEDANG)

484 M-1-40-I 2,905,600 3,486,700 4,067,800
INTERNAL (RINGAN)
485 M-1-40-II 5,152,900 6,183,500 7,214,100
INTERNAL (SEDANG)
486 M-1-40-III 7,357,400 8,828,900 10,300,400
INTERNAL (BERAT)
490 M-1-60-I 5,377,500 6,453,000 7,528,500
491 M-1-60-II 6,760,800 8,112,900 9,465,100
492 M-1-60-III 10,213,000 12,255,500 14,298,100
- 372 -

REGIONAL 2
RAWAT INAP

493 M-1-70-I 9,962,800 11,955,400 13,947,900
KAKI (RINGAN)
494 M-1-70-II 10,959,100 13,150,900 15,342,700
KAKI (SEDANG)
495 M-1-70-III 12,546,700 15,056,000 17,565,400
KAKI (BERAT)
502 M-4-11-I 2,486,000 2,983,200 3,480,400
(RINGAN)
503 M-4-11-II 5,450,400 6,540,500 7,630,600
(SEDANG)
504 M-4-11-III 7,880,300 9,456,400 11,032,500
(BERAT)
505 M-4-12-I 1,984,400 2,381,200 2,778,100
(RINGAN)
506 M-4-12-II 3,300,600 3,960,700 4,620,800
(SEDANG)
507 M-4-12-III 4,414,800 5,297,800 6,180,800
(BERAT)
508 M-4-13-I 3,304,200 3,965,000 4,625,800
509 M-4-13-II 4,964,400 5,957,300 6,950,100
510 M-4-13-III 9,685,400 11,622,500 13,559,600
520 M-4-17-I 2,482,900 2,979,500 3,476,100
(RINGAN)
521 M-4-17-II 3,472,600 4,167,100 4,861,700
(SEDANG)
522 M-4-17-III 4,849,300 5,819,100 6,789,000
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,974,200 2,369,000 2,763,800
(RINGAN)
530 M-4-20-II 2,890,800 3,469,000 4,047,200
(SEDANG)
531 M-4-20-III 3,230,800 3,877,000 4,523,200
(BERAT)
532 M-4-21-I 1,987,800 2,385,400 2,783,000
533 M-4-21-II 2,486,200 2,983,400 3,480,700
- 373 -

REGIONAL 2
RAWAT INAP

534 M-4-21-III 5,574,000 6,688,800 7,803,600
541 N-1-12-I 2,922,400 3,506,800 4,091,300
542 N-1-12-II 5,818,100 6,981,700 8,145,300
543 N-1-12-III 12,625,500 15,150,600 17,675,700
547 N-1-30-I 5,847,400 7,016,900 8,186,400
BAWAH (RINGAN)
548 N-1-30-II 8,846,000 10,615,200 12,384,400
BAWAH (SEDANG)
549 N-1-30-III 10,180,900 12,217,000 14,253,200
BAWAH (BERAT)
550 N-1-40-I 5,251,400 6,301,700 7,351,900
(RINGAN)
551 N-1-40-II 7,131,300 8,557,500 9,983,800
(SEDANG)
552 N-1-40-III 8,299,800 9,959,800 11,619,800
(BERAT)
553 N-4-10-I 2,231,100 2,677,300 3,123,600
(RINGAN)
554 N-4-10-II 2,698,600 3,238,300 3,778,000
(SEDANG)
555 N-4-10-III 3,969,200 4,763,000 5,556,900
(BERAT)
568 N-4-15-I 2,032,100 2,438,600 2,845,000
URIN (RINGAN)
569 N-4-15-II 2,521,500 3,025,800 3,530,100
URIN (SEDANG)
570 N-4-15-III 2,877,500 3,453,000 4,028,500
URIN (BERAT)
571 N-4-16-I 2,488,300 2,986,000 3,483,700
(RINGAN)
572 N-4-16-II 3,551,700 4,262,000 4,972,300
(SEDANG)
573 N-4-16-III 4,727,500 5,673,000 6,618,500
(BERAT)
- 374 -

REGIONAL 2
RAWAT INAP

577 O-6-11-I 2,313,000 2,775,600 3,238,200
578 O-6-11-II 2,570,700 3,084,800 3,598,900
579 O-6-11-III 3,197,900 3,837,500 4,477,100
580 O-6-12-I 1,638,700 1,966,500 2,294,200
581 O-6-12-II 1,968,100 2,361,700 2,755,400
582 O-6-12-III 2,473,000 2,967,600 3,462,200
586 P-8-01-I 36,593,500 43,912,200 51,230,900
587 P-8-01-II 45,279,000 54,334,800 63,390,600
588 P-8-01-III 53,144,800 63,773,800 74,402,700
589 P-8-02-I 49,948,400 59,938,100 69,927,800
590 P-8-02-II 57,295,800 68,755,000 80,214,200
591 P-8-02-III 65,464,600 78,557,500 91,650,400
592 P-8-03-I 6,087,400 7,304,900 8,522,400
593 P-8-03-II 8,644,100 10,373,000 12,101,800
594 P-8-03-III 9,767,900 11,721,500 13,675,000
595 P-8-04-I 19,754,200 23,705,000 27,655,800
596 P-8-04-II 25,636,600 30,763,900 35,891,300
597 P-8-04-III 36,756,500 44,107,800 51,459,100
598 P-8-05-I 10,741,700 12,890,000 15,038,300
599 P-8-05-II 20,253,300 24,304,000 28,354,700
600 P-8-05-III 24,715,900 29,659,100 34,602,300
601 P-8-06-I 3,544,300 4,253,200 4,962,100
602 P-8-06-II 9,937,500 11,925,000 13,912,500
603 P-8-06-III 13,164,800 15,797,700 18,430,700
604 P-8-07-I 3,433,000 4,119,700 4,806,300
605 P-8-07-II 9,625,500 11,550,600 13,475,700
606 P-8-07-III 12,751,400 15,301,700 17,852,000
607 P-8-08-I 3,629,400 4,355,300 5,081,200
608 P-8-08-II 5,150,100 6,180,100 7,210,100
609 P-8-08-III 8,339,100 10,006,900 11,674,700
610 P-8-11-I 5,751,000 6,901,200 8,051,400
MAYOR (RINGAN)
611 P-8-11-II 8,166,400 9,799,700 11,433,000
MAYOR (SEDANG)
- 375 -

REGIONAL 2
RAWAT INAP

612 P-8-11-III 9,228,100 11,073,700 12,919,300
MAYOR (BERAT)
613 P-8-12-I 5,433,200 6,519,800 7,606,400
MAYOR (RINGAN)
614 P-8-12-II 7,725,200 9,270,200 10,815,300
MAYOR (SEDANG)
615 P-8-12-III 8,743,400 10,492,000 12,240,700
MAYOR (BERAT)
616 P-8-13-I 4,714,100 5,657,000 6,599,800
MAYOR (RINGAN)
617 P-8-13-II 6,222,600 7,467,200 8,711,700
MAYOR (SEDANG)
618 P-8-13-III 9,265,800 11,118,900 12,972,100
MAYOR (BERAT)
619 P-8-14-I 2,386,800 2,864,200 3,341,500
620 P-8-14-II 4,858,600 5,830,300 6,802,000
621 P-8-14-III 9,014,500 10,817,400 12,620,300
622 P-8-15-I 1,790,100 2,148,200 2,506,200
ASPIRASI (RINGAN)
623 P-8-15-II 3,584,800 4,301,800 5,018,700
ASPIRASI (SEDANG)
624 P-8-15-III 4,206,100 5,047,400 5,888,600
ASPIRASI (BERAT)
625 P-8-16-I 1,620,100 1,944,100 2,268,100
626 P-8-16-II 3,113,300 3,735,900 4,358,600
627 P-8-16-III 6,348,800 7,618,500 8,888,300
628 P-8-17-I 3,142,800 3,771,300 4,399,900
(RINGAN)
629 P-8-17-II 5,657,000 6,788,300 7,919,700
(SEDANG)
630 P-8-17-III 7,721,500 9,265,800 10,810,100
(BERAT)
631 S-4-10-I 1,826,600 2,192,000 2,557,300
632 S-4-10-II 2,250,700 2,700,800 3,151,000
633 S-4-10-III 3,081,000 3,697,100 4,313,300
640 S-4-13-I 1,983,200 2,379,800 2,776,400
(RINGAN)
641 S-4-13-II 3,518,300 4,221,900 4,925,600
(SEDANG)
642 S-4-13-III 5,710,600 6,852,700 7,994,900
(BERAT)
643 S-4-14-I 1,003,600 1,204,300 1,405,100
644 S-4-14-II 2,131,800 2,558,100 2,984,500
645 S-4-14-III 4,042,600 4,851,100 5,659,600
KANAK-KANAK (BERAT)
646 S-4-15-I 671,200 805,500 939,700
647 S-4-15-II 1,266,700 1,520,100 1,773,400
648 S-4-15-III 1,640,600 1,968,700 2,296,900
- 376 -

REGIONAL 2
RAWAT INAP

652 S-4-17-I 1,675,200 2,010,300 2,345,300
653 S-4-17-II 2,486,300 2,983,500 3,480,800
654 S-4-17-III 2,990,300 3,588,300 4,186,400
655 T-1-10-I 1,120,900 1,345,000 1,569,200
OBAT (RINGAN)
656 T-1-10-II 1,505,500 1,806,600 2,107,700
OBAT (SEDANG)
657 T-1-10-III 2,738,700 3,286,400 3,834,200
OBAT (BERAT)
658 T-4-10-I 511,200 613,400 715,600
659 T-4-10-II 974,300 1,169,100 1,364,000
660 T-4-10-III 1,416,300 1,699,600 1,982,800
661 T-4-11-I 605,400 726,400 847,500
662 T-4-11-II 952,600 1,143,200 1,333,700
663 T-4-11-III 1,534,300 1,841,200 2,148,100
664 T-4-12-I 1,058,700 1,270,500 1,482,200
LAIN (RINGAN)
665 T-4-12-II 1,600,600 1,920,700 2,240,800
LAIN (SEDANG)
666 T-4-12-III 2,498,000 2,997,600 3,497,200
LAIN (BERAT)
670 U-1-11-I 5,666,700 6,800,000 7,933,300
(RINGAN)
671 U-1-11-II 7,183,300 8,620,000 10,056,700
(SEDANG)
672 U-1-11-III 10,335,700 12,402,800 14,470,000
(BERAT)
679 U-1-14-I 2,662,700 3,195,200 3,727,700
(RINGAN)
680 U-1-14-II 3,267,700 3,921,300 4,574,800
(SEDANG)
681 U-1-14-III 3,872,300 4,646,700 5,421,200
(BERAT)
685 U-1-20-I 4,042,300 4,850,800 5,659,300
686 U-1-20-II 6,016,100 7,219,300 8,422,600
687 U-1-20-III 15,444,500 18,533,400 21,622,400
691 U-4-10-I 2,494,800 2,993,800 3,492,700
- 377 -

REGIONAL 2
RAWAT INAP

692 U-4-10-II 5,711,400 6,853,700 7,995,900
693 U-4-10-III 8,768,700 10,522,500 12,276,200
TENGGOROKAN (BERAT)
700 U-4-13-I 1,803,200 2,163,800 2,524,400
701 U-4-13-II 2,125,800 2,550,900 2,976,100
702 U-4-13-III 2,542,500 3,051,000 3,559,500
706 U-4-15-I 1,993,900 2,392,700 2,791,500
707 U-4-15-II 2,484,200 2,981,000 3,477,800
708 U-4-15-III 3,476,600 4,172,000 4,867,300
709 V-1-10-I 3,252,300 3,902,700 4,553,200
(RINGAN)
710 V-1-10-II 6,699,500 8,039,400 9,379,300
(SEDANG)
711 V-1-10-III 8,216,000 9,859,200 11,502,400
(BERAT)
715 V-1-12-I 5,817,200 6,980,700 8,144,100
MODERAT (RINGAN)
716 V-1-12-II 7,943,900 9,532,600 11,121,400
MODERAT (SEDANG)
717 V-1-12-III 10,068,900 12,082,700 14,096,500
MODERAT (BERAT)
718 V-1-13-I 3,034,300 3,641,200 4,248,100
KOMPLEK (RINGAN)
719 V-1-13-II 5,797,600 6,957,100 8,116,700
KOMPLEK (SEDANG)
720 V-1-13-III 9,095,700 10,914,900 12,734,000
KOMPLEK (BERAT)
721 V-1-14-I 5,950,300 7,140,400 8,330,400
(RINGAN)
722 V-1-14-II 8,645,600 10,374,800 12,103,900
(SEDANG)

727 V-4-10-I 2,877,500 3,453,000 4,028,500
(RINGAN)
728 V-4-10-II 4,779,600 5,735,600 6,691,500
(SEDANG)
729 V-4-10-III 7,879,900 9,455,900 11,031,900
(BERAT)
730 V-4-11-I 2,486,300 2,983,600 3,480,800
TUMOR (RINGAN)
731 V-4-11-II 3,336,000 4,003,200 4,670,400
TUMOR (SEDANG)
732 V-4-11-III 4,468,600 5,362,300 6,256,000
TUMOR (BERAT)
- 378 -

REGIONAL 2
RAWAT INAP

733 W-1-01-I 6,776,800 8,132,200 9,487,500
734 W-1-01-II 8,122,500 9,746,900 11,371,400
735 W-1-01-III 11,590,500 13,908,600 16,226,700
739 W-1-11-I 1,502,500 1,802,900 2,103,400
SERVIK (RINGAN)
740 W-1-11-II 1,658,000 1,989,500 2,321,100
SERVIK (SEDANG)
741 W-1-11-III 1,834,000 2,200,800 2,567,600
SERVIK (BERAT)
760 W-4-12-I 2,637,400 3,164,900 3,692,300
761 W-4-12-II 3,620,900 4,345,100 5,069,300
762 W-4-12-III 3,947,000 4,736,400 5,525,800
- 379 -

REGIONAL 2
RAWAT INAP

784 Z-4-12-I 783,400 940,100 1,096,800
785 Z-4-12-II 1,908,800 2,290,600 2,672,400
786 Z-4-12-III 2,420,800 2,904,900 3,389,100
- 380 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,466,800

33 F-3-10-0 TERAPI SHOCK 415,400
- 381 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,525,200
PENGGANTIAN ALAT
81 I-2-42-0 2,426,600
PERKUTAN LAIN
- 382 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,144,300
192 Q-5-12-0 GIGI 207,900
196 Q-5-16-0 VAKSINASI 88,600
201 Q-5-21-0 ABORSI 181,400
206 Q-5-26-0 BRONKIAL AKUT 188,600
- 383 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 127,000
215 Q-5-35-0 INFEKSI AKUT 424,300
218 Q-5-38-0 PARU AKUT 247,300
234 U-2-23-0 RHINOPLASTY 1,221,600
242 U-3-13-0 314,900
TENGGOROKAN
270 Z-3-11-0 1,708,300
EMPEDU
- 384 -

REGIONAL 2
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 900,200
289 Z-3-30-0 FOTOTERAPI 73,200
- 385 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,346,400 2,815,700 3,284,900
(RINGAN)
14 A-4-14-II 3,947,900 4,737,500 5,527,100
(SEDANG)
15 A-4-14-III 4,737,500 5,685,000 6,632,500
(BERAT)

31 B-1-13-I 7,635,900 9,163,100 10,690,300
LAIN (RINGAN)
32 B-1-13-II 12,564,000 15,076,800 17,589,600
LAIN (SEDANG)
33 B-1-13-III 16,256,700 19,508,000 22,759,300
LAIN (BERAT)
34 B-1-14-I 20,006,000 24,007,200 28,008,400
(RINGAN)
35 B-1-14-II 21,012,000 25,214,300 29,416,700
(SEDANG)
40 B-4-11-I 6,844,300 8,213,200 9,582,000
(RINGAN)
41 B-4-11-II 9,582,100 11,498,500 13,415,000
(SEDANG)
42 B-4-11-III 11,608,600 13,930,300 16,252,000
(BERAT)
- 386 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 7,250,500 8,700,600 10,150,700
74 D-1-20-II 19,981,300 23,977,500 27,973,800
75 D-1-20-III 31,696,100 38,035,400 44,374,600
85 D-4-13-I 4,193,700 5,032,500 5,871,200
86 D-4-13-II 5,935,500 7,122,600 8,309,700
87 D-4-13-III 7,591,700 9,110,100 10,628,400
88 D-4-14-I 4,497,900 5,397,500 6,297,100
89 D-4-14-II 7,364,300 8,837,100 10,310,000
90 D-4-14-III 9,007,200 10,808,700 12,610,100
91 E-1-01-I 8,966,100 10,759,300 12,552,600
(RINGAN)
92 E-1-01-II 12,240,100 14,688,100 17,136,100
(SEDANG)

97 E-1-20-I 10,553,100 12,663,700 14,774,300
TIROGLOSAL (RINGAN)
- 387 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 14,204,100 17,045,000 19,885,800
TIROGLOSAL (SEDANG)
99 E-1-20-III 19,576,200 23,491,500 27,406,700
TIROGLOSAL (BERAT)
100 E-4-10-I 3,734,700 4,481,600 5,228,600
METABOLIK (RINGAN)
101 E-4-10-II 7,233,500 8,680,200 10,126,900
METABOLIK (SEDANG)
102 E-4-10-III 12,120,500 14,544,600 16,968,700
METABOLIK (BERAT)
109 E-4-13-I 5,190,700 6,228,900 7,267,000
(RINGAN)
110 E-4-13-II 7,603,500 9,124,200 10,645,000
(SEDANG)

118 F-4-12-I 2,929,800 3,515,700 4,101,700
(RINGAN)
119 F-4-12-II 4,165,200 4,998,300 5,831,300
(SEDANG)
120 F-4-12-III 9,048,700 10,858,500 12,668,200
(BERAT)
130 F-4-16-I 7,697,000 9,236,400 10,775,800
131 F-4-16-II 8,949,000 10,738,800 12,528,600
132 F-4-16-III 11,945,400 14,334,400 16,723,500
142 G-1-01-I 21,682,600 26,019,100 30,355,600
(RINGAN)
- 388 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 31,098,000 37,317,600 43,537,200
(SEDANG)
144 G-1-01-III 50,879,000 61,054,700 71,230,500
(BERAT)
151 G-1-12-I 6,928,400 8,314,100 9,699,800
(RINGAN)
152 G-1-12-II 12,987,700 15,585,200 18,182,800
(SEDANG)
153 G-1-12-III 17,699,700 21,239,600 24,779,500
(BERAT)
163 G-4-10-I 5,947,300 7,136,800 8,326,200
(RINGAN)
164 G-4-10-II 7,269,600 8,723,600 10,177,500
(SEDANG)
165 G-4-10-III 9,975,200 11,970,200 13,965,200
(BERAT)
166 G-4-11-I 6,225,900 7,471,100 8,716,300
167 G-4-11-II 8,270,300 9,924,400 11,578,500
168 G-4-11-III 12,151,900 14,582,300 17,012,700
DEGENERATIF (BERAT)
169 G-4-12-I 6,906,900 8,288,300 9,669,700
(RINGAN)
170 G-4-12-II 8,723,900 10,468,700 12,213,500
(SEDANG)

172 G-4-13-I 4,149,100 4,978,900 5,808,700
(RINGAN)
173 G-4-13-II 7,235,200 8,682,200 10,129,300
(SEDANG)
174 G-4-13-III 8,581,100 10,297,300 12,013,500
(BERAT)
175 G-4-14-I 7,038,400 8,446,100 9,853,800
INFARK (RINGAN)
176 G-4-14-II 9,409,900 11,291,800 13,173,800
INFARK (SEDANG)
177 G-4-14-III 11,810,500 14,172,600 16,534,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 389 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 6,314,600 7,577,500 8,840,400
(RINGAN)
185 G-4-17-II 8,279,800 9,935,800 11,591,800
(SEDANG)
186 G-4-17-III 10,404,000 12,484,800 14,565,600
(BERAT)
190 G-4-19-I 5,188,600 6,226,300 7,264,000
191 G-4-19-II 8,769,900 10,523,900 12,277,900
192 G-4-19-III 11,514,500 13,817,400 16,120,300
211 G-4-26-I 4,037,400 4,844,800 5,652,300
LAIN (RINGAN)
212 G-4-26-II 4,696,700 5,636,000 6,575,400
LAIN (SEDANG)
213 G-4-26-III 7,023,000 8,427,600 9,832,200
LAIN (BERAT)
232 I-1-02-I 36,351,500 43,621,900 50,892,200
(RINGAN)
- 390 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 46,893,000 56,271,600 65,650,200
(SEDANG)
234 I-1-02-III 57,798,600 69,358,300 80,918,000
(BERAT)
235 I-1-03-I 34,283,400 41,140,100 47,996,800
ANOMALI (RINGAN)
236 I-1-03-II 47,523,900 57,028,700 66,533,500
ANOMALI (SEDANG)
237 I-1-03-III 60,311,500 72,373,800 84,436,100
ANOMALI (BERAT)
238 I-1-04-I 51,663,200 61,995,900 72,328,500
JANTUNG (RINGAN)
239 I-1-04-II 81,538,500 97,846,200 114,153,900
JANTUNG (SEDANG)
240 I-1-04-III 130,257,300 156,308,700 182,360,200
JANTUNG (BERAT)
241 I-1-05-I 85,578,800 102,694,500 119,810,300
242 I-1-05-II 104,596,300 125,515,500 146,434,800
243 I-1-05-III 142,631,300 171,157,500 199,683,800
247 I-1-07-I 76,070,000 91,284,000 106,498,000
JANTUNG (RINGAN)
248 I-1-07-II 95,087,500 114,105,000 133,122,500
JANTUNG (SEDANG)
249 I-1-07-III 142,631,300 171,157,500 199,683,800
JANTUNG (BERAT)
250 I-1-11-I 5,696,400 6,835,700 7,975,000
251 I-1-11-II 6,333,800 7,600,600 8,867,400
252 I-1-11-III 8,428,400 10,114,100 11,799,800
253 I-1-12-I 16,397,000 19,676,400 22,955,800
(RINGAN)
254 I-1-12-II 26,779,600 32,135,500 37,491,400
(SEDANG)
255 I-1-12-III 35,232,500 42,279,000 49,325,500
(BERAT)
256 I-1-13-I 15,904,800 19,085,800 22,266,800
KOMPLEK (RINGAN)
257 I-1-13-II 21,180,500 25,416,600 29,652,700
KOMPLEK (SEDANG)
258 I-1-13-III 26,121,500 31,345,700 36,570,000
KOMPLEK (BERAT)
259 I-1-14-I 32,553,300 39,064,000 45,574,600
(RINGAN)
260 I-1-14-II 40,458,900 48,550,700 56,642,500
(SEDANG)
261 I-1-14-III 53,015,200 63,618,200 74,221,200
(BERAT)
265 I-1-16-I 16,031,700 19,238,000 22,444,300
266 I-1-16-II 36,273,200 43,527,800 50,782,500
267 I-1-16-III 41,840,600 50,208,700 58,576,800
268 I-1-17-I 18,563,100 22,275,800 25,988,400
(RINGAN)
269 I-1-17-II 23,242,800 27,891,400 32,539,900
(SEDANG)
- 391 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 28,751,000 34,501,200 40,251,400
(BERAT)
271 I-1-20-I 20,923,900 25,108,600 29,293,400
(RINGAN)
272 I-1-20-II 26,139,600 31,367,600 36,595,500
(SEDANG)
273 I-1-20-III 27,478,200 32,973,800 38,469,400
(BERAT)
274 I-1-30-I 15,827,700 18,993,300 22,158,800
JANTUNG (RINGAN)
275 I-1-30-II 32,925,200 39,510,200 46,095,200
JANTUNG (SEDANG)
276 I-1-30-III 51,022,100 61,226,600 71,431,000
JANTUNG (BERAT)

289 I-4-13-I 4,955,500 5,946,600 6,937,700
(RINGAN)
290 I-4-13-II 8,848,600 10,618,300 12,388,000
(SEDANG)
291 I-4-13-III 12,749,600 15,299,500 17,849,400
(BERAT)
295 I-4-15-I 4,779,200 5,735,000 6,690,800
(RINGAN)
296 I-4-15-II 9,012,100 10,814,500 12,616,900
(SEDANG)

304 I-4-18-I 5,697,000 6,836,400 7,975,800
JANTUNG (RINGAN)
305 I-4-18-II 8,673,900 10,408,700 12,143,500
JANTUNG (SEDANG)
306 I-4-18-III 11,776,300 14,131,500 16,486,800
JANTUNG (BERAT)

308 I-4-19-II 8,580,300 10,296,300 12,012,400
(SEDANG)
- 392 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 4,698,100 5,637,700 6,577,400
320 I-4-23-II 5,768,000 6,921,500 8,075,100
321 I-4-23-III 11,270,300 13,524,300 15,778,400
322 I-4-24-I 3,052,200 3,662,700 4,273,100
(RINGAN)
323 I-4-24-II 7,028,400 8,434,100 9,839,800
(SEDANG)
324 I-4-24-III 8,886,200 10,663,400 12,440,700
(BERAT)
325 J-1-01-I 96,707,900 116,049,400 135,391,000
326 J-1-01-II 109,442,900 131,331,500 153,220,100
327 J-1-01-III 150,119,900 180,143,800 210,167,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 63,090,200 75,708,200 88,326,300
329 J-1-02-II 79,607,500 95,529,100 111,450,600
330 J-1-02-III 93,129,600 111,755,500 130,381,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,299,700 14,759,600 17,219,600
(RINGAN)
332 J-1-10-II 24,888,500 29,866,200 34,843,900
(SEDANG)
333 J-1-10-III 25,865,300 31,038,300 36,211,400
(BERAT)
334 J-1-20-I 33,883,500 40,660,100 47,436,800
(RINGAN)
335 J-1-20-II 35,480,500 42,576,600 49,672,700
(SEDANG)
336 J-1-20-III 39,928,700 47,914,400 55,900,200
(BERAT)
337 J-1-30-I 10,264,400 12,317,300 14,370,200
(RINGAN)
338 J-1-30-II 18,593,900 22,312,600 26,031,400
(SEDANG)

- 393 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,983,800 3,580,600 4,177,400
374 J-4-21-II 6,662,900 7,995,400 9,328,000
375 J-4-21-III 12,551,600 15,061,900 17,572,300
376 K-1-10-I 11,150,400 13,380,500 15,610,600
BESAR (RINGAN)
377 K-1-10-II 14,012,900 16,815,500 19,618,000
BESAR (SEDANG)
378 K-1-10-III 16,423,600 19,708,300 22,993,000
BESAR (BERAT)
382 K-1-12-I 4,678,600 5,614,300 6,550,000
FEMORAL (RINGAN)
383 K-1-12-II 6,085,000 7,302,000 8,519,000
FEMORAL (SEDANG)
384 K-1-12-III 12,055,300 14,466,400 16,877,400
FEMORAL (BERAT)
388 K-1-14-I 7,706,500 9,247,800 10,789,100
(RINGAN)
389 K-1-14-II 9,031,800 10,838,200 12,644,600
(SEDANG)

394 K-1-30-I 9,805,500 11,766,500 13,727,600
395 K-1-30-II 17,414,300 20,897,100 24,380,000
396 K-1-30-III 23,962,300 28,754,700 33,547,200

398 K-1-40-II 12,062,400 14,474,900 16,887,400
(SEDANG)

- 394 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 5,592,600 6,711,100 7,829,600
413 K-4-13-II 7,234,400 8,681,300 10,128,200
414 K-4-13-III 11,143,300 13,371,900 15,600,600
415 K-4-14-I 3,191,200 3,829,400 4,467,600
(RINGAN)
416 K-4-14-II 4,283,600 5,140,300 5,997,000
(SEDANG)
417 K-4-14-III 6,873,500 8,248,200 9,622,900
(BERAT)

424 K-4-17-I 2,020,600 2,424,700 2,828,800
(RINGAN)
425 K-4-17-II 2,488,400 2,986,100 3,483,700
(SEDANG)
426 K-4-17-III 2,986,100 3,583,300 4,180,500
(BERAT)
427 K-4-18-I 1,780,600 2,136,800 2,492,900
(RINGAN)
428 K-4-18-II 3,004,800 3,605,800 4,206,700
(SEDANG)
436 L-1-40-I 6,989,800 8,387,700 9,785,700
(RINGAN)
437 L-1-40-II 14,020,000 16,824,000 19,628,000
(SEDANG)
438 L-1-40-III 23,598,700 28,318,500 33,038,200
(BERAT)
451 L-4-13-I 2,541,700 3,050,000 3,558,300
PAYUDARA (RINGAN)
- 395 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 4,140,500 4,968,600 5,796,700
PAYUDARA (SEDANG)
453 L-4-13-III 8,225,300 9,870,300 11,515,400
PAYUDARA (BERAT)
454 L-4-14-I 4,133,400 4,960,100 5,786,800
(RINGAN)
455 L-4-14-II 6,208,500 7,450,200 8,691,900
(SEDANG)
456 L-4-14-III 8,751,600 10,502,000 12,252,300
(BERAT)
457 M-1-01-I 14,611,100 17,533,400 20,455,600
458 M-1-01-II 20,767,700 24,921,200 29,074,800
459 M-1-01-III 29,172,400 35,006,900 40,841,400
463 M-1-03-I 51,766,000 62,119,200 72,472,400
464 M-1-03-II 60,547,900 72,657,500 84,767,100
465 M-1-03-III 74,938,100 89,925,800 104,913,400
472 M-1-07-I 18,842,000 22,610,400 26,378,800
473 M-1-07-II 25,241,800 30,290,100 35,338,500
474 M-1-07-III 51,419,800 61,703,700 71,987,700
475 M-1-10-I 22,266,200 26,719,500 31,172,700
WAJAH (RINGAN)
476 M-1-10-II 53,237,600 63,885,100 74,532,600
WAJAH (SEDANG)
477 M-1-10-III 114,828,500 137,794,200 160,759,900
WAJAH (BERAT)
478 M-1-20-I 17,350,800 20,821,000 24,291,100
(RINGAN)
479 M-1-20-II 22,167,400 26,600,900 31,034,400
(SEDANG)

484 M-1-40-I 7,271,000 8,725,200 10,179,300
INTERNAL (RINGAN)
485 M-1-40-II 10,745,600 12,894,700 15,043,900
INTERNAL (SEDANG)
486 M-1-40-III 15,342,700 18,411,200 21,479,700
INTERNAL (BERAT)
490 M-1-60-I 11,213,900 13,456,700 15,699,500
491 M-1-60-II 14,098,500 16,918,200 19,737,900
492 M-1-60-III 21,297,500 25,557,000 29,816,500
- 396 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 20,775,800 24,931,000 29,086,200
KAKI (RINGAN)
494 M-1-70-II 22,853,400 27,424,100 31,994,800
KAKI (SEDANG)
495 M-1-70-III 26,164,100 31,397,000 36,629,800
KAKI (BERAT)
502 M-4-11-I 5,184,100 6,220,900 7,257,800
(RINGAN)
503 M-4-11-II 11,365,900 13,639,100 15,912,300
(SEDANG)
504 M-4-11-III 16,433,200 19,719,800 23,006,500
(BERAT)
505 M-4-12-I 4,138,100 4,965,700 5,793,300
(RINGAN)
506 M-4-12-II 6,882,800 8,259,300 9,635,900
(SEDANG)
507 M-4-12-III 9,206,400 11,047,700 12,889,000
(BERAT)
508 M-4-13-I 6,890,300 8,268,400 9,646,500
509 M-4-13-II 10,352,400 12,422,900 14,493,400
510 M-4-13-III 20,197,300 24,236,800 28,276,300
520 M-4-17-I 4,659,900 5,591,900 6,523,900
(RINGAN)
521 M-4-17-II 6,517,400 7,820,900 9,124,400
(SEDANG)
522 M-4-17-III 9,101,200 10,921,400 12,741,600
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,705,100 4,446,100 5,187,200
(RINGAN)
530 M-4-20-II 5,425,500 6,510,600 7,595,700
(SEDANG)
531 M-4-20-III 6,063,700 7,276,400 8,489,100
(BERAT)
532 M-4-21-I 3,730,800 4,476,900 5,223,100
533 M-4-21-II 4,666,100 5,599,300 6,532,600
- 397 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 10,461,300 12,553,600 14,645,900
541 N-1-12-I 6,094,100 7,312,900 8,531,700
542 N-1-12-II 12,132,700 14,559,200 16,985,800
543 N-1-12-III 26,328,400 31,594,100 36,859,700
547 N-1-30-I 12,193,800 14,632,600 17,071,300
BAWAH (RINGAN)
548 N-1-30-II 18,446,800 22,136,200 25,825,600
BAWAH (SEDANG)
549 N-1-30-III 21,230,600 25,476,700 29,722,800
BAWAH (BERAT)
550 N-1-40-I 10,950,900 13,141,100 15,331,300
(RINGAN)
551 N-1-40-II 14,871,100 17,845,300 20,819,500
(SEDANG)
552 N-1-40-III 17,308,000 20,769,600 24,231,200
(BERAT)
553 N-4-10-I 4,652,600 5,583,100 6,513,700
(RINGAN)
554 N-4-10-II 5,627,400 6,752,900 7,878,400
(SEDANG)
555 N-4-10-III 8,277,100 9,932,500 11,588,000
(BERAT)
568 N-4-15-I 4,237,700 5,085,200 5,932,800
URIN (RINGAN)
569 N-4-15-II 5,258,200 6,309,900 7,361,500
URIN (SEDANG)
570 N-4-15-III 6,000,500 7,200,600 8,400,700
URIN (BERAT)
571 N-4-16-I 5,189,000 6,226,800 7,264,600
(RINGAN)
572 N-4-16-II 7,406,400 8,887,700 10,369,000
(SEDANG)
573 N-4-16-III 9,858,500 11,830,200 13,801,900
(BERAT)
- 398 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 4,823,500 5,788,100 6,752,800
578 O-6-11-II 5,360,700 6,432,900 7,505,000
579 O-6-11-III 6,668,800 8,002,600 9,336,300
580 O-6-12-I 3,417,300 4,100,800 4,784,300
581 O-6-12-II 4,104,200 4,925,000 5,745,900
582 O-6-12-III 5,157,100 6,188,500 7,219,900
586 P-8-01-I 76,309,900 91,571,900 106,833,800
587 P-8-01-II 94,422,000 113,306,400 132,190,800
588 P-8-01-III 110,824,900 132,989,900 155,154,900
589 P-8-02-I 104,159,400 124,991,300 145,823,100
590 P-8-02-II 119,481,300 143,377,500 167,273,800
591 P-8-02-III 136,515,800 163,819,000 191,122,100
592 P-8-03-I 15,623,800 18,748,600 21,873,300
593 P-8-03-II 20,680,200 24,816,300 28,952,300
594 P-8-03-III 29,077,400 34,892,800 40,708,300
595 P-8-04-I 50,348,400 60,418,000 70,487,700
596 P-8-04-II 65,341,300 78,409,500 91,477,800
597 P-8-04-III 93,683,000 112,419,600 131,156,200
598 P-8-05-I 27,377,800 32,853,400 38,328,900
599 P-8-05-II 42,235,100 50,682,100 59,129,100
600 P-8-05-III 57,173,000 68,607,500 80,042,100
601 P-8-06-I 7,391,100 8,869,400 10,347,600
602 P-8-06-II 20,723,100 24,867,700 29,012,300
603 P-8-06-III 27,453,000 32,943,600 38,434,200
604 P-8-07-I 8,750,000 10,500,000 12,250,000
605 P-8-07-II 24,532,900 29,439,500 34,346,100
606 P-8-07-III 32,500,100 39,000,100 45,500,100
607 P-8-08-I 5,062,800 6,075,400 7,088,000
608 P-8-08-II 7,183,900 8,620,700 10,057,500
609 P-8-08-III 13,975,600 16,770,700 19,565,800
610 P-8-11-I 13,019,800 15,623,800 18,227,800
MAYOR (RINGAN)
611 P-8-11-II 17,233,500 20,680,200 24,126,900
MAYOR (SEDANG)
- 399 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 24,231,100 29,077,400 33,923,600
MAYOR (BERAT)
613 P-8-12-I 11,836,200 14,203,500 16,570,700
MAYOR (RINGAN)
614 P-8-12-II 14,361,300 17,233,500 20,105,800
MAYOR (SEDANG)
615 P-8-12-III 21,070,500 25,284,700 29,498,800
MAYOR (BERAT)
616 P-8-13-I 6,575,700 7,890,800 9,205,900
MAYOR (RINGAN)
617 P-8-13-II 10,258,000 12,309,700 14,361,300
MAYOR (SEDANG)
618 P-8-13-III 16,208,100 19,449,700 22,691,400
MAYOR (BERAT)
619 P-8-14-I 4,977,300 5,972,700 6,968,200
620 P-8-14-II 10,131,800 12,158,100 14,184,500
621 P-8-14-III 39,615,900 47,539,100 55,462,300
622 P-8-15-I 3,733,000 4,479,600 5,226,200
ASPIRASI (RINGAN)
623 P-8-15-II 7,475,500 8,970,700 10,465,800
ASPIRASI (SEDANG)
624 P-8-15-III 8,771,200 10,525,400 12,279,700
ASPIRASI (BERAT)
625 P-8-16-I 3,378,400 4,054,100 4,729,800
626 P-8-16-II 6,492,200 7,790,600 9,089,100
627 P-8-16-III 15,225,300 18,270,300 21,315,400
628 P-8-17-I 4,383,800 5,260,500 6,137,300
(RINGAN)
629 P-8-17-II 7,890,800 9,469,000 11,047,100
(SEDANG)
630 P-8-17-III 13,506,800 16,208,100 18,909,500
(BERAT)
631 S-4-10-I 3,809,100 4,571,000 5,332,800
632 S-4-10-II 4,693,400 5,632,100 6,570,800
633 S-4-10-III 6,424,800 7,709,800 8,994,800
640 S-4-13-I 4,135,600 4,962,700 5,789,800
(RINGAN)
641 S-4-13-II 7,336,800 8,804,200 10,271,500
(SEDANG)
642 S-4-13-III 11,908,600 14,290,300 16,672,000
(BERAT)
643 S-4-14-I 2,092,900 2,511,500 2,930,000
644 S-4-14-II 4,445,500 5,334,600 6,223,600
645 S-4-14-III 8,430,200 10,116,200 11,802,200
KANAK-KANAK (BERAT)
646 S-4-15-I 1,399,700 1,679,700 1,959,600
647 S-4-15-II 2,641,500 3,169,900 3,698,200
648 S-4-15-III 3,421,300 4,105,500 4,789,800
- 400 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 3,493,500 4,192,200 4,890,800
653 S-4-17-II 5,184,700 6,221,600 7,258,600
654 S-4-17-III 6,235,700 7,482,900 8,730,000
655 T-1-10-I 2,337,400 2,804,900 3,272,400
OBAT (RINGAN)
656 T-1-10-II 3,139,400 3,767,300 4,395,200
OBAT (SEDANG)
657 T-1-10-III 5,711,100 6,853,300 7,995,500
OBAT (BERAT)
658 T-4-10-I 1,279,900 1,535,800 1,791,800
659 T-4-10-II 2,438,800 2,926,500 3,414,300
660 T-4-10-III 3,544,800 4,253,800 4,962,800
661 T-4-11-I 1,236,000 1,483,300 1,730,500
662 T-4-11-II 1,945,200 2,334,200 2,723,300
663 T-4-11-III 3,133,200 3,759,800 4,386,400
664 T-4-12-I 2,896,200 3,475,400 4,054,600
LAIN (RINGAN)
665 T-4-12-II 4,372,000 5,246,400 6,120,800
LAIN (SEDANG)
666 T-4-12-III 6,767,200 8,120,700 9,474,100
LAIN (BERAT)
670 U-1-11-I 12,054,400 14,465,300 16,876,200
(RINGAN)
671 U-1-11-II 18,181,900 21,818,300 25,454,700
(SEDANG)
672 U-1-11-III 21,553,400 25,864,100 30,174,800
(BERAT)
679 U-1-14-I 5,552,500 6,663,100 7,773,600
(RINGAN)
680 U-1-14-II 6,814,300 8,177,200 9,540,100
(SEDANG)
681 U-1-14-III 8,075,000 9,689,900 11,304,900
(BERAT)
685 U-1-20-I 8,429,700 10,115,600 11,801,500
686 U-1-20-II 12,545,700 15,054,800 17,563,900
687 U-1-20-III 32,207,100 38,648,500 45,089,900
691 U-4-10-I 5,202,500 6,243,000 7,283,600
- 401 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 11,910,200 14,292,200 16,674,300
693 U-4-10-III 18,285,800 21,943,000 25,600,100
TENGGOROKAN (BERAT)
700 U-4-13-I 2,047,900 2,457,500 2,867,100
701 U-4-13-II 3,346,500 4,015,800 4,685,100
702 U-4-13-III 5,403,500 6,484,200 7,564,900
706 U-4-15-I 4,158,000 4,989,600 5,821,200
707 U-4-15-II 5,180,300 6,216,400 7,252,500
708 U-4-15-III 7,249,900 8,699,900 10,149,900
709 V-1-10-I 6,782,000 8,138,500 9,494,900
(RINGAN)
710 V-1-10-II 13,970,800 16,764,900 19,559,100
(SEDANG)
711 V-1-10-III 17,133,200 20,559,800 23,986,500
(BERAT)
715 V-1-12-I 12,130,900 14,557,000 16,983,200
MODERAT (RINGAN)
716 V-1-12-II 16,565,700 19,878,800 23,191,900
MODERAT (SEDANG)
717 V-1-12-III 20,997,200 25,196,600 29,396,000
MODERAT (BERAT)
718 V-1-13-I 6,327,600 7,593,100 8,858,700
KOMPLEK (RINGAN)
719 V-1-13-II 12,090,000 14,508,000 16,926,000
KOMPLEK (SEDANG)
720 V-1-13-III 18,967,700 22,761,200 26,554,800
KOMPLEK (BERAT)
721 V-1-14-I 12,408,400 14,890,100 17,371,800
(RINGAN)
722 V-1-14-II 18,029,100 21,634,900 25,240,700
(SEDANG)

727 V-4-10-I 5,400,400 6,480,500 7,560,600
(RINGAN)
728 V-4-10-II 8,970,400 10,764,500 12,558,600
(SEDANG)
729 V-4-10-III 14,789,100 17,746,900 20,704,700
(BERAT)
730 V-4-11-I 5,184,800 6,221,800 7,258,700
TUMOR (RINGAN)
731 V-4-11-II 6,956,700 8,348,000 9,739,300
TUMOR (SEDANG)
732 V-4-11-III 9,318,500 11,182,200 13,045,900
TUMOR (BERAT)
- 402 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 14,131,900 16,958,300 19,784,700
734 W-1-01-II 16,938,100 20,325,700 23,713,300
735 W-1-01-III 24,170,200 29,004,200 33,838,200
739 W-1-11-I 3,133,100 3,759,800 4,386,400
SERVIK (RINGAN)
740 W-1-11-II 3,457,400 4,148,900 4,840,400
SERVIK (SEDANG)
741 W-1-11-III 3,824,600 4,589,500 5,354,400
SERVIK (BERAT)
760 W-4-12-I 2,995,400 3,594,500 4,193,600
761 W-4-12-II 5,700,300 6,840,400 7,980,400
762 W-4-12-III 8,388,400 10,066,100 11,743,800
- 403 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 2,117,600 2,541,100 2,964,700
785 Z-4-12-II 4,251,900 5,102,300 5,952,700
786 Z-4-12-III 8,970,500 10,764,600 12,558,700
- 404 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,264,400

33 F-3-10-0 TERAPI SHOCK 641,300
- 405 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 3,898,400
PENGGANTIAN ALAT
81 I-2-42-0 3,746,100
PERKUTAN LAIN
- 406 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,766,600
192 Q-5-12-0 GIGI 320,900
196 Q-5-16-0 VAKSINASI 106,900
201 Q-5-21-0 ABORSI 280,100
206 Q-5-26-0 BRONKIAL AKUT 227,600
- 407 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 153,300
215 Q-5-35-0 INFEKSI AKUT 655,000
218 Q-5-38-0 PARU AKUT 381,700
234 U-2-23-0 RHINOPLASTY 1,885,900
242 U-3-13-0 486,100
TENGGOROKAN
270 Z-3-11-0 2,637,300
EMPEDU
- 408 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,389,600
289 Z-3-30-0 FOTOTERAPI 88,400
- 409 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,416,800 2,900,100 3,383,500
(RINGAN)
14 A-4-14-II 4,066,300 4,879,600 5,692,900
(SEDANG)
15 A-4-14-III 4,879,600 5,855,500 6,831,500
(BERAT)

31 B-1-13-I 7,865,000 9,438,000 11,011,000
LAIN (RINGAN)
32 B-1-13-II 12,940,900 15,529,100 18,117,200
LAIN (SEDANG)
33 B-1-13-III 16,744,400 20,093,200 23,442,100
LAIN (BERAT)
34 B-1-14-I 20,606,200 24,727,500 28,848,700
(RINGAN)
35 B-1-14-II 21,642,300 25,970,800 30,299,200
(SEDANG)
40 B-4-11-I 7,049,600 8,459,600 9,869,500
(RINGAN)
41 B-4-11-II 9,869,600 11,843,500 13,817,400
(SEDANG)
42 B-4-11-III 11,956,900 14,348,200 16,739,600
(BERAT)
- 410 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 7,468,000 8,961,600 10,455,200
74 D-1-20-II 20,580,700 24,696,800 28,813,000
75 D-1-20-III 32,647,000 39,176,400 45,705,800
85 D-4-13-I 4,319,500 5,183,400 6,047,300
86 D-4-13-II 6,113,600 7,336,300 8,559,000
87 D-4-13-III 7,819,500 9,383,400 10,947,300
88 D-4-14-I 4,632,900 5,559,500 6,486,000
89 D-4-14-II 7,585,200 9,102,200 10,619,300
90 D-4-14-III 9,277,500 11,133,000 12,988,400
91 E-1-01-I 9,235,100 11,082,100 12,929,100
(RINGAN)
92 E-1-01-II 12,607,300 15,128,700 17,650,200
(SEDANG)

97 E-1-20-I 10,869,700 13,043,600 15,217,500
TIROGLOSAL (RINGAN)
- 411 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 14,630,300 17,556,300 20,482,400
TIROGLOSAL (SEDANG)
99 E-1-20-III 20,163,500 24,196,200 28,228,900
TIROGLOSAL (BERAT)
100 E-4-10-I 3,846,700 4,616,100 5,385,400
METABOLIK (RINGAN)
101 E-4-10-II 7,450,500 8,940,600 10,430,700
METABOLIK (SEDANG)
102 E-4-10-III 12,484,100 14,981,000 17,477,800
METABOLIK (BERAT)
109 E-4-13-I 5,346,500 6,415,800 7,485,100
(RINGAN)
110 E-4-13-II 7,831,600 9,398,000 10,964,300
(SEDANG)

118 F-4-12-I 3,017,700 3,621,200 4,224,700
(RINGAN)
119 F-4-12-II 4,290,200 5,148,200 6,006,300
(SEDANG)
120 F-4-12-III 9,320,200 11,184,200 13,048,300
(BERAT)
130 F-4-16-I 7,927,900 9,513,500 11,099,000
131 F-4-16-II 9,217,500 11,061,000 12,904,400
132 F-4-16-III 12,303,700 14,764,500 17,225,200
142 G-1-01-I 22,333,000 26,799,600 31,266,200
(RINGAN)
- 412 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 32,031,000 38,437,200 44,843,400
(SEDANG)
144 G-1-01-III 52,405,300 62,886,400 73,367,500
(BERAT)
151 G-1-12-I 7,136,300 8,563,500 9,990,800
(RINGAN)
152 G-1-12-II 13,377,300 16,052,800 18,728,200
(SEDANG)
153 G-1-12-III 18,230,700 21,876,800 25,522,900
(BERAT)
163 G-4-10-I 6,125,700 7,350,900 8,576,000
(RINGAN)
164 G-4-10-II 7,487,700 8,985,300 10,482,800
(SEDANG)
165 G-4-10-III 10,274,400 12,329,300 14,384,200
(BERAT)
166 G-4-11-I 6,412,700 7,695,200 8,977,700
167 G-4-11-II 8,518,400 10,222,100 11,925,800
168 G-4-11-III 12,516,500 15,019,800 17,523,100
DEGENERATIF (BERAT)
169 G-4-12-I 7,114,100 8,537,000 9,959,800
(RINGAN)
170 G-4-12-II 8,985,600 10,782,800 12,579,900
(SEDANG)

172 G-4-13-I 4,273,500 5,128,300 5,983,000
(RINGAN)
173 G-4-13-II 7,452,200 8,942,700 10,433,100
(SEDANG)
174 G-4-13-III 8,838,500 10,606,200 12,373,900
(BERAT)
175 G-4-14-I 7,249,600 8,699,500 10,149,400
INFARK (RINGAN)
176 G-4-14-II 9,692,200 11,630,600 13,569,000
INFARK (SEDANG)
177 G-4-14-III 12,164,800 14,597,800 17,030,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 413 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 6,504,000 7,804,900 9,105,700
(RINGAN)
185 G-4-17-II 8,528,200 10,233,900 11,939,500
(SEDANG)
186 G-4-17-III 10,716,100 12,859,300 15,002,600
(BERAT)
190 G-4-19-I 5,344,200 6,413,100 7,481,900
191 G-4-19-II 9,033,000 10,839,600 12,646,300
192 G-4-19-III 11,860,000 14,232,000 16,604,000
211 G-4-26-I 4,158,500 4,990,200 5,821,900
LAIN (RINGAN)
212 G-4-26-II 4,837,600 5,805,100 6,772,700
LAIN (SEDANG)
213 G-4-26-III 7,233,700 8,680,400 10,127,200
LAIN (BERAT)
232 I-1-02-I 37,442,100 44,930,500 52,418,900
(RINGAN)
- 414 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 48,299,800 57,959,800 67,619,700
(SEDANG)
234 I-1-02-III 59,532,500 71,439,100 83,345,600
(BERAT)
235 I-1-03-I 35,311,900 42,374,300 49,436,700
ANOMALI (RINGAN)
236 I-1-03-II 48,949,600 58,739,500 68,529,500
ANOMALI (SEDANG)
237 I-1-03-III 62,120,800 74,545,000 86,969,200
ANOMALI (BERAT)
238 I-1-04-I 53,213,100 63,855,700 74,498,400
JANTUNG (RINGAN)
239 I-1-04-II 83,984,700 100,781,600 117,578,600
JANTUNG (SEDANG)
240 I-1-04-III 134,165,000 160,998,000 187,831,000
JANTUNG (BERAT)
241 I-1-05-I 88,146,100 105,775,400 123,404,600
242 I-1-05-II 107,734,200 129,281,000 150,827,800
243 I-1-05-III 146,910,200 176,292,300 205,674,300
247 I-1-07-I 78,352,100 94,022,500 109,693,000
JANTUNG (RINGAN)
248 I-1-07-II 97,940,100 117,528,200 137,116,200
JANTUNG (SEDANG)
249 I-1-07-III 146,910,200 176,292,300 205,674,300
JANTUNG (BERAT)
250 I-1-11-I 5,867,300 7,040,800 8,214,200
251 I-1-11-II 6,523,800 7,828,600 9,133,400
252 I-1-11-III 8,681,300 10,417,500 12,153,800
253 I-1-12-I 16,888,900 20,266,700 23,644,400
(RINGAN)
254 I-1-12-II 27,582,900 33,099,500 38,616,100
(SEDANG)
255 I-1-12-III 36,289,500 43,547,400 50,805,300
(BERAT)
256 I-1-13-I 16,382,000 19,658,400 22,934,800
KOMPLEK (RINGAN)
257 I-1-13-II 21,815,900 26,179,100 30,542,300
KOMPLEK (SEDANG)
258 I-1-13-III 26,905,100 32,286,100 37,667,100
KOMPLEK (BERAT)
259 I-1-14-I 33,529,900 40,235,900 46,941,800
(RINGAN)
260 I-1-14-II 41,672,700 50,007,300 58,341,800
(SEDANG)
261 I-1-14-III 54,605,600 65,526,800 76,447,900
(BERAT)
265 I-1-16-I 16,512,600 19,815,100 23,117,700
266 I-1-16-II 37,361,400 44,833,700 52,305,900
267 I-1-16-III 43,095,800 51,714,900 60,334,100
268 I-1-17-I 19,120,000 22,944,000 26,768,100
(RINGAN)
269 I-1-17-II 23,940,100 28,728,100 33,516,100
(SEDANG)
- 415 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 29,613,500 35,536,200 41,458,900
(BERAT)
271 I-1-20-I 21,551,600 25,861,900 30,172,200
(RINGAN)
272 I-1-20-II 26,923,800 32,308,600 37,693,400
(SEDANG)
273 I-1-20-III 28,302,500 33,963,000 39,623,500
(BERAT)
274 I-1-30-I 16,302,500 19,563,100 22,823,600
JANTUNG (RINGAN)
275 I-1-30-II 33,912,900 40,695,500 47,478,100
JANTUNG (SEDANG)
276 I-1-30-III 52,552,800 63,063,400 73,573,900
JANTUNG (BERAT)

289 I-4-13-I 5,104,100 6,125,000 7,145,800
(RINGAN)
290 I-4-13-II 9,114,000 10,936,800 12,759,700
(SEDANG)
291 I-4-13-III 13,132,000 15,758,500 18,384,900
(BERAT)
295 I-4-15-I 4,922,500 5,907,000 6,891,600
(RINGAN)
296 I-4-15-II 9,282,400 11,138,900 12,995,400
(SEDANG)

304 I-4-18-I 5,867,900 7,041,500 8,215,100
JANTUNG (RINGAN)
305 I-4-18-II 8,934,100 10,721,000 12,507,800
JANTUNG (SEDANG)
306 I-4-18-III 12,129,600 14,555,500 16,981,400
JANTUNG (BERAT)

308 I-4-19-II 8,837,700 10,605,200 12,372,800
(SEDANG)
- 416 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 4,839,100 5,806,900 6,774,700
320 I-4-23-II 5,941,000 7,129,200 8,317,400
321 I-4-23-III 11,608,400 13,930,000 16,251,700
322 I-4-24-I 3,143,800 3,772,500 4,401,300
(RINGAN)
323 I-4-24-II 7,239,300 8,687,100 10,135,000
(SEDANG)
324 I-4-24-III 9,152,800 10,983,400 12,813,900
(BERAT)
325 J-1-01-I 99,609,100 119,530,900 139,452,700
326 J-1-01-II 112,726,200 135,271,500 157,816,700
327 J-1-01-III 154,623,500 185,548,100 216,472,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 64,982,900 77,979,500 90,976,000
329 J-1-02-II 81,995,800 98,394,900 114,794,100
330 J-1-02-III 95,923,400 115,108,100 134,292,800
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,668,700 15,202,400 17,736,200
(RINGAN)
332 J-1-10-II 25,635,100 30,762,200 35,889,200
(SEDANG)
333 J-1-10-III 26,641,200 31,969,500 37,297,700
(BERAT)
334 J-1-20-I 34,900,000 41,879,900 48,859,900
(RINGAN)
335 J-1-20-II 36,544,900 43,853,900 51,162,900
(SEDANG)
336 J-1-20-III 41,126,600 49,351,900 57,577,200
(BERAT)
337 J-1-30-I 10,572,300 12,686,800 14,801,300
(RINGAN)
338 J-1-30-II 19,151,700 22,982,000 26,812,300
(SEDANG)

- 417 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 3,073,400 3,688,000 4,302,700
374 J-4-21-II 6,862,700 8,235,300 9,607,800
375 J-4-21-III 12,928,200 15,513,800 18,099,400
376 K-1-10-I 11,484,900 13,781,900 16,078,900
BESAR (RINGAN)
377 K-1-10-II 14,433,300 17,319,900 20,206,600
BESAR (SEDANG)
378 K-1-10-III 16,916,300 20,299,500 23,682,800
BESAR (BERAT)
382 K-1-12-I 4,818,900 5,782,700 6,746,500
FEMORAL (RINGAN)
383 K-1-12-II 6,267,600 7,521,100 8,774,600
FEMORAL (SEDANG)
384 K-1-12-III 12,417,000 14,900,400 17,383,800
FEMORAL (BERAT)
388 K-1-14-I 7,937,700 9,525,200 11,112,800
(RINGAN)
389 K-1-14-II 9,302,800 11,163,400 13,023,900
(SEDANG)

394 K-1-30-I 10,099,600 12,119,500 14,139,500
395 K-1-30-II 17,936,700 21,524,000 25,111,400
396 K-1-30-III 24,681,100 29,617,400 34,553,600

398 K-1-40-II 12,424,300 14,909,100 17,394,000
(SEDANG)

- 418 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 5,760,400 6,912,400 8,064,500
413 K-4-13-II 7,451,400 8,941,700 10,432,000
414 K-4-13-III 11,477,600 13,773,100 16,068,600
415 K-4-14-I 3,286,900 3,944,300 4,601,700
(RINGAN)
416 K-4-14-II 4,412,100 5,294,500 6,176,900
(SEDANG)
417 K-4-14-III 7,079,700 8,495,600 9,911,500
(BERAT)

424 K-4-17-I 2,081,200 2,497,500 2,913,700
(RINGAN)
425 K-4-17-II 2,563,000 3,075,600 3,588,200
(SEDANG)
426 K-4-17-III 3,075,600 3,690,800 4,305,900
(BERAT)
427 K-4-18-I 1,834,100 2,200,900 2,567,700
(RINGAN)
428 K-4-18-II 3,095,000 3,714,000 4,333,000
(SEDANG)
436 L-1-40-I 7,199,500 8,639,400 10,079,300
(RINGAN)
437 L-1-40-II 14,440,600 17,328,700 20,216,800
(SEDANG)
438 L-1-40-III 24,306,700 29,168,000 34,029,400
(BERAT)
451 L-4-13-I 2,617,900 3,141,500 3,665,100
PAYUDARA (RINGAN)
- 419 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 4,264,700 5,117,600 5,970,600
PAYUDARA (SEDANG)
453 L-4-13-III 8,472,000 10,166,400 11,860,800
PAYUDARA (BERAT)
454 L-4-14-I 4,257,400 5,108,900 5,960,400
(RINGAN)
455 L-4-14-II 6,394,800 7,673,700 8,952,700
(SEDANG)
456 L-4-14-III 9,014,200 10,817,000 12,619,800
(BERAT)
457 M-1-01-I 15,049,500 18,059,400 21,069,300
458 M-1-01-II 21,390,700 25,668,900 29,947,000
459 M-1-01-III 30,047,600 36,057,100 42,066,600
463 M-1-03-I 53,319,000 63,982,800 74,646,600
464 M-1-03-II 62,364,400 74,837,200 87,310,100
465 M-1-03-III 77,186,300 92,623,500 108,060,800
472 M-1-07-I 19,407,200 23,288,700 27,170,100
473 M-1-07-II 25,999,000 31,198,800 36,398,600
474 M-1-07-III 52,962,400 63,554,900 74,147,300
475 M-1-10-I 22,934,200 27,521,100 32,107,900
WAJAH (RINGAN)
476 M-1-10-II 54,834,700 65,801,600 76,768,600
WAJAH (SEDANG)
477 M-1-10-III 118,273,400 141,928,000 165,582,700
WAJAH (BERAT)
478 M-1-20-I 17,871,300 21,445,600 25,019,800
(RINGAN)
479 M-1-20-II 22,832,400 27,398,900 31,965,400
(SEDANG)

484 M-1-40-I 7,489,100 8,986,900 10,484,700
INTERNAL (RINGAN)
485 M-1-40-II 11,068,000 13,281,600 15,495,200
INTERNAL (SEDANG)
486 M-1-40-III 15,802,900 18,963,500 22,124,100
INTERNAL (BERAT)
490 M-1-60-I 11,550,300 13,860,400 16,170,500
491 M-1-60-II 14,521,400 17,425,700 20,330,000
492 M-1-60-III 21,936,400 26,323,700 30,711,000
- 420 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 21,399,100 25,678,900 29,958,700
KAKI (RINGAN)
494 M-1-70-II 23,539,000 28,246,800 32,954,600
KAKI (SEDANG)
495 M-1-70-III 26,949,100 32,338,900 37,728,700
KAKI (BERAT)
502 M-4-11-I 5,339,600 6,407,600 7,475,500
(RINGAN)
503 M-4-11-II 11,706,900 14,048,300 16,389,700
(SEDANG)
504 M-4-11-III 16,926,200 20,311,400 23,696,700
(BERAT)
505 M-4-12-I 4,262,200 5,114,700 5,967,100
(RINGAN)
506 M-4-12-II 7,089,300 8,507,100 9,925,000
(SEDANG)
507 M-4-12-III 9,482,600 11,379,100 13,275,700
(BERAT)
508 M-4-13-I 7,097,000 8,516,400 9,935,800
509 M-4-13-II 10,663,000 12,795,600 14,928,200
510 M-4-13-III 20,803,300 24,963,900 29,124,600
520 M-4-17-I 4,799,700 5,759,700 6,719,600
(RINGAN)
521 M-4-17-II 6,713,000 8,055,500 9,398,100
(SEDANG)
522 M-4-17-III 9,374,200 11,249,000 13,123,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,816,300 4,579,500 5,342,800
(RINGAN)
530 M-4-20-II 5,588,300 6,705,900 7,823,600
(SEDANG)
531 M-4-20-III 6,245,600 7,494,700 8,743,800
(BERAT)
532 M-4-21-I 3,842,700 4,611,200 5,379,800
533 M-4-21-II 4,806,100 5,767,300 6,728,500
- 421 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 10,775,200 12,930,200 15,085,200
541 N-1-12-I 6,276,900 7,532,300 8,787,700
542 N-1-12-II 12,496,700 14,996,000 17,495,300
543 N-1-12-III 27,118,200 32,541,900 37,965,500
547 N-1-30-I 12,559,600 15,071,600 17,583,500
BAWAH (RINGAN)
548 N-1-30-II 19,000,200 22,800,300 26,600,300
BAWAH (SEDANG)
549 N-1-30-III 21,867,500 26,241,000 30,614,500
BAWAH (BERAT)
550 N-1-40-I 11,279,400 13,535,300 15,791,200
(RINGAN)
551 N-1-40-II 15,317,200 18,380,700 21,444,100
(SEDANG)
552 N-1-40-III 17,827,200 21,392,700 24,958,100
(BERAT)
553 N-4-10-I 4,792,200 5,750,600 6,709,100
(RINGAN)
554 N-4-10-II 5,796,200 6,955,500 8,114,700
(SEDANG)
555 N-4-10-III 8,525,400 10,230,500 11,935,600
(BERAT)
568 N-4-15-I 4,364,800 5,237,800 6,110,700
URIN (RINGAN)
569 N-4-15-II 5,416,000 6,499,200 7,582,400
URIN (SEDANG)
570 N-4-15-III 6,180,500 7,416,600 8,652,800
URIN (BERAT)
571 N-4-16-I 5,344,700 6,413,600 7,482,600
(RINGAN)
572 N-4-16-II 7,628,600 9,154,300 10,680,000
(SEDANG)
573 N-4-16-III 10,154,200 12,185,100 14,215,900
(BERAT)
- 422 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 4,968,200 5,961,800 6,955,400
578 O-6-11-II 5,521,500 6,625,800 7,730,200
579 O-6-11-III 6,868,900 8,242,600 9,616,400
580 O-6-12-I 3,519,900 4,223,800 4,927,800
581 O-6-12-II 4,227,300 5,072,800 5,918,300
582 O-6-12-III 5,311,800 6,374,200 7,436,500
586 P-8-01-I 78,599,200 94,319,000 110,038,900
587 P-8-01-II 97,254,700 116,705,600 136,156,600
588 P-8-01-III 114,149,700 136,979,600 159,809,500
589 P-8-02-I 107,284,200 128,741,000 150,197,800
590 P-8-02-II 123,065,700 147,678,900 172,292,000
591 P-8-02-III 140,611,300 168,733,600 196,855,800
592 P-8-03-I 16,092,500 19,311,000 22,529,500
593 P-8-03-II 21,300,600 25,560,800 29,820,900
594 P-8-03-III 29,949,700 35,939,600 41,929,500
595 P-8-04-I 51,858,800 62,230,600 72,602,300
596 P-8-04-II 67,301,500 80,761,800 94,222,100
597 P-8-04-III 96,493,500 115,792,200 135,090,900
598 P-8-05-I 28,199,200 33,839,000 39,478,800
599 P-8-05-II 43,502,100 52,202,500 60,903,000
600 P-8-05-III 58,888,100 70,665,800 82,443,400
601 P-8-06-I 7,612,900 9,135,500 10,658,000
602 P-8-06-II 21,344,800 25,613,700 29,882,700
603 P-8-06-III 28,276,600 33,931,900 39,587,200
604 P-8-07-I 9,012,500 10,815,000 12,617,500
605 P-8-07-II 25,268,900 30,322,700 35,376,500
606 P-8-07-III 33,475,100 40,170,100 46,865,100
607 P-8-08-I 5,214,700 6,257,700 7,300,600
608 P-8-08-II 7,399,400 8,879,300 10,359,200
609 P-8-08-III 14,394,800 17,273,800 20,152,800
610 P-8-11-I 13,410,400 16,092,500 18,774,600
MAYOR (RINGAN)
611 P-8-11-II 17,750,500 21,300,600 24,850,700
MAYOR (SEDANG)
- 423 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 24,958,100 29,949,700 34,941,300
MAYOR (BERAT)
613 P-8-12-I 12,191,300 14,629,600 17,067,800
MAYOR (RINGAN)
614 P-8-12-II 14,792,100 17,750,500 20,708,900
MAYOR (SEDANG)
615 P-8-12-III 21,702,700 26,043,200 30,383,700
MAYOR (BERAT)
616 P-8-13-I 6,772,900 8,127,500 9,482,100
MAYOR (RINGAN)
617 P-8-13-II 10,565,800 12,678,900 14,792,100
MAYOR (SEDANG)
618 P-8-13-III 16,694,400 20,033,200 23,372,100
MAYOR (BERAT)
619 P-8-14-I 5,126,600 6,151,900 7,177,200
620 P-8-14-II 10,435,700 12,522,800 14,610,000
621 P-8-14-III 40,804,400 48,965,300 57,126,200
622 P-8-15-I 3,845,000 4,614,000 5,383,000
ASPIRASI (RINGAN)
623 P-8-15-II 7,699,800 9,239,800 10,779,700
ASPIRASI (SEDANG)
624 P-8-15-III 9,034,300 10,841,200 12,648,100
ASPIRASI (BERAT)
625 P-8-16-I 3,479,800 4,175,700 4,871,700
626 P-8-16-II 6,687,000 8,024,400 9,361,700
627 P-8-16-III 15,682,000 18,818,400 21,954,800
628 P-8-17-I 4,515,300 5,418,400 6,321,400
(RINGAN)
629 P-8-17-II 8,127,500 9,753,000 11,378,500
(SEDANG)
630 P-8-17-III 13,912,000 16,694,400 19,476,700
(BERAT)
631 S-4-10-I 3,923,400 4,708,100 5,492,800
632 S-4-10-II 4,834,200 5,801,100 6,767,900
633 S-4-10-III 6,617,600 7,941,100 9,264,600
640 S-4-13-I 4,259,600 5,111,600 5,963,500
(RINGAN)
641 S-4-13-II 7,556,900 9,068,300 10,579,700
(SEDANG)
642 S-4-13-III 12,265,800 14,719,000 17,172,200
(BERAT)
643 S-4-14-I 2,155,700 2,586,800 3,017,900
644 S-4-14-II 4,578,800 5,494,600 6,410,400
645 S-4-14-III 8,683,100 10,419,700 12,156,300
KANAK-KANAK (BERAT)
646 S-4-15-I 1,441,700 1,730,100 2,018,400
647 S-4-15-II 2,720,800 3,264,900 3,809,100
648 S-4-15-III 3,523,900 4,228,700 4,933,400
- 424 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 3,598,300 4,317,900 5,037,600
653 S-4-17-II 5,340,200 6,408,300 7,476,300
654 S-4-17-III 6,422,800 7,707,400 8,991,900
655 T-1-10-I 2,407,500 2,889,000 3,370,500
OBAT (RINGAN)
656 T-1-10-II 3,233,600 3,880,300 4,527,100
OBAT (SEDANG)
657 T-1-10-III 5,882,400 7,058,900 8,235,400
OBAT (BERAT)
658 T-4-10-I 1,318,300 1,581,900 1,845,600
659 T-4-10-II 2,511,900 3,014,300 3,516,700
660 T-4-10-III 3,651,200 4,381,400 5,111,700
661 T-4-11-I 1,273,100 1,527,800 1,782,400
662 T-4-11-II 2,003,600 2,404,300 2,805,000
663 T-4-11-III 3,227,100 3,872,600 4,518,000
664 T-4-12-I 2,983,000 3,579,700 4,176,300
LAIN (RINGAN)
665 T-4-12-II 4,503,200 5,403,800 6,304,500
LAIN (SEDANG)
666 T-4-12-III 6,970,300 8,364,300 9,758,400
LAIN (BERAT)
670 U-1-11-I 12,416,100 14,899,300 17,382,500
(RINGAN)
671 U-1-11-II 18,727,400 22,472,800 26,218,300
(SEDANG)
672 U-1-11-III 22,200,000 26,640,000 31,080,000
(BERAT)
679 U-1-14-I 5,719,100 6,862,900 8,006,800
(RINGAN)
680 U-1-14-II 7,018,800 8,422,500 9,826,300
(SEDANG)
681 U-1-14-III 8,317,200 9,980,600 11,644,100
(BERAT)
685 U-1-20-I 8,682,500 10,419,100 12,155,600
686 U-1-20-II 12,922,000 15,506,400 18,090,800
687 U-1-20-III 33,173,300 39,808,000 46,442,600
691 U-4-10-I 5,358,600 6,430,300 7,502,100
- 425 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 12,267,500 14,721,000 17,174,500
693 U-4-10-III 18,834,400 22,601,200 26,368,100
TENGGOROKAN (BERAT)
700 U-4-13-I 2,109,400 2,531,300 2,953,100
701 U-4-13-II 3,446,900 4,136,300 4,825,700
702 U-4-13-III 5,565,600 6,678,700 7,791,800
706 U-4-15-I 4,282,700 5,139,300 5,995,800
707 U-4-15-II 5,335,700 6,402,900 7,470,000
708 U-4-15-III 7,467,400 8,960,900 10,454,400
709 V-1-10-I 6,985,500 8,382,600 9,779,700
(RINGAN)
710 V-1-10-II 14,389,900 17,267,900 20,145,800
(SEDANG)
711 V-1-10-III 17,647,200 21,176,600 24,706,100
(BERAT)
715 V-1-12-I 12,494,800 14,993,700 17,492,700
MODERAT (RINGAN)
716 V-1-12-II 17,062,600 20,475,200 23,887,700
MODERAT (SEDANG)
717 V-1-12-III 21,627,100 25,952,500 30,277,900
MODERAT (BERAT)
718 V-1-13-I 6,517,400 7,820,900 9,124,400
KOMPLEK (RINGAN)
719 V-1-13-II 12,452,700 14,943,200 17,433,800
KOMPLEK (SEDANG)
720 V-1-13-III 19,536,700 23,444,100 27,351,400
KOMPLEK (BERAT)
721 V-1-14-I 12,780,700 15,336,800 17,892,900
(RINGAN)
722 V-1-14-II 18,569,900 22,283,900 25,997,900
(SEDANG)

727 V-4-10-I 5,562,500 6,675,000 7,787,400
(RINGAN)
728 V-4-10-II 9,239,500 11,087,400 12,935,400
(SEDANG)
729 V-4-10-III 15,232,800 18,279,300 21,325,900
(BERAT)
730 V-4-11-I 5,340,300 6,408,400 7,476,500
TUMOR (RINGAN)
731 V-4-11-II 7,165,400 8,598,400 10,031,500
TUMOR (SEDANG)
732 V-4-11-III 9,598,100 11,517,700 13,437,300
TUMOR (BERAT)
- 426 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 14,555,900 17,467,000 20,378,200
734 W-1-01-II 17,446,200 20,935,400 24,424,700
735 W-1-01-III 24,895,300 29,874,300 34,853,400
739 W-1-11-I 3,227,100 3,872,600 4,518,000
SERVIK (RINGAN)
740 W-1-11-II 3,561,100 4,273,300 4,985,600
SERVIK (SEDANG)
741 W-1-11-III 3,939,300 4,727,200 5,515,000
SERVIK (BERAT)
760 W-4-12-I 3,085,300 3,702,300 4,319,400
761 W-4-12-II 5,871,300 7,045,600 8,219,800
762 W-4-12-III 8,640,100 10,368,100 12,096,100
- 427 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 2,181,100 2,617,400 3,053,600
785 Z-4-12-II 4,379,500 5,255,400 6,131,300
786 Z-4-12-III 9,239,600 11,087,500 12,935,400
- 428 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,377,700

33 F-3-10-0 TERAPI SHOCK 673,400
- 429 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 4,093,300
PENGGANTIAN ALAT
81 I-2-42-0 3,933,400
PERKUTAN LAIN
- 430 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,854,900
192 Q-5-12-0 GIGI 337,000
196 Q-5-16-0 VAKSINASI 112,200
201 Q-5-21-0 ABORSI 294,100
206 Q-5-26-0 BRONKIAL AKUT 239,000
- 431 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 160,900
215 Q-5-35-0 INFEKSI AKUT 687,800
218 Q-5-38-0 PARU AKUT 400,800
234 U-2-23-0 RHINOPLASTY 1,980,200
242 U-3-13-0 510,400
TENGGOROKAN
270 Z-3-11-0 2,769,100
EMPEDU
- 432 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,459,100
289 Z-3-30-0 FOTOTERAPI 92,800
- 433 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,229,100 2,674,900 3,120,700
(RINGAN)
14 A-4-14-II 2,705,800 3,247,000 3,788,100
(SEDANG)
15 A-4-14-III 3,247,000 3,896,400 4,545,800
(BERAT)

31 B-1-13-I 5,508,900 6,610,700 7,712,500
LAIN (RINGAN)
32 B-1-13-II 9,064,200 10,877,100 12,689,900
LAIN (SEDANG)
33 B-1-13-III 11,728,300 14,074,000 16,419,700
LAIN (BERAT)
34 B-1-14-I 7,569,500 9,083,400 10,597,300
(RINGAN)
35 B-1-14-II 8,418,600 10,102,300 11,786,000
(SEDANG)
40 B-4-11-I 4,789,700 5,747,600 6,705,500
(RINGAN)
41 B-4-11-II 6,705,600 8,046,700 9,387,800
(SEDANG)
42 B-4-11-III 8,123,700 9,748,500 11,373,200
(BERAT)
- 434 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 5,073,900 6,088,700 7,103,500
74 D-1-20-II 13,983,000 16,779,600 19,576,100
75 D-1-20-III 22,181,100 26,617,300 31,053,500
85 D-4-13-I 2,934,800 3,521,700 4,108,700
86 D-4-13-II 4,153,700 4,984,400 5,815,200
87 D-4-13-III 5,312,700 6,375,300 7,437,800
88 D-4-14-I 3,147,700 3,777,200 4,406,700
89 D-4-14-II 5,153,500 6,184,200 7,214,900
90 D-4-14-III 6,303,300 7,564,000 8,824,600
91 E-1-01-I 6,902,000 8,282,400 9,662,800
(RINGAN)
92 E-1-01-II 9,422,200 11,306,700 13,191,100
(SEDANG)

97 E-1-20-I 7,385,100 8,862,100 10,339,100
TIROGLOSAL (RINGAN)
- 435 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 9,940,100 11,928,100 13,916,200
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,123,200 16,947,800 19,772,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,441,500 4,129,800 4,818,100
METABOLIK (RINGAN)
101 E-4-10-II 4,808,900 5,770,700 6,732,500
METABOLIK (SEDANG)
102 E-4-10-III 6,153,400 7,384,100 8,614,800
METABOLIK (BERAT)
109 E-4-13-I 3,632,500 4,359,000 5,085,500
(RINGAN)
110 E-4-13-II 5,321,000 6,385,200 7,449,400
(SEDANG)

118 F-4-12-I 2,050,300 2,460,300 2,870,400
(RINGAN)
119 F-4-12-II 2,914,800 3,497,800 4,080,800
(SEDANG)
120 F-4-12-III 6,332,300 7,598,800 8,865,300
(BERAT)
130 F-4-16-I 5,553,000 6,663,500 7,774,100
131 F-4-16-II 6,456,200 7,747,500 9,038,700
132 F-4-16-III 8,618,000 10,341,500 12,065,100
142 G-1-01-I 16,690,900 20,029,100 23,367,200
(RINGAN)
- 436 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 23,938,800 28,726,500 33,514,300
(SEDANG)
144 G-1-01-III 36,339,400 43,607,300 50,875,200
(BERAT)
151 G-1-12-I 4,848,500 5,818,300 6,788,000
(RINGAN)
152 G-1-12-II 9,369,900 11,243,900 13,117,900
(SEDANG)
153 G-1-12-III 12,769,400 15,323,200 17,877,100
(BERAT)
163 G-4-10-I 4,161,900 4,994,300 5,826,700
(RINGAN)
164 G-4-10-II 5,087,300 6,104,800 7,122,200
(SEDANG)
165 G-4-10-III 7,196,600 8,635,900 10,075,200
(BERAT)
166 G-4-11-I 4,491,700 5,390,000 6,288,300
167 G-4-11-II 5,966,600 7,159,900 8,353,300
168 G-4-11-III 8,767,000 10,520,400 12,273,800
DEGENERATIF (BERAT)
169 G-4-12-I 4,983,000 5,979,600 6,976,200
(RINGAN)
170 G-4-12-II 6,105,000 7,326,000 8,547,100
(SEDANG)

172 G-4-13-I 2,903,500 3,484,200 4,065,000
(RINGAN)
173 G-4-13-II 5,063,200 6,075,800 7,088,500
(SEDANG)
174 G-4-13-III 6,005,100 7,206,100 8,407,100
(BERAT)
175 G-4-14-I 4,925,500 5,910,600 6,895,700
INFARK (RINGAN)
176 G-4-14-II 6,788,700 8,146,500 9,504,200
INFARK (SEDANG)
177 G-4-14-III 8,520,600 10,224,800 11,928,900
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 437 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 4,419,000 5,302,800 6,186,600
(RINGAN)
185 G-4-17-II 5,794,300 6,953,100 8,112,000
(SEDANG)
186 G-4-17-III 7,505,900 9,007,100 10,508,300
(BERAT)
190 G-4-19-I 3,631,000 4,357,200 5,083,400
191 G-4-19-II 6,137,200 7,364,700 8,592,100
192 G-4-19-III 8,057,900 9,669,500 11,281,100
211 G-4-26-I 3,524,600 4,229,500 4,934,500
LAIN (RINGAN)
212 G-4-26-II 4,227,000 5,072,400 5,917,900
LAIN (SEDANG)
213 G-4-26-III 6,131,100 7,357,300 8,583,500
LAIN (BERAT)
232 I-1-02-I 25,438,900 30,526,700 35,614,500
(RINGAN)
- 438 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 32,815,900 39,379,100 45,942,300
(SEDANG)
234 I-1-02-III 40,447,700 48,537,200 56,626,700
(BERAT)
235 I-1-03-I 14,693,600 17,632,300 20,571,000
ANOMALI (RINGAN)
236 I-1-03-II 20,368,400 24,442,000 28,515,700
ANOMALI (SEDANG)
237 I-1-03-III 26,648,500 31,978,200 37,307,900
ANOMALI (BERAT)
238 I-1-04-I 22,827,300 27,392,700 31,958,200
JANTUNG (RINGAN)
239 I-1-04-II 36,027,600 43,233,100 50,438,600
JANTUNG (SEDANG)
240 I-1-04-III 57,553,900 69,064,600 80,575,400
JANTUNG (BERAT)
241 I-1-05-I 53,680,700 64,416,900 75,153,000
242 I-1-05-II 65,609,800 78,731,700 91,853,700
243 I-1-05-III 89,467,800 107,361,400 125,255,000
247 I-1-07-I 47,716,200 57,259,400 66,802,700
JANTUNG (RINGAN)
248 I-1-07-II 59,645,200 71,574,300 83,503,300
JANTUNG (SEDANG)
249 I-1-07-III 89,467,800 107,361,400 125,255,000
JANTUNG (BERAT)
250 I-1-11-I 4,109,700 4,931,600 5,753,500
251 I-1-11-II 4,569,500 5,483,400 6,397,300
252 I-1-11-III 6,080,600 7,296,800 8,512,900
253 I-1-12-I 11,829,500 14,195,500 16,561,400
(RINGAN)
254 I-1-12-II 18,740,400 22,488,500 26,236,600
(SEDANG)
255 I-1-12-III 24,655,900 29,587,000 34,518,200
(BERAT)
256 I-1-13-I 11,474,500 13,769,400 16,064,300
KOMPLEK (RINGAN)
257 I-1-13-II 15,280,600 18,336,800 21,392,900
KOMPLEK (SEDANG)
258 I-1-13-III 18,845,200 22,614,300 26,383,300
KOMPLEK (BERAT)
259 I-1-14-I 23,485,500 28,182,600 32,879,700
(RINGAN)
260 I-1-14-II 29,189,000 35,026,800 40,864,600
(SEDANG)
261 I-1-14-III 38,247,600 45,897,200 53,546,700
(BERAT)
265 I-1-16-I 11,219,000 13,462,800 15,706,600
266 I-1-16-II 26,169,200 31,403,000 36,636,900
267 I-1-16-III 30,185,800 36,222,900 42,260,100
268 I-1-17-I 13,392,300 16,070,800 18,749,300
(RINGAN)
269 I-1-17-II 16,768,400 20,122,100 23,475,800
(SEDANG)
- 439 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 20,742,300 24,890,800 29,039,200
(BERAT)
271 I-1-20-I 15,095,500 18,114,500 21,133,600
(RINGAN)
272 I-1-20-II 18,858,400 22,630,000 26,401,700
(SEDANG)
273 I-1-20-III 19,824,000 23,788,800 27,753,600
(BERAT)
274 I-1-30-I 11,418,900 13,702,600 15,986,400
JANTUNG (RINGAN)
275 I-1-30-II 23,753,800 28,504,500 33,255,300
JANTUNG (SEDANG)
276 I-1-30-III 36,809,800 44,171,700 51,533,700
JANTUNG (BERAT)

289 I-4-13-I 3,575,100 4,290,100 5,005,200
(RINGAN)
290 I-4-13-II 6,383,800 7,660,500 8,937,300
(SEDANG)
291 I-4-13-III 9,198,100 11,037,800 12,877,400
(BERAT)
295 I-4-15-I 4,404,000 5,284,800 6,165,600
(RINGAN)
296 I-4-15-II 5,991,400 7,189,600 8,387,900
(SEDANG)

304 I-4-18-I 3,986,800 4,784,100 5,581,500
JANTUNG (RINGAN)
305 I-4-18-II 6,257,800 7,509,300 8,760,900
JANTUNG (SEDANG)
306 I-4-18-III 8,241,100 9,889,300 11,537,500
JANTUNG (BERAT)

308 I-4-19-II 6,004,500 7,205,400 8,406,300
(SEDANG)
- 440 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 3,287,800 3,945,300 4,602,900
320 I-4-23-II 4,036,400 4,843,700 5,651,000
321 I-4-23-III 7,887,000 9,464,400 11,041,800
322 I-4-24-I 2,747,000 3,296,400 3,845,800
(RINGAN)
323 I-4-24-II 6,325,600 7,590,700 8,855,800
(SEDANG)
324 I-4-24-III 7,997,600 9,597,100 11,196,600
(BERAT)
325 J-1-01-I 53,412,700 64,095,200 74,777,700
326 J-1-01-II 60,446,400 72,535,600 84,624,900
327 J-1-01-III 68,383,800 82,060,600 95,737,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 28,344,200 34,013,000 39,681,800
329 J-1-02-II 39,466,300 47,359,600 55,252,800
330 J-1-02-III 65,172,400 78,206,900 91,241,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,607,400 10,328,800 12,050,300
(RINGAN)
332 J-1-10-II 17,417,100 20,900,500 24,383,900
(SEDANG)
333 J-1-10-III 18,660,400 22,392,500 26,124,600
(BERAT)
334 J-1-20-I 14,718,700 17,662,500 20,606,200
(RINGAN)
335 J-1-20-II 18,538,600 22,246,300 25,954,100
(SEDANG)
336 J-1-20-III 28,626,600 34,351,900 40,077,300
(BERAT)
337 J-1-30-I 7,183,100 8,619,700 10,056,300
(RINGAN)
338 J-1-30-II 13,012,000 15,614,500 18,216,900
(SEDANG)

- 441 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,749,600 3,299,500 3,849,500
374 J-4-21-II 4,429,600 5,315,500 6,201,400
375 J-4-21-III 6,181,100 7,417,300 8,653,500
376 K-1-10-I 7,803,100 9,363,700 10,924,300
BESAR (RINGAN)
377 K-1-10-II 10,109,600 12,131,500 14,153,400
BESAR (SEDANG)
378 K-1-10-III 11,848,700 14,218,500 16,588,200
BESAR (BERAT)
382 K-1-12-I 3,375,300 4,050,400 4,725,500
FEMORAL (RINGAN)
383 K-1-12-II 4,390,000 5,268,000 6,146,000
FEMORAL (SEDANG)
384 K-1-12-III 8,697,300 10,436,700 12,176,200
FEMORAL (BERAT)
388 K-1-14-I 5,393,000 6,471,600 7,550,200
(RINGAN)
389 K-1-14-II 6,320,500 7,584,600 8,848,700
(SEDANG)

394 K-1-30-I 7,074,100 8,488,900 9,903,800
395 K-1-30-II 12,186,600 14,623,900 17,061,200
396 K-1-30-III 17,287,500 20,745,000 24,202,500

398 K-1-40-II 8,702,400 10,442,900 12,183,400
(SEDANG)

- 442 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 3,913,700 4,696,500 5,479,200
413 K-4-13-II 5,062,700 6,075,200 7,087,700
414 K-4-13-III 7,798,100 9,357,700 10,917,300
415 K-4-14-I 2,558,100 3,069,700 3,581,300
(RINGAN)
416 K-4-14-II 3,433,800 4,120,500 4,807,300
(SEDANG)
417 K-4-14-III 5,509,800 6,611,800 7,713,800
(BERAT)

424 K-4-17-I 1,687,900 2,025,500 2,363,100
(RINGAN)
425 K-4-17-II 2,078,700 2,494,400 2,910,100
(SEDANG)
426 K-4-17-III 2,494,400 2,993,300 3,492,200
(BERAT)
427 K-4-18-I 1,427,400 1,712,900 1,998,400
(RINGAN)
428 K-4-18-II 2,408,700 2,890,400 3,372,200
(SEDANG)
436 L-1-40-I 4,891,500 5,869,800 6,848,100
(RINGAN)
437 L-1-40-II 9,811,200 11,773,500 13,735,700
(SEDANG)
438 L-1-40-III 16,514,500 19,817,400 23,120,300
(BERAT)
451 L-4-13-I 2,342,100 2,810,600 3,279,000
PAYUDARA (RINGAN)
- 443 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,752,700 3,303,200 3,853,700
PAYUDARA (SEDANG)
453 L-4-13-III 4,050,600 4,860,700 5,670,800
PAYUDARA (BERAT)
454 L-4-14-I 2,892,600 3,471,100 4,049,600
(RINGAN)
455 L-4-14-II 4,344,700 5,213,700 6,082,600
(SEDANG)
456 L-4-14-III 6,124,400 7,349,300 8,574,200
(BERAT)
457 M-1-01-I 10,224,900 12,269,900 14,314,900
458 M-1-01-II 14,533,300 17,440,000 20,346,600
459 M-1-01-III 20,414,900 24,497,900 28,580,900
463 M-1-03-I 22,872,700 27,447,200 32,021,800
464 M-1-03-II 26,752,900 32,103,500 37,454,100
465 M-1-03-III 33,111,200 39,733,500 46,355,700
472 M-1-07-I 8,075,500 9,690,600 11,305,700
473 M-1-07-II 10,818,400 12,982,100 15,145,800
474 M-1-07-III 22,038,100 26,445,700 30,853,400
475 M-1-10-I 18,652,300 22,382,700 26,113,200
WAJAH (RINGAN)
476 M-1-10-II 44,596,900 53,516,300 62,435,700
WAJAH (SEDANG)
477 M-1-10-III 96,191,400 115,429,700 134,668,000
WAJAH (BERAT)
478 M-1-20-I 12,142,200 14,570,600 16,999,000
(RINGAN)
479 M-1-20-II 15,992,600 19,191,100 22,389,700
(SEDANG)

484 M-1-40-I 4,240,200 5,088,200 5,936,300
INTERNAL (RINGAN)
485 M-1-40-II 7,519,800 9,023,800 10,527,700
INTERNAL (SEDANG)
486 M-1-40-III 10,736,800 12,884,200 15,031,600
INTERNAL (BERAT)
490 M-1-60-I 7,847,500 9,417,100 10,986,600
491 M-1-60-II 9,866,200 11,839,400 13,812,600
492 M-1-60-III 15,365,000 18,438,000 21,511,000
- 444 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 14,988,700 17,986,400 20,984,100
KAKI (RINGAN)
494 M-1-70-II 16,487,500 19,785,000 23,082,500
KAKI (SEDANG)
495 M-1-70-III 18,876,000 22,651,200 26,426,500
KAKI (BERAT)
502 M-4-11-I 3,627,900 4,353,400 5,079,000
(RINGAN)
503 M-4-11-II 7,953,900 9,544,700 11,135,500
(SEDANG)
504 M-4-11-III 11,855,700 14,226,800 16,597,900
(BERAT)
505 M-4-12-I 2,895,800 3,475,000 4,054,200
(RINGAN)
506 M-4-12-II 4,816,600 5,779,900 6,743,200
(SEDANG)
507 M-4-12-III 6,641,900 7,970,300 9,298,700
(BERAT)
508 M-4-13-I 4,821,900 5,786,200 6,750,600
509 M-4-13-II 7,244,700 8,693,600 10,142,500
510 M-4-13-III 14,134,200 16,961,000 19,787,800
520 M-4-17-I 3,623,400 4,348,000 5,072,700
(RINGAN)
521 M-4-17-II 5,067,700 6,081,200 7,094,800
(SEDANG)
522 M-4-17-III 7,076,700 8,492,000 9,907,400
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,880,900 3,457,100 4,033,300
(RINGAN)
530 M-4-20-II 4,218,700 5,062,400 5,906,100
(SEDANG)
531 M-4-20-III 4,714,900 5,657,800 6,600,800
(BERAT)
532 M-4-21-I 2,900,900 3,481,100 4,061,300
533 M-4-21-II 3,628,200 4,353,800 5,079,500
- 445 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 8,134,300 9,761,200 11,388,000
541 N-1-12-I 4,264,700 5,117,600 5,970,500
542 N-1-12-II 8,753,100 10,503,700 12,254,300
543 N-1-12-III 18,994,500 22,793,400 26,592,300
547 N-1-30-I 8,533,300 10,239,900 11,946,600
BAWAH (RINGAN)
548 N-1-30-II 12,909,200 15,491,000 18,072,800
BAWAH (SEDANG)
549 N-1-30-III 14,857,200 17,828,700 20,800,100
BAWAH (BERAT)
550 N-1-40-I 7,900,500 9,480,600 11,060,700
(RINGAN)
551 N-1-40-II 10,728,700 12,874,400 15,020,200
(SEDANG)
552 N-1-40-III 12,486,800 14,984,200 17,481,500
(BERAT)
553 N-4-10-I 3,255,900 3,907,100 4,558,300
(RINGAN)
554 N-4-10-II 4,059,900 4,871,900 5,683,800
(SEDANG)
555 N-4-10-III 5,971,500 7,165,800 8,360,100
(BERAT)
568 N-4-15-I 2,965,500 3,558,700 4,151,800
URIN (RINGAN)
569 N-4-15-II 3,793,500 4,552,200 5,310,900
URIN (SEDANG)
570 N-4-15-III 4,329,100 5,194,900 6,060,700
URIN (BERAT)
571 N-4-16-I 3,631,300 4,357,600 5,083,800
(RINGAN)
572 N-4-16-II 5,183,000 6,219,600 7,256,200
(SEDANG)
573 N-4-16-III 7,112,400 8,534,800 9,957,300
(BERAT)
- 446 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 3,375,500 4,050,600 4,725,700
578 O-6-11-II 3,751,400 4,501,700 5,252,000
579 O-6-11-III 4,811,200 5,773,400 6,735,700
580 O-6-12-I 2,465,400 2,958,500 3,451,600
581 O-6-12-II 2,961,000 3,553,200 4,145,400
582 O-6-12-III 3,720,600 4,464,700 5,208,800
586 P-8-01-I 53,401,900 64,082,300 74,762,700
587 P-8-01-II 66,076,900 79,292,300 92,507,600
588 P-8-01-III 77,555,700 93,066,800 108,578,000
589 P-8-02-I 83,437,800 100,125,300 116,812,900
590 P-8-02-II 95,711,700 114,854,000 133,996,300
591 P-8-02-III 109,357,500 131,229,000 153,100,500
592 P-8-03-I 12,071,300 14,485,600 16,899,800
593 P-8-03-II 17,045,100 20,454,100 23,863,100
594 P-8-03-III 23,857,900 28,629,500 33,401,100
595 P-8-04-I 34,817,000 41,780,400 48,743,800
596 P-8-04-II 45,009,000 54,010,800 63,012,700
597 P-8-04-III 64,531,700 77,438,000 90,344,300
598 P-8-05-I 18,905,700 22,686,900 26,468,000
599 P-8-05-II 29,556,200 35,467,500 41,378,700
600 P-8-05-III 39,334,800 47,201,700 55,068,700
601 P-8-06-I 5,172,300 6,206,800 7,241,300
602 P-8-06-II 14,502,100 17,402,500 20,302,900
603 P-8-06-III 19,211,700 23,054,000 26,896,400
604 P-8-07-I 5,009,900 6,011,900 7,013,900
605 P-8-07-II 14,046,700 16,856,100 19,665,400
606 P-8-07-III 18,608,500 22,330,200 26,051,900
607 P-8-08-I 4,148,200 4,977,800 5,807,400
608 P-8-08-II 5,886,000 7,063,200 8,240,400
609 P-8-08-III 9,530,800 11,436,900 13,343,100
610 P-8-11-I 10,059,400 12,071,300 14,083,200
MAYOR (RINGAN)
611 P-8-11-II 14,204,200 17,045,100 19,885,900
MAYOR (SEDANG)
- 447 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 19,881,600 23,857,900 27,834,300
MAYOR (BERAT)
613 P-8-12-I 9,503,500 11,404,200 13,304,900
MAYOR (RINGAN)
614 P-8-12-II 10,926,300 13,111,600 15,296,800
MAYOR (SEDANG)
615 P-8-12-III 15,293,600 18,352,300 21,411,000
MAYOR (BERAT)
616 P-8-13-I 5,387,700 6,465,300 7,542,800
MAYOR (RINGAN)
617 P-8-13-II 8,404,900 10,085,800 11,766,800
MAYOR (SEDANG)
618 P-8-13-III 13,057,200 15,668,700 18,280,100
MAYOR (BERAT)
619 P-8-14-I 3,590,800 4,309,000 5,027,200
620 P-8-14-II 7,309,500 8,771,400 10,233,300
621 P-8-14-III 13,155,100 15,786,100 18,417,100
622 P-8-15-I 2,693,200 3,231,800 3,770,400
ASPIRASI (RINGAN)
623 P-8-15-II 5,393,200 6,471,900 7,550,500
ASPIRASI (SEDANG)
624 P-8-15-III 6,328,000 7,593,500 8,859,100
ASPIRASI (BERAT)
625 P-8-16-I 2,437,400 2,924,800 3,412,300
626 P-8-16-II 4,683,800 5,620,500 6,557,300
627 P-8-16-III 11,461,800 13,754,200 16,046,500
628 P-8-17-I 3,591,800 4,310,200 5,028,500
(RINGAN)
629 P-8-17-II 6,465,300 7,758,300 9,051,400
(SEDANG)
630 P-8-17-III 9,097,800 10,917,300 12,736,900
(BERAT)
631 S-4-10-I 2,665,600 3,198,800 3,731,900
632 S-4-10-II 3,284,500 3,941,400 4,598,300
633 S-4-10-III 4,496,100 5,395,300 6,294,600
640 S-4-13-I 2,894,100 3,472,900 4,051,700
(RINGAN)
641 S-4-13-II 5,134,300 6,161,200 7,188,100
(SEDANG)
642 S-4-13-III 8,333,700 10,000,400 11,667,100
(BERAT)
643 S-4-14-I 1,464,600 1,757,500 2,050,500
644 S-4-14-II 3,110,900 3,733,100 4,355,300
645 S-4-14-III 5,899,400 7,079,300 8,259,200
KANAK-KANAK (BERAT)
646 S-4-15-I 979,500 1,175,500 1,371,400
647 S-4-15-II 1,848,600 2,218,300 2,588,000
648 S-4-15-III 2,394,200 2,873,000 3,351,900
- 448 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 2,444,700 2,933,700 3,422,600
653 S-4-17-II 3,628,300 4,353,900 5,079,600
654 S-4-17-III 4,363,800 5,236,500 6,109,300
655 T-1-10-I 1,686,300 2,023,600 2,360,800
OBAT (RINGAN)
656 T-1-10-II 2,264,900 2,717,900 3,170,900
OBAT (SEDANG)
657 T-1-10-III 4,120,300 4,944,300 5,768,400
OBAT (BERAT)
658 T-4-10-I 731,500 877,800 1,024,000
659 T-4-10-II 1,394,100 1,672,900 1,951,700
660 T-4-10-III 2,026,600 2,431,900 2,837,300
661 T-4-11-I 998,300 1,198,000 1,397,700
662 T-4-11-II 1,571,000 1,885,200 2,199,500
663 T-4-11-III 2,530,500 3,036,600 3,542,700
664 T-4-12-I 1,644,700 1,973,700 2,302,600
LAIN (RINGAN)
665 T-4-12-II 2,450,700 2,940,800 3,431,000
LAIN (SEDANG)
666 T-4-12-III 3,760,000 4,512,000 5,264,000
LAIN (BERAT)
670 U-1-11-I 8,269,500 9,923,400 11,577,300
(RINGAN)
671 U-1-11-II 10,482,900 12,579,400 14,676,000
(SEDANG)
672 U-1-11-III 15,549,600 18,659,600 21,769,500
(BERAT)
679 U-1-14-I 4,005,900 4,807,000 5,608,200
(RINGAN)
680 U-1-14-II 4,916,200 5,899,400 6,882,600
(SEDANG)
681 U-1-14-III 5,825,700 6,990,800 8,155,900
(BERAT)
685 U-1-20-I 6,081,600 7,297,900 8,514,200
686 U-1-20-II 9,051,000 10,861,200 12,671,400
687 U-1-20-III 22,538,600 27,046,400 31,554,100
691 U-4-10-I 3,753,400 4,504,000 5,254,700
- 449 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 8,334,800 10,001,800 11,668,700
693 U-4-10-III 12,796,500 15,355,800 17,915,100
TENGGOROKAN (BERAT)
700 U-4-13-I 1,945,500 2,334,600 2,723,800
701 U-4-13-II 2,293,600 2,752,300 3,211,000
702 U-4-13-III 2,743,300 3,291,900 3,840,600
706 U-4-15-I 2,909,800 3,491,700 4,073,700
707 U-4-15-II 3,625,200 4,350,300 5,075,300
708 U-4-15-III 5,073,500 6,088,200 7,103,000
709 V-1-10-I 4,892,900 5,871,500 6,850,000
(RINGAN)
710 V-1-10-II 9,776,800 11,732,100 13,687,500
(SEDANG)
711 V-1-10-III 11,989,900 14,387,800 16,785,800
(BERAT)
715 V-1-12-I 8,489,200 10,187,100 11,884,900
MODERAT (RINGAN)
716 V-1-12-II 11,951,300 14,341,500 16,731,800
MODERAT (SEDANG)
717 V-1-12-III 14,693,900 17,632,700 20,571,500
MODERAT (BERAT)
718 V-1-13-I 4,565,000 5,478,000 6,391,100
KOMPLEK (RINGAN)
719 V-1-13-II 8,722,300 10,466,700 12,211,200
KOMPLEK (SEDANG)
720 V-1-13-III 13,273,700 15,928,400 18,583,100
KOMPLEK (BERAT)
721 V-1-14-I 8,683,500 10,420,100 12,156,800
(RINGAN)
722 V-1-14-II 12,616,800 15,140,200 17,663,500
(SEDANG)

727 V-4-10-I 4,329,000 5,194,800 6,060,700
(RINGAN)
728 V-4-10-II 7,190,800 8,628,900 10,067,100
(SEDANG)
729 V-4-10-III 11,855,000 14,226,100 16,597,100
(BERAT)
730 V-4-11-I 3,628,300 4,354,000 5,079,700
TUMOR (RINGAN)
731 V-4-11-II 4,868,300 5,842,000 6,815,600
TUMOR (SEDANG)
732 V-4-11-III 6,722,800 8,067,400 9,411,900
TUMOR (BERAT)
- 450 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 10,195,400 12,234,500 14,273,600
734 W-1-01-II 11,853,300 14,224,000 16,594,600
735 W-1-01-III 17,437,500 20,925,000 24,412,500
739 W-1-11-I 2,260,400 2,712,500 3,164,500
SERVIK (RINGAN)
740 W-1-11-II 2,494,300 2,993,200 3,492,100
SERVIK (SEDANG)
741 W-1-11-III 2,759,200 3,311,100 3,862,900
SERVIK (BERAT)
760 W-4-12-I 2,760,300 3,312,300 3,864,400
761 W-4-12-II 3,789,600 4,547,600 5,305,500
762 W-4-12-III 4,130,900 4,957,100 5,783,300
- 451 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 1,843,900 2,212,600 2,581,400
785 Z-4-12-II 3,869,200 4,643,000 5,416,900
786 Z-4-12-III 5,956,000 7,147,200 8,338,400
- 452 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,491,200

33 F-3-10-0 TERAPI SHOCK 422,300
- 453 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,567,300
PENGGANTIAN ALAT
81 I-2-42-0 2,467,000
PERKUTAN LAIN
- 454 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,224,600
192 Q-5-12-0 GIGI 211,400
196 Q-5-16-0 VAKSINASI 98,900
201 Q-5-21-0 ABORSI 184,500
206 Q-5-26-0 BRONKIAL AKUT 210,600
- 455 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 141,800
215 Q-5-35-0 INFEKSI AKUT 431,400
218 Q-5-38-0 PARU AKUT 251,400
234 U-2-23-0 RHINOPLASTY 1,242,000
242 U-3-13-0 320,100
TENGGOROKAN
270 Z-3-11-0 1,736,800
EMPEDU
- 456 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 963,300
289 Z-3-30-0 FOTOTERAPI 81,700
- 457 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,295,900 2,755,100 3,214,300
(RINGAN)
14 A-4-14-II 2,787,000 3,344,400 3,901,800
(SEDANG)
15 A-4-14-III 3,344,400 4,013,300 4,682,100
(BERAT)

31 B-1-13-I 5,674,200 6,809,000 7,943,900
LAIN (RINGAN)
32 B-1-13-II 9,336,200 11,203,400 13,070,600
LAIN (SEDANG)
33 B-1-13-III 12,080,200 14,496,200 16,912,200
LAIN (BERAT)
34 B-1-14-I 7,796,600 9,355,900 10,915,200
(RINGAN)
35 B-1-14-II 8,671,100 10,405,400 12,139,600
(SEDANG)
40 B-4-11-I 4,933,400 5,920,000 6,906,700
(RINGAN)
41 B-4-11-II 6,906,800 8,288,100 9,669,500
(SEDANG)
42 B-4-11-III 8,367,400 10,040,900 11,714,400
(BERAT)
- 458 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 5,226,100 6,271,400 7,316,600
74 D-1-20-II 14,402,500 17,282,900 20,163,400
75 D-1-20-III 22,846,500 27,415,800 31,985,100
85 D-4-13-I 3,022,800 3,627,400 4,231,900
86 D-4-13-II 4,278,300 5,134,000 5,989,600
87 D-4-13-III 5,472,100 6,566,500 7,660,900
88 D-4-14-I 3,242,100 3,890,500 4,538,900
89 D-4-14-II 5,308,100 6,369,800 7,431,400
90 D-4-14-III 6,492,400 7,790,900 9,089,400
91 E-1-01-I 7,109,000 8,530,800 9,952,600
(RINGAN)
92 E-1-01-II 9,704,900 11,645,900 13,586,800
(SEDANG)

97 E-1-20-I 7,606,600 9,128,000 10,649,300
TIROGLOSAL (RINGAN)
- 459 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 10,238,300 12,286,000 14,333,600
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,546,900 17,456,300 20,365,700
TIROGLOSAL (BERAT)
100 E-4-10-I 3,544,800 4,253,700 4,962,700
METABOLIK (RINGAN)
101 E-4-10-II 4,953,200 5,943,800 6,934,400
METABOLIK (SEDANG)
102 E-4-10-III 6,338,000 7,605,600 8,873,200
METABOLIK (BERAT)
109 E-4-13-I 3,741,500 4,489,800 5,238,100
(RINGAN)
110 E-4-13-II 5,480,600 6,576,700 7,672,900
(SEDANG)

118 F-4-12-I 2,111,800 2,534,100 2,956,500
(RINGAN)
119 F-4-12-II 3,002,300 3,602,700 4,203,200
(SEDANG)
120 F-4-12-III 6,522,300 7,826,800 9,131,200
(BERAT)
130 F-4-16-I 5,719,500 6,863,500 8,007,400
131 F-4-16-II 6,649,900 7,979,900 9,309,900
132 F-4-16-III 8,876,500 10,651,800 12,427,100
142 G-1-01-I 17,191,600 20,629,900 24,068,300
(RINGAN)
- 460 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 24,656,900 29,588,300 34,519,700
(SEDANG)
144 G-1-01-III 37,429,600 44,915,500 52,401,400
(BERAT)
151 G-1-12-I 4,994,000 5,992,800 6,991,600
(RINGAN)
152 G-1-12-II 9,651,000 11,581,200 13,511,400
(SEDANG)
153 G-1-12-III 13,152,500 15,782,900 18,413,400
(BERAT)
163 G-4-10-I 4,286,800 5,144,200 6,001,500
(RINGAN)
164 G-4-10-II 5,239,900 6,287,900 7,335,900
(SEDANG)
165 G-4-10-III 7,412,500 8,894,900 10,377,400
(BERAT)
166 G-4-11-I 4,626,400 5,551,700 6,477,000
167 G-4-11-II 6,145,600 7,374,700 8,603,800
168 G-4-11-III 9,030,000 10,836,000 12,642,000
DEGENERATIF (BERAT)
169 G-4-12-I 5,132,500 6,159,000 7,185,500
(RINGAN)
170 G-4-12-II 6,288,200 7,545,800 8,803,500
(SEDANG)

172 G-4-13-I 2,990,600 3,588,800 4,186,900
(RINGAN)
173 G-4-13-II 5,215,100 6,258,100 7,301,100
(SEDANG)
174 G-4-13-III 6,185,200 7,422,300 8,659,300
(BERAT)
175 G-4-14-I 5,073,300 6,087,900 7,102,600
INFARK (RINGAN)
176 G-4-14-II 6,992,400 8,390,900 9,789,300
INFARK (SEDANG)
177 G-4-14-III 8,776,300 10,531,500 12,286,800
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 461 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 4,551,600 5,461,900 6,372,200
(RINGAN)
185 G-4-17-II 5,968,100 7,161,700 8,355,300
(SEDANG)
186 G-4-17-III 7,731,100 9,277,300 10,823,500
(BERAT)
190 G-4-19-I 3,739,900 4,487,900 5,235,900
191 G-4-19-II 6,321,400 7,585,600 8,849,900
192 G-4-19-III 8,299,600 9,959,600 11,619,500
211 G-4-26-I 3,630,400 4,356,400 5,082,500
LAIN (RINGAN)
212 G-4-26-II 4,353,800 5,224,600 6,095,400
LAIN (SEDANG)
213 G-4-26-III 6,315,000 7,578,000 8,841,000
LAIN (BERAT)
232 I-1-02-I 26,202,100 31,442,500 36,683,000
(RINGAN)
- 462 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 33,800,400 40,560,500 47,320,500
(SEDANG)
234 I-1-02-III 41,661,100 49,993,300 58,325,500
(BERAT)
235 I-1-03-I 15,134,400 18,161,300 21,188,200
ANOMALI (RINGAN)
236 I-1-03-II 20,979,400 25,175,300 29,371,200
ANOMALI (SEDANG)
237 I-1-03-III 27,447,900 32,937,500 38,427,100
ANOMALI (BERAT)
238 I-1-04-I 23,512,100 28,214,500 32,916,900
JANTUNG (RINGAN)
239 I-1-04-II 37,108,400 44,530,100 51,951,800
JANTUNG (SEDANG)
240 I-1-04-III 59,280,500 71,136,600 82,992,700
JANTUNG (BERAT)
241 I-1-05-I 55,291,100 66,349,400 77,407,600
242 I-1-05-II 67,578,000 81,093,700 94,609,300
243 I-1-05-III 92,151,900 110,582,300 129,012,600
247 I-1-07-I 49,147,700 58,977,200 68,806,700
JANTUNG (RINGAN)
248 I-1-07-II 61,434,600 73,721,500 86,008,400
JANTUNG (SEDANG)
249 I-1-07-III 92,151,900 110,582,300 129,012,600
JANTUNG (BERAT)
250 I-1-11-I 4,233,000 5,079,500 5,926,100
251 I-1-11-II 4,706,600 5,647,900 6,589,300
252 I-1-11-III 6,263,100 7,515,700 8,768,300
253 I-1-12-I 12,184,400 14,621,300 17,058,200
(RINGAN)
254 I-1-12-II 19,302,600 23,163,200 27,023,700
(SEDANG)
255 I-1-12-III 25,395,500 30,474,600 35,553,700
(BERAT)
256 I-1-13-I 11,818,700 14,182,500 16,546,200
KOMPLEK (RINGAN)
257 I-1-13-II 15,739,100 18,886,900 22,034,700
KOMPLEK (SEDANG)
258 I-1-13-III 19,410,600 23,292,700 27,174,800
KOMPLEK (BERAT)
259 I-1-14-I 24,190,000 29,028,000 33,866,100
(RINGAN)
260 I-1-14-II 30,064,700 36,077,600 42,090,500
(SEDANG)
261 I-1-14-III 39,395,100 47,274,100 55,153,100
(BERAT)
265 I-1-16-I 11,555,600 13,866,700 16,177,800
266 I-1-16-II 26,954,300 32,345,100 37,736,000
267 I-1-16-III 31,091,300 37,309,600 43,527,900
268 I-1-17-I 13,794,100 16,552,900 19,311,700
(RINGAN)
269 I-1-17-II 17,271,500 20,725,800 24,180,100
(SEDANG)
- 463 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 21,364,600 25,637,500 29,910,400
(BERAT)
271 I-1-20-I 15,548,300 18,658,000 21,767,600
(RINGAN)
272 I-1-20-II 19,424,100 23,308,900 27,193,800
(SEDANG)
273 I-1-20-III 20,418,800 24,502,500 28,586,300
(BERAT)
274 I-1-30-I 11,761,400 14,113,700 16,466,000
JANTUNG (RINGAN)
275 I-1-30-II 24,466,400 29,359,600 34,252,900
JANTUNG (SEDANG)
276 I-1-30-III 37,914,100 45,496,900 53,079,700
JANTUNG (BERAT)

289 I-4-13-I 3,682,400 4,418,800 5,155,300
(RINGAN)
290 I-4-13-II 6,575,300 7,890,400 9,205,400
(SEDANG)
291 I-4-13-III 9,474,100 11,368,900 13,263,700
(BERAT)
295 I-4-15-I 4,536,100 5,443,300 6,350,600
(RINGAN)
296 I-4-15-II 6,171,100 7,405,300 8,639,500
(SEDANG)

304 I-4-18-I 4,106,400 4,927,700 5,748,900
JANTUNG (RINGAN)
305 I-4-18-II 6,445,500 7,734,600 9,023,700
JANTUNG (SEDANG)
306 I-4-18-III 8,488,300 10,186,000 11,883,600
JANTUNG (BERAT)

308 I-4-19-II 6,184,600 7,421,600 8,658,500
(SEDANG)
- 464 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 3,386,400 4,063,700 4,741,000
320 I-4-23-II 4,157,500 4,989,000 5,820,500
321 I-4-23-III 8,123,600 9,748,300 11,373,000
322 I-4-24-I 2,829,400 3,395,300 3,961,200
(RINGAN)
323 I-4-24-II 6,515,400 7,818,400 9,121,500
(SEDANG)
324 I-4-24-III 8,237,500 9,885,000 11,532,500
(BERAT)
325 J-1-01-I 55,015,000 66,018,100 77,021,100
326 J-1-01-II 62,259,800 74,711,700 87,163,700
327 J-1-01-III 70,435,400 84,522,400 98,609,500
TRAKEOSTOMI (BERAT)
328 J-1-02-I 29,194,500 35,033,400 40,872,300
329 J-1-02-II 40,650,300 48,780,400 56,910,400
330 J-1-02-III 67,127,600 80,553,100 93,978,600
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,865,600 10,638,700 12,411,800
(RINGAN)
332 J-1-10-II 17,939,600 21,527,500 25,115,400
(SEDANG)
333 J-1-10-III 19,220,200 23,064,300 26,908,300
(BERAT)
334 J-1-20-I 15,160,300 18,192,300 21,224,400
(RINGAN)
335 J-1-20-II 19,094,800 22,913,700 26,732,700
(SEDANG)
336 J-1-20-III 29,485,400 35,382,500 41,279,600
(BERAT)
337 J-1-30-I 7,398,600 8,878,300 10,358,000
(RINGAN)
338 J-1-30-II 13,402,400 16,082,900 18,763,400
(SEDANG)

- 465 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,832,100 3,398,500 3,964,900
374 J-4-21-II 4,562,400 5,474,900 6,387,400
375 J-4-21-III 6,366,500 7,639,800 8,913,100
376 K-1-10-I 8,037,200 9,644,600 11,252,100
BESAR (RINGAN)
377 K-1-10-II 10,412,800 12,495,400 14,578,000
BESAR (SEDANG)
378 K-1-10-III 12,204,200 14,645,000 17,085,900
BESAR (BERAT)
382 K-1-12-I 3,476,600 4,171,900 4,867,200
FEMORAL (RINGAN)
383 K-1-12-II 4,521,700 5,426,000 6,330,400
FEMORAL (SEDANG)
384 K-1-12-III 8,958,200 10,749,800 12,541,500
FEMORAL (BERAT)
388 K-1-14-I 5,554,800 6,665,800 7,776,800
(RINGAN)
389 K-1-14-II 6,510,100 7,812,200 9,114,200
(SEDANG)

394 K-1-30-I 7,286,300 8,743,600 10,200,900
395 K-1-30-II 12,552,200 15,062,600 17,573,000
396 K-1-30-III 17,806,100 21,367,400 24,928,600

398 K-1-40-II 8,963,500 10,756,200 12,548,900
(SEDANG)

- 466 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 4,031,100 4,837,400 5,643,600
413 K-4-13-II 5,214,500 6,257,400 7,300,300
414 K-4-13-III 8,032,000 9,638,400 11,244,900
415 K-4-14-I 2,634,800 3,161,800 3,688,700
(RINGAN)
416 K-4-14-II 3,536,800 4,244,100 4,951,500
(SEDANG)
417 K-4-14-III 5,675,100 6,810,100 7,945,200
(BERAT)

424 K-4-17-I 1,738,600 2,086,300 2,434,000
(RINGAN)
425 K-4-17-II 2,141,000 2,569,200 2,997,400
(SEDANG)
426 K-4-17-III 2,569,200 3,083,100 3,596,900
(BERAT)
427 K-4-18-I 1,470,200 1,764,300 2,058,300
(RINGAN)
428 K-4-18-II 2,481,000 2,977,200 3,473,300
(SEDANG)
436 L-1-40-I 5,038,200 6,045,900 7,053,500
(RINGAN)
437 L-1-40-II 10,105,600 12,126,700 14,147,800
(SEDANG)
438 L-1-40-III 17,009,900 20,411,900 23,813,900
(BERAT)
451 L-4-13-I 2,412,400 2,894,900 3,377,400
PAYUDARA (RINGAN)
- 467 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,835,200 3,402,300 3,969,300
PAYUDARA (SEDANG)
453 L-4-13-III 4,172,100 5,006,500 5,840,900
PAYUDARA (BERAT)
454 L-4-14-I 2,979,300 3,575,200 4,171,100
(RINGAN)
455 L-4-14-II 4,475,100 5,370,100 6,265,100
(SEDANG)
456 L-4-14-III 6,308,200 7,569,800 8,831,400
(BERAT)
457 M-1-01-I 10,531,700 12,638,000 14,744,300
458 M-1-01-II 14,969,300 17,963,200 20,957,000
459 M-1-01-III 21,027,400 25,232,900 29,438,400
463 M-1-03-I 23,558,900 28,270,600 32,982,400
464 M-1-03-II 27,555,500 33,066,600 38,577,800
465 M-1-03-III 34,104,600 40,925,500 47,746,400
472 M-1-07-I 8,317,800 9,981,300 11,644,900
473 M-1-07-II 11,143,000 13,371,600 15,600,200
474 M-1-07-III 22,699,300 27,239,100 31,779,000
475 M-1-10-I 19,211,800 23,054,200 26,896,600
WAJAH (RINGAN)
476 M-1-10-II 45,934,800 55,121,800 64,308,800
WAJAH (SEDANG)
477 M-1-10-III 99,077,200 118,892,600 138,708,000
WAJAH (BERAT)
478 M-1-20-I 12,506,400 15,007,700 17,509,000
(RINGAN)
479 M-1-20-II 16,472,400 19,766,900 23,061,400
(SEDANG)

484 M-1-40-I 4,367,400 5,240,900 6,114,400
INTERNAL (RINGAN)
485 M-1-40-II 7,745,400 9,294,500 10,843,600
INTERNAL (SEDANG)
486 M-1-40-III 11,059,000 13,270,700 15,482,500
INTERNAL (BERAT)
490 M-1-60-I 8,083,000 9,699,600 11,316,200
491 M-1-60-II 10,162,200 12,194,600 14,227,000
492 M-1-60-III 15,826,000 18,991,100 22,156,300
- 468 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 15,438,300 18,526,000 21,613,700
KAKI (RINGAN)
494 M-1-70-II 16,982,200 20,378,600 23,775,000
KAKI (SEDANG)
495 M-1-70-III 19,442,300 23,330,800 27,219,200
KAKI (BERAT)
502 M-4-11-I 3,736,700 4,484,000 5,231,400
(RINGAN)
503 M-4-11-II 8,192,500 9,831,100 11,469,600
(SEDANG)
504 M-4-11-III 12,211,300 14,653,600 17,095,900
(BERAT)
505 M-4-12-I 2,982,700 3,579,300 4,175,800
(RINGAN)
506 M-4-12-II 4,961,100 5,953,300 6,945,500
(SEDANG)
507 M-4-12-III 6,841,200 8,209,400 9,577,700
(BERAT)
508 M-4-13-I 4,966,500 5,959,800 6,953,100
509 M-4-13-II 7,462,000 8,954,400 10,446,800
510 M-4-13-III 14,558,200 17,469,800 20,381,500
520 M-4-17-I 3,732,100 4,478,500 5,224,900
(RINGAN)
521 M-4-17-II 5,219,700 6,263,700 7,307,600
(SEDANG)
522 M-4-17-III 7,289,000 8,746,800 10,204,600
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,967,400 3,560,900 4,154,300
(RINGAN)
530 M-4-20-II 4,345,200 5,214,300 6,083,300
(SEDANG)
531 M-4-20-III 4,856,300 5,827,600 6,798,800
(BERAT)
532 M-4-21-I 2,987,900 3,585,500 4,183,100
533 M-4-21-II 3,737,000 4,484,400 5,231,800
- 469 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 8,378,300 10,054,000 11,729,700
541 N-1-12-I 4,392,600 5,271,100 6,149,700
542 N-1-12-II 9,015,700 10,818,800 12,622,000
543 N-1-12-III 19,564,400 23,477,200 27,390,100
547 N-1-30-I 8,789,300 10,547,100 12,305,000
BAWAH (RINGAN)
548 N-1-30-II 13,296,400 15,955,700 18,615,000
BAWAH (SEDANG)
549 N-1-30-III 15,302,900 18,363,500 21,424,100
BAWAH (BERAT)
550 N-1-40-I 8,137,500 9,765,000 11,392,500
(RINGAN)
551 N-1-40-II 11,050,600 13,260,700 15,470,800
(SEDANG)
552 N-1-40-III 12,861,400 15,433,700 18,006,000
(BERAT)
553 N-4-10-I 3,353,600 4,024,300 4,695,000
(RINGAN)
554 N-4-10-II 4,181,700 5,018,000 5,854,300
(SEDANG)
555 N-4-10-III 6,150,600 7,380,800 8,610,900
(BERAT)
568 N-4-15-I 3,054,500 3,665,400 4,276,300
URIN (RINGAN)
569 N-4-15-II 3,907,300 4,688,800 5,470,300
URIN (SEDANG)
570 N-4-15-III 4,458,900 5,350,700 6,242,500
URIN (BERAT)
571 N-4-16-I 3,740,200 4,488,300 5,236,300
(RINGAN)
572 N-4-16-II 5,338,500 6,406,200 7,473,900
(SEDANG)
573 N-4-16-III 7,325,700 8,790,900 10,256,000
(BERAT)
- 470 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 3,476,700 4,172,100 4,867,400
578 O-6-11-II 3,864,000 4,636,800 5,409,600
579 O-6-11-III 4,955,500 5,946,600 6,937,700
580 O-6-12-I 2,539,400 3,047,300 3,555,200
581 O-6-12-II 3,049,800 3,659,800 4,269,700
582 O-6-12-III 3,832,200 4,598,600 5,365,100
586 P-8-01-I 55,004,000 66,004,800 77,005,600
587 P-8-01-II 68,059,200 81,671,000 95,282,900
588 P-8-01-III 79,882,300 95,858,800 111,835,300
589 P-8-02-I 85,940,900 103,129,100 120,317,200
590 P-8-02-II 98,583,000 118,299,600 138,016,200
591 P-8-02-III 112,638,200 135,165,800 157,693,500
592 P-8-03-I 12,433,500 14,920,100 17,406,800
593 P-8-03-II 17,556,400 21,067,700 24,579,000
594 P-8-03-III 24,573,700 29,488,400 34,403,200
595 P-8-04-I 35,861,500 43,033,800 50,206,100
596 P-8-04-II 46,359,300 55,631,200 64,903,000
597 P-8-04-III 66,467,600 79,761,200 93,054,700
598 P-8-05-I 19,472,900 23,367,500 27,262,100
599 P-8-05-II 30,442,900 36,531,500 42,620,100
600 P-8-05-III 40,514,800 48,617,800 56,720,700
601 P-8-06-I 5,327,500 6,393,000 7,458,500
602 P-8-06-II 14,937,100 17,924,600 20,912,000
603 P-8-06-III 19,788,000 23,745,700 27,703,300
604 P-8-07-I 5,160,200 6,192,300 7,224,300
605 P-8-07-II 14,468,100 17,361,800 20,255,400
606 P-8-07-III 19,166,700 23,000,100 26,833,400
607 P-8-08-I 4,272,600 5,127,100 5,981,700
608 P-8-08-II 6,062,600 7,275,100 8,487,600
609 P-8-08-III 9,816,700 11,780,000 13,743,400
610 P-8-11-I 10,361,200 12,433,500 14,505,700
MAYOR (RINGAN)
611 P-8-11-II 14,630,300 17,556,400 20,482,500
MAYOR (SEDANG)
- 471 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 20,478,100 24,573,700 28,669,300
MAYOR (BERAT)
613 P-8-12-I 9,788,600 11,746,300 13,704,000
MAYOR (RINGAN)
614 P-8-12-II 11,254,100 13,504,900 15,755,800
MAYOR (SEDANG)
615 P-8-12-III 15,752,400 18,902,800 22,053,300
MAYOR (BERAT)
616 P-8-13-I 5,549,400 6,659,200 7,769,100
MAYOR (RINGAN)
617 P-8-13-II 8,657,000 10,388,400 12,119,800
MAYOR (SEDANG)
618 P-8-13-III 13,448,900 16,138,700 18,828,500
MAYOR (BERAT)
619 P-8-14-I 3,698,600 4,438,300 5,178,000
620 P-8-14-II 7,528,800 9,034,600 10,540,300
621 P-8-14-III 13,549,700 16,259,700 18,969,600
622 P-8-15-I 2,774,000 3,328,800 3,883,600
ASPIRASI (RINGAN)
623 P-8-15-II 5,555,000 6,666,000 7,777,000
ASPIRASI (SEDANG)
624 P-8-15-III 6,517,800 7,821,400 9,124,900
ASPIRASI (BERAT)
625 P-8-16-I 2,510,500 3,012,600 3,514,700
626 P-8-16-II 4,824,300 5,789,100 6,754,000
627 P-8-16-III 11,805,700 14,166,800 16,527,900
628 P-8-17-I 3,699,600 4,439,500 5,179,400
(RINGAN)
629 P-8-17-II 6,659,200 7,991,100 9,322,900
(SEDANG)
630 P-8-17-III 9,370,700 11,244,900 13,119,000
(BERAT)
631 S-4-10-I 2,745,600 3,294,700 3,843,900
632 S-4-10-II 3,383,000 4,059,600 4,736,200
633 S-4-10-III 4,631,000 5,557,200 6,483,400
640 S-4-13-I 2,980,900 3,577,100 4,173,300
(RINGAN)
641 S-4-13-II 5,288,400 6,346,000 7,403,700
(SEDANG)
642 S-4-13-III 8,583,700 10,300,400 12,017,100
(BERAT)
643 S-4-14-I 1,508,500 1,810,300 2,112,000
644 S-4-14-II 3,204,300 3,845,100 4,486,000
645 S-4-14-III 6,076,400 7,291,700 8,507,000
KANAK-KANAK (BERAT)
646 S-4-15-I 1,008,900 1,210,700 1,412,500
647 S-4-15-II 1,904,000 2,284,800 2,665,600
648 S-4-15-III 2,466,000 2,959,200 3,452,400
- 472 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 2,518,100 3,021,700 3,525,300
653 S-4-17-II 3,737,100 4,484,500 5,232,000
654 S-4-17-III 4,494,700 5,393,600 6,292,600
655 T-1-10-I 1,736,900 2,084,300 2,431,700
OBAT (RINGAN)
656 T-1-10-II 2,332,900 2,799,500 3,266,000
OBAT (SEDANG)
657 T-1-10-III 4,243,900 5,092,600 5,941,400
OBAT (BERAT)
658 T-4-10-I 753,400 904,100 1,054,800
659 T-4-10-II 1,435,900 1,723,100 2,010,200
660 T-4-10-III 2,087,400 2,504,900 2,922,400
661 T-4-11-I 1,028,300 1,233,900 1,439,600
662 T-4-11-II 1,618,200 1,941,800 2,265,400
663 T-4-11-III 2,606,400 3,127,700 3,648,900
664 T-4-12-I 1,694,100 2,032,900 2,371,700
LAIN (RINGAN)
665 T-4-12-II 2,524,200 3,029,100 3,533,900
LAIN (SEDANG)
666 T-4-12-III 3,872,800 4,647,300 5,421,900
LAIN (BERAT)
670 U-1-11-I 8,517,600 10,221,100 11,924,600
(RINGAN)
671 U-1-11-II 10,797,300 12,956,800 15,116,300
(SEDANG)
672 U-1-11-III 16,016,100 19,219,400 22,422,600
(BERAT)
679 U-1-14-I 4,126,000 4,951,300 5,776,500
(RINGAN)
680 U-1-14-II 5,063,700 6,076,400 7,089,100
(SEDANG)
681 U-1-14-III 6,000,400 7,200,500 8,400,600
(BERAT)
685 U-1-20-I 6,264,000 7,516,800 8,769,600
686 U-1-20-II 9,322,600 11,187,100 13,051,600
687 U-1-20-III 23,214,800 27,857,800 32,500,700
691 U-4-10-I 3,866,000 4,639,100 5,412,300
- 473 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 8,584,800 10,301,800 12,018,800
693 U-4-10-III 13,180,400 15,816,400 18,452,500
TENGGOROKAN (BERAT)
700 U-4-13-I 2,003,900 2,404,700 2,805,500
701 U-4-13-II 2,362,400 2,834,900 3,307,400
702 U-4-13-III 2,825,600 3,390,700 3,955,800
706 U-4-15-I 2,997,100 3,596,500 4,195,900
707 U-4-15-II 3,734,000 4,480,800 5,227,600
708 U-4-15-III 5,225,700 6,270,900 7,316,000
709 V-1-10-I 5,039,700 6,047,600 7,055,500
(RINGAN)
710 V-1-10-II 10,070,100 12,084,100 14,098,100
(SEDANG)
711 V-1-10-III 12,349,600 14,819,500 17,289,400
(BERAT)
715 V-1-12-I 8,743,900 10,492,700 12,241,500
MODERAT (RINGAN)
716 V-1-12-II 12,309,800 14,771,800 17,233,700
MODERAT (SEDANG)
717 V-1-12-III 15,134,700 18,161,700 21,188,600
MODERAT (BERAT)
718 V-1-13-I 4,702,000 5,642,400 6,582,800
KOMPLEK (RINGAN)
719 V-1-13-II 8,984,000 10,780,700 12,577,500
KOMPLEK (SEDANG)
720 V-1-13-III 13,671,900 16,406,300 19,140,600
KOMPLEK (BERAT)
721 V-1-14-I 8,944,000 10,732,800 12,521,500
(RINGAN)
722 V-1-14-II 12,995,300 15,594,400 18,193,400
(SEDANG)

727 V-4-10-I 4,458,900 5,350,700 6,242,500
(RINGAN)
728 V-4-10-II 7,406,500 8,887,800 10,369,100
(SEDANG)
729 V-4-10-III 12,210,700 14,652,800 17,095,000
(BERAT)
730 V-4-11-I 3,737,200 4,484,600 5,232,100
TUMOR (RINGAN)
731 V-4-11-II 5,014,300 6,017,200 7,020,100
TUMOR (SEDANG)
732 V-4-11-III 6,924,500 8,309,400 9,694,300
TUMOR (BERAT)
- 474 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 10,501,300 12,601,600 14,701,800
734 W-1-01-II 12,208,900 14,650,700 17,092,500
735 W-1-01-III 17,960,600 21,552,700 25,144,900
739 W-1-11-I 2,328,200 2,793,800 3,259,500
SERVIK (RINGAN)
740 W-1-11-II 2,569,200 3,083,000 3,596,800
SERVIK (SEDANG)
741 W-1-11-III 2,842,000 3,410,400 3,978,800
SERVIK (BERAT)
760 W-4-12-I 2,843,100 3,411,700 3,980,300
761 W-4-12-II 3,903,300 4,684,000 5,464,700
762 W-4-12-III 4,254,800 5,105,800 5,956,800
- 475 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 1,899,200 2,279,000 2,658,900
785 Z-4-12-II 3,985,300 4,782,300 5,579,400
786 Z-4-12-III 6,134,700 7,361,600 8,588,600
- 476 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,565,800

33 F-3-10-0 TERAPI SHOCK 443,400
- 477 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,695,600
PENGGANTIAN ALAT
81 I-2-42-0 2,590,300
PERKUTAN LAIN
- 478 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,285,800
192 Q-5-12-0 GIGI 221,900
196 Q-5-16-0 VAKSINASI 103,800
201 Q-5-21-0 ABORSI 193,700
206 Q-5-26-0 BRONKIAL AKUT 221,100
- 479 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 148,800
215 Q-5-35-0 INFEKSI AKUT 452,900
218 Q-5-38-0 PARU AKUT 263,900
234 U-2-23-0 RHINOPLASTY 1,304,100
242 U-3-13-0 336,100
TENGGOROKAN
270 Z-3-11-0 1,823,600
EMPEDU
- 480 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,011,500
289 Z-3-30-0 FOTOTERAPI 85,800
- 481 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,117,600 2,541,200 2,964,700
(RINGAN)
14 A-4-14-II 2,570,500 3,084,600 3,598,700
(SEDANG)
15 A-4-14-III 3,084,600 3,701,500 4,318,400
(BERAT)

31 B-1-13-I 4,087,100 4,904,600 5,722,000
LAIN (RINGAN)
32 B-1-13-II 6,724,900 8,069,900 9,414,800
LAIN (SEDANG)
33 B-1-13-III 8,701,400 10,441,700 12,182,000
LAIN (BERAT)
34 B-1-14-I 5,615,900 6,739,100 7,862,300
(RINGAN)
35 B-1-14-II 6,245,900 7,495,000 8,744,200
(SEDANG)
40 B-4-11-I 3,663,400 4,396,100 5,128,800
(RINGAN)
41 B-4-11-II 5,128,800 6,154,600 7,180,400
(SEDANG)
42 B-4-11-III 6,213,500 7,456,200 8,698,900
(BERAT)
- 482 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 3,880,800 4,657,000 5,433,200
74 D-1-20-II 10,695,000 12,834,000 14,973,000
75 D-1-20-III 16,965,400 20,358,500 23,751,600
85 D-4-13-I 2,244,700 2,693,600 3,142,600
86 D-4-13-II 3,177,000 3,812,400 4,447,800
87 D-4-13-III 4,063,500 4,876,200 5,688,900
88 D-4-14-I 2,407,500 2,889,000 3,370,500
89 D-4-14-II 3,941,700 4,730,100 5,518,400
90 D-4-14-III 4,821,100 5,785,400 6,749,600
91 E-1-01-I 4,285,700 5,142,900 6,000,000
(RINGAN)
92 E-1-01-II 5,613,900 6,736,600 7,859,400
(SEDANG)

97 E-1-20-I 5,648,500 6,778,300 7,908,000
TIROGLOSAL (RINGAN)
- 483 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 7,602,800 9,123,300 10,643,900
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,478,200 12,573,800 14,669,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,370,600 4,044,700 4,718,800
METABOLIK (RINGAN)
101 E-4-10-II 4,709,800 5,651,700 6,593,700
METABOLIK (SEDANG)
102 E-4-10-III 5,845,700 7,014,900 8,184,000
METABOLIK (BERAT)
109 E-4-13-I 2,778,400 3,334,000 3,889,700
(RINGAN)
110 E-4-13-II 4,069,800 4,883,800 5,697,700
(SEDANG)

118 F-4-12-I 1,568,200 1,881,800 2,195,400
(RINGAN)
119 F-4-12-II 2,229,400 2,675,300 3,121,200
(SEDANG)
120 F-4-12-III 4,843,300 5,812,000 6,780,700
(BERAT)
130 F-4-16-I 4,119,800 4,943,800 5,767,700
131 F-4-16-II 4,790,000 5,748,000 6,705,900
132 F-4-16-III 6,393,800 7,672,500 8,951,300
142 G-1-01-I 10,433,400 12,520,100 14,606,700
(RINGAN)
- 484 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 16,247,000 19,496,400 22,745,800
(SEDANG)
144 G-1-01-III 31,246,000 37,495,200 43,744,400
(BERAT)
151 G-1-12-I 3,708,500 4,450,100 5,191,800
(RINGAN)
152 G-1-12-II 6,951,700 8,342,000 9,732,300
(SEDANG)
153 G-1-12-III 9,473,800 11,368,500 13,263,300
(BERAT)
163 G-4-10-I 3,183,300 3,820,000 4,456,600
(RINGAN)
164 G-4-10-II 3,891,100 4,669,300 5,447,500
(SEDANG)
165 G-4-10-III 5,339,200 6,407,100 7,474,900
(BERAT)
166 G-4-11-I 3,332,400 3,998,900 4,665,400
167 G-4-11-II 4,426,700 5,312,100 6,197,400
168 G-4-11-III 6,504,300 7,805,200 9,106,100
DEGENERATIF (BERAT)
169 G-4-12-I 3,696,900 4,436,300 5,175,700
(RINGAN)
170 G-4-12-II 4,669,500 5,603,400 6,537,300
(SEDANG)

172 G-4-13-I 2,220,800 2,665,000 3,109,100
(RINGAN)
173 G-4-13-II 3,872,600 4,647,200 5,421,700
(SEDANG)
174 G-4-13-III 4,593,000 5,511,600 6,430,300
(BERAT)
175 G-4-14-I 3,767,300 4,520,800 5,274,300
INFARK (RINGAN)
176 G-4-14-II 5,036,600 6,044,000 7,051,300
INFARK (SEDANG)
177 G-4-14-III 6,321,600 7,585,900 8,850,200
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 485 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 3,379,900 4,055,900 4,731,900
(RINGAN)
185 G-4-17-II 4,431,800 5,318,200 6,204,500
(SEDANG)
186 G-4-17-III 5,568,800 6,682,500 7,796,300
(BERAT)
190 G-4-19-I 2,777,200 3,332,600 3,888,100
191 G-4-19-II 4,694,100 5,632,900 6,571,800
192 G-4-19-III 6,163,200 7,395,800 8,628,400
211 G-4-26-I 2,995,400 3,594,500 4,193,500
LAIN (RINGAN)
212 G-4-26-II 3,484,600 4,181,500 4,878,400
LAIN (SEDANG)
213 G-4-26-III 5,210,500 6,252,600 7,294,700
LAIN (BERAT)
232 I-1-02-I 19,457,200 23,348,700 27,240,100
(RINGAN)
- 486 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 25,099,600 30,119,500 35,139,400
(SEDANG)
234 I-1-02-III 30,936,800 37,124,100 43,311,500
(BERAT)
235 I-1-03-I 11,238,500 13,486,300 15,734,000
ANOMALI (RINGAN)
236 I-1-03-II 15,578,900 18,694,700 21,810,500
ANOMALI (SEDANG)
237 I-1-03-III 19,770,900 23,725,100 27,679,200
ANOMALI (BERAT)
238 I-1-04-I 16,935,900 20,323,000 23,710,200
JANTUNG (RINGAN)
239 I-1-04-II 26,729,400 32,075,300 37,421,100
JANTUNG (SEDANG)
240 I-1-04-III 42,700,000 51,240,000 59,780,000
JANTUNG (BERAT)
241 I-1-05-I 21,730,300 26,076,300 30,422,400
242 I-1-05-II 26,076,400 31,291,700 36,507,000
243 I-1-05-III 35,881,000 43,057,200 50,233,400
247 I-1-07-I 19,070,800 22,884,900 26,699,100
JANTUNG (RINGAN)
248 I-1-07-II 23,527,700 28,233,200 32,938,800
JANTUNG (SEDANG)
249 I-1-07-III 25,668,600 30,802,300 35,936,100
JANTUNG (BERAT)
250 I-1-11-I 3,049,000 3,658,800 4,268,600
251 I-1-11-II 3,390,200 4,068,200 4,746,300
252 I-1-11-III 4,511,300 5,413,600 6,315,800
253 I-1-12-I 8,776,500 10,531,800 12,287,100
(RINGAN)
254 I-1-12-II 14,333,800 17,200,600 20,067,300
(SEDANG)
255 I-1-12-III 18,858,300 22,629,900 26,401,600
(BERAT)
256 I-1-13-I 8,513,100 10,215,700 11,918,300
KOMPLEK (RINGAN)
257 I-1-13-II 11,336,900 13,604,300 15,871,700
KOMPLEK (SEDANG)
258 I-1-13-III 13,981,600 16,777,900 19,574,200
KOMPLEK (BERAT)
259 I-1-14-I 17,424,200 20,909,000 24,393,900
(RINGAN)
260 I-1-14-II 21,655,700 25,986,900 30,318,000
(SEDANG)
261 I-1-14-III 28,376,500 34,051,800 39,727,000
(BERAT)
265 I-1-16-I 8,581,000 10,297,200 12,013,400
266 I-1-16-II 19,415,300 23,298,300 27,181,400
267 I-1-16-III 22,395,200 26,874,300 31,353,300
268 I-1-17-I 9,936,000 11,923,100 13,910,300
(RINGAN)
269 I-1-17-II 12,440,700 14,928,900 17,417,000
(SEDANG)
- 487 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 15,389,000 18,466,800 21,544,600
(BERAT)
271 I-1-20-I 11,199,500 13,439,400 15,679,300
(RINGAN)
272 I-1-20-II 13,991,300 16,789,500 19,587,800
(SEDANG)
273 I-1-20-III 14,707,700 17,649,300 20,590,800
(BERAT)
274 I-1-30-I 8,471,800 10,166,200 11,860,500
JANTUNG (RINGAN)
275 I-1-30-II 17,623,200 21,147,900 24,672,500
JANTUNG (SEDANG)
276 I-1-30-III 27,309,700 32,771,600 38,233,600
JANTUNG (BERAT)

289 I-4-13-I 2,652,400 3,182,900 3,713,400
(RINGAN)
290 I-4-13-II 4,736,200 5,683,500 6,630,700
(SEDANG)
291 I-4-13-III 6,824,200 8,189,100 9,553,900
(BERAT)
295 I-4-15-I 4,313,200 5,175,800 6,038,500
(RINGAN)
296 I-4-15-II 5,867,800 7,041,400 8,214,900
(SEDANG)

304 I-4-18-I 3,049,300 3,659,200 4,269,100
JANTUNG (RINGAN)
305 I-4-18-II 4,642,700 5,571,300 6,499,800
JANTUNG (SEDANG)
306 I-4-18-III 6,303,300 7,563,900 8,824,600
JANTUNG (BERAT)

308 I-4-19-II 4,592,600 5,511,100 6,429,700
(SEDANG)
- 488 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 2,514,700 3,017,600 3,520,600
320 I-4-23-II 3,087,300 3,704,800 4,322,200
321 I-4-23-III 6,032,400 7,238,900 8,445,400
322 I-4-24-I 2,264,500 2,717,400 3,170,300
(RINGAN)
323 I-4-24-II 5,214,500 6,257,400 7,300,300
(SEDANG)
324 I-4-24-III 6,592,800 7,911,400 9,229,900
(BERAT)
325 J-1-01-I 40,853,200 49,023,800 57,194,500
326 J-1-01-II 46,233,000 55,479,600 64,726,200
327 J-1-01-III 52,304,100 62,764,900 73,225,700
TRAKEOSTOMI (BERAT)
328 J-1-02-I 21,679,300 26,015,200 30,351,000
329 J-1-02-II 30,186,200 36,223,400 42,260,700
330 J-1-02-III 49,847,700 59,817,300 69,786,800
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,583,400 7,900,100 9,216,800
(RINGAN)
332 J-1-10-II 13,321,600 15,985,900 18,650,200
(SEDANG)
333 J-1-10-III 13,844,400 16,613,300 19,382,200
(BERAT)
334 J-1-20-I 9,328,000 11,193,700 13,059,300
(RINGAN)
335 J-1-20-II 12,325,500 14,790,600 17,255,700
(SEDANG)
336 J-1-20-III 18,875,200 22,650,200 26,425,200
(BERAT)
337 J-1-30-I 5,494,000 6,592,800 7,691,700
(RINGAN)
338 J-1-30-II 9,952,400 11,942,900 13,933,300
(SEDANG)

- 489 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,692,900 3,231,500 3,770,100
374 J-4-21-II 4,338,200 5,205,900 6,073,500
375 J-4-21-III 6,053,700 7,264,400 8,475,100
376 K-1-10-I 5,968,300 7,161,900 8,355,600
BESAR (RINGAN)
377 K-1-10-II 7,500,400 9,000,500 10,500,600
BESAR (SEDANG)
378 K-1-10-III 8,790,700 10,548,900 12,307,000
BESAR (BERAT)
382 K-1-12-I 2,504,200 3,005,000 3,505,900
FEMORAL (RINGAN)
383 K-1-12-II 3,257,000 3,908,400 4,559,800
FEMORAL (SEDANG)
384 K-1-12-III 6,452,600 7,743,200 9,033,700
FEMORAL (BERAT)
388 K-1-14-I 4,583,200 5,499,900 6,416,500
(RINGAN)
389 K-1-14-II 5,371,500 6,445,700 7,520,000
(SEDANG)

394 K-1-30-I 5,248,400 6,298,100 7,347,700
395 K-1-30-II 9,321,000 11,185,200 13,049,400
396 K-1-30-III 12,825,800 15,391,000 17,956,200

398 K-1-40-II 6,456,400 7,747,700 9,039,000
(SEDANG)

- 490 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 2,993,400 3,592,100 4,190,800
413 K-4-13-II 3,872,200 4,646,700 5,421,100
414 K-4-13-III 5,964,500 7,157,300 8,350,200
415 K-4-14-I 1,897,900 2,277,400 2,657,000
(RINGAN)
416 K-4-14-II 2,547,600 3,057,100 3,566,600
(SEDANG)
417 K-4-14-III 4,087,800 4,905,400 5,722,900
(BERAT)

424 K-4-17-I 1,423,100 1,707,700 1,992,400
(RINGAN)
425 K-4-17-II 1,946,400 2,335,700 2,725,000
(SEDANG)
426 K-4-17-III 2,335,700 2,802,900 3,270,000
(BERAT)
427 K-4-18-I 1,257,500 1,509,000 1,760,500
(RINGAN)
428 K-4-18-II 1,787,000 2,144,400 2,501,800
(SEDANG)
436 L-1-40-I 3,741,300 4,489,600 5,237,800
(RINGAN)
437 L-1-40-II 7,504,200 9,005,100 10,505,900
(SEDANG)
438 L-1-40-III 12,631,300 15,157,500 17,683,800
(BERAT)
451 L-4-13-I 2,293,800 2,752,600 3,211,400
PAYUDARA (RINGAN)
- 491 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,695,900 3,235,100 3,774,300
PAYUDARA (SEDANG)
453 L-4-13-III 3,967,000 4,760,500 5,553,900
PAYUDARA (BERAT)
454 L-4-14-I 2,212,400 2,654,900 3,097,400
(RINGAN)
455 L-4-14-II 3,323,100 3,987,700 4,652,400
(SEDANG)
456 L-4-14-III 4,684,300 5,621,200 6,558,100
(BERAT)
457 M-1-01-I 7,820,600 9,384,800 10,948,900
458 M-1-01-II 11,115,900 13,339,100 15,562,300
459 M-1-01-III 15,614,600 18,737,500 21,860,400
463 M-1-03-I 18,819,600 22,583,500 26,347,400
464 M-1-03-II 22,012,200 26,414,600 30,817,100
465 M-1-03-III 27,243,800 32,692,600 38,141,300
472 M-1-07-I 6,176,600 7,412,000 8,647,300
473 M-1-07-II 8,274,600 9,929,500 11,584,400
474 M-1-07-III 16,856,100 20,227,300 23,598,500
475 M-1-10-I 10,167,800 12,201,300 14,234,900
WAJAH (RINGAN)
476 M-1-10-II 22,312,000 26,774,400 31,236,800
WAJAH (SEDANG)
477 M-1-10-III 48,124,900 57,749,800 67,374,800
WAJAH (BERAT)
478 M-1-20-I 9,287,000 11,144,500 13,001,900
(RINGAN)
479 M-1-20-II 11,865,100 14,238,200 16,611,200
(SEDANG)

484 M-1-40-I 3,243,200 3,891,800 4,540,400
INTERNAL (RINGAN)
485 M-1-40-II 5,751,600 6,901,900 8,052,200
INTERNAL (SEDANG)
486 M-1-40-III 8,212,200 9,854,600 11,497,100
INTERNAL (BERAT)
490 M-1-60-I 6,002,300 7,202,700 8,403,200
491 M-1-60-II 7,546,200 9,055,500 10,564,700
492 M-1-60-III 11,399,500 13,679,400 15,959,300
- 492 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 11,120,300 13,344,400 15,568,400
KAKI (RINGAN)
494 M-1-70-II 12,232,300 14,678,800 17,125,300
KAKI (SEDANG)
495 M-1-70-III 14,004,400 16,805,300 19,606,200
KAKI (BERAT)
502 M-4-11-I 2,774,800 3,329,800 3,884,700
(RINGAN)
503 M-4-11-II 6,083,600 7,300,400 8,517,100
(SEDANG)
504 M-4-11-III 8,795,900 10,555,100 12,314,300
(BERAT)
505 M-4-12-I 2,214,900 2,657,900 3,100,900
(RINGAN)
506 M-4-12-II 3,684,000 4,420,800 5,157,600
(SEDANG)
507 M-4-12-III 4,927,800 5,913,300 6,898,900
(BERAT)
508 M-4-13-I 3,688,100 4,425,700 5,163,300
509 M-4-13-II 5,541,200 6,649,400 7,757,600
510 M-4-13-III 10,810,700 12,972,800 15,134,900
520 M-4-17-I 2,771,400 3,325,600 3,879,900
(RINGAN)
521 M-4-17-II 3,876,100 4,651,300 5,426,500
(SEDANG)
522 M-4-17-III 5,412,700 6,495,200 7,577,800
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,203,500 2,644,200 3,084,900
(RINGAN)
530 M-4-20-II 3,226,700 3,872,000 4,517,400
(SEDANG)
531 M-4-20-III 3,606,200 4,327,500 5,048,700
(BERAT)
532 M-4-21-I 2,218,800 2,662,500 3,106,300
533 M-4-21-II 2,775,000 3,330,100 3,885,100
- 493 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 6,221,600 7,465,900 8,710,200
541 N-1-12-I 3,261,900 3,914,300 4,566,600
542 N-1-12-II 6,494,000 7,792,900 9,091,700
543 N-1-12-III 14,092,300 16,910,800 19,729,200
547 N-1-30-I 6,526,800 7,832,100 9,137,500
BAWAH (RINGAN)
548 N-1-30-II 9,873,700 11,848,400 13,823,200
BAWAH (SEDANG)
549 N-1-30-III 11,363,700 13,636,400 15,909,200
BAWAH (BERAT)
550 N-1-40-I 5,861,500 7,033,800 8,206,100
(RINGAN)
551 N-1-40-II 7,959,800 9,551,700 11,143,700
(SEDANG)
552 N-1-40-III 9,264,100 11,117,000 12,969,800
(BERAT)
553 N-4-10-I 2,490,300 2,988,400 3,486,400
(RINGAN)
554 N-4-10-II 3,012,100 3,614,500 4,216,900
(SEDANG)
555 N-4-10-III 4,430,300 5,316,400 6,202,500
(BERAT)
568 N-4-15-I 2,268,200 2,721,900 3,175,500
URIN (RINGAN)
569 N-4-15-II 2,814,500 3,377,400 3,940,300
URIN (SEDANG)
570 N-4-15-III 3,211,800 3,854,100 4,496,500
URIN (BERAT)
571 N-4-16-I 2,777,400 3,332,900 3,888,400
(RINGAN)
572 N-4-16-II 3,964,300 4,757,100 5,550,000
(SEDANG)
573 N-4-16-III 5,276,800 6,332,100 7,387,500
(BERAT)
- 494 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 2,581,800 3,098,100 3,614,500
578 O-6-11-II 2,869,300 3,443,200 4,017,100
579 O-6-11-III 3,569,500 4,283,400 4,997,300
580 O-6-12-I 1,829,100 2,195,000 2,560,800
581 O-6-12-II 2,196,800 2,636,100 3,075,500
582 O-6-12-III 2,760,300 3,312,400 3,864,500
586 P-8-01-I 40,845,000 49,014,000 57,183,000
587 P-8-01-II 50,539,500 60,647,500 70,755,400
588 P-8-01-III 59,319,200 71,183,100 83,046,900
589 P-8-02-I 68,814,700 82,577,600 96,340,600
590 P-8-02-II 78,937,500 94,724,900 110,512,400
591 P-8-02-III 90,191,700 108,230,000 126,268,400
592 P-8-03-I 7,436,200 8,923,500 10,410,700
593 P-8-03-II 11,033,000 13,239,600 15,446,200
594 P-8-03-III 12,487,100 14,984,500 17,482,000
595 P-8-04-I 22,049,200 26,459,100 30,868,900
596 P-8-04-II 37,120,900 44,545,100 51,969,200
597 P-8-04-III 53,222,000 63,866,400 74,510,800
598 P-8-05-I 15,592,400 18,710,800 21,829,300
599 P-8-05-II 22,606,400 27,127,700 31,648,900
600 P-8-05-III 32,441,100 38,929,300 45,417,500
601 P-8-06-I 3,956,100 4,747,300 5,538,600
602 P-8-06-II 11,092,100 13,310,500 15,528,900
603 P-8-06-III 14,694,200 17,633,100 20,571,900
604 P-8-07-I 3,831,900 4,598,300 5,364,700
605 P-8-07-II 10,743,800 12,892,500 15,041,300
606 P-8-07-III 14,232,900 17,079,400 19,926,000
607 P-8-08-I 3,887,600 4,665,200 5,442,700
608 P-8-08-II 5,516,500 6,619,800 7,723,000
609 P-8-08-III 8,932,300 10,718,800 12,505,200
610 P-8-11-I 6,760,200 8,112,300 9,464,300
MAYOR (RINGAN)
611 P-8-11-II 10,030,000 12,036,000 14,042,000
MAYOR (SEDANG)
- 495 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 11,351,900 13,622,300 15,892,700
MAYOR (BERAT)
613 P-8-12-I 5,878,400 7,054,100 8,229,800
MAYOR (RINGAN)
614 P-8-12-II 8,358,300 10,030,000 11,701,600
MAYOR (SEDANG)
615 P-8-12-III 9,459,900 11,351,900 13,243,900
MAYOR (BERAT)
616 P-8-13-I 5,049,500 6,059,400 7,069,300
MAYOR (RINGAN)
617 P-8-13-II 7,877,200 9,452,600 11,028,100
MAYOR (SEDANG)
618 P-8-13-III 10,752,000 12,902,400 15,052,800
MAYOR (BERAT)
619 P-8-14-I 2,664,100 3,196,900 3,729,700
620 P-8-14-II 5,423,000 6,507,600 7,592,300
621 P-8-14-III 10,061,800 12,074,100 14,086,500
622 P-8-15-I 1,998,100 2,397,700 2,797,300
ASPIRASI (RINGAN)
623 P-8-15-II 4,001,300 4,801,600 5,601,800
ASPIRASI (SEDANG)
624 P-8-15-III 4,694,800 5,633,800 6,572,700
ASPIRASI (BERAT)
625 P-8-16-I 1,808,300 2,170,000 2,531,600
626 P-8-16-II 3,475,000 4,169,900 4,864,900
627 P-8-16-III 7,086,400 8,503,700 9,920,900
628 P-8-17-I 3,366,300 4,039,600 4,712,800
(RINGAN)
629 P-8-17-II 6,059,400 7,271,200 8,483,100
(SEDANG)
630 P-8-17-III 8,270,800 9,924,900 11,579,100
(BERAT)
631 S-4-10-I 2,038,800 2,446,600 2,854,400
632 S-4-10-II 2,512,200 3,014,600 3,517,000
633 S-4-10-III 3,438,900 4,126,700 4,814,500
640 S-4-13-I 2,213,600 2,656,300 3,099,000
(RINGAN)
641 S-4-13-II 3,927,000 4,712,500 5,497,900
(SEDANG)
642 S-4-13-III 6,374,100 7,648,900 8,923,700
(BERAT)
643 S-4-14-I 1,120,200 1,344,300 1,568,300
644 S-4-14-II 2,379,400 2,855,300 3,331,200
645 S-4-14-III 4,512,300 5,414,700 6,317,200
KANAK-KANAK (BERAT)
646 S-4-15-I 749,200 899,100 1,048,900
647 S-4-15-II 1,413,900 1,696,700 1,979,400
648 S-4-15-III 1,831,200 2,197,500 2,563,700
- 496 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 1,869,900 2,243,900 2,617,800
653 S-4-17-II 2,775,100 3,330,100 3,885,200
654 S-4-17-III 3,337,700 4,005,200 4,672,800
655 T-1-10-I 1,251,100 1,501,300 1,751,500
OBAT (RINGAN)
656 T-1-10-II 1,680,400 2,016,500 2,352,500
OBAT (SEDANG)
657 T-1-10-III 3,056,900 3,668,300 4,279,600
OBAT (BERAT)
658 T-4-10-I 596,600 715,900 835,200
659 T-4-10-II 1,137,000 1,364,500 1,591,900
660 T-4-10-III 1,652,900 1,983,500 2,314,100
661 T-4-11-I 798,700 958,400 1,118,200
662 T-4-11-II 1,256,800 1,508,200 1,759,500
663 T-4-11-III 2,024,400 2,429,300 2,834,200
664 T-4-12-I 1,241,100 1,489,300 1,737,500
LAIN (RINGAN)
665 T-4-12-II 1,875,800 2,251,000 2,626,100
LAIN (SEDANG)
666 T-4-12-III 2,903,900 3,484,700 4,065,500
LAIN (BERAT)
670 U-1-11-I 6,325,000 7,590,000 8,855,000
(RINGAN)
671 U-1-11-II 8,017,900 9,621,500 11,225,100
(SEDANG)
672 U-1-11-III 11,536,500 13,843,800 16,151,100
(BERAT)
679 U-1-14-I 2,972,000 3,566,400 4,160,800
(RINGAN)
680 U-1-14-II 3,647,400 4,376,900 5,106,300
(SEDANG)
681 U-1-14-III 4,322,100 5,186,600 6,051,000
(BERAT)
685 U-1-20-I 4,512,000 5,414,400 6,316,800
686 U-1-20-II 6,715,100 8,058,100 9,401,100
687 U-1-20-III 17,238,900 20,686,700 24,134,500
691 U-4-10-I 2,784,700 3,341,600 3,898,500
- 497 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 6,374,900 7,649,900 8,924,900
693 U-4-10-III 9,787,500 11,745,000 13,702,500
TENGGOROKAN (BERAT)
700 U-4-13-I 1,848,300 2,217,900 2,587,600
701 U-4-13-II 2,178,900 2,614,700 3,050,500
702 U-4-13-III 2,606,100 3,127,300 3,648,500
706 U-4-15-I 2,225,600 2,670,700 3,115,800
707 U-4-15-II 2,772,800 3,327,300 3,881,900
708 U-4-15-III 3,880,500 4,656,700 5,432,800
709 V-1-10-I 3,630,100 4,356,100 5,082,100
(RINGAN)
710 V-1-10-II 7,477,900 8,973,400 10,469,000
(SEDANG)
711 V-1-10-III 9,170,600 11,004,700 12,838,800
(BERAT)
715 V-1-12-I 6,493,100 7,791,700 9,090,300
MODERAT (RINGAN)
716 V-1-12-II 8,866,800 10,640,200 12,413,500
MODERAT (SEDANG)
717 V-1-12-III 11,238,800 13,486,500 15,734,300
MODERAT (BERAT)
718 V-1-13-I 3,386,900 4,064,200 4,741,600
KOMPLEK (RINGAN)
719 V-1-13-II 6,471,200 7,765,400 9,059,700
KOMPLEK (SEDANG)
720 V-1-13-III 10,152,500 12,183,000 14,213,500
KOMPLEK (BERAT)
721 V-1-14-I 6,641,600 7,970,000 9,298,300
(RINGAN)
722 V-1-14-II 9,650,100 11,580,100 13,510,100
(SEDANG)

727 V-4-10-I 3,211,800 3,854,100 4,496,500
(RINGAN)
728 V-4-10-II 5,334,900 6,401,900 7,468,900
(SEDANG)
729 V-4-10-III 8,795,400 10,554,500 12,313,600
(BERAT)
730 V-4-11-I 2,775,200 3,330,200 3,885,200
TUMOR (RINGAN)
731 V-4-11-II 3,723,600 4,468,300 5,213,000
TUMOR (SEDANG)
732 V-4-11-III 4,987,800 5,985,300 6,982,900
TUMOR (BERAT)
- 498 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 7,564,100 9,077,000 10,589,800
734 W-1-01-II 9,066,100 10,879,400 12,692,600
735 W-1-01-III 12,937,100 15,524,500 18,112,000
739 W-1-11-I 1,677,000 2,012,400 2,347,800
SERVIK (RINGAN)
740 W-1-11-II 1,850,600 2,220,700 2,590,800
SERVIK (SEDANG)
741 W-1-11-III 2,047,100 2,456,500 2,866,000
SERVIK (BERAT)
760 W-4-12-I 2,703,300 3,244,000 3,784,700
761 W-4-12-II 3,711,500 4,453,800 5,196,100
762 W-4-12-III 4,045,700 4,854,900 5,664,000
- 499 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 1,180,200 1,416,200 1,652,300
785 Z-4-12-II 2,895,200 3,474,300 4,053,300
786 Z-4-12-III 4,141,800 4,970,200 5,798,500
- 500 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,475,700

33 F-3-10-0 TERAPI SHOCK 417,900
- 501 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,540,400
PENGGANTIAN ALAT
81 I-2-42-0 2,441,200
PERKUTAN LAIN
- 502 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,151,200
192 Q-5-12-0 GIGI 209,100
196 Q-5-16-0 VAKSINASI 91,500
201 Q-5-21-0 ABORSI 182,500
206 Q-5-26-0 BRONKIAL AKUT 194,800
- 503 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 131,100
215 Q-5-35-0 INFEKSI AKUT 426,900
218 Q-5-38-0 PARU AKUT 248,700
234 U-2-23-0 RHINOPLASTY 1,229,000
242 U-3-13-0 316,800
TENGGOROKAN
270 Z-3-11-0 1,718,600
EMPEDU
- 504 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 905,600
289 Z-3-30-0 FOTOTERAPI 75,600
- 505 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,181,200 2,617,400 3,053,600
(RINGAN)
14 A-4-14-II 2,647,600 3,177,100 3,706,600
(SEDANG)
15 A-4-14-III 3,177,100 3,812,500 4,447,900
(BERAT)

31 B-1-13-I 4,209,800 5,051,700 5,893,700
LAIN (RINGAN)
32 B-1-13-II 6,926,600 8,312,000 9,697,300
LAIN (SEDANG)
33 B-1-13-III 8,962,500 10,754,900 12,547,400
LAIN (BERAT)
34 B-1-14-I 5,784,400 6,941,200 8,098,100
(RINGAN)
35 B-1-14-II 6,433,200 7,719,900 9,006,500
(SEDANG)
40 B-4-11-I 3,773,300 4,528,000 5,282,700
(RINGAN)
41 B-4-11-II 5,282,700 6,339,200 7,395,800
(SEDANG)
42 B-4-11-III 6,399,900 7,679,900 8,959,900
(BERAT)
- 506 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 3,997,300 4,796,700 5,596,200
74 D-1-20-II 11,015,900 13,219,000 15,422,200
75 D-1-20-III 17,474,400 20,969,200 24,464,100
85 D-4-13-I 2,312,000 2,774,400 3,236,800
86 D-4-13-II 3,272,300 3,926,800 4,581,200
87 D-4-13-III 4,185,400 5,022,500 5,859,500
88 D-4-14-I 2,479,800 2,975,700 3,471,700
89 D-4-14-II 4,060,000 4,872,000 5,684,000
90 D-4-14-III 4,965,800 5,958,900 6,952,100
91 E-1-01-I 4,414,300 5,297,100 6,180,000
(RINGAN)
92 E-1-01-II 5,782,300 6,938,700 8,095,200
(SEDANG)

97 E-1-20-I 5,818,000 6,981,600 8,145,200
TIROGLOSAL (RINGAN)
- 507 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 7,830,900 9,397,000 10,963,200
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,792,600 12,951,100 15,109,600
TIROGLOSAL (BERAT)
100 E-4-10-I 3,471,700 4,166,000 4,860,300
METABOLIK (RINGAN)
101 E-4-10-II 4,851,000 5,821,300 6,791,500
METABOLIK (SEDANG)
102 E-4-10-III 6,021,100 7,225,300 8,429,600
METABOLIK (BERAT)
109 E-4-13-I 2,861,700 3,434,000 4,006,400
(RINGAN)
110 E-4-13-II 4,191,900 5,030,300 5,868,700
(SEDANG)

118 F-4-12-I 1,615,200 1,938,300 2,261,300
(RINGAN)
119 F-4-12-II 2,296,300 2,755,600 3,214,900
(SEDANG)
120 F-4-12-III 4,988,600 5,986,400 6,984,100
(BERAT)
130 F-4-16-I 4,243,400 5,092,100 5,940,800
131 F-4-16-II 4,933,700 5,920,400 6,907,100
132 F-4-16-III 6,585,600 7,902,700 9,219,800
142 G-1-01-I 10,746,400 12,895,700 15,044,900
(RINGAN)
- 508 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 16,734,400 20,081,300 23,428,200
(SEDANG)
144 G-1-01-III 32,183,400 38,620,100 45,056,800
(BERAT)
151 G-1-12-I 3,819,700 4,583,700 5,347,600
(RINGAN)
152 G-1-12-II 7,160,200 8,592,300 10,024,300
(SEDANG)
153 G-1-12-III 9,758,000 11,709,600 13,661,200
(BERAT)
163 G-4-10-I 3,278,800 3,934,600 4,590,300
(RINGAN)
164 G-4-10-II 4,007,800 4,809,400 5,610,900
(SEDANG)
165 G-4-10-III 5,499,400 6,599,300 7,699,200
(BERAT)
166 G-4-11-I 3,432,400 4,118,900 4,805,400
167 G-4-11-II 4,559,500 5,471,400 6,383,300
168 G-4-11-III 6,699,500 8,039,400 9,379,300
DEGENERATIF (BERAT)
169 G-4-12-I 3,807,800 4,569,400 5,331,000
(RINGAN)
170 G-4-12-II 4,809,600 5,771,500 6,733,400
(SEDANG)

172 G-4-13-I 2,287,400 2,744,900 3,202,400
(RINGAN)
173 G-4-13-II 3,988,800 4,786,600 5,584,400
(SEDANG)
174 G-4-13-III 4,730,800 5,677,000 6,623,200
(BERAT)
175 G-4-14-I 3,880,400 4,656,400 5,432,500
INFARK (RINGAN)
176 G-4-14-II 5,187,700 6,225,300 7,262,800
INFARK (SEDANG)
177 G-4-14-III 6,511,200 7,813,500 9,115,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 509 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 3,481,300 4,177,600 4,873,800
(RINGAN)
185 G-4-17-II 4,564,700 5,477,700 6,390,600
(SEDANG)
186 G-4-17-III 5,735,800 6,883,000 8,030,100
(BERAT)
190 G-4-19-I 2,860,500 3,432,600 4,004,700
191 G-4-19-II 4,834,900 5,801,900 6,768,900
192 G-4-19-III 6,348,100 7,617,700 8,887,300
211 G-4-26-I 3,085,200 3,702,300 4,319,300
LAIN (RINGAN)
212 G-4-26-II 3,589,100 4,306,900 5,024,700
LAIN (SEDANG)
213 G-4-26-III 5,366,800 6,440,100 7,513,500
LAIN (BERAT)
232 I-1-02-I 20,040,900 24,049,100 28,057,300
(RINGAN)
- 510 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 25,852,600 31,023,100 36,193,600
(SEDANG)
234 I-1-02-III 31,864,900 38,237,900 44,610,900
(BERAT)
235 I-1-03-I 11,575,700 13,890,800 16,206,000
ANOMALI (RINGAN)
236 I-1-03-II 16,046,300 19,255,600 22,464,800
ANOMALI (SEDANG)
237 I-1-03-III 20,364,000 24,436,800 28,509,600
ANOMALI (BERAT)
238 I-1-04-I 17,443,900 20,932,700 24,421,500
JANTUNG (RINGAN)
239 I-1-04-II 27,531,300 33,037,500 38,543,800
JANTUNG (SEDANG)
240 I-1-04-III 43,981,000 52,777,200 61,573,400
JANTUNG (BERAT)
241 I-1-05-I 22,382,200 26,858,600 31,335,100
242 I-1-05-II 26,858,700 32,230,500 37,602,200
243 I-1-05-III 36,957,400 44,348,900 51,740,400
247 I-1-07-I 19,642,900 23,571,500 27,500,100
JANTUNG (RINGAN)
248 I-1-07-II 24,233,500 29,080,200 33,926,900
JANTUNG (SEDANG)
249 I-1-07-III 26,438,700 31,726,400 37,014,100
JANTUNG (BERAT)
250 I-1-11-I 3,140,500 3,768,600 4,396,700
251 I-1-11-II 3,491,900 4,190,300 4,888,700
252 I-1-11-III 4,646,700 5,576,000 6,505,300
253 I-1-12-I 9,039,800 10,847,800 12,655,700
(RINGAN)
254 I-1-12-II 14,763,800 17,716,600 20,669,300
(SEDANG)
255 I-1-12-III 19,424,000 23,308,800 27,193,600
(BERAT)
256 I-1-13-I 8,768,500 10,522,200 12,275,900
KOMPLEK (RINGAN)
257 I-1-13-II 11,677,000 14,012,400 16,347,800
KOMPLEK (SEDANG)
258 I-1-13-III 14,401,000 17,281,200 20,161,400
KOMPLEK (BERAT)
259 I-1-14-I 17,946,900 21,536,300 25,125,700
(RINGAN)
260 I-1-14-II 22,305,400 26,766,500 31,227,500
(SEDANG)
261 I-1-14-III 29,227,800 35,073,300 40,918,900
(BERAT)
265 I-1-16-I 8,838,400 10,606,100 12,373,800
266 I-1-16-II 19,997,700 23,997,300 27,996,800
267 I-1-16-III 23,067,100 27,680,500 32,293,900
268 I-1-17-I 10,234,000 12,280,800 14,327,600
(RINGAN)
269 I-1-17-II 12,814,000 15,376,800 17,939,600
(SEDANG)
- 511 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 15,850,700 19,020,800 22,191,000
(BERAT)
271 I-1-20-I 11,535,500 13,842,600 16,149,700
(RINGAN)
272 I-1-20-II 14,411,000 17,293,200 20,175,400
(SEDANG)
273 I-1-20-III 15,149,000 18,178,800 21,208,500
(BERAT)
274 I-1-30-I 8,726,000 10,471,200 12,216,300
JANTUNG (RINGAN)
275 I-1-30-II 18,151,900 21,782,300 25,412,700
JANTUNG (SEDANG)
276 I-1-30-III 28,129,000 33,754,800 39,380,600
JANTUNG (BERAT)

289 I-4-13-I 2,732,000 3,278,400 3,824,800
(RINGAN)
290 I-4-13-II 4,878,300 5,854,000 6,829,600
(SEDANG)
291 I-4-13-III 7,029,000 8,434,700 9,840,500
(BERAT)
295 I-4-15-I 4,442,600 5,331,100 6,219,600
(RINGAN)
296 I-4-15-II 6,043,900 7,252,600 8,461,400
(SEDANG)

304 I-4-18-I 3,140,800 3,769,000 4,397,100
JANTUNG (RINGAN)
305 I-4-18-II 4,782,000 5,738,400 6,694,800
JANTUNG (SEDANG)
306 I-4-18-III 6,492,400 7,790,800 9,089,300
JANTUNG (BERAT)

308 I-4-19-II 4,730,400 5,676,500 6,622,500
(SEDANG)
- 512 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 2,590,100 3,108,100 3,626,200
320 I-4-23-II 3,179,900 3,815,900 4,451,900
321 I-4-23-III 6,213,400 7,456,100 8,698,800
322 I-4-24-I 2,332,400 2,798,900 3,265,400
(RINGAN)
323 I-4-24-II 5,370,900 6,445,100 7,519,300
(SEDANG)
324 I-4-24-III 6,790,600 8,148,700 9,506,800
(BERAT)
325 J-1-01-I 42,078,800 50,494,600 58,910,300
326 J-1-01-II 47,620,000 57,144,000 66,668,000
327 J-1-01-III 53,873,200 64,647,800 75,422,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 22,329,700 26,795,600 31,261,600
329 J-1-02-II 31,091,800 37,310,100 43,528,500
330 J-1-02-III 51,343,200 61,611,800 71,880,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,780,900 8,137,100 9,493,300
(RINGAN)
332 J-1-10-II 13,721,300 16,465,500 19,209,800
(SEDANG)
333 J-1-10-III 14,259,800 17,111,700 19,963,700
(BERAT)
334 J-1-20-I 9,607,900 11,529,500 13,451,000
(RINGAN)
335 J-1-20-II 12,695,300 15,234,300 17,773,400
(SEDANG)
336 J-1-20-III 19,441,400 23,329,700 27,218,000
(BERAT)
337 J-1-30-I 5,658,900 6,790,600 7,922,400
(RINGAN)
338 J-1-30-II 10,251,000 12,301,200 14,351,300
(SEDANG)

- 513 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,773,700 3,328,400 3,883,200
374 J-4-21-II 4,468,400 5,362,000 6,255,700
375 J-4-21-III 6,235,300 7,482,300 8,729,400
376 K-1-10-I 6,147,300 7,376,800 8,606,300
BESAR (RINGAN)
377 K-1-10-II 7,725,400 9,270,500 10,815,600
BESAR (SEDANG)
378 K-1-10-III 9,054,500 10,865,400 12,676,300
BESAR (BERAT)
382 K-1-12-I 2,579,300 3,095,200 3,611,100
FEMORAL (RINGAN)
383 K-1-12-II 3,354,700 4,025,700 4,696,600
FEMORAL (SEDANG)
384 K-1-12-III 6,646,200 7,975,400 9,304,700
FEMORAL (BERAT)
388 K-1-14-I 4,720,700 5,664,900 6,609,000
(RINGAN)
389 K-1-14-II 5,532,600 6,639,100 7,745,600
(SEDANG)

394 K-1-30-I 5,405,800 6,487,000 7,568,200
395 K-1-30-II 9,600,600 11,520,800 13,440,900
396 K-1-30-III 13,210,600 15,852,700 18,494,900

398 K-1-40-II 6,650,100 7,980,100 9,310,200
(SEDANG)

- 514 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 3,083,200 3,699,900 4,316,500
413 K-4-13-II 3,988,400 4,786,100 5,583,700
414 K-4-13-III 6,143,400 7,372,100 8,600,700
415 K-4-14-I 1,954,800 2,345,800 2,736,700
(RINGAN)
416 K-4-14-II 2,624,000 3,148,800 3,673,600
(SEDANG)
417 K-4-14-III 4,210,500 5,052,500 5,894,600
(BERAT)

424 K-4-17-I 1,465,800 1,759,000 2,052,100
(RINGAN)
425 K-4-17-II 2,004,800 2,405,800 2,806,800
(SEDANG)
426 K-4-17-III 2,405,800 2,887,000 3,368,100
(BERAT)
427 K-4-18-I 1,295,200 1,554,300 1,813,300
(RINGAN)
428 K-4-18-II 1,840,600 2,208,700 2,576,800
(SEDANG)
436 L-1-40-I 3,853,500 4,624,200 5,394,900
(RINGAN)
437 L-1-40-II 7,729,300 9,275,200 10,821,100
(SEDANG)
438 L-1-40-III 13,010,200 15,612,200 18,214,300
(BERAT)
451 L-4-13-I 2,362,700 2,835,200 3,307,700
PAYUDARA (RINGAN)
- 515 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,776,800 3,332,100 3,887,500
PAYUDARA (SEDANG)
453 L-4-13-III 4,086,100 4,903,300 5,720,500
PAYUDARA (BERAT)
454 L-4-14-I 2,278,800 2,734,500 3,190,300
(RINGAN)
455 L-4-14-II 3,422,800 4,107,400 4,791,900
(SEDANG)
456 L-4-14-III 4,824,900 5,789,800 6,754,800
(BERAT)
457 M-1-01-I 8,055,300 9,666,300 11,277,400
458 M-1-01-II 11,449,400 13,739,300 16,029,200
459 M-1-01-III 16,083,000 19,299,600 22,516,200
463 M-1-03-I 19,384,200 23,261,000 27,137,800
464 M-1-03-II 22,672,600 27,207,100 31,741,600
465 M-1-03-III 28,061,100 33,673,300 39,285,600
472 M-1-07-I 6,361,900 7,634,300 8,906,700
473 M-1-07-II 8,522,800 10,227,400 11,931,900
474 M-1-07-III 17,361,800 20,834,100 24,306,500
475 M-1-10-I 10,472,800 12,567,400 14,662,000
WAJAH (RINGAN)
476 M-1-10-II 22,981,300 27,577,600 32,173,900
WAJAH (SEDANG)
477 M-1-10-III 49,568,600 59,482,300 69,396,000
WAJAH (BERAT)
478 M-1-20-I 9,565,700 11,478,800 13,391,900
(RINGAN)
479 M-1-20-II 12,221,100 14,665,300 17,109,500
(SEDANG)

484 M-1-40-I 3,340,500 4,008,500 4,676,600
INTERNAL (RINGAN)
485 M-1-40-II 5,924,200 7,109,000 8,293,800
INTERNAL (SEDANG)
486 M-1-40-III 8,458,500 10,150,300 11,842,000
INTERNAL (BERAT)
490 M-1-60-I 6,182,300 7,418,800 8,655,300
491 M-1-60-II 7,772,600 9,327,200 10,881,700
492 M-1-60-III 11,741,500 14,089,800 16,438,100
- 516 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 11,453,900 13,744,700 16,035,500
KAKI (RINGAN)
494 M-1-70-II 12,599,300 15,119,200 17,639,000
KAKI (SEDANG)
495 M-1-70-III 14,424,500 17,309,400 20,194,300
KAKI (BERAT)
502 M-4-11-I 2,858,000 3,429,700 4,001,300
(RINGAN)
503 M-4-11-II 6,266,100 7,519,400 8,772,600
(SEDANG)
504 M-4-11-III 9,059,800 10,871,700 12,683,700
(BERAT)
505 M-4-12-I 2,281,400 2,737,600 3,193,900
(RINGAN)
506 M-4-12-II 3,794,500 4,553,400 5,312,300
(SEDANG)
507 M-4-12-III 5,075,600 6,090,700 7,105,800
(BERAT)
508 M-4-13-I 3,798,700 4,558,400 5,318,200
509 M-4-13-II 5,707,400 6,848,900 7,990,300
510 M-4-13-III 11,135,000 13,362,000 15,589,000
520 M-4-17-I 2,854,500 3,425,400 3,996,300
(RINGAN)
521 M-4-17-II 3,992,400 4,790,800 5,589,300
(SEDANG)
522 M-4-17-III 5,575,100 6,690,100 7,805,100
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,269,600 2,723,600 3,177,500
(RINGAN)
530 M-4-20-II 3,323,500 3,988,200 4,652,900
(SEDANG)
531 M-4-20-III 3,714,400 4,457,300 5,200,200
(BERAT)
532 M-4-21-I 2,285,300 2,742,400 3,199,500
533 M-4-21-II 2,858,300 3,430,000 4,001,600
- 517 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 6,408,300 7,689,900 8,971,600
541 N-1-12-I 3,359,700 4,031,700 4,703,600
542 N-1-12-II 6,688,900 8,026,600 9,364,400
543 N-1-12-III 14,515,100 17,418,100 20,321,100
547 N-1-30-I 6,722,600 8,067,100 9,411,600
BAWAH (RINGAN)
548 N-1-30-II 10,169,900 12,203,900 14,237,900
BAWAH (SEDANG)
549 N-1-30-III 11,704,600 14,045,500 16,386,400
BAWAH (BERAT)
550 N-1-40-I 6,037,300 7,244,800 8,452,300
(RINGAN)
551 N-1-40-II 8,198,600 9,838,300 11,478,000
(SEDANG)
552 N-1-40-III 9,542,100 11,450,500 13,358,900
(BERAT)
553 N-4-10-I 2,565,000 3,078,000 3,591,000
(RINGAN)
554 N-4-10-II 3,102,400 3,722,900 4,343,400
(SEDANG)
555 N-4-10-III 4,563,200 5,475,900 6,388,500
(BERAT)
568 N-4-15-I 2,336,300 2,803,500 3,270,800
URIN (RINGAN)
569 N-4-15-II 2,898,900 3,478,700 4,058,500
URIN (SEDANG)
570 N-4-15-III 3,308,100 3,969,800 4,631,400
URIN (BERAT)
571 N-4-16-I 2,860,800 3,432,900 4,005,100
(RINGAN)
572 N-4-16-II 4,083,200 4,899,900 5,716,500
(SEDANG)
573 N-4-16-III 5,435,100 6,522,100 7,609,100
(BERAT)
- 518 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 2,659,200 3,191,100 3,722,900
578 O-6-11-II 2,955,400 3,546,500 4,137,600
579 O-6-11-III 3,676,600 4,411,900 5,147,200
580 O-6-12-I 1,884,000 2,260,800 2,637,600
581 O-6-12-II 2,262,700 2,715,200 3,167,800
582 O-6-12-III 2,843,200 3,411,800 3,980,400
586 P-8-01-I 42,070,300 50,484,400 58,898,500
587 P-8-01-II 52,055,700 62,466,900 72,878,000
588 P-8-01-III 61,098,800 73,318,600 85,538,300
589 P-8-02-I 70,879,100 85,054,900 99,230,800
590 P-8-02-II 81,305,600 97,566,700 113,827,800
591 P-8-02-III 92,897,400 111,476,900 130,056,400
592 P-8-03-I 7,659,300 9,191,200 10,723,000
593 P-8-03-II 11,364,000 13,636,700 15,909,500
594 P-8-03-III 12,861,700 15,434,100 18,006,400
595 P-8-04-I 22,710,700 27,252,800 31,795,000
596 P-8-04-II 38,234,500 45,881,400 53,528,300
597 P-8-04-III 54,818,600 65,782,400 76,746,100
598 P-8-05-I 16,060,100 19,272,200 22,484,200
599 P-8-05-II 23,284,600 27,941,500 32,598,400
600 P-8-05-III 33,414,300 40,097,200 46,780,100
601 P-8-06-I 4,074,800 4,889,800 5,704,700
602 P-8-06-II 11,424,800 13,709,800 15,994,700
603 P-8-06-III 15,135,100 18,162,100 21,189,100
604 P-8-07-I 3,946,900 4,736,200 5,525,600
605 P-8-07-II 11,066,100 13,279,300 15,492,500
606 P-8-07-III 14,659,900 17,591,800 20,523,800
607 P-8-08-I 4,004,300 4,805,100 5,606,000
608 P-8-08-II 5,682,000 6,818,300 7,954,700
609 P-8-08-III 9,200,300 11,040,300 12,880,400
610 P-8-11-I 6,963,000 8,355,600 9,748,200
MAYOR (RINGAN)
611 P-8-11-II 10,330,900 12,397,000 14,463,200
MAYOR (SEDANG)
- 519 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 11,692,500 14,031,000 16,369,500
MAYOR (BERAT)
613 P-8-12-I 6,054,800 7,265,800 8,476,700
MAYOR (RINGAN)
614 P-8-12-II 8,609,100 10,330,900 12,052,700
MAYOR (SEDANG)
615 P-8-12-III 9,743,700 11,692,500 13,641,200
MAYOR (BERAT)
616 P-8-13-I 5,201,000 6,241,200 7,281,300
MAYOR (RINGAN)
617 P-8-13-II 8,113,500 9,736,200 11,358,900
MAYOR (SEDANG)
618 P-8-13-III 11,074,600 13,289,500 15,504,400
MAYOR (BERAT)
619 P-8-14-I 2,744,000 3,292,800 3,841,600
620 P-8-14-II 5,585,700 6,702,900 7,820,000
621 P-8-14-III 10,363,600 12,436,400 14,509,100
622 P-8-15-I 2,058,000 2,469,700 2,881,300
ASPIRASI (RINGAN)
623 P-8-15-II 4,121,300 4,945,600 5,769,900
ASPIRASI (SEDANG)
624 P-8-15-III 4,835,600 5,802,800 6,769,900
ASPIRASI (BERAT)
625 P-8-16-I 1,862,600 2,235,100 2,607,600
626 P-8-16-II 3,579,200 4,295,000 5,010,900
627 P-8-16-III 7,299,000 8,758,800 10,218,600
628 P-8-17-I 3,467,300 4,160,800 4,854,200
(RINGAN)
629 P-8-17-II 6,241,200 7,489,400 8,737,600
(SEDANG)
630 P-8-17-III 8,518,900 10,222,700 11,926,500
(BERAT)
631 S-4-10-I 2,100,000 2,520,000 2,940,000
632 S-4-10-II 2,587,500 3,105,000 3,622,500
633 S-4-10-III 3,542,100 4,250,500 4,958,900
640 S-4-13-I 2,280,000 2,736,000 3,192,000
(RINGAN)
641 S-4-13-II 4,044,900 4,853,800 5,662,800
(SEDANG)
642 S-4-13-III 6,565,300 7,878,400 9,191,400
(BERAT)
643 S-4-14-I 1,153,800 1,384,600 1,615,400
644 S-4-14-II 2,450,800 2,941,000 3,431,200
645 S-4-14-III 4,647,600 5,577,100 6,506,700
KANAK-KANAK (BERAT)
646 S-4-15-I 771,700 926,000 1,080,400
647 S-4-15-II 1,456,300 1,747,600 2,038,800
648 S-4-15-III 1,886,200 2,263,400 2,640,600
- 520 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 1,926,000 2,311,200 2,696,400
653 S-4-17-II 2,858,400 3,430,000 4,001,700
654 S-4-17-III 3,437,800 4,125,400 4,812,900
655 T-1-10-I 1,288,600 1,546,400 1,804,100
OBAT (RINGAN)
656 T-1-10-II 1,730,800 2,077,000 2,423,100
OBAT (SEDANG)
657 T-1-10-III 3,148,600 3,778,300 4,408,000
OBAT (BERAT)
658 T-4-10-I 614,500 737,400 860,300
659 T-4-10-II 1,171,200 1,405,400 1,639,600
660 T-4-10-III 1,702,500 2,043,000 2,383,500
661 T-4-11-I 822,600 987,200 1,151,700
662 T-4-11-II 1,294,500 1,553,400 1,812,300
663 T-4-11-III 2,085,200 2,502,200 2,919,200
664 T-4-12-I 1,278,300 1,533,900 1,789,600
LAIN (RINGAN)
665 T-4-12-II 1,932,100 2,318,500 2,704,900
LAIN (SEDANG)
666 T-4-12-III 2,991,000 3,589,200 4,187,400
LAIN (BERAT)
670 U-1-11-I 6,514,800 7,817,700 9,120,700
(RINGAN)
671 U-1-11-II 8,258,500 9,910,100 11,561,800
(SEDANG)
672 U-1-11-III 11,882,600 14,259,100 16,635,600
(BERAT)
679 U-1-14-I 3,061,200 3,673,400 4,285,600
(RINGAN)
680 U-1-14-II 3,756,800 4,508,200 5,259,500
(SEDANG)
681 U-1-14-III 4,451,800 5,342,200 6,232,500
(BERAT)
685 U-1-20-I 4,647,300 5,576,800 6,506,300
686 U-1-20-II 6,916,500 8,299,800 9,683,100
687 U-1-20-III 17,756,100 21,307,300 24,858,500
691 U-4-10-I 2,868,200 3,441,800 4,015,500
- 521 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 6,566,200 7,879,400 9,192,700
693 U-4-10-III 10,081,100 12,097,400 14,113,600
TENGGOROKAN (BERAT)
700 U-4-13-I 1,903,700 2,284,500 2,665,200
701 U-4-13-II 2,244,300 2,693,200 3,142,000
702 U-4-13-III 2,684,300 3,221,100 3,758,000
706 U-4-15-I 2,292,300 2,750,800 3,209,300
707 U-4-15-II 2,856,000 3,427,200 3,998,400
708 U-4-15-III 3,997,000 4,796,400 5,595,700
709 V-1-10-I 3,739,000 4,486,800 5,234,600
(RINGAN)
710 V-1-10-II 7,702,200 9,242,700 10,783,100
(SEDANG)
711 V-1-10-III 9,445,700 11,334,800 13,224,000
(BERAT)
715 V-1-12-I 6,687,900 8,025,400 9,363,000
MODERAT (RINGAN)
716 V-1-12-II 9,132,800 10,959,400 12,785,900
MODERAT (SEDANG)
717 V-1-12-III 11,575,900 13,891,100 16,206,300
MODERAT (BERAT)
718 V-1-13-I 3,488,500 4,186,200 4,883,900
KOMPLEK (RINGAN)
719 V-1-13-II 6,665,300 7,998,400 9,331,500
KOMPLEK (SEDANG)
720 V-1-13-III 10,457,100 12,548,500 14,639,900
KOMPLEK (BERAT)
721 V-1-14-I 6,840,900 8,209,100 9,577,200
(RINGAN)
722 V-1-14-II 9,939,600 11,927,500 13,915,400
(SEDANG)

727 V-4-10-I 3,308,100 3,969,800 4,631,400
(RINGAN)
728 V-4-10-II 5,495,000 6,594,000 7,693,000
(SEDANG)
729 V-4-10-III 9,059,300 10,871,100 12,683,000
(BERAT)
730 V-4-11-I 2,858,400 3,430,100 4,001,800
TUMOR (RINGAN)
731 V-4-11-II 3,835,300 4,602,300 5,369,400
TUMOR (SEDANG)
732 V-4-11-III 5,137,400 6,164,900 7,192,300
TUMOR (BERAT)
- 522 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 7,791,100 9,349,300 10,907,500
734 W-1-01-II 9,338,100 11,205,700 13,073,400
735 W-1-01-III 13,325,200 15,990,300 18,655,300
739 W-1-11-I 1,727,300 2,072,800 2,418,300
SERVIK (RINGAN)
740 W-1-11-II 1,906,100 2,287,300 2,668,500
SERVIK (SEDANG)
741 W-1-11-III 2,108,500 2,530,200 2,951,900
SERVIK (BERAT)
760 W-4-12-I 2,784,500 3,341,300 3,898,200
761 W-4-12-II 3,822,900 4,587,400 5,352,000
762 W-4-12-III 4,167,100 5,000,500 5,834,000
- 523 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 1,215,600 1,458,700 1,701,800
785 Z-4-12-II 2,982,100 3,578,500 4,174,900
786 Z-4-12-III 4,266,100 5,119,300 5,972,500
- 524 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,549,400

33 F-3-10-0 TERAPI SHOCK 438,800
- 525 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,667,500
PENGGANTIAN ALAT
81 I-2-42-0 2,563,200
PERKUTAN LAIN
- 526 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,208,800
192 Q-5-12-0 GIGI 219,600
196 Q-5-16-0 VAKSINASI 96,000
201 Q-5-21-0 ABORSI 191,700
206 Q-5-26-0 BRONKIAL AKUT 204,500
- 527 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 137,700
215 Q-5-35-0 INFEKSI AKUT 448,200
218 Q-5-38-0 PARU AKUT 261,200
234 U-2-23-0 RHINOPLASTY 1,290,400
242 U-3-13-0 332,600
TENGGOROKAN
270 Z-3-11-0 1,804,500
EMPEDU
- 528 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 950,900
289 Z-3-30-0 FOTOTERAPI 79,400
- 529 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,117,600 2,541,200 2,964,700
(RINGAN)
14 A-4-14-II 2,570,500 3,084,600 3,598,700
(SEDANG)
15 A-4-14-III 3,084,600 3,701,500 4,318,400
(BERAT)

31 B-1-13-I 3,565,600 4,278,800 4,991,900
LAIN (RINGAN)
32 B-1-13-II 5,866,800 7,040,200 8,213,500
LAIN (SEDANG)
33 B-1-13-III 7,591,100 9,109,400 10,627,600
LAIN (BERAT)
34 B-1-14-I 4,899,300 5,879,200 6,859,100
(RINGAN)
35 B-1-14-II 5,448,900 6,538,700 7,628,500
(SEDANG)
40 B-4-11-I 3,196,000 3,835,200 4,474,400
(RINGAN)
41 B-4-11-II 4,474,400 5,369,300 6,264,200
(SEDANG)
42 B-4-11-III 5,420,700 6,504,800 7,589,000
(BERAT)
- 530 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 3,385,700 4,062,800 4,739,900
74 D-1-20-II 9,330,400 11,196,400 13,062,500
75 D-1-20-III 14,800,700 17,760,800 20,721,000
85 D-4-13-I 1,958,300 2,349,900 2,741,600
86 D-4-13-II 2,771,600 3,325,900 3,880,300
87 D-4-13-III 3,545,000 4,254,000 4,963,000
88 D-4-14-I 2,100,300 2,520,400 2,940,500
89 D-4-14-II 3,438,800 4,126,500 4,814,300
90 D-4-14-III 4,206,000 5,047,200 5,888,400
91 E-1-01-I 3,275,500 3,930,600 4,585,700
(RINGAN)
92 E-1-01-II 4,290,600 5,148,700 6,006,800
(SEDANG)

97 E-1-20-I 4,927,800 5,913,400 6,898,900
TIROGLOSAL (RINGAN)
- 531 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 6,632,700 7,959,200 9,285,800
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,141,200 10,969,500 12,797,700
TIROGLOSAL (BERAT)
100 E-4-10-I 3,202,000 3,842,400 4,482,800
METABOLIK (RINGAN)
101 E-4-10-II 4,474,300 5,369,100 6,264,000
METABOLIK (SEDANG)
102 E-4-10-III 5,553,400 6,664,100 7,774,800
METABOLIK (BERAT)
109 E-4-13-I 2,423,800 2,908,600 3,393,400
(RINGAN)
110 E-4-13-II 3,550,500 4,260,600 4,970,700
(SEDANG)

118 F-4-12-I 1,368,100 1,641,700 1,915,300
(RINGAN)
119 F-4-12-II 1,945,000 2,334,000 2,723,000
(SEDANG)
120 F-4-12-III 4,225,400 5,070,400 5,915,500
(BERAT)
130 F-4-16-I 3,594,100 4,313,000 5,031,800
131 F-4-16-II 4,178,800 5,014,500 5,850,300
132 F-4-16-III 5,578,000 6,693,500 7,809,100
142 G-1-01-I 5,296,500 6,355,800 7,415,000
(RINGAN)
- 532 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 7,298,100 8,757,800 10,217,400
(SEDANG)
144 G-1-01-III 14,187,600 17,025,100 19,862,600
(BERAT)
151 G-1-12-I 3,235,300 3,882,300 4,529,400
(RINGAN)
152 G-1-12-II 6,064,700 7,277,600 8,490,500
(SEDANG)
153 G-1-12-III 8,265,000 9,917,900 11,570,900
(BERAT)
163 G-4-10-I 2,777,100 3,332,600 3,888,000
(RINGAN)
164 G-4-10-II 3,394,600 4,073,500 4,752,400
(SEDANG)
165 G-4-10-III 4,658,000 5,589,600 6,521,100
(BERAT)
166 G-4-11-I 2,907,200 3,488,700 4,070,100
167 G-4-11-II 3,861,900 4,634,300 5,406,600
168 G-4-11-III 5,674,400 6,809,300 7,944,200
DEGENERATIF (BERAT)
169 G-4-12-I 3,225,200 3,870,300 4,515,300
(RINGAN)
170 G-4-12-II 4,073,700 4,888,400 5,703,200
(SEDANG)

172 G-4-13-I 1,937,400 2,324,900 2,712,400
(RINGAN)
173 G-4-13-II 3,378,500 4,054,200 4,729,900
(SEDANG)
174 G-4-13-III 4,007,000 4,808,400 5,609,800
(BERAT)
175 G-4-14-I 3,286,600 3,944,000 4,601,300
INFARK (RINGAN)
176 G-4-14-II 4,394,000 5,272,800 6,151,600
INFARK (SEDANG)
177 G-4-14-III 5,515,000 6,618,000 7,721,000
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 533 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 2,948,600 3,538,400 4,128,100
(RINGAN)
185 G-4-17-II 3,866,300 4,639,600 5,412,800
(SEDANG)
186 G-4-17-III 4,858,200 5,829,800 6,801,500
(BERAT)
190 G-4-19-I 2,422,800 2,907,400 3,392,000
191 G-4-19-II 4,095,200 4,914,200 5,733,200
192 G-4-19-III 5,376,800 6,452,100 7,527,500
211 G-4-26-I 2,613,200 3,135,800 3,658,400
LAIN (RINGAN)
212 G-4-26-II 3,039,900 3,647,900 4,255,900
LAIN (SEDANG)
213 G-4-26-III 4,545,600 5,454,800 6,363,900
LAIN (BERAT)
232 I-1-02-I 16,974,600 20,369,500 23,764,400
(RINGAN)
- 534 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 21,897,000 26,276,300 30,655,700
(SEDANG)
234 I-1-02-III 26,989,400 32,387,200 37,785,100
(BERAT)
235 I-1-03-I 9,804,500 11,765,500 13,726,400
ANOMALI (RINGAN)
236 I-1-03-II 13,591,100 16,309,400 19,027,600
ANOMALI (SEDANG)
237 I-1-03-III 17,248,200 20,697,800 24,147,500
ANOMALI (BERAT)
238 I-1-04-I 14,774,900 17,729,900 20,684,900
JANTUNG (RINGAN)
239 I-1-04-II 23,318,800 27,982,600 32,646,300
JANTUNG (SEDANG)
240 I-1-04-III 37,251,600 44,702,000 52,152,300
JANTUNG (BERAT)
241 I-1-05-I 18,957,600 22,749,100 26,540,600
242 I-1-05-II 22,749,200 27,299,000 31,848,800
243 I-1-05-III 31,302,700 37,563,200 43,823,800
247 I-1-07-I 16,637,400 19,964,900 23,292,400
JANTUNG (RINGAN)
248 I-1-07-II 20,525,600 24,630,800 28,735,900
JANTUNG (SEDANG)
249 I-1-07-III 22,393,400 26,872,100 31,350,700
JANTUNG (BERAT)
250 I-1-11-I 2,660,000 3,192,000 3,724,000
251 I-1-11-II 2,957,600 3,549,100 4,140,700
252 I-1-11-III 3,935,700 4,722,800 5,510,000
253 I-1-12-I 7,656,700 9,188,000 10,719,300
(RINGAN)
254 I-1-12-II 12,504,900 15,005,800 17,506,800
(SEDANG)
255 I-1-12-III 16,452,000 19,742,400 23,032,800
(BERAT)
256 I-1-13-I 7,426,800 8,912,200 10,397,600
KOMPLEK (RINGAN)
257 I-1-13-II 9,890,400 11,868,400 13,846,500
KOMPLEK (SEDANG)
258 I-1-13-III 12,197,600 14,637,100 17,076,600
KOMPLEK (BERAT)
259 I-1-14-I 15,200,900 18,241,100 21,281,300
(RINGAN)
260 I-1-14-II 18,892,500 22,671,000 26,449,500
(SEDANG)
261 I-1-14-III 24,755,700 29,706,900 34,658,000
(BERAT)
265 I-1-16-I 7,486,100 8,983,300 10,480,500
266 I-1-16-II 16,938,000 20,325,600 23,713,200
267 I-1-16-III 19,537,700 23,445,200 27,352,800
268 I-1-17-I 8,668,200 10,401,800 12,135,400
(RINGAN)
269 I-1-17-II 10,853,400 13,024,000 15,194,700
(SEDANG)
- 535 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 13,425,400 16,110,500 18,795,600
(BERAT)
271 I-1-20-I 9,770,500 11,724,600 13,678,700
(RINGAN)
272 I-1-20-II 12,206,000 14,647,300 17,088,500
(SEDANG)
273 I-1-20-III 12,831,100 15,397,300 17,963,500
(BERAT)
274 I-1-30-I 7,390,800 8,869,000 10,347,200
JANTUNG (RINGAN)
275 I-1-30-II 15,374,600 18,449,500 21,524,400
JANTUNG (SEDANG)
276 I-1-30-III 23,825,100 28,590,100 33,355,100
JANTUNG (BERAT)

289 I-4-13-I 2,314,000 2,776,800 3,239,600
(RINGAN)
290 I-4-13-II 4,131,900 4,958,300 5,784,700
(SEDANG)
291 I-4-13-III 5,953,500 7,144,200 8,334,900
(BERAT)
295 I-4-15-I 4,097,500 4,917,000 5,736,600
(RINGAN)
296 I-4-15-II 5,574,400 6,689,300 7,804,200
(SEDANG)

304 I-4-18-I 2,660,200 3,192,300 3,724,300
JANTUNG (RINGAN)
305 I-4-18-II 4,050,300 4,860,400 5,670,500
JANTUNG (SEDANG)
306 I-4-18-III 5,499,000 6,598,800 7,698,600
JANTUNG (BERAT)

308 I-4-19-II 4,006,600 4,807,900 5,609,300
(SEDANG)
- 536 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 2,193,800 2,632,600 3,071,300
320 I-4-23-II 2,693,400 3,232,100 3,770,700
321 I-4-23-III 5,262,700 6,315,200 7,367,800
322 I-4-24-I 1,975,500 2,370,600 2,765,800
(RINGAN)
323 I-4-24-II 4,549,100 5,459,000 6,368,800
(SEDANG)
324 I-4-24-III 5,751,600 6,901,900 8,052,200
(BERAT)
325 J-1-01-I 35,640,500 42,768,600 49,896,700
326 J-1-01-II 40,333,800 48,400,600 56,467,400
327 J-1-01-III 45,630,200 54,756,300 63,882,300
TRAKEOSTOMI (BERAT)
328 J-1-02-I 18,913,100 22,695,700 26,478,300
329 J-1-02-II 26,334,500 31,601,500 36,868,400
330 J-1-02-III 43,487,400 52,184,800 60,882,300
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,743,400 6,892,100 8,040,800
(RINGAN)
332 J-1-10-II 11,621,800 13,946,200 16,270,500
(SEDANG)
333 J-1-10-III 12,077,900 14,493,500 16,909,100
(BERAT)
334 J-1-20-I 6,749,100 8,098,900 9,448,800
(RINGAN)
335 J-1-20-II 7,990,200 9,588,200 11,186,200
(SEDANG)
336 J-1-20-III 12,338,100 14,805,800 17,273,400
(BERAT)
337 J-1-30-I 4,793,000 5,751,600 6,710,200
(RINGAN)
338 J-1-30-II 8,682,500 10,419,000 12,155,500
(SEDANG)

- 537 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,558,300 3,069,900 3,581,600
374 J-4-21-II 4,121,300 4,945,600 5,769,800
375 J-4-21-III 5,751,000 6,901,200 8,051,400
376 K-1-10-I 5,206,700 6,248,100 7,289,400
BESAR (RINGAN)
377 K-1-10-II 6,543,400 7,852,100 9,160,700
BESAR (SEDANG)
378 K-1-10-III 7,669,100 9,202,900 10,736,700
BESAR (BERAT)
382 K-1-12-I 2,184,700 2,621,600 3,058,500
FEMORAL (RINGAN)
383 K-1-12-II 2,841,400 3,409,700 3,978,000
FEMORAL (SEDANG)
384 K-1-12-III 5,629,300 6,755,200 7,881,000
FEMORAL (BERAT)
388 K-1-14-I 3,998,400 4,798,100 5,597,800
(RINGAN)
389 K-1-14-II 4,686,100 5,623,300 6,560,500
(SEDANG)

394 K-1-30-I 4,578,700 5,494,500 6,410,200
395 K-1-30-II 8,131,700 9,758,000 11,384,400
396 K-1-30-III 11,189,300 13,427,200 15,665,000

398 K-1-40-II 5,632,600 6,759,100 7,885,700
(SEDANG)

- 538 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 2,611,500 3,133,800 3,656,100
413 K-4-13-II 3,378,100 4,053,800 4,729,400
414 K-4-13-III 5,203,400 6,244,100 7,284,800
415 K-4-14-I 1,655,700 1,986,800 2,318,000
(RINGAN)
416 K-4-14-II 2,222,500 2,667,000 3,111,500
(SEDANG)
417 K-4-14-III 3,566,200 4,279,500 4,992,700
(BERAT)

424 K-4-17-I 1,092,600 1,311,100 1,529,600
(RINGAN)
425 K-4-17-II 1,638,300 1,965,900 2,293,600
(SEDANG)
426 K-4-17-III 1,965,900 2,359,100 2,752,300
(BERAT)
427 K-4-18-I 1,097,100 1,316,500 1,535,900
(RINGAN)
428 K-4-18-II 1,559,000 1,870,800 2,182,600
(SEDANG)
436 L-1-40-I 3,263,900 3,916,700 4,569,500
(RINGAN)
437 L-1-40-II 6,546,700 7,856,000 9,165,400
(SEDANG)
438 L-1-40-III 11,019,600 13,223,500 15,427,400
(BERAT)
451 L-4-13-I 2,179,100 2,615,000 3,050,800
PAYUDARA (RINGAN)
- 539 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,561,100 3,073,300 3,585,500
PAYUDARA (SEDANG)
453 L-4-13-III 3,768,700 4,522,400 5,276,200
PAYUDARA (BERAT)
454 L-4-14-I 1,930,100 2,316,100 2,702,200
(RINGAN)
455 L-4-14-II 2,899,100 3,478,900 4,058,700
(SEDANG)
456 L-4-14-III 4,086,600 4,903,900 5,721,300
(BERAT)
457 M-1-01-I 6,822,800 8,187,300 9,551,900
458 M-1-01-II 9,697,600 11,637,100 13,576,600
459 M-1-01-III 13,622,200 16,346,600 19,071,100
463 M-1-03-I 14,804,300 17,765,200 20,726,000
464 M-1-03-II 17,315,800 20,779,000 24,242,100
465 M-1-03-III 21,431,200 25,717,400 30,003,700
472 M-1-07-I 5,388,500 6,466,200 7,543,900
473 M-1-07-II 7,218,800 8,662,500 10,106,300
474 M-1-07-III 14,705,300 17,646,400 20,587,400
475 M-1-10-I 8,870,400 10,644,500 12,418,600
WAJAH (RINGAN)
476 M-1-10-II 19,465,000 23,358,100 27,251,100
WAJAH (SEDANG)
477 M-1-10-III 41,984,300 50,381,200 58,778,000
WAJAH (BERAT)
478 M-1-20-I 8,102,000 9,722,500 11,342,900
(RINGAN)
479 M-1-20-II 10,351,200 12,421,400 14,491,700
(SEDANG)

484 M-1-40-I 2,829,300 3,395,200 3,961,100
INTERNAL (RINGAN)
485 M-1-40-II 5,017,700 6,021,300 7,024,800
INTERNAL (SEDANG)
486 M-1-40-III 7,164,300 8,597,200 10,030,100
INTERNAL (BERAT)
490 M-1-60-I 5,236,400 6,283,700 7,331,000
491 M-1-60-II 6,583,400 7,900,000 9,216,700
492 M-1-60-III 9,945,000 11,934,000 13,923,000
- 540 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 9,701,400 11,641,700 13,581,900
KAKI (RINGAN)
494 M-1-70-II 10,671,500 12,805,800 14,940,100
KAKI (SEDANG)
495 M-1-70-III 12,217,500 14,661,000 17,104,500
KAKI (BERAT)
502 M-4-11-I 2,420,700 2,904,900 3,389,000
(RINGAN)
503 M-4-11-II 5,307,400 6,368,900 7,430,300
(SEDANG)
504 M-4-11-III 7,673,600 9,208,300 10,743,000
(BERAT)
505 M-4-12-I 1,932,300 2,318,800 2,705,200
(RINGAN)
506 M-4-12-II 3,213,900 3,856,700 4,499,500
(SEDANG)
507 M-4-12-III 4,299,000 5,158,800 6,018,600
(BERAT)
508 M-4-13-I 3,217,500 3,861,000 4,504,500
509 M-4-13-II 4,834,100 5,800,900 6,767,800
510 M-4-13-III 9,431,300 11,317,500 13,203,800
520 M-4-17-I 2,417,800 2,901,300 3,384,900
(RINGAN)
521 M-4-17-II 3,381,500 4,057,800 4,734,100
(SEDANG)
522 M-4-17-III 4,722,000 5,666,500 6,610,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,922,400 2,306,800 2,691,300
(RINGAN)
530 M-4-20-II 2,815,000 3,378,000 3,941,000
(SEDANG)
531 M-4-20-III 3,146,100 3,775,300 4,404,500
(BERAT)
532 M-4-21-I 1,935,700 2,322,800 2,709,900
533 M-4-21-II 2,421,000 2,905,200 3,389,300
- 541 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 5,427,800 6,513,300 7,598,900
541 N-1-12-I 2,845,700 3,414,800 3,983,900
542 N-1-12-II 5,665,400 6,798,500 7,931,600
543 N-1-12-III 12,294,200 14,753,000 17,211,900
547 N-1-30-I 5,694,000 6,832,800 7,971,600
BAWAH (RINGAN)
548 N-1-30-II 8,613,900 10,336,600 12,059,400
BAWAH (SEDANG)
549 N-1-30-III 9,913,700 11,896,500 13,879,200
BAWAH (BERAT)
550 N-1-40-I 5,113,600 6,136,300 7,159,000
(RINGAN)
551 N-1-40-II 6,944,100 8,333,000 9,721,800
(SEDANG)
552 N-1-40-III 8,082,100 9,698,500 11,314,900
(BERAT)
553 N-4-10-I 2,172,600 2,607,100 3,041,600
(RINGAN)
554 N-4-10-II 2,627,800 3,153,300 3,678,900
(SEDANG)
555 N-4-10-III 3,865,000 4,638,000 5,411,100
(BERAT)
568 N-4-15-I 1,978,800 2,374,600 2,770,300
URIN (RINGAN)
569 N-4-15-II 2,455,400 2,946,400 3,437,500
URIN (SEDANG)
570 N-4-15-III 2,802,000 3,362,400 3,922,800
URIN (BERAT)
571 N-4-16-I 2,423,000 2,907,700 3,392,300
(RINGAN)
572 N-4-16-II 3,458,500 4,150,200 4,841,800
(SEDANG)
573 N-4-16-III 4,603,500 5,524,200 6,444,800
(BERAT)
- 542 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 2,252,300 2,702,800 3,153,300
578 O-6-11-II 2,503,200 3,003,900 3,504,500
579 O-6-11-III 3,114,000 3,736,800 4,359,600
580 O-6-12-I 1,595,700 1,914,900 2,234,000
581 O-6-12-II 1,916,500 2,299,800 2,683,100
582 O-6-12-III 2,408,100 2,889,800 3,371,400
586 P-8-01-I 35,633,300 42,760,000 49,886,600
587 P-8-01-II 44,090,900 52,909,100 61,727,200
588 P-8-01-III 51,750,300 62,100,400 72,450,400
589 P-8-02-I 48,637,800 58,365,300 68,092,900
590 P-8-02-II 55,792,400 66,950,900 78,109,400
591 P-8-02-III 63,746,800 76,496,200 89,245,500
592 P-8-03-I 5,927,700 7,113,200 8,298,800
593 P-8-03-II 8,417,300 10,100,800 11,784,300
594 P-8-03-III 9,511,600 11,413,900 13,316,200
595 P-8-04-I 19,235,800 23,083,000 26,930,100
596 P-8-04-II 24,963,900 29,956,700 34,949,500
597 P-8-04-III 35,792,000 42,950,400 50,108,800
598 P-8-05-I 10,459,800 12,551,800 14,643,700
599 P-8-05-II 19,721,900 23,666,300 27,610,600
600 P-8-05-III 24,067,400 28,880,900 33,694,300
601 P-8-06-I 3,451,300 4,141,600 4,831,900
602 P-8-06-II 9,676,700 11,612,100 13,547,400
603 P-8-06-III 12,819,300 15,383,200 17,947,000
604 P-8-07-I 3,343,000 4,011,600 4,680,200
605 P-8-07-II 9,372,900 11,247,500 13,122,100
606 P-8-07-III 12,416,800 14,900,200 17,383,500
607 P-8-08-I 3,534,200 4,241,000 4,947,900
608 P-8-08-II 5,015,000 6,018,000 7,021,000
609 P-8-08-III 8,120,200 9,744,300 11,368,300
610 P-8-11-I 5,600,100 6,720,100 7,840,100
MAYOR (RINGAN)
611 P-8-11-II 7,952,100 9,542,600 11,133,000
MAYOR (SEDANG)
- 543 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 8,985,900 10,783,100 12,580,300
MAYOR (BERAT)
613 P-8-12-I 5,290,600 6,348,700 7,406,800
MAYOR (RINGAN)
614 P-8-12-II 7,522,500 9,027,000 10,531,500
MAYOR (SEDANG)
615 P-8-12-III 8,513,900 10,216,700 11,919,500
MAYOR (BERAT)
616 P-8-13-I 4,590,400 5,508,500 6,426,600
MAYOR (RINGAN)
617 P-8-13-II 6,059,400 7,271,200 8,483,100
MAYOR (SEDANG)
618 P-8-13-III 9,022,600 10,827,200 12,631,700
MAYOR (BERAT)
619 P-8-14-I 2,324,200 2,789,000 3,253,800
620 P-8-14-II 4,731,100 5,677,300 6,623,500
621 P-8-14-III 8,777,900 10,533,500 12,289,100
622 P-8-15-I 1,743,200 2,091,800 2,440,400
ASPIRASI (RINGAN)
623 P-8-15-II 3,490,700 4,188,900 4,887,000
ASPIRASI (SEDANG)
624 P-8-15-III 4,095,800 4,914,900 5,734,100
ASPIRASI (BERAT)
625 P-8-16-I 1,577,600 1,893,100 2,208,600
626 P-8-16-II 3,031,600 3,637,900 4,244,200
627 P-8-16-III 6,182,200 7,418,600 8,655,100
628 P-8-17-I 3,060,300 3,672,300 4,284,400
(RINGAN)
629 P-8-17-II 5,508,500 6,610,200 7,711,900
(SEDANG)
630 P-8-17-III 7,518,900 9,022,600 10,526,400
(BERAT)
631 S-4-10-I 1,778,700 2,134,400 2,490,200
632 S-4-10-II 2,191,600 2,629,900 3,068,300
633 S-4-10-III 3,000,100 3,600,100 4,200,200
640 S-4-13-I 1,931,100 2,317,400 2,703,600
(RINGAN)
641 S-4-13-II 3,426,000 4,111,200 4,796,400
(SEDANG)
642 S-4-13-III 5,560,800 6,672,900 7,785,100
(BERAT)
643 S-4-14-I 977,300 1,172,700 1,368,200
644 S-4-14-II 2,075,800 2,491,000 2,906,200
645 S-4-14-III 3,936,500 4,723,800 5,511,100
KANAK-KANAK (BERAT)
646 S-4-15-I 653,600 784,300 915,100
647 S-4-15-II 1,233,500 1,480,200 1,726,900
648 S-4-15-III 1,597,600 1,917,100 2,236,600
- 544 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 1,631,300 1,957,500 2,283,800
653 S-4-17-II 2,421,000 2,905,200 3,389,400
654 S-4-17-III 2,911,800 3,494,200 4,076,500
655 T-1-10-I 1,091,500 1,309,800 1,528,000
OBAT (RINGAN)
656 T-1-10-II 1,466,000 1,759,200 2,052,400
OBAT (SEDANG)
657 T-1-10-III 2,666,800 3,200,200 3,733,600
OBAT (BERAT)
658 T-4-10-I 497,800 597,300 696,900
659 T-4-10-II 948,700 1,138,400 1,328,200
660 T-4-10-III 1,379,100 1,655,000 1,930,800
661 T-4-11-I 589,500 707,400 825,300
662 T-4-11-II 927,600 1,113,200 1,298,700
663 T-4-11-III 1,494,100 1,792,900 2,091,700
664 T-4-12-I 1,030,900 1,237,100 1,443,300
LAIN (RINGAN)
665 T-4-12-II 1,558,600 1,870,300 2,182,000
LAIN (SEDANG)
666 T-4-12-III 2,432,500 2,919,000 3,405,500
LAIN (BERAT)
670 U-1-11-I 5,518,000 6,621,600 7,725,200
(RINGAN)
671 U-1-11-II 6,994,900 8,393,800 9,792,800
(SEDANG)
672 U-1-11-III 10,064,500 12,077,400 14,090,300
(BERAT)
679 U-1-14-I 2,592,800 3,111,400 3,629,900
(RINGAN)
680 U-1-14-II 3,182,000 3,818,400 4,454,800
(SEDANG)
681 U-1-14-III 3,770,600 4,524,800 5,278,900
(BERAT)
685 U-1-20-I 3,936,300 4,723,500 5,510,800
686 U-1-20-II 5,858,300 7,029,900 8,201,600
687 U-1-20-III 15,039,300 18,047,100 21,055,000
691 U-4-10-I 2,429,400 2,915,200 3,401,100
- 545 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 5,561,500 6,673,800 7,786,100
693 U-4-10-III 8,538,700 10,246,400 11,954,100
TENGGOROKAN (BERAT)
700 U-4-13-I 1,755,900 2,107,000 2,458,200
701 U-4-13-II 2,070,000 2,484,000 2,898,000
702 U-4-13-III 2,475,800 2,970,900 3,466,100
706 U-4-15-I 1,941,600 2,329,900 2,718,200
707 U-4-15-II 2,419,000 2,902,800 3,386,600
708 U-4-15-III 3,385,400 4,062,500 4,739,600
709 V-1-10-I 3,166,900 3,800,300 4,433,700
(RINGAN)
710 V-1-10-II 6,523,700 7,828,500 9,133,200
(SEDANG)
711 V-1-10-III 8,000,400 9,600,500 11,200,600
(BERAT)
715 V-1-12-I 5,664,600 6,797,500 7,930,400
MODERAT (RINGAN)
716 V-1-12-II 7,735,400 9,282,500 10,829,600
MODERAT (SEDANG)
717 V-1-12-III 9,804,700 11,765,700 13,726,600
MODERAT (BERAT)
718 V-1-13-I 2,954,700 3,545,700 4,136,600
KOMPLEK (RINGAN)
719 V-1-13-II 5,645,500 6,774,600 7,903,700
KOMPLEK (SEDANG)
720 V-1-13-III 8,857,100 10,628,500 12,399,900
KOMPLEK (BERAT)
721 V-1-14-I 5,794,200 6,953,000 8,111,900
(RINGAN)
722 V-1-14-II 8,418,800 10,102,500 11,786,300
(SEDANG)

727 V-4-10-I 2,802,000 3,362,400 3,922,800
(RINGAN)
728 V-4-10-II 4,654,200 5,585,100 6,515,900
(SEDANG)
729 V-4-10-III 7,673,200 9,207,800 10,742,400
(BERAT)
730 V-4-11-I 2,421,100 2,905,300 3,389,500
TUMOR (RINGAN)
731 V-4-11-II 3,248,400 3,898,100 4,547,800
TUMOR (SEDANG)
732 V-4-11-III 4,351,300 5,221,600 6,091,900
TUMOR (BERAT)
- 546 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 6,599,000 7,918,800 9,238,600
734 W-1-01-II 7,909,300 9,491,200 11,073,000
735 W-1-01-III 11,286,400 13,543,700 15,800,900
739 W-1-11-I 1,463,000 1,755,600 2,048,200
SERVIK (RINGAN)
740 W-1-11-II 1,614,500 1,937,300 2,260,200
SERVIK (SEDANG)
741 W-1-11-III 1,785,900 2,143,100 2,500,300
SERVIK (BERAT)
760 W-4-12-I 2,568,200 3,081,800 3,595,500
761 W-4-12-II 3,525,900 4,231,100 4,936,300
762 W-4-12-III 3,843,500 4,612,200 5,380,800
- 547 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 762,800 915,400 1,068,000
785 Z-4-12-II 1,858,700 2,230,500 2,602,200
786 Z-4-12-III 2,357,300 2,828,700 3,300,200
- 548 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,401,100

33 F-3-10-0 TERAPI SHOCK 396,800
- 549 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,412,100
PENGGANTIAN ALAT
81 I-2-42-0 2,317,900
PERKUTAN LAIN
- 550 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,093,100
192 Q-5-12-0 GIGI 198,600
196 Q-5-16-0 VAKSINASI 84,600
201 Q-5-21-0 ABORSI 173,300
206 Q-5-26-0 BRONKIAL AKUT 180,200
- 551 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 121,300
215 Q-5-35-0 INFEKSI AKUT 405,300
218 Q-5-38-0 PARU AKUT 236,200
234 U-2-23-0 RHINOPLASTY 1,166,900
242 U-3-13-0 300,800
TENGGOROKAN
270 Z-3-11-0 1,631,800
EMPEDU
- 552 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 859,800
289 Z-3-30-0 FOTOTERAPI 69,900
- 553 -


REGIONAL 3
RAWAT INAP

13 A-4-14-I 2,181,200 2,617,400 3,053,600
(RINGAN)
14 A-4-14-II 2,647,600 3,177,100 3,706,600
(SEDANG)
15 A-4-14-III 3,177,100 3,812,500 4,447,900
(BERAT)

31 B-1-13-I 3,672,600 4,407,100 5,141,600
LAIN (RINGAN)
32 B-1-13-II 6,042,800 7,251,400 8,459,900
LAIN (SEDANG)
33 B-1-13-III 7,818,900 9,382,600 10,946,400
LAIN (BERAT)
34 B-1-14-I 5,046,300 6,055,600 7,064,800
(RINGAN)
35 B-1-14-II 5,612,400 6,734,900 7,857,300
(SEDANG)
40 B-4-11-I 3,291,900 3,950,200 4,608,600
(RINGAN)
41 B-4-11-II 4,608,700 5,530,400 6,452,100
(SEDANG)
42 B-4-11-III 5,583,300 6,700,000 7,816,600
(BERAT)
- 554 -

REGIONAL 3
RAWAT INAP


73 D-1-20-I 3,487,200 4,184,700 4,882,100
74 D-1-20-II 9,610,300 11,532,300 13,454,400
75 D-1-20-III 15,244,700 18,293,600 21,342,600
85 D-4-13-I 2,017,000 2,420,400 2,823,800
86 D-4-13-II 2,854,800 3,425,700 3,996,700
87 D-4-13-III 3,651,300 4,381,600 5,111,900
88 D-4-14-I 2,163,300 2,596,000 3,028,700
89 D-4-14-II 3,541,900 4,250,300 4,958,700
90 D-4-14-III 4,332,200 5,198,600 6,065,000
91 E-1-01-I 3,373,800 4,048,500 4,723,300
(RINGAN)
92 E-1-01-II 4,419,300 5,303,100 6,187,000
(SEDANG)

97 E-1-20-I 5,075,600 6,090,800 7,105,900
TIROGLOSAL (RINGAN)
- 555 -

REGIONAL 3
RAWAT INAP

98 E-1-20-II 6,831,700 8,198,000 9,564,400
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,415,500 11,298,600 13,181,600
TIROGLOSAL (BERAT)
100 E-4-10-I 3,298,100 3,957,700 4,617,300
METABOLIK (RINGAN)
101 E-4-10-II 4,608,500 5,530,200 6,451,900
METABOLIK (SEDANG)
102 E-4-10-III 5,720,100 6,864,100 8,008,100
METABOLIK (BERAT)
109 E-4-13-I 2,496,600 2,995,900 3,495,200
(RINGAN)
110 E-4-13-II 3,657,000 4,388,400 5,119,800
(SEDANG)

118 F-4-12-I 1,409,100 1,690,900 1,972,800
(RINGAN)
119 F-4-12-II 2,003,300 2,404,000 2,804,700
(SEDANG)
120 F-4-12-III 4,352,100 5,222,500 6,093,000
(BERAT)
130 F-4-16-I 3,702,000 4,442,400 5,182,800
131 F-4-16-II 4,304,100 5,165,000 6,025,800
132 F-4-16-III 5,745,300 6,894,400 8,043,400
142 G-1-01-I 5,455,400 6,546,400 7,637,500
(RINGAN)
- 556 -

REGIONAL 3
RAWAT INAP

143 G-1-01-II 7,517,100 9,020,500 10,523,900
(SEDANG)
144 G-1-01-III 14,613,200 17,535,900 20,458,500
(BERAT)
151 G-1-12-I 3,332,300 3,998,800 4,665,300
(RINGAN)
152 G-1-12-II 6,246,600 7,495,900 8,745,300
(SEDANG)
153 G-1-12-III 8,512,900 10,215,500 11,918,100
(BERAT)
163 G-4-10-I 2,860,400 3,432,500 4,004,600
(RINGAN)
164 G-4-10-II 3,496,400 4,195,700 4,895,000
(SEDANG)
165 G-4-10-III 4,797,700 5,757,200 6,716,800
(BERAT)
166 G-4-11-I 2,994,400 3,593,300 4,192,200
167 G-4-11-II 3,977,700 4,773,300 5,568,800
168 G-4-11-III 5,844,600 7,013,600 8,182,500
DEGENERATIF (BERAT)
169 G-4-12-I 3,322,000 3,986,400 4,650,800
(RINGAN)
170 G-4-12-II 4,195,900 5,035,100 5,874,300
(SEDANG)

172 G-4-13-I 1,995,600 2,394,700 2,793,800
(RINGAN)
173 G-4-13-II 3,479,900 4,175,800 4,871,800
(SEDANG)
174 G-4-13-III 4,127,200 4,952,600 5,778,100
(BERAT)
175 G-4-14-I 3,385,200 4,062,300 4,739,300
INFARK (RINGAN)
176 G-4-14-II 4,525,800 5,431,000 6,336,100
INFARK (SEDANG)
177 G-4-14-III 5,680,400 6,816,500 7,952,600
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 557 -

REGIONAL 3
RAWAT INAP

184 G-4-17-I 3,037,100 3,644,500 4,251,900
(RINGAN)
185 G-4-17-II 3,982,300 4,778,800 5,575,200
(SEDANG)
186 G-4-17-III 5,003,900 6,004,700 7,005,500
(BERAT)
190 G-4-19-I 2,495,500 2,994,600 3,493,700
191 G-4-19-II 4,218,000 5,061,600 5,905,200
192 G-4-19-III 5,538,100 6,645,700 7,753,300
211 G-4-26-I 2,691,600 3,229,900 3,768,200
LAIN (RINGAN)
212 G-4-26-II 3,131,100 3,757,400 4,383,600
LAIN (SEDANG)
213 G-4-26-III 4,682,000 5,618,400 6,554,800
LAIN (BERAT)
232 I-1-02-I 17,483,800 20,980,500 24,477,300
(RINGAN)
- 558 -

REGIONAL 3
RAWAT INAP

233 I-1-02-II 22,553,900 27,064,600 31,575,400
(SEDANG)
234 I-1-02-III 27,799,000 33,358,900 38,918,700
(BERAT)
235 I-1-03-I 10,098,700 12,118,400 14,138,200
ANOMALI (RINGAN)
236 I-1-03-II 13,998,900 16,798,600 19,598,400
ANOMALI (SEDANG)
237 I-1-03-III 17,765,600 21,318,800 24,871,900
ANOMALI (BERAT)
238 I-1-04-I 15,218,200 18,261,800 21,305,400
JANTUNG (RINGAN)
239 I-1-04-II 24,018,400 28,822,000 33,625,700
JANTUNG (SEDANG)
240 I-1-04-III 38,369,200 46,043,000 53,716,900
JANTUNG (BERAT)
241 I-1-05-I 19,526,300 23,431,600 27,336,800
242 I-1-05-II 23,431,700 28,118,000 32,804,300
243 I-1-05-III 32,241,800 38,690,100 45,138,500
247 I-1-07-I 17,136,500 20,563,800 23,991,100
JANTUNG (RINGAN)
248 I-1-07-II 21,141,400 25,369,700 29,598,000
JANTUNG (SEDANG)
249 I-1-07-III 23,065,200 27,678,200 32,291,300
JANTUNG (BERAT)
250 I-1-11-I 2,739,800 3,287,700 3,835,700
251 I-1-11-II 3,046,300 3,655,600 4,264,900
252 I-1-11-III 4,053,800 4,864,500 5,675,300
253 I-1-12-I 7,886,400 9,463,600 11,040,900
(RINGAN)
254 I-1-12-II 12,880,000 15,456,000 18,032,000
(SEDANG)
255 I-1-12-III 16,945,600 20,334,700 23,723,800
(BERAT)
256 I-1-13-I 7,649,700 9,179,600 10,709,500
KOMPLEK (RINGAN)
257 I-1-13-II 10,187,100 12,224,500 14,261,900
KOMPLEK (SEDANG)
258 I-1-13-III 12,563,500 15,076,200 17,588,900
KOMPLEK (BERAT)
259 I-1-14-I 15,657,000 18,788,400 21,919,800
(RINGAN)
260 I-1-14-II 19,459,300 23,351,200 27,243,000
(SEDANG)
261 I-1-14-III 25,498,400 30,598,100 35,697,800
(BERAT)
265 I-1-16-I 7,710,700 9,252,800 10,794,900
266 I-1-16-II 17,446,100 20,935,300 24,424,500
267 I-1-16-III 20,123,800 24,148,600 28,173,300
268 I-1-17-I 8,928,200 10,713,800 12,499,500
(RINGAN)
269 I-1-17-II 11,179,000 13,414,700 15,650,500
(SEDANG)
- 559 -

REGIONAL 3
RAWAT INAP

270 I-1-17-III 13,828,200 16,593,800 19,359,500
(BERAT)
271 I-1-20-I 10,063,600 12,076,300 14,089,100
(RINGAN)
272 I-1-20-II 12,572,200 15,086,700 17,601,100
(SEDANG)
273 I-1-20-III 13,216,000 15,859,200 18,502,400
(BERAT)
274 I-1-30-I 7,612,600 9,135,100 10,657,600
JANTUNG (RINGAN)
275 I-1-30-II 15,835,800 19,003,000 22,170,200
JANTUNG (SEDANG)
276 I-1-30-III 24,539,800 29,447,800 34,355,700
JANTUNG (BERAT)

289 I-4-13-I 2,383,400 2,860,100 3,336,800
(RINGAN)
290 I-4-13-II 4,255,900 5,107,000 5,958,200
(SEDANG)
291 I-4-13-III 6,132,100 7,358,500 8,584,900
(BERAT)
295 I-4-15-I 4,220,500 5,064,600 5,908,600
(RINGAN)
296 I-4-15-II 5,741,700 6,890,000 8,038,300
(SEDANG)

304 I-4-18-I 2,740,000 3,288,100 3,836,100
JANTUNG (RINGAN)
305 I-4-18-II 4,171,800 5,006,200 5,840,600
JANTUNG (SEDANG)
306 I-4-18-III 5,664,000 6,796,800 7,929,600
JANTUNG (BERAT)

308 I-4-19-II 4,126,800 4,952,200 5,777,500
(SEDANG)
- 560 -

REGIONAL 3
RAWAT INAP

319 I-4-23-I 2,259,600 2,711,600 3,163,500
320 I-4-23-II 2,774,200 3,329,000 3,883,900
321 I-4-23-III 5,420,600 6,504,700 7,588,800
322 I-4-24-I 2,034,800 2,441,800 2,848,700
(RINGAN)
323 I-4-24-II 4,685,600 5,622,700 6,559,900
(SEDANG)
324 I-4-24-III 5,924,100 7,109,000 8,293,800
(BERAT)
325 J-1-01-I 36,709,700 44,051,600 51,393,600
326 J-1-01-II 41,543,800 49,852,600 58,161,400
327 J-1-01-III 46,999,200 56,399,000 65,798,800
TRAKEOSTOMI (BERAT)
328 J-1-02-I 19,480,500 23,376,600 27,272,700
329 J-1-02-II 27,124,600 32,549,500 37,974,400
330 J-1-02-III 44,792,000 53,750,400 62,708,800
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,915,700 7,098,900 8,282,000
(RINGAN)
332 J-1-10-II 11,970,500 14,364,600 16,758,700
(SEDANG)
333 J-1-10-III 12,440,300 14,928,300 17,416,400
(BERAT)
334 J-1-20-I 6,951,600 8,341,900 9,732,200
(RINGAN)
335 J-1-20-II 8,229,900 9,875,800 11,521,800
(SEDANG)
336 J-1-20-III 12,708,300 15,249,900 17,791,600
(BERAT)
337 J-1-30-I 4,936,800 5,924,200 6,911,500
(RINGAN)
338 J-1-30-II 8,943,000 10,731,600 12,520,200
(SEDANG)

- 561 -

REGIONAL 3
RAWAT INAP

373 J-4-21-I 2,635,000 3,162,000 3,689,000
374 J-4-21-II 4,245,000 5,093,900 5,942,900
375 J-4-21-III 5,923,500 7,108,200 8,292,900
376 K-1-10-I 5,363,000 6,435,500 7,508,100
BESAR (RINGAN)
377 K-1-10-II 6,739,700 8,087,600 9,435,600
BESAR (SEDANG)
378 K-1-10-III 7,899,200 9,479,000 11,058,800
BESAR (BERAT)
382 K-1-12-I 2,250,200 2,700,300 3,150,300
FEMORAL (RINGAN)
383 K-1-12-II 2,926,700 3,512,000 4,097,300
FEMORAL (SEDANG)
384 K-1-12-III 5,798,200 6,957,800 8,117,400
FEMORAL (BERAT)
388 K-1-14-I 4,118,400 4,942,100 5,765,700
(RINGAN)
389 K-1-14-II 4,826,700 5,792,000 6,757,300
(SEDANG)

394 K-1-30-I 4,716,100 5,659,300 6,602,500
395 K-1-30-II 8,375,600 10,050,800 11,725,900
396 K-1-30-III 11,525,000 13,830,000 16,135,000

398 K-1-40-II 5,801,600 6,961,900 8,122,200
(SEDANG)

- 562 -

REGIONAL 3
RAWAT INAP

412 K-4-13-I 2,689,800 3,227,800 3,765,800
413 K-4-13-II 3,479,500 4,175,400 4,871,300
414 K-4-13-III 5,359,500 6,431,400 7,503,300
415 K-4-14-I 1,705,400 2,046,400 2,387,500
(RINGAN)
416 K-4-14-II 2,289,200 2,747,000 3,204,800
(SEDANG)
417 K-4-14-III 3,673,200 4,407,900 5,142,500
(BERAT)

424 K-4-17-I 1,125,300 1,350,400 1,575,500
(RINGAN)
425 K-4-17-II 1,687,400 2,024,900 2,362,400
(SEDANG)
426 K-4-17-III 2,024,900 2,429,900 2,834,800
(BERAT)
427 K-4-18-I 1,130,000 1,356,000 1,582,000
(RINGAN)
428 K-4-18-II 1,605,800 1,926,900 2,248,100
(SEDANG)
436 L-1-40-I 3,361,800 4,034,200 4,706,600
(RINGAN)
437 L-1-40-II 6,743,100 8,091,700 9,440,300
(SEDANG)
438 L-1-40-III 11,350,100 13,620,200 15,890,200
(BERAT)
451 L-4-13-I 2,244,500 2,693,400 3,142,300
PAYUDARA (RINGAN)
- 563 -

REGIONAL 3
RAWAT INAP

452 L-4-13-II 2,637,900 3,165,500 3,693,100
PAYUDARA (SEDANG)
453 L-4-13-III 3,881,800 4,658,100 5,434,500
PAYUDARA (BERAT)
454 L-4-14-I 1,988,000 2,385,600 2,783,200
(RINGAN)
455 L-4-14-II 2,986,100 3,583,300 4,180,500
(SEDANG)
456 L-4-14-III 4,209,200 5,051,100 5,892,900
(BERAT)
457 M-1-01-I 7,027,400 8,432,900 9,838,400
458 M-1-01-II 9,988,500 11,986,200 13,983,900
459 M-1-01-III 14,030,900 16,837,000 19,643,200
463 M-1-03-I 15,248,400 18,298,100 21,347,800
464 M-1-03-II 17,835,300 21,402,300 24,969,400
465 M-1-03-III 22,074,100 26,489,000 30,903,800
472 M-1-07-I 5,550,200 6,660,200 7,770,300
473 M-1-07-II 7,435,300 8,922,400 10,409,500
474 M-1-07-III 15,146,500 18,175,700 21,205,000
475 M-1-10-I 9,136,500 10,963,800 12,791,100
WAJAH (RINGAN)
476 M-1-10-II 20,049,000 24,058,800 28,068,600
WAJAH (SEDANG)
477 M-1-10-III 43,243,800 51,892,600 60,541,400
WAJAH (BERAT)
478 M-1-20-I 8,345,100 10,014,100 11,683,200
(RINGAN)
479 M-1-20-II 10,661,700 12,794,100 14,926,400
(SEDANG)

484 M-1-40-I 2,914,200 3,497,100 4,079,900
INTERNAL (RINGAN)
485 M-1-40-II 5,168,300 6,201,900 7,235,600
INTERNAL (SEDANG)
486 M-1-40-III 7,379,300 8,855,100 10,331,000
INTERNAL (BERAT)
490 M-1-60-I 5,393,500 6,472,200 7,550,900
491 M-1-60-II 6,780,900 8,137,000 9,493,200
492 M-1-60-III 10,243,300 12,292,000 14,340,600
- 564 -

REGIONAL 3
RAWAT INAP

493 M-1-70-I 9,992,400 11,990,900 13,989,400
KAKI (RINGAN)
494 M-1-70-II 10,991,700 13,190,000 15,388,300
KAKI (SEDANG)
495 M-1-70-III 12,584,000 15,100,800 17,617,600
KAKI (BERAT)
502 M-4-11-I 2,493,400 2,992,000 3,490,700
(RINGAN)
503 M-4-11-II 5,466,600 6,559,900 7,653,300
(SEDANG)
504 M-4-11-III 7,903,800 9,484,500 11,065,300
(BERAT)
505 M-4-12-I 1,990,300 2,388,300 2,786,400
(RINGAN)
506 M-4-12-II 3,310,400 3,972,400 4,634,500
(SEDANG)
507 M-4-12-III 4,428,000 5,313,600 6,199,100
(BERAT)
508 M-4-13-I 3,314,000 3,976,800 4,639,600
509 M-4-13-II 4,979,100 5,975,000 6,970,800
510 M-4-13-III 9,714,200 11,657,000 13,599,900
520 M-4-17-I 2,490,300 2,988,300 3,486,400
(RINGAN)
521 M-4-17-II 3,482,900 4,179,500 4,876,100
(SEDANG)
522 M-4-17-III 4,863,700 5,836,400 6,809,200
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,980,000 2,376,000 2,772,000
(RINGAN)
530 M-4-20-II 2,899,400 3,479,300 4,059,200
(SEDANG)
531 M-4-20-III 3,240,500 3,888,500 4,536,600
(BERAT)
532 M-4-21-I 1,993,700 2,392,500 2,791,200
533 M-4-21-II 2,493,600 2,992,300 3,491,000
- 565 -

REGIONAL 3
RAWAT INAP

534 M-4-21-III 5,590,600 6,708,700 7,826,800
541 N-1-12-I 2,931,000 3,517,300 4,103,500
542 N-1-12-II 5,835,400 7,002,500 8,169,500
543 N-1-12-III 12,663,000 15,195,600 17,728,200
547 N-1-30-I 5,864,800 7,037,700 8,210,700
BAWAH (RINGAN)
548 N-1-30-II 8,872,300 10,646,700 12,421,200
BAWAH (SEDANG)
549 N-1-30-III 10,211,100 12,253,400 14,295,600
BAWAH (BERAT)
550 N-1-40-I 5,267,000 6,320,400 7,373,800
(RINGAN)
551 N-1-40-II 7,152,500 8,582,900 10,013,400
(SEDANG)
552 N-1-40-III 8,324,500 9,989,400 11,654,300
(BERAT)
553 N-4-10-I 2,237,700 2,685,300 3,132,800
(RINGAN)
554 N-4-10-II 2,706,600 3,247,900 3,789,200
(SEDANG)
555 N-4-10-III 3,981,000 4,777,200 5,573,400
(BERAT)
568 N-4-15-I 2,038,200 2,445,800 2,853,400
URIN (RINGAN)
569 N-4-15-II 2,529,000 3,034,800 3,540,600
URIN (SEDANG)
570 N-4-15-III 2,886,000 3,463,200 4,040,400
URIN (BERAT)
571 N-4-16-I 2,495,700 2,994,900 3,494,000
(RINGAN)
572 N-4-16-II 3,562,200 4,274,700 4,987,100
(SEDANG)
573 N-4-16-III 4,741,600 5,689,900 6,638,200
(BERAT)
- 566 -

REGIONAL 3
RAWAT INAP

577 O-6-11-I 2,319,900 2,783,900 3,247,900
578 O-6-11-II 2,578,300 3,094,000 3,609,600
579 O-6-11-III 3,207,500 3,848,900 4,490,400
580 O-6-12-I 1,643,600 1,972,300 2,301,100
581 O-6-12-II 1,974,000 2,368,800 2,763,600
582 O-6-12-III 2,480,400 2,976,500 3,472,500
586 P-8-01-I 36,702,300 44,042,800 51,383,200
587 P-8-01-II 45,413,600 54,496,300 63,579,100
588 P-8-01-III 53,302,800 63,963,400 74,623,900
589 P-8-02-I 50,096,900 60,116,300 70,135,700
590 P-8-02-II 57,466,200 68,959,400 80,452,700
591 P-8-02-III 65,659,200 78,791,100 91,922,900
592 P-8-03-I 6,105,500 7,326,600 8,547,700
593 P-8-03-II 8,669,800 10,403,800 12,137,800
594 P-8-03-III 9,796,900 11,756,300 13,715,700
595 P-8-04-I 19,812,900 23,775,500 27,738,000
596 P-8-04-II 25,712,800 30,855,400 35,998,000
597 P-8-04-III 36,865,800 44,238,900 51,612,100
598 P-8-05-I 10,773,600 12,928,300 15,083,100
599 P-8-05-II 20,313,500 24,376,300 28,439,000
600 P-8-05-III 24,789,400 29,747,300 34,705,200
601 P-8-06-I 3,554,900 4,265,800 4,976,800
602 P-8-06-II 9,967,100 11,960,500 13,953,900
603 P-8-06-III 13,203,900 15,844,700 18,485,500
604 P-8-07-I 3,443,300 4,131,900 4,820,600
605 P-8-07-II 9,654,100 11,584,900 13,515,700
606 P-8-07-III 12,789,300 15,347,200 17,905,000
607 P-8-08-I 3,640,200 4,368,300 5,096,300
608 P-8-08-II 5,165,400 6,198,500 7,231,600
609 P-8-08-III 8,363,800 10,036,600 11,709,400
610 P-8-11-I 5,768,100 6,921,700 8,075,300
MAYOR (RINGAN)
611 P-8-11-II 8,190,700 9,828,800 11,467,000
MAYOR (SEDANG)
- 567 -

REGIONAL 3
RAWAT INAP

612 P-8-11-III 9,255,500 11,106,600 12,957,700
MAYOR (BERAT)
613 P-8-12-I 5,449,300 6,539,200 7,629,000
MAYOR (RINGAN)
614 P-8-12-II 7,748,100 9,297,800 10,847,400
MAYOR (SEDANG)
615 P-8-12-III 8,769,400 10,523,200 12,277,100
MAYOR (BERAT)
616 P-8-13-I 4,728,100 5,673,800 6,619,400
MAYOR (RINGAN)
617 P-8-13-II 6,241,200 7,489,400 8,737,600
MAYOR (SEDANG)
618 P-8-13-III 9,293,300 11,152,000 13,010,600
MAYOR (BERAT)
619 P-8-14-I 2,393,900 2,872,700 3,351,500
620 P-8-14-II 4,873,000 5,847,600 6,822,200
621 P-8-14-III 9,041,300 10,849,500 12,657,800
622 P-8-15-I 1,795,400 2,154,500 2,513,600
ASPIRASI (RINGAN)
623 P-8-15-II 3,595,500 4,314,600 5,033,700
ASPIRASI (SEDANG)
624 P-8-15-III 4,218,600 5,062,400 5,906,100
ASPIRASI (BERAT)
625 P-8-16-I 1,624,900 1,949,900 2,274,900
626 P-8-16-II 3,122,500 3,747,000 4,371,500
627 P-8-16-III 6,367,700 7,641,200 8,914,700
628 P-8-17-I 3,152,100 3,782,500 4,412,900
(RINGAN)
629 P-8-17-II 5,673,800 6,808,500 7,943,300
(SEDANG)
630 P-8-17-III 7,744,400 9,293,300 10,842,200
(BERAT)
631 S-4-10-I 1,832,100 2,198,500 2,564,900
632 S-4-10-II 2,257,400 2,708,800 3,160,300
633 S-4-10-III 3,090,100 3,708,100 4,326,200
640 S-4-13-I 1,989,100 2,386,900 2,784,700
(RINGAN)
641 S-4-13-II 3,528,700 4,234,500 4,940,200
(SEDANG)
642 S-4-13-III 5,727,600 6,873,100 8,018,600
(BERAT)
643 S-4-14-I 1,006,600 1,207,900 1,409,200
644 S-4-14-II 2,138,100 2,565,700 2,993,300
645 S-4-14-III 4,054,600 4,865,500 5,676,400
KANAK-KANAK (BERAT)
646 S-4-15-I 673,200 807,900 942,500
647 S-4-15-II 1,270,500 1,524,600 1,778,700
648 S-4-15-III 1,645,500 1,974,600 2,303,700
- 568 -

REGIONAL 3
RAWAT INAP

652 S-4-17-I 1,680,200 2,016,300 2,352,300
653 S-4-17-II 2,493,600 2,992,400 3,491,100
654 S-4-17-III 2,999,200 3,599,000 4,198,800
655 T-1-10-I 1,124,200 1,349,000 1,573,900
OBAT (RINGAN)
656 T-1-10-II 1,510,000 1,811,900 2,113,900
OBAT (SEDANG)
657 T-1-10-III 2,746,800 3,296,200 3,845,600
OBAT (BERAT)
658 T-4-10-I 512,700 615,200 717,800
659 T-4-10-II 977,100 1,172,600 1,368,000
660 T-4-10-III 1,420,500 1,704,600 1,988,700
661 T-4-11-I 607,200 728,600 850,000
662 T-4-11-II 955,500 1,146,600 1,337,700
663 T-4-11-III 1,538,900 1,846,700 2,154,500
664 T-4-12-I 1,061,900 1,274,200 1,486,600
LAIN (RINGAN)
665 T-4-12-II 1,605,300 1,926,400 2,247,400
LAIN (SEDANG)
666 T-4-12-III 2,505,400 3,006,500 3,507,600
LAIN (BERAT)
670 U-1-11-I 5,683,500 6,820,200 7,956,900
(RINGAN)
671 U-1-11-II 7,204,700 8,645,600 10,086,600
(SEDANG)
672 U-1-11-III 10,366,400 12,439,700 14,513,000
(BERAT)
679 U-1-14-I 2,670,600 3,204,700 3,738,800
(RINGAN)
680 U-1-14-II 3,277,400 3,932,900 4,588,400
(SEDANG)
681 U-1-14-III 3,883,800 4,660,500 5,437,300
(BERAT)
685 U-1-20-I 4,054,400 4,865,200 5,676,100
686 U-1-20-II 6,034,000 7,240,800 8,447,600
687 U-1-20-III 15,490,500 18,588,600 21,686,600
691 U-4-10-I 2,502,200 3,002,700 3,503,100
- 569 -

REGIONAL 3
RAWAT INAP

692 U-4-10-II 5,728,400 6,874,000 8,019,700
693 U-4-10-III 8,794,800 10,553,800 12,312,700
TENGGOROKAN (BERAT)
700 U-4-13-I 1,808,500 2,170,200 2,531,900
701 U-4-13-II 2,132,100 2,558,500 2,984,900
702 U-4-13-III 2,550,100 3,060,100 3,570,100
706 U-4-15-I 1,999,800 2,399,800 2,799,800
707 U-4-15-II 2,491,600 2,989,900 3,488,200
708 U-4-15-III 3,487,000 4,184,400 4,881,800
709 V-1-10-I 3,261,900 3,914,300 4,566,700
(RINGAN)
710 V-1-10-II 6,719,400 8,063,300 9,407,200
(SEDANG)
711 V-1-10-III 8,240,400 9,888,500 11,536,600
(BERAT)
715 V-1-12-I 5,834,500 7,001,400 8,168,300
MODERAT (RINGAN)
716 V-1-12-II 7,967,500 9,561,000 11,154,500
MODERAT (SEDANG)
717 V-1-12-III 10,098,900 12,118,700 14,138,400
MODERAT (BERAT)
718 V-1-13-I 3,043,400 3,652,000 4,260,700
KOMPLEK (RINGAN)
719 V-1-13-II 5,814,900 6,977,800 8,140,800
KOMPLEK (SEDANG)
720 V-1-13-III 9,122,800 10,947,300 12,771,900
KOMPLEK (BERAT)
721 V-1-14-I 5,968,000 7,161,600 8,355,200
(RINGAN)
722 V-1-14-II 8,671,300 10,405,600 12,139,900
(SEDANG)

727 V-4-10-I 2,886,000 3,463,200 4,040,400
(RINGAN)
728 V-4-10-II 4,793,800 5,752,600 6,711,400
(SEDANG)
729 V-4-10-III 7,903,400 9,484,000 11,064,700
(BERAT)
730 V-4-11-I 2,493,700 2,992,400 3,491,200
TUMOR (RINGAN)
731 V-4-11-II 3,345,900 4,015,100 4,684,300
TUMOR (SEDANG)
732 V-4-11-III 4,481,900 5,378,200 6,274,600
TUMOR (BERAT)
- 570 -

REGIONAL 3
RAWAT INAP

733 W-1-01-I 6,796,900 8,156,300 9,515,700
734 W-1-01-II 8,146,600 9,775,900 11,405,200
735 W-1-01-III 11,625,000 13,950,000 16,275,000
739 W-1-11-I 1,506,900 1,808,300 2,109,700
SERVIK (RINGAN)
740 W-1-11-II 1,662,900 1,995,500 2,328,000
SERVIK (SEDANG)
741 W-1-11-III 1,839,500 2,207,400 2,575,300
SERVIK (BERAT)
760 W-4-12-I 2,645,200 3,174,300 3,703,300
761 W-4-12-II 3,631,700 4,358,100 5,084,400
762 W-4-12-III 3,958,800 4,750,500 5,542,300
- 571 -

REGIONAL 3
RAWAT INAP

784 Z-4-12-I 785,700 942,900 1,100,000
785 Z-4-12-II 1,914,500 2,297,400 2,680,300
786 Z-4-12-III 2,428,000 2,913,600 3,399,200
- 572 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,471,200

33 F-3-10-0 TERAPI SHOCK 416,700
- 573 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,532,700
PENGGANTIAN ALAT
81 I-2-42-0 2,433,800
PERKUTAN LAIN
- 574 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,147,700
192 Q-5-12-0 GIGI 208,500
196 Q-5-16-0 VAKSINASI 88,800
201 Q-5-21-0 ABORSI 182,000
206 Q-5-26-0 BRONKIAL AKUT 189,200
- 575 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 127,400
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
270 Z-3-11-0 1,713,400
EMPEDU
- 576 -

REGIONAL 3
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 902,800
289 Z-3-30-0 FOTOTERAPI 73,400
- 577 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,381,200 2,857,400 3,333,600
(RINGAN)
14 A-4-14-II 4,006,400 4,807,700 5,609,000
(SEDANG)
15 A-4-14-III 4,807,700 5,769,200 6,730,800
(BERAT)

31 B-1-13-I 7,749,100 9,298,900 10,848,700
LAIN (RINGAN)
32 B-1-13-II 12,750,200 15,300,200 17,850,300
LAIN (SEDANG)
33 B-1-13-III 16,497,600 19,797,200 23,096,700
LAIN (BERAT)
34 B-1-14-I 20,302,600 24,363,100 28,423,600
(RINGAN)
35 B-1-14-II 21,323,400 25,588,100 29,852,700
(SEDANG)
40 B-4-11-I 6,945,800 8,334,900 9,724,100
(RINGAN)
41 B-4-11-II 9,724,100 11,669,000 13,613,800
(SEDANG)
42 B-4-11-III 11,780,700 14,136,800 16,492,900
(BERAT)
- 578 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 7,358,000 8,829,500 10,301,100
74 D-1-20-II 20,277,400 24,332,900 28,388,400
75 D-1-20-III 32,165,900 38,599,100 45,032,300
85 D-4-13-I 4,255,900 5,107,000 5,958,200
86 D-4-13-II 6,023,500 7,228,200 8,432,900
87 D-4-13-III 7,704,200 9,245,100 10,785,900
88 D-4-14-I 4,564,600 5,477,500 6,390,500
89 D-4-14-II 7,473,400 8,968,100 10,462,800
90 D-4-14-III 9,140,700 10,968,900 12,797,000
91 E-1-01-I 9,099,000 10,918,800 12,738,600
(RINGAN)
92 E-1-01-II 12,421,500 14,905,800 17,390,100
(SEDANG)

97 E-1-20-I 10,709,500 12,851,400 14,993,300
TIROGLOSAL (RINGAN)
- 579 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 14,414,700 17,297,600 20,180,500
TIROGLOSAL (SEDANG)
99 E-1-20-III 19,866,400 23,839,700 27,812,900
TIROGLOSAL (BERAT)
100 E-4-10-I 3,790,000 4,548,100 5,306,100
METABOLIK (RINGAN)
101 E-4-10-II 7,340,700 8,808,800 10,277,000
METABOLIK (SEDANG)
102 E-4-10-III 12,300,200 14,760,200 17,220,200
METABOLIK (BERAT)
109 E-4-13-I 5,267,700 6,321,200 7,374,800
(RINGAN)
110 E-4-13-II 7,716,200 9,259,500 10,802,700
(SEDANG)

118 F-4-12-I 2,973,200 3,567,800 4,162,500
(RINGAN)
119 F-4-12-II 4,227,000 5,072,400 5,917,800
(SEDANG)
120 F-4-12-III 9,182,900 11,019,400 12,856,000
(BERAT)
130 F-4-16-I 7,811,100 9,373,300 10,935,500
131 F-4-16-II 9,081,600 10,898,000 12,714,300
132 F-4-16-III 12,122,400 14,546,900 16,971,400
142 G-1-01-I 22,003,900 26,404,700 30,805,500
(RINGAN)
- 580 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 31,559,000 37,870,800 44,182,600
(SEDANG)
144 G-1-01-III 51,633,100 61,959,700 72,286,300
(BERAT)
151 G-1-12-I 7,031,100 8,437,400 9,843,600
(RINGAN)
152 G-1-12-II 13,180,200 15,816,200 18,452,300
(SEDANG)
153 G-1-12-III 17,962,000 21,554,400 25,146,800
(BERAT)
163 G-4-10-I 6,035,500 7,242,600 8,449,600
(RINGAN)
164 G-4-10-II 7,377,400 8,852,900 10,328,300
(SEDANG)
165 G-4-10-III 10,123,000 12,147,600 14,172,200
(BERAT)
166 G-4-11-I 6,318,200 7,581,800 8,845,500
167 G-4-11-II 8,392,900 10,071,500 11,750,100
168 G-4-11-III 12,332,000 14,798,400 17,264,900
DEGENERATIF (BERAT)
169 G-4-12-I 7,009,300 8,411,200 9,813,000
(RINGAN)
170 G-4-12-II 8,853,200 10,623,900 12,394,500
(SEDANG)

172 G-4-13-I 4,210,600 5,052,700 5,894,800
(RINGAN)
173 G-4-13-II 7,342,400 8,810,900 10,279,400
(SEDANG)
174 G-4-13-III 8,708,300 10,449,900 12,191,600
(BERAT)
175 G-4-14-I 7,142,800 8,571,300 9,999,900
INFARK (RINGAN)
176 G-4-14-II 9,549,300 11,459,200 13,369,100
INFARK (SEDANG)
177 G-4-14-III 11,985,600 14,382,700 16,779,800
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 581 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 6,408,200 7,689,800 8,971,500
(RINGAN)
185 G-4-17-II 8,402,600 10,083,100 11,763,600
(SEDANG)
186 G-4-17-III 10,558,200 12,669,800 14,781,500
(BERAT)
190 G-4-19-I 5,265,500 6,318,600 7,371,700
191 G-4-19-II 8,899,900 10,679,900 12,459,900
192 G-4-19-III 11,685,200 14,022,200 16,359,300
211 G-4-26-I 4,097,200 4,916,600 5,736,100
LAIN (RINGAN)
212 G-4-26-II 4,766,300 5,719,600 6,672,900
LAIN (SEDANG)
213 G-4-26-III 7,127,100 8,552,500 9,977,900
LAIN (BERAT)
232 I-1-02-I 36,890,300 44,268,400 51,646,500
(RINGAN)
- 582 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 47,588,100 57,105,700 66,623,300
(SEDANG)
234 I-1-02-III 58,655,300 70,386,300 82,117,400
(BERAT)
235 I-1-03-I 34,791,600 41,749,900 48,708,200
ANOMALI (RINGAN)
236 I-1-03-II 48,228,300 57,874,000 67,519,600
ANOMALI (SEDANG)
237 I-1-03-III 61,205,400 73,446,500 85,687,600
ANOMALI (BERAT)
238 I-1-04-I 52,429,000 62,914,800 73,400,600
JANTUNG (RINGAN)
239 I-1-04-II 82,747,100 99,296,500 115,845,900
JANTUNG (SEDANG)
240 I-1-04-III 132,187,900 158,625,500 185,063,100
JANTUNG (BERAT)
241 I-1-05-I 86,847,200 104,216,700 121,586,100
242 I-1-05-II 106,146,600 127,375,900 148,605,300
243 I-1-05-III 144,745,400 173,694,500 202,643,500
247 I-1-07-I 77,197,500 92,637,000 108,076,600
JANTUNG (RINGAN)
248 I-1-07-II 96,496,900 115,796,300 135,095,700
JANTUNG (SEDANG)
249 I-1-07-III 144,745,400 173,694,500 202,643,500
JANTUNG (BERAT)
250 I-1-11-I 5,780,900 6,937,000 8,093,200
251 I-1-11-II 6,427,700 7,713,300 8,998,800
252 I-1-11-III 8,553,300 10,264,000 11,974,700
253 I-1-12-I 16,640,000 19,968,000 23,296,000
(RINGAN)
254 I-1-12-II 27,176,500 32,611,800 38,047,100
(SEDANG)
255 I-1-12-III 35,754,800 42,905,700 50,056,700
(BERAT)
256 I-1-13-I 16,140,600 19,368,700 22,596,800
KOMPLEK (RINGAN)
257 I-1-13-II 21,494,500 25,793,400 30,092,300
KOMPLEK (SEDANG)
258 I-1-13-III 26,508,600 31,810,400 37,112,100
KOMPLEK (BERAT)
259 I-1-14-I 33,035,800 39,643,000 46,250,100
(RINGAN)
260 I-1-14-II 41,058,600 49,270,400 57,482,100
(SEDANG)
261 I-1-14-III 53,801,000 64,561,200 75,321,400
(BERAT)
265 I-1-16-I 16,269,300 19,523,100 22,777,000
266 I-1-16-II 36,810,800 44,173,000 51,535,200
267 I-1-16-III 42,460,700 50,952,900 59,445,000
268 I-1-17-I 18,838,300 22,605,900 26,373,600
(RINGAN)
269 I-1-17-II 23,587,300 28,304,800 33,022,200
(SEDANG)
- 583 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 29,177,100 35,012,600 40,848,000
(BERAT)
271 I-1-20-I 21,234,000 25,480,800 29,727,600
(RINGAN)
272 I-1-20-II 26,527,100 31,832,500 37,137,900
(SEDANG)
273 I-1-20-III 27,885,400 33,462,500 39,039,600
(BERAT)
274 I-1-30-I 16,062,300 19,274,800 22,487,200
JANTUNG (RINGAN)
275 I-1-30-II 33,413,200 40,095,800 46,778,500
JANTUNG (SEDANG)
276 I-1-30-III 51,778,400 62,134,100 72,489,800
JANTUNG (BERAT)

289 I-4-13-I 5,028,900 6,034,700 7,040,500
(RINGAN)
290 I-4-13-II 8,979,700 10,775,700 12,571,600
(SEDANG)
291 I-4-13-III 12,938,500 15,526,200 18,114,000
(BERAT)
295 I-4-15-I 4,850,000 5,820,000 6,790,000
(RINGAN)
296 I-4-15-II 9,145,700 10,974,800 12,803,900
(SEDANG)

304 I-4-18-I 5,781,400 6,937,700 8,094,000
JANTUNG (RINGAN)
305 I-4-18-II 8,802,500 10,563,000 12,323,500
JANTUNG (SEDANG)
306 I-4-18-III 11,950,800 14,341,000 16,731,200
JANTUNG (BERAT)

308 I-4-19-II 8,707,500 10,449,000 12,190,400
(SEDANG)
- 584 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 4,767,800 5,721,300 6,674,900
320 I-4-23-II 5,853,400 7,024,100 8,194,800
321 I-4-23-III 11,437,300 13,724,800 16,012,200
322 I-4-24-I 3,097,500 3,716,900 4,336,400
(RINGAN)
323 I-4-24-II 7,132,600 8,559,100 9,985,700
(SEDANG)
324 I-4-24-III 9,017,900 10,821,500 12,625,100
(BERAT)
325 J-1-01-I 98,141,300 117,769,500 137,397,800
326 J-1-01-II 111,065,100 133,278,200 155,491,200
327 J-1-01-III 152,345,000 182,813,900 213,282,900
TRAKEOSTOMI (BERAT)
328 J-1-02-I 64,025,300 76,830,400 89,635,400
329 J-1-02-II 80,787,500 96,945,000 113,102,500
330 J-1-02-III 94,509,900 113,411,900 132,313,900
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,482,000 14,978,400 17,474,800
(RINGAN)
332 J-1-10-II 25,257,400 30,308,900 35,360,300
(SEDANG)
333 J-1-10-III 26,248,700 31,498,400 36,748,100
(BERAT)
334 J-1-20-I 34,385,700 41,262,800 48,140,000
(RINGAN)
335 J-1-20-II 36,006,400 43,207,700 50,409,000
(SEDANG)
336 J-1-20-III 40,520,500 48,624,600 56,728,700
(BERAT)
337 J-1-30-I 10,416,500 12,499,900 14,583,200
(RINGAN)
338 J-1-30-II 18,869,500 22,643,300 26,417,200
(SEDANG)

- 585 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 3,028,100 3,633,700 4,239,300
374 J-4-21-II 6,761,600 8,113,900 9,466,300
375 J-4-21-III 12,737,700 15,285,200 17,832,700
376 K-1-10-I 11,315,700 13,578,800 15,842,000
BESAR (RINGAN)
377 K-1-10-II 14,220,600 17,064,700 19,908,800
BESAR (SEDANG)
378 K-1-10-III 16,667,000 20,000,400 23,333,800
BESAR (BERAT)
382 K-1-12-I 4,747,900 5,697,500 6,647,100
FEMORAL (RINGAN)
383 K-1-12-II 6,175,200 7,410,200 8,645,300
FEMORAL (SEDANG)
384 K-1-12-III 12,234,000 14,680,800 17,127,600
FEMORAL (BERAT)
388 K-1-14-I 7,820,700 9,384,900 10,949,000
(RINGAN)
389 K-1-14-II 9,165,700 10,998,900 12,832,000
(SEDANG)

394 K-1-30-I 9,950,800 11,941,000 13,931,100
395 K-1-30-II 17,672,400 21,206,800 24,741,300
396 K-1-30-III 24,317,400 29,180,900 34,044,400

398 K-1-40-II 12,241,200 14,689,400 17,137,700
(SEDANG)

- 586 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 5,675,500 6,810,600 7,945,700
413 K-4-13-II 7,341,600 8,809,900 10,278,300
414 K-4-13-III 11,308,400 13,570,100 15,831,800
415 K-4-14-I 3,238,500 3,886,200 4,533,800
(RINGAN)
416 K-4-14-II 4,347,100 5,216,500 6,085,900
(SEDANG)
417 K-4-14-III 6,975,300 8,370,400 9,765,500
(BERAT)

424 K-4-17-I 2,050,500 2,460,700 2,870,800
(RINGAN)
425 K-4-17-II 2,525,300 3,030,300 3,535,400
(SEDANG)
426 K-4-17-III 3,030,300 3,636,400 4,242,400
(BERAT)
427 K-4-18-I 1,807,000 2,168,400 2,529,800
(RINGAN)
428 K-4-18-II 3,049,400 3,659,200 4,269,100
(SEDANG)
436 L-1-40-I 7,093,400 8,512,100 9,930,700
(RINGAN)
437 L-1-40-II 14,227,800 17,073,300 19,918,900
(SEDANG)
438 L-1-40-III 23,948,500 28,738,200 33,527,900
(BERAT)
451 L-4-13-I 2,579,300 3,095,200 3,611,100
PAYUDARA (RINGAN)
- 587 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 4,201,900 5,042,200 5,882,600
PAYUDARA (SEDANG)
453 L-4-13-III 8,347,200 10,016,600 11,686,000
PAYUDARA (BERAT)
454 L-4-14-I 4,194,700 5,033,600 5,872,500
(RINGAN)
455 L-4-14-II 6,300,500 7,560,600 8,820,700
(SEDANG)
456 L-4-14-III 8,881,300 10,657,600 12,433,900
(BERAT)
457 M-1-01-I 14,827,700 17,793,200 20,758,800
458 M-1-01-II 21,075,500 25,290,600 29,505,700
459 M-1-01-III 29,604,800 35,525,700 41,446,700
463 M-1-03-I 52,533,300 63,040,000 73,546,600
464 M-1-03-II 61,445,400 73,734,400 86,023,500
465 M-1-03-III 76,048,900 91,258,700 106,468,400
472 M-1-07-I 19,121,300 22,945,500 26,769,800
473 M-1-07-II 25,615,900 30,739,100 35,862,200
474 M-1-07-III 52,181,900 62,618,300 73,054,700
475 M-1-10-I 22,596,300 27,115,500 31,634,800
WAJAH (RINGAN)
476 M-1-10-II 54,026,700 64,832,000 75,637,300
WAJAH (SEDANG)
477 M-1-10-III 116,530,500 139,836,600 163,142,700
WAJAH (BERAT)
478 M-1-20-I 17,608,000 21,129,600 24,651,200
(RINGAN)
479 M-1-20-II 22,496,000 26,995,200 31,494,400
(SEDANG)

484 M-1-40-I 7,378,700 8,854,500 10,330,200
INTERNAL (RINGAN)
485 M-1-40-II 10,904,900 13,085,900 15,266,800
INTERNAL (SEDANG)
486 M-1-40-III 15,570,100 18,684,100 21,798,100
INTERNAL (BERAT)
490 M-1-60-I 11,380,100 13,656,200 15,932,200
491 M-1-60-II 14,307,500 17,169,000 20,030,500
492 M-1-60-III 21,613,100 25,935,800 30,258,400
- 588 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 21,083,800 25,300,500 29,517,300
KAKI (RINGAN)
494 M-1-70-II 23,192,200 27,830,600 32,469,000
KAKI (SEDANG)
495 M-1-70-III 26,551,900 31,862,300 37,172,700
KAKI (BERAT)
502 M-4-11-I 5,260,900 6,313,100 7,365,300
(RINGAN)
503 M-4-11-II 11,534,400 13,841,300 16,148,200
(SEDANG)
504 M-4-11-III 16,676,800 20,012,100 23,347,500
(BERAT)
505 M-4-12-I 4,199,400 5,039,300 5,879,200
(RINGAN)
506 M-4-12-II 6,984,800 8,381,700 9,778,700
(SEDANG)
507 M-4-12-III 9,342,900 11,211,500 13,080,000
(BERAT)
508 M-4-13-I 6,992,500 8,390,900 9,789,400
509 M-4-13-II 10,505,900 12,607,000 14,708,200
510 M-4-13-III 20,496,700 24,596,000 28,695,400
520 M-4-17-I 4,729,000 5,674,800 6,620,600
(RINGAN)
521 M-4-17-II 6,614,000 7,936,800 9,259,600
(SEDANG)
522 M-4-17-III 9,236,100 11,083,300 12,930,500
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,760,000 4,512,000 5,264,000
(RINGAN)
530 M-4-20-II 5,505,900 6,607,100 7,708,300
(SEDANG)
531 M-4-20-III 6,153,500 7,384,300 8,615,000
(BERAT)
532 M-4-21-I 3,786,100 4,543,300 5,300,500
533 M-4-21-II 4,735,300 5,682,300 6,629,400
- 589 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 10,616,400 12,739,700 14,862,900
541 N-1-12-I 6,184,400 7,421,300 8,658,200
542 N-1-12-II 12,312,500 14,775,000 17,237,500
543 N-1-12-III 26,718,600 32,062,400 37,406,100
547 N-1-30-I 12,374,600 14,849,500 17,324,400
BAWAH (RINGAN)
548 N-1-30-II 18,720,300 22,464,300 26,208,400
BAWAH (SEDANG)
549 N-1-30-III 21,545,200 25,854,300 30,163,300
BAWAH (BERAT)
550 N-1-40-I 11,113,200 13,335,900 15,558,500
(RINGAN)
551 N-1-40-II 15,091,500 18,109,800 21,128,100
(SEDANG)
552 N-1-40-III 17,564,500 21,077,400 24,590,300
(BERAT)
553 N-4-10-I 4,721,600 5,665,900 6,610,200
(RINGAN)
554 N-4-10-II 5,710,800 6,853,000 7,995,200
(SEDANG)
555 N-4-10-III 8,399,800 10,079,800 11,759,700
(BERAT)
568 N-4-15-I 4,300,500 5,160,600 6,020,700
URIN (RINGAN)
569 N-4-15-II 5,336,200 6,403,400 7,470,600
URIN (SEDANG)
570 N-4-15-III 6,089,500 7,307,400 8,525,200
URIN (BERAT)
571 N-4-16-I 5,265,900 6,319,100 7,372,300
(RINGAN)
572 N-4-16-II 7,516,200 9,019,400 10,522,700
(SEDANG)
573 N-4-16-III 10,004,600 12,005,500 14,006,400
(BERAT)
- 590 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 4,894,900 5,873,900 6,852,900
578 O-6-11-II 5,440,200 6,528,200 7,616,200
579 O-6-11-III 6,767,700 8,121,200 9,474,700
580 O-6-12-I 3,468,000 4,161,600 4,855,200
581 O-6-12-II 4,165,000 4,998,000 5,831,100
582 O-6-12-III 5,233,500 6,280,200 7,327,000
586 P-8-01-I 77,441,000 92,929,200 108,417,300
587 P-8-01-II 95,821,600 114,985,900 134,150,200
588 P-8-01-III 112,467,600 134,961,100 157,454,600
589 P-8-02-I 105,703,200 126,843,900 147,984,500
590 P-8-02-II 121,252,200 145,502,700 169,753,100
591 P-8-02-III 138,539,300 166,247,100 193,955,000
592 P-8-03-I 15,855,400 19,026,500 22,197,500
593 P-8-03-II 20,986,800 25,184,100 29,381,500
594 P-8-03-III 29,508,300 35,410,000 41,311,700
595 P-8-04-I 51,094,600 61,313,600 71,532,500
596 P-8-04-II 66,309,800 79,571,700 92,833,700
597 P-8-04-III 95,071,600 114,085,900 133,100,200
598 P-8-05-I 27,783,600 33,340,300 38,897,100
599 P-8-05-II 42,861,100 51,433,300 60,005,500
600 P-8-05-III 58,020,400 69,624,500 81,228,500
601 P-8-06-I 7,500,700 9,000,800 10,501,000
602 P-8-06-II 21,030,200 25,236,300 29,442,300
603 P-8-06-III 27,859,900 33,431,900 39,003,800
604 P-8-07-I 8,879,700 10,655,600 12,431,500
605 P-8-07-II 24,896,600 29,875,900 34,855,200
606 P-8-07-III 32,981,800 39,578,200 46,174,500
607 P-8-08-I 5,137,900 6,165,500 7,193,000
608 P-8-08-II 7,290,400 8,748,500 10,206,600
609 P-8-08-III 14,182,700 17,019,300 19,855,800
610 P-8-11-I 13,212,800 15,855,400 18,497,900
MAYOR (RINGAN)
611 P-8-11-II 17,489,000 20,986,800 24,484,500
MAYOR (SEDANG)
- 591 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 24,590,300 29,508,300 34,426,400
MAYOR (BERAT)
613 P-8-12-I 12,011,600 14,414,000 16,816,300
MAYOR (RINGAN)
614 P-8-12-II 14,574,100 17,489,000 20,403,800
MAYOR (SEDANG)
615 P-8-12-III 21,382,900 25,659,400 29,936,000
MAYOR (BERAT)
616 P-8-13-I 6,673,100 8,007,800 9,342,400
MAYOR (RINGAN)
617 P-8-13-II 10,410,100 12,492,100 14,574,100
MAYOR (SEDANG)
618 P-8-13-III 16,448,300 19,738,000 23,027,700
MAYOR (BERAT)
619 P-8-14-I 5,051,100 6,061,300 7,071,500
620 P-8-14-II 10,281,900 12,338,300 14,394,700
621 P-8-14-III 40,203,100 48,243,800 56,284,400
622 P-8-15-I 3,788,400 4,546,000 5,303,700
ASPIRASI (RINGAN)
623 P-8-15-II 7,586,300 9,103,600 10,620,900
ASPIRASI (SEDANG)
624 P-8-15-III 8,901,200 10,681,400 12,461,700
ASPIRASI (BERAT)
625 P-8-16-I 3,428,500 4,114,200 4,799,900
626 P-8-16-II 6,588,400 7,906,100 9,223,800
627 P-8-16-III 15,450,900 18,541,100 21,631,300
628 P-8-17-I 4,448,800 5,338,500 6,228,300
(RINGAN)
629 P-8-17-II 8,007,800 9,609,300 11,210,900
(SEDANG)
630 P-8-17-III 13,707,000 16,448,300 19,189,700
(BERAT)
631 S-4-10-I 3,865,600 4,638,700 5,411,800
632 S-4-10-II 4,763,000 5,715,600 6,668,200
633 S-4-10-III 6,520,100 7,824,100 9,128,100
640 S-4-13-I 4,196,900 5,036,200 5,875,600
(RINGAN)
641 S-4-13-II 7,445,600 8,934,700 10,423,800
(SEDANG)
642 S-4-13-III 12,085,100 14,502,100 16,919,100
(BERAT)
643 S-4-14-I 2,123,900 2,548,700 2,973,500
644 S-4-14-II 4,511,400 5,413,600 6,315,900
645 S-4-14-III 8,555,100 10,266,100 11,977,100
KANAK-KANAK (BERAT)
646 S-4-15-I 1,420,500 1,704,600 1,988,700
647 S-4-15-II 2,680,700 3,216,800 3,753,000
648 S-4-15-III 3,472,000 4,166,400 4,860,700
- 592 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 3,545,200 4,254,300 4,963,300
653 S-4-17-II 5,261,500 6,313,800 7,366,100
654 S-4-17-III 6,328,200 7,593,800 8,859,400
655 T-1-10-I 2,372,000 2,846,500 3,320,900
OBAT (RINGAN)
656 T-1-10-II 3,186,000 3,823,200 4,460,300
OBAT (SEDANG)
657 T-1-10-III 5,795,800 6,954,900 8,114,100
OBAT (BERAT)
658 T-4-10-I 1,298,800 1,558,600 1,818,400
659 T-4-10-II 2,474,900 2,969,900 3,464,900
660 T-4-10-III 3,597,400 4,316,900 5,036,300
661 T-4-11-I 1,254,400 1,505,200 1,756,100
662 T-4-11-II 1,974,000 2,368,800 2,763,600
663 T-4-11-III 3,179,600 3,815,500 4,451,400
664 T-4-12-I 2,939,100 3,526,900 4,114,700
LAIN (RINGAN)
665 T-4-12-II 4,436,800 5,324,200 6,211,600
LAIN (SEDANG)
666 T-4-12-III 6,867,500 8,241,100 9,614,600
LAIN (BERAT)
670 U-1-11-I 12,233,100 14,679,700 17,126,400
(RINGAN)
671 U-1-11-II 18,451,400 22,141,700 25,831,900
(SEDANG)
672 U-1-11-III 21,872,900 26,247,500 30,622,000
(BERAT)
679 U-1-14-I 5,634,800 6,761,800 7,888,800
(RINGAN)
680 U-1-14-II 6,915,300 8,298,400 9,681,500
(SEDANG)
681 U-1-14-III 8,194,600 9,833,600 11,472,500
(BERAT)
685 U-1-20-I 8,554,600 10,265,500 11,976,400
686 U-1-20-II 12,731,600 15,277,900 17,824,300
687 U-1-20-III 32,684,500 39,221,400 45,758,300
691 U-4-10-I 5,279,700 6,335,600 7,391,500
- 593 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 12,086,700 14,504,100 16,921,400
693 U-4-10-III 18,556,800 22,268,200 25,979,600
TENGGOROKAN (BERAT)
700 U-4-13-I 2,078,300 2,494,000 2,909,600
701 U-4-13-II 3,396,100 4,075,300 4,754,500
702 U-4-13-III 5,483,600 6,580,300 7,677,000
706 U-4-15-I 4,219,600 5,063,600 5,907,500
707 U-4-15-II 5,257,100 6,308,500 7,360,000
708 U-4-15-III 7,357,400 8,828,900 10,300,400
709 V-1-10-I 6,882,600 8,259,100 9,635,600
(RINGAN)
710 V-1-10-II 14,177,800 17,013,400 19,849,000
(SEDANG)
711 V-1-10-III 17,387,100 20,864,600 24,342,000
(BERAT)
715 V-1-12-I 12,310,700 14,772,800 17,234,900
MODERAT (RINGAN)
716 V-1-12-II 16,811,200 20,173,500 23,535,700
MODERAT (SEDANG)
717 V-1-12-III 21,308,400 25,570,100 29,831,800
MODERAT (BERAT)
718 V-1-13-I 6,421,400 7,705,700 8,990,000
KOMPLEK (RINGAN)
719 V-1-13-II 12,269,200 14,723,000 17,176,900
KOMPLEK (SEDANG)
720 V-1-13-III 19,248,800 23,098,600 26,948,400
KOMPLEK (BERAT)
721 V-1-14-I 12,592,300 15,110,800 17,629,300
(RINGAN)
722 V-1-14-II 18,296,300 21,955,600 25,614,800
(SEDANG)

727 V-4-10-I 5,480,500 6,576,600 7,672,700
(RINGAN)
728 V-4-10-II 9,103,400 10,924,100 12,744,700
(SEDANG)
729 V-4-10-III 15,008,300 18,009,900 21,011,600
(BERAT)
730 V-4-11-I 5,261,600 6,314,000 7,366,300
TUMOR (RINGAN)
731 V-4-11-II 7,059,800 8,471,700 9,883,700
TUMOR (SEDANG)
732 V-4-11-III 9,456,600 11,348,000 13,239,300
TUMOR (BERAT)
- 594 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 14,341,400 17,209,700 20,077,900
734 W-1-01-II 17,189,100 20,626,900 24,064,800
735 W-1-01-III 24,528,400 29,434,100 34,339,800
739 W-1-11-I 3,179,600 3,815,500 4,451,400
SERVIK (RINGAN)
740 W-1-11-II 3,508,600 4,210,400 4,912,100
SERVIK (SEDANG)
741 W-1-11-III 3,881,300 4,657,500 5,433,800
SERVIK (BERAT)
760 W-4-12-I 3,039,800 3,647,800 4,255,700
761 W-4-12-II 5,784,800 6,941,800 8,098,700
762 W-4-12-III 8,512,800 10,215,300 11,917,900
- 595 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 2,149,000 2,578,800 3,008,600
785 Z-4-12-II 4,314,900 5,177,900 6,040,900
786 Z-4-12-III 9,103,400 10,924,100 12,744,800
- 596 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,298,000

33 F-3-10-0 TERAPI SHOCK 650,800
- 597 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 3,956,100
PENGGANTIAN ALAT
81 I-2-42-0 3,801,600
PERKUTAN LAIN
- 598 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,792,800
192 Q-5-12-0 GIGI 325,700
196 Q-5-16-0 VAKSINASI 108,500
201 Q-5-21-0 ABORSI 284,300
206 Q-5-26-0 BRONKIAL AKUT 231,000
- 599 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 155,500
215 Q-5-35-0 INFEKSI AKUT 664,700
218 Q-5-38-0 PARU AKUT 387,400
234 U-2-23-0 RHINOPLASTY 1,913,900
242 U-3-13-0 493,300
TENGGOROKAN
270 Z-3-11-0 2,676,300
EMPEDU
- 600 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,410,200
289 Z-3-30-0 FOTOTERAPI 89,700
- 601 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,452,600 2,943,100 3,433,600
(RINGAN)
14 A-4-14-II 4,126,600 4,951,900 5,777,300
(SEDANG)
15 A-4-14-III 4,951,900 5,942,300 6,932,700
(BERAT)

31 B-1-13-I 7,981,600 9,577,900 11,174,200
LAIN (RINGAN)
32 B-1-13-II 13,132,700 15,759,200 18,385,800
LAIN (SEDANG)
33 B-1-13-III 16,992,600 20,391,100 23,789,600
LAIN (BERAT)
34 B-1-14-I 20,911,600 25,094,000 29,276,300
(RINGAN)
35 B-1-14-II 21,963,100 26,355,700 30,748,300
(SEDANG)
40 B-4-11-I 7,154,100 8,585,000 10,015,800
(RINGAN)
41 B-4-11-II 10,015,900 12,019,000 14,022,200
(SEDANG)
42 B-4-11-III 12,134,100 14,560,900 16,987,700
(BERAT)
- 602 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 7,578,700 9,094,400 10,610,200
74 D-1-20-II 20,885,800 25,062,900 29,240,100
75 D-1-20-III 33,130,900 39,757,100 46,383,300
85 D-4-13-I 4,383,500 5,260,300 6,137,000
86 D-4-13-II 6,204,200 7,445,000 8,685,900
87 D-4-13-III 7,935,400 9,522,400 11,109,500
88 D-4-14-I 4,701,500 5,641,900 6,582,200
89 D-4-14-II 7,697,600 9,237,100 10,776,700
90 D-4-14-III 9,415,000 11,298,000 13,181,000
91 E-1-01-I 9,372,000 11,246,400 13,120,800
(RINGAN)
92 E-1-01-II 12,794,100 15,353,000 17,911,800
(SEDANG)

97 E-1-20-I 11,030,800 13,236,900 15,443,100
TIROGLOSAL (RINGAN)
- 603 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 14,847,100 17,816,500 20,786,000
TIROGLOSAL (SEDANG)
99 E-1-20-III 20,462,400 24,554,900 28,647,300
TIROGLOSAL (BERAT)
100 E-4-10-I 3,903,800 4,684,500 5,465,300
METABOLIK (RINGAN)
101 E-4-10-II 7,560,900 9,073,100 10,585,300
METABOLIK (SEDANG)
102 E-4-10-III 12,669,200 15,203,000 17,736,800
METABOLIK (BERAT)
109 E-4-13-I 5,425,700 6,510,900 7,596,000
(RINGAN)
110 E-4-13-II 7,947,700 9,537,300 11,126,800
(SEDANG)

118 F-4-12-I 3,062,400 3,674,900 4,287,400
(RINGAN)
119 F-4-12-II 4,353,800 5,224,500 6,095,300
(SEDANG)
120 F-4-12-III 9,458,300 11,350,000 13,241,700
(BERAT)
130 F-4-16-I 8,045,400 9,654,500 11,263,500
131 F-4-16-II 9,354,100 11,224,900 13,095,700
132 F-4-16-III 12,486,100 14,983,300 17,480,500
142 G-1-01-I 22,664,100 27,196,900 31,729,700
(RINGAN)
- 604 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 32,505,700 39,006,900 45,508,000
(SEDANG)
144 G-1-01-III 53,182,100 63,818,500 74,454,900
(BERAT)
151 G-1-12-I 7,242,100 8,690,500 10,138,900
(RINGAN)
152 G-1-12-II 13,575,600 16,290,700 19,005,800
(SEDANG)
153 G-1-12-III 18,500,900 22,201,100 25,901,200
(BERAT)
163 G-4-10-I 6,216,500 7,459,800 8,703,100
(RINGAN)
164 G-4-10-II 7,598,700 9,118,400 10,638,200
(SEDANG)
165 G-4-10-III 10,426,700 12,512,100 14,597,400
(BERAT)
166 G-4-11-I 6,507,700 7,809,300 9,110,800
167 G-4-11-II 8,644,700 10,373,600 12,102,600
168 G-4-11-III 12,702,000 15,242,400 17,782,800
DEGENERATIF (BERAT)
169 G-4-12-I 7,219,600 8,663,500 10,107,400
(RINGAN)
170 G-4-12-II 9,118,800 10,942,600 12,766,400
(SEDANG)

172 G-4-13-I 4,336,900 5,204,300 6,071,600
(RINGAN)
173 G-4-13-II 7,562,700 9,075,200 10,587,800
(SEDANG)
174 G-4-13-III 8,969,500 10,763,400 12,557,300
(BERAT)
175 G-4-14-I 7,357,000 8,828,400 10,299,900
INFARK (RINGAN)
176 G-4-14-II 9,835,800 11,803,000 13,770,200
INFARK (SEDANG)
177 G-4-14-III 12,345,100 14,814,100 17,283,200
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 605 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 6,600,400 7,920,500 9,240,600
(RINGAN)
185 G-4-17-II 8,654,600 10,385,600 12,116,500
(SEDANG)
186 G-4-17-III 10,874,900 13,049,900 15,224,900
(BERAT)
190 G-4-19-I 5,423,400 6,508,100 7,592,800
191 G-4-19-II 9,166,900 11,000,300 12,833,700
192 G-4-19-III 12,035,800 14,442,900 16,850,100
211 G-4-26-I 4,220,100 5,064,100 5,908,200
LAIN (RINGAN)
212 G-4-26-II 4,909,300 5,891,200 6,873,000
LAIN (SEDANG)
213 G-4-26-III 7,340,900 8,809,100 10,277,300
LAIN (BERAT)
232 I-1-02-I 37,997,100 45,596,500 53,195,900
(RINGAN)
- 606 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 49,015,700 58,818,900 68,622,000
(SEDANG)
234 I-1-02-III 60,414,900 72,497,900 84,580,900
(BERAT)
235 I-1-03-I 35,835,300 43,002,400 50,169,400
ANOMALI (RINGAN)
236 I-1-03-II 49,675,200 59,610,200 69,545,200
ANOMALI (SEDANG)
237 I-1-03-III 63,041,600 75,649,900 88,258,200
ANOMALI (BERAT)
238 I-1-04-I 54,001,900 64,802,200 75,602,600
JANTUNG (RINGAN)
239 I-1-04-II 85,229,500 102,275,400 119,321,300
JANTUNG (SEDANG)
240 I-1-04-III 136,153,600 163,384,300 190,615,000
JANTUNG (BERAT)
241 I-1-05-I 89,452,600 107,343,200 125,233,700
242 I-1-05-II 109,331,000 131,197,200 153,063,400
243 I-1-05-III 149,087,700 178,905,300 208,722,800
247 I-1-07-I 79,513,500 95,416,200 111,318,800
JANTUNG (RINGAN)
248 I-1-07-II 99,391,800 119,270,200 139,148,600
JANTUNG (SEDANG)
249 I-1-07-III 149,087,700 178,905,300 208,722,800
JANTUNG (BERAT)
250 I-1-11-I 5,954,300 7,145,100 8,336,000
251 I-1-11-II 6,620,500 7,944,700 9,268,800
252 I-1-11-III 8,809,900 10,571,900 12,333,900
253 I-1-12-I 17,139,200 20,567,100 23,994,900
(RINGAN)
254 I-1-12-II 27,991,800 33,590,100 39,188,500
(SEDANG)
255 I-1-12-III 36,827,400 44,192,900 51,558,400
(BERAT)
256 I-1-13-I 16,624,800 19,949,800 23,274,700
KOMPLEK (RINGAN)
257 I-1-13-II 22,139,300 26,567,200 30,995,000
KOMPLEK (SEDANG)
258 I-1-13-III 27,303,900 32,764,700 38,225,400
KOMPLEK (BERAT)
259 I-1-14-I 34,026,900 40,832,300 47,637,600
(RINGAN)
260 I-1-14-II 42,290,400 50,748,500 59,206,600
(SEDANG)
261 I-1-14-III 55,415,000 66,498,000 77,581,000
(BERAT)
265 I-1-16-I 16,757,400 20,108,800 23,460,300
266 I-1-16-II 37,915,200 45,498,200 53,081,200
267 I-1-16-III 43,734,600 52,481,500 61,228,400
268 I-1-17-I 19,403,400 23,284,100 27,164,800
(RINGAN)
269 I-1-17-II 24,294,900 29,153,900 34,012,900
(SEDANG)
- 607 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 30,052,400 36,062,900 42,073,400
(BERAT)
271 I-1-20-I 21,871,000 26,245,200 30,619,400
(RINGAN)
272 I-1-20-II 27,322,900 32,787,500 38,252,100
(SEDANG)
273 I-1-20-III 28,722,000 34,466,400 40,210,800
(BERAT)
274 I-1-30-I 16,544,200 19,853,000 23,161,900
JANTUNG (RINGAN)
275 I-1-30-II 34,415,600 41,298,700 48,181,800
JANTUNG (SEDANG)
276 I-1-30-III 53,331,700 63,998,100 74,664,400
JANTUNG (BERAT)

289 I-4-13-I 5,179,800 6,215,700 7,251,700
(RINGAN)
290 I-4-13-II 9,249,100 11,099,000 12,948,800
(SEDANG)
291 I-4-13-III 13,326,700 15,992,000 18,657,400
(BERAT)
295 I-4-15-I 4,995,500 5,994,600 6,993,700
(RINGAN)
296 I-4-15-II 9,420,000 11,304,000 13,188,000
(SEDANG)

304 I-4-18-I 5,954,900 7,145,900 8,336,800
JANTUNG (RINGAN)
305 I-4-18-II 9,066,600 10,879,900 12,693,200
JANTUNG (SEDANG)
306 I-4-18-III 12,309,300 14,771,200 17,233,100
JANTUNG (BERAT)

308 I-4-19-II 8,968,700 10,762,400 12,556,200
(SEDANG)
- 608 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 4,910,800 5,893,000 6,875,100
320 I-4-23-II 6,029,100 7,234,900 8,440,700
321 I-4-23-III 11,780,400 14,136,500 16,492,600
322 I-4-24-I 3,190,400 3,828,500 4,466,500
(RINGAN)
323 I-4-24-II 7,346,600 8,815,900 10,285,200
(SEDANG)
324 I-4-24-III 9,288,500 11,146,100 13,003,800
(BERAT)
325 J-1-01-I 101,085,500 121,302,600 141,519,700
326 J-1-01-II 114,397,100 137,276,500 160,155,900
327 J-1-01-III 156,915,300 188,298,400 219,681,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 65,946,100 79,135,300 92,324,500
329 J-1-02-II 83,211,100 99,853,300 116,495,600
330 J-1-02-III 97,345,200 116,814,300 136,283,300
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,856,500 15,427,700 17,999,000
(RINGAN)
332 J-1-10-II 26,015,100 31,218,100 36,421,100
(SEDANG)
333 J-1-10-III 27,036,100 32,443,300 37,850,600
(BERAT)
334 J-1-20-I 35,417,200 42,500,700 49,584,100
(RINGAN)
335 J-1-20-II 37,086,600 44,503,900 51,921,200
(SEDANG)
336 J-1-20-III 41,736,100 50,083,400 58,430,600
(BERAT)
337 J-1-30-I 10,729,000 12,874,900 15,020,700
(RINGAN)
338 J-1-30-II 19,435,500 23,322,600 27,209,800
(SEDANG)

- 609 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 3,118,900 3,742,700 4,366,500
374 J-4-21-II 6,964,500 8,357,400 9,750,200
375 J-4-21-III 13,119,800 15,743,800 18,367,700
376 K-1-10-I 11,655,200 13,986,200 16,317,200
BESAR (RINGAN)
377 K-1-10-II 14,647,200 17,576,600 20,506,100
BESAR (SEDANG)
378 K-1-10-III 17,167,000 20,600,400 24,033,800
BESAR (BERAT)
382 K-1-12-I 4,890,300 5,868,400 6,846,500
FEMORAL (RINGAN)
383 K-1-12-II 6,360,500 7,632,500 8,904,600
FEMORAL (SEDANG)
384 K-1-12-III 12,601,000 15,121,200 17,641,400
FEMORAL (BERAT)
388 K-1-14-I 8,055,300 9,666,400 11,277,500
(RINGAN)
389 K-1-14-II 9,440,700 11,328,800 13,217,000
(SEDANG)

394 K-1-30-I 10,249,300 12,299,200 14,349,000
395 K-1-30-II 18,202,500 21,843,100 25,483,600
396 K-1-30-III 25,047,000 30,056,400 35,065,700

398 K-1-40-II 12,608,400 15,130,100 17,651,800
(SEDANG)

- 610 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 5,845,800 7,014,900 8,184,100
413 K-4-13-II 7,561,900 9,074,200 10,586,600
414 K-4-13-III 11,647,700 13,977,200 16,306,800
415 K-4-14-I 3,335,600 4,002,700 4,669,900
(RINGAN)
416 K-4-14-II 4,477,500 5,373,000 6,268,500
(SEDANG)
417 K-4-14-III 7,184,600 8,621,500 10,058,500
(BERAT)

424 K-4-17-I 2,112,100 2,534,500 2,956,900
(RINGAN)
425 K-4-17-II 2,601,000 3,121,200 3,641,400
(SEDANG)
426 K-4-17-III 3,121,200 3,745,500 4,369,700
(BERAT)
427 K-4-18-I 1,861,200 2,233,500 2,605,700
(RINGAN)
428 K-4-18-II 3,140,800 3,769,000 4,397,200
(SEDANG)
436 L-1-40-I 7,306,200 8,767,400 10,228,700
(RINGAN)
437 L-1-40-II 14,654,600 17,585,500 20,516,500
(SEDANG)
438 L-1-40-III 24,667,000 29,600,400 34,533,800
(BERAT)
451 L-4-13-I 2,656,700 3,188,000 3,719,400
PAYUDARA (RINGAN)
- 611 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 4,327,900 5,193,500 6,059,100
PAYUDARA (SEDANG)
453 L-4-13-III 8,597,600 10,317,100 12,036,600
PAYUDARA (BERAT)
454 L-4-14-I 4,320,500 5,184,600 6,048,700
(RINGAN)
455 L-4-14-II 6,489,500 7,787,400 9,085,400
(SEDANG)
456 L-4-14-III 9,147,800 10,977,300 12,806,900
(BERAT)
457 M-1-01-I 15,272,500 18,327,000 21,381,600
458 M-1-01-II 21,707,800 26,049,300 30,390,900
459 M-1-01-III 30,492,900 36,591,500 42,690,100
463 M-1-03-I 54,109,300 64,931,200 75,753,000
464 M-1-03-II 63,288,700 75,946,500 88,604,200
465 M-1-03-III 78,330,400 93,996,400 109,662,500
472 M-1-07-I 19,694,900 23,633,900 27,572,900
473 M-1-07-II 26,384,400 31,661,200 36,938,100
474 M-1-07-III 53,747,400 64,496,900 75,246,400
475 M-1-10-I 23,274,100 27,929,000 32,583,800
WAJAH (RINGAN)
476 M-1-10-II 55,647,500 66,777,000 77,906,500
WAJAH (SEDANG)
477 M-1-10-III 120,026,400 144,031,700 168,037,000
WAJAH (BERAT)
478 M-1-20-I 18,136,200 21,763,500 25,390,700
(RINGAN)
479 M-1-20-II 23,170,900 27,805,000 32,439,200
(SEDANG)

484 M-1-40-I 7,600,100 9,120,100 10,640,100
INTERNAL (RINGAN)
485 M-1-40-II 11,232,000 13,478,400 15,724,800
INTERNAL (SEDANG)
486 M-1-40-III 16,037,200 19,244,600 22,452,000
INTERNAL (BERAT)
490 M-1-60-I 11,721,500 14,065,900 16,410,200
491 M-1-60-II 14,736,700 17,684,000 20,631,400
492 M-1-60-III 22,261,500 26,713,900 31,166,200
- 612 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 21,716,300 26,059,500 30,402,800
KAKI (RINGAN)
494 M-1-70-II 23,887,900 28,665,500 33,443,100
KAKI (SEDANG)
495 M-1-70-III 27,348,500 32,818,200 38,287,900
KAKI (BERAT)
502 M-4-11-I 5,418,800 6,502,500 7,586,300
(RINGAN)
503 M-4-11-II 11,880,400 14,256,500 16,632,600
(SEDANG)
504 M-4-11-III 17,177,100 20,612,500 24,047,900
(BERAT)
505 M-4-12-I 4,325,400 5,190,500 6,055,600
(RINGAN)
506 M-4-12-II 7,194,300 8,633,200 10,072,100
(SEDANG)
507 M-4-12-III 9,623,200 11,547,800 13,472,400
(BERAT)
508 M-4-13-I 7,202,200 8,642,700 10,083,100
509 M-4-13-II 10,821,000 12,985,300 15,149,500
510 M-4-13-III 21,111,600 25,333,900 29,556,300
520 M-4-17-I 4,870,900 5,845,000 6,819,200
(RINGAN)
521 M-4-17-II 6,812,500 8,174,900 9,537,400
(SEDANG)
522 M-4-17-III 9,513,100 11,415,800 13,318,400
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,872,800 4,647,400 5,422,000
(RINGAN)
530 M-4-20-II 5,671,100 6,805,300 7,939,600
(SEDANG)
531 M-4-20-III 6,338,200 7,605,800 8,873,400
(BERAT)
532 M-4-21-I 3,899,600 4,679,600 5,459,500
533 M-4-21-II 4,877,300 5,852,800 6,828,300
- 613 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 10,934,900 13,121,900 15,308,800
541 N-1-12-I 6,370,000 7,644,000 8,917,900
542 N-1-12-II 12,681,900 15,218,300 17,754,700
543 N-1-12-III 27,520,200 33,024,200 38,528,300
547 N-1-30-I 12,745,800 15,294,900 17,844,100
BAWAH (RINGAN)
548 N-1-30-II 19,281,900 23,138,200 26,994,600
BAWAH (SEDANG)
549 N-1-30-III 22,191,600 26,629,900 31,068,200
BAWAH (BERAT)
550 N-1-40-I 11,446,600 13,736,000 16,025,300
(RINGAN)
551 N-1-40-II 15,544,200 18,653,100 21,761,900
(SEDANG)
552 N-1-40-III 18,091,500 21,709,800 25,328,100
(BERAT)
553 N-4-10-I 4,863,200 5,835,900 6,808,500
(RINGAN)
554 N-4-10-II 5,882,100 7,058,600 8,235,000
(SEDANG)
555 N-4-10-III 8,651,800 10,382,100 12,112,500
(BERAT)
568 N-4-15-I 4,429,500 5,315,400 6,201,300
URIN (RINGAN)
569 N-4-15-II 5,496,200 6,595,500 7,694,700
URIN (SEDANG)
570 N-4-15-III 6,272,100 7,526,600 8,781,000
URIN (BERAT)
571 N-4-16-I 5,423,900 6,508,700 7,593,500
(RINGAN)
572 N-4-16-II 7,741,700 9,290,000 10,838,300
(SEDANG)
573 N-4-16-III 10,304,700 12,365,700 14,426,600
(BERAT)
- 614 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 5,041,800 6,050,200 7,058,500
578 O-6-11-II 5,603,400 6,724,100 7,844,700
579 O-6-11-III 6,970,700 8,364,800 9,759,000
580 O-6-12-I 3,572,000 4,286,400 5,000,900
581 O-6-12-II 4,290,000 5,148,000 6,006,000
582 O-6-12-III 5,390,500 6,468,700 7,546,800
586 P-8-01-I 79,764,200 95,717,000 111,669,900
587 P-8-01-II 98,696,200 118,435,500 138,174,700
588 P-8-01-III 115,841,600 139,009,900 162,178,200
589 P-8-02-I 108,874,300 130,649,200 152,424,100
590 P-8-02-II 124,889,800 149,867,800 174,845,700
591 P-8-02-III 142,695,500 171,234,500 199,773,600
592 P-8-03-I 16,331,000 19,597,200 22,863,500
593 P-8-03-II 21,616,400 25,939,600 30,262,900
594 P-8-03-III 30,393,600 36,472,300 42,551,000
595 P-8-04-I 52,627,500 63,153,000 73,678,500
596 P-8-04-II 68,299,100 81,958,900 95,618,700
597 P-8-04-III 97,923,700 117,508,500 137,093,200
598 P-8-05-I 28,617,100 34,340,500 40,064,000
599 P-8-05-II 44,146,900 52,976,300 61,805,700
600 P-8-05-III 59,761,000 71,713,200 83,665,400
601 P-8-06-I 7,725,700 9,270,900 10,816,000
602 P-8-06-II 21,661,100 25,993,400 30,325,600
603 P-8-06-III 28,695,700 34,434,800 40,174,000
604 P-8-07-I 9,146,100 10,975,300 12,804,500
605 P-8-07-II 25,643,500 30,772,100 35,900,800
606 P-8-07-III 33,971,300 40,765,500 47,559,800
607 P-8-08-I 5,292,000 6,350,400 7,408,800
608 P-8-08-II 7,509,100 9,010,900 10,512,800
609 P-8-08-III 14,608,200 17,529,800 20,451,500
610 P-8-11-I 13,609,200 16,331,000 19,052,900
MAYOR (RINGAN)
611 P-8-11-II 18,013,600 21,616,400 25,219,100
MAYOR (SEDANG)
- 615 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 25,328,000 30,393,600 35,459,200
MAYOR (BERAT)
613 P-8-12-I 12,372,000 14,846,400 17,320,800
MAYOR (RINGAN)
614 P-8-12-II 15,011,400 18,013,600 21,015,900
MAYOR (SEDANG)
615 P-8-12-III 22,024,300 26,429,200 30,834,100
MAYOR (BERAT)
616 P-8-13-I 6,873,300 8,248,000 9,622,700
MAYOR (RINGAN)
617 P-8-13-II 10,722,400 12,866,900 15,011,400
MAYOR (SEDANG)
618 P-8-13-III 16,941,800 20,330,200 23,718,500
MAYOR (BERAT)
619 P-8-14-I 5,202,600 6,243,100 7,283,600
620 P-8-14-II 10,590,400 12,708,500 14,826,500
621 P-8-14-III 41,409,200 49,691,100 57,972,900
622 P-8-15-I 3,902,000 4,682,400 5,462,800
ASPIRASI (RINGAN)
623 P-8-15-II 7,813,900 9,376,700 10,939,500
ASPIRASI (SEDANG)
624 P-8-15-III 9,168,200 11,001,900 12,835,500
ASPIRASI (BERAT)
625 P-8-16-I 3,531,400 4,237,600 4,943,900
626 P-8-16-II 6,786,100 8,143,300 9,500,500
627 P-8-16-III 15,914,500 19,097,400 22,280,300
628 P-8-17-I 4,582,200 5,498,700 6,415,100
(RINGAN)
629 P-8-17-II 8,248,000 9,897,600 11,547,200
(SEDANG)
630 P-8-17-III 14,118,200 16,941,800 19,765,400
(BERAT)
631 S-4-10-I 3,981,600 4,777,900 5,574,200
632 S-4-10-II 4,905,900 5,887,100 6,868,200
633 S-4-10-III 6,715,700 8,058,800 9,401,900
640 S-4-13-I 4,322,800 5,187,300 6,051,900
(RINGAN)
641 S-4-13-II 7,668,900 9,202,700 10,736,500
(SEDANG)
642 S-4-13-III 12,447,600 14,937,200 17,426,700
(BERAT)
643 S-4-14-I 2,187,600 2,625,100 3,062,700
644 S-4-14-II 4,646,700 5,576,000 6,505,400
645 S-4-14-III 8,811,800 10,574,100 12,336,500
KANAK-KANAK (BERAT)
646 S-4-15-I 1,463,100 1,755,700 2,048,300
647 S-4-15-II 2,761,100 3,313,300 3,865,600
648 S-4-15-III 3,576,100 4,291,300 5,006,600
- 616 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 3,651,600 4,381,900 5,112,200
653 S-4-17-II 5,419,400 6,503,300 7,587,100
654 S-4-17-III 6,518,000 7,821,600 9,125,200
655 T-1-10-I 2,443,200 2,931,800 3,420,500
OBAT (RINGAN)
656 T-1-10-II 3,281,500 3,937,800 4,594,200
OBAT (SEDANG)
657 T-1-10-III 5,969,600 7,163,600 8,357,500
OBAT (BERAT)
658 T-4-10-I 1,337,800 1,605,300 1,872,900
659 T-4-10-II 2,549,200 3,059,000 3,568,800
660 T-4-10-III 3,705,300 4,446,400 5,187,400
661 T-4-11-I 1,292,000 1,550,400 1,808,800
662 T-4-11-II 2,033,200 2,439,900 2,846,500
663 T-4-11-III 3,275,000 3,930,000 4,585,000
664 T-4-12-I 3,027,300 3,632,700 4,238,200
LAIN (RINGAN)
665 T-4-12-II 4,569,900 5,483,900 6,397,900
LAIN (SEDANG)
666 T-4-12-III 7,073,600 8,488,300 9,903,000
LAIN (BERAT)
670 U-1-11-I 12,600,100 15,120,100 17,640,100
(RINGAN)
671 U-1-11-II 19,004,900 22,805,900 26,606,900
(SEDANG)
672 U-1-11-III 22,529,100 27,034,900 31,540,700
(BERAT)
679 U-1-14-I 5,803,900 6,964,700 8,125,500
(RINGAN)
680 U-1-14-II 7,122,800 8,547,300 9,971,900
(SEDANG)
681 U-1-14-III 8,440,500 10,128,600 11,816,700
(BERAT)
685 U-1-20-I 8,811,200 10,573,500 12,335,700
686 U-1-20-II 13,113,600 15,736,300 18,359,000
687 U-1-20-III 33,665,000 40,398,000 47,131,000
691 U-4-10-I 5,438,000 6,525,600 7,613,300
- 617 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 12,449,300 14,939,200 17,429,100
693 U-4-10-III 19,113,500 22,936,200 26,759,000
TENGGOROKAN (BERAT)
700 U-4-13-I 2,140,600 2,568,800 2,996,900
701 U-4-13-II 3,498,000 4,197,600 4,897,200
702 U-4-13-III 5,648,100 6,777,700 7,907,300
706 U-4-15-I 4,346,200 5,215,500 6,084,700
707 U-4-15-II 5,414,800 6,497,800 7,580,800
708 U-4-15-III 7,578,100 9,093,800 10,609,400
709 V-1-10-I 7,089,000 8,506,900 9,924,700
(RINGAN)
710 V-1-10-II 14,603,200 17,523,800 20,444,400
(SEDANG)
711 V-1-10-III 17,908,800 21,490,500 25,072,300
(BERAT)
715 V-1-12-I 12,680,000 15,216,000 17,752,000
MODERAT (RINGAN)
716 V-1-12-II 17,315,500 20,778,700 24,241,800
MODERAT (SEDANG)
717 V-1-12-III 21,947,600 26,337,200 30,726,700
MODERAT (BERAT)
718 V-1-13-I 6,614,000 7,936,900 9,259,700
KOMPLEK (RINGAN)
719 V-1-13-II 12,637,300 15,164,700 17,692,200
KOMPLEK (SEDANG)
720 V-1-13-III 19,826,300 23,791,600 27,756,800
KOMPLEK (BERAT)
721 V-1-14-I 12,970,100 15,564,100 18,158,200
(RINGAN)
722 V-1-14-II 18,845,200 22,614,200 26,383,300
(SEDANG)

727 V-4-10-I 5,644,900 6,773,900 7,902,900
(RINGAN)
728 V-4-10-II 9,376,500 11,251,800 13,127,100
(SEDANG)
729 V-4-10-III 15,458,500 18,550,200 21,642,000
(BERAT)
730 V-4-11-I 5,419,500 6,503,400 7,587,300
TUMOR (RINGAN)
731 V-4-11-II 7,271,600 8,725,900 10,180,200
TUMOR (SEDANG)
732 V-4-11-III 9,740,300 11,688,400 13,636,500
TUMOR (BERAT)
- 618 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 14,771,600 17,725,900 20,680,300
734 W-1-01-II 17,704,800 21,245,800 24,786,700
735 W-1-01-III 25,264,300 30,317,100 35,370,000
739 W-1-11-I 3,275,000 3,930,000 4,584,900
SERVIK (RINGAN)
740 W-1-11-II 3,613,900 4,336,700 5,059,500
SERVIK (SEDANG)
741 W-1-11-III 3,997,700 4,797,200 5,596,800
SERVIK (BERAT)
760 W-4-12-I 3,131,000 3,757,200 4,383,400
761 W-4-12-II 5,958,300 7,150,000 8,341,700
762 W-4-12-III 8,768,100 10,521,800 12,275,400
- 619 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 2,213,500 2,656,200 3,098,900
785 Z-4-12-II 4,444,400 5,333,300 6,222,100
786 Z-4-12-III 9,376,500 11,251,800 13,127,100
- 620 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,412,900

33 F-3-10-0 TERAPI SHOCK 683,300
- 621 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 4,153,900
PENGGANTIAN ALAT
81 I-2-42-0 3,991,700
PERKUTAN LAIN
- 622 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,882,400
192 Q-5-12-0 GIGI 342,000
196 Q-5-16-0 VAKSINASI 113,900
201 Q-5-21-0 ABORSI 298,500
206 Q-5-26-0 BRONKIAL AKUT 242,600
- 623 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 163,300
215 Q-5-35-0 INFEKSI AKUT 698,000
218 Q-5-38-0 PARU AKUT 406,700
234 U-2-23-0 RHINOPLASTY 2,009,600
242 U-3-13-0 518,000
TENGGOROKAN
270 Z-3-11-0 2,810,200
EMPEDU
- 624 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,480,700
289 Z-3-30-0 FOTOTERAPI 94,200
- 625 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,262,100 2,714,500 3,167,000
(RINGAN)
14 A-4-14-II 2,745,900 3,295,100 3,844,300
(SEDANG)
15 A-4-14-III 3,295,100 3,954,100 4,613,200
(BERAT)

31 B-1-13-I 5,590,600 6,708,700 7,826,800
LAIN (RINGAN)
32 B-1-13-II 9,198,600 11,038,300 12,878,000
LAIN (SEDANG)
33 B-1-13-III 11,902,200 14,282,600 16,663,000
LAIN (BERAT)
34 B-1-14-I 7,681,700 9,218,000 10,754,300
(RINGAN)
35 B-1-14-II 8,543,400 10,252,000 11,960,700
(SEDANG)
40 B-4-11-I 4,860,700 5,832,800 6,804,900
(RINGAN)
41 B-4-11-II 6,805,000 8,166,000 9,527,000
(SEDANG)
42 B-4-11-III 8,244,100 9,893,000 11,541,800
(BERAT)
- 626 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 5,149,100 6,178,900 7,208,800
74 D-1-20-II 14,190,200 17,028,300 19,866,300
75 D-1-20-III 22,509,800 27,011,800 31,513,800
85 D-4-13-I 2,978,300 3,573,900 4,169,600
86 D-4-13-II 4,215,300 5,058,300 5,901,400
87 D-4-13-III 5,391,500 6,469,700 7,548,000
88 D-4-14-I 3,194,300 3,833,200 4,472,100
89 D-4-14-II 5,229,900 6,275,900 7,321,900
90 D-4-14-III 6,396,700 7,676,100 8,955,400
91 E-1-01-I 7,004,300 8,405,100 9,806,000
(RINGAN)
92 E-1-01-II 9,561,900 11,474,200 13,386,600
(SEDANG)

97 E-1-20-I 7,494,500 8,993,400 10,492,400
TIROGLOSAL (RINGAN)
- 627 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 10,087,400 12,104,900 14,122,400
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,332,500 17,199,100 20,065,600
TIROGLOSAL (BERAT)
100 E-4-10-I 3,492,500 4,191,000 4,889,500
METABOLIK (RINGAN)
101 E-4-10-II 4,880,200 5,856,200 6,832,300
METABOLIK (SEDANG)
102 E-4-10-III 6,244,600 7,493,500 8,742,500
METABOLIK (BERAT)
109 E-4-13-I 3,686,300 4,423,600 5,160,900
(RINGAN)
110 E-4-13-II 5,399,900 6,479,800 7,559,800
(SEDANG)

118 F-4-12-I 2,080,700 2,496,800 2,912,900
(RINGAN)
119 F-4-12-II 2,958,000 3,549,700 4,141,300
(SEDANG)
120 F-4-12-III 6,426,200 7,711,400 8,996,700
(BERAT)
130 F-4-16-I 5,635,300 6,762,300 7,889,400
131 F-4-16-II 6,551,900 7,862,300 9,172,700
132 F-4-16-III 8,745,700 10,494,800 12,244,000
142 G-1-01-I 16,938,300 20,325,900 23,713,600
(RINGAN)
- 628 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 24,293,600 29,152,300 34,011,000
(SEDANG)
144 G-1-01-III 36,878,000 44,253,600 51,629,200
(BERAT)
151 G-1-12-I 4,920,400 5,904,500 6,888,600
(RINGAN)
152 G-1-12-II 9,508,800 11,410,600 13,312,300
(SEDANG)
153 G-1-12-III 12,958,600 15,550,400 18,142,100
(BERAT)
163 G-4-10-I 4,223,600 5,068,400 5,913,100
(RINGAN)
164 G-4-10-II 5,162,700 6,195,300 7,227,800
(SEDANG)
165 G-4-10-III 7,303,200 8,763,900 10,224,500
(BERAT)
166 G-4-11-I 4,558,200 5,469,900 6,381,500
167 G-4-11-II 6,055,000 7,266,100 8,477,100
168 G-4-11-III 8,896,900 10,676,300 12,455,700
DEGENERATIF (BERAT)
169 G-4-12-I 5,056,800 6,068,200 7,079,600
(RINGAN)
170 G-4-12-II 6,195,500 7,434,600 8,673,700
(SEDANG)

172 G-4-13-I 2,946,600 3,535,900 4,125,200
(RINGAN)
173 G-4-13-II 5,138,300 6,165,900 7,193,600
(SEDANG)
174 G-4-13-III 6,094,100 7,312,900 8,531,700
(BERAT)
175 G-4-14-I 4,998,500 5,998,200 6,997,900
INFARK (RINGAN)
176 G-4-14-II 6,889,300 8,267,200 9,645,100
INFARK (SEDANG)
177 G-4-14-III 8,646,900 10,376,300 12,105,700
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 629 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 4,484,500 5,381,400 6,278,300
(RINGAN)
185 G-4-17-II 5,880,100 7,056,200 8,232,200
(SEDANG)
186 G-4-17-III 7,617,200 9,140,600 10,664,100
(BERAT)
190 G-4-19-I 3,684,800 4,421,800 5,158,700
191 G-4-19-II 6,228,200 7,473,800 8,719,500
192 G-4-19-III 8,177,300 9,812,800 11,448,300
211 G-4-26-I 3,576,900 4,292,200 5,007,600
LAIN (RINGAN)
212 G-4-26-II 4,289,700 5,147,600 6,005,600
LAIN (SEDANG)
213 G-4-26-III 6,222,000 7,466,400 8,710,700
LAIN (BERAT)
232 I-1-02-I 25,816,000 30,979,200 36,142,400
(RINGAN)
- 630 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 33,302,300 39,962,800 46,623,200
(SEDANG)
234 I-1-02-III 41,047,200 49,256,600 57,466,100
(BERAT)
235 I-1-03-I 14,911,400 17,893,700 20,875,900
ANOMALI (RINGAN)
236 I-1-03-II 20,670,300 24,804,300 28,938,400
ANOMALI (SEDANG)
237 I-1-03-III 27,043,500 32,452,200 37,860,900
ANOMALI (BERAT)
238 I-1-04-I 23,165,600 27,798,700 32,431,900
JANTUNG (RINGAN)
239 I-1-04-II 36,561,600 43,873,900 51,186,300
JANTUNG (SEDANG)
240 I-1-04-III 58,406,900 70,088,300 81,769,700
JANTUNG (BERAT)
241 I-1-05-I 54,476,400 65,371,600 76,266,900
242 I-1-05-II 66,582,200 79,898,700 93,215,100
243 I-1-05-III 90,794,000 108,952,700 127,111,500
247 I-1-07-I 48,423,400 58,108,100 67,792,800
JANTUNG (RINGAN)
248 I-1-07-II 60,529,300 72,635,200 84,741,000
JANTUNG (SEDANG)
249 I-1-07-III 90,794,000 108,952,700 127,111,500
JANTUNG (BERAT)
250 I-1-11-I 4,170,600 5,004,700 5,838,800
251 I-1-11-II 4,637,300 5,564,700 6,492,200
252 I-1-11-III 6,170,800 7,404,900 8,639,100
253 I-1-12-I 12,004,900 14,405,900 16,806,800
(RINGAN)
254 I-1-12-II 19,018,200 22,821,800 26,625,500
(SEDANG)
255 I-1-12-III 25,021,300 30,025,600 35,029,800
(BERAT)
256 I-1-13-I 11,644,600 13,973,500 16,302,400
KOMPLEK (RINGAN)
257 I-1-13-II 15,507,100 18,608,600 21,710,000
KOMPLEK (SEDANG)
258 I-1-13-III 19,124,600 22,949,500 26,774,400
KOMPLEK (BERAT)
259 I-1-14-I 23,833,600 28,600,300 33,367,000
(RINGAN)
260 I-1-14-II 29,621,600 35,546,000 41,470,300
(SEDANG)
261 I-1-14-III 38,814,600 46,577,500 54,340,400
(BERAT)
265 I-1-16-I 11,385,300 13,662,400 15,939,400
266 I-1-16-II 26,557,100 31,868,500 37,179,900
267 I-1-16-III 30,633,200 36,759,800 42,886,400
268 I-1-17-I 13,590,800 16,309,000 19,027,200
(RINGAN)
269 I-1-17-II 17,017,000 20,420,400 23,823,800
(SEDANG)
- 631 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 21,049,800 25,259,700 29,469,700
(BERAT)
271 I-1-20-I 15,319,200 18,383,000 21,446,900
(RINGAN)
272 I-1-20-II 19,137,900 22,965,500 26,793,000
(SEDANG)
273 I-1-20-III 20,117,900 24,141,400 28,165,000
(BERAT)
274 I-1-30-I 11,588,100 13,905,700 16,223,400
JANTUNG (RINGAN)
275 I-1-30-II 24,105,800 28,927,000 33,748,200
JANTUNG (SEDANG)
276 I-1-30-III 37,355,400 44,826,400 52,297,500
JANTUNG (BERAT)

289 I-4-13-I 3,628,100 4,353,700 5,079,300
(RINGAN)
290 I-4-13-II 6,478,400 7,774,100 9,069,800
(SEDANG)
291 I-4-13-III 9,334,500 11,201,400 13,068,300
(BERAT)
295 I-4-15-I 4,469,300 5,363,100 6,257,000
(RINGAN)
296 I-4-15-II 6,080,200 7,296,200 8,512,200
(SEDANG)

304 I-4-18-I 4,045,900 4,855,000 5,664,200
JANTUNG (RINGAN)
305 I-4-18-II 6,350,500 7,620,600 8,890,700
JANTUNG (SEDANG)
306 I-4-18-III 8,363,200 10,035,900 11,708,500
JANTUNG (BERAT)

308 I-4-19-II 6,093,500 7,312,200 8,530,900
(SEDANG)
- 632 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 3,336,500 4,003,800 4,671,100
320 I-4-23-II 4,096,300 4,915,500 5,734,800
321 I-4-23-III 8,003,900 9,604,600 11,205,400
322 I-4-24-I 2,787,700 3,345,200 3,902,800
(RINGAN)
323 I-4-24-II 6,419,400 7,703,200 8,987,100
(SEDANG)
324 I-4-24-III 8,116,100 9,739,400 11,362,600
(BERAT)
325 J-1-01-I 54,204,400 65,045,200 75,886,100
326 J-1-01-II 61,342,300 73,610,800 85,879,200
327 J-1-01-III 69,397,400 83,276,900 97,156,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 28,764,300 34,517,100 40,270,000
329 J-1-02-II 40,051,300 48,061,500 56,071,800
330 J-1-02-III 66,138,400 79,366,100 92,593,700
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,734,900 10,481,900 12,228,900
(RINGAN)
332 J-1-10-II 17,675,200 21,210,300 24,745,300
(SEDANG)
333 J-1-10-III 18,937,000 22,724,400 26,511,800
(BERAT)
334 J-1-20-I 14,936,900 17,924,200 20,911,600
(RINGAN)
335 J-1-20-II 18,813,400 22,576,100 26,338,800
(SEDANG)
336 J-1-20-III 29,050,900 34,861,100 40,671,300
(BERAT)
337 J-1-30-I 7,289,500 8,747,400 10,205,400
(RINGAN)
338 J-1-30-II 13,204,900 15,845,900 18,486,900
(SEDANG)

- 633 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,790,400 3,348,400 3,906,500
374 J-4-21-II 4,495,200 5,394,300 6,293,300
375 J-4-21-III 6,272,700 7,527,300 8,781,800
376 K-1-10-I 7,918,800 9,502,500 11,086,300
BESAR (RINGAN)
377 K-1-10-II 10,259,400 12,311,300 14,363,200
BESAR (SEDANG)
378 K-1-10-III 12,024,400 14,429,200 16,834,100
BESAR (BERAT)
382 K-1-12-I 3,425,400 4,110,400 4,795,500
FEMORAL (RINGAN)
383 K-1-12-II 4,455,100 5,346,100 6,237,100
FEMORAL (SEDANG)
384 K-1-12-III 8,826,200 10,591,400 12,356,700
FEMORAL (BERAT)
388 K-1-14-I 5,473,000 6,567,600 7,662,200
(RINGAN)
389 K-1-14-II 6,414,200 7,697,000 8,979,900
(SEDANG)

394 K-1-30-I 7,179,000 8,614,800 10,050,600
395 K-1-30-II 12,367,200 14,840,600 17,314,100
396 K-1-30-III 17,543,700 21,052,500 24,561,200

398 K-1-40-II 8,831,400 10,597,700 12,363,900
(SEDANG)

- 634 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 3,971,700 4,766,100 5,560,400
413 K-4-13-II 5,137,700 6,165,200 7,192,800
414 K-4-13-III 7,913,700 9,496,400 11,079,200
415 K-4-14-I 2,596,000 3,115,200 3,634,400
(RINGAN)
416 K-4-14-II 3,484,700 4,181,600 4,878,500
(SEDANG)
417 K-4-14-III 5,591,500 6,709,800 7,828,100
(BERAT)

424 K-4-17-I 1,713,000 2,055,500 2,398,100
(RINGAN)
425 K-4-17-II 2,109,500 2,531,400 2,953,300
(SEDANG)
426 K-4-17-III 2,531,400 3,037,600 3,543,900
(BERAT)
427 K-4-18-I 1,448,600 1,738,300 2,028,000
(RINGAN)
428 K-4-18-II 2,444,400 2,933,300 3,422,200
(SEDANG)
436 L-1-40-I 4,964,000 5,956,800 6,949,600
(RINGAN)
437 L-1-40-II 9,956,700 11,948,000 13,939,300
(SEDANG)
438 L-1-40-III 16,759,300 20,111,100 23,463,000
(BERAT)
451 L-4-13-I 2,376,800 2,852,200 3,327,600
PAYUDARA (RINGAN)
- 635 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,793,500 3,352,100 3,910,800
PAYUDARA (SEDANG)
453 L-4-13-III 4,110,600 4,932,700 5,754,800
PAYUDARA (BERAT)
454 L-4-14-I 2,935,400 3,522,500 4,109,600
(RINGAN)
455 L-4-14-II 4,409,100 5,291,000 6,172,800
(SEDANG)
456 L-4-14-III 6,215,200 7,458,200 8,701,300
(BERAT)
457 M-1-01-I 10,376,500 12,451,800 14,527,100
458 M-1-01-II 14,748,700 17,698,500 20,648,200
459 M-1-01-III 20,717,500 24,861,000 29,004,600
463 M-1-03-I 23,211,700 27,854,100 32,496,400
464 M-1-03-II 27,149,500 32,579,400 38,009,300
465 M-1-03-III 33,602,000 40,322,400 47,042,800
472 M-1-07-I 8,195,200 9,834,300 11,473,300
473 M-1-07-II 10,978,800 13,174,500 15,370,300
474 M-1-07-III 22,364,800 26,837,700 31,310,700
475 M-1-10-I 18,928,700 22,714,500 26,500,200
WAJAH (RINGAN)
476 M-1-10-II 45,257,900 54,309,500 63,361,100
WAJAH (SEDANG)
477 M-1-10-III 97,617,200 117,140,600 136,664,000
WAJAH (BERAT)
478 M-1-20-I 12,322,100 14,786,500 17,251,000
(RINGAN)
479 M-1-20-II 16,229,700 19,475,600 22,721,500
(SEDANG)

484 M-1-40-I 4,303,100 5,163,700 6,024,300
INTERNAL (RINGAN)
485 M-1-40-II 7,631,300 9,157,500 10,683,800
INTERNAL (SEDANG)
486 M-1-40-III 10,896,000 13,075,200 15,254,400
INTERNAL (BERAT)
490 M-1-60-I 7,963,900 9,556,600 11,149,400
491 M-1-60-II 10,012,400 12,014,900 14,017,400
492 M-1-60-III 15,592,700 18,711,300 21,829,800
- 636 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 15,210,800 18,253,000 21,295,200
KAKI (RINGAN)
494 M-1-70-II 16,731,900 20,078,300 23,424,700
KAKI (SEDANG)
495 M-1-70-III 19,155,800 22,987,000 26,818,100
KAKI (BERAT)
502 M-4-11-I 3,681,600 4,418,000 5,154,300
(RINGAN)
503 M-4-11-II 8,071,800 9,686,200 11,300,600
(SEDANG)
504 M-4-11-III 12,031,400 14,437,700 16,844,000
(BERAT)
505 M-4-12-I 2,938,800 3,526,500 4,114,300
(RINGAN)
506 M-4-12-II 4,888,000 5,865,600 6,843,200
(SEDANG)
507 M-4-12-III 6,740,400 8,088,500 9,436,600
(BERAT)
508 M-4-13-I 4,893,300 5,872,000 6,850,700
509 M-4-13-II 7,352,000 8,822,500 10,292,900
510 M-4-13-III 14,343,700 17,212,400 20,081,100
520 M-4-17-I 3,677,100 4,412,500 5,147,900
(RINGAN)
521 M-4-17-II 5,142,800 6,171,400 7,199,900
(SEDANG)
522 M-4-17-III 7,181,600 8,617,900 10,054,200
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,923,700 3,508,400 4,093,100
(RINGAN)
530 M-4-20-II 4,281,200 5,137,400 5,993,700
(SEDANG)
531 M-4-20-III 4,784,700 5,741,700 6,698,600
(BERAT)
532 M-4-21-I 2,943,900 3,532,700 4,121,400
533 M-4-21-II 3,682,000 4,418,300 5,154,700
- 637 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 8,254,900 9,905,900 11,556,800
541 N-1-12-I 4,327,900 5,193,500 6,059,000
542 N-1-12-II 8,882,800 10,659,400 12,436,000
543 N-1-12-III 19,276,100 23,131,300 26,986,500
547 N-1-30-I 8,659,800 10,391,700 12,123,700
BAWAH (RINGAN)
548 N-1-30-II 13,100,500 15,720,600 18,340,700
BAWAH (SEDANG)
549 N-1-30-III 15,077,400 18,092,900 21,108,400
BAWAH (BERAT)
550 N-1-40-I 8,017,600 9,621,100 11,224,700
(RINGAN)
551 N-1-40-II 10,887,700 13,065,300 15,242,800
(SEDANG)
552 N-1-40-III 12,671,900 15,206,300 17,740,600
(BERAT)
553 N-4-10-I 3,304,200 3,965,000 4,625,800
(RINGAN)
554 N-4-10-II 4,120,100 4,944,100 5,768,100
(SEDANG)
555 N-4-10-III 6,060,000 7,272,000 8,484,000
(BERAT)
568 N-4-15-I 3,009,500 3,611,400 4,213,300
URIN (RINGAN)
569 N-4-15-II 3,849,800 4,619,700 5,389,700
URIN (SEDANG)
570 N-4-15-III 4,393,200 5,271,900 6,150,500
URIN (BERAT)
571 N-4-16-I 3,685,100 4,422,200 5,159,200
(RINGAN)
572 N-4-16-II 5,259,900 6,311,800 7,363,800
(SEDANG)
573 N-4-16-III 7,217,800 8,661,300 10,104,900
(BERAT)
- 638 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 3,425,500 4,110,600 4,795,700
578 O-6-11-II 3,807,100 4,568,500 5,329,900
579 O-6-11-III 4,882,500 5,859,000 6,835,500
580 O-6-12-I 2,502,000 3,002,400 3,502,800
581 O-6-12-II 3,004,900 3,605,800 4,206,800
582 O-6-12-III 3,775,700 4,530,900 5,286,000
586 P-8-01-I 54,193,500 65,032,200 75,870,900
587 P-8-01-II 67,056,300 80,467,500 93,878,800
588 P-8-01-III 78,705,200 94,446,300 110,187,300
589 P-8-02-I 84,674,500 101,609,400 118,544,300
590 P-8-02-II 97,130,300 116,556,400 135,982,400
591 P-8-02-III 110,978,400 133,174,100 155,369,700
592 P-8-03-I 12,250,200 14,700,300 17,150,300
593 P-8-03-II 17,297,700 20,757,200 24,216,800
594 P-8-03-III 24,211,600 29,053,900 33,896,200
595 P-8-04-I 35,333,000 42,399,700 49,466,300
596 P-8-04-II 45,676,200 54,811,400 63,946,600
597 P-8-04-III 65,488,200 78,585,800 91,683,400
598 P-8-05-I 19,186,000 23,023,200 26,860,400
599 P-8-05-II 29,994,300 35,993,200 41,992,100
600 P-8-05-III 39,917,800 47,901,400 55,884,900
601 P-8-06-I 5,249,000 6,298,800 7,348,600
602 P-8-06-II 14,717,000 17,660,400 20,603,800
603 P-8-06-III 19,496,400 23,395,700 27,295,000
604 P-8-07-I 5,084,200 6,101,000 7,117,900
605 P-8-07-II 14,254,900 17,105,900 19,956,900
606 P-8-07-III 18,884,300 22,661,100 26,438,000
607 P-8-08-I 4,209,700 5,051,600 5,893,500
608 P-8-08-II 5,973,300 7,167,900 8,362,600
609 P-8-08-III 9,672,000 11,606,500 13,540,900
610 P-8-11-I 10,208,500 12,250,200 14,291,900
MAYOR (RINGAN)
611 P-8-11-II 14,414,800 17,297,700 20,180,700
MAYOR (SEDANG)
- 639 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 20,176,300 24,211,600 28,246,800
MAYOR (BERAT)
613 P-8-12-I 9,644,300 11,573,200 13,502,100
MAYOR (RINGAN)
614 P-8-12-II 11,088,300 13,305,900 15,523,600
MAYOR (SEDANG)
615 P-8-12-III 15,520,200 18,624,300 21,728,300
MAYOR (BERAT)
616 P-8-13-I 5,467,600 6,561,100 7,654,600
MAYOR (RINGAN)
617 P-8-13-II 8,529,400 10,235,300 11,941,200
MAYOR (SEDANG)
618 P-8-13-III 13,250,800 15,900,900 18,551,100
MAYOR (BERAT)
619 P-8-14-I 3,644,100 4,372,900 5,101,700
620 P-8-14-II 7,417,900 8,901,400 10,385,000
621 P-8-14-III 13,350,100 16,020,100 18,690,100
622 P-8-15-I 2,733,100 3,279,700 3,826,300
ASPIRASI (RINGAN)
623 P-8-15-II 5,473,100 6,567,800 7,662,400
ASPIRASI (SEDANG)
624 P-8-15-III 6,421,700 7,706,100 8,990,400
ASPIRASI (BERAT)
625 P-8-16-I 2,473,500 2,968,200 3,462,900
626 P-8-16-II 4,753,200 5,703,800 6,654,500
627 P-8-16-III 11,631,700 13,958,000 16,284,400
628 P-8-17-I 3,645,100 4,374,100 5,103,100
(RINGAN)
629 P-8-17-II 6,561,100 7,873,300 9,185,500
(SEDANG)
630 P-8-17-III 9,232,600 11,079,200 12,925,700
(BERAT)
631 S-4-10-I 2,705,200 3,246,200 3,787,200
632 S-4-10-II 3,333,200 3,999,800 4,666,400
633 S-4-10-III 4,562,800 5,475,300 6,387,900
640 S-4-13-I 2,937,000 3,524,400 4,111,800
(RINGAN)
641 S-4-13-II 5,210,400 6,252,500 7,294,600
(SEDANG)
642 S-4-13-III 8,457,200 10,148,600 11,840,100
(BERAT)
643 S-4-14-I 1,486,300 1,783,600 2,080,800
644 S-4-14-II 3,157,100 3,788,500 4,419,900
645 S-4-14-III 5,986,900 7,184,300 8,381,600
KANAK-KANAK (BERAT)
646 S-4-15-I 994,100 1,192,900 1,391,700
647 S-4-15-II 1,876,000 2,251,200 2,626,300
648 S-4-15-III 2,429,700 2,915,600 3,401,600
- 640 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 2,481,000 2,977,200 3,473,400
653 S-4-17-II 3,682,000 4,418,400 5,154,900
654 S-4-17-III 4,428,500 5,314,200 6,199,900
655 T-1-10-I 1,711,300 2,053,600 2,395,800
OBAT (RINGAN)
656 T-1-10-II 2,298,500 2,758,200 3,217,900
OBAT (SEDANG)
657 T-1-10-III 4,181,300 5,017,600 5,853,900
OBAT (BERAT)
658 T-4-10-I 742,300 890,800 1,039,200
659 T-4-10-II 1,414,700 1,697,700 1,980,600
660 T-4-10-III 2,056,700 2,468,000 2,879,300
661 T-4-11-I 1,013,100 1,215,800 1,418,400
662 T-4-11-II 1,594,300 1,913,200 2,232,100
663 T-4-11-III 2,568,000 3,081,600 3,595,200
664 T-4-12-I 1,669,100 2,002,900 2,336,700
LAIN (RINGAN)
665 T-4-12-II 2,487,000 2,984,400 3,481,800
LAIN (SEDANG)
666 T-4-12-III 3,815,700 4,578,800 5,342,000
LAIN (BERAT)
670 U-1-11-I 8,392,100 10,070,500 11,748,900
(RINGAN)
671 U-1-11-II 10,638,200 12,765,900 14,893,500
(SEDANG)
672 U-1-11-III 15,780,100 18,936,100 22,092,200
(BERAT)
679 U-1-14-I 4,065,200 4,878,300 5,691,300
(RINGAN)
680 U-1-14-II 4,989,000 5,986,900 6,984,700
(SEDANG)
681 U-1-14-III 5,912,000 7,094,400 8,276,800
(BERAT)
685 U-1-20-I 6,171,700 7,406,000 8,640,400
686 U-1-20-II 9,185,200 11,022,200 12,859,300
687 U-1-20-III 22,872,700 27,447,300 32,021,800
691 U-4-10-I 3,809,000 4,570,800 5,332,600
- 641 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 8,458,300 10,150,000 11,841,700
693 U-4-10-III 12,986,100 15,583,400 18,180,600
TENGGOROKAN (BERAT)
700 U-4-13-I 1,974,400 2,369,300 2,764,100
701 U-4-13-II 2,327,600 2,793,100 3,258,600
702 U-4-13-III 2,783,900 3,340,700 3,897,500
706 U-4-15-I 2,952,900 3,543,500 4,134,100
707 U-4-15-II 3,678,900 4,414,700 5,150,500
708 U-4-15-III 5,148,700 6,178,500 7,208,200
709 V-1-10-I 4,965,400 5,958,500 6,951,600
(RINGAN)
710 V-1-10-II 9,921,700 11,906,000 13,890,400
(SEDANG)
711 V-1-10-III 12,167,600 14,601,100 17,034,600
(BERAT)
715 V-1-12-I 8,615,000 10,338,100 12,061,100
MODERAT (RINGAN)
716 V-1-12-II 12,128,400 14,554,100 16,979,800
MODERAT (SEDANG)
717 V-1-12-III 14,911,700 17,894,000 20,876,400
MODERAT (BERAT)
718 V-1-13-I 4,632,700 5,559,200 6,485,800
KOMPLEK (RINGAN)
719 V-1-13-II 8,851,600 10,621,900 12,392,200
KOMPLEK (SEDANG)
720 V-1-13-III 13,470,400 16,164,500 18,858,600
KOMPLEK (BERAT)
721 V-1-14-I 8,812,200 10,574,600 12,337,000
(RINGAN)
722 V-1-14-II 12,803,800 15,364,600 17,925,300
(SEDANG)

727 V-4-10-I 4,393,200 5,271,800 6,150,500
(RINGAN)
728 V-4-10-II 7,297,300 8,756,800 10,216,300
(SEDANG)
729 V-4-10-III 12,030,800 14,436,900 16,843,100
(BERAT)
730 V-4-11-I 3,682,100 4,418,500 5,155,000
TUMOR (RINGAN)
731 V-4-11-II 4,940,500 5,928,500 6,916,600
TUMOR (SEDANG)
732 V-4-11-III 6,822,500 8,187,000 9,551,400
TUMOR (BERAT)
- 642 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 10,346,500 12,415,900 14,485,200
734 W-1-01-II 12,029,000 14,434,800 16,840,600
735 W-1-01-III 17,696,000 21,235,100 24,774,300
739 W-1-11-I 2,293,900 2,752,700 3,211,500
SERVIK (RINGAN)
740 W-1-11-II 2,531,300 3,037,600 3,543,800
SERVIK (SEDANG)
741 W-1-11-III 2,800,100 3,360,100 3,920,200
SERVIK (BERAT)
760 W-4-12-I 2,801,200 3,361,400 3,921,600
761 W-4-12-II 3,845,800 4,615,000 5,384,100
762 W-4-12-III 4,192,100 5,030,600 5,869,000
- 643 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 1,871,200 2,245,400 2,619,700
785 Z-4-12-II 3,926,500 4,711,800 5,497,100
786 Z-4-12-III 6,044,300 7,253,200 8,462,000
- 644 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,513,300

33 F-3-10-0 TERAPI SHOCK 428,600
- 645 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,605,300
PENGGANTIAN ALAT
81 I-2-42-0 2,503,500
PERKUTAN LAIN
- 646 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,242,800
192 Q-5-12-0 GIGI 214,500
196 Q-5-16-0 VAKSINASI 100,300
201 Q-5-21-0 ABORSI 187,200
206 Q-5-26-0 BRONKIAL AKUT 213,700
- 647 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 143,900
215 Q-5-35-0 INFEKSI AKUT 437,800
218 Q-5-38-0 PARU AKUT 255,100
234 U-2-23-0 RHINOPLASTY 1,260,400
242 U-3-13-0 324,900
TENGGOROKAN
270 Z-3-11-0 1,762,500
EMPEDU
- 648 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 977,600
289 Z-3-30-0 FOTOTERAPI 82,900
- 649 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,330,000 2,796,000 3,262,000
(RINGAN)
14 A-4-14-II 2,828,300 3,394,000 3,959,600
(SEDANG)
15 A-4-14-III 3,394,000 4,072,800 4,751,500
(BERAT)

31 B-1-13-I 5,758,300 6,909,900 8,061,600
LAIN (RINGAN)
32 B-1-13-II 9,474,500 11,369,500 13,264,400
LAIN (SEDANG)
33 B-1-13-III 12,259,200 14,711,100 17,162,900
LAIN (BERAT)
34 B-1-14-I 7,912,100 9,494,500 11,077,000
(RINGAN)
35 B-1-14-II 8,799,700 10,559,600 12,319,500
(SEDANG)
40 B-4-11-I 5,006,500 6,007,800 7,009,100
(RINGAN)
41 B-4-11-II 7,009,100 8,411,000 9,812,800
(SEDANG)
42 B-4-11-III 8,491,500 10,189,800 11,888,100
(BERAT)
- 650 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 5,303,600 6,364,300 7,425,000
74 D-1-20-II 14,615,900 17,539,100 20,462,300
75 D-1-20-III 23,185,100 27,822,200 32,459,200
85 D-4-13-I 3,067,600 3,681,100 4,294,700
86 D-4-13-II 4,341,700 5,210,100 6,078,400
87 D-4-13-III 5,553,200 6,663,800 7,774,500
88 D-4-14-I 3,290,200 3,948,200 4,606,200
89 D-4-14-II 5,386,800 6,464,200 7,541,500
90 D-4-14-III 6,588,600 7,906,400 9,224,100
91 E-1-01-I 7,214,400 8,657,300 10,100,200
(RINGAN)
92 E-1-01-II 9,848,700 11,818,500 13,788,200
(SEDANG)

97 E-1-20-I 7,719,400 9,263,200 10,807,100
TIROGLOSAL (RINGAN)
- 651 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 10,390,100 12,468,100 14,546,100
TIROGLOSAL (SEDANG)
99 E-1-20-III 14,762,500 17,715,000 20,667,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,597,300 4,316,800 5,036,200
METABOLIK (RINGAN)
101 E-4-10-II 5,026,600 6,031,900 7,037,200
METABOLIK (SEDANG)
102 E-4-10-III 6,432,000 7,718,300 9,004,700
METABOLIK (BERAT)
109 E-4-13-I 3,796,900 4,556,300 5,315,700
(RINGAN)
110 E-4-13-II 5,561,800 6,674,200 7,786,600
(SEDANG)

118 F-4-12-I 2,143,100 2,571,700 3,000,300
(RINGAN)
119 F-4-12-II 3,046,800 3,656,100 4,265,500
(SEDANG)
120 F-4-12-III 6,619,000 7,942,800 9,266,600
(BERAT)
130 F-4-16-I 5,804,300 6,965,200 8,126,100
131 F-4-16-II 6,748,500 8,098,200 9,447,900
132 F-4-16-III 9,008,100 10,809,700 12,611,300
142 G-1-01-I 17,446,400 20,935,700 24,425,000
(RINGAN)
- 652 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 25,022,400 30,026,900 35,031,400
(SEDANG)
144 G-1-01-III 37,984,400 45,581,300 53,178,100
(BERAT)
151 G-1-12-I 5,068,000 6,081,600 7,095,200
(RINGAN)
152 G-1-12-II 9,794,100 11,752,900 13,711,700
(SEDANG)
153 G-1-12-III 13,347,400 16,016,900 18,686,400
(BERAT)
163 G-4-10-I 4,350,300 5,220,400 6,090,500
(RINGAN)
164 G-4-10-II 5,317,600 6,381,100 7,444,600
(SEDANG)
165 G-4-10-III 7,522,300 9,026,800 10,531,300
(BERAT)
166 G-4-11-I 4,695,000 5,634,000 6,573,000
167 G-4-11-II 6,236,700 7,484,000 8,731,400
168 G-4-11-III 9,163,800 10,996,600 12,829,300
DEGENERATIF (BERAT)
169 G-4-12-I 5,208,500 6,250,200 7,292,000
(RINGAN)
170 G-4-12-II 6,381,400 7,657,700 8,933,900
(SEDANG)

172 G-4-13-I 3,035,000 3,642,000 4,249,000
(RINGAN)
173 G-4-13-II 5,292,400 6,350,900 7,409,400
(SEDANG)
174 G-4-13-III 6,276,900 7,532,300 8,787,700
(BERAT)
175 G-4-14-I 5,148,500 6,178,200 7,207,900
INFARK (RINGAN)
176 G-4-14-II 7,096,000 8,515,200 9,934,400
INFARK (SEDANG)
177 G-4-14-III 8,906,300 10,687,600 12,468,900
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 653 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 4,619,000 5,542,800 6,466,600
(RINGAN)
185 G-4-17-II 6,056,500 7,267,900 8,479,200
(SEDANG)
186 G-4-17-III 7,845,700 9,414,800 10,984,000
(BERAT)
190 G-4-19-I 3,795,300 4,554,400 5,313,500
191 G-4-19-II 6,415,000 7,698,100 8,981,100
192 G-4-19-III 8,422,700 10,107,200 11,791,700
211 G-4-26-I 3,684,200 4,421,000 5,157,800
LAIN (RINGAN)
212 G-4-26-II 4,418,400 5,302,100 6,185,700
LAIN (SEDANG)
213 G-4-26-III 6,408,600 7,690,300 8,972,100
LAIN (BERAT)
232 I-1-02-I 26,590,500 31,908,600 37,226,700
(RINGAN)
- 654 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 34,301,400 41,161,700 48,021,900
(SEDANG)
234 I-1-02-III 42,278,600 50,734,300 59,190,000
(BERAT)
235 I-1-03-I 15,358,700 18,430,500 21,502,200
ANOMALI (RINGAN)
236 I-1-03-II 21,290,400 25,548,500 29,806,500
ANOMALI (SEDANG)
237 I-1-03-III 27,854,800 33,425,700 38,996,700
ANOMALI (BERAT)
238 I-1-04-I 23,860,600 28,632,700 33,404,800
JANTUNG (RINGAN)
239 I-1-04-II 37,658,500 45,190,100 52,721,800
JANTUNG (SEDANG)
240 I-1-04-III 60,159,100 72,191,000 84,222,800
JANTUNG (BERAT)
241 I-1-05-I 56,110,700 67,332,800 78,554,900
242 I-1-05-II 68,579,700 82,295,600 96,011,600
243 I-1-05-III 93,517,800 112,221,300 130,924,900
247 I-1-07-I 49,876,100 59,851,400 69,826,600
JANTUNG (RINGAN)
248 I-1-07-II 62,345,200 74,814,200 87,283,300
JANTUNG (SEDANG)
249 I-1-07-III 93,517,800 112,221,300 130,924,900
JANTUNG (BERAT)
250 I-1-11-I 4,295,700 5,154,800 6,014,000
251 I-1-11-II 4,776,400 5,731,600 6,686,900
252 I-1-11-III 6,355,900 7,627,100 8,898,300
253 I-1-12-I 12,365,000 14,838,000 17,311,000
(RINGAN)
254 I-1-12-II 19,588,700 23,506,500 27,424,200
(SEDANG)
255 I-1-12-III 25,771,900 30,926,300 36,080,700
(BERAT)
256 I-1-13-I 11,993,900 14,392,700 16,791,500
KOMPLEK (RINGAN)
257 I-1-13-II 15,972,300 19,166,800 22,361,300
KOMPLEK (SEDANG)
258 I-1-13-III 19,698,300 23,638,000 27,577,600
KOMPLEK (BERAT)
259 I-1-14-I 24,548,600 29,458,300 34,368,000
(RINGAN)
260 I-1-14-II 30,510,300 36,612,300 42,714,400
(SEDANG)
261 I-1-14-III 39,979,000 47,974,800 55,970,600
(BERAT)
265 I-1-16-I 11,726,900 14,072,200 16,417,600
266 I-1-16-II 27,353,800 32,824,500 38,295,300
267 I-1-16-III 31,552,200 37,862,600 44,173,000
268 I-1-17-I 13,998,600 16,798,300 19,598,000
(RINGAN)
269 I-1-17-II 17,527,500 21,033,000 24,538,500
(SEDANG)
- 655 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 21,681,200 26,017,500 30,353,700
(BERAT)
271 I-1-20-I 15,778,800 18,934,500 22,090,300
(RINGAN)
272 I-1-20-II 19,712,000 23,654,400 27,596,800
(SEDANG)
273 I-1-20-III 20,721,400 24,865,700 29,010,000
(BERAT)
274 I-1-30-I 11,935,800 14,322,900 16,710,100
JANTUNG (RINGAN)
275 I-1-30-II 24,829,000 29,794,800 34,760,600
JANTUNG (SEDANG)
276 I-1-30-III 38,476,000 46,171,200 53,866,400
JANTUNG (BERAT)

289 I-4-13-I 3,736,900 4,484,300 5,231,700
(RINGAN)
290 I-4-13-II 6,672,800 8,007,300 9,341,900
(SEDANG)
291 I-4-13-III 9,614,500 11,537,400 13,460,300
(BERAT)
295 I-4-15-I 4,603,400 5,524,000 6,444,700
(RINGAN)
296 I-4-15-II 6,262,600 7,515,100 8,767,600
(SEDANG)

304 I-4-18-I 4,167,200 5,000,700 5,834,100
JANTUNG (RINGAN)
305 I-4-18-II 6,541,000 7,849,200 9,157,500
JANTUNG (SEDANG)
306 I-4-18-III 8,614,100 10,337,000 12,059,800
JANTUNG (BERAT)

308 I-4-19-II 6,276,300 7,531,600 8,786,800
(SEDANG)
- 656 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 3,436,600 4,123,900 4,811,200
320 I-4-23-II 4,219,200 5,063,000 5,906,800
321 I-4-23-III 8,244,000 9,892,800 11,541,600
322 I-4-24-I 2,871,300 3,445,600 4,019,900
(RINGAN)
323 I-4-24-II 6,611,900 7,934,300 9,256,700
(SEDANG)
324 I-4-24-III 8,359,600 10,031,500 11,703,500
(BERAT)
325 J-1-01-I 55,830,500 66,996,600 78,162,700
326 J-1-01-II 63,182,600 75,819,100 88,455,600
327 J-1-01-III 71,479,400 85,775,200 100,071,100
TRAKEOSTOMI (BERAT)
328 J-1-02-I 29,627,200 35,552,700 41,478,100
329 J-1-02-II 41,252,800 49,503,400 57,754,000
330 J-1-02-III 68,122,500 81,747,100 95,371,600
TRAKEOSTOMI (BERAT)
331 J-1-10-I 8,997,000 10,796,400 12,595,800
(RINGAN)
332 J-1-10-II 18,205,500 21,846,600 25,487,700
(SEDANG)
333 J-1-10-III 19,505,100 23,406,200 27,307,200
(BERAT)
334 J-1-20-I 15,385,000 18,462,000 21,539,000
(RINGAN)
335 J-1-20-II 19,377,800 23,253,400 27,128,900
(SEDANG)
336 J-1-20-III 29,922,500 35,907,000 41,891,400
(BERAT)
337 J-1-30-I 7,508,200 9,009,900 10,511,500
(RINGAN)
338 J-1-30-II 13,601,100 16,321,300 19,041,500
(SEDANG)

- 657 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,874,100 3,448,900 4,023,700
374 J-4-21-II 4,630,100 5,556,100 6,482,100
375 J-4-21-III 6,460,900 7,753,100 9,045,300
376 K-1-10-I 8,156,300 9,787,600 11,418,900
BESAR (RINGAN)
377 K-1-10-II 10,567,200 12,680,600 14,794,000
BESAR (SEDANG)
378 K-1-10-III 12,385,100 14,862,100 17,339,100
BESAR (BERAT)
382 K-1-12-I 3,528,100 4,233,700 4,939,400
FEMORAL (RINGAN)
383 K-1-12-II 4,588,700 5,506,500 6,424,200
FEMORAL (SEDANG)
384 K-1-12-III 9,091,000 10,909,200 12,727,400
FEMORAL (BERAT)
388 K-1-14-I 5,637,200 6,764,600 7,892,000
(RINGAN)
389 K-1-14-II 6,606,600 7,927,900 9,249,300
(SEDANG)

394 K-1-30-I 7,394,300 8,873,200 10,352,100
395 K-1-30-II 12,738,200 15,285,800 17,833,500
396 K-1-30-III 18,070,100 21,684,100 25,298,100

398 K-1-40-II 9,096,300 10,915,600 12,734,900
(SEDANG)

- 658 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 4,090,900 4,909,100 5,727,200
413 K-4-13-II 5,291,800 6,350,200 7,408,600
414 K-4-13-III 8,151,100 9,781,300 11,411,500
415 K-4-14-I 2,673,900 3,208,600 3,743,400
(RINGAN)
416 K-4-14-II 3,589,200 4,307,000 5,024,900
(SEDANG)
417 K-4-14-III 5,759,200 6,911,100 8,062,900
(BERAT)

424 K-4-17-I 1,764,300 2,117,200 2,470,100
(RINGAN)
425 K-4-17-II 2,172,800 2,607,300 3,041,900
(SEDANG)
426 K-4-17-III 2,607,300 3,128,800 3,650,200
(BERAT)
427 K-4-18-I 1,492,000 1,790,400 2,088,800
(RINGAN)
428 K-4-18-II 2,517,700 3,021,300 3,524,800
(SEDANG)
436 L-1-40-I 5,112,900 6,135,500 7,158,100
(RINGAN)
437 L-1-40-II 10,255,400 12,306,400 14,357,500
(SEDANG)
438 L-1-40-III 17,262,000 20,714,500 24,166,900
(BERAT)
451 L-4-13-I 2,448,200 2,937,800 3,427,400
PAYUDARA (RINGAN)
- 659 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,877,300 3,452,700 4,028,200
PAYUDARA (SEDANG)
453 L-4-13-III 4,233,900 5,080,700 5,927,500
PAYUDARA (BERAT)
454 L-4-14-I 3,023,500 3,628,200 4,232,900
(RINGAN)
455 L-4-14-II 4,541,400 5,449,700 6,358,000
(SEDANG)
456 L-4-14-III 6,401,700 7,682,000 8,962,300
(BERAT)
457 M-1-01-I 10,687,800 12,825,300 14,962,900
458 M-1-01-II 15,191,200 18,229,400 21,267,700
459 M-1-01-III 21,339,100 25,606,900 29,874,700
463 M-1-03-I 23,908,100 28,689,700 33,471,300
464 M-1-03-II 27,964,000 33,556,800 39,149,600
465 M-1-03-III 34,610,100 41,532,100 48,454,100
472 M-1-07-I 8,441,100 10,129,300 11,817,500
473 M-1-07-II 11,308,100 13,569,800 15,831,400
474 M-1-07-III 23,035,700 27,642,900 32,250,000
475 M-1-10-I 19,496,600 23,395,900 27,295,200
WAJAH (RINGAN)
476 M-1-10-II 46,615,700 55,938,800 65,261,900
WAJAH (SEDANG)
477 M-1-10-III 100,545,700 120,654,800 140,764,000
WAJAH (BERAT)
478 M-1-20-I 12,691,800 15,230,100 17,768,500
(RINGAN)
479 M-1-20-II 16,716,600 20,059,900 23,403,200
(SEDANG)

484 M-1-40-I 4,432,100 5,318,600 6,205,000
INTERNAL (RINGAN)
485 M-1-40-II 7,860,200 9,432,300 11,004,300
INTERNAL (SEDANG)
486 M-1-40-III 11,222,900 13,467,400 15,712,000
INTERNAL (BERAT)
490 M-1-60-I 8,202,800 9,843,300 11,483,900
491 M-1-60-II 10,312,800 12,375,300 14,437,900
492 M-1-60-III 16,060,500 19,272,600 22,484,700
- 660 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 15,667,200 18,800,600 21,934,000
KAKI (RINGAN)
494 M-1-70-II 17,233,900 20,680,600 24,127,400
KAKI (SEDANG)
495 M-1-70-III 19,730,500 23,676,600 27,622,700
KAKI (BERAT)
502 M-4-11-I 3,792,100 4,550,500 5,308,900
(RINGAN)
503 M-4-11-II 8,314,000 9,976,800 11,639,600
(SEDANG)
504 M-4-11-III 12,392,300 14,870,800 17,349,300
(BERAT)
505 M-4-12-I 3,026,900 3,632,300 4,237,700
(RINGAN)
506 M-4-12-II 5,034,600 6,041,500 7,048,500
(SEDANG)
507 M-4-12-III 6,942,600 8,331,100 9,719,600
(BERAT)
508 M-4-13-I 5,040,100 6,048,200 7,056,200
509 M-4-13-II 7,572,600 9,087,100 10,601,700
510 M-4-13-III 14,774,000 17,728,800 20,683,600
520 M-4-17-I 3,787,400 4,544,900 5,302,300
(RINGAN)
521 M-4-17-II 5,297,100 6,356,500 7,415,900
(SEDANG)
522 M-4-17-III 7,397,000 8,876,400 10,355,900
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,011,400 3,613,600 4,215,900
(RINGAN)
530 M-4-20-II 4,409,600 5,291,500 6,173,500
(SEDANG)
531 M-4-20-III 4,928,300 5,913,900 6,899,600
(BERAT)
532 M-4-21-I 3,032,200 3,638,600 4,245,100
533 M-4-21-II 3,792,400 4,550,900 5,309,400
- 661 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 8,502,500 10,203,000 11,903,500
541 N-1-12-I 4,457,700 5,349,300 6,240,800
542 N-1-12-II 9,149,300 10,979,200 12,809,000
543 N-1-12-III 19,854,400 23,825,200 27,796,100
547 N-1-30-I 8,919,500 10,703,500 12,487,400
BAWAH (RINGAN)
548 N-1-30-II 13,493,500 16,192,200 18,890,900
BAWAH (SEDANG)
549 N-1-30-III 15,529,800 18,635,700 21,741,700
BAWAH (BERAT)
550 N-1-40-I 8,258,100 9,909,800 11,561,400
(RINGAN)
551 N-1-40-II 11,214,400 13,457,200 15,700,100
(SEDANG)
552 N-1-40-III 13,052,000 15,662,400 18,272,800
(BERAT)
553 N-4-10-I 3,403,300 4,084,000 4,764,600
(RINGAN)
554 N-4-10-II 4,243,700 5,092,400 5,941,100
(SEDANG)
555 N-4-10-III 6,241,800 7,490,200 8,738,500
(BERAT)
568 N-4-15-I 3,099,800 3,719,700 4,339,700
URIN (RINGAN)
569 N-4-15-II 3,965,200 4,758,300 5,551,300
URIN (SEDANG)
570 N-4-15-III 4,525,000 5,430,000 6,335,000
URIN (BERAT)
571 N-4-16-I 3,795,700 4,554,800 5,314,000
(RINGAN)
572 N-4-16-II 5,417,600 6,501,200 7,584,700
(SEDANG)
573 N-4-16-III 7,434,300 8,921,200 10,408,000
(BERAT)
- 662 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 3,528,300 4,233,900 4,939,600
578 O-6-11-II 3,921,300 4,705,500 5,489,800
579 O-6-11-III 5,029,000 6,034,800 7,040,600
580 O-6-12-I 2,577,000 3,092,400 3,607,900
581 O-6-12-II 3,095,000 3,714,000 4,333,000
582 O-6-12-III 3,889,000 4,666,800 5,444,600
586 P-8-01-I 55,819,300 66,983,100 78,147,000
587 P-8-01-II 69,068,000 82,881,600 96,695,200
588 P-8-01-III 81,066,400 97,279,700 113,492,900
589 P-8-02-I 87,214,700 104,657,700 122,100,600
590 P-8-02-II 100,044,200 120,053,100 140,061,900
591 P-8-02-III 114,307,700 137,169,300 160,030,800
592 P-8-03-I 12,617,700 15,141,300 17,664,800
593 P-8-03-II 17,816,600 21,380,000 24,943,300
594 P-8-03-III 24,937,900 29,925,500 34,913,100
595 P-8-04-I 36,393,000 43,671,600 50,950,300
596 P-8-04-II 47,046,500 56,455,700 65,865,000
597 P-8-04-III 67,452,800 80,943,400 94,433,900
598 P-8-05-I 19,761,600 23,713,900 27,666,200
599 P-8-05-II 30,894,200 37,073,000 43,251,800
600 P-8-05-III 41,115,300 49,338,400 57,561,500
601 P-8-06-I 5,406,500 6,487,800 7,569,100
602 P-8-06-II 15,158,500 18,190,200 21,222,000
603 P-8-06-III 20,081,300 24,097,600 28,113,900
604 P-8-07-I 5,236,700 6,284,100 7,331,400
605 P-8-07-II 14,682,600 17,619,100 20,555,600
606 P-8-07-III 19,450,800 23,341,000 27,231,100
607 P-8-08-I 4,335,900 5,203,100 6,070,300
608 P-8-08-II 6,152,500 7,382,900 8,613,400
609 P-8-08-III 9,962,200 11,954,700 13,947,100
610 P-8-11-I 10,514,800 12,617,700 14,720,700
MAYOR (RINGAN)
611 P-8-11-II 14,847,200 17,816,600 20,786,100
MAYOR (SEDANG)
- 663 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 20,781,600 24,937,900 29,094,200
MAYOR (BERAT)
613 P-8-12-I 9,933,700 11,920,400 13,907,200
MAYOR (RINGAN)
614 P-8-12-II 11,420,900 13,705,100 15,989,300
MAYOR (SEDANG)
615 P-8-12-III 15,985,800 19,183,000 22,380,200
MAYOR (BERAT)
616 P-8-13-I 5,631,600 6,757,900 7,884,300
MAYOR (RINGAN)
617 P-8-13-II 8,785,300 10,542,400 12,299,500
MAYOR (SEDANG)
618 P-8-13-III 13,648,300 16,377,900 19,107,600
MAYOR (BERAT)
619 P-8-14-I 3,753,400 4,504,100 5,254,800
620 P-8-14-II 7,640,400 9,168,500 10,696,600
621 P-8-14-III 13,750,600 16,500,700 19,250,800
622 P-8-15-I 2,815,100 3,378,100 3,941,100
ASPIRASI (RINGAN)
623 P-8-15-II 5,637,300 6,764,800 7,892,300
ASPIRASI (SEDANG)
624 P-8-15-III 6,614,400 7,937,300 9,260,200
ASPIRASI (BERAT)
625 P-8-16-I 2,547,700 3,057,200 3,566,800
626 P-8-16-II 4,895,800 5,875,000 6,854,100
627 P-8-16-III 11,980,600 14,376,800 16,772,900
628 P-8-17-I 3,754,400 4,505,300 5,256,200
(RINGAN)
629 P-8-17-II 6,757,900 8,109,500 9,461,100
(SEDANG)
630 P-8-17-III 9,509,600 11,411,500 13,313,400
(BERAT)
631 S-4-10-I 2,786,300 3,343,600 3,900,800
632 S-4-10-II 3,433,200 4,119,800 4,806,400
633 S-4-10-III 4,699,600 5,639,600 6,579,500
640 S-4-13-I 3,025,100 3,630,100 4,235,100
(RINGAN)
641 S-4-13-II 5,366,700 6,440,100 7,513,400
(SEDANG)
642 S-4-13-III 8,710,900 10,453,100 12,195,300
(BERAT)
643 S-4-14-I 1,530,900 1,837,100 2,143,300
644 S-4-14-II 3,251,800 3,902,100 4,552,500
645 S-4-14-III 6,166,500 7,399,800 8,633,100
KANAK-KANAK (BERAT)
646 S-4-15-I 1,023,900 1,228,700 1,433,400
647 S-4-15-II 1,932,200 2,318,700 2,705,100
648 S-4-15-III 2,502,600 3,003,100 3,503,600
- 664 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 2,555,400 3,066,500 3,577,600
653 S-4-17-II 3,792,500 4,551,000 5,309,500
654 S-4-17-III 4,561,300 5,473,600 6,385,900
655 T-1-10-I 1,762,600 2,115,200 2,467,700
OBAT (RINGAN)
656 T-1-10-II 2,367,500 2,840,900 3,314,400
OBAT (SEDANG)
657 T-1-10-III 4,306,800 5,168,100 6,029,500
OBAT (BERAT)
658 T-4-10-I 764,600 917,500 1,070,400
659 T-4-10-II 1,457,200 1,748,600 2,040,000
660 T-4-10-III 2,118,400 2,542,000 2,965,700
661 T-4-11-I 1,043,500 1,252,200 1,460,900
662 T-4-11-II 1,642,200 1,970,600 2,299,000
663 T-4-11-III 2,645,000 3,174,000 3,703,000
664 T-4-12-I 1,719,200 2,063,000 2,406,800
LAIN (RINGAN)
665 T-4-12-II 2,561,600 3,073,900 3,586,300
LAIN (SEDANG)
666 T-4-12-III 3,930,200 4,716,200 5,502,200
LAIN (BERAT)
670 U-1-11-I 8,643,900 10,372,600 12,101,400
(RINGAN)
671 U-1-11-II 10,957,400 13,148,900 15,340,300
(SEDANG)
672 U-1-11-III 16,253,500 19,504,200 22,754,900
(BERAT)
679 U-1-14-I 4,187,200 5,024,600 5,862,100
(RINGAN)
680 U-1-14-II 5,138,700 6,166,500 7,194,200
(SEDANG)
681 U-1-14-III 6,089,400 7,307,200 8,525,100
(BERAT)
685 U-1-20-I 6,356,800 7,628,200 8,899,600
686 U-1-20-II 9,460,700 11,352,900 13,245,000
687 U-1-20-III 23,558,900 28,270,700 32,982,500
691 U-4-10-I 3,923,300 4,707,900 5,492,600
- 665 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 8,712,100 10,454,500 12,196,900
693 U-4-10-III 13,375,700 16,050,900 18,726,000
TENGGOROKAN (BERAT)
700 U-4-13-I 2,033,600 2,440,300 2,847,100
701 U-4-13-II 2,397,400 2,876,900 3,356,400
702 U-4-13-III 2,867,400 3,440,900 4,014,400
706 U-4-15-I 3,041,500 3,649,800 4,258,100
707 U-4-15-II 3,789,300 4,547,200 5,305,000
708 U-4-15-III 5,303,200 6,363,800 7,424,500
709 V-1-10-I 5,114,400 6,137,200 7,160,100
(RINGAN)
710 V-1-10-II 10,219,400 12,263,200 14,307,100
(SEDANG)
711 V-1-10-III 12,532,600 15,039,100 17,545,700
(BERAT)
715 V-1-12-I 8,873,500 10,648,200 12,422,900
MODERAT (RINGAN)
716 V-1-12-II 12,492,300 14,990,700 17,489,200
MODERAT (SEDANG)
717 V-1-12-III 15,359,000 18,430,900 21,502,700
MODERAT (BERAT)
718 V-1-13-I 4,771,700 5,726,000 6,680,400
KOMPLEK (RINGAN)
719 V-1-13-II 9,117,100 10,940,500 12,764,000
KOMPLEK (SEDANG)
720 V-1-13-III 13,874,500 16,649,400 19,424,300
KOMPLEK (BERAT)
721 V-1-14-I 9,076,500 10,891,800 12,707,100
(RINGAN)
722 V-1-14-II 13,187,900 15,825,500 18,463,100
(SEDANG)

727 V-4-10-I 4,525,000 5,430,000 6,335,000
(RINGAN)
728 V-4-10-II 7,516,300 9,019,500 10,522,800
(SEDANG)
729 V-4-10-III 12,391,700 14,870,000 17,348,400
(BERAT)
730 V-4-11-I 3,792,600 4,551,100 5,309,600
TUMOR (RINGAN)
731 V-4-11-II 5,088,700 6,106,400 7,124,100
TUMOR (SEDANG)
732 V-4-11-III 7,027,100 8,432,600 9,838,000
TUMOR (BERAT)
- 666 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 10,656,900 12,788,300 14,919,700
734 W-1-01-II 12,389,900 14,867,900 17,345,800
735 W-1-01-III 18,226,800 21,872,200 25,517,600
739 W-1-11-I 2,362,700 2,835,300 3,307,800
SERVIK (RINGAN)
740 W-1-11-II 2,607,200 3,128,700 3,650,100
SERVIK (SEDANG)
741 W-1-11-III 2,884,100 3,461,000 4,037,800
SERVIK (BERAT)
760 W-4-12-I 2,885,200 3,462,300 4,039,300
761 W-4-12-II 3,961,200 4,753,400 5,545,700
762 W-4-12-III 4,317,900 5,181,500 6,045,100
- 667 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 1,927,300 2,312,800 2,698,300
785 Z-4-12-II 4,044,300 4,853,200 5,662,100
786 Z-4-12-III 6,225,600 7,470,800 8,715,900
- 668 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,589,000

33 F-3-10-0 TERAPI SHOCK 450,000
- 669 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,735,600
PENGGANTIAN ALAT
81 I-2-42-0 2,628,700
PERKUTAN LAIN
- 670 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,304,900
192 Q-5-12-0 GIGI 225,200
196 Q-5-16-0 VAKSINASI 105,400
201 Q-5-21-0 ABORSI 196,600
206 Q-5-26-0 BRONKIAL AKUT 224,400
- 671 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 151,100
215 Q-5-35-0 INFEKSI AKUT 459,700
218 Q-5-38-0 PARU AKUT 267,900
234 U-2-23-0 RHINOPLASTY 1,323,400
242 U-3-13-0 341,100
TENGGOROKAN
- 672 -

270 Z-3-11-0 1,850,600
EMPEDU
- 673 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,026,500
289 Z-3-30-0 FOTOTERAPI 87,100
- 674 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,149,000 2,578,800 3,008,600
(RINGAN)
14 A-4-14-II 2,608,600 3,130,300 3,652,000
(SEDANG)
15 A-4-14-III 3,130,300 3,756,300 4,382,400
(BERAT)

31 B-1-13-I 4,147,700 4,977,300 5,806,800
LAIN (RINGAN)
32 B-1-13-II 6,824,600 8,189,500 9,554,400
LAIN (SEDANG)
33 B-1-13-III 8,830,400 10,596,500 12,362,500
LAIN (BERAT)
34 B-1-14-I 5,699,100 6,839,000 7,978,800
(RINGAN)
35 B-1-14-II 6,338,400 7,606,100 8,873,800
(SEDANG)
40 B-4-11-I 3,717,700 4,461,300 5,204,800
(RINGAN)
41 B-4-11-II 5,204,900 6,245,800 7,286,800
(SEDANG)
42 B-4-11-III 6,305,600 7,566,700 8,827,900
(BERAT)
- 675 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 3,938,400 4,726,000 5,513,700
74 D-1-20-II 10,853,500 13,024,200 15,194,900
75 D-1-20-III 17,216,900 20,660,300 24,103,600
85 D-4-13-I 2,278,000 2,733,600 3,189,100
86 D-4-13-II 3,224,100 3,868,900 4,513,700
87 D-4-13-III 4,123,700 4,948,500 5,773,200
88 D-4-14-I 2,443,200 2,931,900 3,420,500
89 D-4-14-II 4,000,200 4,800,200 5,600,200
90 D-4-14-III 4,892,600 5,871,100 6,849,600
91 E-1-01-I 4,349,200 5,219,100 6,088,900
(RINGAN)
92 E-1-01-II 5,697,100 6,836,500 7,975,900
(SEDANG)

97 E-1-20-I 5,732,300 6,878,700 8,025,200
TIROGLOSAL (RINGAN)
- 676 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 7,715,500 9,258,600 10,801,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,633,500 12,760,200 14,886,900
TIROGLOSAL (BERAT)
100 E-4-10-I 3,420,500 4,104,600 4,788,700
METABOLIK (RINGAN)
101 E-4-10-II 4,779,600 5,735,500 6,691,400
METABOLIK (SEDANG)
102 E-4-10-III 5,932,400 7,118,900 8,305,300
METABOLIK (BERAT)
109 E-4-13-I 2,819,500 3,383,400 3,947,400
(RINGAN)
110 E-4-13-II 4,130,100 4,956,200 5,782,200
(SEDANG)

118 F-4-12-I 1,591,400 1,909,700 2,228,000
(RINGAN)
119 F-4-12-II 2,262,500 2,715,000 3,167,500
(SEDANG)
120 F-4-12-III 4,915,100 5,898,200 6,881,200
(BERAT)
130 F-4-16-I 4,180,900 5,017,100 5,853,200
131 F-4-16-II 4,861,000 5,833,200 6,805,300
132 F-4-16-III 6,488,500 7,786,300 9,084,000
142 G-1-01-I 10,588,000 12,705,600 14,823,200
(RINGAN)
- 677 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 16,487,800 19,785,400 23,083,000
(SEDANG)
144 G-1-01-III 31,709,200 38,051,000 44,392,800
(BERAT)
151 G-1-12-I 3,763,400 4,516,100 5,268,800
(RINGAN)
152 G-1-12-II 7,054,700 8,465,700 9,876,600
(SEDANG)
153 G-1-12-III 9,614,200 11,537,000 13,459,900
(BERAT)
163 G-4-10-I 3,230,500 3,876,600 4,522,700
(RINGAN)
164 G-4-10-II 3,948,800 4,738,500 5,528,300
(SEDANG)
165 G-4-10-III 5,418,400 6,502,000 7,585,700
(BERAT)
166 G-4-11-I 3,381,800 4,058,200 4,734,500
167 G-4-11-II 4,492,300 5,390,800 6,289,300
168 G-4-11-III 6,600,700 7,920,900 9,241,000
DEGENERATIF (BERAT)
169 G-4-12-I 3,751,700 4,502,100 5,252,400
(RINGAN)
170 G-4-12-II 4,738,700 5,686,500 6,634,200
(SEDANG)

172 G-4-13-I 2,253,700 2,704,500 3,155,200
(RINGAN)
173 G-4-13-II 3,930,000 4,716,100 5,502,100
(SEDANG)
174 G-4-13-III 4,661,100 5,593,300 6,525,600
(BERAT)
175 G-4-14-I 3,823,200 4,587,800 5,352,400
INFARK (RINGAN)
176 G-4-14-II 5,111,300 6,133,600 7,155,800
INFARK (SEDANG)
177 G-4-14-III 6,415,300 7,698,300 8,981,400
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 678 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 3,430,000 4,116,000 4,802,000
(RINGAN)
185 G-4-17-II 4,497,500 5,397,000 6,296,500
(SEDANG)
186 G-4-17-III 5,651,300 6,781,600 7,911,800
(BERAT)
190 G-4-19-I 2,818,400 3,382,000 3,945,700
191 G-4-19-II 4,763,700 5,716,400 6,669,200
192 G-4-19-III 6,254,500 7,505,400 8,756,300
211 G-4-26-I 3,039,800 3,647,700 4,255,700
LAIN (RINGAN)
212 G-4-26-II 3,536,200 4,243,400 4,950,700
LAIN (SEDANG)
213 G-4-26-III 5,287,700 6,345,200 7,402,800
LAIN (BERAT)
232 I-1-02-I 19,745,600 23,694,700 27,643,900
(RINGAN)
- 679 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 25,471,600 30,565,900 35,660,200
(SEDANG)
234 I-1-02-III 31,395,300 37,674,400 43,953,500
(BERAT)
235 I-1-03-I 11,405,100 13,686,100 15,967,200
ANOMALI (RINGAN)
236 I-1-03-II 15,809,900 18,971,800 22,133,800
ANOMALI (SEDANG)
237 I-1-03-III 20,063,900 24,076,700 28,089,500
ANOMALI (BERAT)
238 I-1-04-I 17,186,900 20,624,300 24,061,700
JANTUNG (RINGAN)
239 I-1-04-II 27,125,600 32,550,700 37,975,800
JANTUNG (SEDANG)
240 I-1-04-III 43,332,900 51,999,500 60,666,100
JANTUNG (BERAT)
241 I-1-05-I 22,052,400 26,462,900 30,873,300
242 I-1-05-II 26,462,900 31,755,500 37,048,100
243 I-1-05-III 36,412,800 43,695,400 50,977,900
247 I-1-07-I 19,353,400 23,224,100 27,094,800
JANTUNG (RINGAN)
248 I-1-07-II 23,876,400 28,651,700 33,427,000
JANTUNG (SEDANG)
249 I-1-07-III 26,049,100 31,258,900 36,468,700
JANTUNG (BERAT)
250 I-1-11-I 3,094,200 3,713,100 4,331,900
251 I-1-11-II 3,440,400 4,128,500 4,816,600
252 I-1-11-III 4,578,200 5,493,800 6,409,500
253 I-1-12-I 8,906,600 10,687,900 12,469,200
(RINGAN)
254 I-1-12-II 14,546,300 17,455,500 20,364,800
(SEDANG)
255 I-1-12-III 19,137,800 22,965,400 26,792,900
(BERAT)
256 I-1-13-I 8,639,300 10,367,100 12,095,000
KOMPLEK (RINGAN)
257 I-1-13-II 11,505,000 13,805,900 16,106,900
KOMPLEK (SEDANG)
258 I-1-13-III 14,188,800 17,026,500 19,864,300
KOMPLEK (BERAT)
259 I-1-14-I 17,682,500 21,219,000 24,755,500
(RINGAN)
260 I-1-14-II 21,976,700 26,372,000 30,767,400
(SEDANG)
261 I-1-14-III 28,797,100 34,556,500 40,315,900
(BERAT)
265 I-1-16-I 8,708,200 10,449,800 12,191,400
266 I-1-16-II 19,703,100 23,643,700 27,584,300
267 I-1-16-III 22,727,200 27,272,600 31,818,100
268 I-1-17-I 10,083,200 12,099,900 14,116,500
(RINGAN)
269 I-1-17-II 12,625,100 15,150,200 17,675,200
(SEDANG)
- 680 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 15,617,100 18,740,500 21,863,900
(BERAT)
271 I-1-20-I 11,365,500 13,638,600 15,911,700
(RINGAN)
272 I-1-20-II 14,198,700 17,038,400 19,878,100
(SEDANG)
273 I-1-20-III 14,925,700 17,910,900 20,896,000
(BERAT)
274 I-1-30-I 8,597,400 10,316,900 12,036,300
JANTUNG (RINGAN)
275 I-1-30-II 17,884,500 21,461,400 25,038,200
JANTUNG (SEDANG)
276 I-1-30-III 27,714,500 33,257,400 38,800,300
JANTUNG (BERAT)

289 I-4-13-I 2,691,700 3,230,100 3,768,400
(RINGAN)
290 I-4-13-II 4,806,400 5,767,700 6,729,000
(SEDANG)
291 I-4-13-III 6,925,400 8,310,400 9,695,500
(BERAT)
295 I-4-15-I 4,377,100 5,252,600 6,128,000
(RINGAN)
296 I-4-15-II 5,954,800 7,145,800 8,336,700
(SEDANG)

304 I-4-18-I 3,094,500 3,713,400 4,332,300
JANTUNG (RINGAN)
305 I-4-18-II 4,711,500 5,653,800 6,596,200
JANTUNG (SEDANG)
306 I-4-18-III 6,396,700 7,676,000 8,955,400
JANTUNG (BERAT)

308 I-4-19-II 4,660,700 5,592,800 6,525,000
(SEDANG)
- 681 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 2,552,000 3,062,300 3,572,700
320 I-4-23-II 3,133,100 3,759,700 4,386,300
321 I-4-23-III 6,121,800 7,346,200 8,570,600
322 I-4-24-I 2,298,000 2,757,700 3,217,300
(RINGAN)
323 I-4-24-II 5,291,800 6,350,100 7,408,500
(SEDANG)
324 I-4-24-III 6,690,500 8,028,600 9,366,700
(BERAT)
325 J-1-01-I 41,458,700 49,750,500 58,042,200
326 J-1-01-II 46,918,300 56,301,900 65,685,600
327 J-1-01-III 53,079,300 63,695,200 74,311,000
TRAKEOSTOMI (BERAT)
328 J-1-02-I 22,000,600 26,400,800 30,800,900
329 J-1-02-II 30,633,600 36,760,300 42,887,100
330 J-1-02-III 50,586,600 60,703,900 70,821,200
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,681,000 8,017,200 9,353,400
(RINGAN)
332 J-1-10-II 13,519,100 16,222,900 18,926,700
(SEDANG)
333 J-1-10-III 14,049,600 16,859,600 19,669,500
(BERAT)
334 J-1-20-I 9,466,300 11,359,600 13,252,800
(RINGAN)
335 J-1-20-II 12,508,200 15,009,800 17,511,500
(SEDANG)
336 J-1-20-III 19,154,900 22,985,900 26,816,900
(BERAT)
337 J-1-30-I 5,575,500 6,690,600 7,805,700
(RINGAN)
338 J-1-30-II 10,099,900 12,119,900 14,139,900
(SEDANG)

- 682 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,732,800 3,279,400 3,826,000
374 J-4-21-II 4,402,500 5,283,000 6,163,500
375 J-4-21-III 6,143,400 7,372,100 8,600,700
376 K-1-10-I 6,056,700 7,268,100 8,479,400
BESAR (RINGAN)
377 K-1-10-II 7,611,600 9,133,900 10,656,200
BESAR (SEDANG)
378 K-1-10-III 8,921,000 10,705,300 12,489,500
BESAR (BERAT)
382 K-1-12-I 2,541,300 3,049,600 3,557,800
FEMORAL (RINGAN)
383 K-1-12-II 3,305,300 3,966,300 4,627,400
FEMORAL (SEDANG)
384 K-1-12-III 6,548,300 7,857,900 9,167,600
FEMORAL (BERAT)
388 K-1-14-I 4,651,200 5,581,400 6,511,600
(RINGAN)
389 K-1-14-II 5,451,100 6,541,300 7,631,500
(SEDANG)

394 K-1-30-I 5,326,200 6,391,400 7,456,700
395 K-1-30-II 9,459,200 11,351,000 13,242,800
396 K-1-30-III 13,016,000 15,619,100 18,222,300

398 K-1-40-II 6,552,100 7,862,600 9,173,000
(SEDANG)

- 683 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 3,037,800 3,645,400 4,252,900
413 K-4-13-II 3,929,600 4,715,500 5,501,500
414 K-4-13-III 6,052,900 7,263,400 8,474,000
415 K-4-14-I 1,926,000 2,311,200 2,696,400
(RINGAN)
416 K-4-14-II 2,585,300 3,102,400 3,619,400
(SEDANG)
417 K-4-14-III 4,148,400 4,978,100 5,807,800
(BERAT)

424 K-4-17-I 1,444,200 1,733,100 2,021,900
(RINGAN)
425 K-4-17-II 1,975,300 2,370,300 2,765,400
(SEDANG)
426 K-4-17-III 2,370,300 2,844,400 3,318,500
(BERAT)
427 K-4-18-I 1,276,200 1,531,400 1,786,600
(RINGAN)
428 K-4-18-II 1,813,500 2,176,200 2,538,900
(SEDANG)
436 L-1-40-I 3,796,700 4,556,100 5,315,400
(RINGAN)
437 L-1-40-II 7,615,400 9,138,500 10,661,600
(SEDANG)
438 L-1-40-III 12,818,500 15,382,200 17,945,900
(BERAT)
451 L-4-13-I 2,327,800 2,793,400 3,259,000
PAYUDARA (RINGAN)
- 684 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,735,900 3,283,000 3,830,200
PAYUDARA (SEDANG)
453 L-4-13-III 4,025,800 4,831,000 5,636,200
PAYUDARA (BERAT)
454 L-4-14-I 2,245,200 2,694,200 3,143,300
(RINGAN)
455 L-4-14-II 3,372,400 4,046,800 4,721,300
(SEDANG)
456 L-4-14-III 4,753,800 5,704,500 6,655,300
(BERAT)
457 M-1-01-I 7,936,600 9,523,900 11,111,200
458 M-1-01-II 11,280,700 13,536,800 15,793,000
459 M-1-01-III 15,846,000 19,015,200 22,184,400
463 M-1-03-I 19,098,500 22,918,200 26,738,000
464 M-1-03-II 22,338,500 26,806,200 31,273,900
465 M-1-03-III 27,647,600 33,177,100 38,706,700
472 M-1-07-I 6,268,200 7,521,800 8,775,500
473 M-1-07-II 8,397,200 10,076,700 11,756,100
474 M-1-07-III 17,105,900 20,527,100 23,948,300
475 M-1-10-I 10,318,500 12,382,200 14,445,900
WAJAH (RINGAN)
476 M-1-10-II 22,642,700 27,171,200 31,699,800
WAJAH (SEDANG)
477 M-1-10-III 48,838,200 58,605,800 68,373,400
WAJAH (BERAT)
478 M-1-20-I 9,424,700 11,309,600 13,194,600
(RINGAN)
479 M-1-20-II 12,041,000 14,449,200 16,857,400
(SEDANG)

484 M-1-40-I 3,291,200 3,949,500 4,607,700
INTERNAL (RINGAN)
485 M-1-40-II 5,836,900 7,004,200 8,171,600
INTERNAL (SEDANG)
486 M-1-40-III 8,333,900 10,000,700 11,667,500
INTERNAL (BERAT)
490 M-1-60-I 6,091,200 7,309,500 8,527,700
491 M-1-60-II 7,658,100 9,189,700 10,721,300
492 M-1-60-III 11,568,500 13,882,200 16,195,900
- 685 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 11,285,100 13,542,100 15,799,200
KAKI (RINGAN)
494 M-1-70-II 12,413,600 14,896,400 17,379,100
KAKI (SEDANG)
495 M-1-70-III 14,212,000 17,054,400 19,896,800
KAKI (BERAT)
502 M-4-11-I 2,815,900 3,379,100 3,942,300
(RINGAN)
503 M-4-11-II 6,173,800 7,408,600 8,643,300
(SEDANG)
504 M-4-11-III 8,926,300 10,711,500 12,496,800
(BERAT)
505 M-4-12-I 2,247,700 2,697,300 3,146,800
(RINGAN)
506 M-4-12-II 3,738,600 4,486,300 5,234,100
(SEDANG)
507 M-4-12-III 5,000,800 6,001,000 7,001,100
(BERAT)
508 M-4-13-I 3,742,700 4,491,300 5,239,800
509 M-4-13-II 5,623,300 6,747,900 7,872,600
510 M-4-13-III 10,970,900 13,165,100 15,359,300
520 M-4-17-I 2,812,500 3,374,900 3,937,400
(RINGAN)
521 M-4-17-II 3,933,500 4,720,200 5,506,900
(SEDANG)
522 M-4-17-III 5,492,900 6,591,500 7,690,100
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,236,200 2,683,400 3,130,700
(RINGAN)
530 M-4-20-II 3,274,500 3,929,400 4,584,300
(SEDANG)
531 M-4-20-III 3,659,700 4,391,600 5,123,500
(BERAT)
532 M-4-21-I 2,251,700 2,702,000 3,152,300
533 M-4-21-II 2,816,200 3,379,400 3,942,700
- 686 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 6,313,800 7,576,600 8,839,400
541 N-1-12-I 3,310,200 3,972,300 4,634,300
542 N-1-12-II 6,590,300 7,908,400 9,226,400
543 N-1-12-III 14,301,200 17,161,400 20,021,700
547 N-1-30-I 6,623,500 7,948,200 9,272,900
BAWAH (RINGAN)
548 N-1-30-II 10,020,000 12,024,100 14,028,100
BAWAH (SEDANG)
549 N-1-30-III 11,532,100 13,838,500 16,145,000
BAWAH (BERAT)
550 N-1-40-I 5,948,400 7,138,100 8,327,700
(RINGAN)
551 N-1-40-II 8,077,800 9,693,300 11,308,900
(SEDANG)
552 N-1-40-III 9,401,400 11,281,700 13,162,000
(BERAT)
553 N-4-10-I 2,527,200 3,032,700 3,538,100
(RINGAN)
554 N-4-10-II 3,056,700 3,668,100 4,279,400
(SEDANG)
555 N-4-10-III 4,496,000 5,395,200 6,294,400
(BERAT)
568 N-4-15-I 2,301,800 2,762,200 3,222,600
URIN (RINGAN)
569 N-4-15-II 2,856,200 3,427,400 3,998,700
URIN (SEDANG)
570 N-4-15-III 3,259,400 3,911,300 4,563,200
URIN (BERAT)
571 N-4-16-I 2,818,600 3,382,300 3,946,000
(RINGAN)
572 N-4-16-II 4,023,000 4,827,700 5,632,300
(SEDANG)
573 N-4-16-III 5,355,000 6,426,000 7,497,000
(BERAT)
- 687 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 2,620,000 3,144,000 3,668,000
578 O-6-11-II 2,911,900 3,494,200 4,076,600
579 O-6-11-III 3,622,400 4,346,900 5,071,400
580 O-6-12-I 1,856,300 2,227,500 2,598,800
581 O-6-12-II 2,229,300 2,675,200 3,121,100
582 O-6-12-III 2,801,300 3,361,500 3,921,800
586 P-8-01-I 41,450,400 49,740,500 58,030,600
587 P-8-01-II 51,288,700 61,546,400 71,804,100
588 P-8-01-III 60,198,500 72,238,100 84,277,800
589 P-8-02-I 69,834,700 83,801,600 97,768,500
590 P-8-02-II 80,107,500 96,129,000 112,150,500
591 P-8-02-III 91,528,500 109,834,200 128,139,900
592 P-8-03-I 7,546,500 9,055,700 10,565,000
593 P-8-03-II 11,196,500 13,435,800 15,675,100
594 P-8-03-III 12,672,200 15,206,600 17,741,100
595 P-8-04-I 22,376,000 26,851,200 31,326,500
596 P-8-04-II 37,671,100 45,205,300 52,739,500
597 P-8-04-III 54,010,800 64,813,000 75,615,200
598 P-8-05-I 15,823,500 18,988,200 22,152,900
599 P-8-05-II 22,941,500 27,529,800 32,118,000
600 P-8-05-III 32,921,900 39,506,300 46,090,700
601 P-8-06-I 4,014,800 4,817,700 5,620,700
602 P-8-06-II 11,256,500 13,507,800 15,759,100
603 P-8-06-III 14,912,000 17,894,500 20,876,900
604 P-8-07-I 3,888,700 4,666,400 5,444,200
605 P-8-07-II 10,903,000 13,083,600 15,264,200
606 P-8-07-III 14,443,800 17,332,600 20,221,400
607 P-8-08-I 3,945,300 4,734,300 5,523,400
608 P-8-08-II 5,598,200 6,717,900 7,837,500
609 P-8-08-III 9,064,700 10,877,700 12,690,600
610 P-8-11-I 6,860,400 8,232,500 9,604,600
MAYOR (RINGAN)
611 P-8-11-II 10,178,600 12,214,400 14,250,100
MAYOR (SEDANG)
- 688 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 11,520,200 13,824,200 16,128,200
MAYOR (BERAT)
613 P-8-12-I 5,965,600 7,158,700 8,351,800
MAYOR (RINGAN)
614 P-8-12-II 8,482,200 10,178,600 11,875,100
MAYOR (SEDANG)
615 P-8-12-III 9,600,100 11,520,200 13,440,200
MAYOR (BERAT)
616 P-8-13-I 5,124,300 6,149,200 7,174,000
MAYOR (RINGAN)
617 P-8-13-II 7,993,900 9,592,700 11,191,500
MAYOR (SEDANG)
618 P-8-13-III 10,911,400 13,093,600 15,275,900
MAYOR (BERAT)
619 P-8-14-I 2,703,600 3,244,300 3,785,000
620 P-8-14-II 5,503,400 6,604,100 7,704,800
621 P-8-14-III 10,210,900 12,253,100 14,295,300
622 P-8-15-I 2,027,700 2,433,300 2,838,800
ASPIRASI (RINGAN)
623 P-8-15-II 4,060,600 4,872,700 5,684,800
ASPIRASI (SEDANG)
624 P-8-15-III 4,764,400 5,717,300 6,670,100
ASPIRASI (BERAT)
625 P-8-16-I 1,835,100 2,202,100 2,569,200
626 P-8-16-II 3,526,500 4,231,800 4,937,100
627 P-8-16-III 7,191,400 8,629,700 10,068,000
628 P-8-17-I 3,416,200 4,099,500 4,782,700
(RINGAN)
629 P-8-17-II 6,149,200 7,379,000 8,608,900
(SEDANG)
630 P-8-17-III 8,393,400 10,072,000 11,750,700
(BERAT)
631 S-4-10-I 2,069,100 2,482,900 2,896,700
632 S-4-10-II 2,549,400 3,059,300 3,569,200
633 S-4-10-III 3,489,900 4,187,800 4,885,800
640 S-4-13-I 2,246,400 2,695,700 3,144,900
(RINGAN)
641 S-4-13-II 3,985,300 4,782,300 5,579,400
(SEDANG)
642 S-4-13-III 6,468,600 7,762,300 9,056,000
(BERAT)
643 S-4-14-I 1,136,800 1,364,200 1,591,600
644 S-4-14-II 2,414,700 2,897,700 3,380,600
645 S-4-14-III 4,579,100 5,495,000 6,410,800
KANAK-KANAK (BERAT)
646 S-4-15-I 760,300 912,400 1,064,400
647 S-4-15-II 1,434,800 1,721,800 2,008,800
648 S-4-15-III 1,858,400 2,230,000 2,601,700
- 689 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 1,897,600 2,277,100 2,656,600
653 S-4-17-II 2,816,200 3,379,500 3,942,700
654 S-4-17-III 3,387,200 4,064,600 4,742,000
655 T-1-10-I 1,269,600 1,523,600 1,777,500
OBAT (RINGAN)
656 T-1-10-II 1,705,300 2,046,300 2,387,400
OBAT (SEDANG)
657 T-1-10-III 3,102,200 3,722,600 4,343,100
OBAT (BERAT)
658 T-4-10-I 605,400 726,500 847,600
659 T-4-10-II 1,153,900 1,384,700 1,615,500
660 T-4-10-III 1,677,400 2,012,900 2,348,400
661 T-4-11-I 810,500 972,600 1,134,700
662 T-4-11-II 1,275,400 1,530,500 1,785,600
663 T-4-11-III 2,054,400 2,465,300 2,876,200
664 T-4-12-I 1,259,500 1,511,300 1,763,200
LAIN (RINGAN)
665 T-4-12-II 1,903,600 2,284,300 2,665,000
LAIN (SEDANG)
666 T-4-12-III 2,946,900 3,536,300 4,125,700
LAIN (BERAT)
670 U-1-11-I 6,418,800 7,702,500 8,986,300
(RINGAN)
671 U-1-11-II 8,136,800 9,764,100 11,391,500
(SEDANG)
672 U-1-11-III 11,707,500 14,049,000 16,390,500
(BERAT)
679 U-1-14-I 3,016,100 3,619,300 4,222,500
(RINGAN)
680 U-1-14-II 3,701,400 4,441,700 5,182,000
(SEDANG)
681 U-1-14-III 4,386,200 5,263,400 6,140,700
(BERAT)
685 U-1-20-I 4,578,900 5,494,600 6,410,400
686 U-1-20-II 6,814,600 8,177,500 9,540,500
687 U-1-20-III 17,494,400 20,993,300 24,492,200
691 U-4-10-I 2,825,900 3,391,100 3,956,300
- 690 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 6,469,400 7,763,300 9,057,200
693 U-4-10-III 9,932,600 11,919,100 13,905,600
TENGGOROKAN (BERAT)
700 U-4-13-I 1,875,700 2,250,800 2,625,900
701 U-4-13-II 2,211,200 2,653,500 3,095,700
702 U-4-13-III 2,644,700 3,173,700 3,702,600
706 U-4-15-I 2,258,600 2,710,300 3,162,000
707 U-4-15-II 2,813,900 3,376,700 3,939,400
708 U-4-15-III 3,938,100 4,725,700 5,513,300
709 V-1-10-I 3,683,900 4,420,700 5,157,500
(RINGAN)
710 V-1-10-II 7,588,700 9,106,500 10,624,200
(SEDANG)
711 V-1-10-III 9,306,500 11,167,800 13,029,100
(BERAT)
715 V-1-12-I 6,589,300 7,907,200 9,225,000
MODERAT (RINGAN)
716 V-1-12-II 8,998,200 10,797,900 12,597,500
MODERAT (SEDANG)
717 V-1-12-III 11,405,400 13,686,400 15,967,500
MODERAT (BERAT)
718 V-1-13-I 3,437,100 4,124,500 4,811,900
KOMPLEK (RINGAN)
719 V-1-13-II 6,567,100 7,880,500 9,193,900
KOMPLEK (SEDANG)
720 V-1-13-III 10,303,000 12,363,600 14,424,200
KOMPLEK (BERAT)
721 V-1-14-I 6,740,100 8,088,100 9,436,100
(RINGAN)
722 V-1-14-II 9,793,100 11,751,700 13,710,400
(SEDANG)

727 V-4-10-I 3,259,400 3,911,300 4,563,100
(RINGAN)
728 V-4-10-II 5,414,000 6,496,800 7,579,600
(SEDANG)
729 V-4-10-III 8,925,800 10,711,000 12,496,100
(BERAT)
730 V-4-11-I 2,816,300 3,379,600 3,942,800
TUMOR (RINGAN)
731 V-4-11-II 3,778,800 4,534,500 5,290,300
TUMOR (SEDANG)
732 V-4-11-III 5,061,700 6,074,000 7,086,400
TUMOR (BERAT)
- 691 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 7,676,200 9,211,500 10,746,700
734 W-1-01-II 9,200,500 11,040,600 12,880,700
735 W-1-01-III 13,128,900 15,754,700 18,380,400
739 W-1-11-I 1,701,900 2,042,200 2,382,600
SERVIK (RINGAN)
740 W-1-11-II 1,878,000 2,253,600 2,629,200
SERVIK (SEDANG)
741 W-1-11-III 2,077,400 2,492,900 2,908,400
SERVIK (BERAT)
760 W-4-12-I 2,743,400 3,292,100 3,840,800
761 W-4-12-II 3,766,500 4,519,800 5,273,100
762 W-4-12-III 4,105,700 4,926,900 5,748,000
- 692 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 1,197,700 1,437,200 1,676,800
785 Z-4-12-II 2,938,100 3,525,800 4,113,400
786 Z-4-12-III 4,203,200 5,043,800 5,884,500
- 693 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,497,500

33 F-3-10-0 TERAPI SHOCK 424,100
- 694 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,578,100
PENGGANTIAN ALAT
81 I-2-42-0 2,477,400
PERKUTAN LAIN
- 695 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,168,300
192 Q-5-12-0 GIGI 212,200
196 Q-5-16-0 VAKSINASI 92,800
201 Q-5-21-0 ABORSI 185,200
206 Q-5-26-0 BRONKIAL AKUT 197,700
- 696 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 133,100
215 Q-5-35-0 INFEKSI AKUT 433,200
218 Q-5-38-0 PARU AKUT 252,400
234 U-2-23-0 RHINOPLASTY 1,247,200
242 U-3-13-0 321,500
TENGGOROKAN
270 Z-3-11-0 1,744,100
EMPEDU
- 697 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 919,000
289 Z-3-30-0 FOTOTERAPI 76,700
- 698 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,213,500 2,656,200 3,098,900
(RINGAN)
14 A-4-14-II 2,686,800 3,224,200 3,761,600
(SEDANG)
15 A-4-14-III 3,224,200 3,869,000 4,513,900
(BERAT)

31 B-1-13-I 4,272,200 5,126,600 5,981,000
LAIN (RINGAN)
32 B-1-13-II 7,029,300 8,435,200 9,841,000
LAIN (SEDANG)
33 B-1-13-III 9,095,300 10,914,400 12,733,400
LAIN (BERAT)
34 B-1-14-I 5,870,100 7,044,100 8,218,200
(RINGAN)
35 B-1-14-II 6,528,600 7,834,300 9,140,000
(SEDANG)
40 B-4-11-I 3,829,300 4,595,100 5,361,000
(RINGAN)
41 B-4-11-II 5,361,000 6,433,200 7,505,400
(SEDANG)
42 B-4-11-III 6,494,800 7,793,700 9,092,700
(BERAT)
- 699 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 4,056,500 4,867,800 5,679,100
74 D-1-20-II 11,179,100 13,415,000 15,650,800
75 D-1-20-III 17,733,400 21,280,100 24,826,700
85 D-4-13-I 2,346,300 2,815,600 3,284,800
86 D-4-13-II 3,320,800 3,985,000 4,649,100
87 D-4-13-III 4,247,400 5,096,900 5,946,400
88 D-4-14-I 2,516,500 3,019,800 3,523,100
89 D-4-14-II 4,120,200 4,944,200 5,768,200
90 D-4-14-III 5,039,400 6,047,300 7,055,100
91 E-1-01-I 4,479,700 5,375,700 6,271,600
(RINGAN)
92 E-1-01-II 5,868,000 7,041,600 8,215,200
(SEDANG)

97 E-1-20-I 5,904,200 7,085,100 8,265,900
TIROGLOSAL (RINGAN)
- 700 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 7,946,900 9,536,300 11,125,700
TIROGLOSAL (SEDANG)
99 E-1-20-III 10,952,500 13,143,000 15,333,500
TIROGLOSAL (BERAT)
100 E-4-10-I 3,523,100 4,227,800 4,932,400
METABOLIK (RINGAN)
101 E-4-10-II 4,922,900 5,907,500 6,892,100
METABOLIK (SEDANG)
102 E-4-10-III 6,110,400 7,332,400 8,554,500
METABOLIK (BERAT)
109 E-4-13-I 2,904,100 3,484,900 4,065,800
(RINGAN)
110 E-4-13-II 4,254,000 5,104,800 5,955,600
(SEDANG)

118 F-4-12-I 1,639,200 1,967,000 2,294,800
(RINGAN)
119 F-4-12-II 2,330,400 2,796,400 3,262,500
(SEDANG)
120 F-4-12-III 5,062,600 6,075,100 7,087,600
(BERAT)
130 F-4-16-I 4,306,300 5,167,600 6,028,800
131 F-4-16-II 5,006,800 6,008,100 7,009,500
132 F-4-16-III 6,683,200 8,019,800 9,356,500
142 G-1-01-I 10,905,700 13,086,800 15,267,900
(RINGAN)
- 701 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 16,982,500 20,379,000 23,775,500
(SEDANG)
144 G-1-01-III 32,660,400 39,192,500 45,724,600
(BERAT)
151 G-1-12-I 3,876,300 4,651,600 5,426,900
(RINGAN)
152 G-1-12-II 7,266,400 8,719,600 10,172,900
(SEDANG)
153 G-1-12-III 9,902,600 11,883,200 13,863,700
(BERAT)
163 G-4-10-I 3,327,400 3,992,900 4,658,400
(RINGAN)
164 G-4-10-II 4,067,200 4,880,700 5,694,100
(SEDANG)
165 G-4-10-III 5,580,900 6,697,100 7,813,300
(BERAT)
166 G-4-11-I 3,483,300 4,179,900 4,876,600
167 G-4-11-II 4,627,100 5,552,500 6,477,900
168 G-4-11-III 6,798,800 8,158,500 9,518,300
DEGENERATIF (BERAT)
169 G-4-12-I 3,864,300 4,637,100 5,410,000
(RINGAN)
170 G-4-12-II 4,880,900 5,857,000 6,833,200
(SEDANG)

172 G-4-13-I 2,321,300 2,785,600 3,249,900
(RINGAN)
173 G-4-13-II 4,047,900 4,857,500 5,667,100
(SEDANG)
174 G-4-13-III 4,801,000 5,761,100 6,721,300
(BERAT)
175 G-4-14-I 3,937,900 4,725,400 5,513,000
INFARK (RINGAN)
176 G-4-14-II 5,264,600 6,317,600 7,370,500
INFARK (SEDANG)
177 G-4-14-III 6,607,700 7,929,300 9,250,800
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 702 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 3,532,900 4,239,500 4,946,100
(RINGAN)
185 G-4-17-II 4,632,400 5,558,900 6,485,400
(SEDANG)
186 G-4-17-III 5,820,800 6,985,000 8,149,200
(BERAT)
190 G-4-19-I 2,902,900 3,483,500 4,064,100
191 G-4-19-II 4,906,600 5,887,900 6,869,300
192 G-4-19-III 6,442,200 7,730,600 9,019,000
211 G-4-26-I 3,131,000 3,757,200 4,383,400
LAIN (RINGAN)
212 G-4-26-II 3,642,300 4,370,700 5,099,200
LAIN (SEDANG)
213 G-4-26-III 5,446,300 6,535,600 7,624,900
LAIN (BERAT)
232 I-1-02-I 20,338,000 24,405,600 28,473,200
(RINGAN)
- 703 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 26,235,700 31,482,900 36,730,000
(SEDANG)
234 I-1-02-III 32,337,200 38,804,600 45,272,100
(BERAT)
235 I-1-03-I 11,747,300 14,096,700 16,446,200
ANOMALI (RINGAN)
236 I-1-03-II 16,284,200 19,541,000 22,797,800
ANOMALI (SEDANG)
237 I-1-03-III 20,665,800 24,799,000 28,932,200
ANOMALI (BERAT)
238 I-1-04-I 17,702,500 21,243,000 24,783,500
JANTUNG (RINGAN)
239 I-1-04-II 27,939,300 33,527,200 39,115,100
JANTUNG (SEDANG)
240 I-1-04-III 44,632,900 53,559,500 62,486,100
JANTUNG (BERAT)
241 I-1-05-I 22,713,900 27,256,700 31,799,500
242 I-1-05-II 27,256,800 32,708,200 38,159,600
243 I-1-05-III 37,505,200 45,006,200 52,507,300
247 I-1-07-I 19,934,000 23,920,900 27,907,700
JANTUNG (RINGAN)
248 I-1-07-II 24,592,700 29,511,300 34,429,800
JANTUNG (SEDANG)
249 I-1-07-III 26,830,500 32,196,700 37,562,800
JANTUNG (BERAT)
250 I-1-11-I 3,187,000 3,824,400 4,461,900
251 I-1-11-II 3,543,700 4,252,400 4,961,100
252 I-1-11-III 4,715,500 5,658,600 6,601,700
253 I-1-12-I 9,173,800 11,008,500 12,843,300
(RINGAN)
254 I-1-12-II 14,982,600 17,979,200 20,975,700
(SEDANG)
255 I-1-12-III 19,711,900 23,654,300 27,596,700
(BERAT)
256 I-1-13-I 8,898,400 10,678,100 12,457,800
KOMPLEK (RINGAN)
257 I-1-13-II 11,850,100 14,220,100 16,590,100
KOMPLEK (SEDANG)
258 I-1-13-III 14,614,500 17,537,300 20,460,200
KOMPLEK (BERAT)
259 I-1-14-I 18,212,900 21,855,500 25,498,100
(RINGAN)
260 I-1-14-II 22,636,000 27,163,200 31,690,400
(SEDANG)
261 I-1-14-III 29,661,000 35,593,200 41,525,400
(BERAT)
265 I-1-16-I 8,969,400 10,763,300 12,557,200
266 I-1-16-II 20,294,200 24,353,000 28,411,800
267 I-1-16-III 23,409,000 28,090,800 32,772,600
268 I-1-17-I 10,385,700 12,462,900 14,540,000
(RINGAN)
269 I-1-17-II 13,003,900 15,604,700 18,205,500
(SEDANG)
- 704 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 16,085,600 19,302,700 22,519,900
(BERAT)
271 I-1-20-I 11,706,500 14,047,800 16,389,100
(RINGAN)
272 I-1-20-II 14,624,600 17,549,600 20,474,500
(SEDANG)
273 I-1-20-III 15,373,500 18,448,200 21,522,900
(BERAT)
274 I-1-30-I 8,855,300 10,626,400 12,397,400
JANTUNG (RINGAN)
275 I-1-30-II 18,421,000 22,105,200 25,789,400
JANTUNG (SEDANG)
276 I-1-30-III 28,545,900 34,255,100 39,964,300
JANTUNG (BERAT)

289 I-4-13-I 2,772,500 3,327,000 3,881,500
(RINGAN)
290 I-4-13-II 4,950,600 5,940,700 6,930,900
(SEDANG)
291 I-4-13-III 7,133,100 8,559,800 9,986,400
(BERAT)
295 I-4-15-I 4,508,400 5,410,100 6,311,800
(RINGAN)
296 I-4-15-II 6,133,400 7,360,100 8,586,800
(SEDANG)

304 I-4-18-I 3,187,400 3,824,800 4,462,300
JANTUNG (RINGAN)
305 I-4-18-II 4,852,900 5,823,500 6,794,000
JANTUNG (SEDANG)
306 I-4-18-III 6,588,600 7,906,300 9,224,000
JANTUNG (BERAT)

308 I-4-19-II 4,800,500 5,760,600 6,720,700
(SEDANG)
- 705 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 2,628,500 3,154,200 3,679,900
320 I-4-23-II 3,227,100 3,872,500 4,517,900
321 I-4-23-III 6,305,500 7,566,600 8,827,700
322 I-4-24-I 2,367,000 2,840,400 3,313,800
(RINGAN)
323 I-4-24-II 5,450,500 6,540,600 7,630,800
(SEDANG)
324 I-4-24-III 6,891,200 8,269,500 9,647,700
(BERAT)
325 J-1-01-I 42,702,500 51,243,000 59,783,500
326 J-1-01-II 48,325,800 57,991,000 67,656,100
327 J-1-01-III 54,671,700 65,606,000 76,540,400
TRAKEOSTOMI (BERAT)
328 J-1-02-I 22,660,700 27,192,800 31,724,900
329 J-1-02-II 31,552,600 37,863,200 44,173,700
330 J-1-02-III 52,104,200 62,525,000 72,945,900
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,881,400 8,257,700 9,634,000
(RINGAN)
332 J-1-10-II 13,924,600 16,709,600 19,494,500
(SEDANG)
333 J-1-10-III 14,471,100 17,365,400 20,259,600
(BERAT)
334 J-1-20-I 9,750,300 11,700,400 13,650,400
(RINGAN)
335 J-1-20-II 12,883,400 15,460,100 18,036,800
(SEDANG)
336 J-1-20-III 19,729,600 23,675,500 27,621,400
(BERAT)
337 J-1-30-I 5,742,700 6,891,300 8,039,800
(RINGAN)
338 J-1-30-II 10,402,900 12,483,500 14,564,100
(SEDANG)

- 706 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,814,800 3,377,800 3,940,700
374 J-4-21-II 4,534,600 5,441,500 6,348,400
375 J-4-21-III 6,327,700 7,593,200 8,858,800
376 K-1-10-I 6,238,400 7,486,100 8,733,800
BESAR (RINGAN)
377 K-1-10-II 7,839,900 9,407,900 10,975,900
BESAR (SEDANG)
378 K-1-10-III 9,188,700 11,026,400 12,864,100
BESAR (BERAT)
382 K-1-12-I 2,617,600 3,141,100 3,664,600
FEMORAL (RINGAN)
383 K-1-12-II 3,404,400 4,085,300 4,766,200
FEMORAL (SEDANG)
384 K-1-12-III 6,744,700 8,093,700 9,442,600
FEMORAL (BERAT)
388 K-1-14-I 4,790,700 5,748,800 6,707,000
(RINGAN)
389 K-1-14-II 5,614,600 6,737,500 7,860,400
(SEDANG)

394 K-1-30-I 5,486,000 6,583,200 7,680,400
395 K-1-30-II 9,742,900 11,691,500 13,640,100
396 K-1-30-III 13,406,400 16,087,700 18,769,000

398 K-1-40-II 6,748,700 8,098,400 9,448,200
(SEDANG)

- 707 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 3,129,000 3,754,700 4,380,500
413 K-4-13-II 4,047,500 4,857,000 5,666,500
414 K-4-13-III 6,234,400 7,481,300 8,728,200
415 K-4-14-I 1,983,800 2,380,500 2,777,300
(RINGAN)
416 K-4-14-II 2,662,900 3,195,400 3,728,000
(SEDANG)
417 K-4-14-III 4,272,900 5,127,400 5,982,000
(BERAT)

424 K-4-17-I 1,487,500 1,785,000 2,082,500
(RINGAN)
425 K-4-17-II 2,034,500 2,441,500 2,848,400
(SEDANG)
426 K-4-17-III 2,441,500 2,929,700 3,418,000
(BERAT)
427 K-4-18-I 1,314,400 1,577,300 1,840,200
(RINGAN)
428 K-4-18-II 1,867,900 2,241,500 2,615,000
(SEDANG)
436 L-1-40-I 3,910,700 4,692,800 5,474,900
(RINGAN)
437 L-1-40-II 7,843,900 9,412,700 10,981,500
(SEDANG)
438 L-1-40-III 13,203,000 15,843,700 18,484,300
(BERAT)
451 L-4-13-I 2,397,700 2,877,200 3,356,700
PAYUDARA (RINGAN)
- 708 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,817,900 3,381,500 3,945,100
PAYUDARA (SEDANG)
453 L-4-13-III 4,146,600 4,975,900 5,805,300
PAYUDARA (BERAT)
454 L-4-14-I 2,312,600 2,775,100 3,237,600
(RINGAN)
455 L-4-14-II 3,473,500 4,168,200 4,863,000
(SEDANG)
456 L-4-14-III 4,896,400 5,875,600 6,854,900
(BERAT)
457 M-1-01-I 8,174,700 9,809,600 11,444,500
458 M-1-01-II 11,619,100 13,942,900 16,266,800
459 M-1-01-III 16,321,400 19,585,700 22,850,000
463 M-1-03-I 19,671,500 23,605,800 27,540,100
464 M-1-03-II 23,008,600 27,610,300 32,212,100
465 M-1-03-III 28,477,000 34,172,400 39,867,900
472 M-1-07-I 6,456,200 7,747,500 9,038,700
473 M-1-07-II 8,649,100 10,379,000 12,108,800
474 M-1-07-III 17,619,100 21,142,900 24,666,700
475 M-1-10-I 10,628,100 12,753,700 14,879,300
WAJAH (RINGAN)
476 M-1-10-II 23,322,000 27,986,400 32,650,800
WAJAH (SEDANG)
477 M-1-10-III 50,303,300 60,364,000 70,424,600
WAJAH (BERAT)
478 M-1-20-I 9,707,400 11,648,900 13,590,400
(RINGAN)
479 M-1-20-II 12,402,200 14,882,700 17,363,100
(SEDANG)

484 M-1-40-I 3,390,000 4,068,000 4,746,000
INTERNAL (RINGAN)
485 M-1-40-II 6,012,000 7,214,400 8,416,700
INTERNAL (SEDANG)
486 M-1-40-III 8,583,900 10,300,700 12,017,500
INTERNAL (BERAT)
490 M-1-60-I 6,274,000 7,528,800 8,783,600
491 M-1-60-II 7,887,800 9,465,400 11,043,000
492 M-1-60-III 11,915,500 14,298,600 16,681,700
- 709 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 11,623,700 13,948,400 16,273,100
KAKI (RINGAN)
494 M-1-70-II 12,786,000 15,343,300 17,900,500
KAKI (SEDANG)
495 M-1-70-III 14,638,300 17,566,000 20,493,700
KAKI (BERAT)
502 M-4-11-I 2,900,400 3,480,500 4,060,600
(RINGAN)
503 M-4-11-II 6,359,000 7,630,800 8,902,600
(SEDANG)
504 M-4-11-III 9,194,100 11,032,900 12,871,700
(BERAT)
505 M-4-12-I 2,315,200 2,778,200 3,241,300
(RINGAN)
506 M-4-12-II 3,850,800 4,620,900 5,391,100
(SEDANG)
507 M-4-12-III 5,150,800 6,181,000 7,211,100
(BERAT)
508 M-4-13-I 3,855,000 4,626,000 5,397,000
509 M-4-13-II 5,792,000 6,950,400 8,108,800
510 M-4-13-III 11,300,000 13,560,000 15,820,000
520 M-4-17-I 2,896,800 3,476,200 4,055,600
(RINGAN)
521 M-4-17-II 4,051,500 4,861,800 5,672,100
(SEDANG)
522 M-4-17-III 5,657,700 6,789,200 7,920,800
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,303,300 2,763,900 3,224,600
(RINGAN)
530 M-4-20-II 3,372,700 4,047,300 4,721,800
(SEDANG)
531 M-4-20-III 3,769,500 4,523,300 5,277,200
(BERAT)
532 M-4-21-I 2,319,200 2,783,100 3,246,900
533 M-4-21-II 2,900,700 3,480,800 4,060,900
- 710 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 6,503,200 7,803,900 9,104,500
541 N-1-12-I 3,409,500 4,091,400 4,773,300
542 N-1-12-II 6,788,000 8,145,600 9,503,200
543 N-1-12-III 14,730,200 17,676,300 20,622,300
547 N-1-30-I 6,822,200 8,186,600 9,551,100
BAWAH (RINGAN)
548 N-1-30-II 10,320,700 12,384,800 14,448,900
BAWAH (SEDANG)
549 N-1-30-III 11,878,100 14,253,700 16,629,300
BAWAH (BERAT)
550 N-1-40-I 6,126,800 7,352,200 8,577,600
(RINGAN)
551 N-1-40-II 8,320,100 9,984,100 11,648,100
(SEDANG)
552 N-1-40-III 9,683,500 11,620,200 13,556,900
(BERAT)
553 N-4-10-I 2,603,000 3,123,700 3,644,300
(RINGAN)
554 N-4-10-II 3,148,400 3,778,100 4,407,800
(SEDANG)
555 N-4-10-III 4,630,900 5,557,100 6,483,200
(BERAT)
568 N-4-15-I 2,370,900 2,845,100 3,319,300
URIN (RINGAN)
569 N-4-15-II 2,941,900 3,530,200 4,118,600
URIN (SEDANG)
570 N-4-15-III 3,357,200 4,028,600 4,700,000
URIN (BERAT)
571 N-4-16-I 2,903,200 3,483,800 4,064,400
(RINGAN)
572 N-4-16-II 4,143,700 4,972,500 5,801,200
(SEDANG)
573 N-4-16-III 5,515,600 6,618,700 7,721,900
(BERAT)
- 711 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 2,698,600 3,238,400 3,778,100
578 O-6-11-II 2,999,200 3,599,100 4,198,900
579 O-6-11-III 3,731,100 4,477,300 5,223,500
580 O-6-12-I 1,911,900 2,294,300 2,676,700
581 O-6-12-II 2,296,200 2,755,500 3,214,700
582 O-6-12-III 2,885,300 3,462,400 4,039,400
586 P-8-01-I 42,693,900 51,232,700 59,771,500
587 P-8-01-II 52,827,300 63,392,800 73,958,200
588 P-8-01-III 62,004,400 74,405,300 86,806,200
589 P-8-02-I 71,929,700 86,315,600 100,701,600
590 P-8-02-II 82,510,700 99,012,800 115,515,000
591 P-8-02-III 94,274,400 113,129,300 131,984,100
592 P-8-03-I 7,772,800 9,327,400 10,882,000
593 P-8-03-II 11,532,400 13,838,900 16,145,300
594 P-8-03-III 13,052,400 15,662,800 18,273,300
595 P-8-04-I 23,047,300 27,656,800 32,266,200
596 P-8-04-II 38,801,200 46,561,500 54,321,700
597 P-8-04-III 55,631,200 66,757,400 77,883,600
598 P-8-05-I 16,298,200 19,557,800 22,817,500
599 P-8-05-II 23,629,700 28,355,600 33,081,600
600 P-8-05-III 33,909,600 40,691,500 47,473,400
601 P-8-06-I 4,135,200 4,962,200 5,789,300
602 P-8-06-II 11,594,200 13,913,000 16,231,800
603 P-8-06-III 15,359,400 18,431,300 21,503,200
604 P-8-07-I 4,005,400 4,806,400 5,607,500
605 P-8-07-II 11,230,100 13,476,100 15,722,200
606 P-8-07-III 14,877,100 17,852,600 20,828,000
607 P-8-08-I 4,063,600 4,876,300 5,689,100
608 P-8-08-II 5,766,200 6,919,400 8,072,600
609 P-8-08-III 9,336,700 11,204,000 13,071,300
610 P-8-11-I 7,066,200 8,479,500 9,892,700
MAYOR (RINGAN)
611 P-8-11-II 10,484,000 12,580,800 14,677,600
MAYOR (SEDANG)
- 712 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 11,865,800 14,238,900 16,612,100
MAYOR (BERAT)
613 P-8-12-I 6,144,500 7,373,500 8,602,400
MAYOR (RINGAN)
614 P-8-12-II 8,736,700 10,484,000 12,231,300
MAYOR (SEDANG)
615 P-8-12-III 9,888,200 11,865,800 13,843,400
MAYOR (BERAT)
616 P-8-13-I 5,278,000 6,333,700 7,389,300
MAYOR (RINGAN)
617 P-8-13-II 8,233,800 9,880,500 11,527,300
MAYOR (SEDANG)
618 P-8-13-III 11,238,700 13,486,500 15,734,200
MAYOR (BERAT)
619 P-8-14-I 2,784,700 3,341,600 3,898,600
620 P-8-14-II 5,668,500 6,802,200 7,935,900
621 P-8-14-III 10,517,200 12,620,700 14,724,100
622 P-8-15-I 2,088,600 2,506,300 2,924,000
ASPIRASI (RINGAN)
623 P-8-15-II 4,182,400 5,018,900 5,855,400
ASPIRASI (SEDANG)
624 P-8-15-III 4,907,300 5,888,800 6,870,200
ASPIRASI (BERAT)
625 P-8-16-I 1,890,200 2,268,200 2,646,200
626 P-8-16-II 3,632,300 4,358,700 5,085,200
627 P-8-16-III 7,407,200 8,888,600 10,370,000
628 P-8-17-I 3,518,700 4,222,400 4,926,200
(RINGAN)
629 P-8-17-II 6,333,700 7,600,400 8,867,100
(SEDANG)
630 P-8-17-III 8,645,200 10,374,200 12,103,200
(BERAT)
631 S-4-10-I 2,131,100 2,557,400 2,983,600
632 S-4-10-II 2,625,900 3,151,100 3,676,200
633 S-4-10-III 3,594,600 4,313,500 5,032,400
640 S-4-13-I 2,313,800 2,776,500 3,239,300
(RINGAN)
641 S-4-13-II 4,104,800 4,925,800 5,746,700
(SEDANG)
642 S-4-13-III 6,662,600 7,995,100 9,327,700
(BERAT)
643 S-4-14-I 1,170,900 1,405,100 1,639,300
644 S-4-14-II 2,487,100 2,984,600 3,482,000
645 S-4-14-III 4,716,500 5,659,800 6,603,100
KANAK-KANAK (BERAT)
646 S-4-15-I 783,100 939,800 1,096,400
647 S-4-15-II 1,477,900 1,773,500 2,069,000
648 S-4-15-III 1,914,100 2,297,000 2,679,800
- 713 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 1,954,500 2,345,400 2,736,300
653 S-4-17-II 2,900,700 3,480,900 4,061,000
654 S-4-17-III 3,488,800 4,186,500 4,884,300
655 T-1-10-I 1,307,700 1,569,300 1,830,800
OBAT (RINGAN)
656 T-1-10-II 1,756,400 2,107,700 2,459,000
OBAT (SEDANG)
657 T-1-10-III 3,195,300 3,834,300 4,473,400
OBAT (BERAT)
658 T-4-10-I 623,600 748,300 873,000
659 T-4-10-II 1,188,500 1,426,200 1,663,900
660 T-4-10-III 1,727,700 2,073,300 2,418,800
661 T-4-11-I 834,800 1,001,800 1,168,800
662 T-4-11-II 1,313,700 1,576,400 1,839,200
663 T-4-11-III 2,116,100 2,539,300 2,962,500
664 T-4-12-I 1,297,200 1,556,700 1,816,100
LAIN (RINGAN)
665 T-4-12-II 1,960,700 2,352,800 2,745,000
LAIN (SEDANG)
666 T-4-12-III 3,035,400 3,642,400 4,249,500
LAIN (BERAT)
670 U-1-11-I 6,611,300 7,933,600 9,255,900
(RINGAN)
671 U-1-11-II 8,380,900 10,057,000 11,733,200
(SEDANG)
672 U-1-11-III 12,058,700 14,470,500 16,882,200
(BERAT)
679 U-1-14-I 3,106,500 3,727,900 4,349,200
(RINGAN)
680 U-1-14-II 3,812,500 4,575,000 5,337,500
(SEDANG)
681 U-1-14-III 4,517,800 5,421,300 6,324,900
(BERAT)
685 U-1-20-I 4,716,200 5,659,500 6,602,700
686 U-1-20-II 7,019,100 8,422,900 9,826,700
687 U-1-20-III 18,019,300 21,623,100 25,227,000
691 U-4-10-I 2,910,700 3,492,900 4,075,000
- 714 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 6,663,500 7,996,200 9,328,900
693 U-4-10-III 10,230,600 12,276,700 14,322,800
TENGGOROKAN (BERAT)
700 U-4-13-I 1,931,900 2,318,300 2,704,700
701 U-4-13-II 2,277,600 2,733,100 3,188,600
702 U-4-13-III 2,724,100 3,268,900 3,813,700
706 U-4-15-I 2,326,300 2,791,600 3,256,900
707 U-4-15-II 2,898,300 3,478,000 4,057,600
708 U-4-15-III 4,056,200 4,867,400 5,678,700
709 V-1-10-I 3,794,400 4,553,300 5,312,200
(RINGAN)
710 V-1-10-II 7,816,400 9,379,600 10,942,900
(SEDANG)
711 V-1-10-III 9,585,700 11,502,800 13,420,000
(BERAT)
715 V-1-12-I 6,787,000 8,144,400 9,501,800
MODERAT (RINGAN)
716 V-1-12-II 9,268,200 11,121,800 12,975,400
MODERAT (SEDANG)
717 V-1-12-III 11,747,500 14,097,000 16,446,500
MODERAT (BERAT)
718 V-1-13-I 3,540,200 4,248,200 4,956,300
KOMPLEK (RINGAN)
719 V-1-13-II 6,764,100 8,116,900 9,469,800
KOMPLEK (SEDANG)
720 V-1-13-III 10,612,100 12,734,500 14,856,900
KOMPLEK (BERAT)
721 V-1-14-I 6,942,300 8,330,700 9,719,200
(RINGAN)
722 V-1-14-II 10,086,900 12,104,300 14,121,700
(SEDANG)

727 V-4-10-I 3,357,200 4,028,600 4,700,000
(RINGAN)
728 V-4-10-II 5,576,400 6,691,700 7,807,000
(SEDANG)
729 V-4-10-III 9,193,600 11,032,300 12,871,000
(BERAT)
730 V-4-11-I 2,900,800 3,481,000 4,061,100
TUMOR (RINGAN)
731 V-4-11-II 3,892,100 4,670,500 5,449,000
TUMOR (SEDANG)
732 V-4-11-III 5,213,500 6,256,200 7,298,900
TUMOR (BERAT)
- 715 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 7,906,500 9,487,800 11,069,100
734 W-1-01-II 9,476,500 11,371,800 13,267,100
735 W-1-01-III 13,522,700 16,227,300 18,931,800
739 W-1-11-I 1,752,900 2,103,500 2,454,100
SERVIK (RINGAN)
740 W-1-11-II 1,934,300 2,321,200 2,708,100
SERVIK (SEDANG)
741 W-1-11-III 2,139,800 2,567,700 2,995,700
SERVIK (BERAT)
760 W-4-12-I 2,825,700 3,390,900 3,956,000
761 W-4-12-II 3,879,500 4,655,400 5,431,300
762 W-4-12-III 4,228,900 5,074,700 5,920,400
- 716 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 1,233,600 1,480,300 1,727,100
785 Z-4-12-II 3,026,300 3,631,500 4,236,800
786 Z-4-12-III 4,329,300 5,195,200 6,061,000
- 717 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,572,400

33 F-3-10-0 TERAPI SHOCK 445,300
- 718 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,707,000
PENGGANTIAN ALAT
81 I-2-42-0 2,601,200
PERKUTAN LAIN
- 719 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,226,700
192 Q-5-12-0 GIGI 222,900
196 Q-5-16-0 VAKSINASI 97,500
201 Q-5-21-0 ABORSI 194,500
206 Q-5-26-0 BRONKIAL AKUT 207,500
- 720 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 139,700
215 Q-5-35-0 INFEKSI AKUT 454,900
218 Q-5-38-0 PARU AKUT 265,100
234 U-2-23-0 RHINOPLASTY 1,309,600
242 U-3-13-0 337,500
TENGGOROKAN
270 Z-3-11-0 1,831,300
EMPEDU
- 721 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 964,900
289 Z-3-30-0 FOTOTERAPI 80,600
- 722 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,149,000 2,578,800 3,008,600
(RINGAN)
14 A-4-14-II 2,608,600 3,130,300 3,652,000
(SEDANG)
15 A-4-14-III 3,130,300 3,756,300 4,382,400
(BERAT)

31 B-1-13-I 3,618,500 4,342,200 5,065,900
LAIN (RINGAN)
32 B-1-13-II 5,953,800 7,144,500 8,335,300
LAIN (SEDANG)
33 B-1-13-III 7,703,700 9,244,400 10,785,100
LAIN (BERAT)
34 B-1-14-I 4,971,900 5,966,300 6,960,700
(RINGAN)
35 B-1-14-II 5,529,700 6,635,600 7,741,600
(SEDANG)
40 B-4-11-I 3,243,400 3,892,000 4,540,700
(RINGAN)
41 B-4-11-II 4,540,700 5,448,900 6,357,000
(SEDANG)
42 B-4-11-III 5,501,000 6,601,300 7,701,500
(BERAT)
- 723 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 3,435,800 4,123,000 4,810,200
74 D-1-20-II 9,468,700 11,362,400 13,256,100
75 D-1-20-III 15,020,100 18,024,100 21,028,100
85 D-4-13-I 1,987,300 2,384,800 2,782,200
86 D-4-13-II 2,812,700 3,375,200 3,937,800
87 D-4-13-III 3,597,500 4,317,000 5,036,600
88 D-4-14-I 2,131,500 2,557,800 2,984,100
89 D-4-14-II 3,489,700 4,187,700 4,885,600
90 D-4-14-III 4,268,300 5,122,000 5,975,700
91 E-1-01-I 3,324,100 3,988,900 4,653,700
(RINGAN)
92 E-1-01-II 4,354,200 5,225,000 6,095,800
(SEDANG)

97 E-1-20-I 5,000,900 6,001,000 7,001,200
TIROGLOSAL (RINGAN)
- 724 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 6,731,000 8,077,200 9,423,400
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,276,700 11,132,100 12,987,400
TIROGLOSAL (BERAT)
100 E-4-10-I 3,249,500 3,899,400 4,549,300
METABOLIK (RINGAN)
101 E-4-10-II 4,540,600 5,448,700 6,356,800
METABOLIK (SEDANG)
102 E-4-10-III 5,635,800 6,762,900 7,890,100
METABOLIK (BERAT)
109 E-4-13-I 2,459,800 2,951,700 3,443,700
(RINGAN)
110 E-4-13-II 3,603,100 4,323,800 5,044,400
(SEDANG)

118 F-4-12-I 1,388,400 1,666,000 1,943,700
(RINGAN)
119 F-4-12-II 1,973,800 2,368,600 2,763,300
(SEDANG)
120 F-4-12-III 4,288,000 5,145,600 6,003,200
(BERAT)
130 F-4-16-I 3,647,400 4,376,900 5,106,400
131 F-4-16-II 4,240,700 5,088,900 5,937,000
132 F-4-16-III 5,660,600 6,792,800 7,924,900
142 G-1-01-I 5,375,000 6,450,000 7,525,000
(RINGAN)
- 725 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 7,406,300 8,887,600 10,368,800
(SEDANG)
144 G-1-01-III 14,397,900 17,277,500 20,157,000
(BERAT)
151 G-1-12-I 3,283,200 3,939,900 4,596,500
(RINGAN)
152 G-1-12-II 6,154,600 7,385,500 8,616,400
(SEDANG)
153 G-1-12-III 8,387,500 10,065,000 11,742,400
(BERAT)
163 G-4-10-I 2,818,300 3,382,000 3,945,600
(RINGAN)
164 G-4-10-II 3,444,900 4,133,900 4,822,900
(SEDANG)
165 G-4-10-III 4,727,000 5,672,400 6,617,800
(BERAT)
166 G-4-11-I 2,950,300 3,540,400 4,130,400
167 G-4-11-II 3,919,100 4,702,900 5,486,800
168 G-4-11-III 5,758,500 6,910,200 8,061,900
DEGENERATIF (BERAT)
169 G-4-12-I 3,273,000 3,927,600 4,582,200
(RINGAN)
170 G-4-12-II 4,134,100 4,960,900 5,787,700
(SEDANG)

172 G-4-13-I 1,966,100 2,359,400 2,752,600
(RINGAN)
173 G-4-13-II 3,428,600 4,114,300 4,800,000
(SEDANG)
174 G-4-13-III 4,066,400 4,879,700 5,692,900
(BERAT)
175 G-4-14-I 3,335,300 4,002,400 4,669,500
INFARK (RINGAN)
176 G-4-14-II 4,459,100 5,350,900 6,242,800
INFARK (SEDANG)
177 G-4-14-III 5,596,700 6,716,100 7,835,400
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 726 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 2,992,300 3,590,800 4,189,300
(RINGAN)
185 G-4-17-II 3,923,600 4,708,300 5,493,100
(SEDANG)
186 G-4-17-III 4,930,200 5,916,200 6,902,300
(BERAT)
190 G-4-19-I 2,458,700 2,950,500 3,442,200
191 G-4-19-II 4,155,900 4,987,000 5,818,200
192 G-4-19-III 5,456,500 6,547,800 7,639,100
211 G-4-26-I 2,651,900 3,182,300 3,712,700
LAIN (RINGAN)
212 G-4-26-II 3,085,000 3,702,000 4,319,000
LAIN (SEDANG)
213 G-4-26-III 4,613,000 5,535,600 6,458,200
LAIN (BERAT)
232 I-1-02-I 17,226,100 20,671,400 24,116,600
(RINGAN)
- 727 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 22,221,500 26,665,800 31,110,100
(SEDANG)
234 I-1-02-III 27,389,400 32,867,300 38,345,200
(BERAT)
235 I-1-03-I 9,949,900 11,939,800 13,929,800
ANOMALI (RINGAN)
236 I-1-03-II 13,792,600 16,551,100 19,309,600
ANOMALI (SEDANG)
237 I-1-03-III 17,503,800 21,004,600 24,505,400
ANOMALI (BERAT)
238 I-1-04-I 14,993,900 17,992,700 20,991,500
JANTUNG (RINGAN)
239 I-1-04-II 23,664,400 28,397,300 33,130,200
JANTUNG (SEDANG)
240 I-1-04-III 37,803,800 45,364,500 52,925,300
JANTUNG (BERAT)
241 I-1-05-I 19,238,600 23,086,300 26,934,000
242 I-1-05-II 23,086,400 27,703,600 32,320,900
243 I-1-05-III 31,766,700 38,120,000 44,473,300
247 I-1-07-I 16,884,000 20,260,800 23,637,600
JANTUNG (RINGAN)
248 I-1-07-II 20,829,900 24,995,800 29,161,800
JANTUNG (SEDANG)
249 I-1-07-III 22,725,300 27,270,400 31,815,400
JANTUNG (BERAT)
250 I-1-11-I 2,699,400 3,239,300 3,779,200
251 I-1-11-II 3,001,500 3,601,700 4,202,000
252 I-1-11-III 3,994,000 4,792,800 5,591,600
253 I-1-12-I 7,770,100 9,324,200 10,878,200
(RINGAN)
254 I-1-12-II 12,690,200 15,228,200 17,766,300
(SEDANG)
255 I-1-12-III 16,695,900 20,035,100 23,374,200
(BERAT)
256 I-1-13-I 7,536,900 9,044,300 10,551,700
KOMPLEK (RINGAN)
257 I-1-13-II 10,037,000 12,044,400 14,051,700
KOMPLEK (SEDANG)
258 I-1-13-III 12,378,300 14,854,000 17,329,700
KOMPLEK (BERAT)
259 I-1-14-I 15,426,200 18,511,500 21,596,700
(RINGAN)
260 I-1-14-II 19,172,600 23,007,100 26,841,600
(SEDANG)
261 I-1-14-III 25,122,700 30,147,200 35,171,700
(BERAT)
265 I-1-16-I 7,597,000 9,116,400 10,635,800
266 I-1-16-II 17,189,000 20,626,800 24,064,600
267 I-1-16-III 19,827,300 23,792,700 27,758,200
268 I-1-17-I 8,796,600 10,556,000 12,315,300
(RINGAN)
269 I-1-17-II 11,014,200 13,217,100 15,419,900
(SEDANG)
- 728 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 13,624,400 16,349,300 19,074,200
(BERAT)
271 I-1-20-I 9,915,300 11,898,400 13,881,500
(RINGAN)
272 I-1-20-II 12,387,000 14,864,400 17,341,800
(SEDANG)
273 I-1-20-III 13,021,300 15,625,500 18,229,800
(BERAT)
274 I-1-30-I 7,500,400 9,000,500 10,500,500
JANTUNG (RINGAN)
275 I-1-30-II 15,602,500 18,723,000 21,843,500
JANTUNG (SEDANG)
276 I-1-30-III 24,178,200 29,013,800 33,849,500
JANTUNG (BERAT)

289 I-4-13-I 2,348,300 2,817,900 3,287,600
(RINGAN)
290 I-4-13-II 4,193,100 5,031,800 5,870,400
(SEDANG)
291 I-4-13-III 6,041,700 7,250,100 8,458,400
(BERAT)
295 I-4-15-I 4,158,300 4,989,900 5,821,600
(RINGAN)
296 I-4-15-II 5,657,100 6,788,500 7,919,900
(SEDANG)

304 I-4-18-I 2,699,700 3,239,600 3,779,500
JANTUNG (RINGAN)
305 I-4-18-II 4,110,400 4,932,400 5,754,500
JANTUNG (SEDANG)
306 I-4-18-III 5,580,500 6,696,600 7,812,700
JANTUNG (BERAT)

308 I-4-19-II 4,066,000 4,879,200 5,692,400
(SEDANG)
- 729 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 2,226,300 2,671,600 3,116,900
320 I-4-23-II 2,733,300 3,280,000 3,826,600
321 I-4-23-III 5,340,700 6,408,900 7,477,000
322 I-4-24-I 2,004,800 2,405,800 2,806,800
(RINGAN)
323 I-4-24-II 4,616,600 5,539,900 6,463,200
(SEDANG)
324 I-4-24-III 5,836,800 7,004,200 8,171,600
(BERAT)
325 J-1-01-I 36,168,700 43,402,500 50,636,200
326 J-1-01-II 40,931,700 49,118,000 57,304,300
327 J-1-01-III 46,306,600 55,567,900 64,829,200
TRAKEOSTOMI (BERAT)
328 J-1-02-I 19,193,400 23,032,100 26,870,800
329 J-1-02-II 26,724,900 32,069,900 37,414,800
330 J-1-02-III 44,131,900 52,958,300 61,784,700
TRAKEOSTOMI (BERAT)
331 J-1-10-I 5,828,500 6,994,200 8,160,000
(RINGAN)
332 J-1-10-II 11,794,100 14,152,900 16,511,700
(SEDANG)
333 J-1-10-III 12,257,000 14,708,300 17,159,700
(BERAT)
334 J-1-20-I 6,849,200 8,219,000 9,588,800
(RINGAN)
335 J-1-20-II 8,108,600 9,730,300 11,352,000
(SEDANG)
336 J-1-20-III 12,521,000 15,025,200 17,529,400
(BERAT)
337 J-1-30-I 4,864,100 5,836,900 6,809,700
(RINGAN)
338 J-1-30-II 8,811,200 10,573,400 12,335,700
(SEDANG)

- 730 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,596,200 3,115,400 3,634,700
374 J-4-21-II 4,182,400 5,018,900 5,855,400
375 J-4-21-III 5,836,200 7,003,500 8,170,700
376 K-1-10-I 5,283,900 6,340,700 7,397,500
BESAR (RINGAN)
377 K-1-10-II 6,640,400 7,968,500 9,296,500
BESAR (SEDANG)
378 K-1-10-III 7,782,800 9,339,300 10,895,900
BESAR (BERAT)
382 K-1-12-I 2,217,100 2,660,500 3,103,900
FEMORAL (RINGAN)
383 K-1-12-II 2,883,500 3,460,200 4,037,000
FEMORAL (SEDANG)
384 K-1-12-III 5,712,700 6,855,300 7,997,800
FEMORAL (BERAT)
388 K-1-14-I 4,057,700 4,869,200 5,680,800
(RINGAN)
389 K-1-14-II 4,755,500 5,706,600 6,657,700
(SEDANG)

394 K-1-30-I 4,646,600 5,575,900 6,505,200
395 K-1-30-II 8,252,200 9,902,700 11,553,100
396 K-1-30-III 11,355,200 13,626,200 15,897,200

398 K-1-40-II 5,716,100 6,859,300 8,002,500
(SEDANG)

- 731 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 2,650,200 3,180,200 3,710,300
413 K-4-13-II 3,428,200 4,113,900 4,799,500
414 K-4-13-III 5,280,500 6,336,600 7,392,700
415 K-4-14-I 1,680,200 2,016,300 2,352,300
(RINGAN)
416 K-4-14-II 2,255,400 2,706,500 3,157,600
(SEDANG)
417 K-4-14-III 3,619,100 4,342,900 5,066,700
(BERAT)

424 K-4-17-I 1,108,700 1,330,500 1,552,200
(RINGAN)
425 K-4-17-II 1,662,500 1,995,100 2,327,600
(SEDANG)
426 K-4-17-III 1,995,100 2,394,100 2,793,100
(BERAT)
427 K-4-18-I 1,113,300 1,336,000 1,558,600
(RINGAN)
428 K-4-18-II 1,582,100 1,898,500 2,215,000
(SEDANG)
436 L-1-40-I 3,312,300 3,974,800 4,637,200
(RINGAN)
437 L-1-40-II 6,643,700 7,972,500 9,301,200
(SEDANG)
438 L-1-40-III 11,182,900 13,419,500 15,656,100
(BERAT)
451 L-4-13-I 2,211,400 2,653,700 3,096,000
PAYUDARA (RINGAN)
- 732 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,599,100 3,118,900 3,638,700
PAYUDARA (SEDANG)
453 L-4-13-III 3,824,600 4,589,500 5,354,400
PAYUDARA (BERAT)
454 L-4-14-I 1,958,700 2,350,500 2,742,200
(RINGAN)
455 L-4-14-II 2,942,100 3,530,500 4,118,900
(SEDANG)
456 L-4-14-III 4,147,200 4,976,600 5,806,100
(BERAT)
457 M-1-01-I 6,923,900 8,308,700 9,693,400
458 M-1-01-II 9,841,300 11,809,600 13,777,900
459 M-1-01-III 13,824,100 16,588,900 19,353,800
463 M-1-03-I 15,023,700 18,028,500 21,033,200
464 M-1-03-II 17,572,500 21,087,000 24,601,400
465 M-1-03-III 21,748,800 26,098,600 30,448,400
472 M-1-07-I 5,468,400 6,562,100 7,655,800
473 M-1-07-II 7,325,800 8,790,900 10,256,100
474 M-1-07-III 14,923,300 17,907,900 20,892,600
475 M-1-10-I 9,001,900 10,802,300 12,602,700
WAJAH (RINGAN)
476 M-1-10-II 19,753,600 23,704,300 27,655,000
WAJAH (SEDANG)
477 M-1-10-III 42,606,600 51,127,900 59,649,200
WAJAH (BERAT)
478 M-1-20-I 8,222,100 9,866,600 11,511,000
(RINGAN)
479 M-1-20-II 10,504,600 12,605,500 14,706,500
(SEDANG)

484 M-1-40-I 2,871,300 3,445,500 4,019,800
INTERNAL (RINGAN)
485 M-1-40-II 5,092,100 6,110,500 7,128,900
INTERNAL (SEDANG)
486 M-1-40-III 7,270,500 8,724,600 10,178,700
INTERNAL (BERAT)
490 M-1-60-I 5,314,000 6,376,800 7,439,600
491 M-1-60-II 6,680,900 8,017,100 9,353,300
492 M-1-60-III 10,092,400 12,110,900 14,129,300
- 733 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 9,845,200 11,814,200 13,783,300
KAKI (RINGAN)
494 M-1-70-II 10,829,700 12,995,600 15,161,600
KAKI (SEDANG)
495 M-1-70-III 12,398,600 14,878,300 17,358,000
KAKI (BERAT)
502 M-4-11-I 2,456,600 2,948,000 3,439,300
(RINGAN)
503 M-4-11-II 5,386,100 6,463,300 7,540,500
(SEDANG)
504 M-4-11-III 7,787,300 9,344,800 10,902,200
(BERAT)
505 M-4-12-I 1,960,900 2,353,100 2,745,300
(RINGAN)
506 M-4-12-II 3,261,600 3,913,900 4,566,200
(SEDANG)
507 M-4-12-III 4,362,700 5,235,300 6,107,800
(BERAT)
508 M-4-13-I 3,265,200 3,918,200 4,571,200
509 M-4-13-II 4,905,800 5,886,900 6,868,100
510 M-4-13-III 9,571,000 11,485,300 13,399,500
520 M-4-17-I 2,453,600 2,944,300 3,435,000
(RINGAN)
521 M-4-17-II 3,431,600 4,117,900 4,804,300
(SEDANG)
522 M-4-17-III 4,792,000 5,750,400 6,708,800
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 1,950,900 2,341,000 2,731,200
(RINGAN)
530 M-4-20-II 2,856,700 3,428,000 3,999,400
(SEDANG)
531 M-4-20-III 3,192,700 3,831,200 4,469,800
(BERAT)
532 M-4-21-I 1,964,400 2,357,200 2,750,100
533 M-4-21-II 2,456,800 2,948,200 3,439,600
- 734 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 5,508,200 6,609,800 7,711,500
541 N-1-12-I 2,887,900 3,465,400 4,043,000
542 N-1-12-II 5,749,400 6,899,300 8,049,200
543 N-1-12-III 12,476,400 14,971,700 17,467,000
547 N-1-30-I 5,778,400 6,934,000 8,089,700
BAWAH (RINGAN)
548 N-1-30-II 8,741,500 10,489,800 12,238,100
BAWAH (SEDANG)
549 N-1-30-III 10,060,700 12,072,800 14,084,900
BAWAH (BERAT)
550 N-1-40-I 5,189,400 6,227,300 7,265,100
(RINGAN)
551 N-1-40-II 7,047,100 8,456,500 9,865,900
(SEDANG)
552 N-1-40-III 8,201,900 9,842,200 11,482,600
(BERAT)
553 N-4-10-I 2,204,800 2,645,700 3,086,700
(RINGAN)
554 N-4-10-II 2,666,700 3,200,000 3,733,400
(SEDANG)
555 N-4-10-III 3,922,300 4,706,800 5,491,300
(BERAT)
568 N-4-15-I 2,008,100 2,409,800 2,811,400
URIN (RINGAN)
569 N-4-15-II 2,491,700 2,990,100 3,488,400
URIN (SEDANG)
570 N-4-15-III 2,843,500 3,412,200 3,980,900
URIN (BERAT)
571 N-4-16-I 2,459,000 2,950,800 3,442,500
(RINGAN)
572 N-4-16-II 3,509,700 4,211,700 4,913,600
(SEDANG)
573 N-4-16-III 4,671,700 5,606,000 6,540,400
(BERAT)
- 735 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 2,285,700 2,742,900 3,200,000
578 O-6-11-II 2,540,300 3,048,400 3,556,400
579 O-6-11-III 3,160,200 3,792,200 4,424,300
580 O-6-12-I 1,619,400 1,943,300 2,267,200
581 O-6-12-II 1,944,900 2,333,900 2,722,800
582 O-6-12-III 2,443,800 2,932,600 3,421,400
586 P-8-01-I 36,161,500 43,393,800 50,626,100
587 P-8-01-II 44,744,400 53,693,300 62,642,200
588 P-8-01-III 52,517,300 63,020,800 73,524,300
589 P-8-02-I 49,358,700 59,230,400 69,102,200
590 P-8-02-II 56,619,400 67,943,300 79,267,200
591 P-8-02-III 64,691,700 77,630,000 90,568,300
592 P-8-03-I 6,015,600 7,218,700 8,421,800
593 P-8-03-II 8,542,100 10,250,500 11,958,900
594 P-8-03-III 9,652,600 11,583,100 13,513,600
595 P-8-04-I 19,520,900 23,425,100 27,329,300
596 P-8-04-II 25,333,900 30,400,700 35,467,500
597 P-8-04-III 36,322,500 43,587,000 50,851,500
598 P-8-05-I 10,614,900 12,737,800 14,860,800
599 P-8-05-II 20,014,200 24,017,100 28,019,900
600 P-8-05-III 24,424,100 29,308,900 34,193,800
601 P-8-06-I 3,502,500 4,203,000 4,903,500
602 P-8-06-II 9,820,200 11,784,200 13,748,300
603 P-8-06-III 13,009,300 15,611,200 18,213,100
604 P-8-07-I 3,392,500 4,071,000 4,749,500
605 P-8-07-II 9,511,800 11,414,200 13,316,600
606 P-8-07-III 12,600,900 15,121,000 17,641,200
607 P-8-08-I 3,586,600 4,303,900 5,021,200
608 P-8-08-II 5,089,300 6,107,200 7,125,000
609 P-8-08-III 8,240,600 9,888,700 11,536,800
610 P-8-11-I 5,683,100 6,819,700 7,956,300
MAYOR (RINGAN)
611 P-8-11-II 8,070,000 9,684,000 11,298,000
MAYOR (SEDANG)
- 736 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 9,119,100 10,942,900 12,766,700
MAYOR (BERAT)
613 P-8-12-I 5,369,000 6,442,800 7,516,600
MAYOR (RINGAN)
614 P-8-12-II 7,634,000 9,160,800 10,687,600
MAYOR (SEDANG)
615 P-8-12-III 8,640,100 10,368,200 12,096,200
MAYOR (BERAT)
616 P-8-13-I 4,658,500 5,590,200 6,521,900
MAYOR (RINGAN)
617 P-8-13-II 6,149,200 7,379,000 8,608,900
MAYOR (SEDANG)
618 P-8-13-III 9,156,400 10,987,600 12,818,900
MAYOR (BERAT)
619 P-8-14-I 2,358,600 2,830,300 3,302,100
620 P-8-14-II 4,801,200 5,761,400 6,721,700
621 P-8-14-III 8,908,000 10,689,700 12,471,300
622 P-8-15-I 1,769,000 2,122,800 2,476,600
ASPIRASI (RINGAN)
623 P-8-15-II 3,542,500 4,251,000 4,959,500
ASPIRASI (SEDANG)
624 P-8-15-III 4,156,500 4,987,800 5,819,100
ASPIRASI (BERAT)
625 P-8-16-I 1,601,000 1,921,200 2,241,300
626 P-8-16-II 3,076,500 3,691,800 4,307,100
627 P-8-16-III 6,273,800 7,528,600 8,783,400
628 P-8-17-I 3,105,600 3,726,800 4,347,900
(RINGAN)
629 P-8-17-II 5,590,200 6,708,200 7,826,200
(SEDANG)
630 P-8-17-III 7,630,300 9,156,400 10,682,400
(BERAT)
631 S-4-10-I 1,805,100 2,166,100 2,527,100
632 S-4-10-II 2,224,100 2,668,900 3,113,800
633 S-4-10-III 3,044,600 3,653,500 4,262,400
640 S-4-13-I 1,959,700 2,351,700 2,743,600
(RINGAN)
641 S-4-13-II 3,476,700 4,172,100 4,867,400
(SEDANG)
642 S-4-13-III 5,643,200 6,771,800 7,900,500
(BERAT)
643 S-4-14-I 991,800 1,190,100 1,388,500
644 S-4-14-II 2,106,600 2,527,900 2,949,200
645 S-4-14-III 3,994,900 4,793,800 5,592,800
KANAK-KANAK (BERAT)
646 S-4-15-I 663,300 796,000 928,600
647 S-4-15-II 1,251,800 1,502,100 1,752,500
648 S-4-15-III 1,621,300 1,945,500 2,269,800
- 737 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 1,655,500 1,986,600 2,317,700
653 S-4-17-II 2,456,900 2,948,300 3,439,700
654 S-4-17-III 2,955,000 3,546,000 4,137,000
655 T-1-10-I 1,107,600 1,329,200 1,550,700
OBAT (RINGAN)
656 T-1-10-II 1,487,700 1,785,200 2,082,800
OBAT (SEDANG)
657 T-1-10-III 2,706,400 3,247,600 3,788,900
OBAT (BERAT)
658 T-4-10-I 505,100 606,200 707,200
659 T-4-10-II 962,800 1,155,300 1,347,900
660 T-4-10-III 1,399,600 1,679,500 1,959,400
661 T-4-11-I 598,200 717,800 837,500
662 T-4-11-II 941,400 1,129,700 1,318,000
663 T-4-11-III 1,516,200 1,819,500 2,122,700
664 T-4-12-I 1,046,200 1,255,500 1,464,700
LAIN (RINGAN)
665 T-4-12-II 1,581,700 1,898,000 2,214,300
LAIN (SEDANG)
666 T-4-12-III 2,468,500 2,962,200 3,455,900
LAIN (BERAT)
670 U-1-11-I 5,599,800 6,719,700 7,839,700
(RINGAN)
671 U-1-11-II 7,098,500 8,518,200 9,937,900
(SEDANG)
672 U-1-11-III 10,213,700 12,256,400 14,299,100
(BERAT)
679 U-1-14-I 2,631,200 3,157,500 3,683,700
(RINGAN)
680 U-1-14-II 3,229,100 3,875,000 4,520,800
(SEDANG)
681 U-1-14-III 3,826,500 4,591,800 5,357,100
(BERAT)
685 U-1-20-I 3,994,600 4,793,500 5,592,500
686 U-1-20-II 5,945,100 7,134,100 8,323,100
687 U-1-20-III 15,262,200 18,314,600 21,367,100
691 U-4-10-I 2,465,400 2,958,400 3,451,500
- 738 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 5,644,000 6,772,800 7,901,500
693 U-4-10-III 8,665,200 10,398,300 12,131,300
TENGGOROKAN (BERAT)
700 U-4-13-I 1,781,900 2,138,300 2,494,600
701 U-4-13-II 2,100,700 2,520,800 2,940,900
702 U-4-13-III 2,512,500 3,015,000 3,517,500
706 U-4-15-I 1,970,400 2,364,500 2,758,500
707 U-4-15-II 2,454,800 2,945,800 3,436,800
708 U-4-15-III 3,435,600 4,122,700 4,809,800
709 V-1-10-I 3,213,900 3,856,600 4,499,400
(RINGAN)
710 V-1-10-II 6,620,400 7,944,500 9,268,600
(SEDANG)
711 V-1-10-III 8,119,000 9,742,800 11,366,600
(BERAT)
715 V-1-12-I 5,748,500 6,898,200 8,047,900
MODERAT (RINGAN)
716 V-1-12-II 7,850,100 9,420,100 10,990,100
MODERAT (SEDANG)
717 V-1-12-III 9,950,100 11,940,100 13,930,100
MODERAT (BERAT)
718 V-1-13-I 2,998,500 3,598,200 4,197,900
KOMPLEK (RINGAN)
719 V-1-13-II 5,729,200 6,875,000 8,020,800
KOMPLEK (SEDANG)
720 V-1-13-III 8,988,400 10,786,000 12,583,700
KOMPLEK (BERAT)
721 V-1-14-I 5,880,100 7,056,100 8,232,100
(RINGAN)
722 V-1-14-II 8,543,600 10,252,300 11,961,000
(SEDANG)

727 V-4-10-I 2,843,500 3,412,200 3,980,900
(RINGAN)
728 V-4-10-II 4,723,200 5,667,800 6,612,500
(SEDANG)
729 V-4-10-III 7,786,900 9,344,300 10,901,600
(BERAT)
730 V-4-11-I 2,457,000 2,948,300 3,439,700
TUMOR (RINGAN)
731 V-4-11-II 3,296,600 3,955,900 4,615,200
TUMOR (SEDANG)
732 V-4-11-III 4,415,800 5,299,000 6,182,200
TUMOR (BERAT)
- 739 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 6,696,800 8,036,100 9,375,500
734 W-1-01-II 8,026,600 9,631,900 11,237,200
735 W-1-01-III 11,453,700 13,744,400 16,035,200
739 W-1-11-I 1,484,700 1,781,700 2,078,600
SERVIK (RINGAN)
740 W-1-11-II 1,638,400 1,966,100 2,293,700
SERVIK (SEDANG)
741 W-1-11-III 1,812,400 2,174,800 2,537,300
SERVIK (BERAT)
760 W-4-12-I 2,606,200 3,127,500 3,648,700
761 W-4-12-II 3,578,200 4,293,800 5,009,500
762 W-4-12-III 3,900,400 4,680,500 5,460,600
- 740 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 774,200 929,000 1,083,800
785 Z-4-12-II 1,886,300 2,263,500 2,640,800
786 Z-4-12-III 2,392,200 2,870,600 3,349,100
- 741 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,421,900

33 F-3-10-0 TERAPI SHOCK 402,700
- 742 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,447,900
PENGGANTIAN ALAT
81 I-2-42-0 2,352,300
PERKUTAN LAIN
- 743 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,109,300
192 Q-5-12-0 GIGI 201,500
196 Q-5-16-0 VAKSINASI 85,900
201 Q-5-21-0 ABORSI 175,900
206 Q-5-26-0 BRONKIAL AKUT 182,800
- 744 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 123,100
215 Q-5-35-0 INFEKSI AKUT 411,300
218 Q-5-38-0 PARU AKUT 239,700
234 U-2-23-0 RHINOPLASTY 1,184,200
242 U-3-13-0 305,200
TENGGOROKAN
270 Z-3-11-0 1,656,000
EMPEDU
- 745 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 872,600
289 Z-3-30-0 FOTOTERAPI 71,000
- 746 -


REGIONAL 4
RAWAT INAP

13 A-4-14-I 2,213,500 2,656,200 3,098,900
(RINGAN)
14 A-4-14-II 2,686,800 3,224,200 3,761,600
(SEDANG)
15 A-4-14-III 3,224,200 3,869,000 4,513,900
(BERAT)

31 B-1-13-I 3,727,000 4,472,400 5,217,900
LAIN (RINGAN)
32 B-1-13-II 6,132,400 7,358,900 8,585,300
LAIN (SEDANG)
33 B-1-13-III 7,934,800 9,521,700 11,108,700
LAIN (BERAT)
34 B-1-14-I 5,121,100 6,145,300 7,169,500
(RINGAN)
35 B-1-14-II 5,695,600 6,834,700 7,973,800
(SEDANG)
40 B-4-11-I 3,340,700 4,008,800 4,676,900
(RINGAN)
41 B-4-11-II 4,677,000 5,612,400 6,547,700
(SEDANG)
42 B-4-11-III 5,666,100 6,799,300 7,932,500
(BERAT)
- 747 -

REGIONAL 4
RAWAT INAP


73 D-1-20-I 3,538,900 4,246,700 4,954,500
74 D-1-20-II 9,752,700 11,703,300 13,653,800
75 D-1-20-III 15,470,700 18,564,800 21,658,900
85 D-4-13-I 2,046,900 2,456,300 2,865,700
86 D-4-13-II 2,897,100 3,476,500 4,055,900
87 D-4-13-III 3,705,500 4,446,600 5,187,600
88 D-4-14-I 2,195,400 2,634,500 3,073,600
89 D-4-14-II 3,594,400 4,313,300 5,032,200
90 D-4-14-III 4,396,400 5,275,600 6,154,900
91 E-1-01-I 3,423,800 4,108,500 4,793,300
(RINGAN)
92 E-1-01-II 4,484,800 5,381,700 6,278,700
(SEDANG)

97 E-1-20-I 5,150,900 6,181,100 7,211,200
TIROGLOSAL (RINGAN)
- 748 -

REGIONAL 4
RAWAT INAP

98 E-1-20-II 6,932,900 8,319,500 9,706,100
TIROGLOSAL (SEDANG)
99 E-1-20-III 9,555,000 11,466,000 13,377,000
TIROGLOSAL (BERAT)
100 E-4-10-I 3,347,000 4,016,400 4,685,800
METABOLIK (RINGAN)
101 E-4-10-II 4,676,800 5,612,200 6,547,500
METABOLIK (SEDANG)
102 E-4-10-III 5,804,800 6,965,800 8,126,800
METABOLIK (BERAT)
109 E-4-13-I 2,533,600 3,040,300 3,547,000
(RINGAN)
110 E-4-13-II 3,711,200 4,453,500 5,195,700
(SEDANG)

118 F-4-12-I 1,430,000 1,716,000 2,002,000
(RINGAN)
119 F-4-12-II 2,033,000 2,439,600 2,846,200
(SEDANG)
120 F-4-12-III 4,416,600 5,299,900 6,183,300
(BERAT)
130 F-4-16-I 3,756,800 4,508,200 5,259,600
131 F-4-16-II 4,367,900 5,241,500 6,115,100
132 F-4-16-III 5,830,500 6,996,500 8,162,600
142 G-1-01-I 5,536,200 6,643,500 7,750,700
(RINGAN)
- 749 -

REGIONAL 4
RAWAT INAP

143 G-1-01-II 7,628,500 9,154,200 10,679,900
(SEDANG)
144 G-1-01-III 14,829,800 17,795,800 20,761,700
(BERAT)
151 G-1-12-I 3,381,700 4,058,100 4,734,400
(RINGAN)
152 G-1-12-II 6,339,200 7,607,000 8,874,900
(SEDANG)
153 G-1-12-III 8,639,100 10,366,900 12,094,700
(BERAT)
163 G-4-10-I 2,902,800 3,483,400 4,064,000
(RINGAN)
164 G-4-10-II 3,548,300 4,257,900 4,967,600
(SEDANG)
165 G-4-10-III 4,868,800 5,842,600 6,816,300
(BERAT)
166 G-4-11-I 3,038,800 3,646,600 4,254,300
167 G-4-11-II 4,036,700 4,844,000 5,651,400
168 G-4-11-III 5,931,300 7,117,500 8,303,800
DEGENERATIF (BERAT)
169 G-4-12-I 3,371,200 4,045,500 4,719,700
(RINGAN)
170 G-4-12-II 4,258,100 5,109,700 5,961,300
(SEDANG)

172 G-4-13-I 2,025,100 2,430,200 2,835,200
(RINGAN)
173 G-4-13-II 3,531,400 4,237,700 4,944,000
(SEDANG)
174 G-4-13-III 4,188,400 5,026,000 5,863,700
(BERAT)
175 G-4-14-I 3,435,400 4,122,500 4,809,600
INFARK (RINGAN)
176 G-4-14-II 4,592,900 5,511,500 6,430,000
INFARK (SEDANG)
177 G-4-14-III 5,764,600 6,917,500 8,070,500
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 750 -

REGIONAL 4
RAWAT INAP

184 G-4-17-I 3,082,100 3,698,500 4,315,000
(RINGAN)
185 G-4-17-II 4,041,300 4,849,600 5,657,900
(SEDANG)
186 G-4-17-III 5,078,100 6,093,700 7,109,400
(BERAT)
190 G-4-19-I 2,532,500 3,039,000 3,545,500
191 G-4-19-II 4,280,500 5,136,700 5,992,800
192 G-4-19-III 5,620,200 6,744,200 7,868,200
211 G-4-26-I 2,731,500 3,277,800 3,824,100
LAIN (RINGAN)
212 G-4-26-II 3,177,500 3,813,100 4,448,600
LAIN (SEDANG)
213 G-4-26-III 4,751,400 5,701,700 6,652,000
LAIN (BERAT)
232 I-1-02-I 17,742,900 21,291,500 24,840,100
(RINGAN)
- 751 -

REGIONAL 4
RAWAT INAP

233 I-1-02-II 22,888,200 27,465,800 32,043,400
(SEDANG)
234 I-1-02-III 28,211,100 33,853,300 39,495,500
(BERAT)
235 I-1-03-I 10,248,400 12,298,000 14,347,700
ANOMALI (RINGAN)
236 I-1-03-II 14,206,400 17,047,600 19,888,900
ANOMALI (SEDANG)
237 I-1-03-III 18,029,000 21,634,800 25,240,500
ANOMALI (BERAT)
238 I-1-04-I 15,443,700 18,532,500 21,621,200
JANTUNG (RINGAN)
239 I-1-04-II 24,374,400 29,249,200 34,124,100
JANTUNG (SEDANG)
240 I-1-04-III 38,937,900 46,725,500 54,513,100
JANTUNG (BERAT)
241 I-1-05-I 19,815,700 23,778,900 27,742,000
242 I-1-05-II 23,779,000 28,534,800 33,290,500
243 I-1-05-III 32,719,700 39,263,600 45,807,500
247 I-1-07-I 17,390,500 20,868,600 24,346,700
JANTUNG (RINGAN)
248 I-1-07-II 21,454,800 25,745,700 30,036,700
JANTUNG (SEDANG)
249 I-1-07-III 23,407,100 28,088,500 32,769,900
JANTUNG (BERAT)
250 I-1-11-I 2,780,400 3,336,500 3,892,500
251 I-1-11-II 3,091,500 3,709,800 4,328,100
252 I-1-11-III 4,113,800 4,936,600 5,759,400
253 I-1-12-I 8,003,200 9,603,900 11,204,500
(RINGAN)
254 I-1-12-II 13,070,900 15,685,100 18,299,300
(SEDANG)
255 I-1-12-III 17,196,800 20,636,100 24,075,500
(BERAT)
256 I-1-13-I 7,763,000 9,315,600 10,868,300
KOMPLEK (RINGAN)
257 I-1-13-II 10,338,100 12,405,700 14,473,300
KOMPLEK (SEDANG)
258 I-1-13-III 12,749,700 15,299,600 17,849,600
KOMPLEK (BERAT)
259 I-1-14-I 15,889,000 19,066,800 22,244,600
(RINGAN)
260 I-1-14-II 19,747,700 23,697,300 27,646,800
(SEDANG)
261 I-1-14-III 25,876,300 31,051,600 36,226,900
(BERAT)
265 I-1-16-I 7,824,900 9,389,900 10,954,900
266 I-1-16-II 17,704,700 21,245,600 24,786,600
267 I-1-16-III 20,422,100 24,506,500 28,590,900
268 I-1-17-I 9,060,500 10,872,600 12,684,800
(RINGAN)
269 I-1-17-II 11,344,600 13,613,600 15,882,500
(SEDANG)
- 752 -

REGIONAL 4
RAWAT INAP

270 I-1-17-III 14,033,200 16,839,800 19,646,400
(BERAT)
271 I-1-20-I 10,212,800 12,255,300 14,297,900
(RINGAN)
272 I-1-20-II 12,758,600 15,310,300 17,862,000
(SEDANG)
273 I-1-20-III 13,411,900 16,094,300 18,776,700
(BERAT)
274 I-1-30-I 7,725,400 9,270,500 10,815,600
JANTUNG (RINGAN)
275 I-1-30-II 16,070,500 19,284,700 22,498,800
JANTUNG (SEDANG)
276 I-1-30-III 24,903,600 29,884,300 34,865,000
JANTUNG (BERAT)

289 I-4-13-I 2,418,700 2,902,500 3,386,200
(RINGAN)
290 I-4-13-II 4,318,900 5,182,700 6,046,500
(SEDANG)
291 I-4-13-III 6,223,000 7,467,600 8,712,200
(BERAT)
295 I-4-15-I 4,283,000 5,139,600 5,996,200
(RINGAN)
296 I-4-15-II 5,826,800 6,992,100 8,157,500
(SEDANG)

304 I-4-18-I 2,780,700 3,336,800 3,892,900
JANTUNG (RINGAN)
305 I-4-18-II 4,233,700 5,080,400 5,927,100
JANTUNG (SEDANG)
306 I-4-18-III 5,747,900 6,897,500 8,047,100
JANTUNG (BERAT)

308 I-4-19-II 4,188,000 5,025,600 5,863,200
(SEDANG)
- 753 -

REGIONAL 4
RAWAT INAP

319 I-4-23-I 2,293,100 2,751,700 3,210,400
320 I-4-23-II 2,815,300 3,378,400 3,941,400
321 I-4-23-III 5,500,900 6,601,100 7,701,300
322 I-4-24-I 2,065,000 2,478,000 2,891,000
(RINGAN)
323 I-4-24-II 4,755,100 5,706,100 6,657,100
(SEDANG)
324 I-4-24-III 6,011,900 7,214,300 8,416,700
(BERAT)
325 J-1-01-I 37,253,800 44,704,600 52,155,300
326 J-1-01-II 42,159,600 50,591,500 59,023,500
327 J-1-01-III 47,695,800 57,234,900 66,774,100
TRAKEOSTOMI (BERAT)
328 J-1-02-I 19,769,200 23,723,100 27,676,900
329 J-1-02-II 27,526,600 33,032,000 38,537,300
330 J-1-02-III 45,455,900 54,547,100 63,638,200
TRAKEOSTOMI (BERAT)
331 J-1-10-I 6,003,400 7,204,100 8,404,700
(RINGAN)
332 J-1-10-II 12,147,900 14,577,500 17,007,100
(SEDANG)
333 J-1-10-III 12,624,700 15,149,600 17,674,500
(BERAT)
334 J-1-20-I 7,054,600 8,465,600 9,876,500
(RINGAN)
335 J-1-20-II 8,351,900 10,022,200 11,692,600
(SEDANG)
336 J-1-20-III 12,896,600 15,476,000 18,055,300
(BERAT)
337 J-1-30-I 5,010,000 6,012,000 7,014,000
(RINGAN)
338 J-1-30-II 9,075,500 10,890,600 12,705,700
(SEDANG)

- 754 -

REGIONAL 4
RAWAT INAP

373 J-4-21-I 2,674,100 3,208,900 3,743,700
374 J-4-21-II 4,307,900 5,169,400 6,031,000
375 J-4-21-III 6,011,300 7,213,600 8,415,800
376 K-1-10-I 5,442,400 6,530,900 7,619,400
BESAR (RINGAN)
377 K-1-10-II 6,839,600 8,207,500 9,575,400
BESAR (SEDANG)
378 K-1-10-III 8,016,200 9,619,500 11,222,700
BESAR (BERAT)
382 K-1-12-I 2,283,600 2,740,300 3,197,000
FEMORAL (RINGAN)
383 K-1-12-II 2,970,000 3,564,100 4,158,100
FEMORAL (SEDANG)
384 K-1-12-III 5,884,100 7,060,900 8,237,800
FEMORAL (BERAT)
388 K-1-14-I 4,179,400 5,015,300 5,851,200
(RINGAN)
389 K-1-14-II 4,898,200 5,877,800 6,857,500
(SEDANG)

394 K-1-30-I 4,786,000 5,743,200 6,700,400
395 K-1-30-II 8,499,800 10,199,700 11,899,700
396 K-1-30-III 11,695,800 14,035,000 16,374,100

398 K-1-40-II 5,887,600 7,065,100 8,242,600
(SEDANG)

- 755 -

REGIONAL 4
RAWAT INAP

412 K-4-13-I 2,729,700 3,275,600 3,821,600
413 K-4-13-II 3,531,100 4,237,300 4,943,500
414 K-4-13-III 5,439,000 6,526,700 7,614,500
415 K-4-14-I 1,730,600 2,076,800 2,422,900
(RINGAN)
416 K-4-14-II 2,323,100 2,787,700 3,252,300
(SEDANG)
417 K-4-14-III 3,727,700 4,473,200 5,218,700
(BERAT)

424 K-4-17-I 1,142,000 1,370,400 1,598,800
(RINGAN)
425 K-4-17-II 1,712,400 2,054,900 2,397,400
(SEDANG)
426 K-4-17-III 2,054,900 2,465,900 2,876,900
(BERAT)
427 K-4-18-I 1,146,700 1,376,100 1,605,400
(RINGAN)
428 K-4-18-II 1,629,600 1,955,500 2,281,400
(SEDANG)
436 L-1-40-I 3,411,700 4,094,000 4,776,300
(RINGAN)
437 L-1-40-II 6,843,100 8,211,700 9,580,300
(SEDANG)
438 L-1-40-III 11,518,400 13,822,100 16,125,700
(BERAT)
451 L-4-13-I 2,277,800 2,733,400 3,188,900
PAYUDARA (RINGAN)
- 756 -

REGIONAL 4
RAWAT INAP

452 L-4-13-II 2,677,000 3,212,400 3,747,800
PAYUDARA (SEDANG)
453 L-4-13-III 3,939,300 4,727,200 5,515,000
PAYUDARA (BERAT)
454 L-4-14-I 2,017,500 2,421,000 2,824,500
(RINGAN)
455 L-4-14-II 3,030,300 3,636,400 4,242,500
(SEDANG)
456 L-4-14-III 4,271,600 5,125,900 5,980,300
(BERAT)
457 M-1-01-I 7,131,600 8,557,900 9,984,200
458 M-1-01-II 10,136,600 12,163,900 14,191,200
459 M-1-01-III 14,238,800 17,086,600 19,934,400
463 M-1-03-I 15,474,500 18,569,300 21,664,200
464 M-1-03-II 18,099,600 21,719,600 25,339,500
465 M-1-03-III 22,401,300 26,881,600 31,361,800
472 M-1-07-I 5,632,400 6,758,900 7,885,400
473 M-1-07-II 7,545,500 9,054,600 10,563,800
474 M-1-07-III 15,371,000 18,445,100 21,519,300
475 M-1-10-I 9,272,000 11,126,300 12,980,700
WAJAH (RINGAN)
476 M-1-10-II 20,346,200 24,415,400 28,484,600
WAJAH (SEDANG)
477 M-1-10-III 43,884,800 52,661,800 61,438,700
WAJAH (BERAT)
478 M-1-20-I 8,468,800 10,162,600 11,856,300
(RINGAN)
479 M-1-20-II 10,819,800 12,983,700 15,147,700
(SEDANG)

484 M-1-40-I 2,957,400 3,548,900 4,140,400
INTERNAL (RINGAN)
485 M-1-40-II 5,244,900 6,293,800 7,342,800
INTERNAL (SEDANG)
486 M-1-40-III 7,488,600 8,986,400 10,484,100
INTERNAL (BERAT)
490 M-1-60-I 5,473,400 6,568,100 7,662,800
491 M-1-60-II 6,881,400 8,257,700 9,633,900
492 M-1-60-III 10,395,100 12,474,200 14,553,200
- 757 -

REGIONAL 4
RAWAT INAP

493 M-1-70-I 10,140,500 12,168,600 14,196,800
KAKI (RINGAN)
494 M-1-70-II 11,154,600 13,385,500 15,616,400
KAKI (SEDANG)
495 M-1-70-III 12,770,500 15,324,600 17,878,700
KAKI (BERAT)
502 M-4-11-I 2,530,300 3,036,400 3,542,500
(RINGAN)
503 M-4-11-II 5,547,600 6,657,200 7,766,700
(SEDANG)
504 M-4-11-III 8,020,900 9,625,100 11,229,300
(BERAT)
505 M-4-12-I 2,019,800 2,423,700 2,827,700
(RINGAN)
506 M-4-12-II 3,359,400 4,031,300 4,703,200
(SEDANG)
507 M-4-12-III 4,493,600 5,392,300 6,291,000
(BERAT)
508 M-4-13-I 3,363,100 4,035,700 4,708,400
509 M-4-13-II 5,052,900 6,063,500 7,074,100
510 M-4-13-III 9,858,200 11,829,800 13,801,500
520 M-4-17-I 2,527,200 3,032,600 3,538,100
(RINGAN)
521 M-4-17-II 3,534,600 4,241,500 4,948,400
(SEDANG)
522 M-4-17-III 4,935,800 5,923,000 6,910,100
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 2,009,400 2,411,300 2,813,100
(RINGAN)
530 M-4-20-II 2,942,400 3,530,900 4,119,400
(SEDANG)
531 M-4-20-III 3,288,500 3,946,200 4,603,900
(BERAT)
532 M-4-21-I 2,023,300 2,427,900 2,832,600
533 M-4-21-II 2,530,600 3,036,700 3,542,800
- 758 -

REGIONAL 4
RAWAT INAP

534 M-4-21-III 5,673,400 6,808,100 7,942,800
541 N-1-12-I 2,974,500 3,569,400 4,164,300
542 N-1-12-II 5,921,900 7,106,300 8,290,600
543 N-1-12-III 12,850,700 15,420,800 17,991,000
547 N-1-30-I 5,951,700 7,142,100 8,332,400
BAWAH (RINGAN)
548 N-1-30-II 9,003,800 10,804,500 12,605,300
BAWAH (SEDANG)
549 N-1-30-III 10,362,500 12,435,000 14,507,500
BAWAH (BERAT)
550 N-1-40-I 5,345,100 6,414,100 7,483,100
(RINGAN)
551 N-1-40-II 7,258,500 8,710,200 10,161,900
(SEDANG)
552 N-1-40-III 8,447,900 10,137,500 11,827,100
(BERAT)
553 N-4-10-I 2,270,900 2,725,100 3,179,300
(RINGAN)
554 N-4-10-II 2,746,700 3,296,000 3,845,400
(SEDANG)
555 N-4-10-III 4,040,000 4,848,000 5,656,000
(BERAT)
568 N-4-15-I 2,068,400 2,482,100 2,895,700
URIN (RINGAN)
569 N-4-15-II 2,566,500 3,079,800 3,593,100
URIN (SEDANG)
570 N-4-15-III 2,928,800 3,514,600 4,100,300
URIN (BERAT)
571 N-4-16-I 2,532,700 3,039,300 3,545,800
(RINGAN)
572 N-4-16-II 3,615,000 4,338,000 5,061,000
(SEDANG)
573 N-4-16-III 4,811,800 5,774,200 6,736,600
(BERAT)
- 759 -

REGIONAL 4
RAWAT INAP

577 O-6-11-I 2,354,300 2,825,200 3,296,000
578 O-6-11-II 2,616,500 3,139,800 3,663,100
579 O-6-11-III 3,255,000 3,906,000 4,557,000
580 O-6-12-I 1,668,000 2,001,600 2,335,200
581 O-6-12-II 2,003,200 2,403,900 2,804,500
582 O-6-12-III 2,517,100 3,020,600 3,524,000
586 P-8-01-I 37,246,300 44,695,600 52,144,900
587 P-8-01-II 46,086,700 55,304,100 64,521,400
588 P-8-01-III 54,092,900 64,911,400 75,730,000
589 P-8-02-I 50,839,500 61,007,400 71,175,300
590 P-8-02-II 58,318,000 69,981,600 81,645,200
591 P-8-02-III 66,632,400 79,958,900 93,285,400
592 P-8-03-I 6,196,000 7,435,200 8,674,400
593 P-8-03-II 8,798,300 10,558,000 12,317,700
594 P-8-03-III 9,942,100 11,930,600 13,919,000
595 P-8-04-I 20,106,600 24,127,900 28,149,200
596 P-8-04-II 26,094,000 31,312,800 36,531,500
597 P-8-04-III 37,412,200 44,894,600 52,377,100
598 P-8-05-I 10,933,300 13,120,000 15,306,600
599 P-8-05-II 20,614,600 24,737,600 28,860,500
600 P-8-05-III 25,156,800 30,188,200 35,219,600
601 P-8-06-I 3,607,600 4,329,100 5,050,600
602 P-8-06-II 10,114,800 12,137,700 14,160,700
603 P-8-06-III 13,399,600 16,079,500 18,759,400
604 P-8-07-I 3,494,300 4,193,200 4,892,000
605 P-8-07-II 9,797,200 11,756,600 13,716,100
606 P-8-07-III 12,978,900 15,574,700 18,170,400
607 P-8-08-I 3,694,200 4,433,000 5,171,800
608 P-8-08-II 5,242,000 6,290,400 7,338,800
609 P-8-08-III 8,487,800 10,185,400 11,882,900
610 P-8-11-I 5,853,600 7,024,300 8,195,000
MAYOR (RINGAN)
611 P-8-11-II 8,312,100 9,974,500 11,636,900
MAYOR (SEDANG)
- 760 -

REGIONAL 4
RAWAT INAP

612 P-8-11-III 9,392,700 11,271,200 13,149,700
MAYOR (BERAT)
613 P-8-12-I 5,530,100 6,636,100 7,742,100
MAYOR (RINGAN)
614 P-8-12-II 7,863,000 9,435,600 11,008,200
MAYOR (SEDANG)
615 P-8-12-III 8,899,300 10,679,200 12,459,100
MAYOR (BERAT)
616 P-8-13-I 4,798,200 5,757,900 6,717,500
MAYOR (RINGAN)
617 P-8-13-II 6,333,700 7,600,400 8,867,100
MAYOR (SEDANG)
618 P-8-13-III 9,431,100 11,317,300 13,203,500
MAYOR (BERAT)
619 P-8-14-I 2,429,400 2,915,300 3,401,100
620 P-8-14-II 4,945,200 5,934,300 6,923,300
621 P-8-14-III 9,175,300 11,010,300 12,845,400
622 P-8-15-I 1,822,100 2,186,500 2,550,900
ASPIRASI (RINGAN)
623 P-8-15-II 3,648,800 4,378,500 5,108,300
ASPIRASI (SEDANG)
624 P-8-15-III 4,281,200 5,137,400 5,993,600
ASPIRASI (BERAT)
625 P-8-16-I 1,649,000 1,978,800 2,308,600
626 P-8-16-II 3,168,800 3,802,600 4,436,300
627 P-8-16-III 6,462,000 7,754,400 9,046,900
628 P-8-17-I 3,198,800 3,838,600 4,478,300
(RINGAN)
629 P-8-17-II 5,757,900 6,909,400 8,061,000
(SEDANG)
630 P-8-17-III 7,859,200 9,431,100 11,002,900
(BERAT)
631 S-4-10-I 1,859,200 2,231,100 2,602,900
632 S-4-10-II 2,290,800 2,749,000 3,207,200
633 S-4-10-III 3,135,900 3,763,100 4,390,300
640 S-4-13-I 2,018,500 2,422,300 2,826,000
(RINGAN)
641 S-4-13-II 3,581,100 4,297,300 5,013,500
(SEDANG)
642 S-4-13-III 5,812,500 6,975,000 8,137,500
(BERAT)
643 S-4-14-I 1,021,500 1,225,800 1,430,100
644 S-4-14-II 2,169,800 2,603,800 3,037,700
645 S-4-14-III 4,114,700 4,937,600 5,760,600
KANAK-KANAK (BERAT)
646 S-4-15-I 683,200 819,800 956,500
647 S-4-15-II 1,289,300 1,547,200 1,805,000
648 S-4-15-III 1,669,900 2,003,900 2,337,800
- 761 -

REGIONAL 4
RAWAT INAP

652 S-4-17-I 1,705,100 2,046,200 2,387,200
653 S-4-17-II 2,530,600 3,036,700 3,542,900
654 S-4-17-III 3,043,600 3,652,300 4,261,100
655 T-1-10-I 1,140,900 1,369,000 1,597,200
OBAT (RINGAN)
656 T-1-10-II 1,532,300 1,838,800 2,145,300
OBAT (SEDANG)
657 T-1-10-III 2,787,600 3,345,100 3,902,600
OBAT (BERAT)
658 T-4-10-I 520,300 624,300 728,400
659 T-4-10-II 991,600 1,190,000 1,388,300
660 T-4-10-III 1,441,600 1,729,900 2,018,200
661 T-4-11-I 616,200 739,400 862,600
662 T-4-11-II 969,600 1,163,600 1,357,500
663 T-4-11-III 1,561,700 1,874,100 2,186,400
664 T-4-12-I 1,077,600 1,293,100 1,508,600
LAIN (RINGAN)
665 T-4-12-II 1,629,100 1,954,900 2,280,800
LAIN (SEDANG)
666 T-4-12-III 2,542,600 3,051,100 3,559,600
LAIN (BERAT)
670 U-1-11-I 5,767,800 6,921,300 8,074,900
(RINGAN)
671 U-1-11-II 7,311,500 8,773,800 10,236,100
(SEDANG)
672 U-1-11-III 10,520,100 12,624,100 14,728,100
(BERAT)
679 U-1-14-I 2,710,200 3,252,200 3,794,200
(RINGAN)
680 U-1-14-II 3,326,000 3,991,200 4,656,400
(SEDANG)
681 U-1-14-III 3,941,300 4,729,600 5,517,900
(BERAT)
685 U-1-20-I 4,114,500 4,937,300 5,760,200
686 U-1-20-II 6,123,400 7,348,100 8,572,800
687 U-1-20-III 15,720,100 18,864,100 22,008,100
691 U-4-10-I 2,539,300 3,047,200 3,555,100
- 762 -

REGIONAL 4
RAWAT INAP

692 U-4-10-II 5,813,300 6,975,900 8,138,600
693 U-4-10-III 8,925,200 10,710,200 12,495,200
TENGGOROKAN (BERAT)
700 U-4-13-I 1,835,300 2,202,400 2,569,500
701 U-4-13-II 2,163,700 2,596,400 3,029,200
702 U-4-13-III 2,587,900 3,105,400 3,623,000
706 U-4-15-I 2,029,500 2,435,400 2,841,300
707 U-4-15-II 2,528,500 3,034,200 3,539,900
708 U-4-15-III 3,538,600 4,246,400 4,954,100
709 V-1-10-I 3,310,300 3,972,300 4,634,400
(RINGAN)
710 V-1-10-II 6,819,000 8,182,800 9,546,600
(SEDANG)
711 V-1-10-III 8,362,600 10,035,100 11,707,600
(BERAT)
715 V-1-12-I 5,921,000 7,105,200 8,289,400
MODERAT (RINGAN)
716 V-1-12-II 8,085,600 9,702,700 11,319,800
MODERAT (SEDANG)
717 V-1-12-III 10,248,600 12,298,300 14,348,000
MODERAT (BERAT)
718 V-1-13-I 3,088,500 3,706,200 4,323,900
KOMPLEK (RINGAN)
719 V-1-13-II 5,901,000 7,081,200 8,261,500
KOMPLEK (SEDANG)
720 V-1-13-III 9,258,000 11,109,600 12,961,200
KOMPLEK (BERAT)
721 V-1-14-I 6,056,500 7,267,800 8,479,000
(RINGAN)
722 V-1-14-II 8,799,900 10,559,800 12,319,800
(SEDANG)

727 V-4-10-I 2,928,800 3,514,600 4,100,300
(RINGAN)
728 V-4-10-II 4,864,900 5,837,900 6,810,800
(SEDANG)
729 V-4-10-III 8,020,500 9,624,600 11,228,700
(BERAT)
730 V-4-11-I 2,530,700 3,036,800 3,542,900
TUMOR (RINGAN)
731 V-4-11-II 3,395,500 4,074,600 4,753,700
TUMOR (SEDANG)
732 V-4-11-III 4,548,300 5,458,000 6,367,600
TUMOR (BERAT)
- 763 -

REGIONAL 4
RAWAT INAP

733 W-1-01-I 6,897,700 8,277,200 9,656,800
734 W-1-01-II 8,267,400 9,920,800 11,574,300
735 W-1-01-III 11,797,300 14,156,700 16,516,200
739 W-1-11-I 1,529,300 1,835,100 2,141,000
SERVIK (RINGAN)
740 W-1-11-II 1,687,500 2,025,000 2,362,500
SERVIK (SEDANG)
741 W-1-11-III 1,866,700 2,240,100 2,613,400
SERVIK (BERAT)
760 W-4-12-I 2,684,400 3,221,300 3,758,200
761 W-4-12-II 3,685,500 4,422,600 5,159,800
762 W-4-12-III 4,017,400 4,820,900 5,624,400
- 764 -

REGIONAL 4
RAWAT INAP

784 Z-4-12-I 797,400 956,900 1,116,300
785 Z-4-12-II 1,942,900 2,331,500 2,720,000
786 Z-4-12-III 2,464,000 2,956,700 3,449,500
- 765 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 1,493,000

33 F-3-10-0 TERAPI SHOCK 422,800
- 766 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 2,570,300
PENGGANTIAN ALAT
81 I-2-42-0 2,469,900
PERKUTAN LAIN
- 767 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,164,800
192 Q-5-12-0 GIGI 211,600
196 Q-5-16-0 VAKSINASI 90,100
201 Q-5-21-0 ABORSI 184,700
206 Q-5-26-0 BRONKIAL AKUT 192,000
- 768 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 129,200
215 Q-5-35-0 INFEKSI AKUT 431,900
218 Q-5-38-0 PARU AKUT 251,700
234 U-2-23-0 RHINOPLASTY 1,243,400
242 U-3-13-0 320,500
TENGGOROKAN
270 Z-3-11-0 1,738,800
EMPEDU
- 769 -

REGIONAL 4
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 916,200
289 Z-3-30-0 FOTOTERAPI 74,500
- 770 -


REGIONAL 5
RAWAT INAP

13 A-4-14-I 2,457,700 2,949,200 3,440,700
(RINGAN)
14 A-4-14-II 4,135,200 4,962,200 5,789,200
(SEDANG)
15 A-4-14-III 4,962,200 5,954,600 6,947,100
(BERAT)

31 B-1-13-I 7,998,100 9,597,700 11,197,300
LAIN (RINGAN)
32 B-1-13-II 13,159,900 15,791,900 18,423,800
LAIN (SEDANG)
33 B-1-13-III 17,027,700 20,433,300 23,838,800
LAIN (BERAT)
34 B-1-14-I 20,954,900 25,145,900 29,336,900
(RINGAN)
35 B-1-14-II 22,008,600 26,410,300 30,812,000
(SEDANG)
40 B-4-11-I 7,168,900 8,602,700 10,036,500
(RINGAN)
41 B-4-11-II 10,036,600 12,043,900 14,051,200
(SEDANG)
42 B-4-11-III 12,159,200 14,591,000 17,022,900
(BERAT)
- 771 -

REGIONAL 5
RAWAT INAP


73 D-1-20-I 7,594,400 9,113,300 10,632,100
74 D-1-20-II 20,929,000 25,114,800 29,300,600
75 D-1-20-III 33,199,500 39,839,400 46,479,300
85 D-4-13-I 4,392,600 5,271,100 6,149,700
86 D-4-13-II 6,217,000 7,460,500 8,703,900
87 D-4-13-III 7,951,800 9,542,200 11,132,500
88 D-4-14-I 4,711,300 5,653,500 6,595,800
89 D-4-14-II 7,713,500 9,256,300 10,799,000
90 D-4-14-III 9,434,500 11,321,400 13,208,200
91 E-1-01-I 9,391,400 11,269,700 13,147,900
(RINGAN)
92 E-1-01-II 12,820,600 15,384,800 17,948,900
(SEDANG)

97 E-1-20-I 11,053,600 13,264,300 15,475,100
TIROGLOSAL (RINGAN)
- 772 -

REGIONAL 5
RAWAT INAP

98 E-1-20-II 14,877,900 17,853,400 20,829,000
TIROGLOSAL (SEDANG)
99 E-1-20-III 20,504,700 24,605,700 28,706,600
TIROGLOSAL (BERAT)
100 E-4-10-I 3,911,800 4,694,200 5,476,600
METABOLIK (RINGAN)
101 E-4-10-II 7,576,600 9,091,900 10,607,200
METABOLIK (SEDANG)
102 E-4-10-III 12,695,400 15,234,500 17,773,600
METABOLIK (BERAT)
109 E-4-13-I 5,436,900 6,524,300 7,611,700
(RINGAN)
110 E-4-13-II 7,964,200 9,557,000 11,149,900
(SEDANG)

118 F-4-12-I 3,068,700 3,682,500 4,296,200
(RINGAN)
119 F-4-12-II 4,362,800 5,235,300 6,107,900
(SEDANG)
120 F-4-12-III 9,477,900 11,373,500 13,269,100
(BERAT)
130 F-4-16-I 8,062,000 9,674,500 11,286,900
131 F-4-16-II 9,373,500 11,248,100 13,122,800
132 F-4-16-III 12,511,900 15,014,300 17,516,700
142 G-1-01-I 22,711,000 27,253,200 31,795,400
(RINGAN)
- 773 -

REGIONAL 5
RAWAT INAP

143 G-1-01-II 32,573,000 39,087,600 45,602,300
(SEDANG)
144 G-1-01-III 53,292,200 63,950,600 74,609,100
(BERAT)
151 G-1-12-I 7,257,100 8,708,500 10,159,900
(RINGAN)
152 G-1-12-II 13,603,700 16,324,400 19,045,200
(SEDANG)
153 G-1-12-III 18,539,200 22,247,000 25,954,900
(BERAT)
163 G-4-10-I 6,229,400 7,475,300 8,721,200
(RINGAN)
164 G-4-10-II 7,614,400 9,137,300 10,660,200
(SEDANG)
165 G-4-10-III 10,448,300 12,538,000 14,627,600
(BERAT)
166 G-4-11-I 6,521,200 7,825,400 9,129,700
167 G-4-11-II 8,662,600 10,395,100 12,127,600
168 G-4-11-III 12,728,300 15,274,000 17,819,600
DEGENERATIF (BERAT)
169 G-4-12-I 7,234,500 8,681,400 10,128,300
(RINGAN)
170 G-4-12-II 9,137,700 10,965,300 12,792,800
(SEDANG)

172 G-4-13-I 4,345,900 5,215,000 6,084,200
(RINGAN)
173 G-4-13-II 7,578,400 9,094,000 10,609,700
(SEDANG)
174 G-4-13-III 8,988,100 10,785,700 12,583,300
(BERAT)
175 G-4-14-I 7,372,300 8,846,700 10,321,200
INFARK (RINGAN)
176 G-4-14-II 9,856,200 11,827,400 13,798,700
INFARK (SEDANG)
177 G-4-14-III 12,370,700 14,844,800 17,318,900
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 774 -

REGIONAL 5
RAWAT INAP

184 G-4-17-I 6,614,100 7,936,900 9,259,800
(RINGAN)
185 G-4-17-II 8,672,600 10,407,100 12,141,600
(SEDANG)
186 G-4-17-III 10,897,500 13,076,900 15,256,400
(BERAT)
190 G-4-19-I 5,434,700 6,521,600 7,608,500
191 G-4-19-II 9,185,900 11,023,100 12,860,300
192 G-4-19-III 12,060,700 14,472,800 16,884,900
211 G-4-26-I 4,228,900 5,074,600 5,920,400
LAIN (RINGAN)
212 G-4-26-II 4,919,500 5,903,400 6,887,300
LAIN (SEDANG)
213 G-4-26-III 7,356,100 8,827,300 10,298,600
LAIN (BERAT)
232 I-1-02-I 38,075,700 45,690,900 53,306,000
(RINGAN)
- 775 -

REGIONAL 5
RAWAT INAP

233 I-1-02-II 49,117,200 58,940,600 68,764,100
(SEDANG)
234 I-1-02-III 60,540,000 72,648,000 84,756,000
(BERAT)
235 I-1-03-I 35,909,500 43,091,400 50,273,300
ANOMALI (RINGAN)
236 I-1-03-II 49,778,000 59,733,600 69,689,200
ANOMALI (SEDANG)
237 I-1-03-III 63,172,100 75,806,500 88,441,000
ANOMALI (BERAT)
238 I-1-04-I 54,113,700 64,936,400 75,759,100
JANTUNG (RINGAN)
239 I-1-04-II 85,406,000 102,487,200 119,568,400
JANTUNG (SEDANG)
240 I-1-04-III 136,435,500 163,722,600 191,009,700
JANTUNG (BERAT)
241 I-1-05-I 89,637,800 107,565,400 125,493,000
242 I-1-05-II 109,557,400 131,468,800 153,380,300
243 I-1-05-III 149,396,400 179,275,700 209,155,000
247 I-1-07-I 79,678,100 95,613,700 111,549,300
JANTUNG (RINGAN)
248 I-1-07-II 99,597,600 119,517,100 139,436,600
JANTUNG (SEDANG)
249 I-1-07-III 149,396,400 179,275,700 209,155,000
JANTUNG (BERAT)
250 I-1-11-I 5,966,600 7,159,900 8,353,200
251 I-1-11-II 6,634,300 7,961,100 9,288,000
252 I-1-11-III 8,828,200 10,593,800 12,359,400
253 I-1-12-I 17,174,700 20,609,600 24,044,600
(RINGAN)
254 I-1-12-II 28,049,700 33,659,700 39,269,600
(SEDANG)
255 I-1-12-III 36,903,600 44,284,400 51,665,100
(BERAT)
256 I-1-13-I 16,659,200 19,991,100 23,322,900
KOMPLEK (RINGAN)
257 I-1-13-II 22,185,100 26,622,200 31,059,200
KOMPLEK (SEDANG)
258 I-1-13-III 27,360,400 32,832,500 38,304,600
KOMPLEK (BERAT)
259 I-1-14-I 34,097,300 40,916,800 47,736,200
(RINGAN)
260 I-1-14-II 42,377,900 50,853,500 59,329,100
(SEDANG)
261 I-1-14-III 55,529,700 66,635,700 77,741,600
(BERAT)
265 I-1-16-I 16,792,100 20,150,500 23,508,900
266 I-1-16-II 37,993,700 45,592,400 53,191,100
267 I-1-16-III 43,825,100 52,590,100 61,355,100
268 I-1-17-I 19,443,600 23,332,300 27,221,100
(RINGAN)
269 I-1-17-II 24,345,200 29,214,300 34,083,300
(SEDANG)
- 776 -

REGIONAL 5
RAWAT INAP

270 I-1-17-III 30,114,700 36,137,600 42,160,500
(BERAT)
271 I-1-20-I 21,916,300 26,299,500 30,682,800
(RINGAN)
272 I-1-20-II 27,379,500 32,855,400 38,331,200
(SEDANG)
273 I-1-20-III 28,781,500 34,537,800 40,294,100
(BERAT)
274 I-1-30-I 16,578,400 19,894,100 23,209,800
JANTUNG (RINGAN)
275 I-1-30-II 34,486,800 41,384,200 48,281,600
JANTUNG (SEDANG)
276 I-1-30-III 53,442,200 64,130,600 74,819,000
JANTUNG (BERAT)

289 I-4-13-I 5,190,500 6,228,600 7,266,700
(RINGAN)
290 I-4-13-II 9,268,300 11,121,900 12,975,600
(SEDANG)
291 I-4-13-III 13,354,300 16,025,100 18,696,000
(BERAT)
295 I-4-15-I 5,005,800 6,007,000 7,008,200
(RINGAN)
296 I-4-15-II 9,439,500 11,327,400 13,215,300
(SEDANG)

304 I-4-18-I 5,967,200 7,160,600 8,354,100
JANTUNG (RINGAN)
305 I-4-18-II 9,085,300 10,902,400 12,719,400
JANTUNG (SEDANG)
306 I-4-18-III 12,334,800 14,801,800 17,268,800
JANTUNG (BERAT)

308 I-4-19-II 8,987,300 10,784,700 12,582,200
(SEDANG)
- 777 -

REGIONAL 5
RAWAT INAP

319 I-4-23-I 4,921,000 5,905,200 6,889,300
320 I-4-23-II 6,041,500 7,249,800 8,458,100
321 I-4-23-III 11,804,800 14,165,800 16,526,700
322 I-4-24-I 3,197,000 3,836,400 4,475,800
(RINGAN)
323 I-4-24-II 7,361,800 8,834,200 10,306,500
(SEDANG)
324 I-4-24-III 9,307,700 11,169,200 13,030,800
(BERAT)
325 J-1-01-I 101,294,800 121,553,800 141,812,700
326 J-1-01-II 114,633,900 137,560,700 160,487,500
327 J-1-01-III 157,240,200 188,688,200 220,136,200
TRAKEOSTOMI (BERAT)
328 J-1-02-I 66,082,600 79,299,100 92,515,600
329 J-1-02-II 83,383,400 100,060,100 116,736,800
330 J-1-02-III 97,546,800 117,056,100 136,565,500
TRAKEOSTOMI (BERAT)
331 J-1-10-I 12,883,100 15,459,700 18,036,300
(RINGAN)
332 J-1-10-II 26,069,000 31,282,800 36,496,600
(SEDANG)
333 J-1-10-III 27,092,100 32,510,500 37,928,900
(BERAT)
334 J-1-20-I 35,490,600 42,588,700 49,686,800
(RINGAN)
335 J-1-20-II 37,163,400 44,596,100 52,028,700
(SEDANG)
336 J-1-20-III 41,822,500 50,187,000 58,551,600
(BERAT)
337 J-1-30-I 10,751,300 12,901,500 15,051,800
(RINGAN)
338 J-1-30-II 19,475,800 23,370,900 27,266,100
(SEDANG)

- 778 -

REGIONAL 5
RAWAT INAP

373 J-4-21-I 3,125,400 3,750,400 4,375,500
374 J-4-21-II 6,978,900 8,374,700 9,770,400
375 J-4-21-III 13,147,000 15,776,300 18,405,700
376 K-1-10-I 11,679,300 14,015,200 16,351,000
BESAR (RINGAN)
377 K-1-10-II 14,677,500 17,613,000 20,548,500
BESAR (SEDANG)
378 K-1-10-III 17,202,600 20,643,100 24,083,600
BESAR (BERAT)
382 K-1-12-I 4,900,500 5,880,600 6,860,600
FEMORAL (RINGAN)
383 K-1-12-II 6,373,600 7,648,300 8,923,100
FEMORAL (SEDANG)
384 K-1-12-III 12,627,100 15,152,500 17,678,000
FEMORAL (BERAT)
388 K-1-14-I 8,072,000 9,686,400 11,300,800
(RINGAN)
389 K-1-14-II 9,460,200 11,352,300 13,244,300
(SEDANG)

394 K-1-30-I 10,270,500 12,324,600 14,378,800
395 K-1-30-II 18,240,200 21,888,300 25,536,300
396 K-1-30-III 25,098,800 30,118,600 35,138,300

398 K-1-40-II 12,634,500 15,161,500 17,688,400
(SEDANG)

- 779 -

REGIONAL 5
RAWAT INAP

412 K-4-13-I 5,857,900 7,029,400 8,201,000
413 K-4-13-II 7,577,500 9,093,000 10,608,500
414 K-4-13-III 11,671,800 14,006,200 16,340,500
415 K-4-14-I 3,342,500 4,011,000 4,679,500
(RINGAN)
416 K-4-14-II 4,486,800 5,384,100 6,281,500
(SEDANG)
417 K-4-14-III 7,199,500 8,639,400 10,079,300
(BERAT)

424 K-4-17-I 2,116,400 2,539,700 2,963,000
(RINGAN)
425 K-4-17-II 2,606,400 3,127,700 3,649,000
(SEDANG)
426 K-4-17-III 3,127,700 3,753,200 4,378,800
(BERAT)
427 K-4-18-I 1,865,100 2,238,100 2,611,100
(RINGAN)
428 K-4-18-II 3,147,300 3,776,800 4,406,300
(SEDANG)
436 L-1-40-I 7,321,300 8,785,600 10,249,800
(RINGAN)
437 L-1-40-II 14,685,000 17,621,900 20,558,900
(SEDANG)
438 L-1-40-III 24,718,000 29,661,700 34,605,300
(BERAT)
451 L-4-13-I 2,662,200 3,194,600 3,727,100
PAYUDARA (RINGAN)
- 780 -

REGIONAL 5
RAWAT INAP

452 L-4-13-II 4,336,900 5,204,300 6,071,600
PAYUDARA (SEDANG)
453 L-4-13-III 8,615,400 10,338,500 12,061,500
PAYUDARA (BERAT)
454 L-4-14-I 4,329,400 5,195,300 6,061,200
(RINGAN)
455 L-4-14-II 6,503,000 7,803,600 9,104,200
(SEDANG)
456 L-4-14-III 9,166,700 11,000,100 12,833,400
(BERAT)
457 M-1-01-I 15,304,200 18,365,000 21,425,800
458 M-1-01-II 21,752,700 26,103,300 30,453,800
459 M-1-01-III 30,556,100 36,667,300 42,778,500
463 M-1-03-I 54,221,300 65,065,600 75,909,900
464 M-1-03-II 63,419,800 76,103,700 88,787,700
465 M-1-03-III 78,492,500 94,191,000 109,889,500
472 M-1-07-I 19,735,700 23,682,800 27,629,900
473 M-1-07-II 26,439,000 31,726,800 37,014,600
474 M-1-07-III 53,858,700 64,630,400 75,402,100
475 M-1-10-I 23,322,300 27,986,800 32,651,300
WAJAH (RINGAN)
476 M-1-10-II 55,762,700 66,915,200 78,067,700
WAJAH (SEDANG)
477 M-1-10-III 120,274,900 144,329,900 168,384,900
WAJAH (BERAT)
478 M-1-20-I 18,173,800 21,808,500 25,443,300
(RINGAN)
479 M-1-20-II 23,218,800 27,862,600 32,506,400
(SEDANG)

484 M-1-40-I 7,615,800 9,139,000 10,662,200
INTERNAL (RINGAN)
485 M-1-40-II 11,255,300 13,506,300 15,757,400
INTERNAL (SEDANG)
486 M-1-40-III 16,070,400 19,284,400 22,498,500
INTERNAL (BERAT)
490 M-1-60-I 11,745,800 14,095,000 16,444,100
491 M-1-60-II 14,767,200 17,720,600 20,674,100
492 M-1-60-III 22,307,600 26,769,200 31,230,700
- 781 -

REGIONAL 5
RAWAT INAP

493 M-1-70-I 21,761,200 26,113,500 30,465,700
KAKI (RINGAN)
494 M-1-70-II 23,937,400 28,724,800 33,512,300
KAKI (SEDANG)
495 M-1-70-III 27,405,100 32,886,100 38,367,200
KAKI (BERAT)
502 M-4-11-I 5,430,000 6,516,000 7,602,000
(RINGAN)
503 M-4-11-II 11,905,000 14,286,000 16,667,100
(SEDANG)
504 M-4-11-III 17,212,600 20,655,200 24,097,700
(BERAT)
505 M-4-12-I 4,334,400 5,201,200 6,068,100
(RINGAN)
506 M-4-12-II 7,209,200 8,651,100 10,092,900
(SEDANG)
507 M-4-12-III 9,643,100 11,571,700 13,500,300
(BERAT)
508 M-4-13-I 7,217,100 8,660,600 10,104,000
509 M-4-13-II 10,843,400 13,012,100 15,180,800
510 M-4-13-III 21,155,300 25,386,400 29,617,400
520 M-4-17-I 4,881,000 5,857,100 6,833,300
(RINGAN)
521 M-4-17-II 6,826,600 8,191,900 9,557,200
(SEDANG)
522 M-4-17-III 9,532,800 11,439,400 13,346,000
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
529 M-4-20-I 3,880,900 4,657,000 5,433,200
(RINGAN)
530 M-4-20-II 5,682,800 6,819,400 7,956,000
(SEDANG)
531 M-4-20-III 6,351,300 7,621,500 8,891,800
(BERAT)
532 M-4-21-I 3,907,700 4,689,300 5,470,800
533 M-4-21-II 4,887,400 5,864,900 6,842,400
- 782 -

REGIONAL 5
RAWAT INAP

534 M-4-21-III 10,957,500 13,149,000 15,340,500
541 N-1-12-I 6,383,100 7,659,800 8,936,400
542 N-1-12-II 12,708,200 15,249,800 17,791,400
543 N-1-12-III 27,577,200 33,092,600 38,608,000
547 N-1-30-I 12,772,200 15,326,600 17,881,000
BAWAH (RINGAN)
548 N-1-30-II 19,321,800 23,186,100 27,050,500
BAWAH (SEDANG)
549 N-1-30-III 22,237,500 26,685,000 31,132,500
BAWAH (BERAT)
550 N-1-40-I 11,470,300 13,764,400 16,058,500
(RINGAN)
551 N-1-40-II 15,576,400 18,691,700 21,807,000
(SEDANG)
552 N-1-40-III 18,128,900 21,754,700 25,380,500
(BERAT)
553 N-4-10-I 4,873,300 5,848,000 6,822,600
(RINGAN)
554 N-4-10-II 5,894,300 7,073,200 8,252,100
(SEDANG)
555 N-4-10-III 8,669,700 10,403,600 12,137,600
(BERAT)
568 N-4-15-I 4,438,700 5,326,400 6,214,200
URIN (RINGAN)
569 N-4-15-II 5,507,600 6,609,100 7,710,700
URIN (SEDANG)
570 N-4-15-III 6,285,100 7,542,200 8,799,200
URIN (BERAT)
571 N-4-16-I 5,435,200 6,522,200 7,609,200
(RINGAN)
572 N-4-16-II 7,757,700 9,309,200 10,860,800
(SEDANG)
573 N-4-16-III 10,326,100 12,391,300 14,456,500
(BERAT)
- 783 -

REGIONAL 5
RAWAT INAP

577 O-6-11-I 5,052,200 6,062,700 7,073,100
578 O-6-11-II 5,615,000 6,738,000 7,861,000
579 O-6-11-III 6,985,100 8,382,100 9,779,200
580 O-6-12-I 3,579,400 4,295,300 5,011,200
581 O-6-12-II 4,298,900 5,158,600 6,018,400
582 O-6-12-III 5,401,700 6,482,000 7,562,400
586 P-8-01-I 79,929,300 95,915,200 111,901,100
587 P-8-01-II 98,900,500 118,680,700 138,460,800
588 P-8-01-III 116,081,400 139,297,700 162,514,000
589 P-8-02-I 109,099,700 130,919,700 152,739,600
590 P-8-02-II 125,148,400 150,178,000 175,207,700
591 P-8-02-III 142,990,900 171,589,100 200,187,200
592 P-8-03-I 16,364,800 19,637,800 22,910,800
593 P-8-03-II 21,661,100 25,993,300 30,325,500
594 P-8-03-III 30,456,500 36,547,800 42,639,100
595 P-8-04-I 52,736,400 63,283,700 73,831,000
596 P-8-04-II 68,440,500 82,128,600 95,816,700
597 P-8-04-III 98,126,500 117,751,800 137,377,100
598 P-8-05-I 28,676,400 34,411,600 40,146,900
599 P-8-05-II 44,238,300 53,086,000 61,933,600
600 P-8-05-III 59,884,700 71,861,700 83,838,600
601 P-8-06-I 7,741,700 9,290,100 10,838,400
602 P-8-06-II 21,706,000 26,047,200 30,388,400
603 P-8-06-III 28,755,100 34,506,100 40,257,100
604 P-8-07-I 9,165,000 10,998,000 12,831,000
605 P-8-07-II 25,696,500 30,835,800 35,975,200
606 P-8-07-III 34,041,600 40,849,900 47,658,200
607 P-8-08-I 5,303,000 6,363,600 7,424,200
608 P-8-08-II 7,524,700 9,029,600 10,534,500
609 P-8-08-III 14,638,400 17,566,100 20,493,800
610 P-8-11-I 13,637,400 16,364,800 19,092,300
MAYOR (RINGAN)
611 P-8-11-II 18,050,900 21,661,100 25,271,300
MAYOR (SEDANG)
- 784 -

REGIONAL 5
RAWAT INAP

612 P-8-11-III 25,380,400 30,456,500 35,532,600
MAYOR (BERAT)
613 P-8-12-I 12,397,600 14,877,100 17,356,700
MAYOR (RINGAN)
614 P-8-12-II 15,042,400 18,050,900 21,059,400
MAYOR (SEDANG)
615 P-8-12-III 22,069,900 26,483,900 30,897,900
MAYOR (BERAT)
616 P-8-13-I 6,887,600 8,265,100 9,642,600
MAYOR (RINGAN)
617 P-8-13-II 10,744,600 12,893,500 15,042,400
MAYOR (SEDANG)
618 P-8-13-III 16,976,900 20,372,300 23,767,600
MAYOR (BERAT)
619 P-8-14-I 5,213,400 6,256,000 7,298,700
620 P-8-14-II 10,612,300 12,734,800 14,857,200
621 P-8-14-III 41,495,000 49,794,000 58,092,900
622 P-8-15-I 3,910,100 4,692,100 5,474,100
ASPIRASI (RINGAN)
623 P-8-15-II 7,830,100 9,396,100 10,962,200
ASPIRASI (SEDANG)
624 P-8-15-III 9,187,200 11,024,700 12,862,100
ASPIRASI (BERAT)
625 P-8-16-I 3,538,700 4,246,400 4,954,100
626 P-8-16-II 6,800,100 8,160,200 9,520,200
627 P-8-16-III 15,947,400 19,136,900 22,326,400
628 P-8-17-I 4,591,700 5,510,000 6,428,400
(RINGAN)
629 P-8-17-II 8,265,100 9,918,100 11,571,100
(SEDANG)
630 P-8-17-III 14,147,400 16,976,900 19,806,400
(BERAT)
631 S-4-10-I 3,989,800 4,787,800 5,585,700
632 S-4-10-II 4,916,000 5,899,300 6,882,500
633 S-4-10-III 6,729,600 8,075,500 9,421,400
640 S-4-13-I 4,331,700 5,198,100 6,064,400
(RINGAN)
641 S-4-13-II 7,684,800 9,221,800 10,758,700
(SEDANG)
642 S-4-13-III 12,473,400 14,968,100 17,462,800
(BERAT)
643 S-4-14-I 2,192,200 2,630,600 3,069,000
644 S-4-14-II 4,656,300 5,587,600 6,518,800
645 S-4-14-III 8,830,000 10,596,000 12,362,000
KANAK-KANAK (BERAT)
646 S-4-15-I 1,466,100 1,759,400 2,052,600
647 S-4-15-II 2,766,800 3,320,200 3,873,600
648 S-4-15-III 3,583,500 4,300,200 5,016,900
- 785 -

REGIONAL 5
RAWAT INAP

652 S-4-17-I 3,659,200 4,391,000 5,122,800
653 S-4-17-II 5,430,600 6,516,700 7,602,800
654 S-4-17-III 6,531,500 7,837,800 9,144,100
655 T-1-10-I 2,448,300 2,937,900 3,427,600
OBAT (RINGAN)
656 T-1-10-II 3,288,300 3,946,000 4,603,700
OBAT (SEDANG)
657 T-1-10-III 5,982,000 7,178,400 8,374,800
OBAT (BERAT)
658 T-4-10-I 1,340,600 1,608,700 1,876,800
659 T-4-10-II 2,554,400 3,065,300 3,576,200
660 T-4-10-III 3,713,000 4,455,600 5,198,200
661 T-4-11-I 1,294,700 1,553,600 1,812,500
662 T-4-11-II 2,037,500 2,444,900 2,852,400
663 T-4-11-III 3,281,800 3,938,100 4,594,500
664 T-4-12-I 3,033,500 3,640,200 4,246,900
LAIN (RINGAN)
665 T-4-12-II 4,579,400 5,495,300 6,411,100
LAIN (SEDANG)
666 T-4-12-III 7,088,200 8,505,900 9,923,500
LAIN (BERAT)
670 U-1-11-I 12,626,200 15,151,400 17,676,700
(RINGAN)
671 U-1-11-II 19,044,300 22,853,100 26,662,000
(SEDANG)
672 U-1-11-III 22,575,700 27,090,800 31,606,000
(BERAT)
679 U-1-14-I 5,815,900 6,979,100 8,142,300
(RINGAN)
680 U-1-14-II 7,137,500 8,565,000 9,992,500
(SEDANG)
681 U-1-14-III 8,458,000 10,149,500 11,841,100
(BERAT)
685 U-1-20-I 8,829,500 10,595,400 12,361,300
686 U-1-20-II 13,140,700 15,768,800 18,397,000
687 U-1-20-III 33,734,700 40,481,700 47,228,600
691 U-4-10-I 5,449,300 6,539,200 7,629,000
- 786 -

REGIONAL 5
RAWAT INAP

692 U-4-10-II 12,475,100 14,970,100 17,465,100
693 U-4-10-III 19,153,100 22,983,700 26,814,400
TENGGOROKAN (BERAT)
700 U-4-13-I 2,145,100 2,574,100 3,003,100
701 U-4-13-II 3,505,200 4,206,300 4,907,300
702 U-4-13-III 5,659,800 6,791,700 7,923,700
706 U-4-15-I 4,355,200 5,226,300 6,097,300
707 U-4-15-II 5,426,000 6,511,200 7,596,500
708 U-4-15-III 7,593,800 9,112,600 10,631,300
709 V-1-10-I 7,103,700 8,524,500 9,945,200
(RINGAN)
710 V-1-10-II 14,633,400 17,560,100 20,486,800
(SEDANG)
711 V-1-10-III 17,945,800 21,535,000 25,124,200
(BERAT)
715 V-1-12-I 12,706,200 15,247,500 17,788,700
MODERAT (RINGAN)
716 V-1-12-II 17,351,400 20,821,700 24,292,000
MODERAT (SEDANG)
717 V-1-12-III 21,993,100 26,391,700 30,790,300
MODERAT (BERAT)
718 V-1-13-I 6,627,700 7,953,300 9,278,800
KOMPLEK (RINGAN)
719 V-1-13-II 12,663,400 15,196,100 17,728,800
KOMPLEK (SEDANG)
720 V-1-13-III 19,867,400 23,840,800 27,814,300
KOMPLEK (BERAT)
721 V-1-14-I 12,997,000 15,596,400 18,195,700
(RINGAN)
722 V-1-14-II 18,884,200 22,661,000 26,437,900
(SEDANG)

727 V-4-10-I 5,656,600 6,787,900 7,919,200
(RINGAN)
728 V-4-10-II 9,395,900 11,275,100 13,154,300
(SEDANG)
729 V-4-10-III 15,490,500 18,588,700 21,686,800
(BERAT)
730 V-4-11-I 5,430,700 6,516,900 7,603,000
TUMOR (RINGAN)
731 V-4-11-II 7,286,600 8,743,900 10,201,300
TUMOR (SEDANG)
732 V-4-11-III 9,760,500 11,712,600 13,664,700
TUMOR (BERAT)
- 787 -

REGIONAL 5
RAWAT INAP

733 W-1-01-I 14,802,200 17,762,600 20,723,100
734 W-1-01-II 17,741,400 21,289,700 24,838,000
735 W-1-01-III 25,316,600 30,379,900 35,443,200
739 W-1-11-I 3,281,700 3,938,100 4,594,400
SERVIK (RINGAN)
740 W-1-11-II 3,621,400 4,345,700 5,069,900
SERVIK (SEDANG)
741 W-1-11-III 4,006,000 4,807,200 5,608,400
SERVIK (BERAT)
760 W-4-12-I 3,137,500 3,765,000 4,392,500
761 W-4-12-II 5,970,700 7,164,800 8,359,000
762 W-4-12-III 8,786,300 10,543,600 12,300,800
- 788 -

REGIONAL 5
RAWAT INAP

784 Z-4-12-I 2,218,100 2,661,700 3,105,300
785 Z-4-12-II 4,453,600 5,344,300 6,235,000
786 Z-4-12-III 9,395,900 11,275,100 13,154,300
- 789 -

REGIONAL 5
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
24 D-2-11-0 PROSEDUR LIMPA 2,371,800

33 F-3-10-0 TERAPI SHOCK 671,700
- 790 -

REGIONAL 5
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
73 I-2-16-0 4,083,300
PENGGANTIAN ALAT
81 I-2-42-0 3,923,700
PERKUTAN LAIN
- 791 -

REGIONAL 5
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
181 O-7-12-0 1,850,400
192 Q-5-12-0 GIGI 336,200
196 Q-5-16-0 VAKSINASI 112,000
201 Q-5-21-0 ABORSI 293,400
206 Q-5-26-0 BRONKIAL AKUT 238,400
- 792 -

REGIONAL 5
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
211 Q-5-31-0 FRAKTUR 160,500
215 Q-5-35-0 INFEKSI AKUT 686,100
218 Q-5-38-0 PARU AKUT 399,800
234 U-2-23-0 RHINOPLASTY 1,975,400
242 U-3-13-0 509,200
TENGGOROKAN
270 Z-3-11-0 2,762,300
EMPEDU
- 793 -

REGIONAL 5
RAWAT JALAN
KODE TARIF
INA-CBG INA-CBG
277 Z-3-18-0 CT-SCAN KEPALA 1,455,500
289 Z-3-30-0 FOTOTERAPI 92,600
- 794 -


REGIONAL 5
RAWAT INAP

13 A-4-14-I 2,531,400 3,037,700 3,544,000
(RINGAN)
14 A-4-14-II 4,259,200 5,111,100 5,962,900
(SEDANG)
15 A-4-14-III 5,111,100 6,133,300 7,155,500
(BERAT)

31 B-1-13-I 8,238,000 9,885,600 11,533,300
LAIN (RINGAN)
32 B-1-13-II 13,554,700 16,265,600 18,976,600
LAIN (SEDANG)
33 B-1-13-III 17,538,600 21,046,300 24,554,000
LAIN (BERAT)
34 B-1-14-I 21,583,600 25,900,300 30,217,000
(RINGAN)
35 B-1-14-II 22,668,800 27,202,600 31,736,400
(SEDANG)
40 B-4-11-I 7,384,000 8,860,800 10,337,600
(RINGAN)
41 B-4-11-II 10,337,700 12,405,200 14,472,800
(SEDANG)
42 B-4-11-III 12,524,000 15,028,800 17,533,600
(BERAT)
- 795 -

REGIONAL 5
RAWAT INAP


73 D-1-20-I 7,822,200 9,386,700 10,951,100
74 D-1-20-II 21,556,900 25,868,200 30,179,600
75 D-1-20-III 34,195,500 41,034,600 47,873,700
85 D-4-13-I 4,524,400 5,429,300 6,334,200
86 D-4-13-II 6,403,600 7,684,300 8,965,000
87 D-4-13-III 8,190,400 9,828,400 11,466,500
88 D-4-14-I 4,852,600 5,823,100 6,793,700
89 D-4-14-II 7,945,000 9,533,900 11,122,900
90 D-4-14-III 9,717,500 11,661,000 13,604,500
91 E-1-01-I 9,673,100 11,607,800 13,542,400
(RINGAN)
92 E-1-01-II 13,205,300 15,846,300 18,487,400
(SEDANG)

97 E-1-20-I 11,385,200 13,662,300 15,939,300
TIROGLOSAL (RINGAN)
- 796 -

REGIONAL 5
RAWAT INAP

98 E-1-20-II 15,324,200 18,389,000 21,453,900
TIROGLOSAL (SEDANG)
99 E-1-20-III 21,119,900 25,343,900 29,567,800
TIROGLOSAL (BERAT)
100 E-4-10-I 4,029,200 4,835,000 5,640,900
METABOLIK (RINGAN)
101 E-4-10-II 7,803,900 9,364,600 10,925,400
METABOLIK (SEDANG)
102 E-4-10-III 13,076,300 15,691,500 18,306,800
METABOLIK (BERAT)
109 E-4-13-I 5,600,100 6,720,100 7,840,100
(RINGAN)
110 E-4-13-II 8,203,100 9,843,700 11,484,400
(SEDANG)

118 F-4-12-I 3,160,800 3,793,000 4,425,100
(RINGAN)
119 F-4-12-II 4,493,700 5,392,400 6,291,100
(SEDANG)
120 F-4-12-III 9,762,300 11,714,700 13,667,200
(BERAT)
130 F-4-16-I 8,303,900 9,964,700 11,625,500
131 F-4-16-II 9,654,700 11,585,600 13,516,500
132 F-4-16-III 12,887,300 15,464,800 18,042,200
142 G-1-01-I 23,392,300 28,070,800 32,749,200
(RINGAN)
- 797 -

REGIONAL 5
RAWAT INAP

143 G-1-01-II 33,550,200 40,260,300 46,970,300
(SEDANG)
144 G-1-01-III 54,891,000 65,869,100 76,847,300
(BERAT)
151 G-1-12-I 7,474,800 8,969,700 10,464,700
(RINGAN)
152 G-1-12-II 14,011,800 16,814,200 19,616,500
(SEDANG)
153 G-1-12-III 19,095,400 22,914,400 26,733,500
(BERAT)
163 G-4-10-I 6,416,300 7,699,500 8,982,800
(RINGAN)
164 G-4-10-II 7,842,900 9,411,400 10,980,000
(SEDANG)
165 G-4-10-III 10,761,800 12,914,100 15,066,500
(BERAT)
166 G-4-11-I 6,716,800 8,060,200 9,403,600
167 G-4-11-II 8,922,500 10,707,000 12,491,500
168 G-4-11-III 13,110,100 15,732,200 18,354,200
DEGENERATIF (BERAT)
169 G-4-12-I 7,451,600 8,941,900 10,432,200
(RINGAN)
170 G-4-12-II 9,411,800 11,294,200 13,176,600
(SEDANG)

172 G-4-13-I 4,476,200 5,371,500 6,266,700
(RINGAN)
173 G-4-13-II 7,805,700 9,366,800 10,928,000
(SEDANG)
174 G-4-13-III 9,257,700 11,109,300 12,960,800
(BERAT)
175 G-4-14-I 7,593,400 9,112,100 10,630,800
INFARK (RINGAN)
176 G-4-14-II 10,151,900 12,182,200 14,212,600
INFARK (SEDANG)
177 G-4-14-III 12,741,800 15,290,200 17,838,500
INFARK (BERAT)
INFARK (RINGAN)
INFARK (SEDANG)
INFARK (BERAT)
- 798 -

REGIONAL 5
RAWAT INAP

184 G-4-17-I 6,812,500 8,175,000 9,537,500
(RINGAN)
185 G-4-17-II 8,932,700 10,719,300 12,505,800
(SEDANG)
186 G-4-17-III 11,224,400 13,469,300 15,714,100
(BERAT)
190 G-4-19-I 5,597,700 6,717,300 7,836,800
191 G-4-19-II 9,461,500 11,353,800 13,246,100
192 G-4-19-III 12,422,500 14,907,000 17,391,500
211 G-4-26-I 4,355,700 5,226,900 6,098,000
LAIN (RINGAN)
212 G-4-26-II 5,067,100 6,080,500 7,093,900
LAIN (SEDANG)
213 G-4-26-III 7,576,800 9,092,200 10,607,500
LAIN (BERAT)
232 I-1-02-I 39,218,000 47,061,600 54,905,200
(RINGAN)
- 799 -

REGIONAL 5
RAWAT INAP

233 I-1-02-II 50,590,700 60,708,900 70,827,000
(SEDANG)
234 I-1-02-III 62,356,200 74,827,500 87,298,700
(BERAT)
235 I-1-03-I 36,986,800 44,384,100 51,781,500
ANOMALI (RINGAN)
236 I-1-03-II 51,271,300 61,525,600 71,779,900
ANOMALI (SEDANG)
237 I-1-03-III 65,067,300 78,080,700 91,094,200
ANOMALI (BERAT)
238 I-1-04-I 55,737,100 66,884,500 78,031,900
JANTUNG (RINGAN)
239 I-1-04-II 87,968,200 105,561,800 123,155,400
JANTUNG (SEDANG)
240 I-1-04-III 140,528,500 168,634,200 196,739,900
JANTUNG (BERAT)
241 I-1-05-I 92,327,000 110,792,400 129,257,800
242 I-1-05-II 112,844,100 135,412,900 157,981,700
243 I-1-05-III 153,878,300 184,654,000 215,429,600
247 I-1-07-I 82,068,400 98,482,100 114,895,800
JANTUNG (RINGAN)
248 I-1-07-II 102,585,500 123,102,600 143,619,700
JANTUNG (SEDANG)
249 I-1-07-III 153,878,300 184,654,000 215,429,600
JANTUNG (BERAT)
250 I-1-11-I 6,145,600 7,374,700 8,603,800
251 I-1-11-II 6,833,300 8,199,900 9,566,600
252 I-1-11-III 9,093,000 10,911,600 12,730,200
253 I-1-12-I 17,689,900 21,227,900 24,765,900
(RINGAN)
254 I-1-12-II 28,891,200 34,669,500 40,447,700
(SEDANG)
255 I-1-12-III 38,010,800 45,612,900 53,215,100
(BERAT)
256 I-1-13-I 17,159,000 20,590,800 24,022,600
KOMPLEK (RINGAN)
257 I-1-13-II 22,850,700 27,420,800 31,991,000
KOMPLEK (SEDANG)
258 I-1-13-III 28,181,200 33,817,500 39,453,700
KOMPLEK (BERAT)
259 I-1-14-I 35,120,200 42,144,300 49,168,300
(RINGAN)
260 I-1-14-II 43,649,300 52,379,100 61,109,000
(SEDANG)
261 I-1-14-III 57,195,600 68,634,700 80,073,900
(BERAT)
265 I-1-16-I 17,295,800 20,755,000 24,214,200
266 I-1-16-II 39,133,500 46,960,200 54,786,900
267 I-1-16-III 45,139,900 54,167,800 63,195,800
268 I-1-17-I 20,026,900 24,032,300 28,037,700
(RINGAN)
269 I-1-17-II 25,075,600 30,090,700 35,105,800
(SEDANG)
- 800 -

REGIONAL 5
RAWAT INAP

270 I-1-17-III 31,018,100 37,221,700 43,425,300
(BERAT)
271 I-1-20-I 22,573,800 27,088,500 31,603,300
(RINGAN)
272 I-1-20-II 28,200,800 33,841,000 39,481,200
(SEDANG)
273 I-1-20-III 29,644,900 35,573,900 41,502,900
(BERAT)
274 I-1-30-I 17,075,800 20,490,900 23,906,100
JANTUNG (RINGAN)
275 I-1-30-II 35,521,400 42,625,700 49,730,000
JANTUNG (SEDANG)
276 I-1-30-III 55,045,400 66,054,500 77,063,600
JANTUNG (BERAT)

289 I-4-13-I 5,346,200 6,415,500 7,484,700
(RINGAN)
290 I-4-13-II 9,546,300 11,455,600 13,364,900
(SEDANG)
291 I-4-13-III 13,754,900 16,505,900 19,256,900
(BERAT)
295 I-4-15-I 5,156,000 6,187,200 7,218,400
(RINGAN)
296 I-4-15-II 9,722,700 11,667,300 13,611,800
(SEDANG)

304 I-4-18-I 6,146,200 7,375,500 8,604,700
JANTUNG (RINGAN)
305 I-4-18-II 9,357,900 11,229,500 13,101,000
JANTUNG (SEDANG)
306 I-4-18-III 12,704,900 15,245,900 17,786,800
JANTUNG (BERAT)

308 I-4-19-II 9,256,900 11,108,200 12,959,600
(SEDANG)
- 801 -

REGIONAL 5
RAWAT INAP

319 I-4-23-I 5,068,600 6,082,300 7,096,000
320 I-4-23-II 6,222,800 7,467,300 8,711,900
321 I-4-23-III 12,159,000 14,590,800 17,022,500
322 I-4-24-I 3,292,900 3,951,500 4,610,000
(RINGAN)
323 I-4-24-II 7,582,700 9,099,200 10,615,700
(SEDANG)
324 I-4-24-III 9,586,900 11,504,300 13,421,700
(BERAT)
325 J-1-01-I 104,333,600 125,200,400 146,067,100
326 J-1-01-II 118,072,900 141,687,500 165,302,100
327 J-1-01-III 161,957,400 194,348,800 226,740,300
TRAKEOSTOMI (BERAT)
328 J-1-02-I 68,065,100 81,678,100 95,291,100
329 J-1-02-II 85,884,900 103,061,900 120,238,900
330 J-1-02-III 100,473,200 120,567,800 140,662,400
TRAKEOSTOMI (BERAT)
331 J-1-10-I 13,269,600 15,923,500 18,577,400
(RINGAN)
332 J-1-10-II 26,851,000 32,221,200 37,591,400
(SEDANG)
333 J-1-10-III 27,904,900 33,485,800 39,066,800
(BERAT)
334 J-1-20-I 36,555,300 43,866,300 51,177,400
(RINGAN)
335 J-1-20-II 38,278,300 45,933,900 53,589,600
(SEDANG)
336 J-1-20-III 43,077,200 51,692,700 60,308,100
(BERAT)
337 J-1-30-I 11,073,800 13,288,600 15,503,300
(RINGAN)
338 J-1-30-II 20,060,000 24,072,100 28,084,100
(SEDANG)

- 802 -

REGIONAL 5
RAWAT INAP

373 J-4-21-I 3,219,100 3,863,000 4,506,800
374 J-4-21-II 7,188,200 8,625,900 10,063,500
375 J-4-21-III 13,541,400 16,249,600 18,957,900
376 K-1-10-I 12,029,700 14,435,600 16,841,500
BESAR (RINGAN)
377 K-1-10-II 15,117,800 18,141,400 21,165,000
BESAR (SEDANG)
378 K-1-10-III 17,718,600 21,262,400 24,806,100
BESAR (BERAT)
382 K-1-12-I 5,047,500 6,057,000 7,066,500
FEMORAL (RINGAN)
383 K-1-12-II 6,564,800 7,877,800 9,190,800
FEMORAL (SEDANG)
384 K-1-12-III 13,005,900 15,607,100 18,208,300
FEMORAL (BERAT)
388 K-1-14-I 8,314,200 9,977,000 11,639,900
(RINGAN)
389 K-1-14-II 9,744,000 11,692,800 13,641,600
(SEDANG)

394 K-1-30-I 10,578,700 12,694,400 14,810,100
395 K-1-30-II 18,787,400 22,544,900 26,302,400
396 K-1-30-III 25,851,800 31,022,100 36,192,500

398 K-1-40-II 13,013,600 15,616,300 18,219,000
(SEDANG)

- 803 -

REGIONAL 5
RAWAT INAP

412 K-4-13-I 6,033,600 7,240,300 8,447,000
413 K-4-13-II 7,804,900 9,365,800 10,926,800
414 K-4-13-III 12,022,000 14,426,300 16,830,700
415 K-4-14-I 3,442,800 4,131,400 4,819,900
(RINGAN)
416 K-4-14-II 4,621,400 5,545,600 6,469,900
(SEDANG)
417 K-4-14-III 7,415,500 8,898,600 10,381,700
(BERAT)

424 K-4-17-I 2,179,900 2,615,900 3,051,900
(RINGAN)
425 K-4-17-II 2,684,600 3,221,500 3,758,400
(SEDANG)
426 K-4-17-III 3,221,500 3,865,800 4,510,100
(BERAT)
427 K-4-18-I 1,921,000 2,305,300 2,689,500
(RINGAN)
428 K-4-18-II 3,241,800 3,890,100 4,538,500
(SEDANG)
436 L-1-40-I 7,541,000 9,049,100 10,557,300
(RINGAN)
437 L-1-40-II 15,125,500 18,150,600 21,175,700
(SEDANG)
438 L-1-40-III 25,459,600 30,551,500 35,643,400
(BERAT)
451 L-4-13-I 2,742,100 3,290,500 3,838,900
PAYUDARA (RINGAN)
- 804 -

REGIONAL 5
RAWAT INAP

452 L-4-13-II 4,467,000 5,360,400 6,253,800
PAYUDARA (SEDANG)
453 L-4-13-III 8,873,900 10,648,600 12,423,400
PAYUDARA (BERAT)
454 L-4-14-I 4,459,300 5,351,200 6,243,100
(RINGAN)
455 L-4-14-II 6,698,100 8,037,700 9,377,300
(SEDANG)
456 L-4-14-III 9,441,700 11,330,100 13,218,400
(BERAT)
457 M-1-01-I 15,763,300 18,915,900 22,068,600
458 M-1-01-II 22,405,300 26,886,400 31,367,400
459 M-1-01-III 31,472,700 37,767,300 44,061,800
463 M-1-03-I 55,848,000 67,017,600 78,187,200
464 M-1-03-II 65,322,300 78,386,800 91,451,300
465 M-1-03-III 80,847,300 97,016,800 113,186,200
472 M-1-07-I

PMK No. 64 2016 TTG Standar Tarif Pelayanan Kesehatan

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PMK No. 64 2016 TTG Standar Tarif Pelayanan Kesehatan

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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

2. Undang-Undang Nomor 36 Tahun 2009 tentang

3. Undang-UndangNomor 24 Tahun 2011 tentang Badan

4. Peraturan Presiden Nomor 12 Tahun 2013 tentang

5. Peraturan Menteri Kesehatan Nomor 9 Tahun 2014

6. Peraturan Menteri Kesehatan Nomor 52 Tahun 2016

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

STANDAR TARIF PELAYANAN KESEHATAN PADA FASILITAS KESEHATAN

TARIF INA-CBG TAHUN 2016

KOD TARI TARI TARI

28 B-1-12-I CHOLESISTEKTOMI TANPA LAPAROSKOPIK (RINGAN) 9,473,000 11,367,600 13,262,200

29 B-1-12-II CHOLESISTEKTOMI TANPA LAPAROSKOPIK (SEDANG) 10,535,700 12,642,800 14,750,000

30 B-1-12-III CHOLESISTEKTOMI TANPA LAPAROSKOPIK (BERAT) 16,481,900 19,778,300 23,074,700

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) 6,797,500 8,157,000 9,516,500

51 B-4-14-III GANGGUAN SALURAN EMPEDU LAIN-LAIN (BERAT) 9,105,400 10,926,500 12,747,600

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

94 E-1-10-I PROSEDUR KELENJAR ADRENAL (RINGAN) 9,211,300 11,053,600 12,895,800

112 F-4-10-I SCHIZOFRENIA (RINGAN) 5,460,700 6,552,800 7,645,000

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) 35,683,500 42,820,200 49,956,900

279 I-1-40-III PROSEDUR KARDIOVASKULAR PERKUTAN (BERAT) 47,661,100 57,193,300 66,725,500

298 I-4-16-I ATHEROSKLEROSIS (RINGAN) 2,918,500 3,502,200 4,085,900

GANGGUAN KONDUKSI & ARITMIA JANTUNG

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

340 J-4-10-I KISTA FIBROSIS (RINGAN) 2,989,800 3,587,800 4,185,700

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

391 K-1-20-I PROSEDUR INTESTINAL KOMPLEKS (RINGAN) 16,383,700 19,660,400 22,937,100

PROSEDUR SISTEM PENCERNAAN LAIN-LAIN

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF

400 K-1-50-I PROSEDUR ANAL (RINGAN) 8,260,600 9,912,700 11,564,800

418 K-4-15-I OBSTRUKSI SALURAN GASTROINTESTINAL (RINGAN) 4,494,700 5,393,600 6,292,600

419 K-4-15-II OBSTRUKSI SALURAN GASTROINTESTINAL (SEDANG) 6,922,300 8,306,800 9,691,200

420 K-4-15-III OBSTRUKSI SALURAN GASTROINTESTINAL (BERAT) 9,853,000 11,823,600 13,794,200

TARIF INA-CBG TAHUN 2016

KODE TARIF TARIF TARIF